Same-day discharge after percutaneous coronary procedures-Structured review and comprehensive meta-analysis.

INTRODUCTION: Percutaneous coronary intervention is a well-established revascularization strategy for patients with coronary artery disease. The safety and feasibility of performing these procedures on a same-day discharge basis for selected patients has been studied in a large number of mostly nonrandomized trials. An up to date literature review should focus on trials with radial access, representing the current standard for coronary procedures in Austria and other European countries. METHODS: The aim of this consensus statement is to review the most recent evidence for the safety and feasibility of performing same-day discharge procedures in selected patients. A structured literature search was performed using prespecified search criteria, focusing on trials with radial access procedures. RESULTS: A total of 44 clinical trials and 4 large meta-analyses were retrieved, spanning 21 years of clinical evidence from 2001 to 2022. The outcome data from a wide range of clinical settings were unanimous in showing no negative effect on early (24 h) or late (30 day) major adverse events after same-day discharge coronary procedures. Based on nine prospective trials a comprehensive meta-analysis was compiled. Using 1­month major adverse events data the pooled odds ratio of same-day discharge versus overnight stay procedures was 0.66 (95% confidence interval, CI 0.35-01.24; p = 0.19; I2 0%), indicating a noninferiority in carefully selected patients. CONCLUSION: Outcome data from same-day discharge coronary intervention trials with radial access confirm the robust safety profile showing no increase in the risk of major adverse events compared to overnight stay.

Prices and complications in hospital-based and freestanding surgery centers.

OBJECTIVES: To quantify differences in prices paid and procedural complications incurred in hospital outpatient departments (HOPDs) and freestanding ambulatory surgery centers (ASCs). STUDY DESIGN: Observational study using deidentified 2019-2020 insurance claims from Blue Cross Blue Shield insurance plans nationally, with information on prices paid and complications incurred for colonoscopy, knee or shoulder arthroscopy, and cataract removal surgery. METHODS: The data include 1,662,183 patients who received a colonoscopy, 53.5% of whom were treated in HOPDs; 259,200 patients who underwent arthroscopy, 61.0% of whom were treated in HOPDs; and 173,664 patients who had cataract removal surgery, 34.7% of whom were treated in HOPDs. Multivariable linear regression methods were used to identify the associations between HOPD and ASC site of care, prices, and complications after adjusting for patient demographics, risk, and geographic market location. RESULTS: After adjusting for patient characteristics, risk, and geographic market location, prices paid in HOPDs were 54.9% higher than those charged in ASCs for colonoscopy (95% CI, 53.6%-56.1%), 44.4% higher for arthroscopy (95% CI, 43.0%-45.8%), and 44.0% higher for cataract removal surgery (95% CI, 42.9%-45.5%). Adjusted rates of complications were slightly higher in HOPDs than ASCs for colonoscopy over a 90-day interval but similar over the 7- and 30-day intervals. Rates were statistically and clinically similar between the 2 sites of care for arthroscopy and cataract removal. CONCLUSIONS: The higher prices charged in HOPDs for the 3 ambulatory procedures were not balanced by better quality-as measured by rates of procedural complications-compared with procedures performed in nonhospital ASCs.

The effectiveness of ambulatory continuous popliteal sciatic nerve blockade on patient-reported overall benefit of analgesia in patients undergoing foot or ankle surgery (CAREFREE trial); a randomized, open label, non-inferiority trial.

STUDY OBJECTIVE: Management of pain after foot and ankle surgery remains a concern for patients and healthcare professionals. This study determined the effectiveness of ambulatory continuous popliteal sciatic nerve blockade, compared to standard of care, on overall benefit of analgesia score (OBAS) in patients undergoing foot or ankle surgery. We hypothesized that usage of ambulatory continuous popliteal sciatic nerve blockade is non-inferior to standard of care. DESIGN: Single center, randomized, non-inferiority trial. SETTING: Tertiary hospital in the Netherlands. PATIENTS: Patients were enrolled if ≥18 years and scheduled for elective inpatient foot or ankle surgery. INTERVENTION: Patients were randomized to ambulatory continuous popliteal sciatic nerve blockade or standard of care. MEASUREMENTS: The primary outcome was the difference in OBAS, which includes pain, side effects of analgesics, and patient satisfaction, measured daily from the first to the third day after surgery. A non-inferiority margin of 2 was set as the upper limit for the 90% confidence interval of the difference in OBAS score. Mixed-effects modeling was employed to analyze differences in OBAS scores over time. Secondary outcome was the difference in opioid consumption. MAIN RESULTS: Patients were randomized to standard of care (n = 22), or ambulatory continuous popliteal sciatic nerve blockade (n = 22). Analyzing the first three postoperative days, the OBAS was significantly lower over time in the ambulatory continuous popliteal sciatic nerve blockade group compared to standard of care, demonstrating non-inferiority (-1.9 points, 90% CI -3.1 to -0.7). During the first five postoperative days, patients with ambulatory continuous popliteal sciatic nerve blockade consumed significantly fewer opioids over time compared to standard of care (-8.7 oral morphine milligram equivalents; 95% CI -16.1 to -1.4). CONCLUSIONS: Ambulatory continuous popliteal sciatic nerve blockade is non-inferior to standard of care with single shot popliteal sciatic nerve blockade on patient-reported overall benefit of analgesia.

Real-World Evidence of the Impact of a Novel Surgical Irrigant on Surgical Site Infections in Primary Total Knee Arthroplasty Performed at an Ambulatory Surgery Center.

Background: Total knee arthroplasty (TKA) is one of the most common inpatient and outpatient surgical procedures performed in the United States and is predicted to increase 401% by 2040. Surgical site infections (SSIs) at an incidence rate of approximately 2% are costly post-operative complications in TKA. Intra-operative surgical irrigants are used to decrease contaminating microbial bioburden within the surgical site to prevent SSI. The primary objective of this retrospective study was to evaluate the impact of a novel surgical irrigant called XPERIENCE® Advanced Surgical Irrigation (XP; Next Science, Jacksonville, FL) on SSI incidence in primary TKA performed at an ambulatory surgery center (ASC). Patients and Methods: Primary TKAs were performed at a free-standing ASC. The novel surgical irrigant was used intra-operatively to rinse away debris and micro-organisms from the surgical site. Retrospective data collation included SSI rates, complication rates, and re-admissions due to SSI within 90 days of index surgery. Results: Among the 524 primary TKA surgeries, one peri-prosthetic joint infection (PJI) was diagnosed within 90 days of index surgery and one superficial incisional SSI was diagnosed within 30 days of index surgery. The PJI was attributed to an exogenously acquired upper respiratory tract infection rather than due to the failure of intra-operative regimes. The 0.19% PJI incidence rate indicated significant efficacy of XP in decreasing PJI. An overall complication rate of 7.82% was noted with none of the complications associated with usage of the novel surgical irrigant. Conclusions: XPERIENCE is a promising intra-operative antimicrobial irrigant that can be easily incorporated into a broader infection prevention strategy.

Electronic Patient-Reported Symptoms After Ambulatory Cancer Surgery.

Importance: Complex cancer procedures are now performed in the ambulatory surgery setting. Remote symptom monitoring (RSM) with electronic patient-reported outcomes (ePROs) can identify patients at risk for acute hospital encounters. Defining normal recovery is needed to set patient expectations and optimize clinical team responses to manage evolving problems in real time. Objective: To describe the patterns of postoperative recovery among patients undergoing ambulatory cancer surgery with RSM using an ePRO platform-the Recovery Tracker. Design, Setting, and Participants: In this retrospective cohort study, patients who underwent 1 of 5 of the most common procedures (prostatectomy, nephrectomy, mastectomy, hysterectomy, or thyroidectomy) at the Josie Robertson Surgery Center at Memorial Sloan Kettering Cancer Center from September 2016 to June 2022. Patients completed the Recovery Tracker, a brief ePRO platform assessing symptoms for 10 days after surgery. Data were analyzed from September 2022 to May 2023. Main Outcomes and Measures: Symptom severity and interference were estimated by postoperative day and procedure. Results: A total of 12 433 patients were assigned 110 936 surveys. Of these patients, 7874 (63%) were female, and the median (IQR) age at surgery was 57 (47-65) years. The survey response rate was 87% (10 814 patients responding to at least 1 of 10 daily surveys). Among patients who submitted at least 1 survey, the median (IQR) number of surveys submitted was 7 (4-8), and each assessment took a median (IQR) of 1.7 (1.2-2.5) minutes to complete. Symptom burden was modest in this population, with the highest severity on postoperative days 1 to 3. Pain was moderate initially and steadily improved. Fatigue was reported by 6120 patients (57%) but was rarely severe. Maximum pain and fatigue responses (very severe) were reported by 324 of 10 814 patients (3%) and 106 of 10 814 patients (1%), respectively. The maximum pain severity (severe or very severe) was highest after nephrectomy (92 of 332 [28%]), followed by mastectomy with reconstruction (817 of 3322 [25%]) and prostatectomy (744 of 3543 [21%]). Nausea (occasionally, frequently, or almost constantly) was common and experienced on multiple days by 1485 of 9300 patients (16%), but vomiting was less common (139 of 10 812 [1%]). Temperature higher than 38 °C was reported by 740 of 10 812 (7%). Severe or very severe shortness of breath was reported by 125 of 10 813 (1%). Conclusions and Relevance: Defining detailed postoperative symptom burden through this analysis provides valuable data to inform further implementation and maintenance of RSM programs in surgical oncology patients. These data can enhance patient education, set expectations, and support research to allow iterative improvement of clinical care based on the patient-reported experience after discharge.

Randomized, Single-Blind, Comparative Study of Remimazolam Besylate vs Propofol for Facial Plastic Surgery.

BACKGROUND: Use of local anesthesia and conscious sedation with a combination of a sedative and anesthetic drug during a surgical procedure is an approach designed to avoid intubation, which produces fewer adverse events compared to general anesthesia. In the present study, a comparison was made between the efficacy and safety of remimazolam besylate and propofol for facial plastic surgery. OBJECTIVES: The objective was to evaluate the clinical efficacy, comfort, and incidence of adverse events of remimazolam compared with propofol combined with alfentanil in outpatient facial plastic surgery. METHODS: In this randomized, single-blind, single-center, comparative study, facial plastic surgery patients were randomly divided into remimazolam-alfentanil (n = 50) and propofol-alfentanil (n = 50) groups for sedation and analgesia. The primary endpoint was the incidence of hypoxemia, while secondary endpoints included efficacy and safety evaluations. RESULTS: There were no significant differences regarding the surgical procedure, sedation and induction times, pain and comfort scores, muscle strength recovery, heart rate, respiratory rate, and blood pressure, but the dosage of alfentanil administered to the remimazolam group (387.5 µg) was lower than that for the propofol group (600 µg). The incidence of hypoxemia (P = .046) and towing of the mandibular (P = .028), as well as wake-up (P = .027) and injection pain (P = .008), were significantly higher in the propofol group than the remimazolam group. CONCLUSIONS: Remimazolam and propofol had similar efficacies for sedation and analgesia during facial plastic surgery, but especially the incidence of respiratory depression was significantly lower in patients given remimazolam.

Pain-related hospitalization and emergency room visit following initial analgesic prescription after outpatient surgery.

PURPOSE: Our study examined the association between outpatient postsurgical analgesic prescription and risk of insufficiently managed pain characterized by pain-associated hospital admission and emergency room (ER) visit. METHODS: Eligible individuals were children 1-17 years of age who filled an incident analgesic following an outpatient surgery during 2013-2018. Pain-associated hospital admission or ER visit were measured within 30 days following the outpatient surgical procedure. A hierarchical multivariable logistic regression model with patients nested under prescribers was fitted to test the association between incident analgesic prescription and risk of having pain-associated hospital admission or ER visit. RESULTS: Of 14 277 children meeting the inclusion criteria, 6224 (43.6%) received an incident opioid and 8053 (56.4%) received an incident non-opioid analgesic prescription respectively. There were a total of 523 (3.7%) children undergoing surgical procedures that had pain-related hospital admissions or ER visits with 5.1% initiated on non-opioid analgesics and 1.8% on opioid analgesics. The multilevel model indicated that initial opioid analgesic recipients were 32% less likely of having a pain-associated hospital admission or ER visit [aOR: 0.68 (95% CI: 0.3-0.8)]. CONCLUSION: Majority of postsurgical patients do not require additional pain management strategies. In the 3.7% of patients requiring additional pain management strategies, those initiated on non-opioid analgesics are more likely to have a pain-associated hospital admission or ER visit compared with their opioid recipient counterparts.

Safety and Outcome Measures of Ankle Open Reduction and Internal Fixation in an Ambulatory Surgical Center.

The transition of traditionally hospital-based orthopedic procedures to the ambulatory surgery center setting provides many benefits from a patient care and financial perspective. Specifically, closed ankle fractures can potentially be managed at such centers without needing hospitalization. Adding to the paucity of data, this study describes the safety, cost, and outcomes of patients undergoing ankle fracture repair in an ambulatory surgery center. A retrospective chart review of 100 patients who underwent ankle fracture open reduction and internal fixation from a single ambulatory surgery center by 1 surgeon were reviewed. Demographic data, surgical characteristics including operating time and cost were collected. Short- and long-term complications, as well as, reoperation rates were reported and functional outcomes were described. Of the 100 patients, 59% were female and the overall average age was 50 ± 16 years. The average cost per case was $8,709.63 ± 6,360.18. The short-term complication rate was 16%, with surgical site infection reported as the most common complication. No postoperative hospital admissions were reported. Planned and unplanned hardware removal was performed in 7% and 5% of patients, respectively. The delayed union rate was 13%, in which 86% shared a history of smoking. Smoking history was the only statistically significant predictor of prolonged bone healing (p = .002). This investigation demonstrates low complications rates for surgeries performed in a surgery center when compared to historical rates of those procedures performed in the hospital. These results suggest that ambulatory surgery center-based ankle fracture repair does not increase complications while may decrease overall cost when compared to ankle ORIF in a hospital setting.

Assessing the Ambulatory Surgery Center Volume-Outcome Association.

Importance: In surgical patients, it is well known that higher hospital procedure volume is associated with better outcomes. To our knowledge, this volume-outcome association has not been studied in ambulatory surgery centers (ASCs) in the US. Objective: To determine if low-volume ASCs have a higher rate of revisits after surgery, particularly among patients with multimorbidity. Design, Setting, and Participants: This matched case-control study used Medicare claims data and analyzed surgeries performed during 2018 and 2019 at ASCs. The study examined 2328 ASCs performing common ambulatory procedures and analyzed 4751 patients with a revisit within 7 days of surgery (defined to be either 1 of 4735 revisits or 1 of 16 deaths without a revisit). These cases were each closely matched to 5 control patients without revisits (23 755 controls). Data were analyzed from January 1, 2018, through December 31, 2019. Main Outcomes and Measures: Seven-day revisit in patients (cases) compared with the matched patients without the outcome (controls) in ASCs with low volume (less than 50 procedures over 2 years) vs higher volume (50 or more procedures). Results: Patients at a low-volume ASC had a higher odds of a 7-day revisit vs patients who had their surgery at a higher-volume ASC (odds ratio [OR], 1.21; 95% CI, 1.09-1.36; P = .001). The odds of revisit for patients with multimorbidity were higher at low-volume ASCs when compared with higher-volume ASCs (OR, 1.57; 95% CI, 1.27-1.94; P < .001). Among patients with multimorbidity in low-volume ASCs, for those who underwent orthopedic procedures, the odds of revisit were 84% higher (OR, 1.84; 95% CI, 1.36-2.50; P < .001) vs higher-volume centers, and for those who underwent general surgery or other procedures, the odds of revisit were 36% higher (OR, 1.36; 95% CI, 1.01-1.83; P = .05) vs a higher-volume center. The findings were not statistically significant for patients without multimorbidity. Conclusions and Relevance: In this observational study, the surgical volume of an ASC was an important indicator of patient outcomes. Older patients with multimorbidity should discuss with their surgeon the optimal location of their care.

Complications related to thyroidectomy among patients with hyperthyroidism: Exploring the potential for ambulatory surgery.

BACKGROUND: Total thyroidectomy for hyperthyroidism is typically followed by overnight admission to monitor for complications including thyrotoxicosis. Outpatient thyroid surgery is increasingly common, but its safety in patients with hyperthyroidism has not been well studied. METHODS: This retrospective study reviewed 183 patients with hyperthyroidism who underwent total thyroidectomy from 2015 to 2022 at one urban, academic center. The main outcomes were rates of thyroid storm, surgical complications, and 30-day ED visits and readmissions. RESULTS: Among 183 patients with hyperthyroidism (mean age, 45 ± 14.5 years; 82.5% female), there were no cases of thyroid storm and complications included recurrent laryngeal nerve (RLN) palsy (7.0%), symptomatic hypocalcemia (4.4%), and hematoma (1.6%). ED visits were present in 1.1% and no patients were readmitted. CONCLUSION: Total thyroidectomy was not associated with thyroid storm and <6% of patients required inpatient management. Ambulatory total thyroidectomy for hyperthyroidism warrants further consideration through identification of predictive factors for postoperative complications.

Safety of Outpatient Plastic Surgery: A Comparative Analysis Using the TOPS Registry with 286,826 Procedures.

BACKGROUND: Outpatient plastic surgery at office-based surgery facilities (OBSFs) and ambulatory surgery centers (ASCs) has become increasingly prevalent over the past 30 years. Importantly, historical data are inconsistent regarding the safety outcomes of these venues, with advocates for both citing supporting studies. This investigation's purpose is to provide a more definitive comparative evaluation of outcomes and safety for outpatient surgery performed in these facilities. METHODS: The most common outpatient procedures were identified using the Tracking Operations and Outcomes for Plastic Surgeons database between 2008 and 2016. Outcomes were analyzed for OBSFs and ASCs. Patient and perioperative information was also analyzed using regression analysis to identify risk factors for complications. RESULTS: A total of 286,826 procedures were evaluated, of which 43.8% were performed at ASCs and 56.2% at OBSFs. Most patients were healthy, middle-aged women categorized as American Society of Anesthesiologists class I. The incidence of adverse events was 5.7%, and most commonly included antibiotic requirement (1.4%), dehiscence (1.3%), or seroma requiring drainage (1.1%). Overall, there was no significant difference in adverse events between ASCs and OBSFs. Age, American Society of Anesthesiologists class, body mass index, diabetes, smoking history, general anesthesia, certified registered nurse anesthetist involvement, operative duration, noncosmetic indications, and body region were associated with adverse events. CONCLUSIONS: This study provides an extensive analysis of common plastic surgery procedures performed in an outpatient setting in a representative population. With appropriate patient selection, procedures are safely performed by board-certified plastic surgeons in ambulatory surgery centers and office-based settings, as evidenced by the low incidence of complications in both environments. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Comparison of the Safety of Inpatient Versus Outpatient Lumbar Fusion : A Systematic Review and Meta-Analysis.

STUDY DESIGN: Systematic Review and Meta-analysis. OBJECTIVE: The objective of this study is to synthesize the early data regarding and analyze the safety profile of outpatient lumbar fusion. SUMMARY OF BACKGROUND DATA: Performing lumbar fusion in an outpatient or ambulatory setting is becoming an increasingly employed strategy to provide effective value-based care. As this is an emerging option for surgeons to employ in their practices, the data is still in its infancy. METHODS: This study was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Studies that described outcomes of inpatient and outpatient lumbar fusion cohorts were searched from PubMed, Medline, The Cochrane Library, and Embase. Rates of individual medical and surgical complications, readmission, and reoperation were collected when applicable. Patient-reported outcomes (PROMs) were additionally collected if reported. Individual pooled comparative meta-analysis was performed for outcomes of medical complications, surgical complications, readmission, and reoperation. PROMs were reviewed and qualitatively reported. RESULTS: The search yielded 14 publications that compared outpatient and inpatient cohorts with a total of 75,627 patients. Odds of readmission demonstrated no significant difference between outpatient and inpatient cohorts [OR=0.94 (0.81-1.11)]. Revision surgery similarly was no different between the cohorts [OR=0.81 (0.57-1.15)]. Pooled medical and surgical complications demonstrated significantly decreased odds for outpatient cohorts compared with inpatient cohorts [OR=0.58 (0.34-0.50), OR=0.41 (0.50-0.68), respectively]. PROM measures were largely the same between the cohorts when reported, with few studies showing better ODI and VAS Leg outcomes among outpatient cohorts compared with inpatient cohorts. CONCLUSION: Preliminary data regarding the safety of outpatient lumbar fusion demonstrates a favorable safety profile in appropriately selected patients, with PROMs remaining comparable in this setting. There is no data in the form of prospective and randomized trials which is necessary to definitively change practice.

Evaluation of the efficacy and safety of day surgery for cervical disc herniation treated with low temperature plasma radiofrequency ablation.

PURPOSE: The purpose of this study was to evaluate and compare the clinical efficacy of patients with cervical disc herniation (CDH) treated by low-temperature plasma radiofrequency ablation (LTP-RFA) as day surgery with traditional inpatients. METHODS: According to the selection criteria, single-segment mild to moderate CDH patients who received LTP-RFA from January 2020 to December 2021 were divided into day surgery procedure (DSP) group and a traditional inpatient procedure (TIP) group. The visual analogue score (VAS) and modified Japanese Orthopedic Association score (mJOA) of neurological function of patients in the two groups were recorded at the time of preoperative, and one day, three months, six months after surgery and the last follow-up respectively. The gender, age, responsible segment, surgical complications, hospitalization time, hospitalization expenses, and patient satisfaction were recorded and analyzed for both groups. The modified Macnab standard was used to evaluate the postoperative efficacy at one month and six months after operation. RESULTS: A total of 127 patients (75 in DSP;52 in TIP) with complete data were enrolled and completed six month follow-up. There were no statistically significant pre-treatment VAS scores and mJOA scores in the two groups (P>0.05). The postoperative VAS and mJOA scores in both groups were improved after surgery (P<0.05). However, there was no significant difference in VAS scores and mJOA scores between the two groups in the same postoperative period (all P > 0.05). The efficacy of MacNab was similar one month and six months after operation (P > 0.05). The hospitalization time and hospitalization cost were significantly lower in DSP group (all P<0.05). As the treatment effects were comparable, patients in both groups were similarly satisfied at discharge. CONCLUSION: LTP-RFA is an effective method for the treatment of mild to moderate CDH. We suggest that the application of LTP-RFA in DSP for mild to moderate CDH is worthy of wide application.

The Effect of Surgical Approach on the Outcomes of Same-Day Discharge Outpatient Total Hip Arthroplasty at a Single Ambulatory Surgery Center.

BACKGROUND: Primary total hip arthroplasty (THA) is increasingly being performed in the outpatient setting. However, there is little known regarding the differences in same-day discharge (SDD) rates and complications of operative approach in same-day total hip arthroplasty in the ambulatory surgery center (ASC) setting. METHODS: A retrospective chart review was performed between July 2019 and October 2021 for all patients who underwent primary THA in a single freestanding ASC. Successful SDDs, surgical approaches, lengths of surgery, estimated blood losses (EBL), complications, and readmission events were recorded for each patient. Complications were compared using Pearson Chi-Squares, while EBL and surgery lengths were compared with 1-way analysis of variances (ANOVA) (alpha = 0.5). There were 17 total complications in 326 total hip arthroplasties (5.2%), including direct admissions to the emergency department, 30-day and 90-day readmissions, wound complications, instability, infection, and revision surgery. Among all complications, there were 5 direct admissions, making the successful SDD rate 98.5%. RESULTS: Complications and direct admissions were not associated with approach. The 30-day readmission rates were associated with approach, with no readmissions in the direct anterior approach (DAA) or the antero-lateral approach (AL) cohorts and 3 (4.3%) in the posterior approach (PA) cohort. CONCLUSIONS: In the ASC setting, patients undergoing THA regardless of approach showed no difference in successful SDDs or complications aside from 30-day readmissions. Same-day THA can be safely performed in the DAA, AL, and PA to the hip.

Patient-selection algorithm for outpatient shoulder arthroplasty in ambulatory surgery center: a retrospective update.

BACKGROUND: Outpatient total shoulder arthroplasty (TSA) presents a safe alternative to inpatient arthroplasty, while helping meet the rapidly rising volume of shoulder arthroplasty needs and minimizing health care costs. Identifying the correct patient for outpatient surgery is critical to maintaining the safety standards with TSA. This study sought to update an ambulatory surgery center (ASC) TSA patient-selection algorithm previously published by our institution. METHODS: A retrospective chart review of TSAs was performed in an ASC at a single institution to collect patient demographics, perioperative risk factors, and postoperative outcomes with regard to reoperations, hospital admissions, and complications. The existing ASC algorithm for outpatient TSA was altered based on collected perioperative information, review of pertinent literature, and anesthesiology recommendations. RESULTS: A total of 319 TSAs were performed in an ASC in 298 patients over 7 years. Medically related complications occurred in 3 patients (0.9%) within 90 days of surgery, 2 of whom required hospital admission (0.6%) for acute kidney injury and pulmonary embolus. There were no instances of major cardiac events. Orthopedic-related complications occurred in 11 patients (3.4%), with hematoma development requiring evacuation and instability requiring revision being the most common causes. CONCLUSIONS: There was a low rate of perioperative complications and hospital admissions, confirming the safety of TSAs in an ASC setting. Based on prior literature and the population included, a pre-existing patient-selection algorithm was updated to better reflect increased comfort, knowledge, and data regarding safe patient selection for TSA in an ASC.

Laryngeal office-based procedures: A safe approach.

PURPOSE: Laryngeal surgeries using a flexible nasopharyngoscope equipped with an operative channel has gained popularity, with gradual increase in the variety of interventional office-based procedures, under local anesthesia. The purpose of this study is to analyze the tolerance of such procedures. MATERIALS AND METHODS: Retrospective cohort study. 337 cases were performed during 2 years. We collected the following data: type of pathology, type of procedure and modalities of anesthesia, adverse events. RESULTS: 19 % of the visits were for the purpose of Biopsy, 65 % for an injection, and Trublue Laser was utilized in 12 % of the procedures. Regarding the pathologies, 27 % were vocal fold paralysis, 18 % leukoplakia or another suspicious lesion, 15 % recurrent respiratory papillomatosis, 13 % neuromuscular disorder, 9 % vocal fold scarring, 7 % vocal cord atrophy and 6 % had an inflammatory presentation. Side effects were documented in 26 visits (7.7 %) and were minor in almost all the encounters: they included strong reflexive cough, deep throat pain, discomfort, gag reflex, anxiety, vagal discomfort, malaise, hypersalivation, nose pain, labile hypertension. More severe side effects were very rare and included septal wound and epistaxis, erythematous rash, dyspnea, and transient dysarthria. 13 procedures were either aborted, or canceled at initial steps, due to inability of the patient to tolerate the procedure and were rescheduled for general anesthesia. 97 % of the cases were released home after 1 h of surveillance. CONCLUSION: Office-based flexible interventional laryngoscopy under local anesthesia is a safe and well-tolerated procedure, with abundance of various interventions feasible on ambulatory, office-based setup.

Safety and Efficiency Outcomes of Ambulatory Gynaecologic Procedures in Canadian Surgical Centres Adopting a Common Model.

OBJECTIVE: The present study aims to compare the safety and efficiency outcomes of ambulatory gynaecologic procedures performed under conscious sedation and/or local anaesthetic at 2 Canadian institutions. METHODS: A retrospective cohort study was completed over 1-year on patients presenting to the ambulatory care centres at 2 Canadian institutions that shared a common care model. Outcomes of interest were lead time (registration to discharge), procedural time, and intraoperative complications. Surgical data was derived from a retrospective chart review and outcomes were compared using the independent t test and one-way analysis of variance. RESULTS: A total of 1495 and 1098 patients presented to the 2 sites. The average age of patients was 35.5 ± 12.3 years and 41.7 ± 10.2 years. The most commonly performed procedures were dilatation and curettages at the first centre and operative hysteroscopies at the second centre. Average lead times were similar: 170.3 ± 35.8 minutes and 171.6 ± 45.4 minutes (P = 0.45). There was a significant difference in mean procedural time being 9.8 ± 5.5 minutes and 17.0 ± 10.0 minutes (P < 0.001). The rate of minor intraoperative complications was 3.8% and 6.6% (P = 0.002); whereas the rate of major complications was 2.7% and 3.3% (P = 0.43). CONCLUSION: In Canada, the majority of gynaecologic procedures are performed under general anesthesia. By comparing outcomes at 2 separate Canadian centres, we demonstrated the reproducibility of a common ambulatory model for minor gynaecologic procedures, supporting the implementation of similar care models across Canada.

Use of chloroprocaine in orthopedic day surgery: a brief report in a cohort of patients undergoing knee arthroscopy.

OBJECTIVE: Spinal anesthesia with local anesthetics is a viable alternative to general anesthesia in orthopedic surgery, and it is currently considered the standard of care for knee arthroscopy. The use of chloroprocaine may offer several potential advantages over other local anesthetics, including, above all, its rapid onset and short duration of action. The aim of the present retrospective study is to evaluate the post-surgical outcomes of patients who underwent knee arthroscopy using spinal anesthesia with chloroprocaine in an outpatient orthopedic setting. PATIENTS AND METHODS: Data from patients who underwent elective knee arthroscopy between January 2022 and December 2022 were collected for the present study. Spinal anesthesia with chloroprocaine 10 mg/mL was administered in the designated subarachnoid space (L3-L4 in the majority of patients). A dosage of 40 mg was used to obtain a satisfactory sensory and motor block. RESULTS: A total number of 302 patients met the inclusion criteria. No complications were reported during surgery in the present series of patients. None of the patients required bladder catheterization. In 84% of cases, the PADSS (Post-Anesthetic Discharge Scoring System) score at discharge was 10, whereas in 16% of cases, the PADSS score was 9. The mean time from anesthesia induction to first urination was 75±9.4 minutes, while the mean time from the anesthesia induction to the discharge from the hospital was 152±18.5 minutes. CONCLUSIONS: Spinal chloroprocaine for knee arthroscopy demonstrated a short motor block duration, resulting in a fast time to discharge. These limited data show that chloroprocaine may be safely and effectively applied in outpatient knee arthroscopy procedures. However, more studies, possibly with a randomized design, are required to confirm these findings.

Day-surgery adult patients with obesity and obstructive sleep apnea: Current controversies and concerns.

Obesity and obstructive sleep apnea are considered independent risk factors that can adversely affect perioperative outcomes. A combination of these two conditions in the ambulatory surgery patient can pose significant challenges for the anesthesiologist. Nevertheless, these patients should not routinely be denied access to ambulatory surgery. Instead, patients should be appropriately optimized. Anesthesiologists and surgeons must work together to implement fast-track anesthetic and surgical techniques that will ensure successful ambulatory outcomes.

Adjuvants for balanced anesthesia in ambulatory surgery.

Balanced anesthesia relies on the simultaneous administration of different drugs to attain an anesthetic state. The classic triad of anesthesia is a combination of a hypnotic, an analgesic, and a neuromuscular blocker. It is predominantly the analgesic pillar of this triad that became more and more supported by adjuvant therapy. The aim of this approach is to evolve into an opioid-sparing technique to cope with undesirable side effects of the opioids and is fueled by the opioid epidemic. The optimal strategy for balanced general anesthesia in ambulatory surgery must aim for a transition to a multimodal analgesic regimen dealing with acute postoperative pain and ideally reduce the most common adverse effects patients are faced with at home; sore throat, delayed awakening, memory disturbances, headache, nausea and vomiting, and negative behavioral changes. Over the years, this continuum of "multimodal general anesthesia" adopted many drugs with different modes of action. This review focuses on the most recent evidence on the different adjuvants that entered clinical practice and gives an overview of the different mechanisms of action, the potential as opioid-sparing or hypnotic-sparing drugs, and the applicability specifically in ambulatory surgery.