Volume 7, No. 2 • Summer 1992

Foreign Correspondence: Day Surgery Recovery: When Is It Safe to Discharge to Home – We Could Not Even Recognize Perfection

Michael Rosen

A great deal of concern has been shown about patients’ return to full activity after “day-stay’ (outpatient) surgery. When is it safe to do so? When would it be legally acceptable to drive? When would it be acceptable to drive a public service vehicle? Or fly an aeroplane? Mostly, a cautious approach is justified, especially in the case of sensitive occupations which could cause damage to more than the individual. What seems to be reasonable then is to take a minimum period based on the pharmacokinetics of the drugs, and then add a further period for safety. That is the cautious approach.

There are two related issues which are often overlooked and require closer examination. Firstly, we accept that those who have minor procedures under local anaesthetic need not restrict their activities. When the patient has a larger dose of local anaesthetic and certain areas are blocked (e.g. a limb) there would be some restrictions imposed, although attitudes may vary greatly. We assume that after local anaesthetic in smallish doses, the patient is not impaired. However, the stress of the situation may have effects. This too should be checked! It is not good enough to assume all is well because the accident rate appears low.

Secondly we ought also to encourage much wider reporting of the incidence of drugs other than alcohol in road casualties. The data is poor as it is; and there is no compulsion to ask or to tell. Perhaps a compulsory urine sample would be appropriate.

When it comes to general anaesthetics, the assumption is that no one ever recovers promptly. The tests that we use are still relatively crude and it can be most difficult to detect impairment. If we can detect a decrement in performance we may assume impairment. However, the converse is not acceptable: no decrement cannot be taken to indicate full recovery. And herein lies the quandary. We know that drugs are being improved all the time. For example, the introduction of propofol is a step forward. Moreover it is not too great a jump in imagination to anticipate a drug which breaks down completely into totally inactive fragments almost instantly (e.g. within 15 minutes). With the emergence of a near-perfect drug, could we actually test for lack of impairment? I doubt whether it is possible now. Perfection could pass us. by unrecognized.

These are matters which are growing in importance with the increase in day-stay surgery and the requirement to get individuals back to work swiftly.

Dr. Rosen is a member of the Department of Anaesthetics, University of Wales College of Medicine, Cardiff. Reproduced with permission of the publisher from The Recovery Times, the second letter @f the Recovery Interest Group, August, 1991.