Anesthesia for day surgery nov 2006

A n e s t e s ia in d a y s u r g e r y
t e c n ic h e e f a r m a c i
fa

C la u d io M e llo n i
Di r et t or e S er v i zio di Anest es ia e Ri ani m azion e O s peda le di F aenza
Di r et or e S er v
di Anes t es ia e Ri ani azion e s peda le di F aenza

Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)

Perché la amb surg ?
beneficio economico finanziario sotto pressione
economica…………….
abbattimento dei costi
riduz personale dei turni notturno/festivi
possibile per
miglioramento delle tecniche chir
miglioramento tecniche anest


Problema

mantenimento qualità
/riduz della spesa
i farmaci per anest rappresentano il
5-6% della spesa farmaceutica totale


Valutazione qualitativa:
macroindicatori
(1) Mortalità/morbidità.
 (2) Prolungamento della degenza postop .
 (3) ricovero ospedaliero non programmato.
 (4) visite di controllo precoci/riammissione in
ospedale
 (5) soddisfazione del paziente

Mortalità e morbilità


Mortalità e morbilità

Misure piuttosto grossolane
Warner MA, Shields SE, Shute CG. Major
morbidity and mortality within one month of
ambulatory surgery and anesthesia. JAMA
1993; 270:1437±1441.
38 598 paz,4 decessi <30 gg :2 MI e 2 incidenti auto,
31 (0.08%) casi di morbilità maggiore;MI,emb polm,insuff
resp...

Nessun decesso perioperatorio
3 grossi studi da 6000 a 17600 paz;
» Duncan PG, Cohen MM, Tweed WA, et al. The Canadian four-centre
study of anaesthetic outcomes: III. Are anaesthetic complications
predictable in day surgical practice? Can J Anaesth 1992; 39:440-8.
» Osborne GA, Rudkin GE. Outcome after day-care surgery in a major
teaching hospital. Anaesth Intensive Care 1993; 21:822-7.
Chung F, Mezei G. Intraoperative adverse events during ambulatory
surgical procedures. Can J Anaesth 1997; 44:A70A.

Morbilità 4 % / 5 % secondo intervento ,ma
includono anche le KO minori che non
compromettono la vita del paz

Natof HE. Complications associated with
ambulatory surgery. JAMA 1980; 244:1116-8.

Nessun decesso
106 patients (0,8 %) su 13 433 Ko chir
Entro 15gg dall’intervento.


Modificazioni negli anni
Ma
» aumento della complessità delle procedure
» Aumento delle patologie coesistenti: comorbidità
» Aumento dell’età media

Varranno le stesse cifre citate?


Complicanze maggiori nella casistica
ambulatoriale della Mayo Clinic (1994):
3220 casi
PAZIENTI CON I.M:

ETÀ,SEX INTERV
,ASA
ENTO

FATTOR ANEST.
I DI
RISCHIO

54,F,II

IPERTENS

BIOPSIA

T.PRESE
NTAZ.

SINTOMI

A.G.

INTRAOP

EPA

FUMO,CAD

A.G.

6 H.

IPOTENS

NO

REG

12 H

DOL.TOR.

MAMM.

62,M,II

BIOPSIA
CORDE

78,M,III

CARPAL
TUNNEL

73,F,II
63,F,III

BUNIONECT

OBESITÀ

REG

COPD,IPERT

A.G.

12 H
24 H

SINCOPE

CISTOSCOPIA

58,M.I

ARTROSCOPI

NO

A.G.

36 H

DOL.TOR.

FUMO,CAD

MAC

36 H

DOL.TOR.

DIABETE

A.G.

42 H

SINCOPE

MALIGNITÀ

A.G.

48 H

DOL.TOR.

NO

REG

3 GG.

SINCOPE

NO

A.G.

4 GG

DOL TOR.

LAPAROSCOPI

ARITMIA,CA

A.G.

7 GG.

SINCOPE

A

DF

ERNIORRAFIA

IPERTENS

A.G.

8 GG

DOL.TOR.

NO

MAC

11 GG

NAUSEA

DOL.TOR.

A GINOCCHIO

74,M,III

BIOPSIA
LINGUA

85,M,III

URETEROSCO
PIA

48,F,II

BIOPSIA
LGH.CERVIC

66,M.I

RILASC.TEND
IN.

83,F,II

RIDUZ
FRATT.NASO

61,F,III
70,M,II

INGUIN.

6PAZEINT
IP

COLONSC
OPIA


Complicanze maggiori nella casistica
ambulatoriale della Mayo Clinic (1994):
9018 casi
Frequenza
0.035
0.03
0.025
0.02
%
0.015
0.01
0.005
0

MI

def.CNS


Emb.polm

Ins.Resp

Deficit neurologici dopo
anest.amb.in 6441 paz
età,se interv
x,ASA
79,f,III

lapar.

61,m,II
72,m,I
60,f,II
71,m,II

graft cut.
ernior.
cisto
biops.
prost.
biops.
lgh.cervic

74,m,II

cofatt. anest. tempo sintom
.
A.G.
mal.carot,i A.G.
pertens
diab.
reg
no
A.G.
mal.carot. A.G.
mal.carot. MAC

intrao
12 h

67,f,II
afasia

12 h
24 h.
48 h
7 gg

confus.
def.vista
emipl
afasia

aritm.

18 gg

perdita
memoria

A.G.


aritm.

Complicanze emboliche polmonari dopo
anest.ambulat. su 9018 pazienti

età,s inter cofat anest temp sinto
ex,A v
t.
.
o
m.
SA
D&C

fumo

56,m,I ureter malig
I
osc. n.
63,f,I imp.d no
ent.
48,m,I biops. malig
II
axill. n.
38,f,III biops. mal.n
musc. eurom

A.G.

24h.

A.G.

24h

A.G.

7 gg

A.G.

13 g

MAC

22gg


dispn
ea
dispn
ea
emoft
oe
dispn
ea
dispn
ea

Complicanze respiratorie su 9018
anest.ambulat.
età,se interv cofatt. anest
x.ASA

occorr sintom
.

21,f,I

intrao

41,f,II
68,m,II
82,f,III
71,m,II

tonsillec
t.
biops.m
amm.
polipect.
nas.
lapar.

no

A.G.

ipertens A.G.

10 h

fumo

A.G.

48 h

CAD

A.G.

4 gg.

reg

5 gg

rip.tend obes.
on


asp.pol
m
asp.pol
m
tosse,fe
bbre
asp
polm.
tosse,fe
bbre

Relazione fra ASA,morbidità e
mortalità
da Warner,JAMA,1994
% o num
50
40
30

19614
14609
%

10867
%

%

20
n

10
0

31 eventi patol,magg.
4 morti

ASA 1

ASA 2

n
ASA 3


%tot
morbil(n)
mortalità

Incidenza delle complicanze in
relazione alle patologie
1.40

da White,1994,Blckwell Sci.Pub.

1.26
1.12
0.57

%

0.43
0.28
ipertens

0.14
0.00

diabete

asma

COPD


mal.card

Incidenza delle complicanze in relazione
alla durata dell’anestesia
3
2.5

%

2

1.5
1
0.5
0

<1 h

1-2 h

2-3 h


>3h

Incidenza delle complicanze secondo
l’anestesia somministrata:
1
0,9
0,8
0,7
0,6
0,5
0,4
0,3
0,2
0,1
0

da White,1994,Blackwell Sci.Pub.

loc solo reg.solo

LoR+
sed


A.G.

Quali sono le KO più frequenti
della chir ambulat?
***************************************


Chung F, Mezei G, Tong D. Pre-existing medical conditions as
predictors of adverse events in day-case surgery. Br J Anaesth
1999; 83:262±270.

Sono le condizioni preop che
condizionano le Ko postop !


Complicanze cardiovasc
Anomalie pressione art:ipo/ipertens circa 2%, ma i
finlandesi 16%°di ipotensioni
Disordini del ritmo;bradicardia,tachicardia ,aritmie
:finlandesi 14%
» Differenze metodologiche

Complicazioni più frequenti nei pazienti che presentano
già problemi cardiovascolari (ipertens;insuff cardiaca)
» Duncan PG, Cohen MM, Tweed WA, et al. The Canadian four-centre study of anaesthetic
outcomes: III. Are anaesthetic complications predictable in day surgical practice? Can J
Anaesth 1992; 39:440-8.
» Chung F, Mezei G. Intraoperative adverse events during ambulatory surgical procedures.
Can J Anaesth 1997; 44:A70A.
» Heino A, Vainio J, Turunen M, Lahtinen J. Results of 500 general surgery patients operated
on in the ambulatory surgical unit. Ann Chir Gynaecol 1992; 81:295-9.

Complicanze respiratorie
Frequenza< 1 %.
Laringospasmo,broncospasmo,con o senza
desaturazione
» (ma anche con apnea ,aspirazione,pnx,EPA)

KO legate
all’intubazione;difficile,esofagea,danni
dentari:0,2 – 0,5 %
Caratteristiche dei pazienti strettamente legate:
» Fumatori,obesi,asmatici da da 2 à 5 +

Le complicazioni postop sono predicibili?


Duncan PD, Reccan PG, Cohen MM, Tweed WA. The Canadian Four
Centre Study of anaesthetic outcomes: are anesthetic complications
predictable in day surgical practice? Can J Anesth 1992; 39:440±448.

6914 paz.
Maggior parte giovani: 84.2% < 50 anni
3.1% anestesia a paz >70 ; 0.8% > 80 years of
age.
Maggior parte di interventi donne giovani ASA I o
II
3% ASA III.
> 75% dei paz nessuna patol preesist

Complicanze in 4 centri ospedalieri canadesi di day surgery
uncan PD, Reccan PG, Cohen MM, Tweed WA.The Canadian Four
predictable in day surgical practice? Can J Anesth 1992; 39:440±448

16
14

intraop

per mille

12
10
8
6
4
2
0

frequenza

sbalzi press
aritmie
intub diff
probl resp
modificaz anest
probl attrezz
incid farmaci
ICU adm

Complicanze in 4 centri ospedalieri canadesi di day surgery
Duncan PD, Reccan PG, Cohen MM, Tweed WA.The Canadian Four

80
70

per mille

60

Nella PACU

50
40
30
20
10
0

frequenza


sbalzi press
ipotermia
PONV
probl resp
probl renali/metab
probl musc
psicol
ustione

Incidenza di complicanze postoperatorie all’intervista
telefonica a 72 :25% dei pazienti Osp A,64% Osp C.
Duncan PD, Reccan PG, Cohen MM, Tweed WA.The Canadian Four


Incidenza di complicanze postoperatorie all’intervista
telefonica a 72 h :risposte da 25% dei pazienti Osp A,64% Osp
C. Duncan PD, Reccan PG, Cohen MM, Tweed WA.The Canadian Four Centre Study of
anaesthetic outcomes: are anesthetic complications,predictable in day surgical practice? Can J
Anesth 1992; 39:440±448

40
35
30
25
%

20

OspA
Osp C

15
10
5
0
s
es

l

ti
at
sf
di

en
ar

cu

a
ol

so
or

t

d
so
in

w
A

l.d
do

s
re
pa

lo

g
di

s

in
pa

he

ea

it

ob
pr

al
m

om
V

us
na

ac

e

s
ne
si
ow
dr

ad
he

cl
us
m


Relazione fra condizioni preop e KO

Duncan PD, Reccan PG, Cohen MM, Tweed WA.The Canadian Four Centre Study of anaesthetic
outcomes: are anesthetic complications,predictable in day surgical practice? Can J Anesth 1992;
39:440±448

Patologia di base

complicanza

COPD

Tratto resp inf

ipertens

Instabilità press

neurol

cardiache

COPD & ipertens

cardiache

diabete

cardiache

Insuff digiuno

Probl pressori

obesità

parecchie

Intub difficile

Probl intubaz


Postoperative symtoms at telephone interview 24 hr.

Chung F,Mezei G, Adverse outcomes in ambulatory anesthesia .Refresher Course Outline.Can J
Anesth 1999 / 46 / R18-R26
Chung F,Un V, Su J .Postoperative symptoms 24 hours after ambulatory anaesthesiaCAN J
ANAESTH 1996 / 43: 11 /

778 pazienti
30.0
25.0

1017 pazienti

20.0

General surg 17.4%
orthopaedic, 11.2%
laparoscopic 9.4%.

laparoscopy 36.1%,
general surgery, 21.4%.

% 15.0

laparoscopy, 24.1%,
general surgery, 16.1%.

10.0
5.0
0.0

pain at surgical site

headache

drowsiness


dizziness

ponv

fever

% di interferenza con le normali attività quotidiane
nei pazienti con dolore > VAS 4

.

Beauregard L, Pomp A, Choinière M.Severity and
impact of pain after day-surgery .Can J Anaesth 1998 / 45 / 304-11

livello di attività
umore
cammino
lavoro
relaz.personali
sonno
piaceri della vita
appetito
concentraz.
interferenza con 3 o + funzioni

100
80
60
40
20
0

24h

48h


7gg

Qualità della ripresa
funzionale=soddisfazione del paziente
Physiologic endpoints

Adverse events


Differenti punti di
vista:
Paziente
Ospedale
Struttura
Assicuraz…

Psychosocial status

Ma dove è la qualità??
Aprile 2001
Lavoro sul fast tracking di bambini a Washington
31% dei genitori riferiscono che il 40% dei loro
bambini è stato molto irrequieto dopo il fast tracking
rispetto al 16%dei piccoli rimasti nella PACU….
Percio’……gli autori…….

Concludono che il processo è fattibile e
tecnicamente vantaggioso per i piccoli!!!

Dove è la qualità???
1000 plastiche erniarie inguinale in anestesia locale non
monitorizzata(ULA)
Anesth.Analg.2001;93:1373
940 questionari postop di ritorno:121 insoddisfatti principalmente a
causa del dolore intraop.
Conclusioni:la plastica erniaria open puo essere

agevolmente effettuata in ULA;offre una sicura
alternativa ad altre tecniche anestetiche con un
acettabile grado di soddisfazione;anche se il sollievo
intraop del dolore necessita di miglioramenti!!!!……..


Anche i migliori………..
Febbr 2001; il gruppo di Dallas paragona
remifentanil con esmolol per la stabilità
cardiovascolare durante laparoscopia ginecol.
:immaginate un poco….:il gruppo remifent accusa
+ nausea nel postop e quello esmolol necessita di
due volte il dosaggio di idrossicodone postop….
Conclusioni:la tecnica è eccellente nell’80% dei
casi……………

Apparenza vs sostanza

Viviamo forse in un
mondo ove cio che è
facilmente misurabile
nasconde cio che è
importante ???


Ricoveri ospedalieri non
programmati

0.28-2.44% adulti;1% bambini
» Fancourt-Smith PF, Hornstein J, Jenkins LG. Hospital
admissions from the day care centre of the Vancouver
General Hospital. Can J Anaesth 1990; 37:699-704.
» Cause chir 0.22%
» Cause anest:0.07%


Ripartizione delle complicanze che portano al ricovero
non programmato
90
80
70

%

60

max
min
media

50
40
30
20
10
0
chir

Sanguinamento
Ko chir

anest

Dolore
Ponv
…..

medic

social

Peggior condiz preesis
Diabete,angina,OSA,
Ko intraop;aritmie,MI,broncospasmo


Unplanned hospital admissions
Day Surgery Toronto Western Division
8/1017


Vuilleumier H, Halkic N.Laparoscopic cholecystectomy as a day surgery
procedure: implementation and audit of 136 consecutive cases in a
university hospital .World J Surg. 2004 Aug;28(8):737-40.

136 paz consecutivi:
» dimissione:74% overnight stay;24% stesso giorno

3 ricoveri non programmati:
» 2 PONV ed 1 caso di ematoma epatico
subcapsulare:diventano 3 su 33……….


Rognas LK, Elkjaer P. Anaesthesia in day case laparoscopic
female sterilization: a comparison of two anaesthetic
methods.Acta Anaesthesiol Scand. 2004 Aug;48(7):899-902.
propofol + fentanyl/alfentanil, N2O and atracurium,
vs TIVA with propofol + remifentanil.
Postop pain :high doses paracetamol + NSAID.

14
12
10
%

alfent
remifent

8
1.8% su 683
Sterilizzaz laparoscopiche

6
4
2
0

pain

PONV


unplanned hosp
admission

Tham C, Koh KF.Unanticipated admission after day
surgery.Singapore Med J. 2002 Oct;43(10):522-6.
70

10801 procedure;1.5% ricoveri non
progr

60
50

75%
prevenibili

40
30
20
10
0

surgical

anesth.


social

medical

Cause di ricovero non programmato post colecistectomia
laparoscopica

.:Lau H, Brooks DC. Predictive factors for unanticipated admissions after

ambulatory laparoscopic cholecystectomy. Arch Surg. 2001 Oct;136(10):1150-3

10
9
8
7
6
5
4
3
2
1
0

1.36%

Significant factors associated with unplanned
25/731=3.41%
admission :
operative duration >60 minutes
thickened gallbladder wall on US
pathological findings.
length of operation
the only independent predictive factor

0.82%

0.68%
0.41%

pain

ponv

urin.retention


pat prfeference

medical observation

Calland JF, Tanaka K, Foley E, Bovbjerg VE, Markey DW,
Blome S, Minasi JS, Hanks JB, Moore MM, Young JS, Jones
RS, Schirmer BD, Adams RB
Outpatient Laparoscopic Cholecystectomy:
Patient Outcomes After Implementation of a Clinical Pathway

12

134 VLC,28% ricoveri non programmati,fase sperimentale…

10
8
6
4
2
0

pain

ponv

osservaz

pt preference


late finish

ipossiemia

??

coledocolitiasi

Armstrong M, Mark LJ, Snyder DS, Parker SD.
Safety of direct laryngoscopy as an outpatient procedure.
Laryngoscope. 1997 Aug;107(8):1060-5
589 direct laryngoscopies performed at a new outpatient
surgery center.
9 unplanned admissions to the hospital:
» 5 airway emergencies that developed within the first 30 min
after extubation:3 patients required reintubation before leaving
the operating room.

On postoperative telephone follow-up, 9% complained of
mild to moderate sore throat
no major complications after discharge
risk of airway emergencies after direct laryngoscopy is
less than 1% in carefully selected patients

Groin hernia surgery: a systematic review.
Cheek CM, Black NA, Devlin HB, Kingsnorth AN, Taylor RS, Watkin
DF. The Royal College of Surgeons of England. Ann R Coll Surg Engl.
1998;80 Suppl S1-80 .
The main methodological shortcomings of the studies
that have been performed are:
lack of agreed method for assessing severity of
hernias;
failure to take confounding into account in nonrandomised studies;
variation in length of follow-up; poor external validity;
lack of objective measures of outcome;
inadequate statistical power.
These problems severely limit the conclusions that
can be drawn from the literature


Visite di ritorno non programmate


Visite di ritorno entro 1 mese/riammissioni in ospedale
Durante:
» le prime 24-72 h: 4-8% di paz visitati da un medico(GP)

Nel primo mese: 12%
Ricovero in ospedale:0.3%
»
»
»
»
»
»

sanguinamento
Febbre
Infezione
Dolore
Deiscenza ferita
Ritenzione urinaria

Twersky R, Fishman D, Homel P. What happens after
discharge? Return hospital visits after ambulatory surgery.
Anesth Analg 1997; 84:319±324
6243 paz
1.3 % rientri in osped entro 1 mese
5.4% in PS
4.6% ricoverati
Interv e cause dei ricoveri:
» Varicocelectomia:
» Idrocelectomia
» D & C: 3 volte+

8.3 volte

» Sanguinamenti!
²

Interventi e dimissioni
autori

intervento

dimissione

riammissione

Tot paz

De Waele Outpatient laparoscopic
gastric banding: initial experience.
Obes Surg. 2004 Sep;14(8):1108-10

Gastric
banding
laparosc

9.6 h

no

10

Edwin
Outpatient laparoscopic splenectomy:
patient safety and satisfaction. Surg
Endosc. 2004 Sep;18(9):1331-4.

Splenect video
lap

2;16.6%

12

Athey. Day-case breast cancer axillary
surgery.
Ann R Coll Surg Engl. 200587(2):96-8.

Nodulect
quadrantec
+ascella

9.7%

165

MacDonald Minimal impact
urethroplasty allows same-day surgery
in most patients. Urology. 2005
Oct;66(4):850-3.

Uretroplast ant

15%

54

Dieter RA JrRemote surgicenter
experience with hernia repair. Int Surg.
2005 Jul-Aug;90(3 Suppl):S2-5.

ernioplast

6 paz:0.22%

2659

No drenaggio


Morales R, Esteve N, Casas I, Blanco C. Why are
ambulatory surgical patients admitted to hospital?
Prospective study. Amb Surg 2002; 9:197±205.

. More

extensive surgery
than planned, and
bleeding are the two most
common.


Chirurgia di giorno e obesità
Linee guida dell’ UK Royal College of Surgeons 1992 :

Pazienti con BMI >30 non adatti per chir amb
Inchiesta questionario postale UK:2004: 85% delle unità
trattato pazienti con BMI >30
» Atkins M, White J, Ahmed K. Day surgery and body mass index:
results of a national survey. Anaesthesia 2002; 57:180±182.

I dati di questa inchiesta postale suggeriscono che
probabilmente I criteri di esclusione si applicano solo agli
obesi patologici,cioè con >35 BMI.

Insoddisfazione del paziente

Con anest
» Anest inadeguata durante mac
» Ponv
» Mal di gola
» Associaz con il numero di sintomi sviluppati


Insoddisfazione dei pazienti Tong,D,Chung F,Wong

D.Predictive Factors in Global and Anesthesia Satisfaction in Ambulatory Surgical Patients
CLINICAL INVESTIGATION Anesthesiology, 87:856-64, 1997

Insoddisfatti 68 su 2,730 (2.5%)
9 scontenti dell’anestesia
Scontento globale associato al numero dui sintomi
spiacevoli postop
La preferenza personale per il ricovero costituisce la
causa più frequente di scontento con la chir
Eventi avversi intra e postop sono le cause principali
di scontento con l’anestesia

Chung F,Mezei G. Adverse outcomes in ambulatory
anesthesia .Refresher Course Outline.
Can J Anesth 1999 / 46 / R18-R26


PONV

Postoperative nausea &
vomiting


Importanza dell’argomento
PONV è :
» Un fattore limitante nella dimissione precoce
» La I o II causa di ammissione ospedaliera non
programmata
» PONV può :
» Allungare la degenza postop
» Accrescere il lavoro degli infermieri
» Aumentare i costi totali dell’assistenza
» Causare elevato discomfort
» Contribuire alla mancanza di soddisfazione

Junger A, Klasen J, Benson M, et al. Factors determining
length of stay of
surgical day-case patients. Eur J Anaesthesiol 2001; 18:314±321
3152 paz
ambulatory surgery all’Ospedale della Justus-Libig Università dal 1997.

Fattori importanti nel prolungamento della degenza :5.4%













Hb
Perdite ematiche
Sesso femminile
Età avanzata
Durata chir
Infusioni abbondanti
Intubazione
Anest.spinale
Oppioid intraop
Rilassanti nondepolarizzanti
Dolore + al VAS
PONV
tempo di attesa prolungato preop

Allora,poichè sono gli interventi
chirurgici a decidere nella maggior
parte dei casi se il paziente è gestibile
in regime di day surgery……………


Quali procedure?
effettuabili in un tempo “ragionevole”
non accompagnate da perdite ematiche
o idro-elettrolitiche importanti
che non richiedono attrezzature
sofisticate o cure specializzate postop
seguite da dolore postop.che può
essere tenuto sotto controllo dal
paziente al proprio domicilio

quali pazienti?
sani solamente?ASA 1?
ASA>1,ma con patologie stabilizzate
collaboranti
accompagnati a casa da un adulto
responsabile...............
capaci di seguire le istruzioni pre e
postop.
problemi degli anziani

Criteri di selezione dei
pazienti
fisici
medici
chirurgici
sociali


laparo vs open
tempo operativo:+++
degenza osped:+
costo attrezz:+++
tempo apprendim:++
lavoro perduto:+
COSTI:??

+
+++
+
+
+++
??


dalla laparocolecistectomia & dalla
laparoscopia ginecologica ad altri interventi
chirurgici.............

erniolaparo....
appendicolaparo......colectomia.
chir. pelvica---isterectomie
laparoscopiche..........
ablazione endometriale vs TAH:LASER
microdiscectomia lombare
uretroplastica transcistoscopica

Altri indicatori di qualità
Microindicatori?


Altre misure di qualità .nel postoperatorio

Dolore
Ponv
Sonnolenza
Gir di testa
Soddisfaz del paz
Ripresa funzionale postop
cefalea

Sintomi accusati dai pazienti a casa dopo interventi
eseguiti in regime di day surgery(da Wu et
al.,Anesthesiology 2002).

dolore
nausea
vomito
cefalea
sonnolenza
gir.di testa
fatica


Quali problemi preferirebbero evitare i pazienti sottoposti a
day surgery?

(da Jenkins, K.; Grady, D.; Wong, J.; Correa, R.; Armanious, S.; Chung,

F.*Post-operative recovery: day surgery patients' preferences
Br. J. Anaesth. 2001; 86:272-274)

30

Valori relativi !

25

dolore
tossire sul tubo et
vomito
nausea
disorientamento
mal di gola
brivido
sonnolenza
sete

20
15
10
5
0


Beauregard L, Pomp A, Choinière M.
Severity and impact of pain after day-surgery Can J Anaesth
1998 / 45 / 304-11


fatica

raucedine

mal di gola

cefalea

sonnolenza

gir.testa

PONV

I g.
II g
VII g

dolore

100
90
80
70
60
% 50
40
30
20
10
0

Applicazioni cliniche


Vantaggi dellla anestesia e
Vantaggi dellla anestesia e
chirurgia ambulatoriali
chirurgia ambulatoriali
diminuita separazione da casa/ambiente/lavoro..........
diminuzione delle infezioni ospedaliere
riduzione dei costi
maggiore flessibilità
diminuzione delle liste di attesa

Scopi della anestesia in day surgery( E NON SOLO DAY
Scopi della anestesia in day surgery( E NON SOLO DAY
SURGERY....)
SURGERY....)
Pre,intra e postop....
Pre,intra e postop....

Ansiolisi
Sedazione
Analgesia
Ipnosi
Amnesia
Protezione dall’insulto chirurgico e dai riflessi indesiderati
indesiderati
Riduzione del rischio di reflusso gastrico acido
rischio
gastrico acido
Profilassi della nausea e del vomito,del dolore postop…..
della nausea
vomito,del dolore

interventi possibili sotto MAC
sedazione +/-anestesia topica
endoscopia GI,bronco,...
ESWLT
TVOC,IVFT
radiologia diagnostica-terapeutica


sedazione +/-anestesia locale o
blocchi regionali
angiografia,pacemaker,caterizzazione vascolare protratta,filtri
venosi....
cure dentarie estrattive-conservative
chirurgia oculare
escissione di lesioni superficiali
chirurgia dei seni e polipectomia
artroscopia,tunnel carpale,chir .ortop.minore...
septorinoplastica,chir.cosmetica
vasectomia,orchidopessia
D&C,chir perineale,procto inclusa

con sedazione e anestesia
regionale
cistoscopia,TURP,TURV...
artroscopia e chir ortop...
D&C,isterectomia vaginale,chir perineale,plastiche vaginali...
erniorrafia,emorroidectomia...


Patient satisfaction;la soddisfazione del
Patient satisfaction;la soddisfazione del
paziente.......
paziente.......
Patient satisfaction after anaesthesia and surgery: results of a prospective survey of 10 811 patients†
Patient satisfaction after anaesthesia and surgery: results of a prospective survey of 10 811 patients†
Clinical Investigation Br. J. Anaesth. 2000; 84:6-10
98% soddisfatti su 10500
98% soddisfatti su 10500
fattori associati con la insoddisfazione:
fattori associati con la insoddisfazione:

intraoperative awareness
intraoperative awareness

moderate or severe postoperative pain
moderate or severe postoperative pain

severe nausea and vomiting
severe nausea and vomiting

other postoperative complications
other postoperative complications


Criteri di scelta della tecnica anestetia
condizioni intraoperatorie ottimali
rapido ritorno di coscienza
effetti sedativi residui minimi
minimo disturbo delle condizioni cognitive postop
assenza di effetti collaterali durante il I periodo di
ripresa;PONV minimi per precoce deambulazione e
dimissione

Riprese "elementari"
Riprese "elementari"
capacità di esprimere nome e
cognome
esecuzione di ordini semplici
data del giorno

criteri di dimissione
criteri di dimissione
capacità di stare seduto
capacità di assumere la posizione eretta
capacità di vestirsi
capacità di camminare
capacità di bere
capacità di urinare
altre...................

Criteri di dimissione
segni vitali stabili >30 min
segni vitali stabili >30 min
assenza di nuovi sintomi postop.
assenza di nuovi sintomi postop.
assenza di sanguinamento o secrezioni dalla incisione
assenza di sanguinamento o secrezioni dalla incisione
no PONV( o minima...)
no PONV( o minima...)
funzione neurocircolatoria normale alle estremità dopo chirurgia degli arti
funzione neurocircolatoria normale alle estremità dopo chirurgia degli arti
minimo capogiro in piedi
minimo capogiro in piedi
dolore sotto controllo con analgesici orali o altro...
dolore sotto controllo con analgesici orali o altro...
minzione?(cistoscopia.....)
minzione?(cistoscopia.....)
accompagnatore affidabile
accompagnatore affidabile

Score di dimissione


PADSS di Chung

Practical issues in outpatient anaesthesia: Discharge criteria - a new trend .Chung, Frances.
Department of Anaesthesia, University of Toronto, Toronto Hospital, University of Toronto, Toronto, Ontario,
Canada.CAN J ANAESTH 1995 / 42: 11 / pp1056-9


MPADSS di Chung


Modified Aldrete Score


Patel RI,Verghese ST,Hannallah RS,Aregawi A,Patel K
M..Fast-Tracking Children After Ambulatory Surgery
Anesthesia and Analgesia 2001; 92:918-922


Criteri dimissione di Oxford nel
cestino di Vaio internet


Scelta della tecnica
Scelta della tecnica
The goal is to anaesthetize the patient for the shortest possible time with the
lowest concentration of anaesthetic.

esigenze chirurgiche
considerazioni anestetiche
condizioni del paziente
preferenze del paziente

Scopi della tecnica di anestesia scelta
condizioni intraop.ottimali
rapida ripresa della coscienza
minimi strascichi sedativi
minimo disturbo delle condizioni cognitve postop.
assenza di effetti collaterali(PONV...)
possibilità di rapida dimissione e deambulazione precoce
ripresa rapida delle normali attività

Sicurezza
Sicurezza
assenza di effetti collaterali
rapidità induzione
rapidità induzione

Propofol
Propofol
Remifentanil
Remifentanil

rapido risveglio
rapido risveglio

Propofol
Propofol
Remifentanil
Remifentanil

minimi effetti cardiovascolari
minimi effetti cardiovascolari

midazolam
midazolam

modesta depressione respiratoria
modesta depressione respiratoria

midazolam
midazolam

assenza di PONV
assenza di PONV

propofol
propofol
midazolam
midazolam

analgesia postoperatoria
analgesia postoperatoria

Ketorolac
Ketorolac
Tramadol
Tramadol

Caratteristiche dei nuovi farmaci
inizio e scomparsa di azione rapide
assenza di residui o code anestetiche
assenza di effetti collaterali(hangover)o
nessuna necessità di antagonizzazione….
assenza di effetti collaterali;istaminoliberazione,effetti cardiovascolari…
predicibilità durate
sicurezza
indipendenza da biotrasformazione da organi….

Nuovi farmaci
Nuovi farmaci
day anestesia-day surgery
ipnotici & sedativi
analgesici,sistemici & locali
adiuvanti
miorilassanti

barbiturici,propofol
benzodiazepine
derivati del fentanile
derivati amidici
antiemetici
analgesici FANS
benzilisochinoline
aminosteroidei

Debate
Debate
Gas vs TIVA
Gas
advantages

disadvantages

induction without
vein

pollution

easy maintenance

Point three

easy recovery
familiar...

Ponv...

Debate
Debate
TIVA
Advantages
no pollution
smooth
emergence...
postop.analgesia
smooth induction
(after i.v...).

Disadvantages
knowledge of
pk-pd
less easy
less reversible

Le tecniche di sedazione
da sole
in associazione a:
anestesia locale:infiltrazione
tissutale,della
cicatrice,topica(EMLA,spray,gel,pasta...)
anestesia di nervi e/o plesso
anestesia regionale e.v.
A.R.spinale o peridurale

obbiettivi della sedazione
concetto di MAC
ansiolisi
sedazione
analgesia
(amnesia)


sedazione +/-anestesia locale o
blocchi regionali
angiografia,pacemaker,caterizzazione vascolare protratta,filtri venosi....
cure dentarie estrattive-conservative
chirurgia oculare
escissione di lesioni superficiali
chirurgia dei seni e polipectomia
artroscopia,tunnel carpale,chir .ortop.minore...
septorinoplastica,chir.cosmetica
vasectomia,orchidopessia
D&C,chir perineale,procto inclusa

definizione di MAC(ASA)
“circostanza in cui l’anestesista è chiamato per
fornire un servizio anestetico specifico ad un
paziente sottoposto a procedura di elezione
durante la quale il paz.riceve o no anestesia
locale .In tale caso l’anestesista offre un servizio
specifico al paziente e controlla i suoi segni vitali
ed è disponibile a somministrare anestetici o altre
cure mediche come indicato”


definizione di MAC(ASA)
DEVE:
essere stata effettuata una visita con valutazione preop;
essere stata prescritta l’ assistenza anestetica necessaria;
esservi una partecipazione personale o la direzione medica di
tutto il piano assistenziale;
esservi la presenza fisica continua dell’anestesista o dello
specializzando o della infermiera sotto direzione medica
esistere la vicinanza o nel caso della supervisione la disponibilità
dell’anestesista per la diagnosi o il trattamento delle emergenze


per la MAC:
monitoraggio usuale noninvasivo
cardiovascolare e respiratorio
somministrazione di O2 se indicata
somministrazione di terapia
farmacologica(sedativi,tranquillanti,antie
metici,narcotici,analgesici,betabloccanti,
vasopressori,broncodilatatori,antiiperten
sivi)indicata.

Intubation without muscle
relaxant
midaz 0.03 mg/kg e alfent 40 microgr/kg
18
16
14
12
10
8
6
4
2
0

eto 0.3
eto 0.3 + lido
prop 2 mg
prop + lido
tps 4 mg
tps + lido
dtc/tps/scc
open

midline

closed


Intubation without muscle
relaxant
midaz 0.03 mg/kg + alfentanil 40 microgr/kg
16
14
12
10
8
6
4
2
0

no movem

2 coughs

cough + or
mov+


eto 0.3
eto 0.3 + lido
prop 2 mg
prop + lido
tps 4
tps + lido
dtc/tps/scc

II miorilassanti
miorilassanti
sempre meno paralisi residue....
più sicurezza
Atracurium & Vecuronium
Mivacurium
Mivacurium
Cisatracurium
Cisatracurium
Rocuronium
rapacuronium

Finalmente una nuova era dal'epoca della dtc e pancuronium...
Finalmente una nuova era dal'epoca della dtc e pancuronium...
Sicurezza nella ripresa,eccetto ii deficit di pseudocolinesterasi...
Sicurezza nella ripresa,eccetto deficit di pseudocolinesterasi...

Affinamento degli effefti collaterali
Affinamento degli effefti collaterali

onset rapido
onset rapido

onset e offset rapidi
onset e offset rapidi


Benzilisochinoline

Glaxo
Wellcome
Degradazione spontanea

aminosteroidi

Organon
Teknika

Metabolizzazione epatica

I miorilassanti oggi:
vecuronium atracurium mivacurium rocuronium cisatracuriumrapacurium
lib.istamina no
no
ipotens
tachicardia no
conservazione ok
confezione polvere
laudanosina no
metabolismo epatico
escrez renale si

si

si

no

no

no

si

si

no

no

no

si

si

si

no

no

freddo

freddo

ok

freddo

ok

pronto

pronto

pronto

pronto

?

si

no

no

(si)

no

Hoffman

pseudocolinest epatico

Hoffman

epatico

no

no

no

si


si

Criteri di scelta dei miorilassanti
in day surgery-day anesthesia
Conoscenza dei tempi chir e anest;
dosi non >1-1.5 ED 95;
monitoraggio ;
vietati i miorilassanti a durata lunga:
evitare antagonismo se possibile
scelta fra:
» Rapacuronium,rocuronium vecuronium
» mivacurium,atracurium,cisatracurium .

Quoziente di sicurezza:
ED95 istaminoliberatrice/ED95 blocco nm.
8
7
6

??

5

atrac
mivac
cisatrac

4
3
2
1
0

safety factor

Future trends
Miraculorium

» fast onset & offset,senza
cumulatività……..
» no metaboliti attivi
» indipendente da organi
» no effetti cardiovascolari
» (selettivo per gruppi muscolari…)

Antagonismo
Ma se si dimostra che la
gammaciclòdestrina(SUGAMMADEX R )non ha
effetti collaterali(diversamente da atropina e
prostigmina….)
Poichè ingloba in pochi secondi la molecola del
rocuronium e fa scomparire il blocco
completamente…(appena meno specifica per il
vecuronium)
La scelta degli aminosteroidei almeno in day
surgery potrebbe divenire obbligata!

Analgesici oppioidi
Analgesici oppioidi
derivati fentanilici

Fentanil
Alfentanil
Remifentanil

Il capostipite
il figlio ,con la velocità
mancante al padre
Una nuova era:gli EMO

antagonismo sempre possibile con il Naloxone!

Principali caratteristiche degli
oppioidi
FARMACO

ONSET(SEC)

DURATA(MIN)

METABOLISMO

Fentanil

240

30

epatico

Alfentanil

50

10

epatico

Sufentanil

180

15

epatico

Remifentanil

45

4

esterasi


Farmacodinamica dei principali oppioidi

durata
tramadol
remifentanil
sufentanil
alfentanil
fentanil

min

onset
sec

0

50

100


150

200

Concentrazioni plasmatiche (relative) di oppioidi
nel tempo dopo il bolo


Ipnotici
Ipnotici
& sedativi......

Pentotal

Il gold standard

Propofol

Il nuovo standard
cinetico-dinamico

Midazolam

L'evoluzione delle BDZ


Propofol(diprivan)
Propofol(diprivan)
vantaggi & svantaggi

vantaggi

svantaggi

rapido

costo

non
cumulativo

depressione
cardiovascolare

duttile

conservazione


Confronto fra pentotal e propofol;punteggio
da 0 a 100
pentotal

propofol

30

45

5

10

depress.cardiovasc

10

15

depress resp

10

15

cumulatività

50

0

separazione sedaz-ipnosi

10

100

100

0

0

100

20

0

rapidità
dolore iniezione

arteriolesivo
infus.cont
antianalgesico

Sedativi-tranquillanti
Dal diazepam(Valium) al
midazolam(Ipnovel,Dormicum)
possibilità di antagonismo!
flumazenil (anexate).


Differenze nelle benzodiazepine
diazepam
irritazione venosa
trombosi
emivita
metaboliti attivi
amnesia
infusione continua
somministrazione
metabolismo
*=corretti se in emulsione lipidica

si,
si

(*)

(*)

midazolam
no
no

lunga

breve

si

no

si,+

si,++

no

si

os,iv,

os,iv,im,rect,nas

epatico

epatico


Meccanismo di azione


Continuum
MAC
protezione
riflessi
analgesia
sedazione

A.G.

Antiemetici
Antiemetici
evoluzione del pensiero
metoclopramide
droperidol
ondansetron

preso dalla gastroenterologia
preso dalla gastroenterologia

preso dagli antipsicotici....
preso dagli antipsicotici....

la nuova frontiera...

granisetron

PONV
PONV
fattori di rischio

donne
giovani
giovani
età
età
fertile
fertile
gravide
gravide
post
post
partum
partum

interventi

bambini

muscoli
muscoli
extraoculari
extraoculari
orecchio
orecchio
medio
medio
pelvi
pelvi
femm.in
femm.in
laparoscopia
laparoscopia
deambulazione
deambulazione
precoce
precoce


soggetti
a
cinetosi

pregresso
PONV

farmaci
oppioidi
oppioidi
anestetici
anestetici
inalatori
inalatori

PONV
PONV
Recettori coinvolti
ondansetron

butirofenoni::droperidol
butirofenoni::droperidol

metoclopramide
metoclopramide

granisetron

fenotiazine
fenotiazine

D2

5Ht3

steroidi

tropisetron
CRTZ

Combination
Combination
therapy
therapy

Ach
scopolamina
scopolamina


H1

antistaminici::imedrinato,idrossizina,ciclizina
antistaminici::imedrinato,idrossizina,ciclizina

Studi comparativi sulla incidenza di
nausea(Raphael,1993) e emesi(Alon,1992).
Donne,RU.
90
80
70
60

%

emesis
nausea

50
40
30
20
10
0
ondansetron

droperidol 1.25


metoclopramide 10
mg

Gli anestetici generali
Gli anestetici generali
evoluzione di una tradizione storica
isoflurano

buono per tutti gli usi

desflurano

la rapidità

sevoflurano
N2O

induzione e risveglio

potente analgesico,rapido,costa poco...


Dati sugli anestetici generali
COEFF
.RIPARTIZIONE
SANGUE/GAS

MAC %

DESFLURANE

0.45

6

0.02

SEVOFLURANE

0.65

2

3

N2O

0.47

105

0.004

ISOFLURANE

1.40

1.15

0.2

HALOTHANE

2.40

0.75

18

ANESTETICO

METABOLISMO

%


Solubilità e aumento della concentrazione alveolare
(FA) rispetto a quella inspirata(Fi)


Solubilità e eliminazione dell’anestetico
,espressa come percentuale di Fa relativa
all’ultima comcentrazione espirata Fao


Anestetici locali
Anestetici locali
per infiltrazione
lidocaina

meno tossica,meno costosa,capostipite

mepivacaina

più tossica,più costosa,ma durata maggiore

bupivacaina

più tossica,più costosa,lunga durata

ropivacaina

meno tox,+ costosa,lunga durata

analgesia postop.

Tabella comparativa degli A.L.
FARMACO

ONSET

DURATA

DURATA CON CONC.EQUIV
ADR
.

lidocaina

2

60

50%
±

0,5

mepivacaina 2

100

50
±

0,5

bupivacaina 5

180

100
±

0,20

ropivacaina

180

50
±

0,20

3


Interventi in day hospital
e anestesia regionale corrispondente...
plastica ernia
inguinale

blocco
ileoipogastrico-ileoinguinale

RU,conizzazione,isteroscopia

blocco paracervicale

circoncisione

blocco nn.dorsali del
pene


& anestesie regionali corrispondenti...
interv.sull'arto inferiore(alluce
valgo,caviglia..)
interventi sulla mano e
avambraccio

interv sull'occhio(cataratta)

interv, dentari

blocchi
nn.femorale,surale,safeno,tibiale
post....
blocco plesso brachiale
ascellare,blocchi dei
nn.mediano,radiale ,ulanre...
Blocco retro & peribulbare

blocchi tronculari,nn mascellare e
mandibolare

Interventi eseguibili con anestesia per
Interventi eseguibili con anestesia per
infiltrazione locale
infiltrazione locale
attenzione ai dosaggi totali......
Cosmetici
ORL
escissione di masse e biopsie
artroscopie

blefaroplastica,liposuzione...
nasali,septoplastica...
nodulectomie(mammella),nevi,.....
ginocchio,spalla

Anestesia topica
Anestesia topica
attenzione ai dosaggi!
mistura eutectica di
AL
spray di lidocaina
lidocaina gel o
crema

litotrissia,innesti cutanei

broncoscopia,endoscopia
digestiva...
circoncisione,uretroscopia,resezioni
transuretrali vescicali...


N.mediano
N.ulnare
Tendine m.palmare lungo

Tendine flessore ulnarecarpo
Tendine flessore rad.carpo


Analgesia postoperatoria
la capacità di controllare il dolore postop. costituisce la
differenza fra un intervento ambulatoriale e da ricoverato...

oppioidi più potenti
agonisti"deboli"
FANS
FANS+ Agonisti deboli

limitati all'immediato postop
tramadol,codeina
Ketorolac,diclofenac
codeina+paracetamolo

proseguimento della tecnica di blocco...
blocchi

continui...

instillazione
intraarticolare

con
AL,clonidina,combinazioni

infiltrazione della
ferita

ernia
inguinale,cicatrici,linee di
incisione....


Nuove metodiche di
somministrazione
Infusione continua
TCI
BIS…
servomeccanismi……..


Livelli plasmatici con boli
I bolo

140

II bolo

120
100

propofol
remifentanil
max
min

80
60
40

Finestra terapeutica

20
0
5

10 15 20 25 30 35 40 45 50 55 60
min


Livelli plasmatici con
infusione continua
120
100
80

propofol
remifentanil
max
min

60
40

Finestra terapeutica

20
0
5

10 15 20 25 30 35 40 45 50 55 60
min


Essential intraoperative monitoring
guidelines
guidelines

continuous presence of trained anesthesia personnel
continuous presence of trained anesthesia personnel

oxygenation
oxygenation

continual assessment of of
continual assessment of of

ventilation
ventilation
circulation
circulation
temperature
temperature

pulse oxymetry
pulse oxymetry
capnography
capnography
NIBP
NIBP

clinical asessment+ standards of care
clinical asessment+ standards of care

ECG
ECG
FiO2
FiO2
disconnect alarm
disconnect alarm
thermometry
thermometry


properties of modern
inhalational agents:
Low blood/ gas solubilities
»fast induction and
emergence
No active metabolites
Recovery times not dependent from
anesthesia duration


Inhalation
induction
Ideal characteristics for an inhaled
agent useful for induction:
Low blood gas solubility
Pleasant smell
Nonirritating for the airway
High potency
sevoflurane ??

Context sensitive half time of opioids(influence of P450
3A4 on alfentanil


)

Inhalational anesthesia vs TIVA
Inhalational anesthesia vs TIVA
similarities...
parameter
cont.adm.
method
titration
how much?
transport
init
basal analg
pre-intraop checks

inhalation anesth.

TIVA

yes

yes

vaporizer

syringe pump

yes

yes

MAC

MIR

airway

i.v.

overpressure

bolus

N2O/titration

analgesics

yes

yes


Discharge of the patient vs home
readiness
Chung

patterns of home readiness

Laparscopy,general surg,orthopedic surg

persistent symptoms

factors that delay discharge

recurrence of pain
PONV

unavailability of escorts

Anesthesia and factors
Anesthesia and factors
associated with PONV
associated with PONV
GA> reg
etomidate,ketamine,(neostigmine),(N2O)

PAIN
Sudden movement
Hypotension
Gastric distention

PONV
PONV
Categories at risk
Females

young,pregnant

kinetosis
certain operations

strabismus, inner
ear,pelvic laparoscopic ...

diabetics

PONV
PONV
we know the risk factors
Preventive strategy

non emetogenic drugs...

Antiemetic
Prophylaxis

Selected at risk groups

Immediate treatment

in case of
occurrence.....

PONV prophylaxis and
treatment
Droperidol 10 microgr/kg ev/im++
Ondansetron 4-8 mg ev(8 p.o.)++
Dexamethasone 4 mg ev+
Ephedrine 10 mg iv?
Scopolamine 0.5 mg/62 hr patch ??
Metoclopramide 10 mg iv +/Propofol 10-20 mg ev??
“setrons”++

Advantages of the LMA>TT
increased speed and ease of placement by
inexperienced personnel;
increased speed of placement by
anaesthetists;
improved haemodynamic stability at induction
and during emergence;
minimal increase in intraocular pressure
following insertion;
reduced anaesthetic requirements for airway
tolerance;
lower frequency of coughing during


Advantages LMA>Face Mask
easier placement by inexperienced
personnel;
improved oxygen saturation;
less hand fatigue;
improved operating conditions during
minor paediatric otological surgery.


Importare diapo LMA imbustata ed
inserita….


Diapo dei monitoraggi


Disadvantages LMA> TT&FM
lower seal pressures
higher frequency of gastric insufflation.
The only disadvantage compared with
the FM was that oesophageal reflux was
more likely.


In conclusion
for the success of day anesthesia & surgery
pk-pd
pk/pd
foundations

clinical
experience

organization

continuous
improvement

technology?

valutazione della ripresa funzionale
valutazione della ripresa funzionale

segni vitali stabili per 30 min
nessun nuovo sintomo postop

FC,PA,SaO2,coscienza
FC,PA,SaO2,coscienza
statu quo ane.....

nessun sanguinamento dal sito op.
nausea e/o vomito minimo per 30 min
orientato nel tempo e spazio e alla persona
minimo gir.di testa seduto o in piedi
dolore minimo & controllabile con analgesici orali
scorta per andare a casa....
Spec:capacità di mingere dopo cistoscopia,funz neurocirc.intatta dopo chir delle estremità....
Spec:capacità di mingere dopo cistoscopia,funz neurocirc.intatta dopo chir delle estremità....

remità
remità


New frontiers in ambulatory anesthes
New frontiers in ambulatory anesthe
day anesthesia-day surgery
new ideas
new ideas
new places
new places
new equipment
new equipment
new devices
new devices
new drugs
new drugs

new physicians..............

Ottimizzazione della anestesia
regionale
Nervi periferici o plessi:
Puntura singola vs multipla
Tecniche continue vs puntura singola
Blocchi centrali
Unilaterale vs bilaterale(minor impatto
emodinamico)
Riduzione della dose di al?

Beauregard L, Pomp A, Choinière M.
Severity and impact of pain after day-surgery
Can J Anaesth 1998 / 45 / 304-11

Purpose: To assess the intensity, duration
and impact of pain after day-surgery
interventions. Predictors of pain severity were
also evaluated along with the quality of
analgesic practices and patent satisfaction.
Methods: Eighty-nine consecutive day-surgery
patients completed self-administered
questionnaires before leaving the hospital and
at 24, 48 hr and seven days after discharge.
The survey instrument was composed of 0–10
pain intensity scales, selected items of the


preferences
Br. J. Anaesth. 2001; 86:272-274

Due to the growing importance of quality
assurance and cost containment in
healthcare, eliciting patients' preferences for
post-operative outcomes may be a more
economical and reliable method of assessing
quality. Three hundred and fifty-five day
surgery patients completed a pre-operative
written questionnaire to identify patients'
preferences for avoiding 10 particular postoperative symptoms: pain, nausea, vomiting,
disorientation, shivering, sore throat,
drowsiness, gagging on the tracheal tube,


Patient satisfaction after anaesthesia and surgery: results of a
prospective survey of 10 811 patients†
: Patient satisfaction after anaesthesia is an important outcome
of hospital care. We analysed our anaesthetic database to
identify potentially modifiable factors associated with
dissatisfaction. At the time of analysis, our database
contained information on 10 811 in-patients interviewed on
the first day after operation. The major subjective outcome
measure was patient satisfaction. We also measured other
predetermined outcomes, such as nausea, vomiting, pain and
complications. The overall level of satisfaction was high
(96.8%); 246 (2.3%) patients were `somewhat dissatisfied'
and 97 (0.9%) were `dissatisfied' with their anaesthetic care.
After adjustment for patient and surgical factors, there was a
strong relation between patient dissatisfaction and: (i)

Anesth Analg 1998; 87:816
Telephone follow-up after ambulatory surgery:
a pilot study
OUTPATIENT ANAESTHESIA
AUTHOR(S): Vrehen, H. M.; Drege, E. J.;
Oostveen, A. W.; Schipper, E.; Knape, J. T.A.
Institute of Anesthesiology, University Hospital
Utrecht, The Netherlands
Br. J. Anaesth. 1999; 82:11


Discharge time (total recovery time) is one
determinant of the overall cost of outpatient
surgery. We performed this study to
determine what factors affect discharge time.
Details regarding patients, anesthesia,
surgery, and recovery were recorded
prospectively for 1088 adult patients
undergoing ambulatory surgery over an 8-mo
period. The contribution of factors to variability
in the discharge time was assessed by using
multivariate linear regression analysis. In the
last 4 mo of the study, nurses indicated the


uncontrolled pain, nausea/vomiting,
drowsiness, unresolved regional block, and
inability to void. Pain, emetic symptoms,
drowsiness, and voiding problems were also
the most frequently identified symptoms
associated with delayed discharge in the
study by Chung . Inability to void as a cause
of delay in our study was, in part, a result of
the requirement that all patients void before
discharge. It was most often observed after
spinal anesthesia and hernia repair (18% and
23%, respectively). Subsequent studies have


This study was performed in a university
teaching center, in which the duration of
surgery is typically long compared with a
private setting. However, because the
duration of surgery was a relatively minor
determinant of discharge time, it may have
limited importance in determining outcome.
The discharge times observed in our study
after general anesthesia for laparoscopy (206
min) are similar to those reported by Chung et
al. (201 min) and Rashiq et al. (160–205 min)
; for lower extremity surgery, our times were


Twersky R, Fishman D, Homel P. What happens after
discharge? Return hospital visits after ambulatory surgery.
Anesth Analg 1997; 84:319±324.
Tutti I paz rentrati nello stesso ospedale dopo chir amb entro 30 gg,sia in PS che nella
ASU che come ricoverati
su 6243 paz in 1 anno 187 rientrati (2.99 %),dei quali 1.3% per KO
5.4% in PS e 4.6% riospedalizzati(ASU o ricoveri)
Analisi multivariata condotta con 2 casi controllo per ciascun ricovero.
urologia è l’unica specialità che predice il ricovero
varicocelectomy and hydrocelectomy procedures were 8.3 times more likely
patients undergoing dilation and curettage were three times as likely to return (CI
1.78–5.55; P = 0.0002).
Bleeding was the most common reason for all hospital returns (41.5%), with 76.5% of
these patients treated and discharged through the ER. The increased likelihood of
return visits after urology procedures warrants further evaluation. As patients with
bleeding were most likely to return to the ER and discharged, more effective pre- and
postprocedure patient education may further reduce this occurrence. Better informing
patients regarding the prognosis of bleeding, and advising them of medical
alternatives, could reduce inappropriate patient returns to the ER.

Ann R Coll Surg Engl. 2006 Mar;88(2):202-6. Links
Day-case septoplasty and unexpected re-admissions at a dedicated day-case unit: a 4-year audit.
Georgalas C,
Obholzer R,
Martinez-Devesa P,
Sandhu G.
The Royal National Throat, Nose and Ear Hospital, London, UK. cgeorgalas1@yahoo.co.uk
INTRODUCTION: Septal surgery has been identified as suitable for day-surgery, but is not widely
performed as such. Guidelines for day-surgery state that the unexpected admission rate should be 2-3%.
Previous audits have not achieved this figure and septoplasty is not universally considered suitable for daysurgery. We have reviewed practice over 4 years in our institution to identify surgical and patient factors
associated with unexpected admission following septoplasty. PATIENTS AND METHODS: A retrospective
case note based audit of day-case septoplasty procedures reviewed at the end of each year between
October 1998 and October 2002. RESULTS: A total of 432 septal surgery procedures were performed,
comprising 378 septoplasties and 54 submucous resections. Thirty-eight patients were admitted,
overwhelmingly because of haemorrhage in the immediate postoperative period, giving an overall admission
rate of 8.8% within the first 24 h. Factors associated strongly with re-admission were the use of intranasal
splints, the performance of revision surgery, submucous resection (as opposed to septoplasty) and, less so,
the performance of additional procedures and the peri-operative administration of diclofenac. There was no
correlation between unexpected admission and grade of surgeon, surgical technique or any of the patient
factors analysed. CONCLUSIONS: The unexpected admission rate of septal surgery performed at our unit
is above that recommended for day-case procedures, but is within the range previously published. Patient
satisfaction with day-case septoplasty has been shown to be high. We believe that septoplasty should be
performed in this setting but there is a significant chance that patients may need admission, and a pathway
should be in place for this to occur with minimal disruption to the patient.

Dieter RA JrRemote surgicenter experience with hernia
repair. Int Surg. 2005 Jul-Aug;90(3 Suppl):S2-5.

Northern Illinois Center for Surgery, Naperville, Illinois 60563, USA.
A remote outpatient surgicenter was planned and constructed with
three partner groups-76 physicians and two competing hospitals.
The CFS was opened in July 1994 and has since performed a large
volume of procedures: >124,800 total and, in 2003, 14,900 cases.
This multispecialty center during that same period of time (1994 to
date) has performed 2659 hernia operations. Patients were
discharged home in 1-2 hours after surgery to be followed as
outpatients in the physician's office. Only six patients were admitted
to the hospital. This efficient and economic model is well suited for
hernia repair in the selected adult and pediatric patient population
without a significant number of adverse events. The community has
readily accepted this program for adult and pediatric hernia repair.
Patients, family members, referring physicians, and participating
physicians have endorsed and recommended the program.

MacDonald MF, Al-Qudah HS, Santucci RAMinimal
impact urethroplasty allows same-day surgery in most
patients. Urology. 2005 Oct;66(4):850-3.
Department of Urology, Wayne State University School of Medicine, Detroit, Michigan, USA.
OBJECTIVES: To present our evaluation of the safety and feasibility of decreasing the
impact of anterior urethroplasty by minimizing the surgery time, maximizing adjuvant pain
therapy, and using anesthetic agents that decrease the incidence and severity of side
effects, which allows most patients to leave the hospital comfortably within 4 hours of
surgery. METHODS: A retrospective chart review of 54 consecutive anterior urethroplasty
patients from August 2000 to August 2004 (34 anterior anastomotic and 20 ventral onlay
buccal mucosal graft urethroplasty) was performed. RESULTS: Historically, 27% of patients
had undergone same-day surgery (SDS). After the initiation of minimal impact surgery and
early discharge, 85% did so. All but one admission was planned (1 patient [2%] had
hypotension in the recovery room and was admitted). No postoperative readmissions or
emergency room visits occurred. The admitted patients had comparable stricture length to,
but slightly older age (49 years compared with 42 years) than, the SDS patients. The
perioperative complications were mild (small wound gap, small scrotal hematoma) and were
seen in 5% of SDS patients and 0% of admitted patients. Late complications (chordee, mild
erectile dysfunction, and urinary tract infection) were seen in 19% of SDS patients and 18%
of admitted patients. The incidence of recurrences after a mean follow-up of 27 months was
comparable (3% for the SDS and 6% for the admitted group). CONCLUSIONS: Decreasing
the impact of urethroplasty surgery allows safe early discharge for most patients.
Unexpected admissions were uncommon, and we continue to plan for admission only for the
extremely elderly, those with severe comorbidities, and those expected to undergo lengthy
(longer than 5 hours) surgery.


Athey N, Gilliam AD, Sinha P, Kurup VJ, Hennessey C,
Leaper DJ. Day-case breast cancer axillary surgery.
Ann R Coll Surg Engl. 2005 Mar;87(2):96-8.

University Hospital of North Tees, Stockton-on-Tees, Cleveland, UK.
nickathey@doctors.org.uk
INTRODUCTION: The standard locoregional management of breast cancer is excision
of the primary tumour and axillary staging with suction drainage of the axilla. The
objective of this study was to determine the safety, tolerability and efficacy of day-case
surgery without suction drainage. PATIENTS AND METHODS: A review of complete,
prospectively collected data was performed on all breast cancer patients (screening
and symptomatic) planned to undergo day-case axillary surgery at a University
Teaching Hospital between 2000 and 2002. Postoperative complications were
recorded and the notes of patients not discharged on the day of their surgery were also
examined to establish the reason for overnight stay. RESULTS:
165 patients underwent intended day-case axillary surgery (axillary dissection level
1/2; median age, 55 years; range, 39-76 years). Of these, 16 (9.7%) were admitted
overnight usually due to over-running of theatre lists (n = 13; 81%). 29 patients (17.6%)
underwent axillary dissection alone, the remainder had axillary surgery combined with
wide local excision (median number of lymph nodes excised 11; range, 2-18).
Complications included symptomatic seroma formation in 37 patients (22%) and wound
infection in 16 patients (10%). CONCLUSIONS: Day-case axillary surgery can be
performed safely with surgical morbidity comparing favourably to published work of
'traditional' axillary drainage following lymphadenectomy


Edwin B, Skattum X, Rader J, Trondsen E,
Outpatient laparoscopic splenectomy: patient safety and
satisfaction. Surg Endosc. 2004 Sep;18(9):1331-4.
hematological or neoplastic indications for splenectomy
American Society of Anesthesiologists (ASA) I-III.
They received general intravenous anesthesia with propofol and remifentanil and
were given keterolac, propacetamol, droperidol, and ondansetron as prophylaxis
against postoperative pain and nausea
Laparoscopic splenectomy was performed via three trocars.
The specimen was removed via an incision in the left iliac fossa. RESULTS:
Ten of the 12 patients were discharged 3-6 h postoperatively;
the other two were admitted primarily to hospital. One was readmitted due to a fever,
which was finally explained by measles. The median operative times was 58 min
(range, 45-135). Patient satisfaction was excellent in nine and intermediate in two
cases; it was poor in one case, due to postoperative pain. CONCLUSION:
Laparoscopic splenectomy can be completed in a relatively short time; therefore, it
is feasible, safe, and satisfactory for most patients as an outpatient procedure


De Waele B, Lauwers M, Van Nieuwenhove Y,
Delvaux G. Outpatient laparoscopic gastric banding: initial
experience. Obes Surg. 2004 Sep;14(8):1108-10
Department of Surgery, VUB University Hospital, Brussels, Belgium.

Laparoscopic adjustable gastric banding (LAGB).
BMI >35 kg/m2 with co-morbid conditions, living within a reasonable distance from the hospital, and adult
company at home.
The patients were admitted at 0700 hours on the day of surgery, underwent laparoscopic placement of a
Lap-Band system and were discharged home that evening.
RESULTS: 9 women and 1 man underwent outpatient LAGB.
Mean age was 36 (range 18-52) years and mean BMI was 38.4 kg/m2 (range 35.1-43.3). Co-morbidities
included functional dyspnea (6), osteoarthritis (4), arterial hypertension (4), type 2 diabetes (2) and
dyslipidemia (1). 7 patients had undergone previous abdominal surgery: cesarean section (4),
appendectomy (3), cholecystectomy (1) and hysterectomy (1).
All patients had an American Society of Anesthesiologists (ASA) classification of II.
The average operating time was 87 minutes (range 65-115).
The mean time lapse between the end of the operation and discharge from hospital was 9.6 hours.
There were no readmissions, and no complications were noticed at 1 month postoperatively.
The patients' satisfaction with the ambulatory LAGB procedure was high.
CONCLUSION: The present study demonstrates that LAGB for obesity may be performed on an
ambulatory basis without complications.


predictable in day surgical practice? Can J Anesth 1992; 39:440±448.
To understand better the factors important to the safety of anaesthesia provided for day
surgical procedures, we analyzed the intraoperative and immediate postoperative
course of patients at four Canadian teaching hospitals' day treatment centres. After
excluding those who received only monitored anaesthesia care, there were 6,914 adult
(non-obstetrical) patients seen over a twelve-month period in 1988–89. The rate of
adverse outcome consequent to their care was identified by a comprehensive
surveillance system which included review of anaesthetic records (four hospitals) and
follow-up telephone calls (two hospitals). The relationship between adverse events and
preoperative factors was determined by using a multiple logistic regression analysis that
included age, sex, duration of the procedure and the hospital care. There were no
deaths during the study period and major morbid events were infrequent. Patient
preoperative disease was predictive of some intraoperative events relating to the same
organ system, but not to events in the PACU. Some unexpected relationships emerged
including preoperative hypertension being related to a greater risk of difficult intubation,
and neurological disease to perioperative cardiac abnormalities. Patients judged obese,
or inadequately fasted, were found to experience a greater rate of recovery problems as
well as discomfort. While the low response rate (36%) to the telephone interviews
created a sampling bias, the high rate of patient dissatisfaction among those reached is
disconcerting. We conclude that day surgical patients with preoperative medical
conditions, even when optimally managed, are at higher risk for adverse events in the
perioperative period.

6914 pazienti:da Duncan PD, Reccan PG, Cohen MM, Tweed
WA.The Canadian Four Centre Study of anaesthetic outcomes: are anesthetic
complications

112 paz (1.6%) sbalzi pressori
74 aritmie transitorie:1.07
Intubazione difficile in 35 (0.5%)
Altri eventi resp sfavorevoli in 87 (1.3%)
21 casi di modificazione di tecnica anest.:0.30
Probl meccanici o di attrezzature:6 casi 0.0087
Incidenti legati ai farmaci:4 casi 0.57 per mille 0.43
per mille
3 ammissioni alla ICU
Eventi avversi intraop : 50 per 1000 anaest.

Rischio relativo di KO e condizioni preop


Relazione fra condizioni preop e
KO
Patz con probl resp hanno un rischio alto di KO intraop,specie del tratto resp inf
Gli iprtesi preoperative hypertensive disease were more likely to run into difficulties with
blood pressure control.
Patients with preoperative hypertension were more likely to experience a difficult
intubation
patients with preoperative neurological diseases were at risk for cardiac events.
Patients with preoperative respiratory problems or hypertension were at higher risk for
cardiac events
diabetics had four times the risk of blood pressure abnormalities.
history of previous anaesthetic problems was not associated with any incremental risks
history of cigarette smoking was only found to be a risk factor for lower respiratory events.
Cases with inadequate fasting were at higher risk for problems with blood pressure
control
cases where a difficult airway was anticipated were, as expected, at higher risk for
difficult intubation and respiratory related events.
Patients judged obese were at higher risk for a number of problems.
decreased risk of nausea or vomiting by those who smoked.

Prolungamento della degenza
postop
Duration of postoperative stay or time to discharge is a
commonly used outcome measure of ambulatory surgery and
anesthesia and is considered to be an intermediate
or surrogate measure of the `real' outcome such as
patient recovery [8]. While postoperative pain and
nausea/vomiting were considered important factors for
prolonged stay and unanticipated hospital admission,
consequences of the surgical procedure are now the most
predictive factors [9]. The rate of unanticipated hospital
admission was 5.4% in a recent large-scale German
study. Intraoperative hemoglobin concentration and
blood loss were the best predictors of prolonged postoperative
stay [10..].
Duration of postoperative stay correlates with the
Servizio
frequency di Anestesia e Rianimazione Ospedale di Faenza(RA)
of minor or moderately severe complications.

8 Richardson MG, Wu CL, Hussain A. Midazolam
premedication increases
sedation but does not prolong discharge times after
brief outpatient general
anesthesia for laparoscopic tubal sterilization. Anesth
Analg 1997; 85:301±
305.
9 Chung F, Ritchie E, Su J. Post-operative pain in
ambulatory surgery. Anesth
Analg 1997; 85:808±816.
..
10.

Ricovero ospedaliero non
programmato
The rate of unplanned hospital admissions following
ambulatory surgery reØects the occurrence of intra- or
postoperative complications. They mirror the frequency
of severe complications, which prevent safe patient
discharge after surgery and necessitate in-patient care.
The rate of unanticipated admissions ranges from 0.3 to
1.4% [13].
The most frequent reason for unanticipated hospital
admission (38±79%) is surgical complications [14].
Amongst these, excessive pain, bleeding, and surgical
misadventure are the most frequent. Morales and
colleagues [15.] reported in a prospective study of
3502 ambulatory patients that the majority of
unanticipated e Rianimazione Ospedale di Faenza(RA)
Servizio di Anestesia

Fortier J, Chung F, Su J. Unanticipated
admission after ambulatory surgery: a
prospective study. Can J Anaesth 1998;
45:612±619.


1 Jarrett PEM. Day care surgery. Eur J Anaesthesiol 2001; 18:32±35.
.
2 White PF, Watcha MF. Pharmacoeconomics in anaesthesia: what are the
issues? Eur J Anaesthesiol 2001; 18:10±15.
Newer more expensive drugs can provide cost saving in ambulatory anesthesia.
.
3 Dahmen KG, Albrecht DM. An approach to quality management in anaesthesia:
a focus on perioperative care and outcome. Eur J Anaesthesiol 2001; 18:4±9.
The implications for perioperative care are explored following the German
government's decision to change from fee-for-service reimbursement to fee per
capita system. It is envisaged that traditional barriers between specialities treating
a patient will be disrupted.
4 5 Chung F, Mezei G, Tong D. Pre-existing medical conditions as predictors of
adverse events in day-case surgery. Br J Anaesth 1999; 83:262±270.
7 Atkins M, White J, Ahmed K. Day surgery and body mass index: results of a
national survey. Anaesthesia 2002; 57:180±182.
BMI patients in the 30±35 range are considered `obese'. Data from this postal
survey suggest that day case exclusion criteria are now confined to the `morbid
obese'Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
(435 BMI) patients.

Discharge Criteria and Complications After Ambulatory Surgery
AMBULATORY ANESTHESIA
AUTHOR(S): Marshall, Scott I., FRCA; Chung, Frances, FRCPC
Department of Anesthesia, The Toronto Hospital, University of
Toronto, Toronto, Ontario, Canada
Accepted for publication December 3, 1998.
Address correspondence to Dr. Frances Chung, Department
of Anesthesia, The Toronto Hospital, University of Toronto, 399
Bathurst St., Toronto, Ontario, Canada M5T 2S8. Address e-mail
to fchung@torhosp.toronto.on.ca.
Anesth Analg 1999; 88:508–17

In a recent study, 2730 patients completed a
satisfaction survey, and only 2.5% were dissatisfied
with the overall experience. Although only 1.1%
expressed dissatisfaction with anesthesia, this was a
powerful predictor of global dissatisfaction with
ambulatory surgery . The most common reasons for
dissatisfaction involved inadequate communication
between the patient and the medical/nursing staff.
Dissatisfaction with anesthesia was also related to the
number of postoperative symptoms suffered.


Tong D, Chung F, Wong D. Predictive
factors in anesthesia and nursing care
satisfaction in patients undergoing
ambulatory surgery. Anesthesiology
1997; 87:856-64. <ldn>!


Tong,D,Chung F,Wong D.Predictive Factors in Global and
Anesthesia Satisfaction in Ambulatory Surgical Patients
CLINICAL INVESTIGATION Anesthesiology, 87:856-64, 1997
Background: Patient satisfaction is one of the variables that affect the outcome of health care and the use of health-care
services. As more procedures are performed on an ambulatory basis, the role of the anesthesiologist becomes more
important. To improve the delivery of care, the predictors of dissatisfaction with the entire process (global dissatisfaction) of
ambulatory surgery and with anesthesia itself must be identified. The authors conducted a hypothesis-generating study to
identify predictors; specifically, they hypothesized that satisfaction with anesthesia was a predictor of global satisfaction
with ambulatory surgery and that 24-h postoperative symptoms were a predictor of satisfaction with anesthesia.
Methods: The authors prospectively studied 5,228 consecutive patients having surgery in the ambulatory setting during a
1-yr period. Preoperative, intraoperative, and postoperative variables were gathered and patient satisfaction was assessed
using a postoperative telephone questionnaire administered 24 h after operation in 2,730 respondents. Significant
univariate variables and clinically important variables were entered into multiple logistic regression models. Qualitative data
on dissatisfaction were obtained by asking patients' reasons for dissatisfaction.
Results: Sixty-eight of the 2,730 respondents (2.5%) had global dissatisfaction with ambulatory surgery. Nine of these
patients were dissatisfied with anesthesia. Dissatisfaction with anesthesia was associated with a 12-fold increase in global
dissatisfaction (P = 0.0001). Thirty-one of the 2,730 respondents (1.1%) were dissatisfied with anesthesia. An increasing
number of symptoms occurring 24 h after operation was associated with an exp(0.28 ´ N)-fold increase in dissatisfaction
with anesthesia for N number of symptoms (P = 0.0001). Qualitative data showed that the most common reason for global
dissatisfaction with ambulatory surgery was personal preference for inpatient care (26%), whereas intraoperative and
postoperative adverse outcomes were the major causes of dissatisfaction with anesthesia (88%).
Conclusions: Dissatisfaction with anesthesia is a predictor of global dissatisfaction with ambulatory surgery. An
increasing number of symptoms 24 h after operation is a predictor of dissatisfaction with anesthesia. The rate of global
dissatisfaction and anesthesia dissatisfaction is very low. The predictors from this model need to be validated by a second
data set from either this or another center. Given the low rate of dissatisfaction, a focused study testing specific
interventions to improve patient satisfaction would be difficult.


Bello per impostazione e
discussione sullq filosofia della
amb surg e anesth…….
Is Outpatient Laparoscopic Cholecystectomy Safe and Cost-effective? : A Model to Study Transition of Care
ECONOMICS
AUTHOR(S): Fleisher, Lee A., M.D.*; Yee, Kelvin, M.D.†; Lillemoe, Keith D., M.D.‡; Talamini, Mark A., M.D.§; Yeo, Charles J., M.D.‡; Heath, Roberta, R.N.,
M.S.N.ï÷; Bass, Eric, M.D., M.P.H.,# Douglas S. Snyder, M.D.**; Parker, Stephen D., M.D.††
* Associate Professor of Anesthesiology and Critical Care Medicine, Joint Appointments in Medicine and Health Policy and Management.
† Assistant Instructor. Current position: Anesthesiologist, Sinai Medical Center, Baltimore, Maryland.
‡ Professor of Surgery.
§ Associate Professor of Surgery. ï÷Director of Patient Care Services,Johns Hopkins Outpatient Center.
#Associate Professor of Medicine.
** Assistant Professor of Anesthesiology.
†† Associate Professor of Anesthesiology, Medical Director, Outpatient Surgery Program.
Received from the Departments of Anesthesiology, Medicine, Surgery, and Health Policy and Management, Johns Hopkins Medical Institutions, Baltimore,
Maryland. Submitted for publication March 30, 1998. Accepted for publication January 25, 1999. Supported by a grant from the National Institutes of Health (CRCRR00035) and by Glaxo Wellcome Pharmaceuticals, Research Triangle Park, North Carolina. Dr. Fleisher was supported by the Richard S. Ross Clinician
Scientist Award. Presented in part at the Society of Ambulatory Anesthesia 1996 Annual Meeting, Boston, Massachussetts, May 2, 1996, and the American
Society of Anesthesiologists October 21, 1996 Annual Meeting, New Orleans, Louisiana.
Address reprint requests to Dr. Fleisher: The Johns Hopkins Hospital, 600 North Wolfe Street, Carnegie 280, Baltimore, Maryland 21287. Address electronic
mail to: lfleishe@welchlink.welch.jhu.edu
ABSTRACT: Background: There is increasing pressure to perform traditional inpatient surgical procedures in an outpatient setting. The aim of the current trial
was to determine the safety and cost savings of performing laparoscopic cholecystectomy in an outpatient setting using a “mock” outpatient setting.
Methods: Patients who were scheduled for laparoscopic cholecystectomy by four attending surgeons and for whom operating time was available in the
outpatient center were studied. All patients received a standardized anesthetic, including ondansetron, and were discharged from the outpatient postanesthesia
care unit if appropriate. At discharge, all patients were admitted to a clinical research center where they were observed in a “mock home” setting and monitored
for complications that would have necessitated readmission. A decision analysis was created assuming all patients underwent outpatient surgery with either direct
admission or discharge to home and readmission if complications developed.
Results: Of 99 patients who were enrolled in this study, 96 patients would have met the discharge criteria for home. No major complications were observed in
these 96 patients. Eleven patients experienced postoperative nausea and vomiting, 3 of whom required an additional 24 h of hospital observation. In the decision
model, the optimal strategy would be to perform the procedure on an outpatient basis and readmit patients only for complications, with an average baseline cost
savings of $742/patient.
Conclusions: The results show that outpatient laparoscopic cholecystectomy is safe and cost-effective in selected patients, and that the mock home setting
provides a means of studying the safety of transition of care.
Anesthesiology
90:1746-55, 1999


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