A 42-year-old Filipino man presented to an outpatient surgery center for scheduled repair of an anal fistula. The patient received pre-procedure anesthesia with a "saddle block" and underwent a successful intervention. When his anesthesia block began to wear off, he was deemed safe for discharge and instructed to take sitz baths with tepid water.
One month later, the patient returned for a second evaluation under anesthesia, and the surgeon noted scarring on the patient's buttocks and proximal posterior thighs. There were also large areas of healed burns and associated skin changes. Additional history from the patient and his wife indicated that they misunderstood the term "tepid" and used scalding hot water for the sitz baths. It also appears the patient's slowly resolving saddle anesthesia in the first 24 hours home blunted his response to the hot water. Unfortunately, the patient did not seek additional medical attention. It was felt that challenges with both health literacy and language barriers contributed to the patient's failed understanding of discharge instructions.
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Table 1. The Post Anesthesia Discharge Score (PADS) is used to assess fitness for discharge home.(7)
Post Anesthesia Discharge Score |
Vital signs |
- Within 20% of preoperative baseline
|
2 |
- 20% to 40% of preoperative baseline
|
1 |
- 40% of preoperative baseline
|
0 |
Activity level |
- Steady gait, no dizziness, consistent with preoperative level
|
2 |
|
1 |
- Unable to ambulate / assess
|
0 |
Nausea and vomiting |
- Minimal: mild, no treatment needed
|
2 |
- Moderate: treatment effective
|
1 |
- Severe: treatment not effective
|
0 |
Pain |
- VAS = 0 to 3 the patient has minimal or no pain prior to discharge
|
2 |
- VAS = 4 to 6 the patient has moderate pain
|
1 |
- VAS = 7 to 10 the patient has severe pain
|
0 |
Surgical bleeding |
- Minimal: does not require dressing change
|
2 |
- Moderate: required up to two dressing changes with no further bleeding
|
1 |
- Severe: required three or more dressing changes and continues bleed
|
0 |
VAS = visual analogue scale. Maximum score = 10; patients scoring ≥ 9 are fit for discharge.
Table 2. Post Anesthesia Discharge Score "add-on module" for patients after spinal anesthesia.
Spinal Anesthesia Add-on Module |
-
Patients should have sensory block at dermatome level of T8 or below and sensory dermatome should recede by at least one level
|
Yes/No |
- Patients should have NO pain, PONV, and shivering
|
Yes/No |
- Patients admitted to PACU with a sensory block at dermatome T10 or below, with some movement of the lower extremity, may be discharged from PACU if above factors are satisfactory
|
Yes/No |
- Patient has voided
|
Yes/No |
- Resolution of sympathetic blockade (i.e., orthostasis)
|
Yes/No |
Patients scoring ≥ 9 on PADS and 5 "yes" marks on spinal anesthesia module are fit for discharge.
(Adapted with permission from Sunnybrook Health Science Centre, University of Toronto, courtesy of Drs. Awad and Belo).