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*Department of Anesthesiology and Intensive Care Medicine, Jorvi Hospital, Helsinki University Central Hospital, Espoo, Finland; Department of Anesthesiology and Intensive Care Medicine, Meilahti Hospital, Helsinki University Central Hospital, Helsinki, Finland; and Department of Anesthesiology, South Carelian Central Hospital, Lappeenranta, Helsinki, Finland
Address correspondence and reprint requests to Kristiina Mattila, MD, Jorvi Hospital, Turuntie 150, 02740 Espoo, Finland. Address e-mail to kristiina.mattila{at}hus.fi.
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Abstract |
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Introduction |
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Previous studies on postoperative symptoms after ambulatory surgery have concentrated mainly on the predischarge period and early postoperative days (2,5,6). In a systematic review of the relevant literature, a marked heterogeneity was noted in the incidences of postdischarge symptoms, presumably because of the methods and timing of patient assessment (7). The aim of the present study was to prospectively define, based on a questionnaire, the daily incidence and intensity of symptoms on 8 consecutive days after surgery in a large outpatient population and to determine the contribution of demographic and clinical variables to minor morbidity. We hypothesized that evaluation of several symptoms during the first week after ambulatory surgery would reveal that symptoms last for a longer period than previously reported.
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Methods |
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Patient characteristics and clinical information including preexisting diagnoses, ASA physical status class, age, sex, height, weight, type of anesthesia, type and duration of surgery, admission to ward, reasons for admission, and prescribed pain medication were documented on a separate standardized sheet by anesthesia nurses in cooperation with anesthesiologists. Adults and parents of children were given a questionnaire asking them to note each day the occurrence and severity of symptoms, starting on the day of the operation after discharge from the ambulatory surgical unit and lasting until the postoperative Day (POD) 7.
Symptoms listed in the questionnaire consisted of the following: postincisional pain, bleeding, drowsiness, dizziness, nausea, vomiting, headache, backache, sore throat, hoarseness, temperature more than 37°C, and voiding difficulty.
Postincisional pain was defined as pain despite pain medication. Patients were also asked to report the occurrence of any symptoms in addition to those mentioned in the questionnaire, for example, sensory, auditory, or visual impairments. Adults and parents of children were instructed to grade all symptoms numerically on a 4-point scale as nonexistent, mild, moderate, or severe in the evening of each POD. Patients and parents were told to contact either the hospital or primary health care provider if they experienced medical problems and to report the respective reasons and dates of health care contacts. The reasons for return visits to the hospital were reviewed later from hospital records by two of the authors. Patients at Jorvi Hospital were asked, in addition, whether they were satisfied with the care given. Unsatisfied patients were asked to specify the reason for their dissatisfaction. At South Carelian Central Hospital, the question about patient satisfaction was accidentally omitted from the questionnaire. This was detected too late for changes to be made so that relevant data would be obtained.
Descriptive and multinomial regression analyses were performed separately for adults and children because of differences in patient characteristics and types of surgical procedures in these subpopulations. Multinomial logistic regression analysis was used to determine predictive factors for minor morbidity. We did not perform a power analysis, but the number of patients was considered sufficient when the size of the study population was more than 15 times the number of the measured variables. In adults, the following variables of clinical interest were chosen for modeling and grouped to form 3–5 subgroups, shown in parenthesis: age (15–39 yr, 40–64 yr, and 
65 yr), body mass index (BMI; <20 kg/m2, 20–24 kg/m2, 25–29 kg/m2, and 30 kg/m2), ASA status (1–3), sex (male or female), smoking status (nonsmoker or smoker), positioning during surgery (supine, supine with reverse Trendelenburg and left lateral tilt for laparoscopic cholecystectomy [LCC], side, prone, or lithotomy), type of anesthesia (general, local, spinal, IV regional anesthesia, or general with local), type of surgery (all surgical specialties), and duration of surgery (<30 min, 30–59 min, or 60 min). In children, the respective variables included age (<3 yr, 3–6 yr, or 7 yr), ASA status (1–3), sex (male or female), type of anesthesia (general or general with local), and type of surgery (pediatric, ear-nose-throat [ENT], or other), and duration of surgery (<15 min, 15–29 min, or 30 min). Logistic regression analysis was performed for each investigated postdischarge symptom in both subpopulations using the NCSS Multinomial Logistic Regression module (NCSS 2001, Kaysville, UT) and the II-degree model. Variables found to be statistically significant were used to create the final models. These models were tested for statistical significance. The effect of clinical variables on the occurrence of investigated symptoms was reported by odds ratios and its 95% confidence interval. Statistical significance was defined by Wald statistic P-value, with P < 0.05 considered significant. Descriptive statistics were analyzed with NCSS and Statview software.
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Results |
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30 kg/m2) in 15%, hypertension in 13%, and bronchial asthma in 7%. Bronchial asthma was reported in 8% of children.
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The main groups of surgical specialties were orthopedics (36%) and gynecology (27%) in adults and ENT surgery (79%) in children. For further surgical data, see Table 2.
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Nearly 5% (106) of adults and 0.5% (3) of children required admission to the hospital wards from the ambulatory surgery unit with pain (34%) or postoperative nausea and vomiting (PONV) (30%) as the main reasons. More than one reason for admission was reported in 25% of cases. Lack of care at home was the reason for 9% of admissions. The rate of hospital admission from the ambulatory surgical unit was most frequent after gastroenterological surgery (13%). Admission rates after vascular surgery, gynecological procedures, orthopedics, and urology were 9%, 5%, 4%, and 4%, respectively.
For adults, the pain medication prescribed at discharge was nonsteroidal antiinflammatory drugs (NSAIDs) (73%), a combination of acetaminophen and codeine (13%), tramadol (5%), or acetaminophen (4%). A combination of two drugs was prescribed for 14% of patients. Information about home medication was missing in 19% of responses. Of children, 24% were prescribed acetaminophen, 16% NSAIDs, and 20% a combination of acetaminophen and NSAIDs. At the time of the study, information concerning medication at home was not registered at South Carelian Central Hospital for 95% of the children (39% of all children).
Pain in adults and drowsiness in children were the most common symptoms experienced during the surveillance period (Table 3). Ten percent of patients reported no symptoms (9% of adults and 13% of children). Miscellaneous symptoms other than those listed in the questionnaire were reported by 12% of adults and by 6% of children. In adults, the most common were sensory disturbance or shoulder pain (both in 3%). At least one symptom was reported on consecutive days by 49% of adults until POD 3 and by 24% until POD 7. For children, one or more symptoms were reported on POD 3 by 22% and on POD 7 by 8%.
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Unplanned contacts, including telephone contacts, visits to doctors' offices, and visits to the emergency department were reported in 240 (9%) questionnaires (13% of children and 8% of adults) after procedures from various surgical specialties. One-fifth of all contacts were reported on POD 2, making it the most frequent day that patients required medical advice. In adults, unplanned contacts were most frequent after urology (14%), gynecology (9%), vascular surgery (8%), and orthopedics (6%). In children, unplanned contacts were more frequent after pediatric surgery (13%) compared to ENT surgery (8%). More than one reason was given in 10% of cases. For adults, the main reasons were pain (31%), bleeding (19%), fever or symptoms of infection (17%), swelling or hematoma (15%), voiding difficulty (7%), and PONV (2%). For children, fever or upper airway infection were the main reasons (55%) why parents contacted health care services; 90% of these contacts were after pediatric ENT surgery. Other reasons for parental contacts were bleeding (10%), voiding difficulty (7%), pain (5%), and PONV (4%).
Forty-one patients (1.5%) returned to the emergency department after discharge. The main reasons were infection or suspected infection of the operation site (24%), bleeding (22%), pain (12%), and voiding difficulty (12%). Thirty-four percent of all return visits were after gynecological procedures, 24% after orthopedics, and 12% after pediatric ENT surgery. The rate of return visits on PODs 0–7 were 5%, 20%, 10%, 24%, 15%, 17%, 7%, and 2%, respectively. One child had two visits because of asthmatic problems.
Nine patients returned to the hospital because of bleeding, and of these, seven had undergone a gynecological procedure. Reabrasion was performed in two patients after dilatation and curettage. After spinal anesthesia, two patients suffered postdural puncture headache. Both were successfully treated with an epidural blood patch. Deep venous thrombosis was diagnosed in two patients and treated on an ambulatory basis.
Nine patients were readmitted as inpatients. The reasons for readmission in adults were postoperative infection after LCC, uterine infection after pregnancy termination, wound infection after lower extremity surgery, suspected wound infection after knee arthroscopy, inability to void or evacuation of hematoma after gynecological perineal surgery, and observation for abdominal pain unrelated to surgery. One child required overnight surveillance after reoperation on POD 4 for bleeding after adenoidectomy. One asthmatic child was admitted for airway obstruction.
In adults, none of the symptoms were significantly related to BMI, ASA class, or smoking. Younger adults and women were more prone to experience several symptoms (Table 4). The risk for several symptoms increased after general anesthesia and a longer duration of surgery. The type of surgical specialty was associated with postoperative pain, bleeding, increase in temperature, and difficulties in voiding. Spinal anesthesia increased the risk for backache only.
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In children, the risk for PONV increased when surgery lasted for a longer period (Table 5). General anesthesia supplemented with a local anesthetic reduced the risk for nausea but increased the risk for pain. Younger children were less prone to nausea but showed a higher risk for experiencing an increase in temperature. The risk for suffering dizziness, headache, and sore throat was increased in older children and in girls. ENT surgery increased the risk for an increase in temperature compared with other types of pediatric surgery.
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At Jorvi Hospital (n = 1376), 98% of patients answered the question asking about satisfaction; of the respondents, 96% were satisfied, 3% dissatisfied, and the remaining subjects expressed both dissatisfaction and satisfaction. Gynecological patients expressed dissatisfaction most frequently (5%), accounting for 57% of dissatisfied adults. Patients criticized inadequate information, long waiting time in the unit before surgery, inadequate communication by personnel, and inadequate pain medication.
The characteristics of nonresponders were analyzed at Jorvi Hospital, where the overall response rate was less than at the South Carelian Central Hospital (67% versus 75%). Nonresponders were more often female (77%), younger (median 35 yr versus 42 yr), more frequently classified as ASA 1 (74% versus 64%), and smokers (30%). Thirty-six percent of female nonresponders had undergone pregnancy termination. Thirty-nine percent of pediatric questionnaires were not returned.
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Discussion |
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Pain was the most frequent symptom reported by the adult patients and was also the main reason for unplanned health care contacts, in agreement with previous nonrandomized outpatient studies (8,9). In comparison with other symptoms, pain was more often moderate or severe, emphasizing the need for more effective pain medication and possibly a more multimodal approach after certain types of surgery (9). The finding that children receiving supplementation with local anesthetic had an increased risk for postdischarge pain is paradoxical. Possibly, the instructions provided for administering pain medication at home were inadequate or the recommendations were not followed (10). Longer duration of surgery increased the risk for pain and overall morbidity. Obviously, more demanding surgery may result in longer procedures followed by more pain and a more complicated recovery.
Drowsiness was common on the first days after surgery and may have disturbed perception and performance of daily activities (2,4). Nearly 20% of our patients experienced moderate or severe drowsiness on the evening after surgery, with drowsiness still being frequent one day later. General anesthesia increased the risk for drowsiness in adults compared with local anesthesia, but no significant difference in risk between general and spinal anesthesia was seen.
Several patients complained of hoarseness and sore throat on the evening after surgery and the next day, with the risk increasing with general anesthesia. We did not specify airway management in our risk analysis, although it has a strong influence on postoperative pharyngeal symptoms (11,12).
The frequency of PONV after ambulatory surgery varies among patient populations. In the present study, the incidence of nausea was slightly more frequent (21% versus 17%) and the incidence of vomiting less frequent (5.7% versus 8%) compared with a systematic review (7). In the present study, of established risk factors for PONV (13), general anesthesia and female gender increased the risk for PONV in adults. Longer duration of surgery increased the risk for nausea only. The type of surgical specialty had no impact on either nausea or vomiting. However, the role of the type of surgical procedure as a risk factor has been debated (13,14). The decreased risk for nausea with increasing age in adults and the increased risk in older children are in accordance with previous findings (13,15). We were unable to detect any specific risk factors related to postdischarge vomiting in the pediatric population.
Aging of the general population will lead to more elderly patients requiring surgery. Old age alone does not seem to affect the duration of recovery and the rate of complications after discharge after ambulatory care (16). Other factors seem to be of greater importance, e.g., physiological age, medical history, physical activity, and social surroundings (17). In the present study, older age did not increase the risk of any of the assessed symptoms. This finding may partly be explained by the fact that older patients may be more satisfied with their care and may place less emphasis on the adverse outcomes than younger patients (18). Better verbal communication skills may partly explain why older children seemed to experience more symptoms than younger children in this kind of survey.
Although morbid obesity (BMI >35 kg/m2) is associated with increased surgical risk, it has not been reported to significantly increase postoperative complications or unplanned admissions in comparison to normal body weight (19). In the present study, obesity was not a significant predictor of any of the assessed postdischarge symptoms in adult patients. Obesity alone may not be an exclusion criterion for a planned procedure when other patient-related factors are not contraindications for ambulatory care (19).
Female gender increased the risk for nearly all symptoms in adults. Although women emerge more rapidly from general anesthesia (20), previous reports also suggest that they experience minor postoperative symptoms more often and return more slowly to their preoperative health status than men (21,22). The fact that girls were also more prone to experience postdischarge symptoms may suggest that there are differences in recovery between sexes that already exist in childhood.
The rate of unanticipated admission in adults was higher (5%) compared with previous studies (23). In addition to the possible need for timely and more multimodal treatment of pain and PONV, this may be attributable to the relatively open access to surgical wards when recovery is delayed beyond working hours of the units. The discharge time from the surgical ward was not recorded. Lack of care at home was actually the indication for 9% of admissions to the hospital, although all patients included in the study were considered to meet outpatient criteria. The relatively infrequent readmission (0.3%) supports the view that ambulatory surgery is safe.
The overall response rate of 70% in the current study can be regarded as satisfactory when compared with the mean response rate of approximately 62% in mail surveys published in medical journals (24). We did not send a second set of questions to eliminate the risk of recall bias. The data may be skewed by the absence of nonresponders, which were mainly gynecological patients and children. The intimacy of gynecological procedures and the hectic routines in families with small children have to be considered when analyzing the response rate. Although mail-in questionnaires minimize the acquiescence bias that may occur in telephone interviews (25), different times of self-assessment and noncompliance with daily entry are distinct possibilities with our method of surveillance. We told the patients when to fill out the questionnaires, but we did not assess the validity of timing. The fact that our questionnaire has not been validated is also a limitation.
Pediatric data, predominately reported by parents, are not a direct patient response, which is always a problem in surveys of young children. We did not document information regarding previous upper respiratory infection, although it may be an important component of perioperative risk. Unfortunately, the influence of anesthesia, anesthetic techniques, and intraoperative and postoperative opioids on the incidence of postdischarge symptoms cannot be analyzed in this kind of observational, nonrandomized study. This limits our ability to extrapolate from our results.
Our relatively frequent incidence of symptoms may be attributable to our questionnaire with its predefined choices of symptoms. It remains unknown whether there was an encouragement bias in the present study. Functional outcome measures are important in evaluating the quality of the recovery process. However, we did not study the impact of postdischarge symptoms on daily living and functional recovery.
In conclusion, minor morbidity was common during the first week after ambulatory surgery. Recovery was influenced by several patient-related, anesthesia-related, and surgery-related variables. Overall, none of the single nonpredefined symptoms exceeded an incidence of 3%. We therefore believe that the symptoms presented in the questionnaire were relevant to the postoperative state. The frequency of postdischarge symptoms, especially on the initial postoperative days, emphasizes the need for further evaluation of their impact on functional recovery and the return to normal life.
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Footnotes |
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