14: Preoperative Care, Anesthesia, and Postoperative Care

Chapter 14 Preoperative Care, Anesthesia, and Postoperative Care




Optimally, a surgeon creates an optimal environment for patient care, but this process may take years, and requires a strong commitment to learning, training personnel, allocating necessary resources, and continually reassessing and improving the processes that define care levels and outcomes


Assuming optimal decisions and planning, the patient’s entire experience with breast augmentation is largely determined by the level of preoperative care, anesthesia, surgical and postoperative care that she receives. A surgeon’s performance is limited by the surgical environment. Optimally, a surgeon creates an optimal environment for patient care, but this process may take years, and requires a strong commitment to learning, training personnel, allocating necessary resources, and continually reassessing and improving the processes that define care levels and outcomes. The details of processes and integration of processes determine success. A surgeon can implement 90% of required processes, but the 10% of proved processes that the surgeon cannot or will not implement will detract from an optimal, state-of-the-art patient experience, recovery, and outcome.




Optimal perioperative care begins by creating and controlling an environment where optimally trained and motivated personnel will interface with and treat the patient the day of her augmentation



Creating An Optimal Perioperative Environment


Optimal perioperative care begins by creating and controlling an environment where optimally trained and motivated personnel will interface with and treat the patient the day of her augmentation. The quality and outcome of the entire patient experience begin with the surgeon. If the surgeon can perform at an optimal level, i.e. increase efficiency to do more operations in a day and enable patients to have a more rapid recovery, the surgeon will likely have much more success asking surgical facility management and anesthesia and surgery center personnel to work with the surgeon to develop and follow protocols that deliver a redefined level of care. If the surgeon does not have the motivation, resources, and commitment to expand the surgeon skill set and implement proved processes in order to be able to deliver a higher level of care, the other people in the surgical environment will not be optimally motivated and cooperative, and redefining the patient experience will be much more difficult or impossible.




Surgeon control of the surgery center environment and surgeon control of anesthesia are essential to optimize the patient experience and outcome, assuming the surgeon has first optimized the surgeon skill set


Surgeon control of the surgery center environment and surgeon control of anesthesia are essential to optimize the patient experience and outcome, assuming the surgeon has first optimized the surgeon skill set. To reasonably expect to predictably deliver 24 hour recovery levels of care, the surgeon must do the following:


1. Develop surgeon skills to perform an augmentation mammaplasty in 45 minutes or less—this includes developing planning skills that optimize preoperative decisions, minimize decisions in the operating room, improve efficiency by decreasing operating times and narcotic drug requirement, and minimize unnecessary and unproductive practices.

2. Develop influence and control that allows the surgeon to implement specific surgical, anesthesia and perioperative care protocols.

3. Develop a relationship with surgical facility management that enables the surgeon to work with consistent personnel when performing augmentations, and to have paid personnel time allocated to train these personnel.

4. Develop a relationship with anesthesia personnel that allows the surgeon to provide specific protocols that the anesthesia personnel make every attempt to implement before modifying the protocols to their personal preferences.

5. Develop a relationship with postanesthesia care personnel that allows the surgeon to implement specific protocols to speed patient recovery.

6. Perform breast augmentation under general anesthesia, preferably general endotracheal anesthesia, and use muscle relaxants.

7. Have all patients arrive so that all can be marked by the surgeon before the surgeon enters the operating room. When doing more than eight cases per day, it may be necessary to have other patients arrive at a later time, depending on the capacity of the facility.



Surgeons and the surgical facility can increase efficiency, profitability, and improve patient recovery by allocating two operating rooms for a single surgeon during a specific period


When surgeons can accomplish the requirements listed above, both the surgeons and the surgical facility can increase efficiency, profitability, and improve patient recovery by allocating two operating rooms for a single surgeon during a specific period (Figure 14-1). This system minimizes surgeon and personnel downtime, maximizes the surgical facility’s return on investment of personnel resources and facility resources, and encourages all team members to perform at a higher level. This system is only logical if surgeons have a reasonable case load of augmentations, and if the surgeon and surgeon’s personnel learn to manipulate patient scheduling to assure a minimum of three augmentations on any surgery day. The system fails miserably when surgeons want to perform one or two augmentations on a day, or during a block time.


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Figure 14-1 (A) Room 1 in author’s surgical facility. (B) Hallway that joins adjacent operating rooms. (C) Room 2 in author’s surgical facility. Allocating two adjacent operating rooms for one surgeon dramatically increases surgeon and facility efficiency, provided the surgeon performs a minimum of three augmentations when the rooms are scheduled, with an operating time of less than 45 minutes per case.




Key to the success of our system of two operating rooms for a single surgeon are: (1) strict scheduling requirements that require surgeons to post at least three cases in order to schedule, and (2) surgeon commitment to expanding the surgeon skill set, discarding preconceptions, and implementing proved processes


Surgeons and surgery facility management personnel that have visited the author have successfully implemented this type of system, but implementation requires a commitment of time and resources by all parties. Key to the success of our system of two operating rooms for a single surgeon are: (1) strict scheduling requirements that require surgeons to post at least three cases in order to schedule, and (2) surgeon commitment to expanding the surgeon skill set, discarding preconceptions, and implementing proved processes.



Preoperative Care



Preoperative Preparations


When a patient schedules surgery, the surgeon’s personnel should begin to prepare the patient for surgery by providing detailed, consistent information about each of the following:


• Date of surgery

• Location of surgery facility

• Time to arrive

• Preoperative laboratory tests—where and when they will be performed

• Arrangement requirements for a driver and overnight caregiver

• What to expect the day of surgery—in detail

• Anesthesia information and arrangements for a preoperative anesthesia consult by phone

• FDA information and implant manufacturer warranty information

• Necessity of completing all required informed consent documents

• Drugs and herbal preparations to avoid preoperatively

• Necessity of no oral intake for 8 hours minimum prior to surgery.

All of this information should be included in printed information to the patient and on a checklist that is immediately accessible to all surgeon personnel who might interact with the patient. A specific surgeon employee should be responsible for providing this information and placing a preoperative checklist (Table 14-1) on the front of the patient’s chart that provides instant information to all other personnel that interact with the patient. This document is available in the Resources folder on the DVDs that accompany this book.


Table 14-1 Surgical and postsurgical arrangements.






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Providing a consistent message in an efficient and comprehensive manner is essential to developing optimal patient confidence. Patient confidence is essential to an optimal perioperative experience


Providing a consistent message in an efficient and comprehensive manner is essential to developing optimal patient confidence. Patient confidence is essential to an optimal perioperative experience. Patients forget, lose confidence, and become fearful when they hear different answers to questions, so the surgeon should build a system that: (a) rechecks to assure that the patient received all of the information listed above, (b) someone calls the patient at intervals to assure that preoperative arrangements are on schedule, and (c) everyone who is in a position to answer patient questions delivers a prompt, consistent answer.


Patients must understand the critical importance of each of the following:


• Providing comprehensive and accurate medical history information

• Divulging all types of drugs or herbal medications

• Strict adherence to all surgeon instructions

• No oral intake for 8 hours minimum prior to surgery

• Necessity to arrange for transportation and 24 hour caregiver

• Availability to speak with anesthesia personnel at a specific time

• Arriving at the surgery facility promptly at the designated time

• Complying totally with all perioperative and postoperative instructions.

A phone call 48 hours prior to surgery from the surgeon office should reconfirm the patient’s understanding and compliance with each of the above, and the personnel making the phone call must be responsible for documenting the contents of the call in the patient chart.




Personnel should plan to have the caregiver available at the surgery center when the patient first enters the recovery room, so that personnel can review postoperative instructions with the caregiver and review them with the patient within the hour after the patient’s operation



Arrival and Transfer to Surgical Holding


When the patient arrives at the surgery facility, personnel (ideally, personnel who know the patient) should be available to meet the patient and caregiver, and immediately accompany the patient to an area where the patient can change into a surgical gown (Figures 14-2, 14-3). All of the patient’s valuables should remain with the patient’s caregiver, and personnel should get a cell phone number for the caregiver or accompany the caregiver to an appropriate waiting area. Personnel should plan to have the caregiver available at the surgery center when the patient first enters the recovery room, so that personnel can review postoperative instructions with the caregiver and review them with the patient within the hour after the patient’s operation. In a 627 consecutive patient series of augmentation patients,1,2 using management protocols and surgical techniques included in this chapter, the average time from the start of the patient’s breast augmentation under general anesthesia to discharge with an ASPAN3 score of 10 was 78 minutes. Continuing to monitor and improve proved processes has further reduced perioperative recovery times and time to discharge from the surgery facility, always with an ASPAN score of 10.


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Figure 14-2 Entrance foyer to author’s surgery center.


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Figure 14-3 Preoperative room where patient changes and can relax with caregiver prior to surgery. These rooms also function as stepdown rooms after the patient leaves recovery, prior to discharge.



Surgery Facility Personnel Responsibilities and Patient Interactions




A member of the surgeon’s staff who knows the patient should ideally accompany the patient and introduce the patient to the surgery center personnel who will care for her initially




If any patient approaches surgery center personnel about making last minute changes to the surgical approach, the operation listed on the operative permit previously signed by the patient, implant type or size, or any other aspect of the surgery, the personnel should immediately inform the surgeon

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Related posts:

2: Ten Essentials 6: Implants and Implant–Soft Tissue Dynamics 4: Anatomy for Augmentation: Cadaver and Surgical 3: Patient Education, Decisions, and Informed Consent 11: The Inframammary Approach for Augmentation 21: Applying Proved Processes: Clinical Case Studies

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Jul 23, 2016 | Posted by in Aesthetic plastic surgery | Comments Off on 14: Preoperative Care, Anesthesia, and Postoperative Care

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