Postanesthesia Discharge Scoring System Research Articles

AMeTHYST (AMbulatory HYsterectomy surgery). Feasibility of minimally invasive outpatient hysterectomy, a preliminary study

ObjectivesHysterectomy, one of the most frequent surgical procedures in women, is commonly performed by a minimally-invasive approach (laparoscopic or vaginal) as recommended by the French guidelines. The French authorities aim to have 66 % of all procedures performed as same-day surgery in 2020. The aim of this study was to evaluate the feasibility and identify factors associated with success or failure of same-day surgery for minimally-invasive hysterectomy. Study designWe conducted a prospective double-center observational study at the Caen and Amiens University Hospitals between September 2017 and May 2018 including hospitalized patients managed for a laparoscopic or vaginal hysterectomy. Patients were younger than 70 and have no major medical problems. The patients were placed into a “fit” or “unfit” group according to their Post Anaesthetic Discharge Scoring System (PADSS) score 6 h post-surgery. All the patients were asked to complete an assessment questionnaire during their hospitalization. ResultsOf the 50 included patients, half were placed in the "fit" group. A history of laparotomy was significantly predictive of failure of same-day discharge (p = 0.003) but not uterine size or Body Mass Index (BMI). The main barriers for discharge were pain (p<0.001) and postoperative nausea/vomiting (PONV) (p<0.001). Four patients, all in the “unfit” group, had Clavien-Dindo grade 1 postoperative complications. ConclusionSame-day minimally invasive hysterectomy is a feasible and safe procedure. Factors associated with same-day hysterectomy failure were laparotomy, pain and postoperative nausea/vomiting.

Computerized 4-choice reaction time test for the measurement of psychomotor recovery after general anesthesia.

The recovery of patients after general anesthesia is usually estimated by using clinical scores. Since there is a lack of objective methods for assessing psychomotor recovery, the aim of this study was to evaluate three psychological tests for this purpose. Patients, scheduled for ambulatory gynecological surgery, underwent 3 standard psychological tests before (T1), 15min after the surgery (T2) and on discharge from the recovery room (T3). The tests used were Wechsler memory scale (test 1, working memory capacity), d2-test (test 2, concentration endurance) and computer-based 4-choice-reaction time (4CRT, test 3, reaction time) as well as Postanesthesia Discharge Scoring System (PADSS). The same test battery was used in healthy female volunteers, all test results were compared at the different time points. In 109 patients, working memory capacity and concentration (tests 1 and 2) decreased, the reaction time (test 3) was prolonged at T2 in comparison with T1 and T3 (P < 0.01). PADSS increased from 8 (T2) to 10 (T3) (medians, P < 0.001). Fifty-seven healthy volunteers demonstrated a practice effect in all 3 tests through the course of the study (P <0.01). 4CRT test had shortest duration and enabled computerized data processing. All three tests objectively assess the recovery of psychomotor function in patients after general anesthesia, the computer-based 4CRT seems to be the most convenient for the clinical routine.

EDITORIAL COMMENT

We congratulate the authors on the largest published prospective study of outpatient robot-assisted radical prostatectomy (RARP) to date. Through this well-designed feasibility study, authors found that outpatient RARP was not feasible in most patients, identifying postoperative nausea and vomiting (PONV) as the most frequent complication. Authors successfully standardized discharge criteria according to Post Anesthesia Discharge Scoring System (PADSS) and performed thorough assessment of perioperative and postoperative outcomes.

Outpatient Robot-assisted Radical Prostatectomy: A Feasibility Study

ObjectiveTo evaluate the feasibility of routine outpatient management after robotic-assisted radical prostatectomy (RARP). Prostate cancer is indeed the second most common cancer in men. Surgical technics have evolved from open surgery to robot-assisted surgery with a reduction of postoperative complications. Such technical improvements associated with modern anesthesia allow outpatient surgery in various types of procedures. Material and MethodsAfter approval of the IRB, this observational prospective and monocentric study was performed in the urology unit at Rennes University Hospital between December 2015 and October 2017. All patients scheduled for RARP performed by one experienced surgeon were consecutively included. The possibility of discharge was evaluated using the Post Anesthesia Discharge Scoring System (PADSS) score until patients had a score of 9 or higher allowing their discharge. Risk factors of delayed discharge were secondarily assessed ResultsNinety-seven patients scheduled for RARP performed by one experienced surgeon were consecutively included. Only 1 patient had a PADSS score ≥ 9 the day of the surgery (day 0). Seventy-four percent of the patients achieved discharge criteria 1 day after surgery whereas, 33% and 66% of the population was effectively discharged on day 2 and day 3, respectively. Patients with a PADSS score ≥ 9 at day 1 experienced significantly less postoperative nausea and vomiting than patients with a PADSS score ≥ 9 at day 2 or 3 (7% vs 28%, P = .01). ConclusionOutpatient RARP was not feasible in most patients. However, routine discharge at day 1 seems conceivable. Improving the management of postoperative nausea and vomiting may even allow outpatient management. This progress remains to be confirmed by further studies.

Readiness for Discharge After F&amp;A Surgery Using Peripheral Nerve Blocks

Category: Other Introduction/Purpose: Neuraxial anesthesia is often viewed as superior to general anesthesia (GA), but there are concerns that it may prolong length of stay (LOS). Most studies comparing the two anesthesias were performed in the absence of peripheral nerve blocks (PNBs), which when used as an analgesic adjunct may overcome the associated negative side effects of GA and allow decreased LOS. We hypothesized that patients given PNBs and GA would be discharged sooner than patients given PNBs and spinal anesthesia plus sedation, without increased incidence of adverse side effects such as pain, opioid administration and nausea. Methods: A single-center triple-blinded randomized controlled trial of 36 consecutive patients receiving elective F&amp;A surgery predicted to take 1-3 hours under planned PNB with either spinal or GA was performed (see table 1. for demographics).The primary outcome was time to meet criteria for home discharge. The a priori clinically relevant difference with 80% power was determined to be 45 minutes. Patients were assessed after admission to the PACU and at 15-minute intervals thereafter. Once an Aldrete score=9 (scale signifying patient no longer needs intensive monitoring) was obtained, patients were transferred to Phase II and assessed until the post anesthesia discharge scoring system, a home readiness scale, was =9. Actual time to discharge was also recorded.Additional outcomes included a series of baseline characterizations which were assessed pre-and post-operatively, and again during Phase II.The primary outcome was compared using multivariable unconditional quantile regression. Various regressions were performed on secondary outcomes. Results: After adjustment for age and surgical duration, patients given GA plus PNB were ready for discharge from PACU 39 minutes prior to patients given neuraxial anesthesia plus PNB, but this difference did not reach the clinically relevant a priori selected difference of 45 minutes (Table 1). However, the adjusted median time to meet ambulation discharge criteria was 52 minutes fewer (p = 0.003) (Table 1). Patients met discharge criteria substantially sooner than their time until actual discharge which was not different between groups (Table 1). Pain scores at rest were higher among GA patients at 1 hour in the PACU (adjusted difference in means [95% CI]: 2.1 [1.0, 3.2], p &lt; 0.001). Subsequent pain scores and all other secondary outcomes were not different. Conclusion: GA with PNB patients were ready for discharge 39 minutes earlier, but that difference may not be clinically significant. Although patients met criteria for discharge sooner due to a significantly more rapid ability to ambulate, they were not discharged sooner because PACU staff was not acclimated to the earlier readiness and so did not push for earlier discharge. These findings suggest that GA plus PNB leads to earlier discharge with similar side effects as spinal plus PNB. Therefore, the use of GA with PNB for foot and ankle surgeries could save the hospital and the patient time and resources.

Outpatient vaginal hysterectomy: Comparison of conventional suture ligature versus electrosurgical bipolar vessel sealing

ObjectiveThe aim of our study was to evaluate the feasibility of vaginal hysterectomy in an ambulatory care system and the best way to perform it between conventional and bipolar vessel sealing system ligatures. Patients and methodsThis was a prospective study of 32 patients with vaginal hysterectomy at Lille University Hospital between December 2013 and May 2015. Two surgical techniques were compared: conventional suture ligature (CSL) and electrosurgical bipolar vessel sealing (BVS). Patients stayed in classical hospitalization but were managed how if they were in an ambulatory unit to evaluate their capacity to come back home the same evening of the surgery. The evaluation of same-day discharge was based on Post Anesthetic Discharge Scoring System (PADSS) score≥9/10 and Visual Analogic Scale (VAS) score≤4/10. Other data collected were: operative time, uterus weight, peroperative bleeding, PADSS score at the 8th postoperative hour, VAS score at the 4th, 6th, 8th, 12th and 24th postoperative hours, the presence of postoperative nausea/vomiting and rehospitalization. ResultsIn the BVS group, 93.8% of patients validated the combined score (PADSS+VAS) on the evening of the intervention against 50% of patients in the CSL group (P<0.05). Hundred percent of BVS group patients were discharged on the day after surgery against 87.5% in the CSL group. The VAS was significantly lower in the BVS group at the 8th (1.4), 12th (1.2) and 24th (1.3) postoperative hours. Operative time was significantly shorter in the BVS group. We found more events such as nausea/vomiting in the CSL group. ConclusionVaginal hysterectomy is feasible in an ambulatory care system most of times. By reducing postoperative pain, electrosurgical bipolar vessel sealing would promote outpatient hospitalization.

Application of Discharge Criteria for Home Readiness Using Bispectral and Supraglottic Airway Devices in Day-care Surgery without Using Muscle Relaxants.

Introduction:The availability of rapid and short-acting intravenous and volatile anesthetics has facilitated early recovery that is why nowadays ambulatory surgery is becoming more common. If the criteria used to discharge patients from the Postanesthesia Care Unit (PACU) are met in the operating room (OR), it would be appropriate to consider bypassing the PACU and transferring the patient directly to the step-down unit. This process is known as “fast-tracking” after ambulatory surgery.Aims:To compare hemodynamic characteristics and recovery profile as per fast-track criteria (FTC) of recovery and postanesthesia discharge scoring system (PADSS) between sevoflurane and desflurane.Materials and Methods:One hundred American Society of Anesthesiologists Class I–II patients aged 20–50 years were randomly divided into two groups. Following anesthesia induction with injection propofol and injection dexmedetomidine airway was secured with i-gel, Group D (n = 50) received desflurane + dexmedetomidine + O2 + N2O and Group S (n = 50) received sevoflurane in place of desflurane. Emergence time was noted and FTC was evaluated in the OR, Score >12 is considered as shifting criteria for ambulatory surgery unit (ASU). PADSS was noted in ASU at an interval of 15 min for 3 h and Score >9 is considered as ready to discharge home.Results:Response to pain, verbal commands, and spontaneous eye opening in Group D was shorter than that in Group S (P = 0.001). Mean time to achieve FTC score >12 was 15 min in both the groups. Eighty-six percent of patients were ready to go home between 60 and 90 min using PADSS.Conclusion:We concluded that early recovery is faster for desflurane, and there is no difference in ready to go home time between desflurane and sevoflurane.

Percutaneous Nephrolithotomy under Thoracic Paravertebral Block: A Preliminary Report

Background: The second look percutaneous nephrolithotomy (PCNL) is usually done under general anesthesia. Thoracic paravertebral block has been shown to provide sufficient postoperative analgesia for a variety of thoracic and upper abdominal surgeries. Objectives: We propose a case series study for performing the second look PCNL under paravertebral block (PVB) and conscious sedation using dexmedetomidine. Methods: 33 patients scheduled for second look PCNL received PVB at the level of T 11, 15 ml of 0.5 % of bupivacaine was injected under ultrasonographic guidance. During the procedure, the patients received conscious sedation with dexmedetomidine (initial infusion of 1 μg/kg/h, followed by a maintenance infusion of 0.2 μg/kg/h). We measured the rate of success of the anesthetic technique, the level of sedation and hemodynamics. The time to complete recovery using (MPADSS), postoperative paracetamol consumption and postoperative intensity of pain using VAS. Results: the anesthetic technique was satisfactory in 30 patients. The median (IQ) patient’s satisfaction with the anesthetic technique was 6 (6:7). The median (IQ) surgeon’s satisfaction with the anesthetic technique was 7 (6:7). Complete recovery from sedation using the modified post anesthesia discharge scoring system (time to score 10) was achieved within 40 (30:52.5) min. The mean MAP and heart rate were significantly decreased in comparison to baseline value. Conclusion: We concluded that the anesthetic technique with PVB and conscious sedation with dexmedetomidine for patients undergoing second look PCN provided sufficient sedation, adequate analgesia, minimal side effects, and rapid recovery.

A comparison of dexmedetomidine with propofol versus esmolol with propofol to attenuate the hemodynamic stress responses after electroconvulsive therapy

Background:Modified electroconvulsive therapy (ECT) under anesthesia is an important modality in the treatment of severe, persistent depression; bipolar disorder and schizophrenia; especially in cases resistant to pharmacologic therapy.Aim:The aim of the present study is to compare the effects of dexmedetomidine and esmolol on patients' hemodynamics, motor seizure duration, and recovery times following ECT.Materials and Methods:Ninety cases aged between 18 and 50 years of the American Society of Anesthesiologists grade I and II; were randomly divided into three groups of 30 each. Group A received normal saline (placebo), Group B received dexmedetomidine 1 μg/kg, and Group C received esmolol 1 mg/kg; followed by induction with propofol 1 mg/kg and muscle relaxation with succinylcholine 0.75 mg/kg. Hemodynamic parameters at baseline, after study drug infusion, after induction, and after ECT application were recorded at different time intervals. The motor seizure duration using arm isolation method and recovery times using postanesthesia discharge scoring system were noted.Results:The maximum increase in hemodynamic parameters was seen following the ECT current application. Post-ECT rise in mean arterial blood pressure and heart rate in dexmedetomidine group was significantly less as compared to esmolol and control group at 2, 4, 6, and 8 min using unpaired t-test. There was no significant difference in motor seizure activity duration, emergence, and recovery times among the three groups.Conclusions:Both dexmedetomidine and esmolol attenuate the hyperdynamic response to ECT without affecting the seizure duration, but dexmedetomidine has a more favorable response in view of stable vitals, smooth emergence and no adverse effect on recovery duration.

Randomized Comparison of Isoflurane versus Sevoflurane and Desflurane for Maintenance of Ambulatory Anesthesia.

Background:Ambulatory surgeries demand safe anesthesia with faster recovery which makes it expensive due to the cost of inhalational anesthetic agents such as sevoflurane and desflurane. Isoflurane is inexpensive agent but can cause delayed recovery. The aim of this study was to evaluate cost-benefit ratio of all three agent with respect to recovery and safety profileMaterials and Methods:Patients posted for elective ambulatory surgeries were divided into three groups. Suitable size laryngeal mask airway was inserted following induction with propofol and vecuronium. Anesthesia was maintained on low-flow anesthesia with inhalational agent as isoflurane for Group I, sevoflurane for Group II and Group III received desflurane. Patients were monitored for recovery as per modified Aldrete score and as per postanesthesia discharge scoring system for discharge from hospital. Cost analysis was done by Dion's formula. Statistical analysis was done with analysis of variance for recovery profile, Chi-square test for safety profile and Kruskal Wallis test for cost comparison between groups.Results:Patient characteristics and duration of anesthesia were similar in all three groups. Time to eye-opening was significantly less with desflurane than sevoflurane and isoflurane (P = 0.001). Time to home readiness was similar in all three groups (P = 0.451). The incidence of airway irritation, pain, and nausea/vomiting was similar in all three groups. Cost of Group I was statistically lower than other two groups (P = 0.00).Conclusion:Home readiness and safety profile were comparable between agents; the cost involved was the least with isoflurane.

COMPARATIVE STUDY BETWEEN KETOFOL VERSUS PROPOFOL ANESTHESIA FOR UTERINE CERVICAL DILATION AND CURRETTAGE

Background: Ketofol (propofol-ketamine admixture) is used to compensate the hemodynamic chanages due to an induction of anesthesia. Uterine cervical dilation and curettage is a common procedure in day- care surgery. Objective: Comparing the effectiveness of sub-dissociative dose of Ketamine ,in ketofol [group -I]on intraoperative hemodynamic stability, O2%, pain ,anesthesia loading dose- verbal response time , incremental anesthesia ,last dose – verbal response time , surgeon's satisfaction and patient's satisfaction versus propofol alone [group-II]. Patients and method: Two hundred females, ASA I & II scheduled for uterine cervical dilation and curettage, were assigned to I or II groups. Intra-operatively the heart rate, non invasive blood pressure and O2% were monitored and recorded at baseline time, 5th, 10th, 15th and 20th minutes. In recovery room, the pain was assesed by visual analogue scale and the patient's and surgeon's satisfactions were assesed and discharge criteria by Aldrete scoring system and post anesthesia discharge scoring system. Results: The demographic characteristics, the duration of surgical procedure, and anesthesia loading dose - verbal response time showed no statistical difference, but incremental dose - verbal response time was significantly longer in group-I than group-II. Hemodynamic stability statistically had showed no significant differences. The ASS and PDSS were significantly higher in group-II than group-I at 5th but insignificant and equal at 10th minute. Pain was significantly lower in the group-I at 5th and 10th minutes than group-II. Conclusion: The combination of propofol and sub-dissociate dose of Ketamine [Ketofol] was superior to Propofol alone and provided adequate sedation and analgesia for brief painful procedures.

Non-anesthesiologist administration of propofol for gastrointestinal endoscopy: European Society of Gastrointestinal Endoscopy, European Society of Gastroenterology and Endoscopy Nurses and Associates Guideline – Updated June 2015

This Guideline is an official statement of the European Society of Gastrointestinal Endoscopy (ESGE) and the European Society of Gastroenterology and Endoscopy Nurses and Associates (ESGENA). It addresses the administration of propofol by non-anesthesiologists for gastrointestinal (GI) endoscopy. Main Recommendations 1 We recommend that the type of endoscopic procedure and the patient’s American Society of Anesthesiologists (ASA) physical status, age, body mass index, Mallampati’s classification, and risk factors for obstructive sleep apnea (OSA) be assessed before each procedure with non-anesthesiologist administration of propofol (NAAP) (strong recommendation, moderate quality evidence). 2 We suggest primary involvement of an anesthesiologist in patients of ASA class ≥ 3, with a Mallampati’s class ≥ 3 or other conditions that put them at risk of airway obstruction (e. g. pharyngolaryngeal tumors), in patients who chronically receive significant amounts of narcotic analgesics, or in cases where a long-lasting procedure is anticipated (weak recommendation, low quality evidence). 3 We suggest consideration of capnographic monitoring during NAAP in specific situations including high risk patients, intended deep sedation, and long procedures (weak recommendation, high quality evidence). 4 We suggest propofol monotherapy except in particular situations (weak recommendation, high quality evidence). 5 We recommend administering propofol through intermittent bolus infusion or perfusor systems, including target-controlled infusion (TCI), and consideration of patient-controlled sedation (PCS) in particular situations (strong recommendation, high quality evidence). 6 We suggest that patients listen to self-selected music during upper and lower GI endoscopy procedures (weak recommendation, moderate quality evidence). 7 We do not suggest using pharyngeal anesthesia during propofol sedation for upper GI endoscopy (weak recommendation, moderate quality evidence). 8 We suggest using the post-anesthetic discharge scoring system (PADSS) to determine when patient recovery is sufficient to allow discharge (weak recommendation, low quality evidence). 9 Minimum discharge criteria should be fulfilled before discharging a patient. We recommend that patients who have received combined regimens, and all patients of ASA class > 2, should upon discharge be accompanied by a responsible person and refrain for 24 hours from driving, drinking alcohol, operating heavy machinery, or engaging in legally binding decisions. Advice should be provided verbally and in written form to the patient, including a 24-hour contact phone number (strong recommendation, low quality evidence). 10 For patients of ASA classes 1 – 2 who have received low dose propofol monotherapy, a 6-hour limit is suggested (weak recommendation, low quality evidence).

Evaluation of the pediatric post anesthesia discharge scoring system in an ambulatory surgery unit.

To optimize the care pathway for children scheduled for ambulatory surgery, a pediatric postanesthetic discharge scoring system (Ped-PADSS) was developed from a score used in adults. The objective of this study was to evaluate this score prospectively on a cohort of children who had a day case surgical procedure. This was a single center prospective observational study. Inclusion criteria were predefined as follows: children aged 6months-16years at the time of the study, with a scheduled day surgery. Discharge was validated by Ped-PADSS scores ≥9, obtained at one hour intervals, after the return from the operating room and with the agreement of the surgeon. The duration of postoperative hospitalization was compared with data collected before the implementation of the score using the Student's t-test. From February to July 2012, 1060 children were included. One hour after the return from the operating room, 97.2% of children were dischargeable using Ped-PADSS. Two hours after the return from the operating room, 99.8% of children were dischargeable. The median postoperative hospital stay (n=1041) was reduced by 69min compared to the median stay before using the output score (n=150) (P<0.01). The Ped-PADSS score allows for the majority of children to be discharged 1h after their return from the postanesthesia care unit. Children who were discharged using the Ped-PADSS score returned home in safe and optimal conditions.

Intrathecal Hyperbaric Ropivacaine for Day Case Pelvic, Perineal and Lower Limb Surgeries – A Prospective Study

Background: The rationale of this study was to evaluate the efficacy of intrathecal hyperbaric ropivacaine for day case pelvic, perenial and lower limb surgeries. Methods: Seventy ASA physical status I-II patients undergoing the above mentioned surgeries were enrolled for the study. Hyperbaric ropivacaine in a dose of 15 mg was injected intrathecally in each of the patients. The primary outcome variables of the study were- duration of sensory and motor block. Secondary outcome variables were- time for onset of sensory block to T10 dermatomal level and motor block to Bromage Score 3, maximum spread of sensory block, time to reach maximum sensory level, quality of intraoperative analgesia and muscle relaxation, time to mobilize, time to spontaneous voiding and side effects. Results: The mean time for onset of sensory block to T10 dermatome level and motor block to Bromage Score 3 were 3.25 + 0.84 mins and 5.12 + 0.76 mins respectively. The median value of HSL was T5 (T4 - T6) and mean time to reach HSL was 9.08 + 1.05 mins. The total duration of sensory and motor block (mean) were 132.22 + 8.44 mins and 104 + 8.56 mins respectively. The time needed to mobilize the patients and spontaneous voiding (mean) were 206 + 9.26 and 230 + 10.33 mins respectively. Based on Modified Postanesthesia Discharge Scoring System (PADS) in addition to spontaneous micturition, 61 (87.14%) patients were discharged on the same day of operation. Conclusion: Results have demonstrated that 15 mg of hyperbaric ropivacaine when injected intrathecally is sufficient to produce anesthesia for day case pelvic, perineal and lower limb surgeries. Keywords: intrathecal, ropivacaine, day case surgery, Modified Postanesthesia Discharge Scoring System (PADS)

Reliability of the surgical Pleth index for assessment of postoperative pain: a pilot study.

Postoperative pain control is essential and may have a beneficial effect on postoperative outcome and morbidity. Analgesia quality is controlled using tools such as a Numerical Rating Scale (NRS). These tools require cooperation and often fail in the presence of reduced awareness. The Surgical Pleth index (SPI) has been introduced as a monitoring tool for intraoperative pain under general anaesthesia. We investigated the correlation between SPI and pain intensity, analgesic consumption and fitness for discharge in the postanaesthesia care unit. An observational study. The central postanaesthesia care unit of our tertiary care hospital. Written informed consent was obtained from 100 patients scheduled for elective surgery under general anaesthesia. Patients below the age of 18 years and those with an abnormal cardiac rhythm were excluded from the study. Patients were interviewed every 10 min for 2 h. Pain intensity measured by NRS, discomfort and Aldrete and Post-Anaesthetic Discharge Scoring System (PADSS) scores were noted. SPI and total dose of opioids administered were recorded. A total of 1300 pain measurements were recorded; 482 (37%) reflected no or mild pain (NRS 0 to 3), 532 (41%) moderate pain (NRS 4 to 6) and 286 (22%) severe pain (NRS 7 to 10). Both NRS (r = 0.62, P < 0.001) and SPI (r = 0.38, P < 0.001) correlated significantly with total opioid consumption. SPI showed a moderate correlation with NRS (r = 0.49, P < 0.001). Receiver operating characteristic analysis showed moderate sensitivity and specificity for discrimination between low and moderate pain (NRS ≤3) (sensitivity 67%, specificity 69% for SPI ≤45), and between moderate and severe pain (NRS >6) (sensitivity 72%, specificity 72% for SPI ≥57). SPI and NRS showed weak negative correlations with Aldrete and PADSS scores. Sensitivity and specificity of SPI to discriminate between low, moderate and severe pain levels was moderate. Both NRS and SPI correlated significantly with total opioid consumption.

Feasibility of fast track discharge in breast cancer patients undergoing definitive surgery and impact on quality of life: a prospective study from tertiary care center in India.

To evaluate the feasibility and impact of fast track discharge in patients undergoing definitive breast cancer surgery. One hundred six breast cancer patients older than 20 years of age were assigned to undergo definitive breast cancer surgery. It was ensured that enrolled patients had a ready access to hospital, reasonable home circumstances. They were assessed by using post-anesthesia discharge scoring system (PADSS) for fast track discharge. Quality of life both in preoperative and postoperative period was assessed by Functional Assessment of Cancer Therapy-Breast cancer version 4 (FACT-B4) questionnaires. Overall 90 patients (84.9%) were fit for fast track discharge. Eighty-nine patients (83.96%) were successfully discharged within 48 hr. One patient (0.94%) could not be discharged despite being fit as she was of concern that it would put too much responsibility on the family. Mean duration of postoperative hospital stay in patients fit for fast track surgery was 42.27 ± 5.73 hr with a median of 44 hr. All patients undergoing breast conservation could be discharged on fast track basis with a mean postoperative hospital stay of 32.12 hr. Fast track discharges in breast cancer patients after definitive surgery are feasible in Indian setting.

English

To find the ideal drug combinations which can be used during day care surgeries and procedures. AIMS: This study was conducted. To evaluate and compare the efficacy, and haemodynamic stability of ketamine and fentanyl combination with propofol. To compare the incidence of side effects. To compare the time of awakening and recovery time. To compare the discharge criteria in both groups. METHODS: The study was conducted in 50 patients of age group 18-50 years of either gender belonging to ASA grade I and II, were divided into two groups of 25 each. They underwent elective surgery of approximately 1 hour duration. Group I received Propofol- ketamine while group II received Propofol-fentanyl for induction and maintenance of anaesthesia. Postoperatively, time for awakening, recovery time '(by modified Aldrete scoring system) and discharge status (by modified post anaesthetic discharge scoring system) were recorded and compared in two groups. RESULTS: Profol-fentanyl combination produced a significantly greater fall in pulse rate and in both systolic and diastolic blood pressure as compared to Propofol-ketamine during induction and maintenance of anaesthesia. Fall in respiratory rate was greater in Propofol- fentanyl group as compared to Propofol-ketamine group. The recovery time in group I was longer than group II. Discharge criteria is significantly earlier in group II. CONCLUSION: Both Profol- ketamine and Propofol-fentanyl combination reduce rapid, pleasant and safe anesthesia with only a few untoward side effects and propofol-ketamine produces better haemodynamic statistic, during anaesthesia.

Extracorporeal shockwave lithotripsy under sedoanalgesia for treatment of kidney stones in infants: a single-center experience with 102 cases.

We present the efficacy of shockwave lithotripsy (SWL) therapy administered with sedoanalgesia in infants with kidney stones. We enrolled 102 patients aged 5-24 months who had kidney stones and received SWL therapy under sedoanalgesia using a Siemens Lithostar Modularis device. Patient and stone characteristics, therapy parameters, pain score, complications, discharge time, and follow-ups were registered and evaluated. Pain score was assessed using a Neonatal Infant Pain Score (NIPS). Postanesthetic discharge scoring system (PADSS) was used for the assessments of postprocedural discharge procedure. Mean age of the patients was 17.2 ± 6.3 months (5-24 months). Mean stone size was 7.9 ± 3.3 mm (5-23 mm). The most common concomitant metabolic disorders were hypercalciuria and hypocitraturia. The stone-free rates of the infants were 70.6, 87.3, and 99.1 % after the first, second, and third sessions of SWL therapy, respectively. The mean NIPS scores procedure during, and at 1 h after SWL procedure were determined as 0.24 ± 0.45 and 0.34 ± 0.47, respectively. There was no statistically significant difference between two pain score values (P = 0.114). The mean discharge time of patients after the SWL procedure were 108.6 ± 27.9 min. Forty-two patients (41.1 %) were followed up. The follow-up period varied between 8 and 48 months (mean 19.5 months); none of those patients showed evidence of diabetes mellitus, hypertension, or renal function impairment. SWL therapy under sedoanalgesia is a safe and efficient treatment modality that can be administered with low complication rates and high stone-free rates in the treatment of renal stones in infants.

Score de sortie pédiatrique en chirurgie ambulatoire

BackgroundIn adults, the Post-Anesthetic Discharge Scoring System (PADSS) was built to secure the discharge after outpatient surgery. We evaluate a pediatric adaptation: the Pediatric-PADSS (Ped-PADSS). Study designProspective cohort. MethodsThis was a prospective, observational, monocentric study for ambulatory patients. Ped-PADSS is built on 5 items each quoted 0, 1, or 2: hemodynamics, state of awakening, nausea/vomiting, pain and bleeding. A result ≥9/10 validated discharge if the anesthetist did not wish to review the patient, if the parents did not wish to revisit the anesthetist or if there was no hoarseness or dyspnea. The discharge was validated by the anesthetist and the surgeon. Ped-PADSS was made without the knowledge of the nursing team, one hour after return in service and repeated hourly. Addition of patient demographic data, the collection included the hours of leave by the anesthetist, surgeon and Ped-PADSS, the duration of hospital stay post procedure. ResultsOn 150 patients, 148 patients were allowed to go out with the Ped-PADSS, one patient was released despite a Ped-PADSS<9. One patient was hospitalized for a surgical bleeding in agreement with the anesthetist, surgeon and the Ped-PADSS. Ninety-five percent of patients had a Ped-PADSS ≥9 after 2hours monitoring in the ambulatory unit. ConclusionThe majority of the children have met the criteria for discharge at the end of 2hours postoperative monitoring. The use of this score could reduce the hospitalization time in ambulatory unit.

Preoperative intravenous parecoxib reduces length of stay on ambulatory laparoscopic cholecystectomy

BackgroundThe complexity of pain after laparoscopic cholecystectomy (LC) needs multi-module analgesia. Opioids are widely used for perioperative pain but associated with numerous adverse effects. We investigated the effect of parecoxib administrated preoperatively and postoperatively for analgesia after ambulatory laparoscopic cholecystectomy. Methods120 patients scheduled for ambulatory LC with general anesthesia were randomly assigned to three groups: group A received 40 mg parecoxib injection 30–45 min before anesthesia induction and 4 ml saline injection when gallbladder was removed; group B received 4 ml saline injection 30–45 min before anesthesia induction and 40 mg parecoxib injection when gallbladder was removed; group C received 4 ml saline injection 30–45 min before anesthesia induction and the time when gallbladder was removed. We recorded the time achieve to modified Aldrete's score > 9 in the post-anesthesia care unit (PACU) and modified Post-Anesthetic Discharge Scoring System (PADSS) > 9 in ambulatory unit. The visual analog scale (VAS) was used to assess the degree of the postoperative pain in the first 24 h, and the numbers of patients who need additional analgesic and postoperative adverse effects were also recorded. ResultsPatients of group A had a shorter length of stay (LOS) in PACU compared to these of group B and group C (32.4 ± 7.2 min vs. 39.1 ± 10.4 min and 42.2 ± 7.6 min, P < 0.05). Patients of group A also had a shorter discharge time compared to these of group B and group C (148.4 ± 39.3 min vs. 187.9 ± 47.7 min and 223.4 ± 52.5 min, P < 0.05). Moreover, patients of group A experienced reduced pain intensity, less postoperative side effect, and less additional analgesic requirement. ConclusionPreoperative administration of parecoxib for postoperative analgesia provided significant effect on reducing PACU length of stay (LOS) and discharge time, and improving patient outcome after ambulatory LC.