The CMS Conditions of Participation Section 482.52(b)(3) requires that all patient receiving anesthesia must have a postanesthesia evaluation within 48 hours surgery.  This has been the case for many years.  The most current version of the Interpretive Guidelines for Surveyors changed the requirements significantly for a “postanesthesia recovery and evaluation”.

The document specifies that surveyors should ensure that “current guidelines are utilized in establishing hospital policies on postanesthesia evaluation and recovery”.  The guidelines clearly recommend very specific items.  Credence is given to this list by referencing the ASA Practice Guidelines for Postanesthetic Care, Anesthesiology Vol. 96, No. 3, March 2002.

In reviewing the referenced article, it is clear the guidelines and list established by the authors reference the time the patient is in the Post Anesthesia Care Unit (PACU).  The authors’ recommendations for practice clearly cite their applicability for “emergence and recovery” under each item.

CMS intends for the postanesthesia evaluation to be performed and noted after the patient has recovered from anesthesia.  By strongly suggesting these criteria be documented, CMS is applying the standards for monitoring during “emergence and recovery” to a period up to 48 hours later.

CMS would have been better served by referencing the ASA Standards for Postanesthesia Care.  They have been recently updated for 2009.

The Anesthesia Patient Safety Foundation posted the results of a discussion by its Board of Directors on ventilatory depression from neuraxial opioids and patient-controlled analgesia (PCA).  The discussion highlights the inherent dangers the techniques bring to postoperative care.  Each is highly effective for treating postoperative pain.

The conference attendees and participants are noted to have recognized the “underappreciated risk” that each carries.  The recommendation is for anesthesia providers to give consideration to continuous pulse oximetry for these patients during the postoperative period.

Dr. Stoelting cautions us to remember that pulse oximetry will monitor hypoxemia but not hypoventilation.  Be mindful of hypercapnia effects which can be somewhat masked by supplemental oxygen.

Recent discussion in the Anesthesia Patient Safety Foundation newsletter led to a discussion during our recent clinical meeting. As a group we reviewed the available literature on the subject. An excellent and leading resource for information is www.lipidrescue.org. The case reports in the literature are compelling for considering the use of 20% Intralipid after standard ACLS protocol has been unsuccessful. Consider  the information at the website above.