Ambulatory Surgery Patients Research Articles

Screening high-risk patients for the ambulatory setting

Screening patients for ambulatory surgery is a team effort that requires diligence by all staff members to elicit information through the use of good communication skills as well as a thorough screening tool. A careful review of body systems is a must, with focused attention on vital organ systems. When a holistic approach is used, the true picture of the patient’s needs and concerns emerges. This article reviews the importance of diligent preoperative screening of high-risk patients for the ambulatory surgical care setting. The primary focus is on patients with cardiac disease, obesity, and sleep apnea.

Postoperative recovery at home after ambulatory gynecologic laparoscopic surgery

The purposes of this descriptive, correlational study were to measure pain, fatigue, and functional limitations affecting the “at home” recovery process for ambulatory gynecologic laparoscopic surgery and to explore the relationships between these variables and the return to normal activities. Subjects (N = 91) recorded daily ratings of pain, fatigue, and function on a Home Recovery Log for 6 days postoperatively. The findings indicate that 95% of subjects resumed basic self-care activities such as dressing, bathing, and eating by postoperative day (POD) 3; however, less than 40% of subjects were able to perform other role functions such as shopping, laundry, and work outside of the home. A logistic regression model indicated that pain ratings and functional status on POD 2 were the best predictors of subjects who would need more than 5 days to resume their usual activities and routines. The findings have implications for preoperative teaching and telephone follow-up for ambulatory surgery patients. Preoperative teaching should prepare women for the additional days needed for recovery of instrumental activities of daily living to enable them to make alternate plans as necessary. Furthermore, because pain on POD 2 was the single most significant predictor of delayed recovery, moving the follow-up phone call from the morning to the late afternoon of POD 1 may help the nurse to identify patients who will need extra assistance with pain management.

Impact des modalités de prescriptions d’antalgiques sur la douleur postopératoire après chirurgie de la main réalisée en urgence en hospitalisation de jour

Objectives. – The assessment of the impact of various analgesic regimens on postoperative pain at home, following emergency and ambulatory hand surgery. Study design. – Prospective comparative study of “before” and “after” groups by phone questionnaire on the first postoperative day. Patients. – All emergency and ambulatory surgery patients undergoing hand surgery in a specialist university hospital unit. Methods. – a) “Before” group (120 patients): analysis of current analgesic practice in the service (prescriptions by surgeon on duty), assessment of the incidence of pain scores with an intensity ≥ 4 on a numerical score of 0 to 10, and identification of the most painful surgical interventions; b) formulation for these surgical interventions of multimodal analgesic protocols drown up by the anaesthetists; c) “After” group (51 patients): assessment of the efficacy of these analgesic protocols through comparison with the “before” group. Results. – a) “Before” group: the total incidence of pain scores with an intensity ≥ 4 was 42% and in the case of conditions involving a joint or sepsis, 88%. Dextropropoxyfen–paracetamol alone was prescribed in 66% of cases and was associated with a 48% analgesic failure rate. Non-steroidal anti-inflammatory drugs were prescribed in 14% of cases, tramadol in 7% and a combination of drugs in 15%; b) “After” group: the incidence of pain scores with an intensity ≥ 4 decreased to 21% in surgical interventions involving joints or sepsis ( p < 0.001). Conclusion. – Multimodal analgesic regimens are more effective than free prescriptions. This study underlines the need to further educate surgeons in this area. Despite these written protocols, there remains a 21% incidence of pain at home on day one.

Does the routine prophylactic use of antiemetics affect the incidence of postdischarge nausea and vomiting following ambulatory surgery?: A systematic review of randomized controlled trials.

Does the routine prophylactic use of antiemetics affect the incidence of postdischarge nausea and vomiting following ambulatory surgery?: A systematic review of randomized controlled trials.

Posterior approach to the sciatic nerve in the popliteal fossa for lower limb surgery

Background and objectives: To evaluate success rate, acceptance and complications of sciatic nerve (SN) block at the popliteal fossa (popliteal block, PB) for ambulatory or inpatient orthopedic and vascular surgical procedures. Methods: A retrospective study was carried out in 312 patients who received a PB for vascular and orthopedic lower leg surgery. A single injection, posterior approach technique with 40 ml of either 0.5% ropivacaine or 1% mepivacaine was used. Data collected included demographic and clinical variables. Results: Observed success rate was 95.5%. Acceptance of anesthetic procedure among outpatients was high (94.1%). There were no intraoperative or postoperative complications. For ambulatory surgery patients, the postoperative stay was 130±25 min. Conclusions: PB was a useful anesthetic technique for minor foot and ankle surgery. The single-injection, posterior approach obtained a high success rate without untoward events. It was well accepted by patients and proved to be suitable for ambulatory surgery.

Elimination of routine testing in patients undergoing cataract surgery allows substantial savings in laboratory costs. A brief report.

To evaluate the possible cost savings when routine preoperative testing is discontinued in ambulatory cataract surgery patients. A policy was introduced at our hospital to stop routine testing in ambulatory cataract patients. Consecutive patients' medical records were analyzed in a four-month period pre- and a four-month period post-discontinuation of routine laboratory tests. Ambulatory cataract surgery is performed under topical (and sometimes retrobulbar block) anesthesia with iv sedation. Co-morbidities, perioperative events, frequency and cost of tests ordered were compared for the two groups. Average costs per patient pre- and post-discontinuation of routine tests, and total possible cost savings were calculated. One thousand two hundred and thirty-one patients were studied; 636 had routine laboratory tests and 595 had no routine laboratory tests. The ratios of gender, co-morbidities and perioperative events were similar in the two groups. There was a significant reduction in the number of tests ordered after the new policy was introduced, from 5.8 tests per patient to 0.4 tests per patient. The cost of tests per patient was reduced from Can $39.67 to $4.01. In ambulatory cataract surgery, over 90% savings in laboratory costs is possible after elimination of routine tests.

Herbal medicine use is frequent in ambulatory surgery patients in Vancouver Canada.

To determine the incidence and nature of herbal medicine use among patients in a busy Canadian surgical day care unit. We undertook a prospective survey of 575 patients attending our surgical day care unit. The questionnaire inquired as to basic demographics, herbal medicine use, the name and number of herbal medicines used, reason, whether it was self prescribed or not, and if the patient's family physician was aware of the use. In the second part of the study, 44 anesthesiologists were asked to answer a questionnaire of 27 yes/no questions to determine their knowledge of herbal medicines. Four hundred eighty-five of 575 patients completed the questionnaire (84%). Thirty-four percent of patients surveyed in our unit responded affirmatively to herbal medicine use. Of these, 39% took them on a daily basis. Forty-five different identifiable herbs were being taken in total, with echinacea being the most common. Less than half of the patients told their family physicians that they were using herbal medicines and only one-third of patients were taking them on the advice of their physician. In the assessment of anesthesiologists' knowledge of herbal medicine, only 32% of the questions were answered correctly. The incidence of herbal medicine ingestion by patients coming to our unit was higher than previously reported. A large variety of preparations were being taken, many without the knowledge of the patient's family physician. The basic knowledge of anesthesiologists with respect to herbal medicine is limited.

Anesthetic considerations and techniques for oral and maxillofacial surgery.

Today, oral and (OMF) surgery encompasses a great range of surgical treatments, from simple tooth extractions to complicated reconstructive craniofacial procedures. This surgical specialty has emerged and evolved from the formal practice of dentistry, dating back to 1844, when two physicians opened the first school of dentistry in Baltimore. Over the next 100 years the specialty continued to take shape. Multiple societies were established, beginning in 1918 as the American Society of Exodontists. In 1921, it became the American Society of Oral Surgeons and Exodontists, in 1946 shortening the name to the American Society of Oral Surgeons. In 1977 the term maxillofacial was formally added, reflecting its current designation and finally describing the tremendous range of skills these specialists master and provide to patients. 1 From an anesthetic standpoint, these procedures may range from the routine application of local anesthetics and titration of intravenous sedation, to the administration of general anesthesia involving skilled airway management techniques, complicated invasive monitoring devices, hemodynamic instability, and significant blood loss. These patients range from ambulatory same-day surgery patients to critically ill inpatients presenting in community hospitals or university medical centers. This is a reflection of the overall growth of this surgical specialty, crossing over to other specialties, including otolarymgology, plastic surgery, and even general surgery. This chapter will present the management of the patient presenting for a variety of major OMF procedures. The relevant anatomic structures of the facial and cranial skeleton involved in these procedures will be reviewed. The preoperative evaluation and preparation, anesthetic concerns and complications, and postoperative management of patients presenting for OMF surgery will follow this. Topics will include exodontia, orthognathic surgery, trauma and infections, tumors, and reconstructive surgery.

Effect Of Mixed Versus Unmixed Lidocaine With Propofol

Propofol is a commonly used agent for induction of general anesthesia. Propofol bolus is often associated with pain. Lidocaine is commonly used to decrease the pain on injection with propofol. The method of administering lidocaine often varies among individual anesthesia providers. A double-blind study was performed on 52 ASA1-3 ambulatory surgery patients, comparing the effectiveness in reducing pain of propofol bolus by administering lidocaine 40 mg as pretreatment versus a mixture of 40mg lidocaine and propofol . An induction dose of propofol at 2.5mg/kg was divided equally and administered simultaneously and into each upper extremity. One alliquot contained soley propofol following a 40mg lidocaine bolus, the other contained propofol mixed with 40mg of lidocaine. Each patient served as his own control. Our data indicates that lidocaine, when mixed with propofol, was more effective in reducing the pain of injection (p < 0.001) than when given as a pretreatment. The opinions or assertions contained herein are the private views of the authors and are not to be construed as reflecting the views of the Departments of the Army, Air Force or Defense. There are no commercial associations in conjunction with these investigators.

Anesthesia safety: model or myth? A review of the published literature and analysis of current original data.

Anesthesia Safety: Model or Myth?: A Review of the Published Literature and Analysis of Current Original Data Robert Lagasse; Anesthesiology

Advances in regional anesthesia for outpatients

This review will bring to the reader's attention recent developments in the literature regarding regional anesthesia in the outpatient setting, and allow the reader to evaluate whether these developments are appropriate for inclusion in clinical practice. The most stimulating developments in the area of regional anesthesia for outpatients revolve around the use of continuous analgesic therapy for outpatients after discharge. This is reflected in recent publications describing the use of continuous catheters for peripheral nerve blockade using portable pumps to provide 48-72 h of postoperative analgesia. These devices have raised the hope of opioid-free pain relief for virtually the entire duration of postsurgical pain in the outpatient setting. There are also increasing numbers of suggestions on ways to improve the quality of spinal anesthesia in the outpatient setting, particularly by using lower doses of lidocaine to reduce the problem of transient neurologic symptoms after spinal blockade. Several authors have investigated the cost implications of regional techniques in the outpatient setting, and have concluded that they are very competitive with the general anesthetic techniques that are frequently employed. Recent publications suggest additional ways to add regional anesthesia techniques to outpatient surgical practice, particularly with the promise of extensive postoperative pain relief for the ambulatory surgery patient.

Pain management for pediatric ambulatory anesthesia

New developments in analgesic drugs and techniques are being applied to the pediatric population. Appropriate pain management for ambulatory surgery patients helps to facilitate early discharge and minimize postoperative morbidity. A variety of opioid-related drugs, as well as novel delivery routes for opioids, have been reported in the pediatric population. New pharmacokinetic information for acetaminophen has resulted in revised dosage recommendations; applications of the nonsteroidal antiinflammatory agents are also discussed. Furthermore, regional anesthesia and adjuncts are useful in the pediatric ambulatory surgery patient. Recent data on techniques for pain management after pediatric ambulatory surgery will help the anesthetist develop a comprehensive plan for the postoperative period.

Pain as a Factor Complicating Recovery and Discharge After Ambulatory Surgery

Pain complicates the recovery process after ambulatory surgery. We surveyed 175 ambulatory surgery patients to determine pain severity, analgesic use, relationship of pain to duration of recovery, and the relative importance of various factors to predicting these outcomes. Multivariate regression analysis was used to determine unique contributions of predictor variables to outcome. Surgical procedures included knee arthroscopy (n = 50), hernia surgery (n = 25), pelvic laparoscopy (n = 25), transvaginal uterine surgery (n = 25), surgery for breast disease (n = 25), and plastic surgery (n = 25). Maximum pain (on a scale of 0-10) varied from 2.3 +/- 0.5 to 5.1 +/- 0.5 (mean +/- SE), depending on surgical procedure; 24% of patients had pain scores of > or =7, and 24% were delayed in Phase 1 recovery by pain. Pain scores were lower if local anesthetic or ketorolac was administered intraoperatively (22% and 26% respectively). Fentanyl dose during recovery correlated with maximum pain scores; fentanyl dose was 42% less if ketorolac was administered intraoperatively. In females, the recovery fentanyl dose increased in proportion to the intraoperative fentanyl dose. The maximum pain score was predictive of total recovery time (135, 172, and 212 min of recovery for maximum pain scores of 0-3, 4-6, and 7-10, respectively; P < 0.001). We conclude that improvements in pain therapy are warranted to improve patient comfort and to expedite recovery. Moderate to severe pain is common after ambulatory surgery and is a frequent cause of delayed discharge. Postoperative pain, opioid-related side effects, and time to discharge were less when nonsteroidal antiinflammatory drugs or local anesthetics were used intraoperatively to prevent pain before patient awakening.

Ambulatory Surgery Patients May Be Discharged before Voiding after Short-acting Spinal and Epidural Anesthesia

Voiding before discharge is usually required after outpatient epidural or spinal anesthesia because of concern about bladder overdistention and dysfunction. Shorter duration spinal and epidural anesthesia may allow return of bladder function before overdistention occurs in low-risk patients (those younger than age 70, not having hernia, rectal, or urologic surgery, and without a history of voiding difficulty), and predischarge voiding may not be necessary. After institutional review board approval and informed consent, 201 low-risk ambulatory patients were prospectively studied in either a standard or accelerated pathway after undergoing spinal or epidural anesthesia with procaine, lidocaine, 2-chloroprocaine, or less than 7 mg bupivacaine; epinephrine was not used in any anesthetic. Standard pathway patients (n = 70) were required to void before discharge. Accelerated pathway (n = 131) patients were not required to void. (After randomization of an initial 163 patients to one of the two tracks, 38 additional patients were assigned to the accelerated pathway.) If accelerated pathway patients voided, they were discharged when all other discharge criteria were met. If they did not spontaneously void after block resolution, a bladder ultrasound (BUS) was performed. If the BUS indicated a urine volume of less than 400 ml, the patients were discharged and instructed to return to the emergency department if they were unable to void within 8 h of discharge. If the BUS indicated a urine volume of greater than 400 ml, the patients were reassessed in 1 h and were discharged if they could void spontaneously. If they could not void spontaneously, they were catheterized to facilitate discharge. All patients were contacted the next day to assess the return of normal bladder function. All standard pathway patients voided without difficulty, and were discharged in 153 +/- 49 (SD) min. 62 patients in the accelerated pathway voided spontaneously after resolution of their block and were discharged in 127 +/- 41 min. 46 patients were discharged with a BUS less than 400 ml in 120 +/- 42 min. 23 patients had a BUS greater than 400 ml: of these, 20 patients voided within an hour and were discharged in 162 +/- 45 min. Three were catheterized after 1 h, and were discharged in 186 +/- 61 min. Mean discharge time for all patients in the accelerated pathway was 22 min shorter than the standard pathway (P = 0.002). No patients had difficulty voiding or returned to the hospital for urinary problems. None reported new urologic symptoms. Delay of discharge after outpatient spinal or epidural anesthesia with short-duration drugs for low-risk procedures is not necessary, and may result in prolonged discharge times.

A comparison of endotracheal intubation and use of the laryngeal mask airway for ambulatory oral surgery patients

Purpose: This study compared current experience with the laryngeal mask airway (LMA) to previous experience with endotracheal intubation for ambulatory patients receiving general anesthesia. Patients and Methods: A retrospective comparison of 157 patients (50 endotracheal intubation [ET] and 107 LMA cases) was conducted. The subjects were American Association of Anesthesiologist (ASA) Class I and II patients who underwent outpatient general anesthesia for dentoalveolar surgery. Procedure time, recovery time, and cost of techniques were compared. Results: The patients undergoing a variety of outpatient dentoalveolar surgical procedures under general anesthesia in the LMA group had a shorter procedure time than the ET group (40 vs 44 minutes) and had a significantly shorter recovery time (54 vs 67 minutes). In addition, compared with the cost of delivering care with ET, the LMA provided slightly lower cost per case ($20 to $30 per case compared with $35 to $80 per case), depending on the anesthetic technique used. Comparing the 2 techniques for removal of 4 impacted third molars (25 patients ET and 68 patients LMA) revealed a similar procedure time of 39 minutes for both groups, but a shorter recovery time for the LMA group (54 vs 68 minutes). Conclusions: Use of the LMA has advantages over endotracheal intubation for outpatients receiving general anesthesia for dentoalveolar surgery. © 2002 American Association of Oral and Maxillofacial Surgeons J Oral Maxillofac Surg 60:2-4, 2002

The Lived Perioperative Experience of Ambulatory Surgery Patients

Understanding patients' perspectives is central to providing appropriate nursing care. The purpose of this study was to explore ambulatory surgery patients' perceptions and views of the perioperative experience. A phenomenological study was conducted that included 16 patients who underwent abdominal surgical procedures in the ambulatory surgery center of a large teaching hospital in the northeastern United States. Intensive semistructured interviews were used to collect data. Patients were interviewed one week after surgery. Data analysis was aimed at gaining understanding of the lived experience of ambulatory surgery patients. Themes identified included fear, knowing, and presence. Results indicate that patients in this study were not prepared adequately for the perioperative experience, suffered needlessly due to inadequate pain management, and did not achieve discharge readiness.

Drug controversies in ambulatory anesthesia

With the growth of ambulatory surgery, a number of new drugs have become available to the anesthesiologist. This access to supposedly superior anesthetics has led us to rethink the traditional role of some of our older drugs. Propofol is an example of such a new drug, and has largely replaced thiopental as the gold standard in the ambulatory setting. Propofol's popularity would inevitably lead to the production of a generic formulation. However, its transition from the original to a cheap generic product has been far from smooth. How significant are the claims in this propofol war? We will try to provide the facts with our interpretation of their possible significance. We also now live in an era of designer drugs such as remifentanil. Although specifically developed for the rapid turnover of a busy ambulatory center, remifentanil just does not seem to have been embraced for this role. We will discuss the possible reasons for its lukewarm reception, and suggest applications in which remifentanil may provide the greatest advantages for the ambulatory surgery patient. Probably the most controversial of the older drugs in modern day anesthesia is nitrous oxide. Until now, the general consensus had been to use nitrous in almost every anesthetic, because we believed that its ubiquitous utilization had survived the test of time. Despite having been administered to more patients than any other inhaled anesthetic, we continue to read new articles about the pros and cons of the continued use of this drug. We will discuss this topic in the ambulatory surgery setting.

Effect of return hospital visits on economics of ambulatory surgery

This review examines the effect of unanticipated admission, return hospital visits and readmission on the economics of ambulatory surgery. The overall rate of unanticipated admission was approximately 1% and the overall rate of readmission to hospital was approximately 1%. Ambulatory surgery allows total cost savings of 20-50% when compared with inpatient surgery. If 98% of ambulatory surgery patients experience uneventful recovery, the decrease in cost savings caused by unanticipated admission and return hospital visit is very small. Modifications of anesthesia and surgical technique can help to further reduce the incidence of unanticipated admission or readmission to hospital.

Use of a modified postanesthesia recovery score in phase II perianesthesia period of ambulatory surgery patients

Use of discharge criteria in the ambulatory surgery setting has been the topic of many research studies and reviews. This article provides a discussion of a research utilization project regarding the use of a modified Postanesthesia Recovery Score for Ambulatory Patients (PARSAP) in Phase II recovery of a perianesthesia unit. The impetus for this project was the closure of a hospital's only inpatient ward, resulting in all surgery performed on an outpatient basis. Based on community standards and a review of literature, this project evaluated the use of the modified PARSAP on ambulatory surgery patients. The intent of the project was to improve the flow of patients through the recovery process in an effort to contain or reduce costs while still maintaining high-quality patient care standards. Results of the project showed a decreased inpatient length of stay without any increase in reports of postoperative complications. The favorable outcomes of the use of this scoring system have led to its implementation on a permanent basis. This is a U.S. government work. There are no restrictions on its use.

Self-reported at-home postoperative recovery.

Although 75% of elective surgery is performed on an outpatient basis, no measures of patients' at-home postoperative recovery were found in the literature. The postdischarge surgical recovery (PSR) scale was designed to serve as a dependent variable capable of measuring variations in perceived recovery in patients dismissed within 24 hours of their surgical procedure. Five concepts: health status; activity; fatigue; work ability; and expectations, derived from an ethnographic analysis, are represented in the 15-item 10-point semantic differential scale. The PSR scale exhibited strong internal consistency in two samples (alpha=.88-.91). The concurrent validity coefficient between the PSR scale and the previously tested Wolfer-Davis Recovery Inventory (1970) was .76 (n = 163; p< or =.001). Construct validity was supported by the relationship (r=.72, p< or =.001) between patients' reported percentage of recovery (0-100%) and PSR scores. Construct val idity was also supported by correlations between the PSR scale and in-home assessment by a master clinical nurse specialist (r=.77, p=.003, n=12) and by trained in-home observers (r=.71, p< or =.001, n=59). Clinicians or researchers interested in the extent of perceived at-home Postoperative recovery may now search for symptom patterns and changes over time in a variety of ambulatory surgery patients using the PSR scale.