Ten year performance of Ambulatory Surgery in England / Diez años de actividad de la Cirugía Mayor Ambulatoria en Inglaterra

Introduction: The development of a new cohort of procedures suitable for Ambulatory Surgery has been recently mooted by the International Association of Ambulatory Surgery.This paper describes a ten year audit of performance of such operations in England, calculating rates for admission, treatment and discharge over the same calendar day. Methods: Data were extrapolated from NHS Digital information for the years 2006-7 to 2016-17, by subtracting emergency operations from the total number of finished consultant episodes, and then calculating the ambulatory surgery rate. Results: There has been a consistent increase in the rates of ambulatory surgery for the periods evaluated. Procedures can be divided into "mature", "rapidly rising" and "low threshold" categories, dependent upon their relative rates. Conclusion: Retrospective audit of ambulatory surgery performance allows assessment of national status to facilitate further development of the speciality

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Peri-operative management of the obese surgical patient 2015: Association of Anaesthetists of Great Britain and Ireland Society for Obesity and Bariatric Anaesthesia.

Guidelines are presented for the organisational and clinical peri-operative management of anaesthesia and surgery for patients who are obese, along with a summary of the problems that obesity may cause peri-operatively. The advice presented is based on previously published advice, clinical studies and expert opinion.

The acute pain service: effective or expensive care?

The effect of introducing an Acute Pain Service into a District General Hospital was evaluated by conducting an audit of pain, emesis, sleep and satisfaction before and after inception. A total of 1518 questionnaires were collected; in which surgical patients had been asked to assess their experience pre- and postoperatively. The introduction of an Acute Pain Service significantly (p < 0.0001) improved in-patient perception of pain relief upon return of consciousness after anaesthesia and for 2 days postoperatively, when compared with the experience before its inception. The incidence of emetic sequelae did not increase and both patient satisfaction (p < 0.001) and sleep pattern (p < 0.05) in hospital were significantly improved. An estimate of the economic benefit suggests that the development of Acute Pain Services may be cost effective as well as providing an improved quality of service for patients undergoing surgery.

Anaesthesia and rheumatoid arthritis.

A review of the implications of rheumatoid arthritis on peri-operative anaesthetic management is presented. Pre-operative assessment should include a careful search for articular and systemic manifestations of the disease that may complicate intraoperative care. Drug disposition may vary from the normal patient as a result of changes in serum protein binding, together with possible exaggeration of pharmacodynamic responses. Airway management presents one of the greatest challenges to the anaesthetist, and care in manipulation of the cervical spine is paramount.

Total i.v. anaesthesia with propofol and alfentanil: dose requirements for propofol and the effect of premedication with clonidine.

We determined in 51 healthy patients undergoing body surface surgery the dose requirements for propofol, as part of a total i.v. anaesthesia technique with an alfentanil infusion. After premedication with temazepam, patients received alfentanil 50 micrograms kg-1 followed by an infusion of 50 micrograms kg-1 h-1. Patients were anaesthetized with a loading dose of propofol followed by a three-stage infusion designed to reach one of five preselected blood concentrations of propofol. The motor response to the initial surgical incision was noted and probit analysis was used to derive the ED50 (2.94 mg kg-1 h-1; 95% confidence limits: 2.35-3.37 mg kg-1 h-1) and ED95 (4.98 mg kg-1 h-1; 95% limits: 4.13-8.8 mg kg-1 h-1) for the final propotol infusion rate under these conditions. Whole blood concentration!of propofol at the time of the incision was related linearly to the inf!sion rate and the EC50 and EC95 (probit analysis) were derived as !.44 (95% confidence limits 0.62-1.87) and 4.05 (95% confidence lim!ts 2.78-30.5) micrograms ml-1, respectively. Post-operative recovery was!rapid, uncomplicated and uneventful. In a subgroup of eight patients,!the addition of clonidine 0.6 mg to the premedication significantly decreased the requirement for propofol (P less than 0.05) during surgery, but resulted in prolonged recovery times.

Preinduction atropine or glycopyrrolate and hemodynamic changes associated with induction and maintenance of anesthesia with propofol and alfentanil.

Total intravenous anesthesia by infusions of propofol and alfentanil may be associated with decreases in heart rate and blood pressure. The effects of two vagolytic agents on these hemodynamic changes were studied in 24 ASA physical status 1 patients undergoing body surface surgery. Patients were randomly allocated to receive atropine 10 micrograms/kg, glycopyrrolate, 5 micrograms/kg, or 0.9% sodium chloride, intravenously, 5 min before induction of anesthesia with loading doses of alfentanil, 50 micrograms/kg and propofol 1 mg/kg. Anesthesia was maintained with infusions of alfentanil 50 micrograms.kg-1.hr-1, and propofol 10 mg.kg-1.hr-1 for the first 10 min, 8 mg.kg-1.hr-1 for the next 10 min, and 6 mg.kg-1.hr-1 thereafter. Patients given glycopyrrolate before anesthesia had significantly higher arterial pressures than did patients receiving either atropine or saline, even though heart rates increased equally after glycopyrrolate and atropine.

The pharmacology of propofol.

A review of the pharmacology of propofol, a new IV anesthetic agent, is presented. Solubilized in a soybean emulsion, propofol is one of a series of sterically hindered phenols that exhibit anesthetic activity. Induction of anesthesia with propofol may be associated with pain on injection, apnea, and a reduction in arterial blood pressure (BP) and cardiac output. Caution should be ascribed to its use in patients with coronary artery disease, where these effects may have the potential for producing myocardial ischemia. The hemodynamic responses to laryngoscopy and intubation are attenuated. The pharmacokinetic profile suggests suitability as an infusion for either maintenance of anesthesia or sedation. Use of propofol as an infusion during surgery may result in a further reduction in cardiac output, particularly with the concomitant administration of adjuvant increments of fentanyl. The ventilatory response to CO2 is depressed during such an infusion. The high clearance of propofol suggests that even after a prolonged infusion, recovery should be rapid. This finding has been confirmed in a series of studies establishing propofol as an ideal agent for use in a total IV anesthetic technique. Both the quality and speed of recovery, together with the absence of emetic sequelae, support the use of propofol in an outpatient setting. Propofol appears to have no long-term effect on adrenocortical function and appears safe for use in patients with acute intermittent porphyria and susceptibility to malignant hyperpyrexia.