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1.
Orthop Clin North Am ; 52(3): 201-208, 2021 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-34053565

RESUMO

Based on a series of 407 outpatient total hip arthroplasties performed by a single surgeon, a standardized protocol for blood loss management in outpatient arthroplasty was developed consisting of a presurgical hematocrit of greater than 36%, administration of tranexamic acid, prophylactic introduction of albumin, hypotensive epidural anesthesia, monopolar electrocautery, and bipolar sealer. This protocol uses techniques that alone are not novel but together create a standardized and reproducible pathway that when implemented can increase the safety of outpatient hip arthroplasty.


Assuntos
Procedimentos Cirúrgicos Ambulatórios/métodos , Artroplastia de Quadril/métodos , Perda Sanguínea Cirúrgica/prevenção & controle , Adulto , Idoso , Procedimentos Cirúrgicos Ambulatórios/normas , Antifibrinolíticos/uso terapêutico , Artroplastia de Quadril/normas , Eletrocoagulação , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Ácido Tranexâmico/uso terapêutico , Adulto Jovem
2.
Ann R Coll Surg Engl ; 103(6): 426-431, 2021 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-34058121

RESUMO

INTRODUCTION: Day-case surgery is safe and efficacious for most breast surgical procedures. Limited data exist on its use in immediate breast reconstruction. We present our experience of day-case management of mastectomy with immediate pre-pectoral implant-based reconstruction (IBR). METHODS: Data were collected on 47 patients who underwent day-case skin-sparing (SSM) or nipple-sparing (NSM) mastectomy with pre-pectoral IBR between October 2017 and September 2019. Clinicopathological data were collected, including postoperative complications, re-admission and re-operation. The data were compared to published national standards. RESULTS: Median age was 52 years (range 37-74). Thirty-two patients (68%) had an SSM and 15 (32%) had an NSM. Two patients (4%) had risk-reducing mastectomies and 45 had treatment for invasive cancer or ductal carcinoma in situ (DCIS). Mean tumour size was 33.3mm (range 7-85mm). Forty-two (89%) patients went home on the day of surgery. No patients required re-operation in the first 48 hours. The median postoperative follow-up time was 11.4 months (range 1.8-22.7 months). During the first 90-day postoperative period, eight patients (17%) developed superficial skin necrosis, five patients (10.6%) developed postoperative infections and five patients (10.6%) suffered an implant loss. Eight patients (17%) were readmitted for re-operation. Compared to UK national standards set in the iBRA study, our cohort has demonstrated comparable postoperative infection, implant loss and re-operation and re-admission rates. CONCLUSION: We have demonstrated close to 90% day-case success rate for mastectomy with IBR. These early data suggest that immediate IBR can be carried out in a manner that is cost-efficient without impacting surgical outcomes.


Assuntos
Procedimentos Cirúrgicos Ambulatórios/métodos , COVID-19/epidemiologia , Mamoplastia/métodos , Adulto , Idoso , COVID-19/prevenção & controle , Feminino , Humanos , Mastectomia/métodos , Pessoa de Meia-Idade , Resultado do Tratamento
3.
J Laryngol Otol ; 135(4): 341-343, 2021 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-33766165

RESUMO

OBJECTIVE: Practices vary regarding the timing of discharge after sinonasal surgery. This study aimed to examine the cost-effectiveness of same-day discharge compared to next-day discharge after sinonasal surgery. METHODS: A retrospective single-surgeon audit of sinonasal surgery over a 12-month period was performed. Demographic and clinical details, including distance travelled home, timing of discharge, hospital re-presentation, and complications, were collected and compared between the same-day discharge and next-day discharge groups. A cost-effectiveness analysis was performed. RESULTS: A total of 181 patients were identified; 117 underwent day-case surgery, of which 6 re-presented to the emergency department. Sixty-four patients stayed overnight after surgery, and six of those patients re-presented to the emergency department. The per patient cost was $3262 for day-case sinonasal surgery and $5050 for those admitted overnight after surgery (p < 0.001). CONCLUSION: Routine same-day discharge after sinonasal surgery is achievable, safe and cost-effective.


Assuntos
Procedimentos Cirúrgicos Ambulatórios/economia , Procedimentos Cirúrgicos Nasais/economia , Doenças Nasais/cirurgia , Alta do Paciente/economia , Adulto , Procedimentos Cirúrgicos Ambulatórios/métodos , Análise Custo-Benefício , Feminino , Humanos , Masculino , Procedimentos Cirúrgicos Nasais/métodos , Doenças Nasais/economia , Estudos Retrospectivos , Fatores de Tempo , Resultado do Tratamento
4.
Ann R Coll Surg Engl ; 103(3): 173-179, 2021 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-33557703

RESUMO

INTRODUCTION: With the emergence of the COVID-19 pandemic, all elective surgery was temporarily suspended in the UK, allowing for diversion of resource to manage the anticipated surge of critically unwell patients. Continuing to deliver time-critical surgical care is important to avoid excess morbidity and mortality from pathologies unrelated to COVID-19. We describe the implementation and short-term surgical outcomes from a system to deliver time-critical elective surgical care to patients during the COVID-19 pandemic. MATERIALS AND METHODS: A protocol for the prioritisation and safe delivery of time-critical surgery at a COVID-19 'clean' site was implemented at the Nuffield Health Exeter Hospital, an independent sector hospital in the southwest of England. Outcomes to 30 days postoperatively were recorded, including unplanned admissions after daycase surgery, readmissions and complications, as well as the incidence of perioperative COVID-19 infection in patients and staff. RESULTS: A total of 128 surgical procedures were performed during a 31-day period by a range of specialties including breast, plastics, urology, gynaecology, vascular and cardiology. There was one unplanned admission and and two readmissions. Six complications were identified, and all were Clavien-Dindo grade 1 or 2. All 128 patients had preoperative COVID-19 swabs, one of which was positive and the patient had their surgery delayed. Ten patients were tested for COVID-19 postoperatively, with none testing positive. CONCLUSION: This study has demonstrated the implementation of a safe system for delivery of time-critical elective surgical care at a COVID-19 clean site. Other healthcare providers may benefit from implementation of similar methodology as hospitals plan to restart elective surgery.


Assuntos
Procedimentos Cirúrgicos Eletivos/métodos , Neoplasias/cirurgia , Procedimentos Cirúrgicos Operatórios/métodos , Tempo para o Tratamento , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Procedimentos Cirúrgicos Ambulatórios/métodos , Derivação Arteriovenosa Cirúrgica , COVID-19 , Teste de Ácido Nucleico para COVID-19 , Cateterismo Cardíaco , Atenção à Saúde/organização & administração , Feminino , Hospitalização/estatística & dados numéricos , Humanos , Histerectomia , Masculino , Programas de Rastreamento , Pessoa de Meia-Idade , Readmissão do Paciente/estatística & dados numéricos , Complicações Pós-Operatórias/epidemiologia , SARS-CoV-2 , Reino Unido/epidemiologia , Procedimentos Cirúrgicos Urológicos , Adulto Jovem
5.
Medicine (Baltimore) ; 100(1): e23995, 2021 Jan 08.
Artigo em Inglês | MEDLINE | ID: mdl-33429761

RESUMO

ABSTRACT: The Chinese government is attaching great importance to the development of ambulatory surgery in order to optimize the healthcare system in China. The study aims to examine the complications and quality indicators of patients who underwent gynecological ambulatory surgery at a tertiary hospital in China.This was a retrospective study of patients who underwent ambulatory surgery between July and September 2019 at the Department of Gynecology of the First Affiliated Hospital of Shandong First Medical University. The patients were followed by phone at 30 days after discharge. The postoperative complications, mortality, unplanned re-operation, delayed discharge, unplanned re-hospitalization, and patient satisfaction were collected. The patients who underwent conventional hysteroscopic resection of uterine lesions during the same period were collected as controls for the economics analysis.A total of 392 patients who underwent ambulatory gynecological surgery were included. Fifteen patients had postoperative complications, and the total complication rate was 3.8% (15/392). Eight (8/392, 2.0%) patients had delayed discharge. There were no unplanned re-operations and deaths. There were two (2/392, 0.5%) cases of unplanned re-hospitalization. At 30 days after discharge, two patients were dissatisfied, and 390 cases were satisfied, for an overall satisfaction rate of 99.5%. Compared with conventional hysteroscopic resection of uterine lesions, ambulatory hysteroscopic surgery had a shorter hospital stay and lower total costs (P < .05) but similar surgery-related costs.Ambulatory gynecological surgery is feasible in China, with an acceptable complication profile and obvious economic and social benefits. Nevertheless, hospital management shall be reinforced.


Assuntos
Procedimentos Cirúrgicos em Ginecologia/métodos , Adulto , Procedimentos Cirúrgicos Ambulatórios/métodos , Procedimentos Cirúrgicos Ambulatórios/normas , Procedimentos Cirúrgicos Ambulatórios/tendências , China/epidemiologia , Estudos de Viabilidade , Feminino , Procedimentos Cirúrgicos em Ginecologia/normas , Procedimentos Cirúrgicos em Ginecologia/tendências , Humanos , Pessoa de Meia-Idade , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Desenvolvimento de Programas/métodos , Estudos Retrospectivos
6.
Am J Cardiol ; 143: 21-28, 2021 03 15.
Artigo em Inglês | MEDLINE | ID: mdl-33359193

RESUMO

Prior studies in patients with noncomplex coronary artery disease have demonstrated the safety of percutaneous coronary intervention (PCI) in the outpatient setting. We sought to examine the outcomes of outpatient PCI in patients with unprotected left main coronary artery disease (LMCAD). In the EXCEL trial, 1905 patients with LMCAD and site-assessed low or intermediate SYNTAX scores were randomized to PCI with everolimus-eluting stents versus coronary artery bypass grafting. The primary end point was major adverse cardiovascular events (MACE; the composite of death, stroke, or myocardial infarction). In this sub-analysis, outcomes at 30 days and 5 years were analyzed according to whether PCI was performed in the outpatient versus inpatient setting. Among 948 patients with LMCAD assigned to PCI, 935 patients underwent PCI as their first procedure, including 100 (10.7%) performed in the outpatient setting. Patients who underwent outpatient compared with inpatient PCI were less likely to have experienced recent myocardial infarction. Distal left main bifurcation disease involvement and SYNTAX scores were similar between the groups. Comparing outpatient to inpatient PCI, there were no significant differences in MACE at 30 days (4.0% vs 5.0% respectively, adjusted OR 0.52 95% CI 0.12 to 2.22; p = 0.38) or 5 years (20.6% vs 22.1% respectively, adjusted OR 0.72, 95% CI 0.40 to 1.29; p = 0.27). Similar results were observed in patients with distal left main bifurcation lesions. In conclusion, in the EXCEL trial, outpatient PCI of patients with LMCAD was not associated with an excess early or late hazard of MACE. These data suggest that outpatient PCI may be safely performed in select patients with LMCAD.


Assuntos
Procedimentos Cirúrgicos Ambulatórios/métodos , Doença da Artéria Coronariana/cirurgia , Hospitalização , Intervenção Coronária Percutânea/métodos , Idoso , Angina Estável/epidemiologia , Angina Instável/epidemiologia , Ponte de Artéria Coronária , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Mortalidade , Infarto do Miocárdio/epidemiologia , Infarto do Miocárdio sem Supradesnível do Segmento ST/epidemiologia , Razão de Chances , Ensaios Clínicos Controlados Aleatórios como Assunto , Infarto do Miocárdio com Supradesnível do Segmento ST/epidemiologia , Acidente Vascular Cerebral/epidemiologia
7.
J Pediatr Orthop ; 41(1): e85-e89, 2021 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-32852367

RESUMO

BACKGROUND: The purpose of this study was to determine the intraoperative and 30-day postoperative complication rates in a large consecutive cohort of pediatric patients who had orthopaedic surgery at a freestanding ambulatory surgery center (ASC). The authors also wanted to identify the rates of same-day, urgent hospital transfers, and 30-day hospital admissions. The authors hypothesized that pediatric orthopaedic procedures at a freestanding ASC can be done safely with a low rate of complications. METHODS: A retrospective review identified patients aged 17 years or younger who had surgery at a freestanding ASC over a 9-year period. Adverse outcomes were divided into intraoperative complications, postoperative complications, need for the secondary procedure, unexpected hospital admission on the same day of the procedure, and unexpected hospital admission within 30 days of the index procedure. Complications were graded as grade 1, the complication could be treated without additional surgery or hospitalization; grade 2, the complication resulted in an unplanned return to the operating room (OR) or hospital admission; or grade 3, the complication resulted in an unplanned return to the OR or hospitalization with a change in the overall treatment plan. RESULTS: Adequate follow-up was available for 3780 (86.1%) surgical procedures. Overall, there were 9 (0.24%) intraoperative complications, 2 (0.08%) urgent hospital transfers, 114 (3%) complications, and 16 (0.42%) readmissions. Seven of the 9 intraoperative complications resolved before leaving the OR, and 2 required return to the OR.Neither complications nor hospitalizations correlated with age, race, gender, or length or type of surgery. There was no correlation between the presence of medical comorbidities, body mass index, or American Society of Anesthesiologists score and complication or hospitalization. CONCLUSIONS: Pediatric orthopaedic surgical procedures can be performed safely in an ASC because of multiple factors that include dedicated surgical teams, single-purpose ORs, and strict preoperative screening criteria. The rates of an emergency hospital transfer, surgical complications, and 30-day readmission, even by stringent criteria, are lower than those reported for outpatient procedures performed in the hospital setting. LEVEL OF EVIDENCE: Level IV-case series.


Assuntos
Instituições de Assistência Ambulatorial , Procedimentos Cirúrgicos Ambulatórios , Procedimentos Ortopédicos , Complicações Pós-Operatórias , Adolescente , Instituições de Assistência Ambulatorial/organização & administração , Instituições de Assistência Ambulatorial/normas , Procedimentos Cirúrgicos Ambulatórios/efeitos adversos , Procedimentos Cirúrgicos Ambulatórios/métodos , Procedimentos Cirúrgicos Ambulatórios/normas , Estudos de Coortes , Feminino , Humanos , Masculino , Procedimentos Ortopédicos/efeitos adversos , Procedimentos Ortopédicos/métodos , Procedimentos Ortopédicos/normas , Avaliação de Processos e Resultados em Cuidados de Saúde , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Estudos Retrospectivos , Estados Unidos/epidemiologia
8.
Spine (Phila Pa 1976) ; 46(10): 658-664, 2021 May 15.
Artigo em Inglês | MEDLINE | ID: mdl-33315775

RESUMO

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: The aim of this study was to evaluate the safety of two-level cervical disc replacement (CDR) in the outpatient setting. SUMMARY OF BACKGROUND DATA: Despite growing interest in CDR, limited data exist evaluating the safety of two-level CDR in the outpatient setting. METHODS: The National Surgical Quality Improvement Program (NSQIP) database was queried for all two-level anterior cervical discectomy and fusion (ACDF) and CDR procedures between 2015 and 2018. Demographics, comorbidities, and 30-day postoperative complication rates of outpatient two-level CDR were compared to those of inpatient two-level CDR and outpatient two-level ACDF. Radiographic data are not available in the NSQIP. RESULTS: A total of 403 outpatient CDRs were compared to 408 inpatient CDRs and 4134 outpatient ACDFs. Outpatient CDR patients were older and more likely to have pulmonary comorbidities compared to inpatient CDR (P < 0.03). Outpatient CDR patients were less likely to have an American Society of Anesthesiologists class ≥2 and have hypertension compared to outpatient ACDF patients (P < 0.0001). Outpatient CDR had a lower 30-day readmission rate (0.5% vs. 2.5%, P = 0.02) and lower 30-day reoperation rate (0% vs. 1%, P = 0.047) compared to inpatient CDR. Outpatient CDR had a lower readmission rate (0.5% vs. 2.1%, P = 0.03) compared to outpatient ACDF, but there was no difference in reoperation rates between the two procedures (0% vs. 0.8%, P = 0.07). Outpatient CDR had an overall complication rate of 0.2%, inpatient CDR had a complication rate of 0.9%, and outpatient ACDF had a complication rate of 1.3%. These differences were not significant. CONCLUSION: To our knowledge, this is the largest multicenter study examining the safety of two-level outpatient CDR procedures. Outpatient two-level CDR was associated with similarly safe outcomes when compared to inpatient two-level CDR and outpatient two-level ACDF. This suggests that two-level CDR can be performed safely in the outpatient setting.Level of Evidence: 3.


Assuntos
Procedimentos Cirúrgicos Ambulatórios/métodos , Vértebras Cervicais/cirurgia , Discotomia/métodos , Melhoria de Qualidade , Fusão Vertebral/métodos , Adulto , Idoso , Procedimentos Cirúrgicos Ambulatórios/tendências , Comorbidade , Discotomia/tendências , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Readmissão do Paciente/tendências , Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/cirurgia , Melhoria de Qualidade/tendências , Reoperação/métodos , Reoperação/tendências , Estudos Retrospectivos
9.
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
10.
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
11.
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
12.
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
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.
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
17.
Breast Cancer Res Treat ; 182(3): 679-688, 2020 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-32562119

RESUMO

PURPOSE: As our hospitals conserve and re-allocate resources during the COVID-19 crisis, there is urgent need to determine how best to continue caring for breast cancer patients. During the time window before the COVID-19 critical peak and particularly thereafter, as hospitals are able to resume cancer operations, we anticipate that there will be great need to maximize efficiency to treat breast cancer. The goal of this study is to present a same-day protocol that minimizes resource utilization to enable hospitals to increase inpatient capacity, while providing care for breast cancer patients undergoing mastectomy and immediate breast reconstruction during the COVID-19 crisis. METHODS: IRB exempt patient quality improvement initiative was conducted to detail the operationalization of a novel same-day breast reconstruction protocol. Consecutive patients having undergone immediate breast reconstruction were prospectively enrolled between February and March of 2020 at Massachusetts General Hospital during the COVID-19 crisis. Peri-operative results and postoperative complications were summarized. RESULTS: Time interval from surgical closure to patient discharge was 5.02 ± 1.29 h. All patients were discharged home, with no re-admissions or emergency department visits. No postoperative complications were observed. CONCLUSION: This report provides an instruction manual to operationalize a same-day breast reconstruction protocol, to meet demands of providing appropriate cancer treatment during times of unprecedented resource limitations. Pre-pectoral implant-based breast reconstruction can be the definitive procedure or be used as a bridge to autologous reconstruction. Importantly, we hope this work will be helpful to our patients and community as we emerge from the COVID-19 pandemic.


Assuntos
Procedimentos Cirúrgicos Ambulatórios/métodos , Neoplasias da Mama/cirurgia , Carcinoma Ductal de Mama/cirurgia , Mamoplastia/métodos , Mastectomia/métodos , Melhoria de Qualidade , Adulto , Assistência ao Convalescente , Anestesiologia , Betacoronavirus , Implante Mamário , Implantes de Mama , Protocolos Clínicos , Infecções por Coronavirus/epidemiologia , Eficiência , Serviço Hospitalar de Emergência , Feminino , Recursos em Saúde , Serviços de Assistência Domiciliar , Humanos , Tempo de Internação , Pessoa de Meia-Idade , Pandemias , Readmissão do Paciente , Assistência Perioperatória/métodos , Pneumonia Viral/epidemiologia , Estudos Prospectivos , Biópsia de Linfonodo Sentinela , Cirurgia Plástica , Oncologia Cirúrgica , Telemedicina , Dispositivos para Expansão de Tecidos
18.
Int Urol Nephrol ; 52(11): 2059-2064, 2020 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-32583371

RESUMO

PURPOSE: It is reported that surgical procedures performed during the COVID-19 pandemic are accompanied by high complications and risks. In this study, the urological interventions applied with appropriate infrastructure and protocols during the pandemic in the pandemic hospital that is carrying out the COVID-19 struggle are analyzed. METHODS: Urological interventions were reviewed in the 5-week period between March 11 and April 16. The distribution of outpatient and interventional procedures was determined by weeks concurrently along with the COVID-19 patient workload, and data in the country, subgroups were further analyzed. Patients intervened were divided into four groups as Emergency, High, Intermediate, and Low Priority cases according to the EAU recommendations. The COVID-19-related findings were recorded; staff and patient effects were reported. RESULTS: Of the 160 interventions, 65 were minimally invasive or open surgical intervention, 95 were non-surgical outpatient intervention, and the outpatient admission was 777. According to the priority level, 33 cases had emergency and high priority, 32 intermediate and low priority. COVID-19 quarantine and follow-up were performed at least 1 week in 22 (33.8%) operated patients at the last week, 43 (66.2%) patients who were operated in the previous 4 weeks followed up at least 2 weeks. No postoperative complications were encountered in any patient due to COVID-19 during the postoperative period. CONCLUSION: In the COVID-19 pandemic, precautions, isolation, and algorithms are required to avoid disruption in the intervention and follow-up of urology patients; priority urological interventions should not be disrupted in the presence of necessary experience and infrastructure.


Assuntos
Assistência Ambulatorial , Procedimentos Cirúrgicos Ambulatórios , Infecções por Coronavirus , Controle de Infecções , Pandemias , Pneumonia Viral , Doenças Urológicas , Procedimentos Cirúrgicos Urológicos , Assistência Ambulatorial/métodos , Assistência Ambulatorial/estatística & dados numéricos , Procedimentos Cirúrgicos Ambulatórios/métodos , Betacoronavirus , Gestão de Mudança , Infecções por Coronavirus/epidemiologia , Infecções por Coronavirus/prevenção & controle , Tratamento de Emergência/métodos , Tratamento de Emergência/estatística & dados numéricos , Feminino , Humanos , Controle de Infecções/métodos , Controle de Infecções/organização & administração , Masculino , Pessoa de Meia-Idade , Procedimentos Cirúrgicos Minimamente Invasivos/estatística & dados numéricos , Avaliação de Processos e Resultados em Cuidados de Saúde , Pandemias/prevenção & controle , Pneumonia Viral/epidemiologia , Pneumonia Viral/prevenção & controle , Turquia/epidemiologia , Doenças Urológicas/epidemiologia , Doenças Urológicas/cirurgia , Procedimentos Cirúrgicos Urológicos/métodos , Procedimentos Cirúrgicos Urológicos/estatística & dados numéricos
19.
J Urol ; 204(5): 956-961, 2020 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-32379565

RESUMO

PURPOSE: We assessed the multi-institutional safety of same day discharge for robot-assisted radical prostatectomy within a single health care system. MATERIALS AND METHODS: We included 358 patients undergoing planned same day discharge for robot-assisted radical prostatectomy at 6 French centers. Primary outcomes were same day discharge failure, and 30-day complication and readmission rates. Secondary outcomes included preoperative characteristics, perioperative parameters, Chung score and pain visual analogue scale at discharge, pathological features and followup. RESULTS: Mean patient age was 64.7 years. Mean operative time and blood loss were 147.5 minutes and 228 ml, respectively. Concomitant lymph node dissection and nerve sparing procedures were performed in 43% and 62% of cases, respectively. No patient required transfusion or conversion. The same day discharge failure, complication and readmission rates were 4.2%, 16.8% and 2.8%, respectively. The most frequent complications were low grade complications including urinary infection (6.4%) and ileus (2.8%). Blood loss, lymph node dissection and pain visual analogue scale were significantly correlated with same day discharge failure. Same day discharge failure was reported in 7.8% of patients with pelvic lymph node dissection compared with only 1.5% of patients who did not undergo lymph node dissection (p=0.003). ASA® score was the only factor significantly associated with postoperative complications (p=0.023). The only factor correlated with readmission was the pain visual analogue scale at discharge (p=0.017). CONCLUSIONS: This first multi-institutional evaluation confirms the safety of same day discharge robot-assisted radical prostatectomy in a single health care system and identifies for the first time factors associated with same day discharge failure and readmission. These findings may help physicians anticipate ideal same day discharge candidates and adapt postoperative followup.


Assuntos
Procedimentos Cirúrgicos Ambulatórios/efeitos adversos , Recuperação Pós-Cirúrgica Melhorada/normas , Prostatectomia/efeitos adversos , Neoplasias da Próstata/cirurgia , Procedimentos Cirúrgicos Robóticos/efeitos adversos , Idoso , Procedimentos Cirúrgicos Ambulatórios/métodos , Procedimentos Cirúrgicos Ambulatórios/normas , Estudos de Viabilidade , França , Humanos , Excisão de Linfonodo/efeitos adversos , Excisão de Linfonodo/métodos , Excisão de Linfonodo/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Duração da Cirurgia , Alta do Paciente/normas , Alta do Paciente/estatística & dados numéricos , Readmissão do Paciente/estatística & dados numéricos , Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/terapia , Cuidados Pré-Operatórios/métodos , Cuidados Pré-Operatórios/normas , Próstata/cirurgia , Prostatectomia/métodos , Prostatectomia/normas , Prostatectomia/estatística & dados numéricos , Procedimentos Cirúrgicos Robóticos/normas , Procedimentos Cirúrgicos Robóticos/estatística & dados numéricos , Fatores de Tempo , Resultado do Tratamento
20.
Curr Opin Anaesthesiol ; 33(3): 395-403, 2020 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-32371633

RESUMO

PURPOSE OF REVIEW: Anesthesia outside the operating room is rapidly expanding for adult and pediatric patients. Anesthesia clinicians practicing in this area need a good understanding of the challenges of the NORA environment and the anesthetic risks and perioperative implications of practice so that they can deliver safe care to their patients. RECENT FINDINGS: Recent reports from large patient databases have afforded anesthesiologists a greater understanding of the risk of NORA when compared to anesthesia in the operating room. Descriptions of advances in team training with the use of simulation have allowed the development of organized procedural teams. With an emphasis on clear communication, an understanding of individual roles, and a patient-centered focus, these teams can reliably develop emergency response procedures, so that critical moments are not delayed in an environment remote from usual assistance. SUMMARY: With appropriate attention to organizational concerns (i.e. team environment, safety protocols) and unrelenting focus on patient safety, anesthesiologists can assist in safely providing the benefit of cutting-edge technical advancements to pediatric patients in these challenging environments.


Assuntos
Procedimentos Cirúrgicos Ambulatórios/métodos , Anestesia/métodos , Anestesiologia , Adulto , Anestesiologistas , Anestesiologia/instrumentação , Criança , Humanos , Segurança do Paciente , Segurança
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