by Michael Wong
In the recent survey that we conducted, 90% of respondents believe that “continuous electronic monitoring of oxygenation and ventilation should be available and considered for all patients and would reduce the likelihood of unrecognized clinically significant opioid-induced depression of ventilation in the postoperative period.”
There were almost 300 respondents, almost all of whom are physicians, nurses, and healthcare providers, who indicated anesthesiology as a medical area of practice. What these respondents are saying is that all patients should be monitored after surgery; and not just those who may before surgery have been identified as having an increased risk, such as that associated with obstructive sleep apnea, obesity, or chronic opioid therapy. This is in accord with recent recommendations by the Anesthesia Patient Safety Foundation (for links to and quotes from anesthesiology experts on the recommendations, please click here).
Do you agree or disagree? How would this affect the management of postoperative patients? What does that say about the 10% who disagreed?
PPAHS is currently looking for funding or grants to pursue the results of this survey.
Monitoring has proved to help doctors prevent many catastrophes. It’s the reason that even with minor ailments, patients are asked to stay in a hospital for a few hours for observation. I agree that patients should be monitored after surgery even with ambulatory procedures. It can be easily done through telemonitoring so patients can resume their lives while doctors receive the information they need.
I do agree that patients be monitored in the postoperative period. The question might be for what time frame? Until the patient is off parenteral opioids? Some arbitrary length of time at which point it is decided that they are at decreased risk or have not shown signs of hypoventilation and hypoxemia? until they are no longer receiving drugs with the potential of inducing respiratory depression? That last comment is purely impractical. It would imply sending patients home on monitors. I made the comment purely as an example of taking it to the extreme as devil’s advocate.
Agree in principle with Dr. Stram: Sure, it’s a no-brainer that patients should be monitored until they’re out of the woods from surgery–anything invasive = surgery for the sake of this argument.
But what really ~is~ the endpoint? If you say it’s three hours, then if you don’t use any sedation at all on a patient (and I don’t), you’re tying up a recovery area and increasing the bill for no obvious reason. If you don’t use sedation and you let a patient go home immediately and they wreck their car because they were on the phone or texting and a lawyer finds out that you let them go–despite guidelines that say you ought not to do that–then you have a “situation.”
It’s always better to have suggestions rather than guidelines, for physicians to act with good judgment (how’s that for a platitude?), and to document why they chose to do what they did. I’m pretty sure that’s the best way to handle the question, and to be able to defend yourself if a patient does something unwise.
Of course post-surgical patients should be monitored and most are to some extent. The real scandal in modern hospital medicine is that ICU survivors, particularly those who have come through major trauma or multiple organ failures, do not routinely receive post-iCU follow-up treatment the critical care specialists who are familiar with ICU complications.
All patients should be monitored after surgery. And they are for a minimum of an hour in PACU typically. Depending on the complexity of the surgery and the frailty of the patient, that time may need to be extended. Honestly, though, we do our very best to get patients up and out of bed and moving around ASAP after surgery. The wires and monitoring equipment often are a barrier to recovery. Patients often feel the more they are hooked up to, the sicker they must be. I notice a big boost in motivation to get out of bed and move when I take the probes off and tell them they can and should get up.
Monitors are fantastic and should be used, but not every second of the hospital stay. They intimidate people into staying in the bed and feeling bad longer.
A monitor also doesn’t work nearly as well as a nurses intuition.
I treat patients, not vital signs.
The National CMT Resource Center encourages monitoring of all patients after surgery, particularly those with Charcot-Marie-Tooth (CMT) disease. Many patients with CMT undergo repeated surgery because of their condition. Named after the three doctors who first identified it, CMT is one of the most common inherited nerve disorders. CMT affects an estimated 1 in 2,500 people in the United States and 2.6 million people worldwide, although experts believe the number could be much higher. CMT can affect breathing and thus recovery after anesthesia. In addition, some types of anesthesia may be contraindicated for CMT. For more information on this issue, please see http://help4cmt.com/articles/?id=90&pn=breathing-anesthetics-and-charcot-marie-tooth.
help4CMT.com
For further comments on whether patients after surgery should be monitored, please see http://wp.me/p1JikT-5Y
agreed that pulse oximetry is a method to improve outcomes in:
Patient receiving opioid therapy, postoperative patients, patients with confirmed or suspected sleep apnea , critical care patients.
Screening for congenital heart defects via pulse oximetry in neonates can improve detection .