Second OpinionsAldrete Score
Does anyone use a different scoring scale than Aldrete? What do you use to assess patients' post-anesthesia conditions, and can you provide an example of the scale/documentation?
Started by: Maureen Darling (Other) at August 1, 2012 (5:28 pm)
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We use a modified White scoring system....you can use any scale you want.....adapt it to your facility
Janel Craig (OR Manager/Supervisor) at September 12, 2012 (5:44 pm)
Always deeply moved to hear someone else has gotten the concept about which I've spent the last 20 years preaching. I am most happy for your patients.
When it comes to BIS, a recent article from Curr Op in Anesthesiol asserts it is cost effective & should be used. One can grab a color VISTA on eBay for ~$2500.
You likely have plastic surgeons who have no difficulty re-injecting local analgesia when the patient moves.
Having done propofol ketamine sans BIS for 5 years (1992-97), I could not get even my most regular surgeons to re-inject with patient movement.
With BIS/EMG, the surgeon cannot argue the patient is 'too light' when all along we've known it is more local that is needed to eliminate 99+% of patient movement.
At to the utility of BIS, it is not unless one trends EMG as a secondary trace & responds to EMG spikes as if they were HR or BP changes.
FWIW, the part of the brain that processes hearing, feeling & remembering is the cortex. Vital signs, though important, are notoriously unreliable guides to cortical activity.
Unfortunately, Aspect viewed the EMG as a contaminant, not a useful tool. They made the esthetic decision to only trend BIS on the default screen. Easily remedied & makes each patient far more interesting.
Even without Gabapentin & Celebrex, my patients have not required opioids postoperatively for the past 15 years. Maybe the preop clonidine has something to do with my success.
Bottom line, as long as one prevents intra-op pain & titrates propofol to adequate hypnosis, patients will repeat the experiences Carrie & I have had.
Bravo! I commend your success. 'Carrie' on. :-)
Barry Friedberg (Anesthesiologist/Nurse Anesthetist) at August 2, 2012 (6:48 pm)
I have used a modification of your procedure for over 10 years at the office based plastic surgery center where I work. I use NO OPIATES, just as you, but do not use a BIS (to costly for our small practice.) I use a continuous propofol infusion as most of our patients prefer to be "completely asleep" for the procedures. Understanding the pharmacokinetics of propofol, my patients awaken on the OR table and we are able to dress them in garments and clothing right in the OR. They are transported to "recovery" upright, in a wheel chair, and are usually alert, ambulatory AND PAIN FREE in 20 minutes, at which time they are discharged.
Not only do I believe in the use of Ketamine prior to infiltration of tumnescent anesthesia, I also believe that most anesthesia practitioners are doing a woefully INADEQUATE job of preventing central sensitization PRIOR to any surgical stimulation when caring for ambulatory patients. ALL my patients (except where contra-indicated) receive oral Gabapentin and Celebrex pre-operatively. Intra-operativiely I use not only Ketamine but also an IV Lidocaine infusion to attenuate the inflammatory response (see recent article in SAMBA) If they are uncomfortable post-operatively, which is only a MINORITY of patients, they receive oral diazepam to aleviate the local muscle spasm that accompanies most surgeries. This seems to alleviate the rest of their discomfort. At least 97% of our patients report NO USE of post operative narcotics on the phone call made by our nurses 24 hours after the surgery. Less than 0.1% of our patients have PONV.
There are MULTIPLE receptors involved in the transmission, modulation and perception of pain. If you are going to successfully prevent central sensitization you MUST attenuate the response of MULTIPLE pain receptors, not just one.
It is not difficult to tell when a patient is ready for discharge when they are already in their own clothes, in a wheel chair, pain free, have no PONV, can eat, speak clearly and ambulate with minimal assistance within 20 minutes of leaving the OR.
Carrie Frederick (Anesthesiologist/Nurse Anesthetist) at August 2, 2012 (12:43 pm)
In response to the Ramsey scale as a post op assessment tool... This does not even come close to monitoring the appropriate systems..ie cardiovascular status and respiratory status. In our center we have included nausea as an indicator, removing color as this is to subjective. I wonder... is the Ramsey scale used so the patient can be moved along at a quicker pace??? Safety first is our motto.
patricia o. (Other) at August 2, 2012 (12:09 pm)
RAMSEY Sedation scale
Sharon N. (Administrator/Director/Manager/Owner/Exec. Officer) at August 2, 2012 (10:38 am)
No opioid requiring pain
Able to be discharged within 1 postop hour or less
As long as anesthesia providers insist on enabling surgeons to inflict pain upon helpless, unconscious patients, the quest for better outcomes will continue.
Failure to give 50 mg ketamine 3 minutes prior to injection/incision enables the primary pain signal, the breaching of the boundary between the world of self & the world of danger (the skin), to reach the cerebral cortex.
For the past 15 BIS/EMG monitored years, no patient has required postop opioid pain rx.
This experience has led me to the radical notion that postoperative pain is a function of intra-operative pain.
Over 20 years of propofol ketamine anesthesia, not a single patient has filed suit against me. Pretty good patient satisfaction.
It took me many years to understand why my female patients kept asking me if I was married when they experienced this incremental induction...
Friedberg's Triad is the answer to better recoveries...
Measure the brain (BIS/EMG)
Preempt the pain ('nifty 50')
Emetic drugs abstain (no opioids/stinky gases)
Barry Friedberg (Anesthesiologist/Nurse Anesthetist) at August 2, 2012 (10:22 am)
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