Enhanced Recovery and Surgical Optimization Protocol for Minimally Invasive Gynecologic Surgery: An AAGL White Paper.

This is the first Enhanced Recovery After Surgery (ERAS) guideline dedicated to standardizing and optimizing perioperative care for women undergoing minimally invasive gynecologic surgery. The guideline was rigorously formulated by an American Association of Gynecologic Laparoscopists Task Force of US and Canadian gynecologic surgeons with special interest and experience in adapting ERAS practices for patients requiring minimally invasive gynecologic surgery. It builds on the 2016 ERAS Society recommendations for perioperative care in gynecologic/oncologic surgery by serving as a more comprehensive reference for minimally invasive endoscopic and vaginal surgery for both benign and malignant gynecologic conditions. For example, the section on preoperative optimization provides more specific recommendations derived from the ambulatory surgery and anesthesia literature for the management of anemia, hyperglycemia, and obstructive sleep apnea. Recommendations pertaining to multimodal analgesia account for the recent Food and Drug Administration warnings about respiratory depression from gabapentinoids. The guideline focuses on workflows important to high-value care in minimally invasive surgery, such as same-day discharge, and tackles controversial issues in minimally invasive surgery, such as thromboprophylaxis. In these ways, the guideline supports the American Association of Gynecologic Laparoscopists and our collective mission to elevate the quality and safety of healthcare for women through excellence in clinical practice.

Does performing outpatient total hip arthroplasty contribute to early complications and readmissions? Retrospective case-control study of 50 patients.

INTRODUCTION: Advances in anesthesia and surgical practices have allowed total hip arthroplasty to be performed as an outpatient procedure. The aim of this study was to demonstrate its feasibility in a selected population compared to a group of inpatients by analyzing the cumulative length of hospital stay, complications and readmissions. PATIENTS AND METHODS: This was a retrospective, single-surgeon study of continuous adult patients between October 2016 and May 2018 who underwent primary total hip arthroplasty (THA) and were eligible to undergo this procedure either as an inpatient or outpatient based on their health and comprehension level. Two groups of patients were set up. The outpatient group was given a preoperative treatment education session. The same anesthesia protocol and surgical technique was used in both groups. RESULTS: Fifty outpatients were compared to 77 inpatients. In the outpatient group, the patients were significantly younger, had a greater walking distance and were predominantly male. The two groups were comparable in terms of functional and medical criteria. The mean cumulative hospital stay was 1.2days in the outpatient group with one discharge failure because of nausea and vomiting, versus 5.1days in the inpatient group (p<0.0001). There were three complications in each group (p=1.00). There were three readmissions in the outpatient group and four in the inpatient group (p=1.00) that were of similar length (p=0.86). There was no difference in the mean number of additional office visits over this period between the two groups. CONCLUSION: Outpatient THA procedures can be done reliably and safely in France in a carefully selected population without increasing the complication rate or readmission rate. Expanding this practice requires implementing specific anesthesia and surgery protocols, along with close perioperative monitoring to help manage risk. LEVEL OF EVIDENCE: IV (retrospective cohort study).

Low Preoperative Mental and Physical Health is Associated with Poorer Postoperative Recovery in Patients Undergoing Day Surgery: A Secondary Analysis from a Randomized Controlled Study.

BACKGROUND: Day surgical procedures are increasing both in Sweden and internationally. Day surgery patients prepare for and handle their recovery on their own at home. The aim of this study was to investigate patients' preoperative mental and physical health and its association with the quality of their recovery after day surgery. METHOD: This was a secondary analysis of a randomized controlled trial. Data were collected at four-day surgery units in Sweden. Health-related quality of life was measured using the Short Form 36 (SF-36) Health Survey, and postoperative recovery was assessed using the Swedish web version of the Quality of Recovery (SwQoR) scale. RESULT: This study included 756-day surgery patients. A low, compared with a high, preoperative mental component score was associated with poorer recovery as shown by responses to 21/24 and 22/24 SwQoR items, respectively, on postoperative days (PODs) 7 and 14. A low compared with a high preoperative physical component score was associated with poorer recovery in 18/24 SwQoR items on POD 7 and 13/24 on POD 14. CONCLUSION: A clear message from this study is for surgeons, anaesthetists and nurses to consider the fact that postoperative recovery largely depends on patients' preoperative mental and psychical status. A serious attempt must be made, as a part of the routine preoperative assessment, to assess and document not only the physical but also the mental status of patients undergoing anaesthesia and surgery. TRIAL REGISTRATION: Clinicaltrials.gov Identifier: NCT0249219.

Impact of caregiver overnight stay on postoperative outcomes.

PURPOSE: The purpose of this paper is to determine the impact of having a patient-designated caregiver remain overnight with ambulatory extended recovery patients on early postoperative clinical outcomes. DESIGN/METHODOLOGY/APPROACH: This was a retrospective cohort study of patients undergoing surgery requiring overnight stay in a highly resourced free-standing oncology ambulatory surgery center. Postoperative outcomes in patients who had caregivers stay with them overnight were compared with outcomes in those who did not. All other care was standardized. Primary outcomes were postoperative length of stay, hospital readmission rates, urgent care center (UCC) visits within 30 days and perioperative complication rates. FINDINGS: Among patients staying overnight, 2,462 (57 percent) were accompanied by overnight caregivers. In this group, time to discharge was significantly lower. Readmissions (though rare) were slightly higher, though the difference was not statistically significant (p=0.059). No difference in early (<30 day) complications or UCC visits was noted. Presence of a caregiver overnight was not associated with important differences in outcomes, though further research in a less well-structured environment is likely to show a more robust benefit. Caregivers are still recommended to stay overnight if that is their preference as no harm was identified. ORIGINALITY/VALUE: This study is unique in its evaluation of the clinical impact of having a caregiver stay overnight with ambulatory surgery patients. Little research has focused on the direct impact of the caregiver on patient outcomes, especially in the ambulatory setting. With increased adoption of minimally invasive surgical techniques and enhanced recovery pathways, a larger number of patients are eligible for short-stay ambulatory surgery. Factors that impact discharge and early postoperative complications are important.

Evaluation of postoperative recovery in day surgery patients using a mobile phone application: a multicentre randomized trial.

BACKGROUND: Many patients undergoing anaesthesia and surgery experience postoperative complications. Our aim was to investigate whether a systematic follow-up smartphone-based assessment, using recovery assessment by phone points (RAPP) compared with standard care, had a positive effect on day surgery patients' postoperative recovery. We also investigated whether there were differences in women and men's recovery and recovery scores. METHODS: The study was a single-blind, multicentre randomized controlled trial. A total of 997 patients were randomly allocated to either RAPP or standard care. The Swedish web version of a quality of recovery (SwQoR) questionnaire was used to evaluate the patients' postoperative recovery, either on paper or using an application (RAPP) on postoperative days seven and 14. RESULTS: On postoperative day seven the RAPP group reported significantly better values in seven out of 24 items of the SwQoR: sleeping difficulties; not having a general feeling of wellbeing; having difficulty feeling relaxed/comfortable; and dizziness; headache; pain in the surgical wound; and a swollen surgical wound compared with the control group, implying a good postoperative recovery. Both men and women in the RAPP group reported significantly better values (and, hence good postoperative recovery) compared with the control group in the items sleeping difficulties; not having a general feeling of wellbeing and pain in the surgical wound. CONCLUSIONS: Measurement of patient-reported outcomes using a smartphone-based application was associated with decreased discomfort from several postoperative symptoms. Systematic e-assessment can thereby increase patients' quality of recovery and identify key areas for improvement in perioperative care. CLINICAL TRIAL REGISTRATION: NCT02492191.

Cost-effectiveness of a systematic e-assessed follow-up of postoperative recovery after day surgery: a multicentre randomized trial.

BACKGROUND: Most surgeries are done on a day-stay basis. Recovery assessment by phone points (RAPP) is a smartphone-based application (app) to evaluate patients after day surgery. The aim of this study was to estimate the cost-effectiveness of using RAPP for follow-up on postoperative recovery compared with standard care. METHODS: This study was a prospective parallel single-blind multicentre randomized controlled trial. Participants were randomly allocated to the intervention group using RAPP or the control group receiving standard care. A cost-effectiveness analysis was performed based on individual data and included costs for the intervention, health effect [quality-adjusted life-years (QALYs)], and costs or savings in health-care use. RESULTS: The mean cost for health-care consumption during 2 weeks after surgery was estimated at €37.29 for the intervention group and €60.96 for the control group. The mean difference was €23.66 (99% confidence interval -46.57 to - 0.76; P=0.008). When including the costs of the intervention, the cost-effectiveness analysis showed net savings of €4.77 per patient in favour of the intervention. No difference in QALYs gained was seen between the groups (P=0.75). The probability of the intervention being cost-effective was 71%. CONCLUSIONS: This study shows that RAPP can be cost-effective but had no effect on QALY. RAPP can be a cost-effective tool in providing low-cost health-care contacts and in systematically assessing the quality of postoperative recovery. CLINICAL TRIAL REGISTRATION: NCT02492191.

Impacto económico de la variabilidad clínica en la petición de pruebas preoperatorias en cirugía mayor ambulatoria / Economic impact of clinical variability in preoperative testing for major outpatient surgery

INTRODUCCIÓN: Con el propósito de disminuir la variabilidad en la petición de pruebas preoperatorias y facilitar la toma de decisiones, nuestro centro ha establecido un protocolo de pruebas preoperatorias para pacientes ASA I y ASA II tratados mediante cirugía mayor ambulatoria (CMA). El objetivo del estudio fue calcular el impacto económico relacionado con la falta de adherencia de los profesionales al protocolo establecido. MÉTODOS: Estudio de costes retrospectivo con un muestreo aleatorizado simple de 353 pacientes atendidos en la consulta de anestesia durante un año. Se analizaron aspectos relacionados con los costes, así como el perfil de pacientes y especialidades según el grado de cumplimiento del protocolo establecido. RESULTADOS: La falta de adherencia al protocolo fue del 70%. Se realizaron 138 radiografías de tórax y 218 electrocardiogramas no indicados, lo que supuso un exceso de coste medio de 34 € por paciente. Teniendo en cuenta el coste de ambas pruebas y la población atendida en CMA durante el año evaluado, la falta de adherencia al protocolo supuso un exceso de coste anual para el centro entre 69.337 € y 84.727 €. CONCLUSIONES: Es preciso reducir la variabilidad clínica y favorecer la creación de sinergias entre los diferentes servicios para adecuar la petición de pruebas complementarias, disminuir los costos de la atención y mejorar la calidad asistencial

BACKGROUND: With the purpose of decreasing the existing variability in the criteria of preoperative evaluation and facilitating the clinical decision-making process, our hospital has a protocol of preoperative tests to use with ASA I and ASA II patients. The aim of the study was to calculate the economic impact caused by clinicians' non-adherence to the protocol for the anaesthesiological evaluation of ASA 1 and ASA II patients. METHODS: A retrospective study of costs with a random sample of 353 patients that were seen in the consultation for Anesthesiology over a period of one year. Aspects related to the costs, patient's profiles and specialties were analysed, according to the degree of fulfillment of the protocol. RESULTS: The lack of adherence to the the protocol was 70%. 130 chest X-rays and 218 ECG were performed without indication. This generated an excess costs of 34 € per patient. Taking into account the expenses of both tests and the attended population undergoing ambulatory surgery during the one-year period, an excess spending for the hospital of between 69.164 € and 83.312 € was estimated. CONCLUSIONS: Clinical variability should be reduced and the creation of synergies between the different departments should be enhanced in order to adjust the request for unnecessary complementary tests to decrease health care and to improve the quality of patient care

Estudio de los procedimientos de anesthesia en CMA utilizados en Área III y IV de la comunidad de Cantabria en 2013-2014 / Study of anesthesia in ambulatory surgery procedures used in área III y and IV of the community of Cantabria

Los aspectos anestésicos de la Cirugía Mayor Ambulatoria (CMA) no suelen detallarse con precisión en las estadísticas oficiales de actividad sanitaria. Generalmente en España y en sus distintas comunidades autónomas se conoce la actividad quirúrgica ambulatoria, pero sin proporcionar datos anestésicos. Se recogieron las técnicas anestésicas administradas para procedimientos quirúrgicos en régimen de CMA de las distintas especialidades llevadas a cabo en el área III y IV del SCS durante los años 2013 y 2014. Se analizaron la actividad anestésica en primer lugar, y su relación con el ASA (escala de riesgo anestésico) en segundo lugar. De manera global, se observa un claro predominio de la Vigilancia Anestésica Monitorizada (VAM), que representa un 65% de la casuística. Esta técnica anestésica es la de elección en los procedimientos de oftalmología (especialidad con un peso importante en el total de pacientes de CMA), y con comorbilidades asociadas. La segunda técnica más utilizada fue la Anestesia General (AG) alrededor del 23% presentando porcentajes similares la técnica de AG con intubación orotraqueal respecto a la mascarilla laríngea. La suma de las anestesias locorregionales supuso un 10% del total, resultando la anestesia intradural la variedad más utilizada con un 6,8 y 7% respectivamente durante los años 2013 y 2014. La elección de la técnica anestésica se hará en función del paciente, de la intervención y de nuestra propia capacidad organizativa teniendo en cuenta en todo momento el coste-beneficio de los fármacos y del equipo empleados en su desarrollo

Anesthetic aspects of Ambulatory Surgery (AS) tend not precisely detailed in the official statistics of health activity. Usually in Spain and its different regions ambulatory surgical activity is known, but without providing data anesthetics. They administered anesthetic techniques for surgical procedures in the context of the various specialties CMA carried out in the area III and IV of SCS for the years 2013 and 2014 were collected. Anesthetic activity was first analyzed, and their relationship with ASA (scale of anesthetic risk) second. Globally, a clear predominance of Monitored Anesthesia Monitoring (VAM), which represents 65% of casuistry is observed. This is the anesthetic technique of choice in ophthalmology procedures (specialty with an important weight in the total of patients CMA), and comorbidities. The second most used technique was general anesthesia (GA) about 23% presenting similar percentages technique endotracheal intubation AG with respect to the LMA. The sum of regional blocks represented 10% of the total, resulting spinal anesthesia variety most commonly used with 6.8 and 7% respectively for the years 2013 and 2014. The choice of anesthetic technique will be based patient intervention and our own organizational capacity taking into account at all times the cost-effectiveness of drugs and equipment used in its development

Prevalence and Predictors of Quality of Recovery at Home After Day Surgery.

Traditionally, major complications and unanticipated admission/readmission rates were used to assess outcome after day surgery. However, in view of the relative absence of major complications the quality of recovery (QOR) should be considered one of the principal endpoints after day surgery. In our study, the level of QOR is defined by a combination of the Global Surgical Recovery (GSR) Index and the Quality of Life (QOL). The aim of this study was to analyze prevalence and predictors of QOR after day surgery on the fourth postoperative day. Elective patients scheduled for day surgery from November 2008 to April 2010 were enrolled in a prospective cohort study. Outcome parameters were measured by using questionnaire packages at 2 time points: 1 week preoperatively and 4 days postoperatively. Primary outcome parameter is the QOR and is defined as good if the GSR index >80% as well as the postoperative QOL is unchanged or improved as compared with baseline. QOR is defined as poor if both the GSR index ≤ 80% and if the postoperative QOL is decreased as compared with baseline. QOR is defined as intermediate in all other cases. Three logistic regression analyses were performed to determine predictors for poor QOR after day surgery. A total of 1118 patients were included. A good QOR was noted in 17.3% of patients, an intermediate QOR in 34.8%, and a poor QOR in 47.8% 4 days after day surgery. The best predictor for poor QOR after day surgery was type of surgery. Other predictors were younger age, work status, and longer duration of surgery. A history of previous surgery, expected pain (by the patient) and high long-term surgical fear were significant predictors of poor QOR in only 1 of 3 prediction models. The QOR at home 4 days after day surgery was poor in the majority of patients and showed a significant procedure-specific variation. Patients at risk for poor QOR can be identified during the preoperative period based on type of surgery, age, work status, and the duration of the surgery.

Home recovery following day surgery: a patient perspective.

AIMS AND OBJECTIVES: To investigate aspects of care potentially most influencing home recovery following day surgery. BACKGROUND: Elective surgery undertaken on a day-case basis is expanding. Many medical aspects of recovery have been investigated although less is known about the psychosocial view of postdischarge recovery. Greater insight into such issues is required for the development of a more coordinated nurse-led approach. DESIGN: Cross-sectional questionnaire. METHOD: As part of a larger study, questionnaires were distributed to 2401 adult patients on the day of operation (September 2010-October 2011) to examine patients' experiences of psychosocial recovery. Participants were requested to complete and return the questionnaire by mail one week after surgery with 684 returned. RESULTS: Eighty-five per cent were fully prepared for all events during home recovery. Satisfaction with pre- and postoperative surgical information was high although less so anaesthetic information. Using factor analysis, preoperative information, pain management, postdischarge information, anxiety management, postoperative nausea and vomiting, help and rest once home were central features. Multiple regression analysis demonstrated pre- and postoperative information provision to have a statistically significant positive association with patients' being 'fully prepared for all events during home recover'. Unsatisfactory pain management, increased anxiety and reduced help once home had a statistically significant negative association with patients' being 'fully prepared for all events during home recovery'. CONCLUSION: Focusing on the delivery of surgical and anaesthetic information, managing pain and anxiety and ensuring support once home may help to enhance recovery. A more comprehensive plan embracing such aspects could help enhance the day surgery patients' experience. RELEVANCE TO CLINICAL PRACTICE: Increased satisfaction and surgical/anaesthetic information are central to the continued success of minimal-stay surgery. A broader hospital/home strategy is required as too frequently nursing care can become fragmented between the preoperative outpatient visit, preassessment, day of surgery and postoperative outpatient visit.

Patient and caregiver experience following ambulatory surgery: qualitative analysis in a cohort of patients 65 yr and older.

PURPOSE: Patients over the age of 65 represent 15% of Canada's population and one-third of patients undergoing surgery. Older surgical patients often have lasting disability following "minor" ambulatory procedures. This study sought to explore the postoperative experience of ambulatory surgery, as described by older surgical patients and their caregivers. METHODS: Following research ethics board approval, patients 65 yr of age and older who were booked for ambulatory surgical procedures and their caregivers were recruited for the study. Both patients and caregivers were given a daily diary in which to respond to questions assessing functional autonomy, postoperative pain, and caregiver burden. Each daily entry concluded with the following request: "Using the space provided, please record any comments related to your postoperative experience as a patient (caregiver) that you feel are important for us to know." Responses were analyzed for emergent themes using qualitative description. RESULTS: There were 105 patient-caregiver dyads assessed: 90 patients and 64 caregivers offered at least one response. Ten themes, each with a positive and negative construct, clustered around three categories emerged from the comments. Anticipated themes regarding efficacy and side effects of perioperative care were noted. The impact of physical disability on home life was vividly described. Both patients and caregivers expressed concerns regarding preoperative information and postoperative support from the institution. CONCLUSIONS: Patients and caregivers ardently described real challenges during convalescence. Ambulatory care facilities should prepare this specific demographic of patients and caregivers for the post-discharge experience. Paramount for participants was the need for clear communication and a commitment to ongoing support following discharge. The trial on which this analysis was based was registered with Clinical Trials.gov (NCT01382251).

Patient function and caregiver burden after ambulatory surgery: a cohort study of patients older than 65.

PURPOSE: The primary objective of this prospective cohort study was to assess the impact of ambulatory surgery on patient function one week and one month following surgery among surgical patients ≥ 65 yr of age. Secondary objectives were to determine whether changes in patient function were correlated with increased burden of care in the patient's primary caregiver and with patient assessments of postoperative pain and quality of life. METHODS: Following Research Ethics Board approval, patients aged ≥ 65 yr undergoing elective ambulatory surgery and their caregivers were recruited. Patients completed the système de mesure de l'autonomie fonctionnelle (SMAF) and the Brief Pain Inventory. Primary caregivers completed the Zarit Burden Interview (ZBI). All measurements were obtained preoperatively and on postoperative days (POD) 7 and 30. RESULTS: Patient function decreased on POD 7 and had not returned to baseline on POD 30 (mean change in SMAF 6.9; 95% confidence interval (CI) 5.3 to 8.4 on POD 7 and mean change in SMAF 2.6; 95% CI 1.3 to 4.0 on POD 30). Interval changes in caregiver burden were not significant (mean change in ZBI -0.4; 95% CI -1.8 to 0.96 on POD 7 and mean change in ZBI -0.6; 95% CI -2.1 to 0.8 on POD 30). Decreased patient function was associated with increased caregiver burden at all time points (P < 0.001). Decreased caregiver function at baseline was also associated with higher ZBI (linear association 0.71; P = 0.02). CONCLUSIONS: Patients exhibited reduced function seven days following ambulatory surgery. Patient function largely recovered by POD 30. Caregiver burden was variable and influenced by both patient and caregiver function. This trial was registered with Clinical Trials.gov (NCT01382251).

Predicting recovery at home after ambulatory surgery.

UNLABELLED: The correct implementation of Ambulatory Surgery must be accompanied by an accurate monitoring of the patient post-discharge state. We fit different statistical models to predict the first hours postoperative status of a discharged patient. We will also be able to predict, for any discharged patient, the probability of needing a closer follow-up, or of having a normal progress at home. BACKGROUND: The status of a discharged patient is predicted during the first 48 hours after discharge by using variables routinely used in Ambulatory Surgery. The models fitted will provide the physician with an insight into the post-discharge progress. These models will provide valuable information to assist in educating the patient and their carers about what to expect after discharge as well as to improve their overall level of satisfaction. METHODS: A total of 922 patients from the Ambulatory Surgery Unit of the Dr. Peset University Hospital (Valencia, Spain) were selected for this study. Their post-discharge status was evaluated through a phone questionnaire. We pretend to predict four variables which were self-reported via phone interviews with the discharged patient: sleep, pain, oral tolerance of fluid/food and bleeding status. A fifth variable called phone score will be built as the sum of these four ordinal variables. The number of phone interviews varies between patients, depending on the evolution. The proportional odds model was used. The predictors were age, sex, ASA status, surgical time, discharge time, type of anaesthesia, surgical specialty and ambulatory surgical incapacity (ASI). This last variable reflects, before the operation, the state of incapacity and severity of symptoms in the discharged patient. RESULTS: Age, ambulatory surgical incapacity and the surgical specialty are significant to explain the level of pain at the first call. For the first two phone calls, ambulatory surgical incapacity is significant as a predictor for all responses except for sleep at the first call. CONCLUSIONS: The variable ambulatory surgical incapacity proved to be a good predictor of the patient's status at home. These predictions could be used to assist in educating patients and their carers about what to expect after discharge, as well as to improve their overall level of satisfaction.

Psychometric evaluation of the post-discharge surgical recovery scale.

UNLABELLED: RATIONALE, AIM AND OBJECTIVES: Day surgery patients are discharged after a short period of postoperative surveillance, and reliable and valid instruments for assessment at home are needed. The aim of this study was to evaluate the psychometric properties of a Swedish version of the post-discharge surgical recovery (PSR) scale, an instrument to monitor the patient's recovery after day surgery, in terms of data quality, internal consistency, dimensionality and responsiveness. METHODS: Data were collected on postoperative days 1 and 14 and included 525 patients. Data quality and internal consistency were evaluated using descriptive statistics, correlation analyses and Cronbach's alpha. The dimensionality of the scale was determined through an exploratory factor analysis. Responsiveness was evaluated using the standardized response mean and the area under the receiver operating characteristics curve (AUC). The correlation between change score in PSR and change score in self-rated health was assessed using Pearson's correlation coefficient. Patients' ability to work and their self-rated health on postoperative day 14 were used as external indicators of change. RESULTS: Six items showed floor or ceiling effects. Cronbach's coefficient alpha was 0.90 and the average inter-item correlation coefficient was 0.44 after the deletion of two items. The items were closely related to each other, and a one-factor solution was decided on. A robust ability to detect changes in recovery (standardized response mean = 1.14) was shown. The AUC for the entire scale was 0.60. When initial PSR scores were categorized into three intervals, the ability to detect improved and non-improved patients varied (AUC 0.58-0.81). There was a strong correlation between change scores in PSR and health (0.63). CONCLUSIONS: The Swedish version of the PSR scale demonstrates acceptable psychometric properties of data quality, internal consistency, dimensionality and responsiveness. In addition to previous findings, these results strengthen the PSR scale as a potential instrument of recovery at home.

Patient assessed health profile: a six-month quality of life questionnaire survey after day surgery.

AIM: Patient assessed quality of life is one of the principal end-points after day surgery. The aim of the present study was to describe the natural course, differences and timing of final evaluation for three common day surgical procedures; inguinal hernia repair (IHR), arthroscopic procedures (AS); and cosmetic breast augmentation (CBA). METHOD: A total of 355 patients prospectively completed an extended eight-item EQ-5D questionnaire (pain, mobility, mood, self-care, activities, sleep, sex, need for analgesic), preoperatively and at one, three and six months postoperatively. RESULTS: Pain and mobility problems were frequently reported prior to surgery among IHR and AS patients, while CBA patients had less deviation from normal in the preoperative health profile. The proportions of patients reporting surgery-related deviations were 35%, 20% and 5% at one, three and six months respectively. After one month, 50% of AS patients still suffered subjective discomfort as compared to 13% and 20% of the IHR and CBA patients, respectively. Pain and ambulation problems were the most common symptoms in all groups. Six months after surgery, 94% of IHR, 89% of AS and 97% of CBA patients were fully recovered. CONCLUSIONS: No major morbidity or severe complications were observed and patients' satisfaction was high overall. We found procedure-specific changes in the postoperative health profile after day surgery. AS patients recovered more slowly compared with IHR and CBA patients. We conclude that time for final evaluation differs significantly between procedures.

Walking in PACU after unilateral spinal anesthesia a criteria for hospital discharge: a 100 outpatient survey.

PURPOSE: This study measured time and ability to walk in PACU after unilateral spinal anaesthesia. METHODS: Orthopaedic adult patients ASA 1-2, in the lateral decubitus position and placed on the operative side, received via a 25-gauge Whitacre needle 5 mg of 0.5% bupivacaine plus 2.5 microg of sufentanil. Lateral decubitus was maintained for 15 minutes. Time from the spinal injection to eligibility for discharge was recorded. Discharge criteria were stable hemodynamic and ability to walk without crutches. RESULTS: One hundred consecutive patients (38 females), 48 +/- 15 years-old were included. Unilateral sensory block was noted in 70% of patients. The maximum level of sensory block was at L1-T12 in 30 patients, at T11-T10 in 55 patients, at T9-T8 in 6 patients and at T7-T6 in 9. Criteria for PACU discharge were completed at 140 +/- 14 min (extremes: 55-235). All patients were discharged home uneventfully. CONCLUSION: Unilateral spinal anesthesia combining bupivacaine and sufentanil gives fast ability to walk for discharge.

Resumption of daily physical activity after day-case laparoscopic cholecystectomy.

BACKGROUND: Laparoscopic cholecystectomy has been proven to be safe and feasible as a day-case procedure. Few studies investigated postoperative activity resumption. The goal of this study was to objectively assess daily physical activity after day-case laparoscopic cholecystectomy and evaluate the effect of encouragement of patients. METHODS: This prospective controlled study measured daily physical activity in an unselected patient population undergoing day-case laparoscopic cholecystectomy by using an accelerometer for 1 week before surgery to 1 week after. First, a control group received standard care. Subsequently, an intervention group was encouraged to swift resumption of daily physical activity by means of standardized advice combined with individualized activity goals. Outcome measures were activity scores, visual analogue scores (VAS) for pain and nausea and subjective factors limiting activity. RESULTS: Sixty-four patients completed the study (n = 28 in the control group, n = 36 in the intervention group). In the control group, 36% of the patients reached their preoperative activity level after 1 week, as compared to 50% in the intervention group (p = 0.19). Resumption of daily physical activity during the first postoperative week in the intervention group was not significantly different from the control group [repeated measures analysis of variance (MANOVA), p = 0.05]. However, in contrast with men, women in the intervention group did show a faster recovery of daily physical activity as compared to the control group (MANOVA, p = 0.02). Although there was no significant difference in postoperative VAS scores for pain and nausea between both groups, patients in the intervention group experienced pain less often as a limiting factor (p = 0.006). CONCLUSION: Recovery of daily physical activity exceeded 1 week in most patients undergoing day-case laparoscopic cholecystectomy. The use of an accelerometer and standardized encouragement accelerated recovery in women.