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1.
Curr Opin Anaesthesiol ; 33(6): 718-723, 2020 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-33002955

RESUMO

PURPOSE OF REVIEW: This review evaluates more complex surgical procedures to see whether they might be suitable for ambulatory surgery. Operations that have shown an increasing daycase rate in England include thyroidectomy, joint arthroplasty, spinal surgery and hysterectomy, and these procedures are evaluated. Similarly, there have been recent developments in the management of nonelective ambulatory surgery with more timely throughput and home discharge for suitable patients. RECENT FINDINGS: Caveats on patient selection with the development of focussed educational programmes about the proposed operation have assisted with the development of shorter discharge times. Strict antiemetic guidelines, multimodal analgesic protocols and postoperative multidisciplinary follow-up are core components of the pathway for effective ambulatory management. Communication after discharge should include phone calls from the Ambulatory Unit and easy access to the medical staff who conducted their operation. SUMMARY: There should be no reason why more complex surgical operations could not be included in a day surgery armamentarium. Similarly, the evidence for more effective use of timely emergency care with shortened length of stay is increasing.


Assuntos
Procedimentos Cirúrgicos Ambulatórios/métodos , Artroplastia , Histerectomia , Coluna Vertebral/cirurgia , Tireoidectomia , Emergências , Feminino , Humanos , Tempo de Internação , Alta do Paciente
2.
Curr Opin Anaesthesiol ; 33(6): 768-773, 2020 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-33002956

RESUMO

PURPOSE OF REVIEW: To discuss the importance of validated tools that measure patient-reported outcomes and their use in ambulatory surgery. RECENT FINDINGS: Sustained increases in ambulatory surgical care reflect advances in surgical techniques and perioperative anaesthetic care. Use of patient-reported outcomes allows identification of minor adverse events that are more common in this population compared with traditional endpoints such as mortality. Variability in reported outcomes restricts research potential and limits the ability to benchmark providers. The standardized endpoints in perioperative medicine initiative's recommendations on patient-reported outcomes and patient comfort measures are relevant to evaluating ambulatory care. Combining validated generic and disease-specific patient-reported outcome measures (PROMs) examines the widest spectrum of outcomes. Technological advances can be used to facilitate outcome measurement in ambulatory surgery with digital integration optimizing accurate real-time data collection. Telephone or web-based applications for reviewing ambulatory patients were found to be acceptable in multiple international settings and should be harnessed to allow remote follow-up. SUMMARY: Use of validated tools to measure patient-reported outcomes allows internal and external quality comparison. Tools can be combined to measure objective outcomes and patient satisfaction. These are both key factors in driving forward improvements in perioperative ambulatory surgical care.


Assuntos
Procedimentos Cirúrgicos Ambulatórios , Medidas de Resultados Relatados pelo Paciente , Satisfação do Paciente , Assistência Ambulatorial , Humanos , Assistência Perioperatória
3.
Curr Opin Anaesthesiol ; 33(6): 711-717, 2020 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-33002957

RESUMO

PURPOSE OF REVIEW: Implementation of enhanced recovery pathways have allowed migration of complex surgical procedures from inpatient setting to the outpatient setting. These programs improve patient safety and patient-reported outcomes. The present article discusses the principles of enhanced recovery pathways in adults undergoing ambulatory surgery with an aim of improving patient safety and postoperative outcomes. RECENT FINDINGS: Procedure and patient selection is one of the key elements that influences perioperative outcomes after ambulatory surgery. Other elements include optimization of comorbid conditions, patient and family education, minimal preoperative fasting and adequate hydration during the fasting period, use of fast-track anesthesia technique, lung-protective mechanical ventilation, maintenance of fluid balance, and multimodal pain, nausea, and vomiting prophylaxis. SUMMARY: Implementation of enhanced recovery pathways requires a multidisciplinary approach in which the anesthesiologist should take a lead in collaborating with surgeons and perioperative nurses. Measuring compliance with enhanced recovery pathways through an audit program is essential to evaluate success and need for protocol modification. The metrics to assess the impact of enhanced recovery pathways include complication rates, patient reported outcomes, duration of postoperative stay in the surgical facility, unplanned hospital admission rate, and 7-day and 30-day readmission rates.


Assuntos
Procedimentos Cirúrgicos Ambulatórios/métodos , Anestesia , Procedimentos Clínicos , Recuperação Pós-Cirúrgica Melhorada , Complicações Pós-Operatórias/prevenção & controle , Adulto , Anestesia/efeitos adversos , Procedimentos Clínicos/normas , Medicina Baseada em Evidências , Humanos , Tempo de Internação , Seleção de Pacientes , Cuidados Pós-Operatórios , Complicações Pós-Operatórias/epidemiologia , Recuperação de Função Fisiológica
4.
Curr Opin Anaesthesiol ; 33(6): 746-752, 2020 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-33002959

RESUMO

PURPOSE OF REVIEW: General anesthesia is a popular choice for ambulatory surgery. Spinal anesthesia is often avoided because of perceived delays due to time required to administer it and prolonged onset, as well as concerns of delayed offset, which may delay recovery and discharge home. However, the reports of improved outcomes in hospitalized patients undergoing total joint arthroplasty have renewed the interest in spinal anesthesia. This review article critically assesses the role of spinal anesthesia in comparison with fast-track general anesthesia for the outpatient setting. RECENT FINDINGS: The purported benefits of spinal anesthesia include avoidance of airway manipulation and the adverse effects of drugs used to provide general anesthesia, improved postoperative pain, and reduced postoperative opioid requirements. Improved postoperative outcomes after spinal anesthesia in hospitalized patients may not apply to the outpatient population that tends to be relatively healthier. Also, it is unclear if spinal anesthesia is superior to fast-track general anesthesia techniques, which includes avoidance of benzodiazepine premedication, avoidance of deep anesthesia, use of an opioid-sparing approach, and minimization of neuromuscular blocking agents with appropriate reversal of residual paralysis. SUMMARY: The benefits of spinal anesthesia in the outpatient setting remain questionable at best. Further studies should seek clarification of these goals and outcomes.


Assuntos
Procedimentos Cirúrgicos Ambulatórios/métodos , Analgésicos Opioides , Raquianestesia/efeitos adversos , Dor Pós-Operatória/prevenção & controle , Procedimentos Cirúrgicos Ambulatórios/tendências , Analgésicos Opioides/administração & dosagem , Analgésicos Opioides/efeitos adversos , Anestesia Geral/efeitos adversos , Raquianestesia/tendências , Humanos
5.
Curr Opin Anaesthesiol ; 33(6): 753-759, 2020 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-33027075

RESUMO

PURPOSE OF REVIEW: Postoperative pain is frequent while, on the other hand, there is a grooving general concern on using effective opioid pain killers in view of the opioid crisis and significant incidence of opioid abuse. The present review aims at describing nonopioid measures in order to optimize and tailor perioperative pain management in ambulatory surgery. RECENT FINDINGS: Postoperative pain should be addressed both preoperatively, intraoperatively and postoperatively. The management should basically be multimodal, nonopioid and procedure-specific. Opioids should only be used when needed on top of multimodal nonopioid prophylaxis, and then limited to a few days at maximum, unless strict control is applied. The individual patient should be screened preoperatively for any risk factors for severe postoperative pain and/or any abuse potential. SUMMARY: Basic multimodal analgesia should start preoperatively or peroperatively and include paracetamol, cyclo-oxygenase (COX)-2 specific inhibitor or conventional nonsteroidal anti-inflammatory drug (NSAID) and in most cases dexamethasone and local anaesthetic wound infiltration. If any of these basic analgesics are contraindicated or there is an extra risk of severe postoperative pain, further measures may be considered: nerve-blocks or interfascial plane blocks, gabapentinnoids, clonidine, intravenous lidocaine infusion or ketamine infusion. In the abuse-prone patient, a preferably nonopioid perioperative approach should be aimed at.


Assuntos
Procedimentos Cirúrgicos Ambulatórios , Analgésicos Opioides/efeitos adversos , Manejo da Dor , Dor Pós-Operatória/prevenção & controle , Humanos , Epidemia de Opioides , Medição da Dor , Dor Pós-Operatória/tratamento farmacológico
6.
Curr Opin Anaesthesiol ; 33(6): 724-731, 2020 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-33093300

RESUMO

PURPOSE OF REVIEW: This article describes the processes for identifying high-risk patients at the time of ambulatory procedure scheduling, enabling the implementation of multidisciplinary collaborative pathways for prehabilitation and optimization, allowing for risk mitigation and improvement in outcomes. This review is particularly relevant because of the current proliferation of ambulatory surgery with more complex procedures being performed on an outpatient basis on patients who may be American Society of Anesthesiologists Physical Status 3 or greater. RECENT FINDINGS: Increased longevity and rising prevalence of obesity have resulted in patients with a wide variety of comorbidities presenting for complex ambulatory procedures with the expectation of rapid recovery and same-day discharge to home. Recent literature highlights the importance of patient preparation, value-based healthcare, patient outcomes, and the role of anesthesiologists as perioperative physicians. SUMMARY: The focus of this article is on general principles and establishment of best practices based on current evidence and a brief description of anesthetic management of specific comorbidities. This review will provide guidance to the practicing anesthesiologist on identifying, stratifying, optimizing, and managing high-risk patients in the ambulatory setting.


Assuntos
Procedimentos Cirúrgicos Ambulatórios , Seleção de Pacientes , Médicos/psicologia , Cuidados Pré-Operatórios , Medição de Risco/métodos , Humanos , Pacientes Ambulatoriais , Assistência Perioperatória , Fatores de Risco
9.
Rev Panam Salud Publica ; 44, sept. 2020
Artigo em Espanhol | PAHO-IRIS | ID: phr-52653

RESUMO

Dada la incertidumbre que acompaña a la pandemia por SARS-CoV-2 y ante la necesidad de dar respuesta a múltiples problemas de salud crónicos y agudos que afectan a la población general, incluidos aquellos que precisan de una intervención quirúrgica, se presentan las recomendaciones implementadas en clínicas y hospitales de Colombia como guía para lograr una reapertura de los servicios de cirugía electiva de forma segura, escalonada y monitoreada acorde a la dinámica que impone la pandemia, la regulación nacional e internacional y la velocidad en la producción de evidencia científica relacionada con la COVID-19.


Given the uncertainty that accompanies the SARS-CoV-2 pandemic and the need to respond to multiple chronic and acute health problems affecting the general population, including those requiring surgical intervention, the recommendations implemented in clinics and hospitals in Colombia are presented as a guide to achieve a reopening of elective surgery services in a safe, staggered and monitored manner in accordance with the dynamics imposed by the pandemic, national and international guidelines and the speed of production of scientific evidence related to COVID-19.


Assuntos
Infecções por Coronavirus , Betacoronavirus , Pandemias , Betacoronavirus , Procedimentos Cirúrgicos Ambulatórios , Vírus da SARS , Salas Cirúrgicas , Cirurgia Geral , Colômbia , América Latina , Procedimentos Cirúrgicos Ambulatórios , Vírus da SARS , Salas Cirúrgicas , Cirurgia Geral
10.
Rev. cuba. pediatr ; 92(3): e1010, jul.-set. 2020. tab
Artigo em Espanhol | LILACS, CUMED | ID: biblio-1126775

RESUMO

En las últimas décadas se ha prestado mayor atención a los resultados de la actividad quirúrgica debido a factores económicos, la mejora de los cuidados perioperatorios y la preocupación por la calidad de la asistencia y satisfacción de la población. A este propósito han contribuido el desarrollo y aplicación de guías de práctica clínica. Estas guías reducen la variación en los cuidados del paciente quirúrgico, aumentan la eficiencia de dicho cuidado y proporcionan que los pacientes se beneficien de iniciativas institucionales encaminadas a mejorar la calidad de la asistencia sanitaria. La cirugía de alta precoz es un modelo de atención médico-quirúrgica encaminado a disminuir los costos de la atención médica mediante esfuerzos coordinados que permitan la reducción de la estancia hospitalaria en los pacientes, sin que ocurra incremento de complicaciones posoperatorias, ni insatisfacción de pacientes y familiares con el servicio prestado. Su empleo ha ido incrementándose en afecciones pediátricas. En el hospital pediátrico de Cienfuegos se aplica el modelo hace varios años y la guía fue aprobada en el Servicio de Cirugía Pediátrica en diciembre de 2018. Compartir esta guía mediante su publicación permitiría a otros servicios de cirugía pediátrica del país emplearla como referencia para la aplicación del modelo en sus propias instituciones y beneficiar a un mayor número de pacientes(AU)


In the last decades, there has been more attention on the results of the surgical activity due to economic factors, the improvement of perioperative cares and the concern on the quality of the care and the population´s satisfaction. The development and implementation of the clinical pratice´s guides had contributed to that purpose. These guides reduce the variations in the cares to the surgical patients, increase efficiency in that kind of care and foster that the patients are benefited with institutional initiatives addressed to improve health care quality. The Fast Track Pediatric Surgery is a model of medical-surgical care directed to lower the costs of medical care by means of coordinated efforts that allow the reduction of the hospital stay in patients without increasing the rates of postoperative complications, or dissatisfaction of the patients and relatives with the service given. The use of this procedure has been increasing in pediatric conditions. It has been implemented since some years ago in the Pediatric Hospital of Cienfuegos province, and the guide was approved in the Pediatric Surgery service in December, 2018.To share this guide by publishing it will be a way to allow other pediatric surgery services in the country to use it as a reference for the implementation of that model in their institutions and in that way to benefit a higher number of patients(AU)


Assuntos
Humanos , Masculino , Feminino , Pediatria/educação , Procedimentos Cirúrgicos Ambulatórios/métodos , Alta do Paciente/normas
11.
Medicine (Baltimore) ; 99(35): e21609, 2020 Aug 28.
Artigo em Inglês | MEDLINE | ID: mdl-32871877

RESUMO

BACKGROUND: Cervical disc replacement (CDR) has been widely used as an effective treatment for cervical degenerative disc diseases in recent years. However, the cost of this procedure is very high and may bring a great economic burden to patients and the health care system. It is reported that outpatient procedures can reduce nearly 30% of the costs associated with hospitalization compared with inpatient procedures. However, the safety profile surrounding outpatient CDR remains poorly resolved. This study aims to evaluate the current evidence on the safety of outpatient CDR METHODS:: Four English databases were searched. The inclusion and exclusion criteria were developed according to the PICOS principle. The titles and abstracts of the records will be screened by 2 authors independently. Records that meet the eligibility criteria will be screened for a second time by reading the full text. An extraction form will be established for data extraction. Risk of bias assessment will be performed by 2 authors independently using Cochrane risk of bias tool or Newcastle-Ottawa scale. Data synthesis will be conducted using Stata software. Heterogeneity among studies will be assessed using I test. The funnel plot, Egger regression test, and Begg rank correlation test will be used to examine the publication bias. RESULTS: The results of this meta-analysis will be published in a peer-review journal. CONCLUSION: This will be the first meta-analysis that compares the safety of outpatient CDR with inpatient CDR. Our study will help surgeons fully understand the complications and safety profile surrounding outpatient CDR. OSF REGISTRATION NUMBER:: doi.org/10.17605/OSF.IO/3597Z.


Assuntos
Procedimentos Cirúrgicos Ambulatórios/estatística & dados numéricos , Vértebras Cervicais/patologia , Degeneração do Disco Intervertebral/cirurgia , Substituição Total de Disco/métodos , Efeitos Psicossociais da Doença , Feminino , Humanos , Pacientes Internados , Masculino , Viés de Publicação , Segurança , Substituição Total de Disco/economia , Resultado do Tratamento
12.
Plast Reconstr Surg ; 146(5): 680e-683e, 2020 11.
Artigo em Inglês | MEDLINE | ID: mdl-32732794

RESUMO

Telemedicine holds vast amounts of potential in changing the way outpatient plastic and reconstructive surgery is practiced. Before the coronavirus disease 2019 (COVID-19) pandemic, video conferencing was used by a small fraction of medical specialties. However, since the start of the pandemic, the Centers for Medicare and Medicaid Services and the largest private health insurance companies have relaxed regulations to allow the majority of specialties to use video conferencing in lieu of in-person visits. Most importantly, video conferencing minimizes patient and physician exposure in situations such as these, and decreases risk in the immunocompromised population. Video conferencing, which has been shown to be just as safe and efficacious in treating patients, offers the ability to follow up with physicians while saving travel time and travel-related expenses. This in turn correlates with increased patient satisfaction. Video conferencing also allows physicians to expand their reach to patients in rural areas seeking advanced professional advice. Incorporating video conferencing into existing practices will make for a more efficient practice, improve patient satisfaction, and decrease cost to patients and the health care system.


Assuntos
Procedimentos Cirúrgicos Ambulatórios , Infecções por Coronavirus , Pandemias , Pneumonia Viral , Procedimentos Cirúrgicos Reconstrutivos , Cirurgia Plástica , Telemedicina/métodos , Comunicação por Videoconferência , Infecções por Coronavirus/prevenção & controle , Acesso aos Serviços de Saúde/organização & administração , Humanos , Pandemias/prevenção & controle , Satisfação do Paciente , Pneumonia Viral/prevenção & controle , Cirurgia Plástica/métodos , Cirurgia Plástica/organização & administração , Telemedicina/organização & administração , Estados Unidos , Comunicação por Videoconferência/organização & administração
13.
J Am Acad Orthop Surg ; 28(20): e900-e909, 2020 Oct 15.
Artigo em Inglês | MEDLINE | ID: mdl-32826663

RESUMO

As the length of stay for hip and knee arthroplasty has decreased over the years, "outpatient," or same-calendar-day discharge has become increasingly common. Outpatient arthroplasty offers several possible benefits over traditional inpatient arthroplasty, including potential for cost reductions, faster rehabilitation, improved patient satisfaction, and reduced reliance on hospital resources. Despite these possible benefits, concerns remain over feasibility and patient safety. To date, multiple studies have demonstrated that, for select patients, "outpatient" hip and knee arthroplasty can be safe and effective and yield complication and readmission rates similar to inpatient procedures at potentially significant cost savings. Successful outpatient pathways have emphasized careful patient selection, detailed patient education, enlistment of strong social support, utilization of multimodal analgesia and strong "episode ownership," and involvement on behalf of the surgical team. As outpatient hip and knee arthroplasty becomes increasingly common, continued investigation into all aspects of the surgical episode is warranted.


Assuntos
Assistência Ambulatorial/métodos , Procedimentos Cirúrgicos Ambulatórios/métodos , Artroplastia de Quadril/métodos , Artroplastia do Joelho/métodos , Alta do Paciente , Seleção de Pacientes , Adulto , Idoso , Idoso de 80 Anos ou mais , Assistência Ambulatorial/economia , Analgesia/métodos , Artroplastia de Quadril/economia , Artroplastia do Joelho/economia , Redução de Custos , Estudos de Viabilidade , Feminino , Humanos , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Manejo da Dor/métodos , Educação de Pacientes como Assunto , Segurança do Paciente , Fatores de Risco
14.
Curr Opin Anaesthesiol ; 33(6): 732-739, 2020 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-32769745

RESUMO

PURPOSE OF REVIEW: The number and the complexity of procedures taking place at ambulatory surgery centers is steadily increasing. The rate at which medically complex patients, including those with baseline neurocognitive disorders, are undergoing ambulatory procedures is seeing a concurrent rise. Given the significant physical and psychological stress associated with surgery even in the ambulatory setting, it is essential to evaluate the ability of a patient to acclimate to stressful triggers in order to assess risk of subpar medical outcomes and increased mortality. In this review, we discuss recent advances in the assessment of both cognition and frailty and describe the implementation of these tools in the ambulatory surgery setting. RECENT FINDINGS: Recent Society for Perioperative Assessment and Quality Improvement (SPAQI) recommendations for evaluating at-risk patients focus on a two-pronged approach that encompasses screening for both impaired cognition and frailty. Screening should ideally occur as early as possible, but tools such as the Mini-Cog examination and FRAIL Questionnaire are efficient and effective even when used the day of surgery in high-risk patients. SUMMARY: The recognition of at-risk patients using standardized screening and the use of this assessment to guide perioperative monitoring and interventions is essential for optimizing outcomes for the complex ambulatory surgery patient.


Assuntos
Procedimentos Cirúrgicos Ambulatórios , Disfunção Cognitiva , Idoso Fragilizado , Fragilidade/complicações , Avaliação Geriátrica/métodos , Complicações Pós-Operatórias/prevenção & controle , Cuidados Pré-Operatórios/métodos , Medição de Risco/métodos , Idoso , Cognição , Disfunção Cognitiva/diagnóstico , Disfunção Cognitiva/etiologia , Fragilidade/diagnóstico , Humanos , Pacientes Ambulatoriais , Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/epidemiologia , Inquéritos e Questionários
15.
Plast Reconstr Surg ; 146(2): 437-446, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32740603

RESUMO

The coronavirus disease 2019 (COVID-19) pandemic has confronted the U.S. health care system with unprecedented challenges amidst a tenuous economic environment. As inpatient hospitals across the country prepare for an overwhelming influx of highly contagious COVID-19 cases, many nonemergent procedures have been cancelled or indefinitely postponed without guidance regarding eventual safe accommodation of these procedures in the future. Given the potentially prolonged impact of the COVID-19 pandemic on health care use, it is imperative for plastic surgeons to collaborate with other medical and surgical specialties to develop surge capacity protocols that allow continuation of safe, high-quality, nonemergent procedures. The purpose of this article is to provide necessary and timely public health information relevant to plastic surgery and also share a conceptual framework to guide surge capacity protocols for nonemergent surgery.


Assuntos
Betacoronavirus/patogenicidade , Infecções por Coronavirus/prevenção & controle , Pandemias/prevenção & controle , Pneumonia Viral/prevenção & controle , Regionalização/organização & administração , Capacidade de Resposta ante Emergências/organização & administração , Cirurgia Plástica/organização & administração , Procedimentos Cirúrgicos Ambulatórios/normas , Betacoronavirus/isolamento & purificação , Infecções por Coronavirus/epidemiologia , Infecções por Coronavirus/terapia , Infecções por Coronavirus/transmissão , Procedimentos Cirúrgicos Eletivos/normas , Humanos , Controle de Infecções/normas , Colaboração Intersetorial , Pneumonia Viral/epidemiologia , Pneumonia Viral/terapia , Pneumonia Viral/transmissão , Guias de Prática Clínica como Assunto , Procedimentos Cirúrgicos Reconstrutivos/normas , Regionalização/normas , Cirurgia Plástica/normas , Centros Cirúrgicos/organização & administração , Centros Cirúrgicos/normas , Telemedicina/organização & administração , Telemedicina/normas , Estados Unidos
16.
PLoS One ; 15(7): e0236833, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32735604

RESUMO

Opioids play a critical role in acute postoperative pain management. Our objective was to develop machine learning models to predict postoperative opioid requirements in patients undergoing ambulatory surgery. To develop the models, we used a perioperative dataset of 13,700 patients (≥ 18 years) undergoing ambulatory surgery between the years 2016-2018. The data, comprising of patient, procedure and provider factors that could influence postoperative pain and opioid requirements, was randomly split into training (80%) and validation (20%) datasets. Machine learning models of different classes were developed to predict categorized levels of postoperative opioid requirements using the training dataset and then evaluated on the validation dataset. Prediction accuracy was used to differentiate model performances. The five types of models that were developed returned the following accuracies at two different stages of surgery: 1) Prior to surgery-Multinomial Logistic Regression: 71%, Naïve Bayes: 67%, Neural Network: 30%, Random Forest: 72%, Extreme Gradient Boost: 71% and 2) End of surgery-Multinomial Logistic Regression: 71%, Naïve Bayes: 63%, Neural Network: 32%, Random Forest: 72%, Extreme Gradient Boost: 70%. Analyzing the sensitivities of the best performing Random Forest model showed that the lower opioid requirements are predicted with better accuracy (89%) as compared with higher opioid requirements (43%). Feature importance (% relative importance) of model predictions showed that the type of procedure (15.4%), medical history (12.9%) and procedure duration (12.0%) were the top three features contributing to model predictions. Overall, the contribution of patient and procedure features towards model predictions were 65% and 35% respectively. Machine learning models could be used to predict postoperative opioid requirements in ambulatory surgery patients and could potentially assist in better management of their postoperative acute pain.


Assuntos
Procedimentos Cirúrgicos Ambulatórios , Analgésicos Opioides/uso terapêutico , Aprendizado de Máquina , Dor Pós-Operatória/tratamento farmacológico , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Modelos Teóricos , Manejo da Dor/métodos
17.
J Am Acad Orthop Surg ; 28(15): 639-649, 2020 Aug 01.
Artigo em Inglês | MEDLINE | ID: mdl-32732657

RESUMO

BACKGROUND: The purpose of this study was to identify the utilization rate and most common reasons for presentation to the emergency department (ED) after elective outpatient hand surgery and to determine preoperative risk factors for these ED visits. METHODS: Patients who underwent elective hand surgery at an ambulatory surgery center between 2014 and 2015 were retrospectively evaluated using the New York and Florida State Databases. The primary outcome was all-cause 7- and 30-day ED utilization rates. Reasons for presentation to the ED were recorded and manually stratified. Bivariate and multivariate analyses were performed to identify independent predictors of ED utilization. RESULTS: From 2014 to 2015, 212,506 procedures were identified; the 7- and 30-day ED visit rates were 1.8% and 4.4%, respectively. Postoperative pain was the most common cause of an ED visit after outpatient hand surgery at 7 days (25.4%) and 30 days (16.1%) postoperatively. Overall, 98% of patients presenting to the ED for postoperative pain were subsequently discharged home. After controlling for confounding, comorbid congestive heart failure, chronic lung disease, diabetes, renal failure, schizophrenia, and depression were independent risk factors for an ED visit at up to 30 days postoperatively. Those with Medicare insurance were 94% more likely to present to the ED within 30 days than those with private health insurance, whereas those with Medicaid were more than three times as likely to present to the ED as those with private insurance. DISCUSSION: ED utilization after outpatient hand surgery is low, with postoperative pain being the most common cause of an ED visit at all time points. Nearly 98% of patients presenting to the ED for postoperative pain are subsequently discharged home. LEVEL OF EVIDENCE: Level III, Retrospective Cohort.


Assuntos
Assistência Ambulatorial/estatística & dados numéricos , Procedimentos Cirúrgicos Ambulatórios/estatística & dados numéricos , Procedimentos Cirúrgicos Eletivos/estatística & dados numéricos , Serviço Hospitalar de Emergência/estatística & dados numéricos , Mãos/cirurgia , Procedimentos Ortopédicos/estatística & dados numéricos , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Idoso , Estudos de Coortes , Humanos , Pessoa de Meia-Idade , Dor Pós-Operatória , Estudos Retrospectivos , Fatores de Risco
18.
Medicine (Baltimore) ; 99(32): e21580, 2020 Aug 07.
Artigo em Inglês | MEDLINE | ID: mdl-32769907

RESUMO

BACKGROUND: We aim to perform a network meta-analysis (NMA) to quantify and rank-order the efficacy and safety of analgesic medications for ambulatory surgery. METHODS: We will search MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials, and Google Scholar databases to identify all randomized controlled trials (RCTs) of analgesics, beginning from their inception to February 2020. The primary endpoints will be pain score measured using a visual analog scale (VAS) or a numerical rating scale (NRS) at 3 different time points: Phase I recovery, phase II recovery, and recovery at home. Adverse events, including nausea, vomiting, headache, dizziness, arrhythmia, and respiratory depression, will be also assessed.We will conduct NMA and use surface under the cumulative ranking curve (SUCRA) values and rankograms to present the hierarchy of analgesic medication. A comparison-adjusted funnel plot will be used to assess the presence of small study effects. The quality of the included studies will be assessed using the risk of bias tool 2.0. All statistical analyses will be performed using Stata SE version 15.0. RESULTS: The results of this systematic review and NMA will be published in a peer-reviewed journal. CONCLUSION: This systematic review and NMA will provide comprehensive and convincing evidence regarding analgesic medication for pain after ambulatory surgery. TRIAL REGISTRATION NUMBER: CRD42018100000.


Assuntos
Procedimentos Cirúrgicos Ambulatórios/métodos , Analgésicos/normas , Protocolos Clínicos , Analgésicos/uso terapêutico , Humanos , Metanálise como Assunto , Revisões Sistemáticas como Assunto , Escala Visual Analógica
20.
Am Surg ; 86(6): 652-658, 2020 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-32683977

RESUMO

BACKGROUND: Surgery is a risk factor for opioid initiation and subsequent abuse. Discharge opioid prescription patterns after surgery are often varied and not evidence based, which may lead to unnecessary prescription of opioids. We aimed to assess opioid prescribing and unused opioid prescriptions in ambulatory surgery patients at our academic hospital. METHODS: We conducted a retrospective observational study based on phone survey and electronic medical records. Adult patients who underwent ambulatory surgery at our large, multisite, tertiary-care hospital system were asked whether they were using the opioids that were prescribed at discharge. Our main outcomes were opioid prescription (defined as being prescribed an opioid on discharge) and unused opioid prescription (defined as being prescribed an opioid but not taking any opioids on postoperative day 1). We evaluated predictors of opioid prescription and unused opioid prescription through univariable and multivariable analyses. We also stratified outcomes by surgical service. RESULTS: Of 4248 adult patients who underwent ambulatory surgical procedures, 3279 (77.2%) responded to the survey. Of all responders, 2146 (65.4%) were prescribed postoperative opioids, and 1240 (57.8%) reported not taking them on postoperative day 1. The highest rates of unused opioid prescriptions were for patients whose primary service were orthopedic surgery (65%) and plastic surgery (62%). DISCUSSION: Opioid prescribing and unused opioid prescriptions are prevalent in our hospital's ambulatory surgical population. Patients undergoing selected ambulatory surgical procedures may not require as much opioid as is currently being prescribed.


Assuntos
Procedimentos Cirúrgicos Ambulatórios/estatística & dados numéricos , Analgésicos Opioides/uso terapêutico , Prescrições de Medicamentos/estatística & dados numéricos , Manejo da Dor/métodos , Dor Pós-Operatória/tratamento farmacológico , Adulto , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Padrões de Prática Médica/estatística & dados numéricos , Estudos Retrospectivos
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