2013+ASA实践指南：麻醉后的护理

Anesthesiology, V 118 • No 2 291 February 2013 P RACTICE Guidelines are systematically developed rec-ommendations that assist the practitioner and patient in making decisions about health care. These recommen- dations may be adopted, modified, or rejected according to clinical needs and constraints, and are not intended to replace local institutional policies. In addition, Practice Guidelines developed by the American Society of Anesthe- siologists (ASA) are not intended as standards or absolute requirements, and their use cannot guarantee any specific outcome. Practice Guidelines are subject to revision as war- ranted by the evolution of medical knowledge, technology, and practice. They provide basic recommendations that are supported by a synthesis and analysis of the current litera- ture, expert and practitioner opinion, open forum commen- tary, and clinical feasibility data. This document updates the “Practice Guidelines for Post- anesthetic Care: A Report by the American Society of Anes- thesiologists Task Force on Postanesthetic Care,” adopted by the ASA in 2001 and published in 2002.* Methodology A. Definition of Postanesthetic Care A standard definition for postanesthetic care cannot be iden- tified in the available literature. For these Practice Guide- lines, postanesthetic care refers to those activities undertaken to manage the patient after completion of a surgical proce- dure and the concomitant primary anesthetic. B. Purpose of the Guidelines for Postanesthetic Care The purpose of these Guidelines is to improve postanesthetic care outcomes for patients who have just had anesthesia or sedation and analgesia care. This is accomplished by evaluat- ing available evidence and providing recommendations for patient assessment, monitoring, and management with the goal of optimizing patient safety. It is expected that the recom- mendations will be individualized according to patient needs. C. Focus These Guidelines focus on the perioperative management of patients, with the goals of reducing postoperative adverse events, providing a uniform assessment of recovery, improv- ing postanesthetic quality of life, and streamlining postop- erative care and discharge criteria. These Guidelines apply to patients of all ages who have just received general anesthesia, regional anesthesia, or mod- erate or deep sedation. The Guidelines may need to be modi- fied to meet the needs of certain patient populations, such as children or the elderly. The Guidelines do not apply to Practice Guidelines for Postanesthetic Care An Updated Report by the American Society of Anesthesiologists Task Force on Postanesthetic Care Updated by the Committee on Standards and Practice Param- eters: Jeffrey L. Apfelbaum, M.D. (Chair), Chicago, Illinois; and the Task Force on Postanesthetic Care: Jeffrey H. Silverstein, M.D. (Task Force Chair), New York, New York; Frances F. Chung, M.D., Toronto, Ontario; Richard T. Connis, Ph.D., Woodinville, Wash- ington; Ralph B. Fillmore, M.D., Dothan, Alabama; Sean E. Hunt, M.D., Manchester, New Hampshire; David G. Nickinovich, Ph.D., Bellevue, Washington; and Mark S. Schreiner, M.D., Philadelphia, The original Guidelines were developed by the American Society of Anesthesiologists Task Force on Postanesthetic Care: Jeffrey H. Sil- verstein, M.D. (Chair), New York, New York; Jeffrey L. Apfelbaum, M.D., Northbrook, Illinois; Jared C. Barlow, M.D., Grand Island, New York; Frances F. Chung, M.D., Toronto, Ontario; Richard T. Connis, Ph.D., Woodinville, Washington; Ralph B. Fillmore, M.D., Dothan, Alabama; Sean E. Hunt, M.D., Manchester, New Hamp- shire; Thomas A. Joas, M.D., San Diego, California; David G. Nicki- novich, Ph.D., Bellevue, Washington; and Mark S. Schreiner, M.D., Philadelphia, Pennsylvania. Pennsylvania. Received from American Society of Anesthesiologists, Park Ridge, Illinois. Submitted for publication October 18, 2012. Accepted for publication October 18, 2012. Supported by the American Society of Anesthesiologists and developed under the direction of the Committee on Standards and Practice Parameters, Jeffrey L. Apfelbaum, M.D. (Chair). Approved by the ASA House of Delegates on October 17, 2012. A complete bibliography that was used to develop these updated Guidelines, arranged alphabetically by author, is available as Supplemental Digital Content 1, http:// links.lww.com/ALN/A906. Address reprint requests to the American Society of Anesthesi- ologists: 520 North Northwest Highway, Park Ridge, Illinois 60068. These Practice Guidelines, as well as all ASA Practice Parameters, may be obtained at no cost through the Journal Web site, www. anesthesiology.org. * American Society of Anesthesiologists: Practice guidelines for postanesthetic care. Anesthesiology 2002; 96:742–752. Copyright © 2013, the American Society of Anesthesiologists, Inc. Lippincott Williams & Wilkins. Anesthesiology 2013; 118:291–307 ALN Practice Guidelines Practice Guidelines XX 10.1097/ALN.0b013e31827773e9 2 Saranya devi XX Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are available in both the HTML and PDF versions of this article. Links to the digital files are provided in the HTML text of this article on the Journal’s Web site (www.anesthesiology.org). • What other guideline statements are available on this topic? ○ These Practice Guidelines update the “Practice Guidelines for Postanesthetic Care,” adopted by the American Society of Anesthesiologists in 2001 and published in 2002* • Why was this Guideline developed? ○ In October 2011, the Committee on Standards and Prac- tice Parameters elected to collect new evidence to deter- mine whether recommendations in the existing Practice Guideline were supported by current evidence • How does this statement differ from existing Guidelines? ○ New evidence presented includes an updated evaluation of scientific literature. The new findings did not necessitate a change in recommendations • Why does this statement differ from existing Guidelines? ○ The American Society of Anesthesiologists Guidelines differ from the existing Guidelines because it provides updated evidence obtained from recent scientific literature www.medlive.cn Anesthesiology 2013; 118:291-307 292 Practice Guidelines Practice Guidelines patients receiving infiltration local anesthesia without seda- tion, patients receiving minimal sedation (anxiolysis), or patients receiving intensive care. D. Application The Guidelines are intended for use by anesthesiologists and may also serve as a resource for other physicians and health- care professionals who direct anesthesia or sedation and anal- gesia care. General medical supervision and coordination of patient care in the postanesthesia care unit should be the responsibility of an anesthesiologist. E. Task Force Members and Consultants The original Guidelines were developed by an ASA appointed Task Force of ten members, consisting of anesthesiologists in private and academic practices from various geographic areas of the United States, and two consulting methodolo- gists from the ASA Committee on Standards and Practice Parameters. The Task Force developed the original Guidelines by means of a seven-step process. First, they reached consen- sus on the criteria for evidence. Second, original published research studies from peer-reviewed journals relevant to post- anesthetic care were reviewed and evaluated. Third, expert consultants were asked to: (1) participate in opinion surveys on the effectiveness of various postanesthetic care-manage- ment recommendations and (2) review and comment on a draft of the Guidelines. Fourth, opinions about the Guide- line recommendations were solicited from a sample of active members of the ASA. Fifth, opinion-based information obtained during an open forum for the original Guidelines, held at a major national meeting,† was evaluated. Sixth, the consultants were surveyed to assess their opinions on the fea- sibility of implementing the Guidelines. Seventh, all avail- able information was used to build consensus to finalize the Guidelines. In 2011, the ASA Committee on Standards and Practice Parameters requested the updating of the scientific evidence for this Guideline. This update consists of an evalu- ation of literature published after completion of the original Guidelines. A summary of recommendations is provided in appendix 1. F. Availability and Strength of Evidence Preparation of these updated Guidelines followed a rigor- ous methodological process. Evidence was obtained from two principal sources: scientific evidence and opinion-based evidence (appendix 2). Scientific Evidence Scientific evidence used in the development of these Guidelines is based on findings from literature published in peer-reviewed journals. Literature citations are obtained from PubMed and other healthcare databases, direct internet searches, task force members, liaisons with other organizations, and from hand searches of references located in reviewed articles. Findings from the aggregated literature are reported in the text of the Guidelines by evidence category, level, and direction. Evidence categories refer specifically to the strength and quality of the research design of the studies. Category A evidence represents results obtained from ran- domized controlled trials (RCTs), and Category B evidence represents observational results obtained from nonrandom- ized study designs or RCTs without pertinent controls. When available, Category A evidence is given precedence over Category B evidence in the reporting of results. These evidence categories are further divided into evidence levels. Evidence levels refer specifically to the strength and quality of the summarized study findings (i.e., statistical findings, type of data, and the number of studies reporting/replicat- ing the findings) within the two evidence categories. For this document, only the highest level of evidence is included in the summary report for each intervention, including a directional designation of benefit, harm, or equivocality for each outcome. Category A RCTs report comparative findings between clinical interventions for specified outcomes. Statistically significant (P < 0.01) outcomes are designated as either beneficial (B) or harmful (H) for the patient; statistically nonsignificant findings are designated as equivocal (E). Level 1: The literature contains a sufficient number of RCTs to conduct meta-analysis,‡ and meta-analytic findings from these aggregated studies are reported as evidence. Level 2: The literature contains multiple RCTs, but the number of RCTs is not sufficient to conduct a viable meta-analysis for the purpose of these Guidelines. Find- ings from these RCTs are reported as evidence. Level 3: The literature contains a single RCT, and findings from this study are reported as evidence. Category B Observational studies or RCTs without pertinent compar- ison groups may permit inference of beneficial or harmful relationships among clinical interventions and outcomes. Inferred findings are given a directional designation of ben- eficial (B), harmful (H) or equivocal (E). For studies that report statistical findings, the threshold for significance is P < 0.01. Level 1: The literature contains observational comparisons (e.g., cohort, case-control research designs) between clinical interventions for a specified outcome. Level 2: The literature contains observational studies with associative statistics (e.g., relative risk, correlation, sensitivity/specificity). † Society for Ambulatory Anesthesia 16th Annual Meeting, Indian Wells, CA, May 5, 2001. ‡ All meta-analyses are conducted by the ASA methodology group. Meta-analyses from other sources are reviewed but not included as evidence in this document. www.medlive.cn Anesthesiology 2013; 118:291-307 293 Practice Guidelines SPECial artiClES Level 3: The literature contains noncomparative observa- tional studies with descriptive statistics (e.g., frequen- cies, percentages). Level 4: The literature contains case reports. insufficient Evidence The lack of sufficient scientific evidence in the literature may occur when the evidence is either unavailable (i.e., no per- tinent studies found) or inadequate. Inadequate literature cannot be used to assess relationships among clinical inter- ventions and outcomes, since such literature does not permit a clear interpretation of findings due to methodological con- cerns (e.g., confounding in study design or implementation) or does not meet the criteria for content as defined in the “Focus” of the Guidelines. Opinion-based Evidence The original Guidelines contained formal survey informa- tion collected from expert consultants and a random sam- ple of active members of the ASA. Additional information was obtained from open-forum presentations and other invited and public sources. All opinion-based evidence relevant to each topic (e.g., survey data, open-forum tes- timony, internet-based comments, letters, and editorials) was considered in the development of the original Guide- lines. However, only the findings obtained from formal surveys are reported. Survey responses from the consultants and ASA members obtained during development of the original Guidelines are summarized in the text of this update and reported in appendix 2. No new surveys were conducted for this update. Category A: Expert Opinion Survey responses from Task Force–appointed expert con- sultants are reported in summary form in the text, with a complete listing of consultant survey responses reported in appendix 2. Category B: Membership Opinion Survey responses from a random sample of active ASA mem- bers are reported in summary form in the text, with a com- plete listing of ASA member survey responses reported in appendix 2. Survey responses from expert and membership sources are recorded using a three-point scale and summarized based on weighted values. The following terms describe survey responses for any specified issue. Responses are assigned a numeric value of agree = +1, undecided = 0, or disagree = −1. The average weighted response represents the mean value for each survey item. Agree: The average weighted response must be equal to or greater than +0.30 (on a scale of −1 to 1) to indicate agreement. Equivocal: The average weighted response must be between −0.30 and +0.30 (on a scale of −1 to 1) to indi- cate an equivocal response. Disagree: The average weighted response must be equal to or less than −0.30 (on a scale of −1 to 1) to indi- cate disagreement. Category C: Informal Opinion Open-forum testimony during development of the previous Guidelines, internet-based comments, letters, and editorials are all informally evaluated and discussed during the formu- lation of Guideline recommendations. When warranted, the Task Force may add educational information or cautionary notes based on this information. Guidelines I. Patient Assessment and Monitoring Perioperative and postanesthetic management of the patient includes periodic assessment and monitoring of respiratory function, cardiovascular function, neuromuscular function, mental status, temperature, pain, nausea and vomiting, fluid assessment, urine output and voiding, and drainage and bleeding. Respiratory Function. The original literature indicated that assessment and monitoring of respiratory function during recovery is associated with early detection of hypoxemia (Category A2-B evidence); new literature is insufficient to fur- ther evaluate these findings. The consultants and ASA members agree that periodic assessment and monitoring of airway patency, respiratory rate, and oxygen saturation (SpO2) should be done during emergence and recovery. Cardiovascular Function. The literature continues to be insufficient to evaluate the impact of cardiovascular assess- ment and monitoring or routine electrocardiographic moni- toring of perioperative complications. The Consultants and ASA members agree that routine pulse, blood pressure, and electrocardiographic monitoring detect cardiovascular complications, reduce adverse out- comes, and should be done during emergence and recov- ery. The Task Force notes that there are certain categories of patients or procedures for which routine electrocardio- graphic monitoring may not be necessary. Neuromuscular Function. Assessment of neuromuscular function primarily includes physical examination and, on occasion, may include neuromuscular blockade monitor- ing. The original literature indicated that neuromuscular blockade monitoring is effective in detecting neuromuscular dysfunction (Category B2-B evidence); new literature is insuf- ficient to further evaluate these findings. The consultants and ASA members agree that assessment of neuromuscular function identifies potential complica- tions, reduces adverse outcomes, and should be done during emergence and recovery. www.medlive.cn Anesthesiology 2013; 118:291-307 294 Practice Guidelines Practice Guidelines Mental Status. The literature continues to be insufficient to evaluate the impact of the assessment of mental status and behavior on reducing postoperative complications. The consultants and ASA members agree that assessment of mental status detects complications, reduces adverse out- comes, and should be done during emergence and recovery. Several scoring systems are available for such assessments. Temperature. The literature continues to be insufficient regarding whether routine assessment of patient temperature is associated with fewer postoperative complications. The consultants and ASA members agree that routine assessment of patient temperature detects complications, reduces adverse outcomes, and should be done during emer- gence and recovery. Pain. The literature continues to be insufficient regarding whether routine assessment and monitoring of pain is asso- ciated with fewer postoperative complications. The consultants and ASA members agree that routine assessment and monitoring of pain detects complications, reduces adverse outcomes, and should be done during emer- gence and recovery. Nausea and Vomiting. The literature continues to be insuf- ficient regarding whether the routine periodic assessment of nausea and vomiting is associated with fewer postoperative complications. The consultants are equivocal, but the ASA members agree that routine assessment and monitoring of nausea and vomiting detects complications and reduces adverse out- comes. Both the consultants and ASA members agree that routine assessment and monitoring of nausea and vomiting should be done during emergence and recovery. Fluids. The literature continues to be insufficient to evaluate the benefits of assessing the hydration status of patients in the postanesthesia care unit. The consultants and ASA members agree that routine perioperative assessment of patients’ hydration status and fluid management reduces adverse outcomes and improves patient comfort and satisfaction. Urine Output and Voiding. The original Guidelines indicated that assessment of urine output is effective in identifying patients with urinary retention (Category B3-B evidence); new literature is insufficient to further evaluate these findings. The literature is insufficient regarding whether assessment of urine output is associated with other postoperative com- plications. The literature is insufficient regarding whether assessment and monitoring of urinary voiding is associated with fewer postoperative complications. The consultants and ASA members agree that assessment of urine output detects complications and reduces adverse outcomes. They agree that asses