Ambulatory Surgical Unit Research Articles

Sedation and Anesthesia in Pediatric Endoscopy: One Size Does Not Fit All

Sedation and Anesthesia in Pediatric Endoscopy: One Size Does Not Fit All

Factors affecting recovery and discharge following ambulatory surgery

Recovery and discharge following ambulatory surgery are important components of the ambulatory surgery experience. This review provides contemporary perspectives on the issues of discharge criteria, fast-tracking, patient escort requirements, and driving after ambulatory anesthesia. A search was performed in the Cochrane Central Register for Controlled Trials, MEDLINE(R), EMBASE(R), CINAHL, and PsycINFO, to review factors delaying discharge following ambulatory surgery. The following subject headings were used: "ambulatory surgery, discharge, recovery, car driving, escort, transport, fast tracking, patient discharge, recovery, transportation of patients, hospital discharge, recovery room, patient transport, hospital discharge, recovery room, anesthetic recovery, patient transport, ambulatory surgical procedures, patient discharge, recovery of function, automobile driving, patient escort service, recovery room". Using the same search engines, the following keywords were used: "fast tracking, recovery, and discharge". The current literature supports that discharge scoring systems may be useful to guide discharge following ambulatory surgery. While fast-tracking has become common in some centres, further studies are required to justify more routine implementation of this practice in the management of patients undergoing ambulatory surgery. Patients at low risk for urinary retention can be discharged home without voiding. Patients should not drive until at least 24 hr postoperatively. Ensuring rapid postoperative recovery and safe discharge following ambulatory surgery are important components of the ambulatory surgical program. A clearly defined process should be established for each ambulatory surgical unit to ensure the safe and timely discharge of patients after anesthesia, in accordance with current best evidence.

Obstetric Anesthesia: The 1982 American College of Obstetricians and Gynecologists Standards and the Role of Robert E. Johnstone, M.D.

Obstetric Anesthesia: The 1982 American College of Obstetricians and Gynecologists Standards and the Role of Robert E. Johnstone, M.D.

Cognitive function is minimally impaired after ambulatory surgery

To evaluate the magnitude of subjective cognitive failure in the three days following general anesthesia (GA) for ambulatory surgery. After Research Ethics Board approval, 258 patients undergoing general anesthesia (GA) and 250 patients scheduled for local anesthesia (LA) were recruited from our ambulatory surgical unit. Following the method of Tzabar, Asbury and Millar, patients were asked to complete the cognitive failures questionnaire (CFQ) before their procedure (with respect to the previous three days) and on the third postoperative day (with respect to their recovery period). General anesthesia and LA groups were similar in demographic make-up, except that the LA group contained more patients of American Society of Anesthesiologists physical status I (64.5% vs 52.7%, P < 0.05) and had significantly shorter procedure duration (25 vs 51 min, P < 0.01) than the GA group. Median preoperative CFQ scores (interquartile range) were 26 (18) for the LA group and 26 (18) for the GA group. Postoperative CFQ scores were 25 (20) for the LA group and 28 (22) for the GA group. There was no significant difference in preoperative CFQ score between groups (Mann-Whitney U). When preoperative and postoperative CFQ scores were compared, the small increase seen in the GA group was statistically significant (P < 0.05, Wilcoxon). A statistically significant impairment of cognitive function in the three days following GA, but not LA was found. However, the magnitude of this impairment was small, and is of doubtful clinical significance. Modern ambulatory anesthesia may cause less delayed cognitive impairment than was previously thought.

181: Office Operative Hysteroscopy

To evaluate the benefits of office operative hysteroscopic systems with or without general anesthesia. We retrospectively reviewed our case series since the introduction in our practice of an office operative system. Tertiary referral center. From October 2002 to March 2005 234 endometrial polyps were diagnosed using office hysteroscopy. When the size was < 2 cm a see and treat approach was offered to the patients. When the procedure was performed in general anesthesia the same hysteroscopic system was employed if the size was < 3 cm. One hundred two were judged less than two centimeter in size, while 132 were more than 2 cm. In the former a see and treat approach was proposed, and 74% accepted the procedure. The others were treated in an ambulatory surgical unit and discharged few hours later the procedure using the same hysteroscopic system (57%) or a resectoscope (43%). In our series, office operative hysteroscopy may avoid cervical dilatation and the use of a regular resectoscope in 78% of cases; furthermore, the procedure is well accepted without anesthesia in 74% of selected cases.

Prolonged hemidiaphragmatic paralysis following interscalene brachial plexus block

We present a case of persistent phrenic nerve paralysis after a successful interscalene brachial plexus block. In addition, there was no observed diaphragmatic stimulation, and the patient underwent an uneventful early postoperative period. Warning signs of a complication were either missed or absent until several days after discharge from the ambulatory surgical unit.

Directed parathyroid exploration: Evolution and evaluation of this approach in a single‐institution review of 346 patients

Critical evaluation of a directed exploration protocol used by a single surgeon in the management of surgical parathyroid disease. Retrospective chart review was made of patients surgically managed for hyperparathyroidism at an academic tertiary care center. Three hundred forty-six patients were evaluated for biochemically proven hyperparathyroidism between March 1995 and February 2002. A directed exploration protocol was implemented in appropriately selected patients with primary hyperparathyroidism and in patients with secondary or tertiary hyperparathyroidism requiring repeat operation. The protocol included preoperative technetium-99m sestamibi imaging for hyperfunctional parathyroid localization, targeted neck exploration, rapid intraoperative parathyroid hormone determination, and limited-stay discharge from the ambulatory surgical recovery unit. Data collection was accomplished by entering patient evaluation, management, and outcome information prospectively into collective case report forms. A retrospective analysis of the data was conducted for the purpose of evaluating the effectiveness of the protocol. Sustained normocalcemia beyond 6 months postoperatively was achieved in 323 of 327 (99%) patients with primary hyperparathyroidism. Eighty-four percent (84%) of patients with secondary or tertiary hyperparathyroidism achieved normocalcemia or had resolution of symptoms as a measure of therapeutic success. The complication rate for the entire series of patients was 2.8%. Ninety-two percent of positive findings on sestamibi scan correctly predicted the location of an adenoma, whereas a negative finding accurately predicted the absence of an enlarged gland in a "usual" location in 81% of patients. Twenty-six patients (9%) had a false-positive finding on the scan, whereby a solitary adenoma was found contralateral to the side indicated by the scan. Overall, the positive predictive value for sestamibi imaging in the series was 91%. Intraoperative parathyroid hormone determination yielded an overall rate of reduction of 80% from preoperative levels during directed exploration. Sustained normocalcemia was achieved in all patients in whom intraoperative parathyroid hormone determination demonstrated a minimum decline of 50% from preoperative levels following resection of hyperfunctional parathyroid tissue (adenoma[s]). The majority (72%) of patients were managed in an outpatient (ambulatory surgery) setting and were discharged to home within 8 to 12 hours after surgery. The directed exploration protocol for surgical management of hyperparathyroidism generated surgical rates of success that were as good as and, in most cases, improved over that of traditional bilateral exploration. This achievement was associated with low morbidity and reduced time and facility utilization, conveying improved cost-effectiveness. This surgical strategy should serve to enhance the capability of the surgeon to safely and efficiently manage the majority of patients with surgical parathyroid disease.

The Influence of Nurse-Sensitive Variables on Patient Satisfaction

A DESCRIPTIVE STUDY was conducted in an ambulatory surgical unit to explore the influence of selected nurse-sensitive variables on patient satisfaction and compare the reliability and validity of existing instruments that measure patient satisfaction. STUDY RESULTS indicate that age, gender, culture, pain control, and communication affect patient satisfaction in ambulatory care. A reliable tool to measure patient satisfaction is needed to promote improvements in care.

Systematic review and analysis of postdischarge symptoms after outpatient surgery.

OVER the past decade, the percentage of surgical procedures being performed in outpatient centers has increased. In response, outpatient anesthetic practice and research have focused on providing anesthetics that minimize symptoms (e.g., nausea and vomiting) in the postanesthesia care unit and hasten time to discharge. Much effort has been placed on development of newer agents with a more favorable recovery profile. Similarly, examination of the economic parameters (e.g., length of recovery room stay, cost-effectiveness of drugs) after ambulatory surgery has focused on the immediate predischarge, postoperative period. A significant portion of research in this area has concentrated on minimizing immediate postoperative symptoms to facilitate patient discharge from the hospital. On the other hand, relatively few studies have evaluated the impact of patient-reported symptoms after discharge from the postanesthesia care unit. Postdischarge symptoms (those occurring after discharge from the ambulatory surgical unit) may have an important impact on patient recovery after ambulatory surgery and the economic burden on patients and their caregivers; however, there has not been a systematic examination of postdischarge symptoms. It is important to know the frequency with which patients experience postdischarge symptoms so that providers can better inform patients and researchers can better estimate the burden of these symptoms and potential for the incidence of postdischarge symptoms to serve as a measure of quality of care. Quantification of the incidence of postdischarge symptoms would be the first step in the process in determining the extent of the problem and if perioperative interventions (e.g., intraoperative anesthetic technique, multimodal analgesia, or pharmacologic agents) would be effective in diminishing the impact of these patient-related symptoms on functional recovery and health-related quality of life. Therefore, we conducted a systematic review and analysis to evaluate the incidence of patient-reported symptoms after outpatient surgery.

When should diclofenac be given in ambulatory surgery: preoperatively or postoperatively?

Study Objective: To determine the optimum time of administration of diclofenac in patients undergoing ambulatory knee arthroscopy: either preoperatively or postoperatively. Design: Randomized, double-blind study. Setting: Ambulatory surgical unit in a tertiary referral hospital. Patients: 127 ASA physical status I and II patients undergoing ambulatory knee arthroscopy. Interventions: Patients were randomized into three groups. The Preop group received 50 mg of potassium diclofenac orally 1 hour preoperatively and a placebo 30 minutes postoperatively. The Pre+postop group received 25 mg of potassium diclofenac 1 hour preoperatively and 25 mg diclofenac 30 minutes postoperatively. The Postop group received a placebo 1 hour before surgery and 50 mg of potassium diclofenac 30 minutes postoperatively. Measurements and Main Results: The Postop group received a placebo 1 hour preoperatively and 50 mg of potassium diclofenac 30 min postoperatively. Postoperatively, patients used intravenous patient-controlled analgesia (PCA) with fentanyl. Total fentanyl consumption was recorded. During the recovery period, pain was assessed using a visual analog scale (VAS) at 30-minute intervals. Pain was assessed in both legs at rest, on flexion, and extension of the knee. There were no significant differences in pain scores either at rest or on movement of the operative knee among the Preop, Pre+postop, and Postop groups. The consumption of fentanyl via PCA showed no significant differences among the groups. Conclusions: There is no difference in pain relief whether diclofenac is given preoperatively or postoperatively in patients undergoing unilateral ambulatory knee arthroscopy. Preoperative and postoperative treatment with diclofenac potassium is equally effective.

Quality indicators in ambulatory surgery. A prospective study

Introduction: Ambulatory Surgery has emerged and developed in Spain in a similar way as in other occidental countries. Once established as a model for surgical care, results must be improved using objective quality indicators to assure minimal morbidity, efficient use of resources and satisfaction of patients and family. Objective: To provide a list of quality assessment indicators in Ambulatory Surgery and to discuss the necessity of obtaining a general consensus regarding the complexity of both the operations and the patients undergoing surgery. Design: Prospective and descriptive study. Patients and Methods: The study was performed on 833 ambulatory patients operated on in the Ambulatory Surgical Unit of the Can Misses Hospital of Ibiza. Surgical specialities involved were General Surgery, Ophthalmology, Orthopaedics, Urology, Gynaecology, and E.N.T. All diagnoses and proceedings were classified according to the CIE-9 and DGR systems, showing as an example the codes related to the General Surgery department. Quality Indicators evaluated were: (a) unplanned admission index; (b) re-admission index; (c) emergency department consultations; (d) cancellation index; (e) substitution index; and (f) postoperative pain evaluation. Results: Specialities involved were: Ophthalmology 277 patients (33.2%), General Surgery 189 (22.8%), Orthopaedics 142 (17%), Urology 90 (10.8%), E.N.T. 79 (9.5%) and Gynaecology 56 (6.7%). Unplanned Admission Index was 7.2%; Re-Admission Index 0.4%; Emergency department consultation 1.6%; Cancellation Index 3.3% and Substitution Index 70%. The reasons for unplanned admission were due to specific complications in 36 cases (60.1%), followed by those secondary to an inadequate selection of the patient in 22 cases (36.6%). Conclusions: It is necessary to apply a series of Quality Indicators in Ambulatory Surgery. Their systematic evaluation may help us define national standards in order to continuously improve our results.

Return hospital visits and hospital readmissions after ambulatory surgery.

To determine the overall and complication-related readmission rates within 30 days after ambulatory surgery at a major ambulatory surgical center. Currently in North America, 65% of the surgical procedures are carried out in ambulatory settings. The safety of ambulatory surgery is well documented, with low rates of adverse events during or immediately after surgery. The consequences of ambulatory surgery during an extended period, however, have not been studied extensively. Preoperative, intraoperative, and postoperative data were collected on 17,638 consecutive patients undergoing ambulatory surgery at a major ambulatory surgical center in Toronto, Ontario. With the use of the database of the Ontario Ministry of Health, the authors identified all return hospital visits and hospital readmissions occurring in Ontario within 30 days after the ambulatory surgery. Return visits were categorized as emergency room visits, ambulatory surgical unit admissions, or inpatient admissions. The readmissions were categorized as those resulting from surgical, medical, or anesthesia-related complications or those not related to the ambulatory surgery. One hundred ninety-three readmissions occurred within 30 days after ambulatory surgery (readmission rate 1.1%). Six patients returned to the emergency room, 178 patients were readmitted to the ambulatory surgical unit, and 9 patients were readmitted as inpatients. Twenty-five readmissions were the result of surgical complications, and one resulted from a medical complication (pulmonary embolism). The complication-related readmission rate was 0.15% (1 in 678 procedures). The complication rate was significantly higher among patients undergoing transurethral resection of bladder tumor (5.7%). No anesthesia-related readmissions or deaths were identified. The rate of complication-related readmissions was extremely low (0.15%). This result further supports the view that ambulatory surgery is a safe practice.

Experience in integral management of advanced carpal tunnel syndrome in an ambulatory surgical unit

Experience in the integral management of carpal tunnel syndrome over a period of 4 years is presented. All cases were treated at an ambulatory surgical unit. Among this series, special attention is payed to eight cases of severe advanced carpal tunnel syndrome. All cases presented in this study had at the time of evaluation at the ambulatory surgical unit, symptoms of severe pain, thenar atrophy, weakness and decreased sensation. The only treatment received by some patients in this series ( n=7), before admission at the ambulatory surgical unit, was conservative therapy, with splinting, anti-inflammatory drugs and corticosteroid infiltrations. In one case, the patient had rejected all therapeutic options and no therapy had been undertaken at the time of first clinical evaluation. Several surgical findings were found in five of the eight cases of severe carpal tunnel syndrome: Basal joint arthritis of the thumb in three patients; A ganglion in another case; A flexor tendon synovitis in another. The diagnostic procedures, the indications for surgery and the postoperative results kin such advanced carpal tunnel syndrome are analyzed and discussed.

Can postoperative nausea and vomiting be predicted?

Iletrospective studies fail to identify predictors of postoperative nausea and vomiting (PONV). The authors prospectively studied 17,638 consecutive outpatients who had surgery to identify predictors. Data on medical conditions, anesthesia, surgery, and PONV were collected in the post-anesthesia care unit, in the ambulatory surgical unit, and in telephone interviews conducted 24 h after surgery. Multiple logistic regression with backward stepwise elimination was used to develop a predictive model An independent set of patients was used to validate the model Age (younger or older), sex (female or male), smoking status (nonsmokers or smokers), previous PONV, type of anesthesia (general or other), duration of anesthesia (longer or shorter), and type of surgery (plastic, orthopedic shoulder, or other) were independent predictors of PONV. A 10-yr increase in age decreased the likelihood of PONV by 13%. The risk for men was one third that for women. A 30-min increase in the duration of anesthesia increased the likelihood of PONV by 59%. General anesthesia increased the likelihood of PONV 11 times compared with other types of anesthesia. Patients with plastic and orthopedic shoulder surgery had a sixfold increase in the risk for PONV. The model predicted PONV accurately and yielded an area under the receiver operating characteristic curve of 0.785+/-0.011 using an independent validation set. A validated mathematical model is provided to calculate the risk of PONV in outpatients having surgery. Knowing the factors that predict PONV will help anesthesiologists determine which patients will need antiemetic therapy.

Discharge criteria and complications after ambulatory surgery.

I n recent years, the emphasis in providing surgical services has undergone remarkable change. Previously, patients undergoing surgical procedures remained in a hospital for many days after the operation. In 1994, 66% of all elective operations in the United States were performed on an outpatient basis (1). More complex ambulatory procedures are being performed on sicker patients (2). With the increased emphasis on early discharge after surgery and anesthesia, it is important to identify criteria that can be used to determine when patients can safely go home under the care of a friend or relative. In this article, we review current knowledge regarding the assessment of home-readiness after ambulatory surgery and discuss potential complications and appropriate treatment regimens.

Discharge Criteria and Complications After Ambulatory Surgery

Discharge Criteria and Complications After Ambulatory Surgery

An anesthetic data acquisition system in ambulatory surgery

Rapid access to and analysis of information constitutes an important element in the health care quality of an ambulatory surgical unit. We have developed a database for application to ambulatory anesthesia, based on commercially available software (Claris File Maker Pro 3.0, allowing full compatibility between Apple Macintosh and PC systems). Three integrated bases are used (preanesthesia, anesthesia and postanesthesia), and the different fields are automatically introduced by order. The design is open and allows for subsequent modifications; reports may be presented, and direct telephone communication is facilitated, along with net-based operations.

Outpatient ACL reconstruction using intraoperative local analgesia and oral postoperative pain medication.

Thirty-five consecutive anterior cruciate ligament (ACL) reconstructions were performed in an ambulatory surgical unit using a bone-patellar tendon-bone autograft. Patients were evaluated postoperatively to determine the amount of pain medication used, the readmission rate, postoperative complications, and cost. Outpatient ACL reconstruction led to a savings of $4700 compared with the cost of performing the same procedure in a hospital operating room with an overnight admission. This study demonstrates that outpatient ACL reconstruction, using local analgesia intraoperatively and oral narcotic pain medication postoperatively, is a safe and cost-effective procedure with minimal to no morbidity.

Postoperative pain in ambulatory surgery.

Postoperative pain is a common reason for the delayed discharge and unanticipated hospital admission of out-patients. In this study, we examined the pattern of pain in ambulatory surgical patients and determined those factors that predict postoperative pain. Ten thousand eight consecutive ambulatory surgical patients were prospectively studied. Preoperative patient characteristics, intraoperative variables, and pain in the postanesthesia care unit (PACU) and the ambulatory surgical unit (ASU) and 24 h postoperatively were documented. The incidence of severe pain was 5.3% in the PACU, 1.7% in the ASU, and 5.3% 24 h postoperatively. In the PACU, younger male adults (36 +/- 13 vs 47 +/- 22 yr), ASA physical status I patients, and patients with a higher body mass index (26 +/- 5 vs 25 +/- 5 kg) had a higher incidence of severe pain. In the group with severe pain, the duration of anesthesia, the duration of stay in the PACU and the ASU, and the time to discharge was longer than in the group without severe pain. In the PACU, orthopedic patients had the highest incidence of pain (16.1%), followed by urologic (13.4%), general surgery (11.5%), and plastic surgery (10.0%) patients. In patients who had general anesthesia, the intraoperative dose of fentanyl was significantly smaller in the group with severe pain than in the group without severe pain when body mass index and duration of anesthesia were taken into consideration. Body mass index, duration of anesthesia, and certain types of surgery were significant predictors of severe pain in the PACU. This knowledge will allow us to identify those patients at risk of severe postoperative pain and manage them prophylactically. The pattern of pain was examined in 10,008 consecutive ambulatory surgical patients. The incidence of severe pain was 5.3% in the postanesthesia care unit, 1.7% in the ambulatory surgical unit, and 5.3% 24 h postoperatively. Body mass, duration of anesthesia, and certain types of surgery were significant predictors of pain in the postanesthesia care unit. These data will allow us to better predict those patients who need intense prophylactic analgesic therapy.

Modified open laparoscopy through placement of an optical surgical obturator

Objective: To describe a new technique for open laparoscopy. Design: Prospective case series. Setting: Ambulatory surgical unit. Patient(s): Fifty-six women undergoing laparoscopic sterilization. Intervention(s): Intra-abdominal placement of an optical surgical obturator. Main Outcome Measure(s): Evaluation of surgical technique. Result(s): The technique was completed successfully in all cases. Conclusion(s): This new surgical approach may assist surgeons in avoiding inadvertent injuries.