Unanticipated admission after ambulatory surgery--a prospective study

Improved Postoperative Pain Management Outcomes After Implementation of Enhanced Recovery After Surgery (ERAS) Protocol for Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy (CRS-HIPEC)

BACKGROUND

Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) for patients with peritoneal carcinomatosis is promising but has potential for significant morbidity and prolonged hospitalization. Enhanced Recovery After Surgery (ERAS) is a standardized protocol designed to optimize perioperative care. This study describes trends in epidural and opioid use after implementing ERAS for CRS-HIPEC at a tertiary academic center.

METHODS

A retrospective analysis of patients undergoing CRS-HIPEC from January 2020 to September 2023 was conducted. ERAS was implemented in February 2022. Medication and outcomes data were compared before and after ERAS initiation. All opioids were converted to morphine milligram equivalents (MMEs).

RESULTS

A total of 136 patients underwent CRS-HIPEC: 73 (54%) pre- and 63 (46%) post-ERAS. Epidural usage increased from 63% pre-ERAS to 87% post-ERAS (p = 0.001). Compared with those without epidurals, patients with epidurals had decreased total 7-day oral and intravenous (IV) opioid requirements (45 MME vs. 316 MME; p < 0.001). There was no difference in 7-day opioid totals between pre- and post-ERAS groups. After ERAS, more patients achieved early ambulation (83% vs. 53%; p < 0.001), early diet initiation (81% vs. 25%; p < 0.001), and early return of bowel function (86% vs. 67%; p = 0.012).

CONCLUSIONS

ERAS implementation for CRS-HIPEC was associated with increased epidural use, decreased oral and IV opioid use, and earlier bowel function return. Our study demonstrates that epidural analgesia provides adequate pain control while significantly decreasing oral and IV opioid use, which may promote gastrointestinal recovery postoperatively. These findings support the implementation of an ERAS protocol for effective pain management in patients undergoing CRS-HIPEC.

Transfers and anesthesia-related postoperative outcomes after 3361 same-day cancer surgeries at a freestanding surgery center: An observational retrospective study

BACKGROUND AND OBJECTIVES

Expanding outpatient surgery to the increasing number of procedures and patient populations warrants continuous evaluation of postoperative outcomes to ensure the best care and safety. We describe adverse postoperative outcomes and transfer rates related to anesthesia in a large sample of patients who underwent same-day cancer surgery at a freestanding ambulatory surgery center.

METHODS

Between January 2017 and June 2021, 3361 cancer surgeries, including breast and plastic, head and neck, gynecology, and urology, were performed. The surgeries were indicated for diagnosis, staging, and/or treatment. We report the incidence of transfers and adverse postoperative outcomes related to anesthesia.

RESULTS

Breast and plastic surgeries were the most common (1771, 53%), followed by urology (1052, 31%), gynecology (410, 12%), and head and neck surgeries (128, 4%). Based on patients' first procedure, comorbidity levels were highest for urology (75% American Society of Anesthesiologists physical status score 3, 1.7% score 4) and lowest for breast surgeries (31% score 3, 0.2% score 4). Most gynecology surgeries used general anesthesia (97.6%), whereas breast surgeries used the least (38%). A total of seven patients (0.2%; 95% CI: 0.08%-0.4%) were immediately transferred to an outside hospital; four due to anesthesia-related reasons. Only 7 (0.2%) patients needed additional postoperative care related to anesthesia-related adverse events, specifically cardiac events (4), difficult intubations (2), desaturation (1), and agitation, nausea, and headache (1).

CONCLUSIONS

The incidence of anesthesia-related adverse postoperative outcomes is low in cancer patients undergoing outpatient surgeries at our freestanding ambulatory surgery center. This suggests that carefully selected cancer patients, including patients with metastatic cancer, can undergo anesthesia for same-day surgery, making cancer care accessible locally and reducing stress associated with travel for treatment. More research investigating complication rates related to surgery and to cancer disease trajectory are needed to establish a complete evaluation of safety for outpatient cancer surgery.

Acceptance of outpatient enhanced recovery after surgery (ERAS©) protocols for implant-based breast reconstruction nudged on by the COVID-19 pandemic

We retrospectively identified 295 women undergoing outpatient implant breast reconstruction (IBR) who received standardized ERAS care pre-pandemic (PP; April 2018-March 2020) and during the pandemic (DP; April 2020-March 2022). The majority of IBR was completed as outpatient surgeries DP versus PP (73% versus 38%, p < 0.001). Immediate IBR increased DP versus PP (p < 0.001). Preoperative ERAS© order sets were used 54% of the time. Lack of ERAS© order set use was associated with unplanned admissions (55.3% versus 44.7%, p = 0.02). COVID-19 changed health care and nudged IBR to outpatient procedures. With ERAS© recommendations, IBR can be safely and effectively transitioned to outpatient settings.

[Comparison of different prediction models for the occurrence of nausea and vomiting in the postoperative phase : A systematic qualitative comparison based on prospectively defined quality indicators]

BACKGROUND

Various prognostic prediction models exist for evaluating the risk of nausea and vomiting in the postoperative period (PONV). So far, no systematic comparison of these prognostic scores is available.

METHOD

A systematic literature search was carried out in seven medical databases to find publications on prognostic PONV models. Identified scores were assessed against prospectively defined quality criteria, including generalizability, validation and clinical relevance of the models.

RESULTS

The literature search revealed 62 relevant publications with a total of 81,834 patients which could be assigned to 8 prognostic models. The simplified Apfel score performed best, primarily because it was extensively validated. The Van den Bosch score and Sinclair score tied for second place. The simplified Koivuranta score was in third place.

CONCLUSION

The qualitative analysis highlights the strengths and weaknesses of each prediction system based on predetermined standardized quality criteria.

The effect of perioperative benzodiazepine administration on postoperative nausea and vomiting: a systematic review and meta-analysis of randomised controlled trials

BACKGROUND

Despite recent systematic reviews suggesting their benefit for postoperative nausea, vomiting, or both (PONV) prevention, benzodiazepines have not been incorporated into guidelines for PONV prophylaxis because of concerns about possible adverse effects. We conducted an updated meta-analysis to inform future practice guidelines.

METHODS

We included randomised controlled trials (RCTs) of all languages comparing benzodiazepines with non-benzodiazepine comparators in adults undergoing inpatient surgery. Our outcomes were postoperative nausea, vomiting, or both. We assessed risk of bias for RCTs using the Cochrane Risk of Bias tool. We pooled data using a random-effects model and assessed the quality of evidence for each outcome using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach.

RESULTS

We screened 31 413 abstracts and 950 full texts. We included 119 RCTs; 104 were included in quantitative synthesis. Based on moderate certainty evidence, we found that perioperative benzodiazepine administration reduced the incidence of PONV (52 studies, n=5086, relative risk [RR]: 0.77, 95% confidence interval [CI] 0.66-0.89; number needed to treat [NNT] 16; moderate certainty), postoperative nausea (55 studies, n=5916, RR: 0.72, 95% CI 0.62-0.83; NNT 21; moderate certainty), and postoperative vomiting (52 studies, n=5909, RR: 0.74, 95% CI 0.60-0.91; NNT 55; moderate certainty).

CONCLUSIONS

Moderate quality evidence shows that perioperative benzodiazepine administration decreases the incidence of PONV. The results of this systematic review and meta-analysis will inform future clinical practice guidelines.

SYSTEMATIC REVIEW PROTOCOL

The protocol for this systematic review was pre-registered with PROSPERO International Prospective Register of Systematic Reviews (CRD42022361088) and published in BMJ Open (PMID 31831540).

Comparison of the Quality of Recovery-15 score in patients undergoing oncoplastic breast-conserving surgery under monitored anesthesia care versus general anesthesia: a prospective quality improvement study

PURPOSE

Whether changing the institutional practice from general anesthesia (GA) to monitored anesthesia care (MAC) affects postoperative quality of recovery for oncoplastic breast-conserving surgery (BCS) is currently unknown. We designed this quasi-experimental study to evaluate a quality improvement (QI) initiative instituted in Edmonton, AB, Canada.

METHODS

We chose a prospective controlled cohort study design for this QI study, where patients underwent oncoplastic BCS under MAC in one hospital and BCS under GA at another hospital (control). A total of 125 patients undergoing surgery between May 2021 and February 2022 were enrolled. Exclusion criteria were male sex, total mastectomy, or age under 18. All other patients were included. The primary outcome was the change in Quality of Recovery-15 score at 24 hr compared with a preoperative baseline. Secondary outcomes included intra- and postoperative time profiles, perioperative analgesic and antiemetic use and length of hospital stay. Statistical analysis included a propensity score analysis to account for confounding variables.

RESULTS

Sixty-four patients received GA and 61 MAC. No enrolled patients were lost to follow up but two were excluded secondarily. No patients receiving MAC needed conversion to GA or unplanned airway management. Monitored anesthesia care was associated with superior outcomes for the primary outcome (β/SE[β], 3.31; 99.5% confidence interval, 0.45 to 6.17; P = 0.001) and most secondary outcomes, when accounting for confounding factors.

CONCLUSIONS

A care transformation initiative for patients undergoing oncoplastic BCS under MAC was associated with a higher quality recovery profile and shorter length of stay without any increase in perioperative or postoperative adverse events.

Postoperative nausea and vomiting after artificial joint replacement surgery: comparison between remimazolam and sevoflurane, a propensity score analysis

PURPOSE

Remimazolam, a newly synthesized ultrashort-acting benzodiazepine, has not been previously compared with sevoflurane with regard to postoperative nausea and vomiting (PONV). The aim of this study is to investigate the incidence of PONV between remimazolam and sevoflurane among patients undergoing artificial joint replacement surgery.

METHODS

We conducted a retrospective analysis of the electronic medical records of patients who underwent artificial joint replacement surgery at Kobe City Medical Center General Hospital from 2020 to 2022, with a focus on comparing the incidence of PONV among those who received sevoflurane versus remimazolam anesthesia. To control for confounding factors, we employed a propensity score-matching technique to pair patients who received sevoflurane anesthesia with those who received remimazolam anesthesia.

RESULTS

The records of 292 patients receiving general anesthesia for artificial joint replacement surgery were collected and categorized into group sevoflurane (n = 241) or group remimazolam (n = 51). Before propensity score matching, age and ASA-PS exhibited significant differences between two groups. There was no significant difference in the incidence of PONV between them (p = 0.461). After matching, there were 51 patients in each group. However, there is no significant difference in the incidence of PONV between the two matched cohorts (p = 0.243).

CONCLUSIONS

This study demonstrated that there was no difference in the prevalence of PONV between remimazolam and sevoflurane anesthesia in patients undergoing artificial joint replacement surgery.

Impact of Peripheral Nerve Block Technique on Incidence of Phrenic Nerve Palsy in Shoulder Surgery

Peripheral nerve blocks are an increasingly common method of providing postoperative analgesia for shoulder surgeries. However, the standard technique, the interscalene block (ISB), inevitably causes hemidiaphragmatic paresis (HDP), secondary to phrenic nerve palsy. This can cause morbidity in patients with preexisting respiratory compromise, prompting investigation into alternative "phrenic-sparing" nerve blocks. The aim of this review was to give an overview of these blocks and critically evaluate the current literature to determine if any are suitable replacements for ISB. The incidence of HDP and analgesic efficacy were considered. We queried four electronic databases and one register. Twenty-eight original articles were selected for review. The use of ultrasound guidance, lower volumes of local anaesthetic (LA), and injection 4 mm outside the brachial plexus fascia reduced HDP incidence for the ISB; however, no single modification did so sufficiently. While the anterior suprascapular nerve block (SSNB) showed comparable analgesic effects to the ISB, HDP prevalence was also high. The posterior SSNB produced consistently low HDP incidences but also inferior analgesia to ISB, except when combined with an infraclavicular brachial plexus block. The superior trunk block (STB) provided equivalent analgesia to the ISB while reducing HDP incidence, but not significantly. Lower LA volumes consistently led to lower HDP incidence across all blocks, likely due to a reduced ability to spread to the phrenic nerve. Further investigation into the minimum effective volumes of the extrafascial ISB, anterior SSNB, STB, and combined posterior SSNB with infraclavicular block is warranted to determine if any of these blocks can successfully balance HDP prevention with analgesic efficacy.

Remimazolam's Effects on Postoperative Nausea and Vomiting Are Similar to Those of Propofol after Laparoscopic Gynecological Surgery: A Randomized Controlled Trial

(1) Background: Remimazolam is a novel benzodiazepine that prevents postoperative nausea and vomiting (PONV), is more effective than volatile anesthetics, and was recently approved for use in Japan. (2) Methods: This prospective, double-blind, randomized controlled trial study aimed to compare the efficacy of remimazolam and propofol as general anesthetics in terms of the incidence of PONV after laparoscopic gynecological surgery (UMIN000046237). High-risk female patients who underwent general anesthesia with either remimazolam or propofol for the maintenance of anesthesia were enrolled. The primary outcome was the incidence of PONV in the two groups (i.e., REM versus PROP) 2 h and 24 h after surgery. The incidence of vomiting without nausea, rescue antiemetic use, and the severity of nausea were also evaluated. (3) Results: No significant differences in PONV were identified between the REM and PROP groups at 2 h or 24 h. Furthermore, no differences were observed in any of the measured parameters, and no adverse events were reported. (4) Conclusions: The results of the present study suggest that remimazolam may be as effective as propofol in preventing PONV; however, further investigation is necessary to identify possible differences between these two agents.

Acupuncture combined with ondansetron for prevention of postoperative nausea and vomiting in high-risk patients undergoing laparoscopic gynaecological surgery: A randomised controlled trial

BACKGROUND

Consensus guidelines recommend the use of multiple antiemetics as prophylaxis in patients at high risk of postoperative nausea and vomiting (PONV), but the evidence regarding combining acupuncture and antiemetics as a multimodal approach was of very low quality.

OBJECTIVE

This study aimed to assess the effect of combinations of acupuncture with ondansetron versus ondansetron alone for PONV prophylaxis in women at a high risk.

METHODS

This parallel, randomised controlled trial was conducted in a tertiary hospital in China. Patients who had three or four PONV risk factors on the Apfel simplified risk score, undergoing elective laparoscopic gynaecological surgery for benign pathology, were recruited. Patients in the combination group received two sessions of acupuncture treatment and 8 mg intravenous ondansetron, whereas those in the ondansetron group received ondansetron alone. The primary outcome was the incidence of PONV within 24 h postoperatively. Secondary outcomes included the incidence of postoperative nausea, postoperative vomiting, adverse events etc. RESULTS: Between January and July 2021, a total of 212 women were recruited, 91 patients in the combination group and 93 patients in the ondansetron group were included in the modified intention-to-treat analysis. In the first 24 h postoperatively, 44.0% of the patients in the combination group and 60.2% of the patients in the ondansetron group experienced nausea, vomiting, or both (difference, -16.3% [95% CI, -30.5 to -2.0]; risk ratio, 0.73 [95% CI, 0.55-0.97]; p = 0.03). However, the results of the secondary outcomes showed that compared to ondansetron alone, acupuncture together with ondansetron was only effective in reducing nausea but did not have a significant impact on vomiting. The incidence of adverse events was similar between the groups.

CONCLUSION

Acupuncture combined with ondansetron as a multimodal prophylaxis approach is more effective than ondansetron alone in preventing postoperative nausea in high-risk patients.

Opioid-sparing anesthesia with dexmedetomidine provides stable hemodynamic and short hospital stay in non-intubated video-assisted thoracoscopic surgery: a propensity score matching cohort study

OBJECTIVES

Dexmedetomidine is an alpha-2 agonist with anti-anxiety, sedative, and analgesic effects and causes a lesser degree of respiratory depression. We hypothesized that the use of dexmedetomidine in non-intubated video-assisted thoracic surgery (VATS) may reduce opioid-related complications such as postoperative nausea and vomiting (PONV), dyspnea, constipation, dizziness, skin itching, and cause minimal respiratory depression, and stable hemodynamic status.

METHODS

Patients who underwent non-intubated VATS lung wedge resection with propofol combined with dexmedetomidine (group D) or alfentanil (group O) between December 2016 and May 2022 were enrolled in this retrospective propensity score matching cohort study. Intraoperative vital signs, arterial blood gas data, perioperative results and treatment outcomes were analyzed. Of 100 patients included in the study (group D, 50 and group O, 50 patients), group D had a significantly lower degree of decrement in the heart rate and the blood pressure than group O. Intraoperative one-lung arterial blood gas revealed lower pH and significant ETCO₂. The common opioid-related side effects, including PONV, dyspnea, constipation, dizziness, and skin itching, all of which occurred more frequently in group O than in group D. Patients in group O had significantly longer postoperative hospital stay and total hospital stay than group D, which might be due to opioid-related side effects postoperatively.

CONCLUSIONS

The application of dexmedetomidine in non-intubated VATS resulted in a significant reduction in perioperative opioid-related complications and maintenance with acceptable hemodynamic performance. These clinical outcomes found in our retrospective study may enhance patient satisfaction and shorten the hospital stay.

Investigating the Association Between a Risk-Directed Prophylaxis Protocol and Postoperative Nausea and Vomiting: Validation in a Low-Income Setting

BACKGROUND

The efficacy of postoperative nausea and vomiting (PONV) prevention protocols in low-income countries is not well known. Different surgical procedures, available medications, and co-occurring diseases imply that existing protocols may need validation in these settings. We assessed the association of a risk-directed PONV prevention protocol on the incidence of PONV and short-term surgical outcomes in a teaching hospital in Rwanda.

METHODS

We compared the incidence of PONV during the first 48 hours postoperatively before (April 1, 2019-June 30, 2019; preintervention) and immediately after (July 1, 2019-September 30, 2019; postintervention) implementing an Apfel score-based PONV prevention strategy in 116 adult patients undergoing elective open abdominal surgery at Kigali University Teaching Hospital in Rwanda. Secondary outcomes included time to first oral intake, hospital length of stay, and rate of wound dehiscence. Interrupted time series analyses were performed to assess the associated temporal slopes of the outcome before and immediately after implementation of the risk-directed PONV prevention protocol.

RESULTS

Compared to just before the intervention, there was no change in the odds of PONV at the beginning of the postintervention period (odds ratio [OR], 0.23; 95% confidence interval [CI], 0.05-1.01). There was a decreasing trend in the odds of nausea (OR, 0.60; 95% CI, 0.36-0.97) per month. However, there was no difference in the incidence of nausea immediately after implementation of the protocol (OR, 0.96; 95% CI, 0.25-3.72) or in the slope between preintervention and postintervention periods (OR, 1.48; 95% CI, 0.60-3.65). In contrast, there was no change in the odds of vomiting during the preintervention period (OR, 1.01; 95% CI, 0.61-1.67) per month. The odds of vomiting decreased at the beginning of the postintervention period compared to just before (OR, 0.10; 95% CI, 0.02-0.47; P = .004). Finally, there was a significant decrease in the average time to first oral intake (estimated 14 hours less; 95% CI, -25 to -3) when the protocol was first implemented, after adjusting for confounders; however, there was no difference in the slope of the average time to first oral intake between the 2 periods ( P = .44).

CONCLUSIONS

A risk-directed PONV prophylaxis protocol was associated with reduced vomiting and time to first oral intake after implementation. There was no substantial difference in the slopes of vomiting incidence and time to first oral intake before and after implementation.

Extended Release of Bupivacaine from Temperature-responsive Hydrogels Provides Multi-day Analgesia for Postoperative Pain

OBJECTIVE

A local anesthetic that provides analgesia lasting at least three days could significantly improve postoperative pain management. This study evaluated the analgesic efficacy and safety of an extended-release formulation of bupivacaine based on the injectable hydrogel carrier poly(N-isopropylacrylamide-co-dimethylbutyrolactone acrylamide-co-Jeffamine M-1000 acrylamide) (PNDJ).

METHODS

The efficacy of PNDJ containing 4% bupivacaine (SBG004) given by peri-incisional subcutaneous injection (SBG004 SC) or wound filling instillation (SBG004 WF) was evaluated compared to saline, liposomal bupivacaine, bupivacaine collagen sponge, bupivacaine-meloxicam polyorthoester, and bupivacaine HCl in a porcine skin and muscle incision model. Mechanical allodynia was assessed by withdrawal from application of von Frey filaments, and local tolerance was evaluated by histology. Bupivacaine pharmacokinetics for SBG004 SC were measured in rabbits (16.5 mg bupivacaine/kg).

RESULTS

Animals demonstrated less mechanical allodynia at incisions receiving SBG004 SC for up to 96 hours postoperatively. Incisions treated with SBG004 SC tolerated more force without a withdrawal indicative of pain compared to saline for 96 hours, and compared to SBG004 WF and all active controls at 24, 48, and 72 hours except bupivacaine-meloxicam polyorthoester at 72 hours. By 49 days, SBG004 was histologically absent and was replaced with granulation tissue infiltrated with immune cells in some areas. In rabbits, Cmax was 41.6 ± 9.7 ng/mL with t1/2 82.0 ± 35.8 hours (mean ± SD).

CONCLUSIONS

Peri-incisional SBG004 SC provided extended release of bupivacaine sufficient to reduce sensation of incisional pain for 96 hours, in vivo bupivacaine delivery for at least 7 days, and a favorable local and systemic toxicity profile.

A Medico-Economic Evaluation of a Telehealth platform for elective Outpatient Surgeries: Protocol for a Randomized Controlled Trial (Preprint)

BACKGROUND

The number of elective outpatient surgeries in Canada has increased markedly in the last 10 years. However, unanticipated cancellations on the day of surgery and adverse postoperative events are frequent. Modern technologies have been shown to be of great help in the medical field in improving patient care. Thus, it is likely that dedicated technologies could also significantly improve surgical outpatients' pathways. Therefore, the department of anesthesiology at the University of Montreal Medical Center, in collaboration with LeoMed, a telemedicine platform, has developed a telehealth solution to offer more efficient perioperative support and follow-up for patients undergoing ambulatory surgery.

OBJECTIVE

The objective is to evaluate the medicoeconomic benefit of a dedicated perioperative telehealth platform for patients undergoing day surgery. Our hypothesis is that this dedicated telecare solution will allow more efficient patient care, which will reduce all types of medical costs related to day surgery pathways.

METHODS

This study is a single-center, single-blinded, 2-group randomized controlled trial. One thousand patients aged over 18 years with internet access who are scheduled to undergo ambulatory surgery will be enrolled and randomized either to follow a perioperative path that includes a patient-tailored perioperative digital app via the LeoMed telecare platform for 1 month or to follow the standard of care, which does not offer personalized digital support. The primary outcome will be to evaluate the cost-effectiveness of the telecare platform, assessing direct costs from factors such as unanticipated cancellations on the day of surgery due to preoperative instructions not being followed, calls to the local health information line, calls to the provincial health information line, emergency department consultations, unplanned readmissions, or medical visits for problems related to the surgical procedure within the first 30 days after the intervention. The secondary outcome will be to evaluate cost utility using a questionnaire assessing quality-adjusted life years. A blinded independent research team will analyze outcomes. All data will be analyzed according to the intention-to-treat principle. A sample size of 500 subjects in each group was calculated to detect a 21% reduction in postoperative complications with a power of 90%. This study has been approved by the ethics board of Centre hospitalier de l'Université de Montréal (University of Montreal Health Centre). No employee of LeoMed was involved in the study conception, and none will be involved in either data collection or analysis.

RESULTS

Results of this trial will be useful to determine the economic benefit of a telecare platform specifically developed for surgical outpatient pathways.

CONCLUSIONS

We believe that the deployment of a dedicated perioperative telehealth app will lead to better patient care and fewer postoperative complications, which will lower all types of costs related to surgical outpatient care.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04948632; https://ClinicalTrials.gov/ct2/show/NCT04948632.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/44006.

Feasibility and applicability of pulmonary nodule day surgery in thoracic surgery

Background

More patients with lung diseases were identified with low-dose computed tomography (CT) popularization and increasing physical examination awareness. Day surgery was routinely conducted in many departments as a relatively mature diagnosis and treatment mode. Thus, this study aimed to assess the feasibility of day surgery in thoracic surgery for pulmonary surgery and provide guidance for selecting suitable patients.

Methods

This study retrospectively analyzed the clinical data of patients with pulmonary nodule surgeries. Patients were divided into the day and routine surgery groups following chest tube removal within 48 h postoperatively and the discharge criteria. Each group was further divided into the wedge and anatomic lung resection groups. The feasibility and applicability of day surgery in thoracic surgery was evaluated by calculating the percentage of the day surgery group and comparing the clinical data of the two groups, and corresponding guidance was given for selecting suitable patients for day surgery.

Results

The day surgery group accounted for 53.4% of the total number of patients in both groups. Data comparison revealed differences in age, hypertension, coronary heart disease, pulmonary function index, nodule localization, pleural adhesion, total postoperative drainage, and complications in the wedge resection and age, gender, smoking history, pulmonary function indexes, intraoperative adhesions, operative duration, total postoperative drainage volume, and complications in the anatomic lung resection (P < 0.05). There were no significant differences in the rates of re-hospitalization (1/172 ratio 1/150) and re-drainage (0/172 ratio 1/150) (P > 0.05).

Conclusion

This study concluded that more than half of the pulmonary surgery can be applied to the treatment mode of day surgery, and day surgery can be applied to the screened patients. It conforms to the concept of accelerated rehabilitation and can speed up bed turnover so that more patients can receive high-level medical treatment promptly.

Surgeon-Performed Saphenous Nerve Block at the Medial Femoral Condyle for Arthroscopic Partial Meniscectomy and Meniscus Repair: A Randomized Control Trial

Introduction

With the rising number of arthroscopic partial meniscectomy and meniscus repair procedures performed in outpatient surgical centers, there has been significant interest in limiting postoperative pain and optimizing recovery. Postoperative pain is a common reason for admission at these surgical centers, and opioid-related mortality is becoming an increasing concern. A surgeon-performed saphenous nerve block (SNB) represents a promising adjunct treatment option for pain control. The purpose of this randomized controlled trial was to determine if an SNB would result in decreased postoperative pain and opioid usage compared to control following arthroscopic meniscus repair or partial meniscectomy.

Methods

We randomized patients between two groups: one receiving an SNB and the other without an SNB. The operating surgeon performed the SNB using a landmark-based approach at the medial femoral epicondyle/adductor hiatus with 5 mL of 1% lidocaine preoperatively and 5 mL of 0.5% ropivacaine postoperatively. Neither ultrasound nor nerve stimulator was utilized to confirm the success of the block. The visual analog scale was utilized to record pain preoperatively and in the immediate postoperative period, one day, and seven to 10 days postoperatively. The nursing staff in the post-anesthesia care unit monitored patient pain levels and provided pain medication accordingly.

Results

We enrolled 80 patients, with 40 patients in each group. There was no difference in age, sex, body mass index, or laterality between study groups. Overall, there were no differences between groups in preoperative or postoperative pain at any time. The average pain scores preoperatively were 2.78 in the experimental group and 3.05 in the control group (p=0.502). In the immediate postoperative period, pain scores were 1.57 for the experimental group and 2.66 for the control group (p=0.090). No statistically significant difference was detected in the number of patients requiring opioids postoperatively or in the morphine milligram equivalents (MME) provided to patients receiving opioids. Twelve patients in the experimental group received opioids in the immediate postoperative period while 18 patients in the control group received opioids (p=0.248). We observed no adverse events in patients from either group.

Conclusion

As a pure sensory nerve, the saphenous nerve is an excellent target for pain control without associated leg weakness. We utilized a low-resource SNB in knee arthroscopy for partial meniscectomy and meniscus repair as an adjunct therapy for postoperative pain control. This randomized controlled trial suggests that surgeon-performed blocks via a landmark-based approach are not effective in controlling pain or limiting opioid use in the immediate postoperative period. However, given our lack of confirmatory testing via ultrasound or nerve stimulation, a true nerve block may not have been achieved in all patients. We believe this adds to the external validity of this study, as these tools may not be readily available in all settings.

Risk factors for immediate failure of outpatient surgery in gynecologic surgery

OBJECTIVE

To describe the risk factors for immediate failure of gynecologic outpatient surgery. The secondary objective was to describe the risk factors for rehospitalization within 30 days after surgery.

METHODS

This is a single-center retrospective cohort study conducted on all patients operated on in outpatient surgery in gynecology at the Lille University Hospital. The primary outcome was defined as any unanticipated admission to the inpatient postoperative care unit on the day of the operation. The secondary outcome was defined as any rehospitalization within 30 days following the intervention. Our statistical analysis included 916 patients operated on between January and July 2019.

RESULTS

In our study, 84 patients (9.2%) had an immediate failure of outpatient surgery. The most frequent etiologies were surgical (58.3%). In multivariate analysis with logistic regression, the following variables were associated with an increased risk of immediate failure of outpatient surgery: urogynecologic surgery (P < 0.001), complex laparoscopy (P = 0.004), endometriosis surgery (P < 0.001), and a duration of intervention longer than 1 hour (P < 0.001).

CONCLUSION

We find an increased risk of immediate failure of gynecologic outpatient surgery depending on the type of surgery as well as for surgeries lasting more than 1 hour.

Analgesic benefit of metamizole and ibuprofen vs. either medication alone: a randomized clinical trial

BACKGROUND

Postoperative pain relief remains a key problem after surgery. Multimodal pain therapy has proven beneficial in alleviating pain to a certain extent. However, when combining non-opioids, the focus has been on NSAIDs and paracetamol, but effects of combined use are only moderate. Metamizole could be a potent adjunct, due to its preclusion in several countries, data on its combined use are sparse, despite its common use in many countries. The aim of this study was to examine whether the combination of metamizole and ibuprofen is superior in relieving postoperative pain to either drug alone.

METHODS

For this randomized, placebo-controlled, cross-over study, 35 patients undergoing bilateral lower third molar extraction were randomized. Each patient received three applications of 1000mg metamizole + 400mg ibuprofen for surgery on one side and either 1000mg metamizole + placebo or 400mg ibuprofen + placebo on the other side. Pain ratings, rescue-medication (tramadol), and sleep were assessed for 18 hours.

RESULTS

The combined treatment of metamizole and ibuprofen showed lower mean pain scores over 12 hours than ibuprofen (2.4±1.3 vs 3.8±1.6; P=0.005)). Further, combined treatment showed lower mean pain scores over 6 hours than ibuprofen (2.0±1.2 vs. 3.1±1.6; P=0.022) or metamizole alone (2.0±1.2 vs. 3.3±1.7; P=0.015). Consumption of rescue medication was lowest in the combination-group (25% vs. 46%-metamizole; 50%-ibuprofen). The trial was stopped prematurely as the COVID-pandemic halted elective surgeries.

CONCLUSIONS

Combined use enables superior pain control compared to ibuprofen after molar extraction and tends to be superior to metamizole alone. The premature study-termination may overestimate this effect.

Assessment of post-operative nausea and vomiting prophylaxis usage for cesarean section, 2021: A cross sectional study

Background

Objective

Methods

Results

Conclusions

•

PONV is the most common morbidity after surgery and anesthesia.

•

Untreated PONV is associated with complications.

•

Appropriate anti emetic prophylactic agents can reduce PONV.

•

Practice of PONV prophylactic usage is low.

Effect of intraoperative subhypnotic infusion of propofol on postoperative nausea and vomiting: A retrospective analysis

STUDY OBJECTIVE

To measure the possible association between subhypnotic propofol infusion during general balanced anesthesia and the incidence of PONV.

DESIGN

Retrospective Cohort Analysis Using Propensity Score Matching.

SETTING

Postanesthesia care unit and inpatient unit.

PATIENTS

Patients with American Society of Anesthesiologists (ASA) physical status I-IV, undergoing non-cardiac surgery lasting >2 h were included. Patients were excluded if transferred to the intensive care unit after surgery or received ketamine. Initially 70,976 patients were screened, and a cohort of 51,707 eligible adult patients undergoing non-cardiac surgery under general balanced anesthesia between 2015 and 2019 were included. Using a propensity score matching, 3185 patients who received subhypnotic propofol during general balanced anesthesia were matched with 5826 patients who did not receive subhypnotic propofol in a 1:2 ratio.

INTERVENTIONS

None.

MEASUREMENTS

The primary outcome was the incidence of PONV during PACU stay. The secondary outcome was the incidence of PONV within the first 24 h after surgery. Exploratory outcomes were time-to-extubation and length of hospital stay.

MAIN RESULTS

A total of 9011 patients were included (3185 patients who received propofol infusion, and 5826 patients who did not receive propofol infusion) after propensity score matching. The adjusted odds ratio for PONV incidence was 1.03 (95% CI: 0.90, 1.18; p = 0.635) in PACU, and 1.05 (95% CI: 0.90, 1.23; P = 0.50) within 24 h after surgery. The length of hospital stay was 6 h shorter (ratio of means (95% CI) of 0.92, 0.89, 0.94), p < 0.001) and time-to-extubation was 2 min longer (ratio of means 1.24 (1.20, 1.28), p < 0.001) in patients receiving subhypnotic propofol infusion.

CONCLUSIONS

Our study suggests that subhypnotic propofol infusion during general balanced anesthesia is not associated with a reduction in the incidence of PONV during PACU stay and within the first 24 h after surgery. However, it is associated with decreased LOS and increased time-to-extubation, but differences in neither outcome were clinically important.

Subramanya Kumar AVS. Efficacy of palonosetron in the management of postoperative nausea vomiting in oral and maxillofacial surgery

Objective:

The objective is to evaluate the efficacy of prophylactic single intravenous dose of palonosetron in the management of postoperative nausea and vomiting (PONV) following oral and maxillofacial surgical interventions performed through an intraoral approach under general anesthesia (GA).

Materials and Methods:

A prospective study was conducted on 100 subjects who underwent intraoral surgical procedures for the management of maxillofacial trauma, pathology, dentofacial anomalies, and deformities under GA. All subjects received a prophylactic single intravenous dose of 0.075 mg palonosetron along with premedication. Predisposing factors for PONV such as patient age, gender, Apfel risk score, history of motion sickness, smoking, type of procedure, and administration of postoperative opioids were taken into consideration. All the patients were monitored for PONV for the 1^st 24 h postoperatively (PO). First, at an interval of 30 min for 1^st 4 h and then at every 2 h interval for next 8 h followed by monitoring every 6 h interval till 24 h. Time and frequency of rescue medication were noted.

Results:

Seventy-nine percentage subjects did not have PONV. 15% subjects had a single episode of vomiting PO which could be attributed to multiple intra oral surgical sites performed as well as longer duration of exposure to anesthetic agents in addition to providing opioid analgesics for the management of postoperative pain. Only 6% subjects needed rescue antiemetic drug. Palonosetron did not show any significant changes in cardiac status and serum profile.

Conclusion:

Palonosetron is effective in the management of PONV for maxillofacial surgical procedures performed through an intraoral approach under GA.

Patient Selection for Adult Ambulatory Surgery: A Narrative Review

With migration of medically complex patients undergoing more extensive surgical procedures to the ambulatory setting, selecting the appropriate patient is vital. Patient selection can impact patient safety, efficiency, and reportable outcomes at ambulatory surgery centers (ASCs). Identifying suitability for ambulatory surgery is a dynamic process that depends on a complex interplay between the surgical procedure, patient characteristics, and the expected anesthetic technique (eg, sedation/analgesia, local/regional anesthesia, or general anesthesia). In addition, the type of ambulatory setting (ie, short-stay facilities, hospital-based ambulatory center, freestanding ambulatory center, and office-based surgery) and social factors, such as availability of a responsible individual to take care of the patient at home, can also influence patient selection. The purpose of this review is to present current best evidence that would provide guidance to the ambulatory anesthesiologist in making an informed decision regarding patient selection for surgical procedures in freestanding ambulatory facilities.

Prophylactic transdermal scopolamine for the reduction of postoperative length of stay after uterine aspiration at Kaiser Permanente Northern California from 2017-2018

OBJECTIVE

To determine if transdermal scopolamine is associated with decreased postoperative nausea and vomiting and shorter length of stay in the postoperative care unit among patients undergoing uterine aspiration for abortion or early pregnancy loss.

STUDY DESIGN

We conducted a retrospective cohort study at an integrated medical center that initiated a protocol to prescribe transdermal scopolamine to patients undergoing uterine aspiration under moderate sedation. We compared outcomes among patients who underwent uterine aspiration in 2017, before the institution enacted the protocol, with their counterparts in 2018, immediately after the institution instated the protocol. We reviewed patient charts for data on the postoperative length of stay, use of additional antiemetics, and a standardized clinician designated postoperative nausea and vomiting score. We analyzed outcomes by relevant demographic and clinical characteristics using chi-square or Fisher's exact tests for categorical variables and t tests for continuous variables.

RESULTS

The final sample included 386 patients; 228 who did not receive scopolamine and 158 who did. The cohorts were comparable in terms of demographic and clinical characteristics. The cohort that received transdermal scopolamine had a similar mean postoperative length of stay (75.4 ± 54.1 vs 71.1 ± 50.8 minutes; p = 0.43). There were no differences in the proportions of patients who were provided additional antiemetics (26 ± 11.4 vs 17 ± 10.8; p = 0.84) or had transient vomiting and retching (3 ± 1.9 vs 3 ± 1.3; p = 0.69) between the cohorts.

CONCLUSION

We found no evidence that prophylactic transdermal scopolamine reduces postoperative nausea, vomiting, or length of stay among patients undergoing uterine aspiration.

IMPLICATIONS

Among patients who underwent uterine aspiration under moderate sedation, use of prophylactic transdermal scopolamine was not associated with shorter postoperative length of stay or lesser use of antiemetics. Prophylactic transdermal scopolamine is not likely to be useful for patients undergoing uterine aspiration and could be an unnecessary cost.

Development of a recovery-room discharge checklist (SAMPE checklist) for safe handover and its comparison with Aldrete and White scoring systems

Background

The postoperative care transition from the postanesthetic recovery room (PACU) to the common ward or even home discharge represents a critical step of the surgical patients’ handover. Although some systems have been proposed to measure the ability to discharge after an anesthetic-surgical procedure effectively, there is no consensus defining which variables should necessarily be evaluated by these instruments. The instruments routinely used do not evaluate important domains for discharge and are laborious to fill, which compromises the professionals’ adhesion. The objectives are to describe the creation of a new recovery room discharge tool (SAMPE checklist) and determine the degree of agreement of the new tool with two classical scales.

Methods

In a cross-sectional observational study, 997 patients were selected from the general population undergoing a wide range of surgical procedures in a quaternary care hospital. At 90 minutes after leaving the operating room (OR), patients were evaluated and information was collected to fill out the new SAMPE checklist and two other scores (Aldrete and White) to examine the degree of agreement between them.

Results

SAMPE checklist has presented a satisfactory agreement with the White score and lower agreement with Aldrete modified score.

Conclusion

This new instrument, as demonstrated in this study with nearly 1000 patients from different contexts, is easy to apply, has high adhesion potential, and can be considered a new option to formalize the discharge from the recovery room.

Unplanned hospital visits after ambulatory surgical care

Objectives

We sought to assess the rate of unplanned hospital visits among patients undergoing ambulatory surgery.

Summary background data

The majority of surgeries performed in the United States now take place in outpatient settings. Post-discharge hospital visit rates have been shown to vary widely, suggesting variation in surgical or discharge care quality. Complicating efforts to address quality, most facilities and surgeons are unaware of their patients’ hospital visits after surgery since patients may present to a different hospital.

Methods

We used state-level, administrative data from the Agency for Healthcare Research and Quality’s Healthcare Cost and Utilization Project from California to assess unplanned hospital visits after ambulatory surgery. To compare rates across centers, we determined the age, sex, and procedure-adjusted rates of hospital visits for each facility using 2-level, hierarchical, generalized linear models using methods similar to existing Centers for Medicare and Medicaid Services measures.

Results

Among a total of 1,260,619 ambulatory same-day surgeries from 440 surgical facilities, the risk adjusted 30-day rate of unplanned hospital visits was 4.8%, with emergency department visits of 3.1% and hospital admissions of 1.7%. Several patient characteristics were associated with increased risk of unplanned hospitals visits, including increased age, increased number of comorbidities (using the Elixhauser score), and type of procedure (p<0.001).

Conclusions

The overall rate unplanned hospital visits within 30 days after same-day surgery is low but variable, suggesting a difference in the quality of care provided. Further, these rates are higher among specific patient populations and procedure types, suggesting areas for targeted improvement.

Comparison of efficacy between palonosetron-midazolam combination and palonosetron alone for prevention of postoperative nausea and vomiting in patients undergoing breast surgery and patient controlled analgesia: A prospective, randomized, double-blind study: A CONSORT-compliant study

BACKGROUND

Postoperative nausea and vomiting (PONV) is a common complaint in patients following general anesthesia. Various antiemetics, including 5-hydroxytryptamine type 3 (5-HT3) receptor antagonists, are effective but still have limited efficacy. Therefore, combination therapy is preferable to using a single drug alone in high-risk patients. We performed a comparative study on the antiemetic effect of palonosetron, a 5-HT3 receptor antagonist, monotherapy vs palonosetron-midazolam combination therapy for the prevention of PONV.

METHODS

A total of 104 female patients scheduled for breast cancer surgery were enrolled. They were randomly divided into 2 groups, a palonosetron monotherapy group (group P) and palonosetron-midazolam combination therapy group (group PM). Both groups received 0.075 mg palonosetron intravenously after induction of anesthesia. Patient-controlled analgesia (PCA) was applied according to the allocated group. Intravenous (IV)-PCA in group P consisted of fentanyl 20 μg/kg plus normal saline (total volume: 100 ml); IV-PCA in group PM consisted of fentanyl 20 μg/kg plus midazolam 4 mg plus normal saline (total volume: 100 ml). Efficacy parameters were collected during 0 to 1, 1 to 6, 6 to 24, and 24 to 48 hours postoperative time intervals. These measures included complete response (defined as no PONV and no rescue anti-emetic use) rate, incidence of PONV, sedation score, rescue antiemetic use, rescue analgesic use, and numerical rating scale (NRS) for pain. The complete response rate during the 0 to 24 hours interval was analyzed as the primary outcome.

RESULTS

Although the complete response rate between 0 and 24 hours was higher in group PM (42.3% and 48.1% in group P and PM, respectively), there was no statistically significant difference (P = .55). The complete response rates in other time intervals were not different between the 2 groups as well. The sedation score and NRS score also showed no differences between the 2 groups.

CONCLUSIONS

The combination therapy of palonosetron with midazolam did not lead to a greater reduction in the incidence of PONV than monotherapy in patients undergoing breast surgery and receiving IV-PCA containing fentanyl.

Factors Associated With Unanticipated Admission After Outpatient Endoscopic Sinonasal Surgery

OBJECTIVES/HYPOTHESIS

To identify factors that may increase the risk of unplanned admission following elective outpatient endoscopic sinonasal surgery (ESS).

STUDY DESIGN

Retrospective analysis of the National Surgical Quality Improvement Program (NSQIP).

METHODS

All cases of ESS were extracted from the 2010 to 2018 NSQIP database using Current Procedural Terminology codes. Only cases coded as outpatient, elective, and nonemergent procedures were included. Unplanned admissions were defined as cases with a total hospital stay of 1 day or more. Univariate and multivariate analyses were performed to identify variables that independently predicted unanticipated admission.

RESULTS

A total of 971 cases met inclusion criteria, of which 274 (28.2%) were unanticipated admissions. Patients in the unplanned admission group were more likely to be older (46.8 vs. 41.1 years, P < .001), male (57.7% vs. 48.4%, P = .009), obese (54.8% vs. 43.8%, P = .003), and have hypertension (35.0% vs. 25.0%, P = .002). Unplanned admitted patients were also more likely to be included under American Society of Anesthesiologists (ASA) classification III-IV (43.1% vs. 27.2%, P < .001). There were no significant differences in race, smoking, diabetes, or chronic steroid use. Unplanned admitted patients had a higher rate of surgical complications (2.9% vs. 1.0%, P = .041). Upon multivariate analysis, independent preoperative risk factors for unplanned admission included age (OR: 1.018, P = .002), male gender (OR: 1.415, P = .025), obesity (OR: 1.527, P = .008), and ASA III-IV (OR 1.501, P = .018).

CONCLUSIONS

Factors independently associated with unplanned admission following outpatient ESS were older age, male gender, obesity, and higher ASA. Identification of patients at risk may reduce unanticipated hospital admission after ESS.

LEVEL OF EVIDENCE

4 Laryngoscope, 2021.

A Prospective Evaluation of Postoperative Readmissions After Outpatient Hand and Upper Extremity Surgery

Introduction

Hand and upper extremity surgeries are largely performed in free-standing ambulatory surgery centers (ASCs). Rates of unexpected hospitalizations or visits to the urgent care or emergency departments in the month following hand and upper extremity surgery have been widely varied in the literature. We prospectively followed patients after hand and upper extremity outpatient surgery to determine the rate of unplanned health care utilization with the hypothesis that hospital admissions, emergency room visits, and urgent care center visits would be higher than the rates currently reported by retrospective studies.

Methods

All patients undergoing outpatient hand and upper extremity surgery by five hand surgeons were prospectively followed to monitor for hospital readmissions, emergency room visits, and urgent care presentations. The patients’ postoperative course was evaluated for direct transfers from the surgical center to the hospital. In addition, any urgent care or emergency room visits and hospital admissions for the first month after surgery were tabulated. Points of review of the patients’ postoperative course included the following: (1) phone contact on the first postoperative day, (2) routine ASC postoperative phone calls two to three days postoperatively, (3) first postoperative office at approximately one to two weeks, and (4) phone contact or office evaluation one-month postoperatively based on surgeon preference for follow-up.

Results

A total of 583 patients were identified for participation, of whom 22 patients were excluded; thus, 561 patients were included for evaluation, with 47.2% women (n=265) and 52.8% men (n=296). The average age was 54 years (range: 14-102 years). Nine (1.6%) patients presented postoperatively for further evaluation at an urgent care or hospital (95% C.I. 0.8-3.1%). Five patients presented to an emergency room and four patients presented to an urgent care facility. Of those patients, two were admitted to the hospital due to shortness of breath (0.35%; 95% CI: -0.08 to 1.4%). Emergency room and urgent care visits that did not lead to admission accounted for 1.25% (95% CI: 0.6-2.6%). No patients were transferred from the ASC to the hospital or emergency room.

Conclusion

There was a low rate of postoperative utilization of urgent care and emergency room services with hand and upper extremity surgery performed at free-standing, ASCs. Hospital readmissions were rare, and no patients required transfer from an ambulatory care center to the hospital. Outpatient hand and upper extremity surgery is safe in an ambulatory care center, with low postoperative transfers and readmissions in the month following surgery.

Pain evaluation after day-surgery using a mobile phone application

INTRODUCTION

Few studies assess postoperative outcomes after discharge in the ambulatory setting. The aim of this study was to investigate postoperative pain and adverse effects at 24 h and at 7 days after day surgery using an e-health follow-up smartphone-based application named SATELIA®.

MATERIALS AND METHODS

This retrospective, observational and monocentric cohort study was conducted at the University Hospital of Bordeaux. All eligible patients for SATELIA® follow-up between May 2018 and June 2019 were screened for the analysis. Data were extracted from two databases. Those with a missing primary outcome were excluded from the analysis. The main outcome was the worst pain score on POD 1, self-reported via SATELIA®. The secondary outcomes were the incidence of adverse effects on POD1, as well as the worst pain score and adverse effects on POD7. Quantitative data were reported by the median (IQR) and categorical data were presented as absolute numbers (%).

RESULTS

A total of 2283 patients were screened for analysis, from which 592 were excluded due to missing data for the main outcome; 1691 patients were thus finally included. The median worst pain score at POD 1 was 3.0 (1.0-5.0); 35.5% (n = 601/1691) and 29.1% (n = 492/1691) of the patients reported moderate-to-severe pain at POD1 and POD7, respectively.

CONCLUSION

This retrospective study shows that 35.5% of patients experience moderate-to-severe pain after day surgery. Even if SATELIA® should be further developed and evaluated, it also demonstrates the interest of using phone based software to follow patients after discharge and ensure a better personalised management.

Identifying Risks and Opportunities in Outpatient Surgical Patient Safety: A Qualitative Analysis of Veterans Health Administration Staff Perceptions

OBJECTIVES

Little is known about patient safety risks in outpatient surgery. Inpatient surgical adverse events (AEs) risk factors include patient- (e.g., advanced age), process- (e.g., inadequate preoperative assessment), or structure-related characteristics (e.g., low surgical volume); however, these factors may differ from outpatient care where surgeries are often elective and in younger/healthier patients. We undertook an exploratory qualitative research project to identify risk factors for AEs in outpatient surgery.

METHODS

We developed a conceptual framework of patient, process, and structure factors associated with surgical AEs on the basis of a literature review. This framework informed our semistructured interview guide with (1) open-ended questions about a specific outpatient AE that the participant experienced and (2) outpatient surgical patient safety risk factors in general. We interviewed nationwide Veterans Health Administration surgical staff. Results were coded on the basis of categories in the conceptual framework, and additional themes were identified using content analysis.

RESULTS

Fourteen providers representing diverse surgical roles participated. Ten reported witnessing an AE, and everyone provided input on risk factors in our conceptual framework. We did not find evidence that patient race/age, surgical technique, or surgical volume affected patient safety. Emerging factors included patient compliance, postoperative patient assessments/instruction, operating room equipment needs, and safety culture.

CONCLUSIONS

Surgical staff are familiar with AEs and patient safety problems in outpatient surgery. Our results show that processes of care undertaken by surgical providers, as opposed to immutable patient characteristics, may affect the occurrence of AEs. The factors we identified may facilitate more targeted research on outpatient surgical AEs.

The provision of a time-critical elective surgical service during the COVID-19 Crisis: a UK experience

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.

Unplanned Emergency Visits and Admissions After Orthopaedic Ambulatory Surgery in the First 2 Years of Operation of a University Ambulatory Surgery Center

BACKGROUND

Ambulatory surgeries have increased in recent decades to help improve efficiency and cost; however, there is a potential need for unplanned postoperative admission, clinic visits, or evaluation in the emergency department (ED).

PURPOSE/HYPOTHESIS

The purpose was to determine the frequency, reasons, and factors influencing hospitalizations, return to clinic, and/or ED encounters within 24 hours of ambulatory surgery. The time frame for data collection was the first 2 years of operation of a university sports medicine ambulatory surgery center (ASC). We hypothesized that the percentage of encounters would be low and primarily because of pain or postoperative complication.

STUDY DESIGN

Case-control study; Level of evidence, 3.

METHODS

A retrospective review was performed of all patients undergoing ambulatory surgery at an ASC during the first 2 years of its operation (November 2016 to October 2018). Data including age, sex, Current Procedural Terminology code, procedure performed, American Society of Anesthesiologists classification, body mass index, medical history, and tobacco use were collected. Patients seeking care in the ED, inpatient, or outpatient setting within the first 24 hours after surgery were identified and the reasons for these encounters were categorized into 1 of 3 groups: (1) medical complication, (2) postoperative pain, or (3) other postoperative complication. Logistic regression models were used to assess risk factors for these encounters.

RESULTS

A total of 4650 sports medicine procedures were performed at the university ASC during the study period. A total of 35 patients (0.75%) sought additional care within 24 hours of surgery. Medical complications were the primary reason for seeking care (n = 16; 45.7%). Patients who sought treatment within 24 hours of surgery tended to be older, had more medical comorbidities, and were more likely to have undergone upper extremity (particularly shoulder) procedures. In the multivariable analysis, patients with higher ASA scores were more likely to seek additional care (P < .005) and there was a trend toward increased risk of seeking additional care with upper extremity surgery (P = .077).

CONCLUSION

Orthopaedic procedures performed in an ASC result in a relatively low percentage of patients seeking additional care within the first 24 hours after surgery, consistent with other reports in the literature. Upper extremity procedures, particularly those of the shoulder, may carry an increased risk of requiring medical treatment within 24 hours of surgery. Even in the first 2 years of operation of a university-based ASC, low rates of postoperative complications and unplanned admissions can be maintained.

Acute Pain Management of Chronic Pain Patients in Ambulatory Surgery Centers

PURPOSE OF REVIEW

With the widespread growth of ambulatory surgery centers (ASCs), the number and diversity of operations performed in the outpatient setting continue to increase. In parallel, there is an increase in the proportion of patients with a history of chronic opioid use and misuse undergoing elective surgery. Patients with such opioid tolerance present a unique challenge in the ambulatory setting, given their increased requirement for postoperative opioids. Guidelines for managing perioperative pain, anticipating postoperative opioid requirements and a discharge plan to wean off of opioids, are therefore needed.

RECENT FINDINGS

Expert guidelines suggest using multimodal analgesia including non-opioid analgesics and regional/neuraxial anesthesia whenever possible. However, there exists variability in care, resulting in challenges in perioperative pain management. In a recent study of same-day admission patients, anesthesiologists correctly identified most opioid-tolerant patients, but used non-opioid analgesics only half the time. The concept of a focused ambulatory pain specialist on site at each ASC has been suggested, who in addition to providing safe anesthesia, could intervene early once problematic pain issues are recognized. This review focuses on perioperative pain management in three subsets of patients who exhibit opioid tolerance: those on large doses of opioids (including abuse-deterrent formulations) for chronic non-malignant or malignant pain; those who have ongoing opioid misuse; and those who were prior addicts and are now on methadone/suboxone maintenance. We also discuss perioperative pain management for patients who have implanted devices such as spinal cord stimulators and intrathecal pain pumps.

Preoperative oral carbohydrate loading: Effects on intraoperative blood glucose levels, post-operative nausea and vomiting, and intensive care unit stay

Background and Aims:

Material and Methods:

Results:

Conclusion:

Unplanned hospital admission after ambulatory surgery: a retrospective, single cohort study

PURPOSE

We estimated the rate of unplanned hospital and intensive care unit (ICU) admissions following ambulatory surgery centre (ASC) procedures, and identified factors associated with their occurrence.

METHODS

This retrospective cohort included adult patients who underwent ASC procedures within a large community practice from January 2010 to December 2014. Patients were categorized into two groups: unplanned postoperative hospital/ICU admission within 24 hr of procedure or uneventful discharge. Demographics, comorbidities, anesthesia type, procedure type, procedure group, and ASC facility were assessed.

RESULTS

Of the 211,389 patients included, there were 211,147 uneventful discharges (99.89%) and 242 unplanned hospital admissions (0.11%), of which 75 were ICU admissions (0.04%). The multivariable logistic regression model for hospital admission showed an increased risk associated with age > 50 yr (odds ratio [OR], 1.53); American Society of Anesthesiologists (ASA) physical status (III vs II: OR, 1.45; IV vs II: OR, 1.88), comorbidity (chronic obstructive pulmonary disease: OR, 2.63; diabetes mellitus: OR, 1.62; transient ischemic attack: OR, 2.48) procedure (respiratory: OR, 2.92; digestive: OR, 2.66; musculoskeletal system: OR, 2.53), anesthetic management (general anesthesia [GA] and peripheral nerve block vs GA: OR, 1.79), and ASC facility (189BB: OR, 2.29; 30E9A: OR, 7.41; and BD21F: OR, 1.69). The multivariable logistic regression model for ICU admission showed increased risk of unplanned ICU admission associated with ASA physical status (ASA III vs II: OR, 3.0; ASA IV vs II: OR, 8.52), procedure (musculoskeletal system: OR, 2.45), and ASC facility (00E6C: OR, 3.14; 189BB: OR, 2.77; 30E9A: OR, 2.59; and BD21F: OR, 3.71).

CONCLUSION

While a small percentage of adult patients who underwent ASC procedures required unplanned hospital admission (0.07%), approximately one-third of these admissions were to the ICU (0.04%). Facility was at least as strong a predictor of hospital admission as the patient- and/or procedure-specific variables.

Unplanned hospital admission after ambulatory surgery: a retrospective, single cohort study

PURPOSE

We estimated the rate of unplanned hospital and intensive care unit (ICU) admissions following ambulatory surgery centre (ASC) procedures, and identified factors associated with their occurrence.

METHODS

This retrospective cohort included adult patients who underwent ASC procedures within a large community practice from January 2010 to December 2014. Patients were categorized into two groups: unplanned postoperative hospital/ICU admission within 24 hr of procedure or uneventful discharge. Demographics, comorbidities, anesthesia type, procedure type, procedure group, and ASC facility were assessed.

RESULTS

Of the 211,389 patients included, there were 211,147 uneventful discharges (99.89%) and 242 unplanned hospital admissions (0.11%), of which 75 were ICU admissions (0.04%). The multivariable logistic regression model for hospital admission showed an increased risk associated with age > 50 yr (odds ratio [OR], 1.53); American Society of Anesthesiologists (ASA) physical status (III vs II: OR, 1.45; IV vs II: OR, 1.88), comorbidity (chronic obstructive pulmonary disease: OR, 2.63; diabetes mellitus: OR, 1.62; transient ischemic attack: OR, 2.48) procedure (respiratory: OR, 2.92; digestive: OR, 2.66; musculoskeletal system: OR, 2.53), anesthetic management (general anesthesia [GA] and peripheral nerve block vs GA: OR, 1.79), and ASC facility (189BB: OR, 2.29; 30E9A: OR, 7.41; and BD21F: OR, 1.69). The multivariable logistic regression model for ICU admission showed increased risk of unplanned ICU admission associated with ASA physical status (ASA III vs II: OR, 3.0; ASA IV vs II: OR, 8.52), procedure (musculoskeletal system: OR, 2.45), and ASC facility (00E6C: OR, 3.14; 189BB: OR, 2.77; 30E9A: OR, 2.59; and BD21F: OR, 3.71).

CONCLUSION

While a small percentage of adult patients who underwent ASC procedures required unplanned hospital admission (0.07%), approximately one-third of these admissions were to the ICU (0.04%). Facility was at least as strong a predictor of hospital admission as the patient- and/or procedure-specific variables.

Unplanned admission after ambulatory anaesthesia in France: analysis of a database of 36,584 patients

BACKGROUND

Unplanned admission (UA) after ambulatory procedures is an unexpected event that has organisational and financial impacts. This study was undertaken to determine the current rate of UA in France and to evaluate the factors associated with the occurrence of this event.

METHOD

This is a retrospective analysis of a database of 36,584 patients issued from a private hospital in France. This study received an IRB approval. All of the patients that received ambulatory anaesthesia between April 2015 and June 2017 were included in this database.

RESULTS

The overall rate of UA was 1.8% (95%CI: 1.3-2.3]. Hospitalisation after endoscopic procedures (gastrointestinal endoscopy and bronchial fibroscopy) was 1.1% (95%CI: 0.3-1.9), whereas it was 2.5% (95%CI: 1.8-3.2) after surgical procedures (p < 0.01). Organisational concerns, medical reason and surgical complications accounted respectively for one third of the hospitalisations. Pain was liable in 13% of cases, whereas PONV, residual sedation and urinary retention accounted respectively for 6.9%, 2.8% and 2.6% of cases. In a multivariate analysis, age > 60 years, ASA status > 2, general anaesthesia and the type of the procedures were identified risk factors.

CONCLUSIONS

In this large cohort of ambulatory patients, the rate of UA remains significant. This is probably related, at least partly, to more invasive procedures scheduled in ambulatory setting. However, organisational problems occurred still frequently. Some factors appear to be easily improvable by appropriate preoperative information, better operating theatre scheduling and better analgesic strategy.

Socioenvironmental criteria and postoperative complications in ambulatory surgery in a French university hospital: a prospective cross-sectional observational study

BACKGROUND

Ambulatory surgery lowers hospitalisation costs, shortens the time to return to work but requires caution regarding socioenvironmental risk factors for complications and rehospitalisation.

METHODS

This was a single-centre prospective cross-sectional observational study conducted in a university hospital centrein January 2017. The primary objective was to assess the rate of conversion from ambulatory surgery to conventional hospitalisation or emergency department visit within 30 days following discharge from ambulatory unit. Secondary objectives were to describe the socioenvironmental characteristics of outpatients and to identify risk factors for severe postoperative complications.

RESULTS

598 outpatients were included. The most represented surgical specialties were ophthalmology (23.5%), gynaecology (19%) and orthopaedics (17.7%). Patients' mean age was 50.8 years (SD, 19.8) and the male/female sex ratio was 0.68. There were 22 (3.68%, 95% CI 2.32% to 5.52%) severe complications, including 11 (1.84%, 95% CI 0.92% to 3.27%) conversions to conventional hospitalisation and 11 (1.84%) conversions to emergency department visit, 3 of which led to readmission. Regarding socioenvironmental characteristics, 116 outpatients (19.7%) lived alone but were not isolated and 15 (2.6%) lived alone and were socially isolated. Following ambulatory surgery, 9 outpatients (1.6%) returned home on foot, 20 (3.4%) by public transportation and 8 (1.4%) drove home; 133 outpatients (13.7%) were alone the first night following surgery. Severe complication rates were not significantly different according to socioenvironmental subgroups.

CONCLUSION

In our study, the prevalence of severe complications was low, conforming to the literature. The study was underpowered to estimate the effect of socioenvironmental variables.

Management of Ambulatory Anesthesia in Older Adults

The number of older patients is increasing globally. Combined with the growing number of ambulatory surgeries, many older patients will undergo ambulatory surgery in the future. The ambulatory setting offers many advantages: early mobilization, higher patient satisfaction, lower costs, and a low incidence of several complications such as infections and thromboembolic events. Moreover, cognitive recovery seems to be enhanced compared with in-hospital surgery, and both frail patients and patients with dementia can benefit from ambulatory surgery. This review provides suggestions for managing perioperative anesthesia for older patients in the ambulatory setting. Not all older patients are eligible for ambulatory surgery, and clinicians must be aware of risk factors for complications, especially frailty. Most anesthesia techniques and agents can be used in the ambulatory setting, but short-acting agents are preferred to ensure fast recovery. Both regional and general anesthesia are useful, but clinicians must be familiar with the physiological changes and specific implications in the older population. The older patients are more sensitive to anesthetic agents, meaning that a lower dose is needed to obtain the desired effect. However, they exhibit huge variation in pharmacodynamics and pharmacokinetics. Prolonged onset time may lead to overdosing and extended recovery. After surgery, effective pain management with opioid minimization is essential to ensure rapid recovery.

Efficiency of Text Message Contact on Medical Safety in Outpatient Surgery: Retrospective Study

BACKGROUND

Establishing pre- and postoperative contact with patients is part of successful medical management in outpatient surgery. In France, this is mostly done via telephone. Automated information with short message service (SMS) reminders might be an interesting alternative to increase the rate of compliance with preoperative instructions, but no study has shown the safety of this approach.

OBJECTIVE

The objective of this study was to evaluate the impact of pre- and postoperative automated information with SMS reminders on medical safety in outpatient surgery.

METHODS

We conducted a retrospective, single-center, nonrandomized, controlled study with a before-after design. All adult patients who had outpatient surgery between September 2016 and December 2017 in our university hospital center were included. Before April 2017, patients were contacted by telephone by an outpatient surgery nurse. After April 2017, patients were contacted by SMS reminder. All patients were contacted the day before and the day after surgery. Patients contacted by SMS reminder were also contacted on day 7 after surgery. The primary end point was the conversion rate to full-time hospitalization. Secondary end points were hospitalization causes (anesthetic, surgical, organizational) and hospitalization costs.

RESULTS

A total of 4388 patients were included, 2160 before and 2228 after the introduction of SMS reminders. The conversion rate to full-time hospitalization was 34/4388 (0.77%) with a difference between SMS group (8/2228, 0.36%) and telephone group (26/2160, 1.20%). The cost of SMS reminders was estimated as half that of telephone calls.

CONCLUSIONS

In this work, we report a decrease in the rate of conversion to full-time hospitalization with the use of pre- and postoperative SMS reminders. This new approach could represent a safe and cost-effective method in an outpatient surgery setting.

Policy Implications for the COVID-19 Pandemic in Light of Most Patients (≥72%) Spending at Most One Night at the Hospital After Elective, Major Therapeutic Procedures

A large number of inpatients with Coronavirus disease 2019 (COVID-19) in some regions of the United States may interfere with the ability of hospitals to take care of patients requiring treatment for other conditions. Nonetheless, many patients need surgery to improve their quality of life and to prevent deterioration in health. Curtailment of services also negatively affects the financial health of hospitals and health systems. Broad policies to prohibit all "elective" surgical procedures to ensure that there is sufficient hospital capacity for pandemic patients may be unnecessarily restrictive because, for many such procedures, patients are rarely admitted following surgery or only stay overnight. We studied all elective inpatient and ambulatory cases involving major therapeutic procedures performed in the state of Florida in 2018. We mapped the primary procedure to the corresponding Clinical Classification Software (CCS) category. We determined the distributions of lengths of stay overall and as stratified by CCS category, then calculated the percentage of cases that had a hospital length of stay of ≤1 night (i.e., 0 or 1 day). A threshold of one night was selected because patients discharged home on the day of surgery have no effect on the inpatient census, and those staying overnight would either have a transient effect or no effect if observed overnight in the postoperative care unit. Among the 1,852,391 elective cases with one or more major therapeutic procedures, 65.2% (95% lower confidence limit [LCL] = 65.1%) of cases had a length of stay of 0 days and 72.9% (95% LCL = 72.8%) had stay ≤1 day. There were 38 different CCS categories for which at least 95% of patients had a length of stay of ≤1 day. There were 28 CCS codes that identified 80% of the patients who were discharged with a length of stay ≤1 day, showing representation of multiple surgical specialties. Our results show that even in the face of constraints imposed by a high hospital census, many categories of major therapeutic elective procedures could be performed without necessarily compromising hospital capacity. Most patients will be discharged on the day of surgery. If overnight admission is required, there would be an option to care for them in the postanesthesia care unit, thus not affecting the census. Thus, policies can reasonably be based on allowing cases with a substantial probability of at most an overnight stay rather than a blanket ban on "elective" surgery or creating a carve-out for specified surgical subspecialties. Such policies would apply to at least 72% of elective, major therapeutic surgical procedures.

Epidural Naloxone Attenuates Fentanyl Induced PONV in Patients Undergoing Lower Limb Orthopaedic Surgeries. a Prospective Randomized Double-Blind Comparative Study

Background and aim

Epidural administration of opioids with local anaesthetics is a popular choice for perioperative pain relief. But opioid induced side effects limit their use for postoperative analgesia. Hence, this study was designed to evaluate the effectiveness of epidural naloxone, an opioid receptor antagonist, in reducing PONV in patients receiving epidural fentanyl.

Methods

After obtaining the Institutional Ethics Committee approval and written informed consent, 46 patients, between 18–80 years, of either sex, with ASA physical status 1–3, undergoing lower limb orthopaedic surgeries were enlisted for this prospective, randomized, double blind comparative study. Subjects were allocated to one of the two groups and received epidurally, either fentanyl with bupivacaine (Group C, n = 23) or fentanyl with bupivacaine and naloxone 2 mcg (Group N, n = 25), for reducing postoperative pain. PONV score and Wong Bakers Scale (WBS) for pain score were recorded at 6, 12 and 18hrs, postoperatively.

Results

All patients were comparable with respect to age, gender, ASA PS, height, body weight as well as duration of surgery. A statistically significant decrease in PONV score was observed in Group N at 6 and 12 hours, postoperatively. The patients who required rescue antiemetic were also significantly lower in Group N at 6 and 12 hours. The mean WBS score for pain also showed significant reduction in Group N at 6 hours, postoperatively.

Conclusion

Concomitant use of low dose epidural naloxone and fentanyl is effective in attenuating PONV, besides enhancing analgesia in the earlypostoperative period.

Association Between Race and Ethnicity with Intraoperative Analgesic Administration and Initial Recovery Room Pain Scores in Pediatric Patients: a Single-Center Study of 21,229 Surgeries

INTRODUCTION

Perioperative pain may have deleterious effects for all patients. We aim to examine disparities in pain management for children in the perioperative period to understand whether any racial and ethnic groups are at increased risk of poor pain control.

METHODS

Medical records from children ≤ 18 years of age who underwent surgery from May 2014 to May 2018 were reviewed. The primary outcome was total intraoperative morphine equivalents. The secondary outcomes were intraoperative non-opioid analgesic administration and first conscious pain score. The exposure was race and ethnicity. The associations of race and ethnicity with outcomes of interest were modeled using linear or logistic regression, adjusted for preselected confounders and covariates. Bonferroni corrections were made for multiple comparisons.

RESULTS

A total of 21,229 anesthetics were included in analyses. In the adjusted analysis, no racial and ethnic group received significantly more or less opioids intraoperatively than non-Hispanic (NH) whites. Asians, Hispanics, and Pacific Islanders were estimated to have significantly lower odds of receiving non-opioid analgesics than NH whites: odds ratio (OR) = 0.83 (95% confidence interval (CI): 0.70, 0.97); OR = 0.84 (95% CI: 0.74, 0.97), and OR = 0.53 (95% CI: 0.33, 0.84) respectively. Asians were estimated to have significantly lower odds of reporting moderate-to-severe pain on awakening than NH whites: OR = 0.80 (95% CI: 0.66, 0.99).

CONCLUSIONS

Although children of all races and ethnicities investigated received similar total intraoperative opioid doses, some were less likely to receive non-opioid analgesics intraoperatively. Asians were less likely to report moderate-severe pain upon awakening. Further investigation may delineate how these differences lead to disparate patient outcomes and are influenced by patient, provider, and system factors.

Root causes of extended length of stay and unplanned readmissions after orthopedic surgery and hand surgery: a retrospective observational cohort study

Background

While previous studies have evaluated the effect of some patient characteristics (e.g. gender, American Society of Anesthesiologists (ASA) class and comorbidity) on outcome in orthopedic and hand day surgery, more detailed information on anesthesia related factors has previously been lacking. Our goal was to investigate the perioperative factors that affect overstay, readmission and contact after day surgery in order to find certain patient profiles more prone to problemed outcomes after day surgery.

Methods

We examined orthopedic and hand day surgery at an orthopedic day surgery unit of Helsinki University Hospital. Patient data of all adult orthopedic and hand day surgery patients (n = 542) over a 3-month period (January 1 – March 31, 2015) operated on at the unit were collected retrospectively using the hospital’s surgery database. These data comprised anesthesia and patient records with a follow-up period of 30 days post-operation. Patients under the age of 16 and patients not eligible for day surgery were excluded. Patient records were searched for an outcome of overstay, readmission or contact with the emergency room or policlinic. Pearson chi-square test, Fischer’s exact test and multivariable logistic regression were used to analyze the effect of various perioperative factors on postoperative outcome.

Results

Various patient and anesthesia related factors were examined for their significance in the outcomes of overstay, readmission or contact. Female gender (p = 0.043), total amount of fentanyl (p = 0.00), use of remifentanil (p = 0.036), other pain medication during procedure (p = 0.005) and administration of antiemetic medication (p = 0.048) emerged as statistically significant on outcome after day surgery.

Conclusions

Overstay and readmission in orthopedic and hand day surgery were clearly connected with female patients undergoing general anesthesia and needing larger amounts of intraoperative opioids. By favoring local and regional anesthesia, side effects of general anesthesia, as well as recovery time, will decrease.

Day Surgery Program at West China Hospital: Exploring the Initial Experience

Healthcare facilities in China are facing increasing demands as the country has the fastest aging populations in the world. Day surgery can be utilized to address some of these demands. Benefits of day surgery include shortened hospital stay, decreased risk of hospital-associated infections, and increased cost efficiency. We present a retrospective study of eight years of day surgery data from West China Hospital, one of the largest hospitals in China, with an emphasis on an examination of the growth in day surgeries. We examined patterns of utilization of day surgery versus inpatient surgery (including types of surgeries performed in the Day Surgery Center and the ratio of day surgery versus elective surgery), as well as unplanned readmission and return to inpatient department rates, and a comparison of average costs and length of stay for day surgery versus hospital surgery.

Day surgery has a safe and cost-effective way to alleviate the soaring healthcare demands in West China. There is potential opportunity to further address the ever-increasing demands on the healthcare system in this area by performing more complex surgeries as day surgeries. This article presents an effective organizational protocol and proposes a reliable medical quality assurance system, which prioritizes safety of the growing day surgery program; furthermore, it describes the factors and lessons learned from the successful implementation of a day surgery system.

Functional status as a marker of need for hospital admission following outpatient hernia repair

INTRODUCTION

The careful selection of patients for hernia repair in ambulatory surgery centres is critical to prevent unanticipated inpatient admissions. The aim of this study was to evaluate risk factors associated with inpatient admission.

METHODS

A multivariable logistic regression was performed utilising the ACS NSQIP database from 2007 to 2016. The primary outcome was same-day hospital discharge. The primary exposure variable was preoperative functional status. Additional covariates included sex, obesity, age, smoking status, steroid use, dyspnoea, diabetes mellitus, chronic obstructive pulmonary disease, congestive heart failure, hypertension, bleeding disorder, dialysis-dependence and American Society of Anesthesiologists classification score.

RESULTS

A total of 194,822 patients underwent hernia repair in the outpatient setting; 8705 (4.5%) required hospital admission. The variables with the most significantly increased odds for hospital admission were partially dependent and totally dependent preoperative functional status.

CONCLUSION

A non-independent baseline functional status is the strongest predictor of need for admission following outpatient hernia repair.

Efficacy and Safety of a Surgeon-Performed Laparoscopic-Guided, 4-point Transversus Abdominis Plane Block: A retrospective review

We performed a retrospective chart review from October 2017 to March 2019 to demonstrate the safety and efficacy of a surgeon-performed, laparoscopically guided, transversus abdominis plane (TAP) blocks for robot-assisted gynecologic procedures. A total of 116 patients who underwent robot-assisted gynecologic surgery, at 1 academic hospital, with administration of a 4-point TAP block were included. A 4-point TAP block was performed under laparoscopic visualization, by the same surgeon, after induction of anesthesia and immediately after placement of the laparoscope. Liposomal bupivacaine (20 mL) and 0.5% bupivacaine (20 mL) mixed with saline were used as the injectant. All information from the surgical admission and the postoperative follow-up were reviewed. Data were presented in our descriptive study. A total of 116 patients were included with a mean age of 40.6 years (19-80 years) and a mean body mass index of 30.6 kg/m² (17.2-53.3 kg/m²). Of the patients, 70.7% were discharged to home on the day of surgery. Of the 29.3% of patients who were admitted, 20.6% were admitted because of pain control. Those who were admitted for pain control comprised 6.0% of the total of all study participants. There were no adverse events in our cohort and no readmissions because of pain control. A surgeon-performed TAP block, under laparoscopic visualization, is a safe and efficacious intervention to reduce postoperative pain and may add to a multimodal approach for enhanced recovery protocols.