Ambulatory Surgery最新文献

The nature and practice of anesthesiology problematises informed consent, particularly in the ambulatory setting. Timing and time-constraints counter an interactive free flow of information; access to understandable, contextual information forms the basis of free choice by empowering the patient to engage in an interactive conversation with the anesthesiologist, and broadens the base for further discussions and questions. Separate informed consent in anesthesiology is philosophically mandated by the requirement of rationality in choice and respect for personal autonomy, and legally to prevent litigation. The paradigmatic cascade model of consent entails determining competence, supplying information and promoting free choice. Particular measures to counteract the difficulties of anesthesiological informed consent in ambulatory surgery include measures to increase anesthesiologist–patient contact time, and wider use of pre-op clinics. Pre-printed forms are useful but do not replace an interview, tapered to the needs and requirements of the particular patient. Appropriate illustrative material and aids are advised.

Ambulatory surgery in Germany is mostly performed in private units like day clinics, specialized doctor's offices and ambulatory surgery centres. In contrast, hospitals prefer inpatient treatment. Their hierarchical system often inhibited introduction of new techniques like endo-microsurgery. Total costs of tracer procedures are half in private units as compared to hospitals, and this at the same quality level. This points to an inherent inefficiency of the hospital system for most procedures that can be handled on an ambulatory base.

Day-case surgery is convenient and safe allowing patients to have the appropriate medical service without long waits. The issue of safety has been extensively studied and presented in the literature. In this paper, the Security Forces Hospital experience with otolaryngology day-surgery cases is presented.

Objective

To evaluate the rate of complications and their timing and to assess the safety of day-surgery procedures.

Methods

A total of 300 children undergoing tonsillectomy, adenotonsillectomy, adenoidectomy, myringotomy, and other minor surgeries (e.g. reduction of fracture nasal bone, foreign body removal, etc.) were observed. Post-operatively after recovery from anaesthesia, a number of parameters were recorded at intervals of 15 min for the first 4 h, 30 min for the following 3 h, and hourly until discharge. Bleeding was considered to have occurred only if medical attention was required.

Results

In the evaluation of haemorrhage as an important complication, nine cases (3%) bled in the first 6 h (six following adenoidectomy and three following tonsillectomies) after day-surgery procedures, while six cases bled after 3 days (2%). Results were compared with post-operative haemorrhage after operations done in the main OR and there it was reported in 11 out of 101 cases in whom adenotonsillectomy was performed: only one patient (1%) needed control in the OR.

Conclusion

Post-operative complications after day-surgery procedures are comparable to that after main OR procedures. The common paediatric ENT procedures, e.g. adenoidectomy, tonsillectomy, adenotonsillectomy, and myringotomy, can be done safely as day-case procedures in a busy hospital.

One hundred and fifty-five patients were included in this prospective, open, multicenter study to examine the use of nerve stimulation to locate the median and ulnar nerves in ambulatory hand surgery. A sensory response was obtained in 65% of cases and a motor response in 65% with median nerve: the failure to elicit a motor response during median nerve stimulation was related to a higher failure rate of blocks (P = 0.041). A sensory response was reported in 63% and a motor response in 70% of the cases concerning the ulnar blocks: a sensory response was associated with greater success in the ulnar nerve (P = 0.01), while fourth and fifth fingers flexion increased the likelihood of failure (P = 0.075). This technique does not impair the organization of the surgical theatre (4 ± 3 min, mean ± S.D. block performance time) and 96% of patients were satisfied with the technique.

The purpose of this paper is to review pediatric obstructive sleep apnea syndrome (OSAS) with an emphasis on ambulatory adenotonsillectomy. Difficulties in establishing a diagnosis by clinical criteria alone are discussed. Diagnostic tests to establish a diagnosis of OSAS are discussed. The child with severe obstructive sleep apnea is at increased risk for post-adenotonsillectomy respiratory morbidity. The perioperative management with a focus on the ambulatory candidate is discussed.

The child with OSAS presents a challenge to ambulatory surgery because of the high prevalence of OSAS, difficulty in establishing a diagnosis of OSAS and the increased risk of respiratory morbidity.

Twenty-five women receiving sedation for outpatient hysteroscopic polypectomy were injected with 0.25% bupivacaine 10 mL (paracervical group) and another 25 received the same volume of saline (control group) at the cervical fornix. Both groups were given target-controlled propofol sedation during the procedure. More propofol (mg/min) was needed for adequate anesthesia in the control group compared to the paracervical group (6.5 versus 4.6). In addition, the postoperative pain scores were lower in the paracervical group than in the control group. Hemodynamic changes and postoperative side effects were similar in the two groups. This prospective, randomized, double-blind, placebo-controlled study confirmed the effective use of paracervical blocks. This approach has the effect of reducing the amount of intraoperative propofol and decreasing postoperative pain in outpatient hysteroscopic surgery.

This randomized controlled trial compared the clinical outcome from inpatient and ambulatory laparoscopy for benign gynaecological conditions. While 658 consecutive patients were considered for inclusion into the study, data from 26 inpatients and 40 ambulatory cases were analysed. Inpatient surgery was undertaken by more senior surgeons (p < 0.001), but complication rates were similar. For remedial surgery (but not diagnostic), ambulatory laparoscopy had shorter anaesthetic and operating times (p < 0.05) than inpatient surgery. Both inpatient and ambulatory patients reported significant improvements (p < 0.01) in immediate postoperative pain; similar proportions (64% and 74%, respectively) experienced postoperative nausea; 39% of inpatients and 58% of ambulatory patients reported problems after hospital discharge. Severity of pelvic pain was lower for both groups 1 month after operation in comparison to preoperative levels (inpatients: from 8.0 to 5.0, ambulatory: 6.0 to 3.0; on a 0–10 VAS). It was concluded that clinical and patient outcome was similar for the patients undergoing inpatient and ambulatory surgery for gynaecological laparoscopy.

Background

Day case laparoscopic cholecystectomy in the UK is reported in selected patient groups but its role in managing the majority of patients with symptomatic gallstones is unclear. We examined use of the ambulatory surgery unit (ASU) for unselected elective laparoscopic cholecystectomy.

Methods

Data were collected for 1 year. High-risk patients with known bile duct calculi, BMI > 40 and/or previous upper abdominal open surgery were excluded from ASU laparoscopic cholecystectomy. Standard surgical or anaesthetic protocols were used and standard criteria for discharge were employed.

Results

In 1 year, 258 of 275 patients (94%) admitted for elective laparoscopic cholecystectomy via the ASU were discharged within 23 h of admission including 62 patients (23%) discharged on the day of surgery. There were 16 (5%) conversions to open surgery and 10 (4%) unplanned readmissions to inpatient beds. Forty ‘high-risk’ patients underwent laparoscopic cholecystectomy from inpatient beds of which 29 (73%) were discharged within 23 h.

Conclusion

The ASU is the optimal location for elective laparoscopic cholecystectomy to maximize day case throughput and minimize impact on inpatient bed occupancy.

Major ambulatory surgery (MAS) is an alternative to traditional hospitalization. Its goals are to reduce cost while increasing patient safety and satisfaction. The substitution index of MAS has been used to identify those surgical procedures, which present the largest impact in avoidable stays. There is a wide margin for improvement in relation to the performance of MAS. Five DRG's account for more than 50% of the avoidable stays. To promote MAS, it would be necessary to introduce changes in financing and incentive policies, include new procedures, review clinical guidelines and establish benchmarking strategies.