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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 http://royalcentreofplasticsurgery.com/

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 royalcentreofplasticsurgery.com   Stay In Touch Twitter: @RCPSurgery Twitter Personal: @DrKennethDickie Google+: plus.google.com/+RoyalcentreofplasticsurgeryinBarrie/ Google+ Personal: plus.google.com/+DrKennethDickieBarrie or Call Us at 705-726-2800

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