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1.
Orthop Clin North Am ; 51(1): 1-5, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31739873

RESUMO

Using an age- and comorbidity-matched cohort, we compared patients who underwent unicompartmental knee arthroplasty in an ambulatory surgery center with those who underwent the procedure in a traditional hospital inpatient setting. Postoperatively, the ambulatory surgery center cohort had fewer major complications than the inpatient cohort. No ambulatory surgery center patients required acute hospital admission and none had major complications. Four major complications occurred in the inpatient cohort. There was no difference in complication rates. Our results suggest that outpatient unicompartmental knee arthroplasty in a freestanding ambulatory surgery center is a safe and reasonable alternative to the traditional inpatient hospital setting.


Assuntos
Procedimentos Cirúrgicos Ambulatórios/economia , Artroplastia do Joelho/economia , Análise Custo-Benefício/métodos , Procedimentos Cirúrgicos Ambulatórios/efeitos adversos , Procedimentos Cirúrgicos Ambulatórios/estatística & dados numéricos , Artroplastia do Joelho/efeitos adversos , Artroplastia do Joelho/estatística & dados numéricos , Estudos de Coortes , Comorbidade , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Pacientes Ambulatoriais , Complicações Pós-Operatórias/epidemiologia , Resultado do Tratamento
2.
Plast Reconstr Surg ; 144(5): 836e-840e, 2019 11.
Artigo em Inglês | MEDLINE | ID: mdl-31688759

RESUMO

BACKGROUND: Many ambulatory surgery centers use body mass index as a screening tool to make admissions decisions because of complication risks associated with high-body mass index patients. The objective of this investigation was to evaluate perioperative complications in a cohort of high-body mass index patients undergoing hand and elbow surgery at an ambulatory surgery center. The authors' hypothesis was that anesthesia-related complications for this cohort would be similar to those of a normal-body mass index group. METHODS: The authors retrospectively reviewed data from all hand and elbow procedures performed on patients with a high body mass index (>40 kg/m). One hundred eighty-nine high-body mass index patients and 189 normal-body mass index patients were included in the analysis. RESULTS: The average weight-based dosage of propofol was similar in both groups but was lower in the high-body mass index group for midazolam and fentanyl. Two high-body mass index patients had oxygen desaturations in the postanesthesia care unit. No patients developed complications related to anesthesia. In the high-body mass index group, one patient developed hypotension in the postanesthesia care unit, was admitted to the emergency room for monitoring, but was discharged the following morning. CONCLUSIONS: Outpatient hand surgical care of high-body mass index patients can be performed safely. Body mass index alone should not be considered as an absolute contraindication for surgery. Careful patient selection, evaluation of comorbidities, and close involvement of the anesthesia and medical teams are critical. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.


Assuntos
Procedimentos Cirúrgicos Ambulatórios/métodos , Índice de Massa Corporal , Articulação do Cotovelo/cirurgia , Mãos/cirurgia , Satisfação do Paciente/estatística & dados numéricos , Adulto , Procedimentos Cirúrgicos Ambulatórios/efeitos adversos , Anestésicos Intravenosos/administração & dosagem , Estudos de Coortes , Bases de Dados Factuais , Articulação do Cotovelo/fisiopatologia , Fentanila/administração & dosagem , Mãos/fisiopatologia , Humanos , Masculino , Midazolam/administração & dosagem , Pessoa de Meia-Idade , Assistência Perioperatória/métodos , Valores de Referência , Estudos Retrospectivos , Medição de Risco
3.
Acta Clin Croat ; 58(Suppl 1): 43-47, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-31741558

RESUMO

Ambulatory surgery often involves surgical procedures on the thorax, abdomen and limbs, which can be associated with substantial postoperative pain. The aim of this narrative review is to provide an analysis of the effectiveness of paravertebral block (PVB) alone or in combination with general anaesthesia, in this setting, with an emphasis on satisfactory postoperative analgesia in comparison to other modalities. We have conducted a search of current medical literature written in English through PubMed, Google Scholar and Ovid Medline®. Peer-reviewed professional articles, review articles, retrospective and prospective studies, case reports and case series were systematically searched for during the time period between November 2003 and February 2019. The literature used for the purpose of creating this review showed that utilisation of paravertebral block either alone or in combination with general anaesthesia, has a positive effect on satisfactory analgesia in ambulatory surgery. With a multimodal analgesic approach of PVB and other techniques of anaesthesia and analgesia there is a reduction in postoperative opioid consumption, fewer side effects, lower pain scores, decreased mortality, earlier mobilisation of patients and reduced hospital stay.


Assuntos
Procedimentos Cirúrgicos Ambulatórios , Bloqueio Nervoso/métodos , Dor Pós-Operatória/prevenção & controle , Nervos Espinhais , Procedimentos Cirúrgicos Ambulatórios/efeitos adversos , Analgesia , Analgésicos Opioides/uso terapêutico , Humanos , Manejo da Dor , Dor Pós-Operatória/etiologia
4.
Acta Clin Croat ; 58(Suppl 1): 62-66, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-31741561

RESUMO

Use of local infiltration anaesthesia with 2% lidocaine in combination with epinephrine 1/100000 in rhinoplasty and 0.25% levobupivacaine in this research as an adjunct to general anaesthesia is compared analysing the need for postoperative analgesia in rhinoplasty patients. 30 patients received lidocaine combined with epinephrine (LA) and other 30 patients received levobupivacaine (LB). Comparison is done with Visual Analogue Scale in 30 min and 1, 3, 6 h postoperatively. Also 24 h need for analgesic treatment was recorded. In conclusion postoperative analgesia in LB group with general anaesthesia was significantly prolonged (P = 0.038).


Assuntos
Anestesia Local , Anestésicos Locais , Levobupivacaína , Lidocaína , Dor Pós-Operatória/tratamento farmacológico , Dor Pós-Operatória/prevenção & controle , Rinoplastia/efeitos adversos , Adulto , Procedimentos Cirúrgicos Ambulatórios/efeitos adversos , Analgésicos/uso terapêutico , Anestesia Geral , Anestesia Local/métodos , Método Duplo-Cego , Epinefrina/administração & dosagem , Feminino , Humanos , Masculino , Medição da Dor , Dor Pós-Operatória/etiologia , Cuidados Pós-Operatórios , Estudos Prospectivos , Vasoconstritores/administração & dosagem , Adulto Jovem
5.
Acta Clin Croat ; 58(Suppl 1): 67-73, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-31741562

RESUMO

Purpose of this study was assessing of local infiltration analgesia (LIA) with levobupivacaine on the trend of acute postoperative pain and outcome in individuals who underwent rhinoplasty procedure and abdominoplasty performed in general anaesthesia. The research was conducted on 60 patients, of which 30 patients underwent rhinoplasty procedure and the other 30 patients underwent abdominoplasty procedure in general anaesthesia with LIA in "Bagatin" Polyclinic in the time period between 01.01.2014. and 01.01.2017. Postoperative analgesics doses on the same day of surgery were noted in 85% of participants who underwent an abdominoplasty procedure and in 45% of participants underwent rhinoplasty procedure. Patients who underwent abdominoplasty were discharged from the facility within 48 hours, while all patients who underwent rhinoplasty procedure were discharged on the same day of the surgery. During the first postoperative day patients who underwent a rhinoplasty procedure did not require analgesics, while only 3% of patients who underwent an abdominal liposuction procedure required an additional dose of analgesics. The research results had shown, when LIA was performed, the manifestation of acute postoperative pain and vomiting did not lead to prolonged stay in day surgery.


Assuntos
Analgesia/métodos , Anestesia Local , Anestésicos Locais , Levobupivacaína , Dor Pós-Operatória/prevenção & controle , Adulto , Procedimentos Cirúrgicos Ambulatórios/efeitos adversos , Analgésicos/uso terapêutico , Anestesia Geral/efeitos adversos , Feminino , Humanos , Tempo de Internação , Lipoabdominoplastia/efeitos adversos , Masculino , Manejo da Dor/métodos , Náusea e Vômito Pós-Operatórios/etiologia , Período Pós-Operatório , Rinoplastia/efeitos adversos , Adulto Jovem
6.
Am Surg ; 85(9): 956-960, 2019 Sep 01.
Artigo em Inglês | MEDLINE | ID: mdl-31638506

RESUMO

Postoperative pain managed with opioids has contributed to the opioid crisis through overprescribing practices. We assessed opioid-prescribing habits and their use by patients undergoing surgery for cutaneous malignancies. An Institutional Review Board-approved retrospective analysis was conducted for patients who underwent skin cancer resection between January 2018 and June 2018. Data were collected from the electronic medical record, and opioid-related data were collected from patient interviews and state registries. There were 120 study participants (42 females and 78 males) with a median age of 67 years (range, 21-94 years). All received preincision local anesthetic: 64 had liposomal bupivacaine (LB) (53%) and 56 had non-LB bupivacaine (47%). Most participants (n = 88) used 0 opioids (73%), including 43 LB-anesthetic (67%) and 45 non-LB-anesthetic (80%). No significance was seen between those with a diagnosis of chronic pain, narcotic tolerance, an area of resection, and nodal sampling groups in opioid use. Four patients (3%) requested a refill. Of 105 prescriptions written for opioids, 99 had leftover opioids for an overprescribing rate of 94 per cent. This study suggests pain after skin cancer surgery is manageable with very limited opioid requirements. Our results support prescribing no more than five opioid tablets for postoperative pain control in patients undergoing resection for skin malignancies.


Assuntos
Procedimentos Cirúrgicos Ambulatórios/efeitos adversos , Analgésicos Opioides/uso terapêutico , Prescrição Inadequada/estatística & dados numéricos , Dor Pós-Operatória/tratamento farmacológico , Neoplasias Cutâneas/cirurgia , Adulto , Idoso , Idoso de 80 Anos ou mais , Anestésicos Locais/administração & dosagem , Bupivacaína/administração & dosagem , Feminino , Humanos , Lipossomos , Masculino , Pessoa de Meia-Idade , Manejo da Dor/métodos , Estudos Retrospectivos , Sudeste dos Estados Unidos , Adulto Jovem
7.
BMC Musculoskelet Disord ; 20(1): 441, 2019 Oct 10.
Artigo em Inglês | MEDLINE | ID: mdl-31601208

RESUMO

BACKGROUND: Continuous popliteal sciatic nerve block (CPSNB) has been performed in outpatient foot and ankle surgery as a regional anesthesia method to relieve postoperative pain. Its efficacy as well as safety is yet to be established. There are two purposes of this study: (1) to validate the efficacy of CPSNB with regards to better pain relief and reduced analgesics consumption; (2) to assess the safety of CPSNB. METHODS: We performed a comprehensive literature review on Web of Science, the Cochrane Library, PubMed and Embase and only included randomized controlled trials (RCTs). Five RCTs that compared the efficacy and safety of CPSNB with the single-injection popliteal sciatic nerve block group were included. The primary outcome parameters were visual analog scale (VAS) scores at postoperative 24, 48 and 72 h. The secondary outcome parameters were amount of oral analgesics consumed, overall patient satisfaction and need of admission after surgery. A sensitivity analysis was performed to explore the consistency of the results. RESULTS: In comparison with the single-injection group, CPSNB was associated with a lower VAS score at postoperative 24 and 48 h (p < 0.05). There were no neuropathic symptoms or infection events after the nerve block. However, there were several minor complications associated with the pump and catheter system, with drug leakage being the most common complication (N = 26 of 187, 13.9%). CONCLUSION: CPSNB is an effective method in pain management for outpatient foot and ankle surgery. Both methods appear to be safe as none of the patients experienced neuropathic symptoms or infection. Further studies with larger sample size are needed to compare the risk of major complications between the two methods. LEVEL OF EVIDENCE: I; meta-analysis.


Assuntos
Procedimentos Cirúrgicos Ambulatórios/efeitos adversos , Anestésicos Locais/administração & dosagem , Bloqueio Nervoso/métodos , Procedimentos Ortopédicos/efeitos adversos , Dor Pós-Operatória/prevenção & controle , Nervo Isquiático/efeitos dos fármacos , Anestésicos Locais/efeitos adversos , Tornozelo/cirurgia , Esquema de Medicação , Pé/cirurgia , Humanos , Bloqueio Nervoso/efeitos adversos , Medição da Dor , Dor Pós-Operatória/diagnóstico , Dor Pós-Operatória/etiologia , Resultado do Tratamento
8.
Cutis ; 104(2): 120-124, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31603956

RESUMO

Electrosurgery generates smoke that may be harmful. We created a survey to evaluate perceptions of electrosurgical smoke and how information on the harm it potentially causes changes these perceptions. We distributed the survey to the membership of the American College of Mohs Surgery and the American Society for Dermatologic Surgery and received 437 useable responses. Results indicated that many dermatologic surgeons were aware of and bothered by surgical smoke, and these reactions were more prevalent after being educated on the potential hazards of electrosurgical smoke.


Assuntos
Procedimentos Cirúrgicos Ambulatórios/efeitos adversos , Procedimentos Cirúrgicos Dermatológicos/efeitos adversos , Eletrocirurgia/efeitos adversos , Fumaça/efeitos adversos , Procedimentos Cirúrgicos Ambulatórios/métodos , Procedimentos Cirúrgicos Dermatológicos/métodos , Dermatologia/métodos , Eletrocirurgia/métodos , Humanos , Exposição Ocupacional/efeitos adversos , Cirurgiões/estatística & dados numéricos , Inquéritos e Questionários
9.
G Chir ; 40(3): 182-187, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31484006

RESUMO

INTRODUCTION: Since 1899 outpatient management of surgical patients had been increasing, becoming the best option when possible. In 1988 was described the first experience of outpatient management of proctologic disease. Advances in local anesthesia techniques have improved the outpatient approach to surgical disease, particularly in patients with proctological diseases. METHODS: From 2010 to 2016, 1160 patients who needed surgery for proctologic disease have been recruited: 239 hemorrhoidectomies using the variant of Milligan Morgan technique described by Phillips, 45 trans-anal hemorrhoidal DE-arterialization (THD), 315 sphincterotomies, 12 anal polypectomies, 230 loop seton positions, 65 cone-like fistulectomies and 254 fistulotomies for perianal fistulas. In 329 cases, we used the posterior perineal block, 603 local perineal blocks, and 228 tumescent anesthesia. RESULTS: On a total of 1160 procedure failure rate was of 4.7% (55 cases). Urinary retention (69% 38 cases); bleeding 18% (10 cases), uncontrolled pain 12% of cases (7 cases). The chi-square test demonstrates (p<0.01) that the failure rate of the three types of anesthesia is very different with high statistical significance. The failure rate in patient underwent Posterior Perineal Block was 27/329 cases (8.2%), 8/228 (3.5%) in patients who underwent Tumescent Anesthesia and 20/603 (3.3%) in who underwent Local Perineal Block. CONCLUSIONS: Outpatient protocols represent the most common approach to minor proctologic disease that needs a good local block, with a good analgesic and sedative assistance, the different local block seems to be the same concerning the pain control, but presents some little, not relevant difference concerning urinary retention rate.


Assuntos
Procedimentos Cirúrgicos Ambulatórios/métodos , Anestesia Local/métodos , Doenças Retais/cirurgia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Procedimentos Cirúrgicos Ambulatórios/efeitos adversos , Canal Anal/cirurgia , Doenças do Ânus/cirurgia , Feminino , Hemorroidectomia/métodos , Hemorroidectomia/estatística & dados numéricos , Hemorroidas/cirurgia , Humanos , Masculino , Pessoa de Meia-Idade , Bloqueio Nervoso/métodos , Bloqueio Nervoso/estatística & dados numéricos , Pacientes Ambulatoriais , Estudos Retrospectivos , Falha de Tratamento , Adulto Jovem
10.
Acta Orthop ; 90(5): 439-444, 2019 10.
Artigo em Inglês | MEDLINE | ID: mdl-31274038

RESUMO

Background and purpose - Length of hospital stay (LOS) following total hip arthroplasty (THA) has been markedly reduced. Recently, same-day THA (SD-THA) was introduced, and previous studies have indicated satisfactory safety. However, studies are heterogeneous and only a few report results on SD-THA when using a posterolateral surgical approach. Thus, our aim was to evaluate the feasibility of and complications after SD-THA when using a posterolateral approach. Patients and methods - Consecutive patients scheduled for SD-THA between October 2015 and June 2016 were included. Eligibility criteria for SD-THA were: primary THA, motivation for same-day procedure, age > 18 years, ASA I or II, and the presence of a support person who could remain with the patient for 24 hours after surgery. A posterolateral surgical approach was used. Data were collected retrospectively from hospital records and the Danish National Patient Registry. Outcome measures were: complications during admission, LOS, causes of prolonged admission, and prevalence and causes of readmission at 90 days' follow-up. Results - 102 of 116 (88%) patients scheduled for SD-THA were discharged on the day of surgery. The remaining 14 patients were discharged the following day. Primary causes of prolonged admission were: dizziness/nausea, pain, and wound seepage. 7 patients had an estimated blood loss above 400 mL, but all were discharged as planned. No major complications occurred during admission. At follow-up, 3 patients had been readmitted due to pneumonia, wound infection, and dislocation, respectively. Interpretation - The results indicate that SD-THA performed with a posterolateral approach is feasible and can be performed with a low complication rate in a selected group of patients.


Assuntos
Procedimentos Cirúrgicos Ambulatórios/efeitos adversos , Artroplastia de Quadril/efeitos adversos , Complicações Pós-Operatórias/etiologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Procedimentos Cirúrgicos Ambulatórios/métodos , Artroplastia de Quadril/métodos , Estudos de Coortes , Procedimentos Clínicos/organização & administração , Estudos de Viabilidade , Feminino , Humanos , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Alta do Paciente , Readmissão do Paciente/estatística & dados numéricos , Estudos Retrospectivos
11.
Trials ; 20(1): 392, 2019 Jul 03.
Artigo em Inglês | MEDLINE | ID: mdl-31269978

RESUMO

BACKGROUND: Ambulatory phlebectomies and foam sclerotherapy are two of the most common treatments for varicose vein tributaries. Many studies have been published on these treatments, but few comparative studies have attempted to determine their relative effectiveness. METHODS/DESIGN: This is a prospective single-centre randomised clinical trial. Patients with primary truncal vein incompetence and varicose vein tributaries requiring treatment will be assigned randomly to either ambulatory phlebectomies or foam sclerotherapy. The primary outcome measure is the re-intervention rate for the varicose vein tributaries during the study period. The secondary outcomes include the degree of pain during the first two post-operative weeks and the time to return to usual activities or work. Improvements in clinical scores, quality of life scores, occlusion rates and cost-effectiveness for each intervention are other secondary outcomes. The re-intervention rate will be considered from the third month. DISCUSSION: This study compares ambulatory phlebectomies and foam sclerotherapy in the treatment of varicose vein tributaries. The re-intervention rates, safety, patient experience and the cost-effectiveness of each intervention will be assessed. This study aims to recruit 160 patients and is expected to be completed by the end of 2019. TRIAL REGISTRATION: ClinicalTrials.gov, NCT03416413 . Registered on 31 January 2018.


Assuntos
Procedimentos Cirúrgicos Ambulatórios/métodos , Veia Safena/cirurgia , Soluções Esclerosantes/administração & dosagem , Escleroterapia , Varizes/terapia , Procedimentos Cirúrgicos Vasculares/métodos , Procedimentos Cirúrgicos Ambulatórios/efeitos adversos , Humanos , Londres , Estudos Prospectivos , Ensaios Clínicos Controlados Aleatórios como Assunto , Retratamento , Veia Safena/diagnóstico por imagem , Soluções Esclerosantes/efeitos adversos , Escleroterapia/efeitos adversos , Fatores de Tempo , Resultado do Tratamento , Varizes/diagnóstico por imagem , Procedimentos Cirúrgicos Vasculares/efeitos adversos
12.
Medicine (Baltimore) ; 98(29): e16605, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-31335743

RESUMO

BACKGROUND: We aimed to conduct a systematic review and network meta-analysis (NMA) of published studies to comprehensively compare and rank the efficacy and safety of pharmacological interventions for preventing nausea and vomiting after ambulatory surgery. METHODS: A systematic and comprehensive search will be performed using the MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials, and Google Scholar databases, beginning from their inceptions to July and August 2019. Only randomized clinical trials on the efficacy and safety of pharmacologic interventions for preventing nausea and vomiting after ambulatory surgery will be included.The primary endpoints will be the incidences of postoperative nausea (PON), postoperative vomiting (POV), and postoperative nausea and vomiting (PONV) in the following recovery phases: before discharge (recovery phase I and II), after discharge but within 24 hours following surgery, and after discharge, after the initial 24-hour postoperative period.The incidences of delayed post-discharge nausea, post-discharge vomiting, and post-discharge nausea and vomiting, which occur after the initial 24-hour postoperative period, severities of PON, POV, and PONV, use of rescue antiemetics, and the incidence of complete response, as well as safety issues, including complications, such as headache, dizziness, and drowsiness, will be also assessed.We will conduct both pairwise meta-analysis and NMA. We will use surface under the cumulative ranking curve values and rankograms to present the hierarchy of the pharmacologic interventions. A comparison-adjusted funnel plot will be used to assess the presence of small-study effects. The quality of the studies included will be assessed using the risk of bias tool 2.0. All statistical analyses will be performed using Stata SE, version 15.0 (StataCorp, College Station, TX). 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 summarizing the efficacy and safety of pharmacological interventions for preventing nausea and vomiting after ambulatory surgery. TRIAL REGISTRATION NUMBER: CRD42018103068.


Assuntos
Procedimentos Cirúrgicos Ambulatórios/efeitos adversos , Antieméticos/efeitos adversos , Antieméticos/uso terapêutico , Náusea e Vômito Pós-Operatórios/prevenção & controle , Humanos , Meta-Análise em Rede
13.
Ann Surg Oncol ; 26(10): 3295-3304, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31342371

RESUMO

BACKGROUND: During the past 15 years, opioid-related overdose death rates for women have increased 471%. Many surgeons provide opioid prescriptions well in excess of what patients actually use. This study assessed a health systems intervention to control pain adequately while reducing opioid prescriptions in ambulatory breast surgery. METHODS: This prospective non-inferiority study included women 18-75 years of age undergoing elective ambulatory general surgical breast procedures. Pre- and postintervention groups were compared, separated by implementation of a multi-pronged, opioid-sparing strategy consisting of patient education, health care provider education and perioperative multimodal analgesic strategies. The primary outcome was average pain during the first 7 postoperative days on a numeric rating scale of 0-10. The secondary outcomes included medication use and prescription renewals. RESULTS: The average pain during the first 7 postoperative days was non-inferior in the postintervention group despite a significant decrease in median oral morphine equivalents (OMEs) prescribed (2.0/10 [100 OMEs] pre-intervention vs 2.1/10 [50 OMEs] post-intervention; p = 0.40 [p < 0.001]). Only 39 (44%) of the 88 patients in the post-intervention group filled their rescue opioid prescription, and 8 (9%) of the 88 patients reported needing an opioid for additional pain not controlled with acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs) postoperatively. Prescription renewals did not change. CONCLUSION: A standardized pain care bundle was effective in minimizing and even eliminating opioid use after elective ambulatory breast surgery while adequately controlling postoperative pain. The Standardization of Outpatient Procedure Narcotics (STOP Narcotics) initiative decreases unnecessary and unused opioid medication and may decrease risk of persistent opioid use. This initiative provides a framework for future analgesia guidelines in ambulatory breast surgery.


Assuntos
Procedimentos Cirúrgicos Ambulatórios/efeitos adversos , Neoplasias da Mama/cirurgia , Mastectomia/efeitos adversos , Entorpecentes/normas , Entorpecentes/uso terapêutico , Transtornos Relacionados ao Uso de Opioides/prevenção & controle , Dor Pós-Operatória/tratamento farmacológico , Adolescente , Adulto , Idoso , Neoplasias da Mama/patologia , Feminino , Seguimentos , Humanos , Pessoa de Meia-Idade , Dor Pós-Operatória/etiologia , Prognóstico , Estudos Prospectivos , Adulto Jovem
14.
Curr Opin Anaesthesiol ; 32(5): 643-648, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31356361

RESUMO

PURPOSE OF REVIEW: To summarize the safety and feasibility of outpatient total joint arthroplasty (TJA) from the perspectives of short-term complications, long-term functional outcomes, patient satisfaction and financial impact, and to provide evidence-based guidance on how to establish an outpatient TJA programme. RECENT FINDINGS: TJA has been recently transitioned from an exclusively inpatient procedure for all Medicare and Medicaid patients to an outpatient surgery in properly selected total knee arthroplasty patients. This change may decrease costs while maintaining comparable rates of readmission, adverse events, positive surgical outcomes and patient satisfaction. SUMMARY: With a standardized clinical pathway, outpatient TJA can be safe and effective in a subset of patients. Essential components of a successful outpatient TJA programme include proper patient selection, preoperative patient/family education, perioperative multidisciplinary coordination and opioid-sparing analgesia, and early and effective postdischarge planning. More studies are needed to further assess and optimize this new care paradigm.


Assuntos
Procedimentos Cirúrgicos Ambulatórios/métodos , Artroplastia de Quadril/métodos , Artroplastia do Joelho/métodos , Procedimentos Clínicos/organização & administração , Implementação de Plano de Saúde/organização & administração , Procedimentos Cirúrgicos Ambulatórios/efeitos adversos , Procedimentos Cirúrgicos Ambulatórios/economia , Artroplastia de Quadril/efeitos adversos , Artroplastia de Quadril/economia , Artroplastia do Joelho/efeitos adversos , Artroplastia do Joelho/economia , Procedimentos Clínicos/economia , Estudos de Viabilidade , Implementação de Plano de Saúde/economia , Humanos , Tempo de Internação , Medicaid/economia , Medicare/economia , Educação de Pacientes como Assunto/economia , Educação de Pacientes como Assunto/organização & administração , Readmissão do Paciente/economia , Satisfação do Paciente , Seleção de Pacientes , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/prevenção & controle , Avaliação de Programas e Projetos de Saúde , Resultado do Tratamento , Estados Unidos
15.
Urology ; 132: 37-42, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31310773

RESUMO

OBJECTIVES: To examine the safety and effectiveness of placing ureteral stents in an office-based setting vs in the operating room (OR). METHODS: A retrospective chart review was performed to examine outcomes, specifically complication rate, unanticipated hospitalizations, and stent failures, when patients received JJ stents in the clinic procedure suite, using local analgesia and/or nitrous oxide gas analgesia, compared to patients who had ureteral stents placed in the OR, typically with general anesthesia. Additionally, multivariable analysis was performed to determine predictors of complications. RESULTS: Around 565 procedures were performed in the clinic and 179 were performed in the OR. The complication rate for the clinic group was 4.1%, compared to 7.8% in the OR group. Unplanned admissions to the hospital occurred after 3.0% of clinic procedures and 9.5% of OR procedures. Stent placements failed in 1.1% of clinic procedures and 0.56% of OR procedures. Clinic procedure time was 10 minutes vs 12 minutes in the OR (P <0.01). Clinic vs OR setting was not predictive of complications (P = 0.99). We did not identify factors that impacted complication rate in ureteral stent placement in the clinic vs OR setting. Notably, the procedure time for a clinic stent placement was significantly shorter than the OR stent placement. CONCLUSIONS: This study demonstrates excellent outcomes with a novel approach to a standard procedure, with shorter procedure time and no difference in complication rates.


Assuntos
Procedimentos Cirúrgicos Ambulatórios , Analgésicos não Entorpecentes , Sedação Consciente/métodos , Óxido Nitroso , Salas Cirúrgicas , Stents , Ureter/cirurgia , Procedimentos Cirúrgicos Urológicos/métodos , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Procedimentos Cirúrgicos Ambulatórios/efeitos adversos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Resultado do Tratamento , Procedimentos Cirúrgicos Urológicos/efeitos adversos , Adulto Jovem
16.
Anticancer Res ; 39(6): 3141-3146, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-31177160

RESUMO

BACKGROUND/AIM: Breast cancer treatment represents a substantial amount of health-care costs and has a negative impact on womens' psychological health. Day-Surgery managment (DS) is a favorable alternative to a classic inpatient setting. In our prospective study we evaluated DS-treatment feasibility in terms of patient satisfaction, same-day-discharge rate, surgical-reintervention rate, psychological impact and costs. PATIENTS AND METHODS: We operated on 131 early breast cancer patients in DS. Surgical outcomes were evaluated. In 64 DS-treated breast cancer patients, psychological outcomes were analyzed using validated psychometric questionnaires and comparison was made with a corresponding group of women treated as inpatients. RESULTS: The same-day-discharge rate was 95.4%. No patient required readmission. The surgical-reintervention rate was 6.2%. DS-treatment significantly reduced anxiety (p=0.05) and depression (p=0.01) and afforded cost savings of 49%. CONCLUSION: DS-treatment of early breast cancer was feasible, with low reintervention rate, reduced anxiety and depression, high patients' satisfaction and substantial financial savings.


Assuntos
Procedimentos Cirúrgicos Ambulatórios , Neoplasias da Mama/cirurgia , Mastectomia , Saúde Mental , Adulto , Idoso , Idoso de 80 Anos ou mais , Procedimentos Cirúrgicos Ambulatórios/efeitos adversos , Procedimentos Cirúrgicos Ambulatórios/economia , Procedimentos Cirúrgicos Ambulatórios/psicologia , Ansiedade/etiologia , Ansiedade/psicologia , Neoplasias da Mama/economia , Neoplasias da Mama/patologia , Neoplasias da Mama/psicologia , Redução de Custos , Análise Custo-Benefício , Depressão/etiologia , Depressão/psicologia , Estudos de Viabilidade , Feminino , Custos de Cuidados de Saúde , Humanos , Mastectomia/efeitos adversos , Mastectomia/economia , Mastectomia/psicologia , Pessoa de Meia-Idade , Estadiamento de Neoplasias , Satisfação do Paciente , Estudos Prospectivos , Reoperação , Fatores de Risco , Resultado do Tratamento
17.
Anesth Analg ; 129(1): e5-e7, 2019 07.
Artigo em Inglês | MEDLINE | ID: mdl-31210651

RESUMO

Preoperative cognitive impairment increases the risk of adverse events after surgery but its prevalence in outpatient surgery has not been defined. We aimed to determine the prevalence and multivariable factors associated with cognitive impairment in individuals who present for outpatient surgery. We used data from the Health and Retirement Study, a longitudinal panel survey of older Americans. Of 1836 participants who reported having outpatient surgery, we found that 16.1% had evidence of cognitive impairment. Significant multivariable factors associated with preoperative cognitive impairment included non-Hispanic African American race, prior stroke, preoperative functional dependence, and lower socioeconomic status and education level.


Assuntos
Procedimentos Cirúrgicos Ambulatórios , Cognição , Disfunção Cognitiva/epidemiologia , Idoso , Idoso de 80 Anos ou mais , Procedimentos Cirúrgicos Ambulatórios/efeitos adversos , Disfunção Cognitiva/diagnóstico , Disfunção Cognitiva/psicologia , Feminino , Humanos , Masculino , Saúde Mental , Prevalência , Medição de Risco , Fatores de Risco , Estados Unidos
18.
Surgery ; 166(3): 375-379, 2019 09.
Artigo em Inglês | MEDLINE | ID: mdl-31196705

RESUMO

BACKGROUND: In response to the growing opioid crisis, Florida recently implemented a law restricting the duration of opioid prescriptions for acute pain. Little is known about the impact of such legislation on opioid prescription practices at the time of discharge after surgery. The objective of this study was to determine whether Florida's new legislation changed opioid prescription practices for analgesia after surgery. METHODS: Adults 18 years of age and older undergoing cholecystectomy, appendectomy, hernia repair, hysterectomy, mastectomy, or lymph node dissection were included in this retrospective cohort study at a large public university-affiliated hospital. We analyzed opioid prescriptions on discharge after these common outpatient surgical procedures between June 1, 2017, and December 31, 2018. Florida House Bill 21 was passed on March 2, 2018, and subsequent implementation of this law took place on July 1, 2018. The law restricts the duration of opioid prescriptions for acute pain to 3 days, which can be extended up to a maximum of 7 days with additional documentation. The outcomes studied included the following: the proportion of patients receiving opioid prescriptions on discharge, total opioid dose prescribed, daily opioid dose prescribed, and the proportion of patients receiving more than a 3-day supply of opioids. We colledted data on emergency department cumulative visits within 7 and 30 days after discharge. Drug doses were converted to morphine milligram equivalents and calculated for each selected procedure. RESULTS: A total of 1,467 surgical encounters were included. The cohort was predominantly female (963 [65.6%]) with a mean (SD) age of 49.6 (14.4) years. At 6 months after implementation of HB 21, the proportion of patients receiving opioid prescriptions decreased by 21% (95% CI 16.8% to 25.3%, P < .001), mean total opioid dose prescribed decreased by 64.2 morphine milligram equivalents (95% CI 54.7 to 73.7, P < .001) from a baseline mean (SD) of 172.5 (78.9) morphine milligram equivalents. The mean daily opioid dose prescribed increased by 3.5 morphine milligram equivalents (95% CI 1.8 to 5.1, P < .001) from a baseline mean (SD) of 30.5 (9.4) morphine milligram equivalents. The proportion of patients receiving opioid prescriptions for longer than a 3-day supply decreased by 68% (95% CI 63.4% to 72.7%, P < .001). We observed no change in the number of postoperative emergency department visits before and after implementation of the law. CONCLUSION: Opioid prescriptions for patients undergoing common outpatient surgical procedures at a large public university-affiliated hospital in Florida were substantially reduced within 6 months after implementation of state legislation limiting the duration of opioid prescriptions. This reduction was not associated with an increase in the number of postoperative emergency department visits. The legislation should significantly decrease the amount of unused opioid pills potentially available for diversion and abuse. Secondary effects from the enactment of this law remain to be evaluated.


Assuntos
Dor Aguda/epidemiologia , Dor Aguda/etiologia , Procedimentos Cirúrgicos Ambulatórios/efeitos adversos , Analgésicos Opioides , Prescrições de Medicamentos , Manejo da Dor , Dor Pós-Operatória/epidemiologia , Centros Médicos Acadêmicos , Dor Aguda/tratamento farmacológico , Adulto , Procedimentos Cirúrgicos Ambulatórios/métodos , Analgésicos Opioides/administração & dosagem , Estudos de Coortes , Prescrições de Medicamentos/estatística & dados numéricos , Feminino , Florida/epidemiologia , Humanos , Masculino , Pessoa de Meia-Idade , Manejo da Dor/métodos , Manejo da Dor/estatística & dados numéricos , Dor Pós-Operatória/tratamento farmacológico
19.
BMC Gastroenterol ; 19(1): 81, 2019 May 30.
Artigo em Inglês | MEDLINE | ID: mdl-31146697

RESUMO

BACKGROUND: Ambulatory surgery maintains the advantages of a more rapid return to work and overall reduced hospital costs. The specific impact of ambulatory surgery for anal fistula using the LIFT procedure (ligation of the intersphincteric fistula tract) is presented. METHODS: A total of 218 consecutive patients with anal fistula who underwent ambulatory LIFT surgery were retrospectively compared with 386 cases managed as in-patients. Patient demographics, comorbidities, postoperative morbidity and pain as well as readmission rates within 30 days and satisfaction ratings were compared between the two groups. RESULTS: When compared with patients undergoing in-patient surgery, those in the ambulatory group were younger with a better level of education (P < 0.05). Ambulatory cases returned to work after shorter postoperative periods (P < 0.01) but experienced more frequent postoperative external hemorrhoidal thrombosis and more reported postoperative pain (P < 0.05). There were no differences in the overall rate of complications or readmissions between the two groups. Ambulatory patients reported higher satisfaction ratings than in-patients (P < 0.05). CONCLUSIONS: The LIFT procedure for anal fistula can be safely performed in the ambulatory setting resulting in an acceptable level of satisfaction and a more rapid return to work when compared with in-patient fistula management.


Assuntos
Procedimentos Cirúrgicos Ambulatórios , Hemorragia Pós-Operatória/etiologia , Fístula Retal/cirurgia , Adolescente , Adulto , Procedimentos Cirúrgicos Ambulatórios/efeitos adversos , Estudos de Viabilidade , Feminino , Humanos , Ligadura , Masculino , Pessoa de Meia-Idade , Dor Pós-Operatória/etiologia , Satisfação do Paciente , Estudos Retrospectivos , Retorno ao Trabalho , Cicatrização , Adulto Jovem
20.
Anesth Analg ; 129(2): 347-349, 2019 08.
Artigo em Inglês | MEDLINE | ID: mdl-31166228

RESUMO

This document represents a joint effort of the Society for Ambulatory Anesthesia (SAMBA) and the Ambulatory Surgical Care Committee of the American Society of Anesthesiologists (ASA) concerning the safe anesthetic care of adult malignant hyperthermia (MH)-susceptible patients in a free-standing ambulatory surgery center (ASC). Adult MH-susceptible patients can safely undergo a procedure in a free-standing ASC assuming that proper precautions for preventing, identifying, and managing MH are taken. The administration of preoperative prophylaxis with dantrolene is not indicated in MH-susceptible patients scheduled for elective surgery. There is no evidence to recommend an extended stay in the ASC, and the patient may be discharged when the usual discharge criteria for outpatient surgery are met. Survival from an MH crisis in an ASC setting requires early recognition, prompt treatment, and timely transfer to a center with critical care capabilities.


Assuntos
Procedimentos Cirúrgicos Ambulatórios/normas , Anestesia/normas , Hospitalização , Hipertermia Maligna/terapia , Centros Cirúrgicos/normas , Procedimentos Cirúrgicos Ambulatórios/efeitos adversos , Anestesia/efeitos adversos , Dantroleno/administração & dosagem , Diagnóstico Precoce , Humanos , Hipertermia Maligna/diagnóstico , Hipertermia Maligna/etiologia , Relaxantes Musculares Centrais/administração & dosagem , Transferência de Pacientes/normas , Medição de Risco , Fatores de Risco , Resultado do Tratamento
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