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1.
Surgery ; 167(1): 117-123, 2020 01.
Artigo em Inglês | MEDLINE | ID: mdl-31582306

RESUMO

BACKGROUND: Overnight hospitalization after thyroid surgery has been a widely adopted practice because of the concern for complications such as hypocalcemia and hematoma. Same-day discharge, however, has become popular in recent years. METHODS: The American College of Surgeons National Surgical Quality Improvement Program Targeted Thyroidectomy database (2016-2017) was used to identify patients who underwent thyroid resections. A 1:1 propensity score matching was used to match patients who were discharged on postoperative day 0 and those discharged on postoperative days 1 or 2. Multivariable logistic regression models were constructed to assess the association between discharge timing and postoperative outcomes. RESULTS: Of the 10,502 patients, 2,776 (26.4%) were discharged on postoperative day 0, and 7,726 (73.6%) were discharged on postoperative days 1 or 2. After propensity score matching, 1,977 matched pairs were created. In this matched cohort, the rates of readmission were similar when comparing patients discharged on postoperative day 0 with those discharged on postoperative days 1 or 2 (odds ratio 1.26, 95% confidence interval 0.78-2.05). Likewise, no differences were observed in the rates of surgical site infection, clinically severe hypocalcemia, neck hematoma, or recurrent laryngeal nerve injury. CONCLUSION: In a national cohort of patients undergoing thyroid surgery, same-day discharge was not associated with greater rates of readmission or complications when compared with discharge 1 or 2 days after thyroid surgery.


Assuntos
Procedimentos Cirúrgicos Ambulatórios/efeitos adversos , Procedimentos Cirúrgicos Eletivos/efeitos adversos , Tempo de Internação , Alta do Paciente/normas , Complicações Pós-Operatórias/epidemiologia , Tireoidectomia/efeitos adversos , Adulto , Idoso , Idoso de 80 Anos ou mais , Procedimentos Cirúrgicos Ambulatórios/métodos , Procedimentos Cirúrgicos Ambulatórios/normas , Estudos de Coortes , Procedimentos Cirúrgicos Eletivos/métodos , Procedimentos Cirúrgicos Eletivos/normas , Feminino , Hematoma/epidemiologia , Hematoma/etiologia , Hematoma/prevenção & controle , Humanos , Hipocalcemia/epidemiologia , Hipocalcemia/etiologia , Hipocalcemia/prevenção & controle , Masculino , Pessoa de Meia-Idade , Pescoço , Alta do Paciente/estatística & dados numéricos , Readmissão do Paciente/estatística & dados numéricos , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/prevenção & controle , Período Pós-Operatório , Guias de Prática Clínica como Assunto , Fatores de Risco , Tireoidectomia/métodos , Tireoidectomia/normas
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.
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
4.
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
5.
J Physiol Pharmacol ; 70(3)2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-31539887

RESUMO

Prilocaine is widely used for spinal anesthesia. Its intermediate effect makes it a valuable choice for one-day surgery. The duration of the motor blockade (DMB) may have an impact on the length of stay. The goal of this study was to establish a correlation between the DMB and different parameters (hyperbaric prilocaine dose, puncture level, surgical position, age, patient weight, and patient height). We prospectively enrolled adult patients scheduled for ambulatory surgery (n = 384). Univariate and multivariate regressions (backward stepwise) were applied. A P value lower than 0.05 was considered significant. We performed first analyzes on the entire population. We achieved same on a subgroup only composed of patients who received 60 mg of hyperbaric prilocaine between L4 and L5 and staying on dorsal position during surgery. The univariate analyses of the entire population demonstrate a significant correlation between DMB and 1) the prilocaine dose (P < 0.001), and 2) the BMI (P = 0.011). On the same population, the multivariate analyses confirm these two independent parameters correlated to the DMB: the patient height (P = 0.03) and the hyperbaric prilocaine dose (P < 0.001). The second analyses performed on the subgroup (n = 65), demonstrate a wide variability in the DBM (mean ± SD): 90.12 ± 30.36 minutes. For this concern, univariate analyses illustrate that only the patient height was significantly correlated to the DMB (P = 0.005). The multivariate analyses confirm that patient height could be considered as an independent parameter of DBM (P = 0.005). Within our entire population, there exists a considerable variation in the duration of the motor block after a unique injection of hyperbaric prilocaine. The prilocaine dose and the patient height were the only independent factors of the extension of the DMB. However, this relation is extremely weak and only allows explaining the variability of the DMB in a minority of the patients. This unknown pharmacological property of hyperbaric prilocaine could restrict its use for day-care surgery.


Assuntos
Prilocaína/uso terapêutico , Procedimentos Cirúrgicos Ambulatórios/métodos , Raquianestesia/métodos , Feminino , Humanos , Injeções/métodos , Injeções Espinhais/métodos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos
6.
Medicine (Baltimore) ; 98(31): e16639, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31374033

RESUMO

The number of elective day-case surgeries has considerably increased in recent years, especially in China. Few studies have investigated the ability of mobile applications to assist recovery for patients having undergone day-surgery; however, these studies have indicated that the use of mobile applications is cost-efficient and has a positive effect on recovery after surgery. This study aimed to evaluate the utility and efficacy of using the 317-nursing mobile application program (317NAPP) for monitoring home recovery following day-surgery involving high ligation of the hernial sac in pediatric patients.Prospective clinical study involving 2 parallel groups.Patients were randomly divided into the "intervention 317NAPP group" (n = 64) and the control group (n = 63). Patients were followed-up using the 317NAPP in the intervention group and via telephonic consultations in the control group. All patients were enrolled after being provided sufficient guidance with respect to discharge and health education. The health index, including the physiological function, ability to perform daily activities, and the injury response, was evaluated before and 24 hours after surgery. The time duration of each follow-up session was also evaluated in both groups.The preoperative (T1) health index scores were significantly higher than the postoperative (T0) ones in both groups (P = .00). The quality of recovery (T1-T0) of the intervention group (10.75 ±â€Š5.28) was better than that of the control group (11.78 ±â€Š5.16), but the differences were not significant (P = .27). In the intervention group, the follow-up time duration was significantly lower in comparison to that in the control group (P = .00).This study demonstrated that 317NAPP had a positive effect on recovery following day-surgery, and the time-duration for follow-up was shorter than that performed using telephonic consultation. Monitoring recovery using 317NAPP was safe, efficient, inexpensive, and relatively easy; therefore, it may help improve the recovery of patients having undergone day-surgery.


Assuntos
Assistência ao Convalescente/métodos , Procedimentos Cirúrgicos Ambulatórios/métodos , Procedimentos Cirúrgicos Eletivos/métodos , Aplicativos Móveis , Cuidados Pós-Operatórios/métodos , Atividades Cotidianas , Adolescente , Criança , Pré-Escolar , Feminino , Humanos , Lactente , Masculino , Educação de Pacientes como Assunto , Estudos Prospectivos , Telefone
7.
Urology ; 133: 247, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31374287

RESUMO

OBJECTIVE: To provide a step-by-step guide for performing in-office transperineal prostate biopsy using biplanar ultrasound guidance. PATIENTS AND METHODS: Biopsies are performed using a freehand technique with the PrecisionPoint Transperineal Access System (Perineologic, Cumberland, MD). This disposable needle guide includes 3 components: a rail/clamp subassembly, a needle carriage with 5 aperture holes, and a 15 gauge access needle. The device is clamped to a side-fire biplanar ultrasound probe, ensuring alignment of the biopsy needle with the probe's ultrasound arrays. Once the patient is sufficiently anesthetized using 1% lidocaine, the access needle is engaged into the perineal skin. This allows for multiple passes of the biopsy needle through a common puncture site. A separate puncture is made for each side of the prostate and the aperture hole is chosen based on the overall height of the prostate. Biopsies are taken using a disposable 18 gauge biopsy gun. RESULTS: The presented video details our approach for performing transperineal prostate biopsy under local anesthesia. Biopsies are performed in the office setting without the need for periprocedural antibiotics. The PrecisionPoint Transperineal Access System ensures proper alignment of the biopsy needle with the ultrasound probe, while minimizing the number of individual needle sticks to the perineal skin. The use of biplanar ultrasound makes it possible to guide the biopsy needle with excellent precision to virtually any area of the prostate. The descried technique can be used for systematic biopsies as well as for targeted biopsies using cognitive fusion with magnetic resonance imaging. CONCLUSION: We provide a step-by-step guide for performing in-office transperineal prostate biopsy. The presented technique minimizes the risk of infectious complications by eliminating the need for biopsy needles to pass through the rectal mucosa. Biopsies are performed without the need for periprocedural antibiotics, thus furthering the goals of antibiotic stewardship.


Assuntos
Procedimentos Cirúrgicos Ambulatórios/métodos , Próstata/patologia , Ultrassonografia de Intervenção/métodos , Biópsia por Agulha/métodos , Humanos , Biópsia Guiada por Imagem/métodos , Masculino , Períneo
8.
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
9.
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
10.
Prog Urol ; 29(8-9): 402-407, 2019.
Artigo em Francês | MEDLINE | ID: mdl-31266700

RESUMO

INTRODUCTION: Spinal anesthesia in outpatient urology is controversial (longer hospital stay, risk of urinary retention). The main goal was to evaluate outpatient spinal anesthesia and to compare 2 local anesthetics secondarily. MATERIAL: Monocentric retrospective study including all patients undergoing surgery in urological ambulatory surgery under spinal anesthesia between December 2011 and May 2015, split into two groups according to the local anesthetic used: bupivacaine (BP) and chloroprocaine (CP). Quantitative variables were compared by Student's t-test, qualitative variables by χ2 test. RESULTS: Seventy-one (95%) out of the 75 patients included have been discharged the same day. Discharge was impossible in these cases: patient alone at home (1), bladder clot (1), JJ intolerance (1), delayed micturition (1). The mean duration of the procedure was 27±19min, the SSPI's was 55±31min, the stay's was 360±91min. A total of 45 patients (60%) received BP and 30 (40%) received CP. The mean residence time in SSPI was significantly reduced in the CP group (47±24min vs. 61±34min, P=0.04). One patient experienced urination delay in the BP group with no significant difference. No significant difference for the other criteria studied despite the mean age, which is higher in the CP group (P=0.02). CONCLUSION: Spinal anesthesia is adapted to ambulatory urology, and does not increase the risk of urinary retention, especially with CP that would decrease the length of stay in SSPI compared to BP. LEVEL OF EVIDENCE: 4.


Assuntos
Raquianestesia/métodos , Anestésicos Locais/administração & dosagem , Bupivacaína/administração & dosagem , Procaína/análogos & derivados , Procedimentos Cirúrgicos Urológicos/métodos , Adulto , Idoso , Procedimentos Cirúrgicos Ambulatórios/métodos , Raquianestesia/efeitos adversos , Anestésicos Locais/efeitos adversos , Bupivacaína/efeitos adversos , Feminino , Humanos , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Procaína/administração & dosagem , Procaína/efeitos adversos , Estudos Retrospectivos , Retenção Urinária/epidemiologia , Retenção Urinária/etiologia
11.
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
12.
Ann Surg Oncol ; 26(10): 3354-3360, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31342384

RESUMO

BACKGROUND: Same-day surgery (SDS) following mastectomy is safe and well accepted. Overnight admission in patients fit for discharge is an inefficient use of health resources. In response to a national review highlighting SDS following mastectomy at 1.4% in Alberta, a perioperative pathway was conceived. METHODS: The pathway was implemented across Alberta at 13 hospitals beginning in 2016. A steering committee was assembled, and clinical and administrative leads at each site were identified. Opportunities along the patient care experience whereby action could be taken to promote uptake of SDS were identified. Provincially branded support materials including presentations, order sets, and standard operating procedures were developed. Nurse educators provided in-service teaching such as standardized drain care and discharge teaching. Educational booklets, group classes, and online resources were developed for patients and families. An audit of SDS rates, unscheduled return to the emergency department (ED), and readmission rates was reported to teams quarterly, allowing for iterative modifications. Patient-reported experience measures (PREMs) were collected. RESULTS: SDS following mastectomy increased from 1.7 to 47.8%, releasing an estimated 831 bed days per year. No differences in unexpected return to the ED or readmission to hospital existed between SDS patients and those admitted overnight. A total of 102 patients completed the PREM survey, of whom 90% felt "excellent or good" with the plan to go home, how to care for themselves once home, and who to contact should issues arise. CONCLUSIONS: Implementation of a provincial perioperative pathway improved uptake of SDS following mastectomy and demonstrated favorable PREMs.


Assuntos
Procedimentos Cirúrgicos Ambulatórios/métodos , Neoplasias da Mama/cirurgia , Mastectomia/métodos , Segurança do Paciente , Assistência Perioperatória , Melhoria de Qualidade , Reoperação , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Neoplasias da Mama/patologia , Feminino , Seguimentos , Humanos , Pessoa de Meia-Idade , Alta do Paciente , Complicações Pós-Operatórias , Resultado do Tratamento , Adulto Jovem
13.
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
14.
Ann Otol Rhinol Laryngol ; 128(11): 1073-1077, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31161772

RESUMO

OBJECTIVES: To review the natural history of type I posterior glottic stenosis (PGS-I) and its treatment outcomes through a case presentation and demonstrate the feasibility of in-office management of PGS-I. METHODS: The case of a middle-aged woman who developed PGS-I after prolonged intubation is presented. A review of the literature on management and treatment outcomes of PGS-I is also performed. RESULTS: Initially presenting with a large granuloma that failed conservative management, the patient deferred surgical intervention and developed unilateral vocal fold hypomobility with posterior glottic synechia. The adhesion was successfully ablated in the office with potassium-titanyl-phosphate (KTP) laser; however, vocal fold hypomobility persisted after treatment. CONCLUSIONS: This case illustrates the natural history of the development of PGS-I, demonstrates the feasibility of office-based management of this condition, and provides further evidence that lysis of PGS-I synechia does not uniformly lead to restoration of normal laryngeal function and mobility.


Assuntos
Procedimentos Cirúrgicos Ambulatórios/métodos , Glote/diagnóstico por imagem , Glote/cirurgia , Laringoscopia/métodos , Laringoestenose/cirurgia , Terapia a Laser/métodos , Qualidade da Voz , Feminino , Humanos , Laringoestenose/diagnóstico , Laringoestenose/fisiopatologia , Lasers de Estado Sólido/uso terapêutico , Pessoa de Meia-Idade
15.
Ann R Coll Surg Engl ; 101(7): 519-521, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31155898

RESUMO

INTRODUCTION: Daycase trauma surgery is an evolving and a novel approach. The aim of our study was to report our experience of daycase trauma surgery with a focus on safety, patient experience, complications and limitations. MATERIAL AND METHODS: Patients scheduled and operated on a daycase trauma list from January 2013 to December 2016 were included in the study. Age, sex, case mix, readmissions within 48 hours, complications, patient satisfaction, reasons for overnight stay and cost effectiveness were evaluated. RESULTS: A total of 229 procedures were carried out. The mean age of the patients was 44.3 years (range 16-85 years) . There were 128 men and 101 women, 178 upper-limb and 51 lower-limb cases. Only 2.6% of the patients had stayed overnight for pain control, physiotherapy and neurological observations; 94.5% of the patients were satisfied. The mean visual analogue scale score for satisfaction was 8.7. There were no admissions within 48 hours of discharge and one complication with failure of ankle fixation. The estimated cost saving was £65,562. CONCLUSION: We conclude that a daycase trauma service is safe, cost effective, and yields high patient satisfaction. It reduces the burden on hospital beds and a wide range of upper- and lower-limb cases can be performed as daycase trauma surgery with adequate planning and teamwork.


Assuntos
Procedimentos Cirúrgicos Ambulatórios/estatística & dados numéricos , Sistema Musculoesquelético/lesões , Procedimentos Ortopédicos/estatística & dados numéricos , Dor Pós-Operatória/epidemiologia , Ferimentos e Lesões/cirurgia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Procedimentos Cirúrgicos Ambulatórios/efeitos adversos , Procedimentos Cirúrgicos Ambulatórios/economia , Procedimentos Cirúrgicos Ambulatórios/métodos , Análise Custo-Benefício , Feminino , Humanos , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Procedimentos Ortopédicos/efeitos adversos , Procedimentos Ortopédicos/economia , Procedimentos Ortopédicos/métodos , Medição da Dor , Dor Pós-Operatória/diagnóstico , Dor Pós-Operatória/etiologia , Dor Pós-Operatória/terapia , Readmissão do Paciente/estatística & dados numéricos , Segurança do Paciente , Satisfação do Paciente/estatística & dados numéricos , Estudos Retrospectivos , Reino Unido , Adulto Jovem
16.
Hepatobiliary Pancreat Dis Int ; 18(3): 273-277, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-31056482

RESUMO

BACKGROUND: Single-incision laparoscopic surgery has emerged as an alternative to conventional laparoscopic cholecystectomy (LC) in the clinical setting. Limited information is available on the possibility of performing single-incision laparoscopic surgery as an ambulatory procedure. This study aimed to determine the feasibility and safety of single-incision laparoscopic cholecystectomy (SILC) versus conventional LC in an ambulatory setting. METHODS: Ninety-one patients were randomized to SILC (n = 49) or LC (n = 42). The success rate, operative duration, blood loss, hospital stay, gallbladder perforation, drainage, delayed discharge, readmission, total cost, complications, pain score, vomiting, and cosmetic satisfaction of the two groups were then compared. RESULTS: There were significant differences in the operative time (46.89 ±â€¯10.03 min in SILC vs. 37.24 ±â€¯10.23 min in LC; P < 0.001). As compared with LC, SILC was associated with lower total costs (8012.28 ±â€¯752.67 RMB vs. 10258.91 ± 1087.63 RMB; P < 0.001) and better cosmetic satisfaction (4.94 ± 0.24 vs. 4.74 ± 0.54; P = 0.031). There were no significant differences between-group in terms of general data, success rate, blood loss, hospital stay, gallbladder perforation, drainage, delayed discharge, readmission, complications, pain score, and vomiting (P > 0.05). CONCLUSIONS: Ambulatory SILC is safe and feasible for selected patients. The advantages of SILC as compared with LC are improved cosmetic satisfaction and lower total costs.


Assuntos
Procedimentos Cirúrgicos Ambulatórios/métodos , Colecistectomia Laparoscópica/métodos , Doenças da Vesícula Biliar/cirurgia , Cálculos Biliares/cirurgia , Pólipos/cirurgia , Adulto , Procedimentos Cirúrgicos Ambulatórios/efeitos adversos , Procedimentos Cirúrgicos Ambulatórios/economia , Perda Sanguínea Cirúrgica , Colecistectomia Laparoscópica/efeitos adversos , Colecistectomia Laparoscópica/economia , Redução de Custos , Análise Custo-Benefício , Estudos de Viabilidade , Feminino , Doenças da Vesícula Biliar/diagnóstico por imagem , Cálculos Biliares/diagnóstico por imagem , Custos de Cuidados de Saúde , Humanos , Masculino , Pessoa de Meia-Idade , Duração da Cirurgia , Satisfação do Paciente , Pólipos/diagnóstico por imagem , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/terapia , Resultado do Tratamento , Adulto Jovem
17.
J Urol ; 202(5): 959-963, 2019 11.
Artigo em Inglês | MEDLINE | ID: mdl-31112102

RESUMO

PURPOSE: The typical mean length of stay following robot-assisted laparoscopic prostatectomy is 24 to 48 hours. We began routinely offering same day discharge from the hospital after robot-assisted laparoscopic prostatectomy. We evaluated the success rate, safety and cost implications in what is to our knowledge the only large series of same day discharge to date. MATERIALS AND METHODS: Beginning in September 2016 all patients were given the option of same day discharge without it being mandated. After allowing 3 months to solidify the protocol we evaluated our prospective database for the next 500 patients. RESULTS: Of the 500 consecutive men who underwent robot-assisted laparoscopic prostatectomy performed by 1 surgeon in 18 months 246 (49.2%) were discharged home the day of surgery and all of the remaining 254 were discharged the next day for a mean 0.51-day length of stay. Mean patient age was 62 years (range 42 to 81) and mean body mass index was 29.7 kg/m2 (range 20 to 53). Of the patients 34 (6.8%) had a Clavien-Dindo grade I-III complication within 90 days but there were no grade IV-V complications. Only 5 patients (1%) required an emergency department visit and only 8 (1.6%) required readmission. Only 1 of the patients who elected same day discharge was rehospitalized and only 1 presented to the emergency department. The estimated charge for an overnight stay at our institution is $2,109. The approximate reduction in charges was $518,814 during 18 months ($345,876 per year) with no increased cost due to emergency department visits or hospital readmissions compared with that of overnight patients. In the most recent 100 patients the rate of same day discharge improved to 65%. CONCLUSIONS: Same day discharge following robot-assisted laparoscopic prostatectomy can be safely routinely offered with no increase in readmissions or emergency visits. It may lead to significant savings in health care costs.


Assuntos
Procedimentos Cirúrgicos Ambulatórios/métodos , Alta do Paciente/estatística & dados numéricos , Prostatectomia/métodos , Procedimentos Cirúrgicos Robóticos/métodos , Adulto , Idoso , Idoso de 80 Anos ou mais , Procedimentos Cirúrgicos Ambulatórios/economia , Serviço Hospitalar de Emergência/economia , Utilização de Instalações e Serviços/economia , Utilização de Instalações e Serviços/estatística & dados numéricos , Estudos de Viabilidade , Custos Hospitalares/estatística & dados numéricos , Humanos , Masculino , Pessoa de Meia-Idade , Ohio , Alta do Paciente/economia , Readmissão do Paciente/economia , Readmissão do Paciente/estatística & dados numéricos , Complicações Pós-Operatórias/economia , Complicações Pós-Operatórias/epidemiologia , Prostatectomia/economia , Procedimentos Cirúrgicos Robóticos/economia
18.
Eur Arch Otorhinolaryngol ; 276(7): 2025-2029, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-31139923

RESUMO

PURPOSE: Parotidectomy is the definitive procedure for diagnosis and treatment of most parotid masses but, due to the risk of haematoma and seroma formation, has traditionally included a drain. The drain itself comes with its own risks and, in most hospitals, the need for overnight admission, which has significant cost implications (Mallon et al. Ann R Coll Surg Engl 95(4):258-262; 2013). Fibrin glue, with its haemostatic and adhesive properties, reduces the risk of collection or haematoma and therefore may negate the need for a drain. This is the first study to look at the use of ARTISS as an alternative to drains in parotidectomy. METHODS: We performed a retrospective study of all the patients who underwent a partial parotidectomy over a 4-year period from 2014 until 2018 under the same senior surgeon. Patients were divided into those that had a drain and those that had ARTISS. Their operative record, inpatient notes and clinic letters were reviewed to record information regarding length of stay, histology, complications and recurrence. RESULTS: A total of 34 patients were identified; 17 ARTISS and 17 drain patients. We showed that the mean length of stay improved significantly from 1.6 days with the drain to 0.5 days with ARTISS (Fig. 1) but without a difference in complication rate (Fig. 2), which was 5/17 (29%) in each group. CONCLUSIONS: In conclusion, parotidectomy can be undertaken safely as a day-case procedure with the application of ARTISS. This new approach to parotid surgery not only offers less morbidity for patients but also positive financial revenue for public health institutions.


Assuntos
Adesivo Tecidual de Fibrina/uso terapêutico , Fibrinogênio/farmacologia , Hematoma , Doenças Parotídeas , Complicações Pós-Operatórias/prevenção & controle , Seroma , Adulto , Procedimentos Cirúrgicos Ambulatórios/economia , Procedimentos Cirúrgicos Ambulatórios/métodos , Redução de Custos , Feminino , Hematoma/etiologia , Hematoma/prevenção & controle , Hemostáticos/farmacologia , Humanos , Masculino , Pessoa de Meia-Idade , Doenças Parotídeas/patologia , Doenças Parotídeas/cirurgia , Glândula Parótida/cirurgia , Projetos Piloto , Estudos Retrospectivos , Seroma/etiologia , Seroma/prevenção & controle , Reino Unido
19.
Surgery ; 166(2): 172-176, 2019 08.
Artigo em Inglês | MEDLINE | ID: mdl-31126588

RESUMO

BACKGROUND: In the midst of our national opioid crisis, recommendations have encouraged judicious stewardship of opioid prescription through the expanded use of non-opioid analgesic medications. This study aims to characterize trends in perioperative pain medication use for children undergoing ambulatory operations. METHODS: A cross-sectional, retrospective review was conducted using the Pediatric Health Information System. Patients younger than 18 years of age who underwent ambulatory surgery during 2010 to 2017 by one of five surgical subspecialties (otolaryngology, general pediatric, plastic or reconstructive, orthopedics, and urology) were included. Medications were identified using Current Procedural Terminology codes based on billing information for 18 commonly used analgesics along with the route of administration during their encounter. RESULTS: A total of 1,795,329 patients with a median age of 10 years were identified, of whom 84.3% received an opioid or non-opioid analgesic. Opioid use in the perioperative setting for ambulatory procedures decreased during the study period from 74.9% to 66.9% as a proportion of total analgesic prescriptions. Among opioids commonly used, intravenous morphine decreased the most from 19.8% to 15.4%, and intravenous hydromorphone and oral oxycodone use remained largely unchanged. Conversely, non-opiate medications increased, specifically intravenous ketorolac from 8.4% to 13.6%, and intravenous acetaminophen use increased from 0% to 8.5%. Intravenous acetaminophen use more than doubled between 2013 and 2017 (3.4% to 8.2%) and was accompanied by a decrease in oral acetaminophen use (14.4% to 9.3%). CONCLUSION: Overall, perioperative opioid utilization appears to be decreasing in favor of non-opioid analgesics. Other trends, such as increased intravenous acetaminophen, raise concerns for the cost effectiveness of perioperative analgesia and resource utilization.


Assuntos
Procedimentos Cirúrgicos Ambulatórios/métodos , Analgésicos não Entorpecentes/administração & dosagem , Analgésicos Opioides/administração & dosagem , Dor Pós-Operatória/tratamento farmacológico , Assistência Perioperatória/métodos , Adolescente , Fatores Etários , Procedimentos Cirúrgicos Ambulatórios/efeitos adversos , Chicago , Criança , Pré-Escolar , Estudos Transversais , Relação Dose-Resposta a Droga , Esquema de Medicação , Feminino , Hospitais Pediátricos , Humanos , Infusões Intravenosas , Injeções Intravenosas , Modelos Lineares , Masculino , Medição da Dor , Dor Pós-Operatória/fisiopatologia , Estudos Retrospectivos , Medição de Risco , Resultado do Tratamento
20.
Anesthesiol Clin ; 37(2): 195-213, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-31047124

RESUMO

Most surgery in the United States occurs in offices, free-standing surgicenters, and hospital-based outpatient facilities. Patients are frequently elderly with comorbidities, and procedures are increasingly complex. Traditionally, patients have been evaluated on the day of surgery by anesthesia providers. Obtaining information on patients' health histories, establishing criteria for appropriateness, and communicating medication instructions streamline throughput, lower cancellations and delays, and improve provider and patient satisfaction. Routine testing does not lower risk or improve outcomes. Evaluating and optimizing patients with significant diseases, especially those with suboptimal management, has positive impact on ambulatory surgery and anesthesia.


Assuntos
Procedimentos Cirúrgicos Ambulatórios/métodos , Anestesia/métodos , Cuidados Pré-Operatórios/métodos , Adulto , Idoso , Humanos , Programas de Rastreamento , Melhoria de Qualidade , Comportamento de Redução do Risco , Centros Cirúrgicos
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