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Ambulatory Surgery by Dr. Kenneth Dickie


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Dr. Kenneth Dickie from Royal Centre of Plastic Surgery in Barrie, Ontario explained the refining experience for Ambulatory Surgery.

If you have any questions, please contact Dr. Kenneth Dickie at

Published in: Health & Medicine
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Ambulatory Surgery by Dr. Kenneth Dickie

  1. 1. AMBULATORY SURGERY REFINING THE EXPERIENCE Dr. Kenneth Dickie Royal Centre of Plastic Surgery
  2. 2. Measurement of Outcomes of Elective Surgery • Health Related Quality of Life (HRQOL) • Patients self reported HRQOL for specific elective surgical procedures is a more valid outcome measure than a surgeons own impression of outcome • Objective assessments must incorporate the patient’s view of the impact of the procedure on their HRQOL
  3. 3. Emotional and Physical Reactions from Plastic Surgery • Physical Reactions – Patients must be aware of nature’s “healing curve” – Timetable for swelling, bruising, tightness, and numbness must be re-enforced – 4 weeks to “looking good” – 3 months to “healed”
  4. 4. OUTPATIENT SURGERY • Plastic Surgery procedures • 80% are performed as day surgery procedures • Majority are ASA class I and II • Can we refine the patient experience?
  5. 5. Pre-Operative Preparation • Patient information and informed consent – General information – Specific information – Smoking and increased surgical risks – Thrombosis risk factor assessment – Emotional & Physical reactions from Plastic Surgery
  6. 6. Smoking and Increased Surgical Risk • Nicotine –vasoconstriction may compromise circulation to tissue – Facelift – Breast Reduction – Abdominoplasty – Free tissue transfers and skin flaps
  7. 7. Stop Smoking • One month prior to surgery • Two weeks after surgery • Patient must sign “Smoking and Increased Surgical Risks” form • Cancel surgery if still smoking
  8. 8. Thrombosis Risk Factor Assessment • Low risk—T.E.D. stockings + early ambulation • Moderate risk- T.E.D. stockings +Sequential Compression Device or Anticoagulant • High risk- T.E.D. stockings + SCD + Anticoagulant
  9. 9. Sequential Compression Device • Surgery over 1 hour and patient over 40 places patient in moderate risk category for DVT • Routine use of SCD in Plastic Surgery procedures
  10. 10. Oral Contraceptives and DVT • Increased risk with oral contraceptives and hormone replacement therapy • Stop BCP/HRT therapy (if possible) 1 cycle pre- op and 1 cycle post op • Informed consent regarding DVT and Pulmonary Embolism
  11. 11. Emotional and Physical Reactions from Plastic Surgery • Emotional Roller Coaster – Low point day 3 to 4 – Support person crashes end of first week – Feeling good by end of 2nd week – Office staff must not “abandon” patient
  12. 12. Postoperative Recovery • Hypothermia (core temp < 36 C.) – Over 70% of post op patients are hypothermic (depressed thermoregulation, exposure, IV fluids, skin preps) – Results in: • ^ Oxygen consumption post op (shivering) • ^ Cardiac output, hypertension, PVC’s, and arrhythmias • ^ Patient discomfort = ^ Narcotic requirement • LONGER STAYS IN THE RECOVERY ROOM
  13. 13. Hypothermia • Patient Warming System – Surrounds the patient with warm air at desired temperature: • Low 30-34 degrees • Medium 36-40 degrees • High 42-46 degrees
  14. 14. Patient Warming System • Use intra-operatively for procedures longer than 2 hours • Use postoperatively for procedures longer than 1 hour • In ALL cases, there is a dramatic reduction in narcotic requirement, post operative nausea and vomiting. • In ALL cases, there is an enhanced speed of post operative stabilization of the patient.
  15. 15. Patient Warming System
  16. 16. Postoperative Recovery • ZOFRAN (Ondansetron HCl) – 4mg I.V. q4hr. Prn – Marked reduction in post operative nausea and vomiting – Increased comfort for the patient – More rapid discharge following Day Surgery
  17. 17. Postoperative Recovery • Nerve Blocks – Peripheral nerve blocks with long acting anaesthetics (Marcaine) provide enhanced patient comfort and facilitate earlier discharge – Reduced requirements for narcotics postoperatively – May be performed by the anesthesiologist or surgeon while the patient is still under anaesthesia
  18. 18. Prophylactic Vasodilators • Healing complications are one of the leading causes of litigation in Plastic Surgery • “High Risk” zones benefit from proactive management with topical vasodilators • Breast Reduction (nipple ischemia), Abdominoplasty (skin flap ischemia), Facelift (skin flap ischemia), any tissue with impaired blood supply.
  19. 19. Prophylactic Vasodilators • Nitro-Dur patch: 0.4 or 0.6 mgm patch • Patients initial reaction to medication must be monitored in the recovery room • Patches are applied at completion of surgery and may be easily removed if BP problems develop (unusual) • Patients may apply patch every 12 hours if ischemia persists
  20. 20. Prophylactic Antibiotics in Elective Plastic Surgery • Any surgery greater than 2 hours in length • Any surgery where circulation to tissue is compromised as a result of the surgical procedure – Breast Reduction – Abdominoplasty – Facelift – Selected Reconstructive Procedures – (any situation where prophylaxis is indicated for medical reasons)
  21. 21. If you have any questions, feel free to contact Dr. Kenneth Dickie at   Stay In Touch Twitter: @RCPSurgery Twitter Personal: @DrKennethDickie Google+: Google+ Personal: or Call Us at 705-726-2800