Welcome to SAMBA - The Society for Ambulatory Anesthesia

Surgical Techniques and Clinical Practice Management

Oral Presentations

O-1

AMBULATORY THYROIDECTOMY IS A SAFE AND FEASIBLE OPTION IN A DISTRICT GENERAL HOSPITAL SETTING IN THE UNITED KINGDOM

Taleb A. Jeddy*, Veerasiri Punchihewa, Shay Tinloi. ¹Department of General and Endocrine Surgery* and Anaesthesiology, Basildon Hospital, Basildon, Essex SS16 5NL, United Kingdom.

AIMS

To assess the safety and feasibility of ambulatory thyroidectomy on selected patients in a prospective study.

METHODS

Patients requiring thyroid surgery with a reliable carer at home, who understood the procedure and able to comply with the post operative care, were offered same day surgery. The operative technique was standard with few modifications. Between December 2001 and January 2003 thirty-two operations on twenty-eight patients were successfully performed as ambulatory cases.

RESULTS

The patients were admitted in the morning of operation and discharged 6 to 8 hours after surgery. All patients were under 70 years of age (Range 23 - 70) with an ASA grade of less than three. Female: Male ratio was 24:4. Twenty-two patients underwent a lobectomy, four of these patients required a second operation of completion thyroidectomy. Six patients had total thyroidectomy. None required readmission. Post-operative analgesia usage and pain score showed a decreasing profile and return to normal in three days.

CONCLUSION

Ambulatory thyroidectomy is feasible and safe in selected patients and has the added advantage of convenience with substantial cost savings to health care.

O-2

MINIMAL CARBONDIOXIDE INSUFFLATION FOR LAPARASCOPIC TUBAL STERILIZATION. A QUALITY REGISTRATION STUDY

Bjarne Finnerup,¹ Annelise Bove Rud,¹ Kirsten Wagner Engsig,¹ Ulla Grantzau,¹ John Wagner Engsig.¹ ¹Anesthetic/Surgical Department, Aeroe Hospital of Funen, DK-5970 Aeroeskoebing, Funen, Denmark.

BACKGROUND: Minimal invasive surgery is preferred in outpatient surgery, allowing rapid resumption of normal activity. Postoperative pain and nausea are the most important factors, delaying patients in resuming their normal activities in outpatient surgery. The use of multimodal pain management may improve this outcome¹. The amount of insufflated carbondioxid is a factor involved in postoperative pain. The aim of this study was to measure postoperative pain during minimal carbondioxid insufflation technique for laparascopic sterilization.

METHODS: Twenty consecutive females were included after informed consent. ASA group 1-3 were included.

Body mass index > 30 were excluded. Anaesthesia: Propofol/remifentanil, oxygen in air, laryngeal mask and controlled ventilation. Paintreatment standardizes with ibuprofen 800 mg x 3. Fentanyl 50 mikrogram iv and proparacetamol 2000 mg iv if VAS score › 3. Surgical techniques: Local infiltration with bupivakain 2.5 mg/ml in infraumbilical incision. Introduction of uterine grasping forceps (Schacke) via vagina. Introduction of single use Trocar (Johnson and Johnson) via infraumbilical incision. Placement of the trocar is secured with the laparoscope before insufflation of carbondioxide. After placement of patient in head down position (Trendelenburg) insufflation is performed until exposure of operating field is good. Filchie-clips cremed with local anaesthesia on right and left salpinx. After securing clips position, and before placement of patient i normal position, exufflation of carbondioxide is performed. After removal of trocar, the wound is closed with dexon in fascie and novafil in skin. Uterin grasping forceps is removed.

RESULTS: All included patients returned the questionnarie. Height 167 cm (159-173)² and weight 65 kg (54-88). Duration of anaesthesia: 32 min (20 - 50), Duration of surgery: 11 min (4-22) carbondioxide amount: 0.85 L (0.30-5.0), fentanyl iv: 70 mikrogram (0-350), proparacetamol iv 900 mg (0-2000), 10 % (2 patients) received ondansetron in the postoperative period. No patients received opioids after discharge. Ibuprofen 800 mg max x 3 and/or paracetamol 1 gram max x 4 were used after discharge as shown in Fig 1. VAS-score preoperative and until day 7 are shown in Fig 2. There were no major complication but one patient had a wound infection and one patient complained of a distended abdomen postdischarge. CONCLUSION: Minimmal carbondioxide insufflation during laparascopic sterilization seems promising in minimizing postoperative pain.

References: ¹ Current opinion in Anaesthesiology 1997:408

² All values in ( ) are 0 - 100 %

Anesthesia Techniques and Clinical Management

Oral Presentations

O-3

LOCAL ANESTHETIC FIELD BLOCK WITH PERIOPERATIVE ROFECOXIB REDUCES PAIN AFTER OUTPATIENT OPEN INGUINAL HERNIA REPAIR - TOP

D. J. Pavlin, E. G. Pavlin, K. Horvath, L. Amundsen, K. Roesen. ¹Department of Anesthesiology, University of Washington School of Medicine, Seattle, WA, United States.

Introduction Inguinal hernia repair is most often performed at our institution under general anesthesia with local anesthetic wound infiltration at the end of surgery. Pain after surgery is treated by intravenous fentanyl, and an oral opioid/acetaminophen combination (oxycodone 5mg/acetaminophen 325mg) (O/A) as needed after discharge. This study was done to determine whether local anesthetic infiltration before incision, with or without an anti-inflammatory (rofecoxib) before and after surgery, would provide more effective pain relief than the standard regimen.

Methods The study was approved by the local IRB, and all patients consented to participate. Patients undergoing outpatient open inguinal hernia repair (n=75) under general anesthesia were randomly assigned to receive: GROUP (1) 10ml subfascial local anesthetic infiltration at the end of surgery (LAES); GROUP (2) a field block with 40ml of local anesthetic before surgery (LABS) and 10ml at the end of surgery (LAES); GROUP (3) rofecoxib 50mg p.o. 30 minutes before surgery and daily for 5 days after surgery plus LABS and LAES. Groups 1 and 2 received a placebo instead of rofecoxib at comparable times. The local anesthetic used was 1% lidocaine/0.5% bupivacaine (1:1). Anesthetic technique was standardized. Postoperative pain was treated by fentanyl i.v. and by O/A before and after discharge. Patients reported pain on a scale of 0 to 10 and satisfaction with analgesia on a scale of 1 to 6 in the recovery unit (PACU) before discharge, and at 24 hours, 48 hours, and 7 days after discharge. Analgesic use was tabulated. Distress related to pain and other side effects was rated on a scale of 0-5 (0=absent, 5=as bothersome as could be imagined). Patients, nurses, and study personnel were blinded to group assignment. Outcomes in Group 2 and Group 3 were compared to Group 1 by unpaired t test or Mann Whitney.

Results are shown in the table. Pain scores, opioid use, and symptom distress scores related to pain were significantly reduced in the first 24-48 hours after surgery in Group 3 compared to Group 1. This correlated with decreased recovery time, and increased satisfaction. Patients in Group 2 initially had less severe pain compared to Group 1, but this effect only persisted for 60-90 minutes.

Conclusions We conclude that pretreatment with a field block and rofecoxib, continued into the postoperative period (Group 3), provides pain relief superior to the standard regimen for up to 48 hours after surgery (Group 1). Field block alone before surgery (Group 2) was associated with transient improvement of 60-90 minutes duration.

	Group 1	Group 2	Group 3
Local anesthetic	LAES	LABS, LAES	LABS, LAES
Rofecoxib/placebo	placebo	placebo	rofecoxib
Duration of pain >3/10 (min)	64(12)	48(12)*	27(8)*
Pain scores (0-10)
PACU 15"	4.3(0.5)	2.6(0.5)*	1.9(0.5)***
PACU 60"	4.3(0.5)	2.7(0.4)*	2.2(0.4)**
PACU 90"	3.0(0.4)	3.0(0.4)	1.0(0.3)*
PACU maximum	5.3(0.5)	4.3(0.5)	3.7(0.5)*
24 h maximum	6.7(0.4)	7.0(0.3)	5.3(0.6)*
48 h maximum	5.2(0.6)	5.0(0.7)	4.2(0.6)
Analgesic use
PACU fentanyl (mg)	69(11)	49(12)	34(8)**
24 h O/A # doses	6.8(0.5)	7.3(0.6)	4.9(0.8)*
48 h O/A # doses	6.2(1)	5.5(0.8)	5.0(1.1)
Satisfaction (1-6)
in hospital	5.6(0.1)	5.8(0.1)	6.0(0.1)*
at home	4.9(0.2)	4.9(0.2)	5.5(0.1)*
Pain distress score (0-5)
24 h	3.3(0.2)	3.4(0.2)	2.3(0.2)***
48 h	2.9(0.2)	2.9(0.3)	2.0(0.3)*
Recovery stay (min)	175(10)	159(14)	148(7)**

All values are mean (SE); *p<.05; **p<.01; ***p<.001

O-4

COMPARISON OF THE COSTS AND EFFICACY OF PROPHYLACTIC ONDANSETRON AND DOLASETRON IN PREVENTING PEDIATRIC POSTOPERATIVE VOMITING - TOP

Mehernoor F. Watcha,¹ Olutoyin Olutoye,¹ Ellen C. Jantzen,¹ Lisa M. Fazi,¹ Mark S. Schreiner.¹ ¹Anesthesiology & Critical Care Medicine, Children’s Hospital of Philadelphia, Philadelphia, PA, United States.

Introduction: Postoperative vomiting (POV) after ambulatory surgery remains a major problem¹. This study was designed to determine the lowest dose of dolasetron equivalent to the FDA approved dose of ondansetron 100 mg/kg IV, for the prophylaxis of POV in children undergoing surgery ².

Methods: We enrolled 204 healthy ASA 1 –2 children aged 2-12 years of age, undergoing superficial ambulatory (Day –Case) surgery in this double-blind study after obtaining IRB approval and written informed consent from their parents. Subjects were randomized to receive either ondansetron 100 mg/kg IV, or dolasetron 45, 175, 350 or 700 mg/kg, IV during a standardized anesthetic and postoperative pain management regimen. Demographic data, duration of anesthesia and surgery, times to awakening, achieving preset discharge criteria, use of rescue analgesic and antiemetic drugs and the incidence of postoperative emesis were recorded. Phone calls were made at 24 hours and 5 days after surgery to determine the incidence of post-discharge emesis, recovery characteristics and satisfaction. The primary end-point was the incidence of complete response, defined as the absence of POV symptoms. Costs were calculated from the perspective of the Surgicenter using a previously described model.³ Power analysis was based on a test for trends across proportions (logistic model) assuming a success rate of 70% and 40% with the most and least effective dose respectively, alpha=0.05 and power of 80%. P values of <0.05 were considered statistically significant.

Results: There were no significant differences between the study groups in demographic data, patients with previous POV or motion sickness, surgical procedure, duration of surgery and anesthesia or times to achieving discharge readiness. The incidence of early (0-6 hr), 24 hour and repeated (³ 2 episodes) emesis were higher in the dolasetron 45 mg/kg group compared to the dolasetron 350 and 700 mg/kg groups and to the ondansetron group. There were no significant differences in the emesis rates between the dolasetron 350 and 700 mg/kg groups or between these groups and the ondansetron 100 mg/kg group. There were no significant differences in the early and 24 hr emesis rates between the dolasetron 175 mg/kg group and the other 4 groups. However, repeated emesis occurred more frequently in the dolasetron 45 mg/kg and 175 mg/kg groups compared to the other 3 groups. There were no differences in the side effect profile. Institutional costs for managing POV were lower with dolasetron 350 mg/kg compared to ondansetron 100 mg/kg.

Conclusions: Dolasetron, 350 mg/kg, was the lowest dose that had an acceptable equivalent efficacy in preventing POV and achieving patient satisfaction compared to ondansetron 100 mg/kg. Institutional costs for managing POV were lower when POV prophylaxis was provided by dolasetron 350 mg/kg than ondansetron. If prophylaxis of POV is indicated in this patient population, dolasetron 350 mg/kg should be used.

References: (1) Rose JB, Watcha MF: BJA 1999; 83: 104-117 (2) Package insert Zofran® (3) Zarate et al: Anesth Analg 2000; 90: 1352-8

Early and 24 hr complete response (CR) rates, repeated POV incidence, mean costs ± SD and satisfaction scores
Dose	N	Early CR	24 hr complete response	Repeated POV	Mean ± SD of POV related costs in US $	Satisfaction Scores
Dolasetron 45mg/kg	35	54%†	47%†	25%†	1.10 ± 1.82 †	8.1 ± 3.3
Dolasetron 175mg/kg	32	72%	68%	22%†	3.00 ± 2.01 * †	9.0 ± 1.8 *
Dolasetron 350mg/kg	31	87%*	73%*	3% * §	6.13 ± 3.13 * †	9.2 ± 2.0 *
Dolasetron 700mg/kg	37	78% *	73%*	3% * §	12.28 ± 4.96 *†§	9.4 ± 1.9 *
Ondansetron 100mg/kg	69	80%*	78%*	9% * §	9.43 ± 3.34 *§	9.6 ± 0.9 *

* P<0.05 vs. dolasetron 45 mg/kg, †P<0.05 vs. ondansetron 100mg/kg, § P<0.05 vs. dolasetron 175 mg/kg

O-5

LOW DOSE BOLUS OF PROPOFOL AT THE END OF AMBULATORY SURGERY IN HIGH RISK PATIENTS POSTPONES PONV AND SHIFTS COSTS - TOP

Arpad I. Kormos, Jeno P. Marton, Mark Comunale, Senthilkumar Sadhasivam. ¹Department of Anesthesia, Beth Israel Deaconess Medical Center, Harvard Medical Schoool, Boston, MA.

Background: In spite of wide spread use of propofol at emergence controversy exists regarding its effectiveness and cost saving potentials in decreasing the incidence and severity of Post Operative Nausea and Vomiting (PONV). A recent study (1) showed beneficial effect on small subsets of patients of undergoing dental procedures, however the effect of low dose of propofol in ambulatory surgery population with high risk for PONV has not been investigated. The aim of this study was to evaluate the antiemetic effectiveness and cost saving potentials of propofol 50 mg administered at the emergence from inhalational anesthesia.

Methods: This is a prospective, randomized, double-blinded, placebo controlled study. Two hundred twenty outpatients (n=110 patients in each group) undergoing day case procedures with high risk for PONV were assigned randomly to receive 50 mg propofol or 5 ml intralipid intravenously at emergence from inhalational anesthesia. Patients with high risk of PONV were selected based on Apfel’s PONV prediction system (prediction factors: female patients, previous history of PONV or motion sickness, non smokers and postoperative opioid use). Patients with one or more PONV predicting factors were studied. The study medication was administered when the endtidal concentration of inhalational anesthetics was 0.3 MAC. Incidence of PONV at 0-2 hours, 2-6 hours and 6-24 hours were evaluated. Rescue antiemetic medication requirements, duration of PACU stay, and patient satisfaction were evaluated during the first 24 hours after the procedure.

Results: The demographic data, duration of anesthesia, intraoperative opioid and intravenous fluid use, propofol induction doses and postoperative recovery profiles were comparable between the two groups. The mean predicted incidence (Apfel scores) of PONV was high (>50%), and was comparable between the two groups. The frequency of postoperative nausea between the two groups was not significantly different during the first 6 hours after surgery. However, the frequency of postoperative nausea surprisingly was higher (p= 0.03) in the propofol group 6-24 hours after the surgery. The antiemetics requirement in the PACU was lower in the propofol group, however the difference was not statistically significant. The patients who received less or no antiemetics in the PACU had significantly higher incidence of PONV 6-24 hours after surgery in both the propofol and the placebo groups. Duration of PACU stay, and patient satisfaction scores at PACU and 24 hours were comparable in both the groups. Extensive economic analysis will be presented at the time of meeting.

Conclusions: The effectiveness of small dose propofol to decrease the frequency of PONV had been demonstrated in non high risk patients requiring no or low dose narcotic analgesics postoperatively in several recent studies. Most of our patients had one or more risk factors and PONV and required narcotic analgesics before and after discharge from the hospital because of the invasiveness of the procedures. This study on high PONV risk patients undergoing ambulatory surgery showed that low dose propofol administered at the time of emergence from inhalational anesthesia was not effective in decreasing the incidence of PONV in the early postoperative period (0-6 hours); and the incidence of PONV was higher in the propofol group at late postoperative period (6-24 hour) (p=0.03). This higher incidence of late PONV in the propofol group is because of clinically decreased use of antiemetics prior to discharge. Propofol group had a trend towards a lower incidence PONV before discharge in our high risk population and also fewer requirement of rescue antiemetics, but they were not statistically significant. However, in our study, patients getting fewer antiemetics before discharge had the disadvantage of having higher incidence of PONV after leaving the hospital, especially in the propofol group. Propofol at a low dose at emergence did not significantly decrease PONV before discharge and postponed PONV to the late postoperative period. Propofol alone in high risk patients is not effective in decreasing PONV and is likely to shift costs of health care from hospitals to patients and society with associated patient discomfort.

Reference:

1. Fujii Y, et al. J Oral Maxillofac Surg 2002; 60: 1246-9.

O-6

NEUROSTIMULATED EVOKED MOTOR RESPONSE PREDICTS THE SUCCESS AND LATENCY OF SINGLE INJECTION SCIATIC NERVE BLOCK - TOP

Joshua Goldner,¹ Antoun Nader,¹ Kenneth D. Candido,¹ Radha Sukhani,¹ Horonio T. Benzon.¹ ¹Anesthesiology, Northwestern University,Feinberg School of Medicine, Chicago, IL.

Introduction: The sciatic nerve has two distinct components - the tibial nerve located medially and the common peroneal nerve located laterally. Because of its large width (0.9 – 2 cm) and two distinct components, a single injection of local anesthetic may produce incomplete block of the sciatic nerve. The present study evaluated the correlation between the 4 possible evoked motor responses (EMR) of the foot - inversion, eversion, dorsiflexion, and plantar flexion, versus the latency and success of a neurostimulation-assisted single injection SNB.

Methods: Following IRB approval, written consent was obtained from 100 patients undergoing reconstructive ankle surgery. SNB blocks were performed with the patient prone or in the lateral decubitus position using the infragluteal-parabiceps approach with a 100mm 22g insulated needle. All patients received midazolam IV prior to the procedure. After obtaining one of the following EMR’s: 1) Plantar Flexion (Group-PF), 2) Eversion or Dorsiflexion (Group-ED), or 3) Inversion (Group-I), at <0.4 mA, levobupivacaine 0.625% with epinephrine 1:200,000 (0.4 ml/kg maximum 40 ml) was incrementally injected. Onset of surgical anesthesia was assessed q 2 min for 10 mins then q 5 min until 45 mins. A three level scale was used to grade the intensity of sensory block using pinprick stimulation; 0 = normal sensation (pin prick felt as sharp); 1 = analgesia, (pin prick felt, not sharp); 2 = anesthesia, (pin prick not felt). Motor block intensity was also graded on a three level scale; 0 = normal strength; 1 = paresis; 2 = paralysis. The frequency of complete block (grade 2 sensory and motor score) was compared using a c² statistic. The latencies to grade 2 sensory and motor scores were compared using the Kruskal-Wallis H-test and the Mann Whitney U test with Bonferroni correction.

Results: Demographic parameters were comparable between the 3 groups. The incidence of complete block in Group-I (n=25) was 100% which was statistically significantly higher than Group-PF (n=27) (76% success) and Group-ED (n=9) (22% success). Time to surgical anesthesia and motor paralysis was significantly shorter in the distributions of 4 nerves in Group I compared to Group PF and Group ED (fig).

Discussion: EMR of inversion when performing neurostimulation assisted SNB results in the highest incidence of complete block (100% cases) and the shortest latency of block onset. The results of the current study support the hypothesis proposed by Benzon, et al, that inversion of the foot is due to the action of both the tibialis posterior muscle, which is innervated by the tibial nerve, and the tibialis anterior muscle, which is innervated by the deep peroneal nerve. The greater frequency of complete nerve block with an elicited inversion, therefore, is due to the proximity of the needle to both branches of the sciatic nerve.

Reference: Benzon HT, Kim C, Benzon HP et al: Anesthesiology 1997; 87: 547 -52

O-7

COMPARISON OF ORAL GRANISETRON (KYTRIL) TO IV ONDANSETRON (ZOFRAN) FOR ANTIEMETIC PROPHYLAXIS IN OUTPATIENTS UNDERGOING LAPAROSCOPIC SURGERY - TOP

Mohamed A. Hamza,¹ Irinia Gasanova,¹ Paul F. White.¹ ¹Department of Anesthesiology & Pain Management, University of Texas Southwestern Medical Center, Dallas, TX, United States.

Introduction: Granisetron is a 5-HT₃ antagonist which has been found to be highly effective in the treatment and prevention of chemotherapy-induced-nausea and vomiting. Although granisetron has also has been reported to be effective in the treatment and prevention of postoperative nausea and vomiting (PONV), the cost of granisetron has raised questions regarding its cost-efficacy as a routine prophylactic and rescue antiemetic in anesthetic practice. The purpose of this study is to compare the antiemetic efficacy of oral granisetron (1 mg) and ondansetron (4 mg IV) when administered for routine prophylaxis against PONV on patients undergoing major laparoscopic surgery procedures. A cost-efficacy analysis of the two 5-HT₃ antagonists will be presented.

Methods: 31 outpatients undergoing elective laparoscopic surgery (e.g., cholecystectomy and tubal ligation) under a standardized general anesthetic technique were randomly assigned to two antiemetic prophylaxis groups according to a placebo-controlled, double-blind protocol. Group 1 (Control) received an oral placebo 1 h prior to surgery and ondansetron, 4 mg IV, at the end of surgery. Group 2 received Granisetron 1 mg po 1 h before surgery and saline (1 ml) at the end of surgery. Nausea scores were assessed using an 11-point verbal rating scale, with 0=none to 10=maximal, at 30 min intervals in the postoperative period, as well as at 24 and 48 h after surgery. In addition, the time to the first postoperative episode of emesis, the number of patients with emetic symptoms and requiring rescue antiemetics were recorded. The opioid analgesic requirement and the recovery times, as well as the quality of recovery (using an 18-point questionnaire), were recorded on the day of surgery, as well as on postoperative days #1 (POD 2) and #2 (POD2). * P-values <0.05 versus Ondansetron (Control) group.

Results: The demographic characteristics were similar in both treatment groups. The incidence of PONV in the PACU was also similar in both groups (Table), with 44% and 46% of the patients, respectively, requiring rescue antiemetics in the PACU. However, the incidences of both nausea and emesis, as well as the need for antiemetic therapy, in the post discharge period were significantly reduced in the Granisetron (vs Ondansetron) group.

	ONDANSETRON	GRANISETRON

Number (n)	16	15
Age (yr)	37 ± 16	34 ± 10
Weight (kg)	73 ± 13	74 ± 17
Anesthesia time (min)	100 ± 30	107 ± 39
Surgery time (min)	70 ± 30	71 ± 37
Eye opening (min)	8 ± 3	11 ± 9
Orientation (min)	25 ± 12	26 ± 16
PACU stay (min)	56 ± 16	57 ± 39
Patients with nausea in the PACU [n(%)]	10 (62)	10 (66)
Patients with vomiting in PACU (n(%)]	3 (18)	4 (27)
Rescue antiemetic in PACU [n(%)]	7 (44)	7 (46)
Time to first antiemetic rescue (min)	103 ± 77	53 ± 22
Max. nausea score after 24-48 h (n)	3.5 (3-4)	0 (0-2)*
Patients requiring rescue antiemetics [n(%)]
£24 h	5 (31)	0
24-48 h	1 (6)	0
Patients developing nausea and/or vomiting [n(%)]
£24 h	12 (75)	4 (26)
24-48 h	5 (31)	2 (13)

Values are mean ± SD, medians (inter-quartile range), numbers (n), and percentages (%).

Conclusion: Granisetron (1 mg PO) and Ondansetron (4 mg IV) were similar with respect to their ability to reduce PONV in the early postoperative period after laparoscopic surgery. However, Granisetron provided more effective antiemetic prophylaxis in the postdischarge period.

Patient Safety and Quality Improvement

Oral Presentations

O-8

AMBULATORY SURGICAL PATIENT SELECTION CRITERIA IN CANADA- WHAT IS THE CURRENT CLINICAL PRACTICE?

Zeev Z. Friedman,¹ Frances Chung,¹ David T. Wong.¹ ¹Department of Anesthesiology, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON, Canada.

INTRODUCTION:

Ambulatory surgery is steadily increasing in popularity as more patients with complex medical problems are considered suitable for this approach. The aim of this study was to identify the current clinical practice of ambulatory surgical patients selection across Canada.

METHODS:

A standardized questionnaire was sent to all practicing members of the Canadian Anesthesiologists’ Society. Recipients were asked to indicate if they would provide ambulatory anesthesia (yes/no answers) for an adult patient with each of the 30 specified isolated conditions.

RESULTS:

1337 questionnaires were sent and 790 replies were received (59%). Sixteen questionnaires were unanswered for different reasons and excluded.

DISCUSSION:

The results indicate a few clear- cut issues. Over 90% of anesthesiologists were willing to include in their selection criteria ASA 3 patients, patients with Angina Pectoris (AP) class 2, prior (more then 6 month) myocardial infarction, congestive heart failure (CHF)- New York Heart Association (NYHA) grade 1, asymptomatic valvular disease, low grade morbid obesity (MO) without complications and Insulin Dependent Diabetes Mellitus. Over 90% of responders found patients with AP class 4, CHF NYHA grade 4, and severe MO with complications to be unsuitable for ambulatory anesthesia. These results reflect the common practice and may form the basis for consensus-based guidelines in the future. Sleep apnea (SA), a very controversial issue, is of special interest. The majority of responders (>90%) would provide anesthesia when general anesthesia (GA) and narcotic substances are not used but exclude patients (>84%) when GA and narcotics are required. Opinions were almost equally distributed on other subjects. Further studies are needed, especially in the areas of controversy to allow us to establish safety guidelines for ambulatory patient selection.

Questionnaire- Results
*Condition*	*YES (No. (%))*	*NO (No. (%))*
ASA status III stable patients	727 (93.9)	35 (4.5)

ASA status IV stable patients	132 (17.1)	638 (82.4)
Angina Pectoris Class II- symptoms when walking more then 2 blocks, or climbing more then 1 flight of stairs	746 (96.4)	21 (2.7)
Angina Pectoris Class III- symptoms when walking 1-2 blocks, or climbing 1 flight of stairs	513 (66.3)	254 (32.8)
Angina Pectoris Class IV- symptoms with daily activities, or present at rest	31 (4.0)	738 (95.3)
Prior Myocardial Infarction (1-6 months before surgery)	123 (15.9)	643 (83.1)
Prior Myocardial Infarction (more than 6 month before surgery)	734 (94.8)	30 (3.9)
Congestive Heart Failure, NYHA Class I: Symptoms with strenuous activity	724 (93.5)	47 (6.1)
Congestive Heart Failure, NYHA Class II: Symptoms with moderate activity	544 (70.3)	227 (29.3)
Congestive Heart Failure, NYHA Class III: Symptoms with mild activity	129 (16.7)	639 (82.6)
Congestive Heart Failure, NYHA Class IV: Symptoms at rest	10 (1.3)	762 (98.4)
Asymptomatic valvular heart disease	723 (93.4)	41 (5.3)
Sleep Apnea- under monitored anesthesia care	708 (91.5)	56 (7.2)
Sleep Apnea- under regional anesthesia,does not require narcotic analgesia postoperatively	751 (97.0)	21 (2.7)
Sleep Apnea- under regional anesthesia,requires narcotic analgesia postoperatively	273 (35.3)	495 (64.0)
Sleep Apnea- under general anesthesia,does not require narcotic analgesia postoperatively	491 (63.4)	279 (36.0)
Sleep Apnea- under general anesthesia,requires narcotic analgesia postoperatively	114 (14.7)	652 (84.2)
Morbid Obesity- (BMI=35 - 44 kg/m2 ) without cardiovascular or respiratory complications	704 (91.0)	70 (9.0)
Morbid Obesity- (BMI=35 - 44 kg/m2 ) with cardiovascular or respiratory complications	140 (18.1)	632 (81.7)
Morbid Obesity- (BMI > 45 kg/m2 ) without cardiovascular or respiratory complications	383 (49.5)	388 (50.1)
Morbid Obesity- (BMI > 45 kg/m2 ) with cardiovascular or respiratory complications	36 (4.7)	737 (95.2)
Insulin Dependant Diabetes Mellitus	718 (92.8)	51 (6.6)
Malignant Hyperthermia Susceptibility	635 (82.0)	136 (17.6)
Proven Malignant Hyperthermia	385 (49.7)	383 (49.5)
Active substance abuse	534 (69.0)	231 (29.8)
Patient on concurrent MAOI treatment	538 (69.5)	229 (29.6)
Sickle cell anemia	412 (53.2)	352 (45.5)
Chronic renal failure (hemo or peritoneal dialysis)	559 (72.2)	212 (27.4)
Age>90	461 (59.6)	308 (39.8)
No escort	87 (11.2)	682 (88.1)

O-9

SHOULDER/DECOMPRESSION AND THE ANALGESIC TREATMENT AFTER THE DISCHARGE – A QUALITY STUDY

Jane Elgoe,¹ Birgitte Nielsen,¹ Arne Brehm Hoej,² Lena Ploug,² Jane Uldahl,² Anita Doefler Soerensen,³ Gitte Merrild,³ Kirsten Hauberg-Lund.³ ¹Day Surgery Units, Herning, Esbjerg and Horsens, Denmark.

A quality study of the patient treatment in connection to a shoulderartroscopi/decompression in the day surgery unit in Herning has shown a moderate increase in the patients’ VAS- scores after the discharge. But it also shows that the patients not always follow the advice and directions they receive about the analgesic medicine.

Postoperative analgesic treatment of patients who has had been operated in the shoulder is not always optimal. And this will effect the experience of an well-organised patient course.

Shoulderartroscopi/decompression is very suitable for daysurgery and is performed, for instance, at Horsens, Herning and Esbjerg hospitals. The postoperative stay in the day surgery centres last 2-3 hours where the primary nursing and treatment is focused on the analgesic treatment. The analgesic treatment in the day surgery centres deals with the preoperative medicine, the analgesic treatment in connection to the operation including application of a block (anaesthesia) and the postoperative analgesic treatment including cryocuff/ icebag- treatment. In this phase most patients experience sufficient analgesic treatment with a VAS-score between one and four.

Before the patients are discharged they are informed about the analgesic treatment after the discharge and are assigned analgesics.

After the discharge and the two first night and days after the operation we do not know to what extend the patients follow the directions about the analgesics that they have received and how great an effect the analgesics has.

Objectives:

That each patient:

- Follow the prescribed analgesic treatment

- Experience as little pain as possible after the operation with a VAS- painscore less than 4.

The Nursing intervention:

That the patients receive goal-directed information and follow the planed treatment after the discharge from the day surgery centre.

That the patients get support and are guided in the postoperative analgesic treatment through a telephone interview.

Method:

The Day Surgery Unit in Herning, the Day Surgery Unit in Horsens and the Day Surgery Centre in Esbjerg are involved in this project with 20 patients each. The patients have all had a shoulderartroscopi with decompression.

The nurse responsible for the project, before the operation informs the patients about the following:

- That participation in the project is voluntarily

- That the treatment is the same whether the patient participate in the project or not.

- That the patient at any time can withdraw from the project

Inclusion criteria:

- Shoulderartroscopi/ decompression

- Block applied before the operation

- Cryocuff or icebag

- Collar´n´cuff

- Beachchair or sideway position

- Universal anaesthesia

- ASA 1-2

- Age 20-50 years

- Both men and women are included

Before the discharge:

The patient is treated according to the unit’s clinical guidelines until the time of the discharge.

15 minutes before the discharge the patient is informed about the plan for the postoperative analgesic treatment. This plan follows the single unit’s clinical guidelines and the patient is instructed in the use of VAS – score / the schedule for doses. The patient uses the schedule the first five days after the operation.

The patient is handed medicine according to the standards of the single unit.

The patient is responsible for doing his/hers own VAS-score before the discharge.

The patient is informed about the telephone interviews on the first and the fifth day after the operation.

A stamped envelope is handed out to the patient.

The postoperative day:

A nurse phones the patient and interviews the patient according to the unit’s structured guideline.

Day 1-5 postoperative:

The patient VAS- scores twice a day and register the use of the analgesic medicine on the schedule for doses.

The fifth day postoperative:

A nurse from the unit phones the patient and interviews the patient according to the unit’s structured guideline. The patient is also asked to return the VAS-score/ schedule for doses in the stamped envelope.

If the patient does not return the VAS –score/dose schedule the patient may be contacted once.

The result of the study will be ready in April 2003.

( For a poster presentation)

O-10

CATARACT EXTRACTION WITH LENS INSERTION

Sam J. W. Romeo, Deborah Connah, Betty Bozzuto, Jack Egnatinsky, John T. Henley, Jr., Naomi Kuznets,¹ AAAHC Institute for Quality Improvement ASC Work Group & Performance Measurement Initiative. ¹NA, AAAHC Institute for Quality Improvement, Wilmette, IL, United States.

Cataract is the most frequent diagnosis for ambulatory surgery visits; approximately 2.5 million cataract surgeries were reported in 1996.¹ The intent of this study is to provide organizations with alternatives in practice to provide a better value. From December 2001 to February 2002, 57 organizations used the AAAHC Institute for Quality Improvement’s survey to prospectively collect patient de-identified data on 1395 cataract cases. 65% of organizations were single specialty; annual cataract extraction volumes ranged from 131-16,443. Patients ranged from 63-79 years of age; 66% were classified as ASA 1 or 2. Aspects of process/outcomes studied included: procedure times; use of multiple operating rooms (ORs); intraoperative complications; eye patch/dressing and/or suture use; anesthetic technique, administrator, who evaluates/monitors the patient for anesthesia; supply costs; and patient outcomes. 10 selected findings follow (the entirety of the report will be available for review at the session). 1-Preprocedure, procedure, turnover, and discharge times varied greatly, with overall facility times ranging from approximately 75-200 minutes. 2-34 organizations used more than one OR per surgeon; this did not appear to affect procedure times. 3-The intraoperative complication rate was 1.8%; no association was found between type of anesthesia and complications. 4-An eye patch/dressing was used in 1/3 of cases; sutures were used in 9% of cases. 5-In 60% of cases, a peri- and/or retrobulbar anesthetic (no topical anesthetic) was used. Intravenous (IV) sedation was used in 74% of topical and 81% of block combinations. 6-Anesthesiologists monitored 42% of cases, surgeons 34%, and CRNAs 24%. Anesthesiologists were involved in the evaluation of the patient for anesthesia in 42% pf cases, CRNAs alone in 29%, and, surgeons/CRNAs in 18%. 7-IOL price varied from less than $50-250 per lens and was not correlated with organizations’ annual cataract surgery volumes. 8-Almost all participants had an average sedative/narcotic cost per case of $1-10; lower costs were associated with using fentanyl; midazolam (generic/non); and diazepam. Midazolam (generic/ non) was used alone, with fentanyl, or propofol, or both in approximately 400, 300, 100, and 100, cases respectively. 9-Patient outcomes (understanding of/comfort in procedure, preparation for discharge, pain control post-discharge; change in vision) were almost all (97%+) positive. 10-Unscheduled follow up visits (4%) were primarily associated with pain control; problems/questions regarding instructions, medication, and prognosis; and/or, vision problems (blurriness, double vision, flashing, floater, line). It is concluded that organizations that have demonstrated and validated differences in clinical practice can have similar outcomes, but at a dramatically different cost. ¹Vital Health Statistics. 1998. 300:1-16.

O-11

A COMPARATIVE OUTCOMES ANALYSIS OF PROCEDURES PERFORMED IN FLORIDA PHYSICIAN OFFICES AND AMBULATORY SURGERY CENTERS

Hector Vila, Jr.,¹ Roy G. Soto, Alan B. Cantor, David C. Mackey. ¹Departments of Anesthesiology, Interdisciplinary Oncology, and Biostatistics and Informatics, H. Lee Moffitt Cancer Center and Research Institute, University of South Florida, Tampa, FL.

Introduction: In Florida, an increasing number of surgical procedures are performed in physician offices. This is due to the popularity of cosmetic surgery and other minimally invasive procedures such as endoscopy. Driven by media reports of office surgery deaths, the Florida Board of Medicine enacted strict regulations for office surgery that include accreditation of the office facility, credential requirement for the surgeon, qualifications of anesthesia personnel, and mandatory reporting of adverse incidents.¹

Methods: This retrospective study reviews the first two years of mandatory reporting of adverse incident data from Florida offices and compares that to outcomes data from Florida ambulatory surgery centers (ASC) for a one-year period. All 182 adverse incident reports filed between April 2000 and April 2002 were reviewed. The reported volume of office surgery procedures was obtained from the Florida Board of Medicine and estimated for the study period. Ambulatory surgery center injury and death statistics and procedure volumes were obtained from the Florida Agency for Healthcare Administration and the website http://www.floridahealthstat.com.

Results: There were 13 surgically related deaths and approximately 141,404 procedures performed in offices between April 2000 and April 2002. There were 18 reported deaths and 2,316,249 procedures in ambulatory surgery centers during 2000. The death rate was 9.2 and 0.78 deaths per 100,000 procedures performed in offices and ambulatory surgery centers, respectively. The relative risks for injuries and deaths for office procedures vs. ambulatory surgery centers were 12.4 (95% CI 9.5 to 16.2) and 11.8 (95% CI 5.8 to 24.1), respectively. In the office deaths, 84 percent of the physicians were board certified and held active hospital privileges, yet only 38 percent of the facilities were accredited and only 15 percent had a dedicated physician anesthesia provider. The types of procedures performed and causes of death were similar in ASC’s and offices making the comparison valid.

Discussion: The death rates for offices and ambulatory surgery centers found in this study are consistent with rates reported in previous studies which, in some cases, had depended upon voluntary reporting.^2,3,4 There is a more than ten-fold greater mortality in offices compared to ambulatory surgery centers despite Florida regulations. There appears to be a relationship between the presence of a dedicated physician anesthesia provider and facility accreditation and better outcomes; however, there was insufficient data for statistical analysis.

References:

1. Florida Board of Medicine Rule 64B8-9.009.www.doh.state.fl.us.

2. Plast Reconstr Surg 2000;105:436-46.

3. JAMA 1993;70:1437-41.

4. Anesth Analg 1996;82:1273-83

Business Operations Management

Oral Presentations

O-12

23 HOUR SURGERY IN THE UNITED KINGDOM - THE FIRST FIVE YEARS

Judith M. Healy, Carole Page, Matthew Sandham, Robin Souter, Doug McWhinnie. ¹Department of Ambulatory Surgery, Milton Keynes General NHS Trust, Milton Keynes, Buckinghamshire, United Kingdom.

Formally in the UK surgical patients have been admitted to a 12-hour day surgery unit, or an inpatient ward and in some places to a five-day ward. However, the development of new surgical procedures, the increasing co-morbidity of patients and ageing population led us to look for new ways of working within the ambulatory setting. Five years ago in Milton Keynes we introduced the first 23-hour ambulatory unit in the UK, adhering to day surgery principles i.e. pre-assessment, day of surgery admission and nurse-led discharge.

Aim: A prospective five-year audit of ambulatory surgery within a district general hospital in the United Kingdom.

Methods: An extended day surgery facility was opened in October 1997 as an addition to the existing day surgery unit and inpatient surgical beds. The unit operates on the same principles as the traditional day surgery unit, with all patients pre-assessed prior to admission in line with a modified criteria i.e. no upper age limit, no maximum body mass index and patients with an ASA status of I, II & III (stable) were accepted for admission to the unit. Patients were discharged to a transit lounge at 0730 to facilitate the following days admissions.

Results:

RESULTS
YEAR	NUMBER OF PATIENTS ADMITTED TO UNIT	PATIENTS DISCHARGED WITHIN 23 HOURS	NUMBER OF FAILED EDSU PATINETS
1997 - 1998	1149	833	36 (4.3%)
1998 - 1999	1158	855	45 (5.2%)
1999 - 2000	1363	872	29 (3.3%)
2000 - 2001	1449	1136	32 (2.8%)
2001 - 2002	1920	1414	35 (2.5%)

Conclusion: These results demonstrate that by opening an extended day surgery unit the number of patients suitable for ambulatory surgery can be increased while maintaining the philosophy of day surgery. 23-hour surgery offers another option for ambulatory surgery and enables the downsizing of procedures from traditional inpatients to extended day cases and of day cases to the outpatient department.

O-13

WHY BUDGETS WORK IN DAY SURGERIES

Ann M. McHardy. ¹Management, Albury Day Surgery & Ballarat Day Procedure Centre, Albury, New South Wales, Australia.

This abstract will outline how Budgets have worked within Day Surgery settings in Australian Day Surgeries and the benefits the staff have gained from utilizing Budgets in their daily work practises. This information is based on 3 free standing rural Day Surgeries over a 10 year period.

In 1992 we set up our first free standing Day Surgery, we soon realized that most people working in health did not understand or utilize "Budgets". To ensure that our business would be successful we had to educate our staff on the benefits of budgets. We divided the day surgery into cost centres and involved the Nursing Unit Manager, purchasing person, admin manager and also gave an overview of the benefits of working with Budgets to all staff members. Company Objectives were put into place these are:

Short Term Objective:

1. To maintain our current profit level.

Long Term Objective:

1. To achieve profit in 2002 of 15%

2. To achieve profit in 2003 of 20%

3. To achieve profit in 2004 of 25%

New Procedures:

1. To evaluate and trial new procedures which can be funded by increased profit levels therefore increase turnover.

Other Objectives(Goals)

1. To not exceed a marketing budget of 3%

2. To not exceed a payroll budget of 5%

3. To not exceed a general overhead budget of 5%

The tools that are utilized for measuring and monitoring processes are:

1. Monthly casemix reports

2. Monthly staffing level reports

3.Monthly post-op follow-up reports

4.Monthly theatre utilization reports

5.Monthly financial budgets and target reports

6.Monthly Management review meetings

The financial budgets are allocated to the following staff:

1. Nursing Unit Manager - Nursing staff hours

2. Purchasing Person - Medical supplies

3. Admin Manager - Office staff hours

All the above staff meet with the CEO every 3 month period to review the budgets and targets and at these meetings all areas of the Day Surgery are discussed and reveiwed.

By involving staff members in the financial budgets it has enabled Albury Day Surgery to clearly see the position the Company is in and where it is headed. In doing so the Company can control and review excessive spending in any area.

When first introducing the budgets with our staff our main problem area was the fact that the staff really did not have any idea of the cost of medical supplies and also their need to have excess stock levels in the centre. After we educated the staff on the cost of medical goods they embraced the budgets and understood the benefits the Company would gain. Not only would the Budgets ensure that the day surgery remained financially sound it would also enable management to establish a Staff Bonus system - Albury Day Surgery has a clear system that all staff acknowledges and accepts. The Bonus system is based on the overall performance of the centre, these levels are reviewed at Christmas time and at the end of each financial year. Due to the success of our Budgets in Albury Day Surgery this enable the CEO to establish Budgets in the next 2 Day Surgeries Wagga Wagga Day Surgery and Ballarat Day Procedure Centre all 3 Day Surgeries have benefited from the embracing Budgets.

O-14

COMPETENCY DEVELOPMENT FOR NEWLY EDUCATED NURSES IN DAY SURGERY. A NURSING EDUCATION PROGRAM

Pia M. Christensen,¹ Ulla Thyssen,¹ Jane Voigt, Jens Engbaek.¹ ¹Day Surgery Unit, Dept of Anesthesiology, Copenhagen University Hospital, Herlev, Copenhagen, Denmark.

Introduction. Advanced education of nurses often focuses on specialization rather than ‘multi-skilled nurse’ training. The rapid development of day surgery puts great demands on the nurses to meet all of the patient needs during the pre- per- and post operative period and the complexity of day surgery requires nursing programs to enhance the knowledge, attitudes and skills of nursing care.

Purpose. A structured training program was developed for nurses to meet the demands of nursing in the day-surgery setting.

Methods and results. Specific demands to day-surgery nursing competences were identified and systematized to describe a program based on ‘The successful course for day-surgery patients’. The program delivers the process of competence development for a newly employed nurse within the fields of pre- per- and post operative nursing care and operates with three educational levels: novice, advanced novice and competent [1].

The components of pre- per- and post-operative nursing care are:

Clinical competence deals with professional and task related functions including the ability of reflection and acquiring new knowledge.

Organizational competence deals with the understanding of structural and economical aspects of the organization and the significance of trainees’ own efforts to influence the organization and the multidisciplinary team.

Educational competence deals with guidance and instruction of the patients and their relatives and the ability to share knowledge with the rest of the team.

Social and personal competence deals with the ability to associate with other people including communication and cooperation within the health care professions and the ability to conduct oneself professionally and ethically in relation to individual patients and to the profession.

The four components are based on the competence model of Edwardsson and Thomasson adapted to day-surgery nursing [2].

The program has detailed descriptions within the three educational levels and may easily be adapted to new registered nurses or more experienced nurses within pre- per- and post-operative care. Nurses with either pre- per- or post-operative care competences are expected to complete the training according to the program within one year.

Conclusion. Training to be a competent multi-skilled nurse is a time consuming process and includes training both in general, special surgery and in recovery. The necessary competences for practicing nursing in day-surgery are now substantial. This is suggesting limitations in the number of specialities that can be handled by one nurse or future sub-specialisation within the areas of pre-per and postoperative nursing.

[1] Benner Patricia. From Novice to Expert – Excellence and Power in clinical Nursing practice. Addison-Wesley Publishing Company 1984.

[2] Edwardsson B and Thomassons B. Kvalitetsudveckling- et manegement perspektiv. Studenterlitteratur 1991/1992. Lund Sweden

The project was supported by grants from Copenhagen County Competency Development fund, Copenhagen County, Denmark

Surgical Techniques and Clinical Practice Management

Poster Presentations

P-1

THE USEFULNESS OF PRE-OPERATIVE TESTS IN AMBULATORY SURGERY

Rebollar Saenz Jose, Campo Cimarras Eugenia, Sardon Ramos Jose Domingo, Gomez-Acedo Leyre, Saez de Ugarte Jaione, Errasti Alustiza Jose. ¹Ambulatory Surgery Unit. General surgery, Hospital Txagorritxu, Vitoria, Alava, Spain.

The objective of this review is to evaluate the usefulness of preoperative tests in ambulatory surgery to:

- Find unsuspected pathology and peri-operative complications

- Know the economic impact of these tests

812 medical histories have been reviewed. These patients were ASA I (American Society of Anesthesiologists) and they had been operated with general or regional anaesthesia between 1994 and 2002 with different diagnosis (inguinal hernia, anal pathology, pilonidal cyst…)

There is a protocole edited by OSTEBA (Service of Technology Sanitaries Evaluation of the Basque Government, Sanitary Departament) to be followed to choose these patients´preoperative tests. This protocole is only for patients catalogued ASA I, and it is applied or not by the surgeons in the first visit. Later, other tests can be solicited in preoperative anaesthesia evaluation.

The patients have been separated in two groups, in one these,the protocole has been applied (52%) and in other not (48%). Peri-operative complications (serious and minor) and unsuspected pathology found have been comparated between both groups. The cost of preoperative tests have been calculated as well.

The conclusion of our review are:

- The economic cost difference is minimal.

- There are not differences between complications of both groups and we did not found serious unsuspected pathologies.

In fact, the preoperative tests must be made in a selective way based either on the type of surgical operation and the patient´s pathology.

There must be made only the necessary tests because they ca not apport great segurity for the patient and besides, they can produce innecessary discomfort.

P-2

QUALITY EVALUATION OF AN AMBULATORY SURGERY PROGRAM IN PATIENTS WITH BREAST CANCER. THE NEW HORIZON OF THE SENTINEL LYMPH NODE BIOPSY

Acea-Nebril Benigno, Cereijo-Garea Carmen, Bazarra-Martin Ana, Lopez-Alvarez Servando, Nisarre-Gonzalez Carmen, Candia-Bouso Berta, Gomez-Freijoso Carlos. ¹Servicio de Cirugia General. Hospital Juan Canalejo, Xubias de Arriba, 84., 15006 La Coruna, La Coruna, Spain.

Objetive: to analyse the quality of care in patients with breast cancer undergoing ambulatory surgery.

Patients: eligible patients included women with histologically proven invasive breast cancer underwent a lumpectomy and sentinel lymph node biopsy (SLNB) in the major ambulatory surgery unit of Abente y Lago Hospital. Patients underwent mastectomy and/or lymphadenectomy were excluded and so as ASA IV women. SLNB was performed with peritumoral injection of technetium-99 and periareolar injection of isosulfan blue dye. All operations were performed by the same surgeon and informed consent was obtained in all cases.

Method: a prospective analysis of related variables with postoperative events were evaluated by two specialized nurses with no interaction with the surgical and anaesthesic team. The first postoperative clinical control was at 48 hours. The end points of this study were the following quality clinical indicators: incidence of anaesthesic and surgical side effects, degree of pain using a visual analog scale (VAS), funtional status upon home arrival, treatment discontinuity due to extra medical requeriments not related to the surgical team, and daily activities resumption.

Results: A total of 48 consecutive patients were treated between august 2002 and December 2002. Of these, 31 women underwent an ambulatory management (index of substitution 64%). Postoperative side effects related with anaesthesia were nausea (16%) and vomiting (10%). At the first clinical control (48 hours), 93% of patients did not require analgesics because up the 80% did not experience postoperative pain. Pain was absent or low (VAS<2) in 86% of women and severe (VAS>8) in 3,3%. Patient performance status was: daily activities at home 65% and limited activities 35%. Postoperative events related with surgery occurred in 15% (hematoma 6%, seroma 6%, abscess 3%). A woman (3%) with wound hematoma required extraphone information by her surgeon at 24 hours but none patient needed to call a hospital emergency department.

Conclusions:

- Conservative surgery for breast cancer can be safely performed on an ambulatory basis with a low morbidity and good control of pain.

- Ambulatory surgery in breast cancer patients can be increase with the use of sentinel lymph node biopsy.

P-3

THE IMPACT OF DIFFERENT SURGICAL PROCEDURES ON THE POSTOPERATIVE MANAGEMENT OF PAIN

Anne Marie Coll,¹ Jamal R. M. Ameen.¹ ¹School of Care Sciences, University of Glamorgan, Pontypridd, Mid Wales, United Kingdom.

Introduction: Despite the technological advancements in anaesthesia and analgesia, pain levels remain high even for the most common day surgical procedures. This problem will continue to escalate as more elective surgery is now being performed on a day case basis with both social and economic implications.

Aim: To establish the implications of different pain trajectories on the management of pain after different surgical procedures.

Method: Data on pain experience has been collected from three independent ambulatory surgical units across the United Kingdom on three operation types (Hernia, Laparoscopic sterilisation and varicose vein surgery) using the Visual Analogue Scale (VAS) for a period of three days postoperatively. This was a pre and postoperative postal questionnaire during the periods of 1998 and 1999 involving a consecutive sample of 785 patients with a response rate of 79% (578).

Results: Different operation types were found to have different trajectories of pain experience with laparoscopic sterilisations patients experiencing the most severe pain on the day with varicose vein and hernia patients experiencing pain as far as the third post-operative day and possibly longer. The results for the third day are displayed in the following table.

The incidence of pain by operation type on the third day for three cutting points using the Visual Analogue Scale (VAS).

See Table.

Discussion:

Evidence suggests that patients undergoing different operative procedures continue to experience unacceptable levels of pain postoperatively. The impact of different postoperative pain trajectories on pain experience and its management has not been explored sufficiently in the literature.

Conclusions:

Raising awareness and knowledge on pain trajectories for different operation types can have major implications for its postoperative management.

Keywords: surgical operations, pain management, trajectories of pain behavior, Visual Analogue Scale, nurses’ knowledge

The incidence of pain by operation type on the third day for three cutting points using the Visual Analogue Scale (VAS)
Pain level	Hernia	Lap Sterilisation	Varicose Veins	Overall
30mm.	54%	32%	41%	44%
40mm.	44%	25%	33%	35%
50mm.	29%	17%	26%	25%
Total	244	170	185	599

One-Way ANOVA, F=25.69, df=2, p=0.005

P-4

UROLOGY DAY SURGERY - EXPANDING THE PRACTICE - A MULTIPROFESSIONAL APPROACH

Sarah M. Lloyd, Stuart N. Lloyd, Gloria Bailey. ¹St James University Hospital, Leeds Teaching Hospitals NHS Trust, Leeds, Yorkshire, United Kingdom.

The British Association of Day Surgery (BADS) and the Audit Commission have proposed that 75% of all surgery in the UK could be performed on a day case basis. Leeds Teaching Hospitals Trust (LTHT) is a group of hospitals with 7 consultant urologists providing general and subspecialist services to a population of approximatly one million. At nearly 75% Urology has one of the highest day case rates in the trust. We have explored the possibility of further extending one conslutant’s practice (SNL) usuing a multi professional approach consisting of the Urologist, Anaesthetist, Nurse and Manager. The procedures targeted for day surgery include Transurethral Resecetion of the Prostate (TURP), Transurethral Resecetion of Bladder tumour (TURBT), grafting procedures for Peyronie’s desiese and ureteroscopic procedures including the use of lasers.

This is a team approach with members cotributing to developments in all areas, however some of the major contributions of the different groups are decribed:

Urologist Assessment and selection of appropriate cases. The use of new techniques more suitable to the day surgery setting eg. vaporisation (Gyrus PKVP) TURP, meticulous attention to detail of surgical technique to minimise tissue damage and ensure haemostasis.

Anaesthetist Working with nurses to assess, select and prepare patients for these procedures. Challenges include managing fluid balance and post operative analgesia and also in anaesthesia for prolonged day surgery procedures (grafting techniques for Peyonie’s disease lasting more than two hours),

Nurses The pre-assessment of patients with more complex problems (ASA3) including presenting problems at meetings with anaesthetists. Nurses in all areas of the unit need to understand the procedures so patients and their carars can be fully informed. Specialised practical skills have had to be acquired including all aspects of catheter management, bladder irrigation and laser safety.

Manager The 9pm closing time and development of ‘hotel’ beds within the day unit has facilitated this expansion. These patients often have specific scheduling requirements including returning to the unit for ‘trial without catheter’ which have had to be accomodated.

Patients managed as day cases include 20 patients having TURP, 10 patients having TURBT and 20 for complex reconstruction for Peyronies disease. Due to the need for structural alterations to the theatre and staff training and accreditation ureteric procedures requiring use of the laser have only been possible in the day unit since Dec 2002. Two patients after TURP and 1 after TURBT have required admission to an inpatient bed for bleeding requiring bladder irrigation overight; all were discharged the next day. All patients are followed within 48 hours.

A review of a sample of patients currently managed as inpatients for these procedures has indicated that 50% of these might be suitable to be managed as day cases in the future.

Based on this work a questionnaire has been designed to assess the needs and input from all professionals in order to move a given procedure from an inpatient to a day case setting.

In order to achieve 75% of surgery as a day case in the UK it will be necessary to include more complex procedures and patients with significant medical problems (ASA3). This presents numerous challenges to all those working in day surgery. We feel that a coordinated approach as described provides a model for managing the change which will allow the expansion of day surgery as a safe and high quality service.

P-5

LAPAROSCOPIC INCISIONAL AND VENTRAL HERNIA REPAIR: OUR INITIAL EXPERIENCE IN A DAY SURGERY UNIT

Juan Marin, Octavio Mulet, Antonio Gallardo, Daniel Diaz, Salvador Marrero, Antonio Fdez. Zulueta. ¹Unidad Cirugia Mayor Ambulatoria, Hospital El Tomillar (Area Valme), Sevilla, Spain.

Background: Incisional and ventral hernias are an important problem. Laparoscopic repair of these hernias is still controversial but is an appropriate option to open surgery. This report describes the technique and reviews our protocols and early results at a day surgery unit.

Methods: data was collected prospectively from 80 patients between October 2000 and January 2003. 60 women and 20 men (mean age, 56.7 years; range 29-89 years) underwent laparoscopic hernioplasty. Patients were selected according to hernia size: small (< 5 cm in width or length) an giant hernias were performed as open surgery. A double-layer mesh was stapled to the peritoneal surface of the abdominal wall using a helicoidal suture device (Tacker)

Results: There were 27 ventral hernias and 53 incisional hernias. Hernias (mean area 104 cm2, range 9-490) were midline (68), subcostal (5), Spiegel 2 and McBurney (5), and were recurrent in 21 patients. The mean operative time was 71 min. (range 25-270 min). Intestinal adhesiolysis was necessary in 25 patients. There were 6 associated cholecystectomies. There was no mortality. Three patients were converted: 2 accidental enterotomies; 1 pneumoperitoneum intolerance). The intraoperative complications were: 2 trocar site bleeding; 1 epigastric vessel bleeding; 3 accidental enterotomies and 1 pneumoperitoneum intolerance. 8 patients were discharged home 6 hrs after the procedure, 55 stayed < 23 hrs and 17 required hospitalization > 24 hrs (12 for severe pain and 6 for perioperative complications). The mean follow-up period was 12 months (range, 1-28 months). Patients were given appointments for 1 week, 2 months and 1 year after the operation. 61 patient referred no pain. The early recurrence rate was 5%. There was no case of infection or mesh rejection.

Conclusions: Laparoscopic intraperitoneal approach to ventral and incisional hernias is a safe ,easy and effective procedure that contributes to reduce the length of hospital stay in comparison with open repair and can be performed safely on a day- surgery setting. Long-term follow-up evaluation is required for recurrences.

P-6

TEN YEARS OF EXPERIENCE OF A DAY SURGERY UNIT IN THE UNIVERSITY HOSPITAL OF MILAN (OSPEDALE MAGGIORE POLICLINICO DI MILANO IRCCS)

Fernando Zennaro, Barbara Chella, Alberto Orio, Paola Granelli, Claudio Morelli, Matteo Santamaria, Alberto Peracchia. ¹One Day Surgery Unit - First General Surgery Department, Ospedale Maggiore Policlinico di Milano, Milano, Italy.

Since its disclosure, day surgery had to achieve some important aims: to reduce the negative psychological effect of hospitalization, to decrease waiting lists, to increase patient turn-over and finally to utilize less human resources. At the same time, a useful management of this kind of surgical approach could warrant a positive budget; this profit could converted in a resource for the department the unit it is assigned to.

In our country Day Surgery is still opposed and it’s difficult to find dedicated units in surgical departments. The optimization of integrated sections could be obtained with the rationalization of the common resources; it means: punctual work organization of the day-surgery team, with precise operating room and outpatients department shifts.

In the Day Surgery Unit that is dedicated and integrated in the First General Surgery Department of the Ospedale Maggiore Policlinico di Milano, we treated 9640 patients from 1991 to 2002. They were affected with abdominal wall hernias (25.8%), anal-rectal disease (20.8%), venous disease (11.1%), breast disease (5.1%), skin disease (13.6%), urological disease (2.9%) and esophageal and colic lesion (20.7%, treated with operative endoscopy). Global morbidity was 5.3% at the beginning of the experience and 0.9% in the last four-year period; we had a patient satisfaction index of 98%.

We have to underline that the bed-space was dedicated to the general and oncologic surgery, but the profit of the day surgery unit management reduces significantly the global running costs.

P-7

THE HOSPITAL’S OUTPATIENT SURGERY UNIT: ITS UTILITY IN SURGICAL ONCOLOGY

Mariano Cherubini,^A.P. Angelo Turoldo, Pietro Baxa. ¹Department of Surgical Sciences.Clinica Chirurgica, Univ. Hospital of Cattinara (Trieste)-Str. di Fiume 447, 34149 Trieste, I, Italy.

We propose to define which contribution the Hospital’s Outpatient Surgery Unit (HOSU), a unit of ambulatory surgery connected to Day Surgery and hospitalization, can give to surgical oncology. We listed some oncological lesions, taking them from the total data observed in these years and so subdivided:

1. Tumours diagnosed during screening. Particular attention is directed to breast cancer screening, a model that permits a precise diagnosis. 2. Non Hodgkin lymphoma and pseudolymphoma, localized in periareolar area. Paget’s periareolar disease. 3. Glomus tumours. 4. Schwannoma and Abrikossoff’s myoblastoma. 5. Melanoma. Basal, Squamous Cell and Sebaceous Gland, Carcinomas. 6. Merkel’s carcinoma 7. Kaposi’s sarcoma.8. Metastases. 9. Implantable infusion ports.

The results obtained concern the activity performed in these years and are thus represented:

No. of Total Services for surgical patients (including consultancies, dressings, etc.)….........................…65.062

No. of Ambulatory Surgical Operations…............... 4.392

1. The results concerning the breast cancer screening, not including the cases of re-screening, are thus represented:

Breast cancer screening…………………… …No. 4150

Breast benign lesions………………… …… ...No. 435

Breast cancers……………………………….. No. 166

The 3 classes of age, with major breast cancer, are in order: 50-59, 60-69, 40-49. Early lesions (T 1) were 41.5%, and treated by quadrantectomy, axillary dissection and radiotherapy. Late lesions (T 2, 3, 4) were 58.5% and treated by mastectomy, axillary dissection, adjuvant therapy.

2. In periareolar lumps removal, 4 cases of Non-Hodgkin lymphoma and 3 cases of pseudolymphoma were observed. The histology of Paget’s periareolar disease was performed in 4 cases. 3. Glomus tumours: 12 clinical cases. They are benign, terribly painful small tumours. 4. Schwannoma is a lesion involving the periferal nerves (3 clinical cases). Verocay bodies are typical. For many histologists this tumor is similar to Abrikossoff’s myoblastoma ( 3 cases). 5. Melanoma. It is important to know the thickness, because if treated less than 0.75 mm. thick and if lymph nodes are not involved, the survival rate increases to 47%. The epithelial carcinomas may be aggressive. 1 case was observed of sebaceous carcinoma, cured by wide excision. 6. Merkel tumour (1 clinical case observed): belongs to neuroendocrine carcinomas. In the clinical case reported good prognosis 5 years after treatment was obtained. 7. Kaposi’s sarcoma, belongs to the tumours of blood vessels. (2 cases). 8. Metastasis excision, may be performed in ambulatory surgery, with diagnostic and therapeutic purpose (22 cases).

9. Implantable infusion ports. Systems useful to implantation, via transcutaneous, of a central venous catheter, for a long-term infusional chemotherapy.

With clinical examination, aimed at oncological screening, the therapeutic perspectives are increasing, because it is possible to define neoplastic lesions with a microscopic examination before operation, to clarify the staging and to widen the treatment for malignant lesions. These therapies can become interdisciplinary. Moreover the usefulness of treatment up to 3 day stay, constitutes emerging trends in short stay surgery, significantly increasing the surgical procedures. We wish to show that in a country unused to these procedures, there can exist wide spaces for obtaining screening, the oncologic evaluation of a disease (1), the treatment and the follow-up. These clinical cases, go from screening, as a model of research, to the removal of benign or malignant lesions, to the settlement of histologically doubtful lumps, lymphomas and pseudolymphomas which do not need wide therapeutic excisions and to all the other examples described. The implantable infusion ports represent a useful help in the treatment of tumours, in patients who need chemotherapy, aimed at particular and diffusive breast and colorectal cancers. Nowadays oncology takes advantage of these procedures, with minor hospitalization and more efficient health care. All this typology may be increased in future.

(1) Cherubini M., Ambulatory Surgery 2001; 9S:45

http://www.iaascongress.org/events.htmhttp://www.iaascongress.org/events.htmhttp://www.iaascongress.org/events.

P-8

REOPERATION FOR RECURRENT SAPHENO-FEMORAL INCOMPETENCE: OUR EXPERIENCE IN A DAY SURGERY SETTING

Patrizia Pavei,¹ Enzo Giraldi,² Giorgio Spreafico,² Gabriele Armellin,³ Maurizio Ferrini,² Ugo Baccaglini.¹ ¹Dept. of Medical and Surgical Sciences University of Padova (Italy), Clin.Chir.IV(1)and Day Surgery Unit (2) and Intensive Care Unit(3), Padova Via Gattamelata 64, Italy, Italy.

INTRODUCTION

Recurrent varices after surgery are a very common, complex and costly problem. Many retrospective studies indicate a 20-80% rate of clinical recurrence following varicose vein surgery at 5 to 20 years (1,2). The majority of these recurrences are associated with reflux emanating from the sapheno-femoral junction (3). Re-exploration of this area is often beset with difficulties.

MATERIAL AND METHODS

61 consecutive patients (9 men and 52 women) with recurrent varices emanating from the femoral vein were treated in an outpatient setting between 1995 and 2002. All patients underwent clinical and duplex examinations before surgery and all had previously undergone flush ligation of the sapheno-femoral junction associated with stripping of the long saphenous vein. From 1995 up to 2000 all re-operations were performed under spinal anesthesia (38 patients) while between 2001 and 2002 we operated on 23 patients: in 15 cases under spinal anesthesia and in 8 cases under monitored anesthesia care (MAC). All patients were classified as ASA I or ASAII. According to the clinical CEAP classification 38 patients were C2; 8 C3; 6 C4; 4 C5; and 5 C6. Twelve patients required treatment for recurrent phlebitis and 2 patients had erysipelas before treatment. In all cases a re-exploration of the groin was performed using a lateral approach as described by Li (4). In 43 cases a longitudinal skin incision in the groin just over the femoral pulse was made, while in 18 patients we used an inguinal incision made just above the previous one. After the exposure of femoral artery and vein above and below the new sapheno-femoral junction, the recurrent vein was legated and divided (5). In all the cases we performed multiple phlebectomies and in 12 cases a stripping of a residual trunk. Fourteen patients subsequently underwent sclerotherapy for residual varices. Post-operatively all the patients were encouraged to ambulate early and had to wear graduated compression stockings to prevent pain, hematomas and deep vein thrombosis. In one patient, with a post-thrombotic syndrome in the non operated leg, we also administered low molecular weight heparin for 7 days.

RESULTS

All patients were discharged the same day of operation between 3 and 5 hours after the end of surgery and we registered no unanticipated admission to hospital. The discharge criteria were: haemodynamic stability, ability to tolerate and maintain oral fluids and food. In those cases treated under spinal anesthesia the return of strength, sensation and proprioception in the operated leg and spontaneous urination were required. We didn’t observe major complications, while minor ones were: 3 groin hematomas, 2 superficial infections of the groin wound, 2 aching hematomas in the thigh, 1 limph fistulae. As anesthesiology complications we recorded 2 post-spinal headaches and 1 lombar pain. Clinical follow up visits and duplex examinations were performed on day 3, 7 and at 3, 6 months and then yearly after surgery. All patients underwent follow up visits with a mean follow up period of 5 months. After 1 year in 2 patients duplex revealed the presence of persistent sapheno-femoral incompetence and in 1 case recurrent varices due to a thigh perforator incompetence was found. During follow up none of the patients developed phlebitis, deep vein thrombosis or other complications related to venous disorders.

CONCLUSIONS

Re-operation for recurrent sapheno-femoral incompetence may be a difficult and bloody procedure. Using the lateral approach, proposed by Nabatoff and Li, it is possible to obtain an early control of the femoral vein and to avoid scar tissue and friable recurrent varicose veins which do not lend themselves to dissection and hemostases. Modern anesthesiology techniques and an adequate surgical approach permit a safe and satisfactory treatment of recurrent varicose veins on an outpatient’s setting with a reduction of complications related to venous disorders.

BIBLIOGRAPHY

1. Phlebologie 1998, n. 4, 403-413

2. World J. Surg. 1986 , vol .10, 944-953

3. Surgery 1996, 119 n.4, 406-409

4. Br. J. Surg, vol. 62 1975, 745-746

5. Eur. J. Vasc. Endovasc. Surg. 18, 1999 494-498

P-9

INGUINAL HERNIA IN DAY SURGERY: TEN YEARS OF EXPERIENCE

Fernando Zennaro, Barbara Chella, Alberto Orio, Paola Granelli, Claudio Morelli, Matteo Santamaria, Alberto Peracchia. ¹Day Surgery Unit - First General Surgery Department, Ospedale Maggiore Policlinico di Milano IRCCS, Milan, Italy.

In 1992 a Day Surgery Unit has been instituted in our General Surgery Department with the aim of reducing waiting lists and health-care costs.

We operated on 2247 patients, 2003 males (89.14%) and 244 females (10.86%) with a mean age of 57.31 years; ASA score was I or II and in selected cases III. Hernia type was sliding in 1396 patients, scrotal in 147, direct in 393, mixed (direct + sliding) in 212 and recurrent in 99 patients.

A short-term prophylaxis with a third generation cephalosporin was given 30 minutes before operation. Local anesthesia was preferred in 1957 patients, whereas 206 subjects underwent epidural anesthesia and 24 a general one. 2068 (92.03%) patients were discharged the day of operation and 179 (7.97%) the day after.

All sliding hernias (1543 pts) were repaired with Lichtenstein procedure in 1094 pts (70,91%), with modified Lichtenstein operation in 172 cases (modified means that the mesh was fixed to Cooper’s ligament, 11.14%), with Trabucco technique in 236 patients (15.29%) and recently with PAD procedure according to Valenti description in 41 patients .

Direct hernias (343) required trasversalis fascia suture combined with Trabucco hernioplasty in 92 cases (23.42%), trasversalis fascia duplication suture combined with Lichtenstein procedure in 247 patients (62.84%) and Lichtenstein procedure with T2 plug in 54 patients (13.74%).

Mixed hernias (212) were repaired with modified Lichtenstein procedure in 175 cases (82.54%) and with Lichtenstein procedure with T2 plug in 37 (17.46%).

For recurrent hernias (99) we adopted a patch in 15 cases (15.15%), the modified Lichtenstein operation in 49 subjects (49.5%) and Wantz technique in 35 cases (35.35%).

Ten patients were converted from local to general anesthesia, due to intolerance. Post-operative complication rate was 4.79%: 6.6% at the beginning of the experience and 2.3% in the last period. We had 34 (1.51%) seromas, 31 (1.37%) hematomas, 27 (1.2%)neuritic pain, 14 (0.62%) orchitis and 2 wound infections (0.09%). We observed moreover recurrent inguinal hernias (due to mesh dislocation) and 3 homolateral femoral hernias, occurring six months after the operation. At 10 years follow-up, we report a 95.2 % success rate with a patient satisfaction index of 98.9% . We can conclude that inguinal hernia can be treated safely in day surgery; this approach could really reduce patient psychological stress and post-operative discomfort and allow advantages in terms of waiting list length and health-care costs.

P-10

AMBULATORY SURGERY DURING THE YEAR OF 2002

Carlos Magalhães, Eurico Alves, Manuel Seca. ¹Departamento de Cirurgia, Hospital Geral de Santo António, Oporto, Portugal.

The authors present a revision of the surgical interventions made in the Unit of Ambulatory Surgery, with the presence of an anesthesist, during the year of 2002.

This Unit exists as independent from the year of 1991, and all patients leave the hospital in the same day of the surgery (Day’s surgery).

The Ambulatory Unit as a total area of 150 m2 (2 Operating Rooms, 1 Recovery Room and Day’s Hospital with 6 beds and 4 armchairs).

The specialities that are working in Ambulatory regimen are:

- General Surgery, Vascular Surgery, Urology, Gynaecology, Neurosurgery, Orthopaedics, Dermatology, Neuropathology, Nephrology.

The operating period of the General Surgery is 10 hours/week.

In 2002, there were operated 697 patients, and the main pathologies were:

- Hernias of several locations (mainly Inguinal), Pilonidal Cysts, Thyroid pathology, Haemorrhoids, Fissures and Fistulas, Varicosed Veins, Breast Nodes, Excisional Biopsies, Hidrocels, Epididymal Cysts, Thyroglossal Duct cysts, Volumous Lipomas and Cholelithiasis.

From each patient it was studied the following:

- Sex (male – 60% and female – 40%), age (average of 47), residence, profession, origin, time of waiting for the first consultation, time of waiting for the surgery, pathological antecedents, surgical antecedents. Related to the surgical procedure, it was analysed the type and median duration, and the type of anaesthesia used.

On the early post-surgical period (during the stay in the Ambulatory Unit) the main occurrences were:

- Pain – 76 patients (10%); - Haemorrhagy – 3 (0,4%)

- Pain, Nausea and vomiting - 4 (0,5%); - Nausea and vomiting – 3 (0,4%)

The number of patients that, by surgical or anaesthesic criteria, spent the night at the hospital, was 2 (0,2%), because of haemorrhagy, and both of them left of the hospital, in the morning after the surgery.

On the post-surgery, it was evaluated the average number of consultations, time of follow-up and rate of complications, that in the present study was 12%.

P-11

EXCISION WITH APPLICATION OF FIBRIN GLUE: A NEW TECHNIQUE FOR TREATMENT OF PILONIDAL DISEASE

Guner Ogunc.¹ ¹Department of General Surgery, University of Akdeniz, Antalya, Turkey.

Pilonidal disease consist of a hair-containing sinus or abscess that involves the skin and subcutaneous tissues in the postsacral intergluteal region. There are numerous treatments reported in the literature, all with imperfect results. Incision, drainage, curettage and excision of the sinus followed by a Z-plasty are used for treatment (1).

The study included 9 patients (8 male, 1 male), median: 25.7 years, range 15-40. Under local anesthesia (Lidocaine-HCl 1.0% and bupivacaine-HCl 0.5% mixed in equal volumess) soft tissues surrounding the sinus exhibiting chronic inflammation was excised with eliptical incision. After the meticulous hemostasis, 2-0 prolene sutures were placed but not tightened . The fibrin glue was applied then the sutures were tightened immediately.There was no necessity of analgesics after the procedure. Patients were discharged in 6 hours following the operation. The sutures were removed in two to three days, with the incision was reinforced with steril paper strip. There was no morbidity and no recurrence in the 10 days-12 months follow-up period.

To the best of my knowledge , this information is the first reporting on this kind of treatment for pilonidal disease.

In conclusion, this new approach which is excision of pilonidal sinus followed by application of fibrin glue could prove extremely useful for treatment of pilonidal disease.

Reference: 1. Pilonidal disease. Surg Clin North Am 2002; 82(6):1169-85.

P-12

SURGICAL CERVICAL PATHOLOGY - IS IT POSSIBLE IN AMBULATORY SURGERY?

Carlos Magalhães, Eurico Alves, Manuel Seca. ¹Departamento de Cirurgia, Hospital Geral de Santo António, Oporto, Portugal.

Ambulatory Surgery registered a big improvement last years, with a major number of surgeries performed and with the dealing of different pathologies.

The treatment of cervical pathology mainly Branquial Cysts,

Thyroglossal Duct cysts and Thyroid pathology is one of the examples, of "new" surgical procedements that we include in our ambulatory programme. In our definition, all patients submitted to ambulatory surgery leave the Hospital in the same day (Day’s Surgery).

The authors present a revision of the cervical surgical interventions, made in the Unit of Ambulatory Surgery, during the period of 1998 and 2002.

During this period there were submitted to surgery, 88 patients, with the next distribution:

- Branquial Cysts – 10

- Thyroglossal Duct cysts -14

- Thyroid pathology – 64 (hemithyroidectomies)

From each patient it was studied the following:

- Sex, age, residence, profession, origin, time of waiting for the first consultation, time of waiting for the surgery, pathological antecedents, surgical antecedents. Related to the surgical procedure, it was analysed the type and median duration, and the type of anaesthesia used.

We present the complications registered in the early post-surgery period, in the Recovery Room and Day’s Hospital.

All patients left the Hospital in the same day of the surgery.

We relate the medium drainages anf the final anatomo-pathological results, from this group of patients.

On the post-surgery, it was evaluated the average number of consultations, time of follow-up and rate of complications, that in this serie, registered one injurie of the recurrent laryngeal nerve (transitory lesion).

The conclusions of the study are based on the results obtained, mainly the early and the late complications, as also its aplicability in ambulatory surgery programmes.

P-13

FORMS OF PROFILING OF SURGICAL CENTERS IN SAINT-PETERSBURG SAINT-PETERSBURG, RUSSIA

Alecsey Lisitsyn, Leonid Vinnik, Sergey Dergatchev, Vladimir Vorobyev, Yriy Savelyev. ¹Military Medical Academy, Multiprofile Clinic of Ambulatory Surgery, Saint-Petersburg, Russian Federation.

The establishment of ASC network in Saint-Petersburg allows to perform the structural reconstruction of surgical service of the city having as its purpose the formation of system of qualified and specialized aid to population on the pre-hospital stage.

The centers are established in the city districts on territorial base for servicing population of the given district with the right of granting the appropriate medical aid to population of several city districts in the system of compulsory medical insurance. The necessity of center establishment and their specialization is determined by the public health authority bodies of the district Administration taking into account number of district population (200,000 – 400,000), structure of surgical diseases in the State public health establishments of the district, possibility to select the base establishment and its equipping for the needs of the Center, availability of the trained staff of surgeons, anesthesiologists and nursing staff of the due qualification. According to the conditions of Center formation within the base establishment, availability of trained specialists, medicinal and preventive possibilities of the Centers and needs of practical public health of the given district, the profile of each Center activity is determined.

Currently the following forms of Center profiling have taken shape in Saint-Petersburg:

1. Centers of ambulatory scheduled surgery (ASSC¹) (of general surgery) with day-time surgical stationary clinics (DTSSC);

2. Centers of ambulatory scheduled surgery with specialized cabinets and (DTSSC);

3. Specialized Centers of ambulatory abscess surgery (AASC) with (DTSSC);

4. Centers of ambulatory specialized surgery (Center of ambulatory children’s surgery, Center of otolaryngologic surgery, etc) with (DTSSC);

5. Multiprofile Center of ambulatory specialized surgery (ASSC²) with (DTSSC);

6. Center of specialized surgery with short-time twenty-four-hour stationary clinic (STSC) (one-three days);

7. Multiprofile clinic of ambulatory surgery at Military Medical Academy with (one-day) (DTSSC).

ASSC¹s and daily surgical stationary clinics are intended for urgent and conservative treatment of general surgical patients, i.e. the ambulatory surgical interventions of the extended nature typical for general surgical stationary clinic having in its staff the specialized cabinet (department) allowing to grant the specialized aid to the patients of certain profile together with the general surgical patients are performed there:

for peripheral vessel pathology - angiosurgical,

for diseases of hands – orthopedic-traumatologic, etc.

The main purpose of AASC is the extension of volume of specialized surgical aid at abscesses.

The multiprofile ASSC² and day-time surgical stationary clinic are established at multiprofile stationary clinic having the specialized departments in its staff providing for participation in the ASSC² activity of specialists of adjacent surgical profiles: urologists, gynecologists, ophthalmologists, orthopedists- traumatologists, otolaryngologists, etc.

SSC with short-time twenty-four-hours stationary clinic is an independent establishment having necessary functional sections and services providing for scheduled surgical interventions for patients with more manifested forms of surgical pathologies of different profiles (endocrinologic, angiologic, general surgical) and successive observation of patients for 1 – 3 days after intervention. CCS with STSC allows to extend the age and clinical limits of the patients being intervened.

The clinic of ambulatory surgery at Military Medical Academy having the specialized sections – diagnostic, scheduled surgery, abscess surgery, thermal affections, traumatologic, medical rehabilitation, anesthesiology and reanimation is scientific and methodical center providing for scientific study of actual problems of ambulatory surgery, development and probation of new treatment methods of profile patients, theoretical and practical training of graduates of higher educational establishments and advanced medical training of medical staff on ambulatory surgery and day-time stationary surgery.

P-14

LIECHTENSTEIN’S HERNIOPLASTY IN AMBULATORY SURGERY

Carlos Magalhães, Eurico Alves, Manuel Seca. ¹Departamento de Cirurgia, Hospital Geral de Santo António, Oporto, Portugal.

The present work has the purpose to present an analysis of the Inguinal Hernioplasty, made in the Ambulatory Surgery’s Unit and the satisfaction degree of the patients submitted to this surgery.

It was made a retrospective study of 868 patients submitted to Inguinal Hernia repair (Liechtenstein: – 756, Rutkow-Robbins: – 52, Gilbert: – 60) in the period between January 1994 and December 2002.

From these, 837 (96,4%) were male and 31 (3,6%) female patients, and the medium age was 48,5 years (14 – 84).

An evaluation was made from the following parameters from each patient: - residence, profession, origin, time of waiting for the first consultation, time of waiting for the surgery, pathological antecedents, surgical antecedents of the abdominal wall and distribution trough the years.

In relation to the surgical procedure, it was analysed the type and median duration, as also the type of anaesthesia and antibiotic profilaxys used.

All patients, except 3, left the hospital in the same day of the surgery.

On the post-surgery it was evaluated the medium number of consultations (2,5), the medium time of follow-up (15 months) and the rate of complications (11%).

The authors present the results of a telephone inquiry (made when the patient had one year of post-surgery) where it was evaluated the presence of complications and the post-surgical pain degree, the inability period for labour, the quality of attendance and the satisfaction degree of the surgical patient.

The conclusions of the study are based on the results obtained, mainly the early and the late complications and the rate of recurrence, that in the present study was of 6 cases (0,6%).

P-15

HAEMORRHOIDE: RUBBER BAND LIGATION IN AMBULATORY SURGERY

Sardon Ramos Jose Domingo, Rebollar Saenz Jose, Errasti Alustiza Jose, Campo Cimarras Eugenia, Saenz de Ugarte Jaione, Gomez-Acedo Leyre. ¹Coloproctology Unit. General Surgery, Hospital Txagorritxu, Vitoria, Alava, Spain.

Introduction: to analize our results on a group of patients treated with rubber band ligation as a day-case procedure.

Patients and methods: from January 1999 to December 2002 we have treated on 321 patients (491 procedures) with symptomatic haemorrhoids with rubber band ligation as a day-case procedure.

The technique is performed, at consulting room, by suction the mucosa of the proximal portion of the prolapsing cushion, at least 1-5 cm above the dentale line using haemorrhoid suction ligator (KilRoid ® - ASTRA). All entered the perioperatory circuit of our Unit of Short Stay Surgery.

Results: only 2 patients required admission during 24 hours because of severe pain with indication to remove the band in one case. None required admission after being discharged. Pain could be controled with non-steroidal antiinflammatoty drugs and the phone survey, carried out at 24 hours after hospital discharge, yielded a satisfactory state at home in all cases. However, failure of treatment happened in 5% patients, whose required subsequent haemorrhoidectomy.

Discussion: rubber band ligation, as a day-case procedure, is our preferred method for most symptomatic haemorrhoids if the medical treatment fails or the surgical treatment isn´t indicated.

P-16

THE USE OF IT - TECHNOLOGY IN A NEW STARTED DAY SURGERY CENTRE

Arne B. Hoej,¹ Jane Uldahl,¹ Lena Ploug,¹ Anne B. Nielsen,¹ Louise Steen,¹ Elsebeth Pedersen,¹ Lotte C. Andersen.¹ ¹Day Surgery Centre, Esbjerg Central Hospital, Esbjerg, Denmark.

We present a new started Day Surgery Centre with five different specialities. The Centre is lead by a nurse manager and organized with nurse specialist and nurses performing multidiscipline assignments.

At the start-up we had problems organizing procedures and standards written on paper, which made it difficult for the nurses to achieve access to clinical guidelines and information’s, when they changed between the clinical specialities.

The nurse manager and the nurse specialist therefore drew up the following demands to organization of the documents:

• Clearness

• Fast accessibility

• Systematism

• A categorizing system, that allows several people to use the system simultaneously

• Integration of text, pictures and video clips

• Search function

• Individual access, depending on charge

The final choice was a web-based system with a categorizing system adjusted to our organisation.

The demands on use the system were PC-access as well in all clinical areas, as in offices and guardrooms.

The aim of using IT-technology is to improve the quality of care performed by the nurses.

All procedures and standards are now placed in a website and connected through hyperlinks. Several procedures have series of pictures and video clips.

This means, that nurses at clinical pathways have the opportunities by hyperlinks to have a fast and clear access to procedures and standards.

The IT-technology has in our Day Surgery Centre lightened the access to information and increased the nurse’s opportunities to switch between the specialities.

Anesthesia Techniques and Clinical Management

Poster Presentations

P-17

CONTINUOUS FEMORAL NERVE CATHETER INFUSIONS FOR OUTPATIENT ANTERIOR CRUCIATE LIGAMENT REPAIR

Michael Mulroy.¹ ¹Department of Anesthesia, Virginia Mason Medical Center, Seattle, WA, United States.

Regional anesthesia for postoperative pain relief facilitates recovery and discharge in the outpatient setting. Long acting local anesthetics can provide pain relief for 12-24 hours following arm and leg surgery, and allow for significant comfort on the first day following outpatient surgery (1). This analgesia can be prolonged by the insertion of continuous catheters in the vicinity of peripheral nerves, with both infraclavicular blocks and popliteal fossa blocks providing better pain relief and better sleep patterns for up to 72 hours following arm and foot surgery respectively (2,3). Femoral nerve catheters provide prolonged analgesia and enhanced rehabilitation following knee surgery on inpatients. We studied the feasibility of femoral nerve catheters following discharge after outpatient anterior cruciate ligament (ACL) repair.

METHODS

Following institutional review board approval, 31 healthy (ASA 1-2) adults aged 17-70 were enrolled to receive a femoral nerve block (FNB) and insertion of a femoral nerve catheter following ACL repair with a patellar tendon autograft Patients were randomized to receive a FNB with either 0.25% levobupivacaine (L) or 0.25% bupivacaine (B). On the day following surgery, they initiated and infusion at 10 cc per hour of either normal saline, 0.125% bupivacaine, or 0.125% levobupivacaine. The patients and the anesthetist performing the block were blinded to the choice of drugs, both for the initial block and for the infusions. All patients were scored on a verbal analog pain scale for their pain relief and opioid consumption at the time of discharge and at 4 hour intervals after discharge. Patients were followed with phone calls twice a day by one of the investigators, and were given a phone number that they could call at any time.

RESULTS

All but one of the initial blocks produced excellent analgesia prior to discharge home. This patient was withdrawn from the study and given a standard femoral nerve block. There were no technical problems with the pumps or with the catheters themselves. There were no infections or hematomas associated with the use of the catheter, nor any persistent neuropathy following any of the infusions. One patient suffered a fall at home because of weakness in the quadriceps muscles.

All patients reported adequate pain control with the use of multimodal therapy (cryotherapy, ibuprophen, oral opioids as needed). Patients receiving local anesthesia in their in their infusions (n= 16) used half as many opioid tablets (avg. 3.6 vs 7.2, p= 0.14) compared to those receiving saline (n=14). Nine patients in the LA group used no opioids compared to 5 in the saline group.

DISCUSSION

1) it is technically possible and practical to place femoral nerve catheters and discharge patients home with continuous infusions for at least 48 hours following ACL repair.

2) there were no complications related to infection or local anesthetic toxicity

3) we could detect no difference in the pain relief between B and L groups

4) in this patient population receiving multimodal aggressive analgesic therapy, there was a trend to lower opioid analgesic consumption in the patients receiving local anesthetic infusions. While several of the patients who received local anesthetics reported delightful and enthusiastic subjective relief of pain, there was a wide variability in the perception of pain and in the use of oral analgesics which made the differences between the groups statistically equivalent. It may require a larger study group or a longer infusion time in order to demonstrate a statistically significant difference. Further study is required to substantiate an economic or sociological benefit that would justify the increased work load and cost associated with the insertion or femoral nerve catheters.

1. Mulroy, RAPM 2001:26:24-9.

2. Ilfeld, Anesthesiology. 2002 97:959-65.

3. Ilfeld, Anesthesiology. 2002 96:1297-304.

P-18

NEUROSTIMULATION ASSISTED INTERSCALENE BLOCK – ASSOCIATION BETWEEN EVOKED MOTOR RESPONSE AND EXTENT OF SENSORY ANESTHESIA AND ANALGESIA

Jimmy Park,¹ Mark C. Kendall,¹ Robert Doty, Jr.,¹ Rahda Sukhani,¹ Robert J. McCarthy.¹ ¹Department of Anesthesiology, Northwestern University, Feinberg School of Medicine, Chicago, IL.

Introduction: A deltoid or more distal motor response has been considered a satisfactory end point for injection of local anesthetic, for meurostimulatory guided interscalene brachial plexus block (ISB). While evoked motor response (EMR) of the proximal muscle groups – deltoid, biceps and brachialis represents stimulation of the axillary and musculocutaneous nerves originating from C5-C6 nerve roots, distal muscle EMR responses (triceps and forearm flexors/extensors) represent stimulation of the radial and median nerves originating from C5-C8 nerve roots. Theoretically, this difference may influence the latency and extent of sensory and motor block. This study evaluated the correlation between EMR versus the latency and extent of sensory/motor block using a neurostimulation technique for ISB.

Methods: After IRB approval and written consent, 86 adult patients, ASA I-III, participated. All blocks were performed at least 30 min prior to surgery, with appropriate sedation and the aid of a nerve stimulator. Needle placement was considered satisfactory when EMR of one or more of the following muscles – deltoid, biceps, triceps or forearm was obtained at < 0.4mA. Levobupivacaine 0.625% with epinephrine 1:200,000 was injected in 3ml increments to a total volume of 0.5ml/kg (max 40ml). The latency to onset and extent of motor and sensory block were compared between the two EMR groups: Group P – proximal motor response group (deltoid/biceps); and Group PD – proximal and distal motor response group (deltoid/biceps/triceps/forearm). Sensory block assessments (0 = normal, 1 = analgesia, 2 = anesthesia) were performed in the distribution of dermatomes C3-T1. Motor block (0 = normal, 1 = paresis, 2 = paralysis) assessments were performed at the shoulder, elbow and wrist q 2mins for 10 min then q 5 mins for 30 mins. The block was considered delayed if a grade 2 motor block at the shoulder was not obtained within 15 mins. The frequency of a grade 1 and grade 2 sensory block at the tested determatomes and latencies to onset of analgesia and anesthesia were compared using a c² statistic or the Mann Whitney U-test.

Results: Demographic parameters were comparable between groups with 3 cases of delayed block were excluded. Of the 83 remaining cases, there were 50(62%) in Group P and 33(38%) in Group PD. Success rate of analgesia and anesthesia in each dermatome is depicted in Fig 1. Although the extent of sensory analgesia was more distal in Group D, Group P had more rapid onset of anesthesia in the distribution of C4 (Fig 2).

Discussion: The present study demonstrated that the site of local anesthetic injection for ISB (proximal EMR vs. distal EMR) does influence the latency as well as the success of ISB with respect to proximal and distal dermatomes. A proximal response more reliably blocks proximal dermatomes (C4) whereas a distal response results in a greater incidence of T1 blockade.

P-19

INTERSCALENE BRACHIAL PLEXUS BLOCK: A PROSPECTIVE ANALYSIS OF NEURAL SIDE-EFFECTS IN 251 PATIENTS

Christopher Fichter,¹ Antoun Nader,¹ Robrt Doty, Jr.,¹ Mark C. Kendall,¹ Radha Sukhani.¹ ¹Anesthesiology, Northwestern University,Feinberg School of Medicine, Chicago, IL.

Introduction: Interscalene block (ISB) of the brachial plexus provides safe and effective anesthesia and postoperative analgesia for patients undergoing shoulder surgery. Several side-effects related to the proximity of the roots of the brachial plexus (C5-T1) to several nerves (phrenic, recurrent laryngeal and vagus nerves) and nerve masses (the stellate ganglion) have been described. However, there are no prospective quanitifications of the relative incidences of the side-effects following ISB in a large series of patients. The present, evaluated the incidence of ; i) Horner’s Syndrome ii) Hoarseness iii) Cough iv) Subjective breathing difficulty (SBD) v) Hemodynamic perturbations (paradoxical Bezhold-Jarisch Reflex) and compared the incidences in right vs. left-sided ISB.

Methods: Following IRB approval, written consent was obtained from 251 adult patients undergoing shoulder surgery. Exclusion to study eligibility included: severe pulmonary disease, morbid obesity, hemostatic disorders, or known allergy to amino-amide local anesthetics. Patients received neurostimulator-guided ISB using the standard technique described by Winnie (3). ISB was achieved using levobupivacaine 0.6% with epinephrine 1:200,000, injected incrementally (0.4 mL/kg , maximum volume 40 mL). Supplemental sedation or general anesthesia per patient/surgeon request or extent of surgery was provided. The occurrences of any of the above-mentioned side-effects were recorded for the first 24 hours following ISB. Hoarseness was graded as to its severity (I=subjective; II=objective). Therapeutic interventions for SBD were recorded as: maximizing diaphragmatic excursion by upright position (grade I), supplemental nasal O₂for SpO₂< 94% (grade II), and incentive spirometry (grade III) when O₂failed to offset SpO₂decrease. The frequency of side effects between right and left ISB were compared by constructing contingency tables and c² statistic. A P<0.05 was required to reject the null hypothesis.

Results: 96 (39%) patients received left and 153 (61%) right sided ISB’s. Two patients were excluded from the analysis due to incomplete follow-up. Two patients in the beach-chair position required ephedrine for HR<40 associated with hypotension (BP systolic < 90 mmHg). Demographic parameters were similar between groups. The incidence of Horner’s syndrome and grades I and II hoarseness were higher in patients receiving right than left ISB’s (fig). Persistent intermittent coughing occurred in 8.4 and 6.0 percent of patients receiving left and right sided ISB’s respectively. Subjective breathing difficultly occurred in 7.7% of patients overall and at a similar rate following right and left ISB. Grade II and III therapeutic interventions for breathing difficulty were required in 6 and 5 patients receiving right and left sided ISB’s respectively. Patients requiring Grade II and III therapeutic interventions had mean BMI’s of 33±5 compared to 27±4 in those requiring Grade I interventions (P=0.018). All side effects resolved within 24 hours.

Discussion: This observational study represents the first prospective quantification and comparison of the incidences of side-effects following right and left ISB. The higher incidence of hoarseness and Horner’s syndrome following right-sided ISB may be likely a result of the proximity of the plexus to the recurrent laryngeal nerve. The incidence of SBD was comparable between left and right ISB, and the severity of this side-effect may be exacerbated in patients with BMI’s > 30 kg/m².

Reference: Winnie A P. Anesth Anal 1990, 49: 455-60.

P-20

DOES CEREBRAL MONITORING IMPROVE RECOVERY AFTER AMBULATORY ANESTHESIA? A COMPARISON OF BIS AND AEP MONITORING DEVICES

Jun Tang,¹ Hong Ma,¹ Paul F. White,¹ Ronald H. Wender.¹ ¹Department of Anesthesiology, UT Southwestern Medical Center at Dallas, Dallas, TX, United States.

Introduction: The bispectral index (BIS) monitor has been reported to improve the titration of inhalational anesthetics during general anesthesia (1,2). The auditory evoked potential (AEP) has also been shown to be a quantifiable measure of the sedative and hypnotic effects of anesthetic drugs. This study was designed to assess the comparative effects of AEP and BIS monitoring on the utilization of desflurane and the recovery profiles after ambulatory surgery.

Methods: 30 consenting women undergoing outpatient laparoscopic procedures were randomly assigned to one of three treatment groups. Anesthesia was induced with propofol, 2 mg/kg IV, and fentanyl, 1 µg/kg IV. Desflurane 2-4% in combination with N2O 60% in oxygen was administered for maintenance of anesthesia. In the Control group, the anesthesiologists were blinded to the AEP and BIS values, and desflurane was administered according to standard clinical practice. In the BIS group, desflurane was titrated to maintain a BIS value between 50-60. In the AEP group, desflurane was titrated to maintain an AEP-derived index (AAI) between 15-25. The AAI and BIS values, as well as the recovery times and side effects were recorded. Data were analyzed using one-way ANOVA for continuous variables, paired t-test for intragroup differences, and Chi-square test for categorical data. (* p<0.05 vs Control)

Results: During the maintenance period, the BIS and AAI values were significantly lower in the Control group (BIS values of 42±12 and AAI values of 12±6) compared with the BIS-titrated group (BIS of 60±15), and AEP-titrated group (AAI of 21±10), respectively. Even though they failed to achieve statistical difference among the three groups, early recovery times to eyes opening, extubation, and orientation were consistently shorter in both the BIS and AEP groups (vs Control). However, the times to sitting up, tolerating oral fluid, standing up, ambulating, "fitness" for discharge, and actual discharge were significantly decreased in both the AEP-titrated and BIS-titrated groups when compared to the Control group.

Conclusions: Titration of desflurane using the AEP and BIS monitors contributed to a faster emergence and earlier discharge home following outpatient laparoscopic procedures.

References:

(1) Anesthesiology 1997;87:842-8.

(2) Anesth Analg 2001;93:1165-9.

	Control	BIS	AEP
Age (yrs)	45±8	40±7	39±14
Weight (kg)	60±15	65±13	66±13
Surgery time (min)	48±27	38±22	42±32
Eyes opening (min)	9±4	7±4	7±5
Extubation (min)	9±5	7±4	6±4
Following commands (min)	9±4	7±4	7±5
Orientation (min)	10±5	7±4	7±5
Sitting up (min)	157±51	92±54*	105±58*
Tolerating oral fluid (min)	167±48	100±57*	109±52*
Standing up (min)	196±59	126±54*	120±56*
Ambulation (min)	196±59	126±54*	120±56*
Stay PACU time (min)	204±55	146±47*	149±44*
"Fit" for discharge (min)	201±52	117±45*	120±47*
Actual discharge home (min)	216±58	144±43*	140±41*

P-21

ANESTHETIC PROFILE AND TRANSIENT NEUROLOGIC SYMPTOMS AFTER AMBULATORY SPINAL ANESTHESIA USING PLAIN 1% MEPIVACAINE

Hiroko Iida,¹ Gotaro Shirakami,¹ Yuriko Teratani,² Tsunehisa Namba,¹ Kazuhiko Fukuda.¹ ¹Department of Anesthesia and ²Day Surgery Unit, Kyoto University Hospital, Kyoto, Japan.

Introduction: The use of lidocaine in ambulatory spinal anesthesia is questioned because of the high incidence (22% in Ref 1) of transient neurologic symptoms (TNS) occurring after subarachnoid lidocaine administration. Recently, mepivacaine has been recommended as an adequate local anesthetic for ambulatory surgical patients to decrease the risk of TNS ^1-3). Nevertheless, the occurrence of TNS is reported after spinal anesthesia with hyperbaric 4% (30% in Ref 4), isobaric 2% (7.5% in Ref 2) or isobaric 1.5% (7.4% in Ref 3) mepivacaine. To investigate whether lower concentration of mepivacaine is an alternative, we studied the anesthetic and recovery profiles and the incidence of TNS after subarachnoid anesthesia using plain 1% mepivacaine.

Methods: Seventy-one consecutive adult patients without neurological symptoms were studied (male 52, female 19; ASA PS I 26, II 43, III 2; age 57 ± 20, mean ± SD, 18-92 yr). They were scheduled to undergo perineal, lower extremity or groin surgeries on an outpatient basis in our Day Surgery Unit (DSU). The study was approved by the Ethics Committee of our Institution and informed consent was obtained from the patients. After a peripheral IV infusion was begun, subarachnoid puncture was performed in left or right lateral decubitus position at L3-4 or L4-5 interspace using a 25-gauge Quincke needle. Immediately after the subarachnoid injection of 5 mL (50 mg) of plain 1% mepivacaine, patients were positioned supine. Forty-three of the patients were repositioned in the lithotomy position after 10 min placement in the supine position. Other patients were laid in the supine position during the operation. An investigator assessed sensory level to pinprick and motor block using a modified Bromage scale ¹⁾. The incidences of hypotension (systolic blood pressure <90 mmHg), bradycardia (heart rate < 50 bpm) and other adverse events, as well as the use of ephedrine, atropine and other drugs were recorded. No sedative or narcotic drugs were administered perioperatively. All patients were interviewed 1 and 3 days after the operation and asked about TNS ¹⁾ and other unpleasant symptoms by telephone. If TNS or headache were not resolved on postoperative day 3, the patients were also contacted 7 days after surgery.

Results: The peak sensory level was T3-L2 (median T9) and the peak Bromage scale was 1-3 (median 3). Five patients (inguinal herniorrhaphy 4 and testicular sperm extraction 1) were given local anesthetic supplementation in the surgical field during surgery because of inadequate surgical anesthesia. Hypotension occurred in 5 patients and bradycardia in 11 during surgery. Four patients were administered ephedrine and one atropine. Three patients reported nausea during surgery, one in PACU and one 24h after DSU discharge. No vomiting was reported. None of the patients had severe cardiorespiratory derangement, emesis or other side effects perioperatively. The times from subarachnoid injection to complete resolution of motor block (Bromage scale = 0) and to sensory regression to S1 were 186 ± 36 min and 208 ± 38 min, respectively. The times to drinking and ambulation were 233 ± 41 min and 274 ± 39 min, respectively. The time required to void was 270 ± 48 min in patients without urinary catheterization (n=41). Twelve patients reported having headache after DSU discharge and seven were diagnosed as post-dural puncture headache. Twenty patients reported back pain or discomfort and two (knee arthroscopy 1, cystoscopy 1) were diagnosed as TNS. The TNS disappeared on postoperative day 4 in both patients. All complaints were not severe and transient.

Conclusion: The results demonstrate that spinal anesthesia with plain 1% mepivacaine in 50 mg dose is a suitable choice for ambulatory surgery in lower extremity and perineal regions with respect to anesthetic as well as recovery profiles including low incidences of TNS (3%) and other side effects. However, spinal anesthesia with this dose is sometimes inadequate and supplemental local anesthetic infiltration is required in groin surgery.

References: (1) Anesthesiology 1998;88:619, (2) Acta Anaesthesiol Scand 2001;45:240, (3) Anesth Analg 1999;89:1167, (4) Br J Anaesth 1997;79:301

P-22

SYSTEMATIC REVIEW OF POSTOPERATIVE OUTCOME FOLLOWING AMBULATORY SURGERY. INTRAVENOUS VS INHALATION ANESTHESIA

Anil Gupta,¹ Stephen D. Parker, Tracy Stierer, Lee A. Fleisher. ¹Department of Anesthesiology and Critical Care, Johns Hopkins Medical Institutions, and University Hospital, Baltimore and Örebro, MD, Sweden.

This systematic review focuses on postoperative recovery and complications using four different anesthetic techniques. The database Medline was searched via PubMed (1966 to June 2002) using the search words "anesthesia" and ambulatory surgical procedures limited to adults (> 19 yrs), in the English language and in Humans. A second search strategy was used combining two of the words "propofol", "isoflurane", "sevoflurane" or "desflurane". Screening and data extraction revealed a total of 42 articles, which were included in the final meta-analysis. No differences were found between propofol and isoflurane in early recovery, but intermediate recovery (home discharge) was faster in propofol (17 min). Minor postoperative complications including nausea and vomiting, use of anti-emetics and headache were all in favor of propofol compared to isoflurane. Early recovery was faster in desflurane compared to propofol (1.5-1.7 min) but postoperative complications including nausea and vomiting were greater in desflurane. Early recovery (time to obey commands) was also quicker with sevoflurane (1.26 min) compared to propofol. Intermediate recovery (‘time to home readiness’ (8.8 min) and ‘home discharge’ (10.3 min)) was found to be in favor of propofol. Significant differences were found in the incidence of postoperative nausea and vomiting, and the use of antiemetics in favor of propofol (Tables 1-3). In conclusion, the differences in early recovery times between the different agents was small and in favor of the inhalation agents, but home readiness was earlier in the propofol group, as also the incidence of side effects, specifically postoperative nausea and vomiting.

Table 1. Incidence of minor complications. Propofol vs Isoflurane
	Propofol	Isoflurane	RR (CI)	p-value	NNT
Postoperative nausea	92/765 (12%)	190/774 (25%)	2.03 (1.63-2.54)	0.00001*	8.0
Postoperative vomiting	24/524 (4.6%)	77/530 (15%)	3.01 (1.96-4.63)#	0.00001*	10.0
Anti-emetics given	21/303 (6.9%)	58/311 (19%)	2.65 (1.66-4.22)	0.00004*	8.5
Postoperative headache	3/180 (1.7%)	11/179 (6.2%)	3.29 (1.04-10.47)	0.04*	22.3

PON (Day 1)	49/319 (15%)	90/324 (28%)	1.8 (1.32-2.45)	0.0002*	8.0
POV (Day 1)	20/298 (6.7%)	53/306 (17%)	2.54 (1.57-4.13)	0.0002*	9.4

Results are presented as the numbers (%) of patients experiencing the complication. RR = relative risk, CI = confidence interval, PON = postoperative nausea, POV = postoperative vomiting. * Favors propofol. # Significant heterogeneity between studies. NNT = numbers-need-to-treat

Table 2. Incidence of minor complications. Propofol vs Sevoflurane
	Propofol	Sevoflurane	RR (CI)	p-value	NNT
Postoperative nausea	98/717 (13.7%)	188/704 (26.7%)	1.94 (1.57-2.39)#	0.00001*	7.7
Postoperative vomiting	30/602 (5.0%)	84/590 (14.2%)	2.64 (1.82-3.83)#	0.00001*	10.8
Anti-emetics given	2/171 (1.2%)	24/168 (14.3%)	6.63 (2.36-18.63)	0.0003*	7.6
Postoperative shivering	26/198 (13.1%)	20/197 (10.2%)	0.77 (0.46-1.29)	0.3
PON (Day 1)	21/221 (9.5%)	38/219 (17.4%)	1.81 (1.12-2.92)	0.02*	12.7
POV (Day 1)	2/136 (1.5%)	6/135 (4.4%)	2.60 (0.65-10.45)	0.18

Results are presented as the numbers (%) of patients experiencing the complication. * Favors propofol. # Significant heterogeneity between studies.

Table 3. Incidence of minor complications. Propofol vs Desflurane
	Propofol	Desflurane	RR (CI)	p-value	NNT
Postoperative nausea	76/406 (18.7%)	160/413 (38.7%)	2.06 (1.64-2.57)	0.00001*	5.0
Postoperative vomiting	25/349 (7.2%)	72/360 (20.0%)	2.51 (1.70-3.72)	0.00001*	7.8
Anti-emetics given	20/305 (6.6%)	81/322 (25.2%)	3.49 (2.28-5.33)	0.00001*	5.4
Postoperative headache	3/80 (3.8%)	10/82 (12.2%)	3.10 (0.97-9.87)	0.06
PON (Day 1)	14/105 (13%)	17/110 (16%)	1.18 (0.65-2.14)	0.6

Results are presented as the numbers (%) of patients experiencing the complication. * Favors propofol.

P-23

DOSE-RESPONSE RELATIONSHIP OF PROPOFOL BOLUS TO THE SNAP INDEX

Cynthia A. Wong,¹ Robert J. Fragen,¹ Paul Fitzgerald,¹ Robert J. McCarthy.¹ ¹Anesthesiology, Northwestern University, Chicago, IL, United States.

Introduction: The SNAP™ (Viasys Corp.) is a new level-of-consciousness monitor that uses an algorithm based on low (1-40Hz) and high (80-420Hz) frequency EEG components to derive a SNAP index. The purpose of this study was to define the dose-response relationship of a bolus of propofol to the SNAP index.

Methods: 110 ASA 1 or 2 patients scheduled for elective surgery under general anesthesia gave written informed consent to participate in this IRB-approved study. Exclusion criteria included BMI > 30, chronic use of CNS depressants, or a contraindication to propofol. The SNAP monitor signal averaging time was set to zero. The electrode montage was applied to the forehead of the unpremedicated subjects, and a baseline SNAP index was documented. The subjects were instructed to hold a weighted 20-mL syringe in one hand and not to drop it. They were then randomized to one of 11 groups (propofol 0, 0.6, 0.8, 1.0, 1.2, 1.4, 1.6, 1.8, 2.0, 2.2, or 2.4 mg/kg, N = 10/group). The propofol bolus was injected into a rapidly-running forearm IV. An investigator, blinded to the propofol dose, recorded the SNAP index when the subject released the syringe (endpoint) or at 160 s after the injection if the subject did not drop the syringe (endpoint SNAP value), and recorded the lowest SNAP index. Data were analyzed using probit analysis (ED₅₀ for propofol), the Wilcoxan Signed Rank test (endpoint SNAP value: subjects who reached the endpoint vs. those who did not), logistic regression, and Pearson’s correlation (SNAP index vs. propofol dose). P < 0.05 was considered significant.

Results: 56.4% of the subjects were female, age was 38 ± 9 y, and BMI 24 ± 3 (mean ± SD). ED₅₀ for propofol was 1.1 mg/kg (95% CI 0.93-1.24). Awake (baseline) SNAP index values were 92 ± 4, median 92 (range 78-99). The injection-endpoint time interval did not differ among doses (26 ± 19 s). The endpoint SNAP index decreased from baseline in the subjects who dropped the syringe, but not in those who did not (P < 0.005) (Fig. 1). In the logistic regression model the change in SNAP index was a significant predictor of the endpoint (P = 0.000). The area under the ROC curve for this model was 0.854 (Fig. 2). The Pearson’s correlation coefficient between the change in SNAP index and the propofol dose was 0.613 (P = 0.01).

Discussion: The SNAP index correlated with propofol-induced loss-of-consciousness, with the median index = 76 (range 57-94). The SNAP index appears to be a useful indicator of loss-of-consciousness and should be further investigated as a monitor of depth of anesthesia.

Study funded by Viasys Healthcare, Inc.

P-24

OUTCOME OF ASA 3 PATIENTS UNDERGOING AMBULATORY SURGERY

Gillian L. Ansell,¹ Jane E. Montgomery.¹ ¹Department of Anaesthesia, Torbay District General Hospital, Lawes Bridge, Torquay, Devon. TQ2 7AA, United Kingdom.

Background.

Ambulatory surgery is convenient and efficient for both patients and staff. It is also cost effective and safe when patient selection criteria are applied. Ambulatory surgery is becoming more widely acceptable, even for patients with complex medical conditions. In the United Kingdom government targets mean that it is likely that 75% of all elective operations will be carried out as day cases⁽¹⁾although no trusts are yet achieving this level. Current recommendations suggest that patients who are American Society of Anaesthesiologists (ASA) Grade 3 may be suitable for this approach⁽²⁾ although no published data seems to be available to support this. We present a retrospective review of ASA 3 patients who had undergone ambulatory surgical procedures in our unit.

Methods.

We carried out a retrospective case controlled review of 896 ASA 3 patients who had undergone ambulatory surgical procedures between January 1998 and June 2002 using the existing computerised patient information system (Daynamics, Calcius Systems Ltd). The system records admission rates, unplanned contact with healthcare services and common post-operative complications in the first 24 hours after discharge. Data is collected during the time the patient spends in the Day Case Unit and during a follow up telephone call 24 hours after discharge when the patient completes a standard telephone questionnaire. ASA 1 and 2 controls were identified by matching for age, sex and operation type.

Results.

We demonstrated no significant differences in unplanned admission rates between ASA 3 and ASA 1 or 2 patients (admission rate for ASA 3 patients was 2.9% and for ASA 1 and 2 patients was 1.9%, p=0.16). We also demonstrated no significant differences in unplanned contact with health care services in the first 24 hours after discharge in either group (incidence rate 1.0% for ASA 3 patients and 1.1% for ASA 1 and 2 patients, p=0.82). There were no significant differences in the incidence of the most common post-operative complications, namely drowsiness, nausea, bleeding and pain between ASA1 and 2 and ASA 3 patients (see table 1). No patient vomited and incidence of other post-operative complications was very low. The only significant difference between groups was in those experiencing moderate pain (incidence for ASA 3 patients 4.8% and for ASA 1 and 2 patients 1.8%, p=0.03). Total numbers of patients experiencing pain still remain low compared to national guidelines⁽³⁾.

Incidence of most common post-operative complications.
		*None*	*Mild*	*Moderate*	*Severe*	*Total with symptom(%)*
*Drowsiness*	ASA 1/2	648	9	4	0	10 (1.6%)
	ASA 3	637	8	8	0	10 (1.5%)
*Nausea*	ASA 1/2	648	8	1	0	9 (1.4%)
	ASA 3	638	6	2	0	8 (1.2%)
*Bleeding*	ASA 1/2	648	0	4	0	4 (0.6%)
	ASA 3	633	0	8	0	8 (1.2%)
*Pain*	ASA 1/2	512	4	12*	5	160 (23.8%)
	ASA 3	485	8	32*	3	175 (26.5%)

* p=0.03. All other p values are p>0.05

Conclusion.

With good pre-assessment and adequate preparation ASA 3 patients can be treated safely in the ambulatory surgery setting.

References.

1. National Good Practice Guidance on Pre-operative Assessment for Day Surgical Units. September 2002. UK Modernisation Agency: Operating theatre and pre-operative assessment programme.

2. Day Surgery: Operational guide. Waiting, booking and choice. August 2002. Department of Health, UK.

3. Raising the Standard: A compendium of audit recipes for continuous quality improvement in anaesthesia. 2000. J.A. Lack, L.A. White, et al. The Royal College of Anaesthetists.

P-25

NEUROSTIMULATION ASSISTED FEMORAL NERVE BLOCK (FNB): ANATOMICAL INDICATORS FOR SEEKING THE OPTIMAL MOTOR RESPONSE

John Lee,¹ Kenneth D. Candido,¹ Edward Yaghmour,¹ Mark C. Kendall,¹ Radha Sukhani.¹ ¹Anesthesiology, Northwestern University,Feinberg School of Medicine, Chicago, IL.

Introduction: A single-injection technique of FNB using neurostimulation relies on quadriceps femoris contraction ("patellar snap")(PS) as an end-point. Within 3-4 cm beneath the inguinal ligament, the femoral nerve (FN) terminates into anterior (superficial) and posterior (deep) divisions which immediately subdivide into muscular and cutaneous branches (1, 2). The femur, knee and patella are supplied by the posterior division of femoral nerve which also supplies the quadriceps femoris muscle. To achieve optimal motor response (PS) for FNB, the operator must be familiar with: i) The optimal needle insertion site and ii) Corrective strategies to seek patellar snap. To date, no study has evaluated the use of anatomical indicators to define optimal needle insertion site and the corrective needle adjustment strategies necessary to obtain a patellar snap. The purpose of this was to use anatomical indicators to guide needle placement and adjustment to a obtain patellar snap.

Methods: Gross anatomy of the femoral nerve was reviewed using standard anatomical texts, and 10 cadaver dissections were performed. The anatomical indicators considered useful for performing FNB were the following: i) At the level of the inguinal crease, the FN is widest, superficial, and lateral to the femoral artery (FA)(3). ii) Anterior and posterior divisions of the FN maintain superficial and deep orientations, respectively. iii) The anterior division supplies the sartorius muscle and the posterior division supplies the quadriceps femoris muscle.

After IRB approval and written, informed consent, 105 adults (age: 38±15),(weight 80±15 kg), gender distribution (F:33%/M:67%) participated. After appropriate monitoring and sedation, FNB was performed 30" prior to surgery. The primary needle insertion site was 1 cm lateral to the FA along the inguinal crease. The insulated needle was inserted at the marked site at 60° angle aiming cephalad using nerve stimulator guidance. If the needle-nerve contact (sartorius or quadriceps femoris evoked motor response-EMR) was not obtained, the needle was re-directed medially and subsequently laterally from the marked site until an EMR was obtained. 3 types of EMR were obtained; i) quadriceps femoris (QFC), or, ii) distal sartorius (SMC), or, iii) a combination of the two (S-QFC). If the response was other than QFC the following sequential steps were applied; i) needle was advanced further posteriorly. If still no QFC, the needle was withdrawn and re-directed posterolaterally. If still no QFC, the needle was withdrawn and re-directed posteromedially. Optimal needle position was considered only at brisk PS at <0.4 mA. Levo-Bupivacaine 0.6% with epinephrine 1:200,000 was incrementally injected (total volume: 20-30 mL). Sensory and motor block assessments were performed sequentially each 5 min. Parameters recorded were patient demographics, ultimate EMR site in comparison to marked site, type of initial EMR, and needle adjustment required to obtain PS.

Results: The median number of attempts to locate PS was 1 (range 1-7). The average needle depth was 27± 8 mm, and the mean time to complete FNB was 3.9 ± 2.6 min. The block was successful in 95% of cases, complete motor/sensory anesthesia obtained in 11.7± 6.6 minutes). Table I depicts the needle adjustments required to obtain QFC (PS).

Discussion: The FN was >/= 1 cm lateral to the FA in 91% of patients. If the EMR was S-QFC or SMC, patellar snap was obtained in 86% of patients by advancing the needle further posterior or posterolaterally. This objectifies our anatomical indicators whereby we found that the nerve supply to the quadriceps femoris lies posterior or in a posterolateral orientation to the nerve supplying the sartorius.

References:

1) Hall-Croggs E.C.B. ed. Anatomy As a Basis for Clinical Medicine. 3^rd ed., 1995.

2) Last RJ ed. Anatomy; Regional and Applied. 6^th ed., 1978.

3) Vloka JD, Hadzic A, Drobnik L et al.: Anesthesiology 1998, 89 3A.

Needle Adjustments to Obtain QFC ("PS")
*Needle-Nerve Contact*
Marked site:	64%
Lateral to marked site:	27%
Medial to marked site:	9%
*Type of EMR*
QFC("PS")	29%
S-QFC	28%
SMC	43%
*Needle Adjustments for S-QFC*
Posterior	52%
Posterolateral	45%
Posteromedial	3%
*Needle Adjustments for SMC*
Posterior	47%
Posterolateral	42%
Posteromedial	11%

P-26

A COMPARISON OF PROPHYLATIC DOLASETRON VERSUS ONDANSETRON IN PATIENTS AT HIGH RISK FOR POST-OPERATIVE NAUSEA AND VOMITING

Sean Birmingham, Richard Green, Eugenio Lujan, Dacanay Rhodel, Boyle Patrick, Maye John. ¹Department of Anesthesiology, Naval Medical Center San Diego, San Diego, CA, United States.

Background: Postoperative nausea and vomiting (PONV) is a common and distressing occurrence that decreases patient satisfaction, and increases morbidity as well as the expense of general anesthesia and surgery. Dolasetron and ondansetron are two 5HT3 antagonists commonly used in the prevention and treatment of PONV. The optimal 5HT3 antagonist for prophylactic treatment against PONV in high-risk patients remains controversial. 5HT3 antagonists appear to be most effective when administered to high-risk patients 15-30 minutes prior to the end of surgery (1). The Surgical Prophylactic Antiemetic Intervention Assessment Scale has been previously described as a way to predict who may benefit most from prophylactic treatment of postoperative nausea and vomiting (2).

Methods: We performed a prospective, double blinded effectiveness study comparing the effects of prophylaxis with either dolasetron or ondansetron in outpatient surgical patients deemed to be at high risk for PONV. Following Institutional Review Board approval and informed consent, patients at high risk for PONV undergoing general anesthesia were randomly assigned to receive 12.5mg dolasetron or 4mg ondansetron, 15-30 minutes prior to the end of surgery. Patients were observed in the PACU, and completed a home questionnaire 24 hours following surgery. We recorded the incidence of PONV, delay in PACU discharge, unanticipated hospital admission, and the incidence of "complete response". Complete response was defined as a study patient who demonstrated no postoperative emesis for 24 hours following surgery and did not require rescue antiemetic medication. Rescue antiemetic medication was given for episodes of emesis, Verbal Numeric Rating Scale for nausea of greater than 4 out of 10, or upon patient request for medication to treat nausea.

Results: 100 patients were randomized into two groups, and 95 patients completed the home questionnaire. No statistically significant difference existed between study groups in demographics, history of PONV, history of motion sickness, or type and duration of surgery and anesthesia. Complete response rates were not statistically different between study groups, 19/48(40%) in the dolasetron group versus 23/47(49%) in the ondansetron group (p=. 36). The percentage of study patients delayed in discharge from the PACU due to PONV was 18% in the dolasetron group, and 16% in the ondansetron group (p=. 79). There were no unanticipated admissions to the hospital for prolonged nausea or vomiting in either group.

Discussion: When patients at risk for PONV based on the Surgical Prophylactic Antiemetic Intervention Assessment Scale were given antiemetic prophylaxis near the end of surgery, 12.5mg dolasetron versus 4mg ondansetron, this study showed no difference in terms of complete response, delay in discharge from the post anesthesia care unit, or hospital admission due to post operative nausea and vomiting. In addition, we found that greater than 50% of patients at high-risk for PONV still suffered nausea and/or vomiting and required rescue medications despite single drug prophylaxis with 5HT3 antagonists given 15-30 minutes prior to the end of surgery. Both medications were well tolerated without any observed side effects.

References:

1)Kovac, A.L. Drugs 2000; 59:213-243

2)Gan, T.J. GlaxoWellcome Physician Information Handout 1999

P-27

PERIPHERAL NERVE BLOCKS (PNB) ARE SUPERIOR TO GENERAL ANESTHESIA (GA) IN REDUCING INTENSIVE POSTOPERATIVE CARE IN SAME-DAY KNEE ARTHOSCOPY PATIENTS

Alex Visan,¹ Admir Hadzic,¹ Jerry Vloka,¹ Paul Hobeika,¹ Pelin Karaca,¹ Alan C. Santos,¹ Daniel M. Thys.¹ ¹Anesthesiology, St. Luke’s\Roosevelt Hospital, New York, NY, United States.

Introduction

It has been suggested that efficiency of an ambulatory surgery center can be improved by allowing a selective PACU bypass of surgical patients to be prepared for home readiness in the second stage unit. A trial was conducted to compare the PACU bypass rate and incidence of complications associated with this practice between two anesthetic techniques (peripheral nerve blocks (PNBs) and general anesthesia (GA) in outpatients undergoing knee arthroscopy.

Methods

After IRB approval and informed consent, patients scheduled to undergo knee arthroscopy were prospectively randomized to receive a "fastrack" GA or lumbar plexus/sciatic blocks. Patients receiving GA received short-acting anesthetics (dolasetron, midazolam, fentanyl, propfol, N₂O/O₂/Desflurane via LMA), followed by intra-articular injection of 20 ml 0.25% bupivacaine. Patients in the PNBs group received midazolam (up to 4 mg) and alfentanyl (500-750µg) prior to block placement; chloroprocaine 3% as the local anesthetic, and propofol 30-50 mg/kg/min for intraoperative sedation). All anesthetics were induced in the operating room. The eligibility of the patients for PACU bypass (Aldrette score) was graded by PACU nurses blinded to the type of anesthesia and study goals.

Results

Fifty-one patients were enrolled; 25 patients received general anesthesia and 26 received PNBs (Table 1). One patient in the PNB group was excluded because of inadequate anesthesia requiring GA. The groups did not differ in age or ASA physical status. Time to meet criteria for home readiness was significantly shorter for patients who bypassed the PACU than for those who were admitted (138 ± 80 v 195 ± 86 mins, p = 0.02); subsequently, their time to actual discharge from the hospital was also significantly shorter (168 ± 84 v 218 ± 89 mins, respectively, p < 0.05). The three main reasons for failure to bypass were excessive somnolence, pain requiring treatment and occurrence of nausea.

Discussion

Same-day surgical patients who are awake, alert and mobile requiring no parenteral pain medications and with no nausea at the end of the knee-arthroscopy can safely bypass the PACU. When performed by experienced anesthesiologists, lumbar plexus/sciatic block using a short-acting local anesthetic (3% chloroprocaine) was associated with a superior recovery profile compared to a "fastrack" GA in patients having outpatient knee arthroscopy.

Table 1
	PNB	GA
Induction Time (min)	12 ± 6	8 ± 5
Surgery Time (min)	42 ± 7	41 ±7
Total OR Time (min)	97 ± 37	91 ± 42
Home Readiness (min)	131 ± 62*	205 ± 94
Discharge Time (min)	162 ± 74*	226 ± 96
PACU Bypass (%)	72*	24
Post-Op VAS Pain Score <2 (%)	84*	52

Mean ± SD; *p<0.05

P-28

OUTPATIENT TOTAL MASTECTOMY: A REVIEW OF 62 CASES

Lisa A. Ross,¹ Kode R. Ediale,¹ George G. Neuman,¹ Donald M. Mathews,¹ Amr S. Morsy,¹ Bledi Zhaku,¹ Deborah Axelrod.² ¹Anesthesiology, St Vincents Hospital Manhattan, Comprehensive Cancer Center, New York, NY, United States.

Introduction: Mastectomies performed in the outpatient setting began in the early 1990s and by 1994 some of these mastectomies were moved to freestanding ambulatory surgery centers. Insurance companies subsequently imposed limits on length of stay for mastectomy operations as a form of cost containment. In 1997 a public outcry from both patients and surgeons who labeled these procedures "drive-by" or "one-stop" mastectomies forced the insurance companies to reconsider their position. A number of states legislated that insurance companies pay for 48-hour in-hospital care. Part of this outcry stemmed from the presumption that an outpatient mastectomy precluded immediate reconstruction. We report a series of 62 patients who underwent total mastectomy with or without axillary dissection and total mastectomy with or without immediate reconstruction at our freestanding ambulatory surgery center. We reviewed our experience with this procedure to determine whether or not our outcome supported the continued practice.

Methods: Following IRB approval we reviewed the charts of all female patients (n=62) who underwent total mastectomy as an outpatient (surgery and discharge on the same day) from October 1999 through January 2003 in our surgicenter. All were given the option to have the procedure either as an outpatient or inpatient. Of the 62 patients, 21 had total mastectomy (six with insertion of tissue expander), 26 had total mastectomy with sentinel lymph node biopsy (five with insertion of tissue expander) and 15 had total mastectomy with axillary dissection. All procedures were performed under general anesthesia. The majority of patients received percocet pre-operatively and were maintained with propofol, fentanyl and desflurane (administered via LMA). All received ondansetron as prophylaxis for nausea and vomiting.

Results: All patients were ASA III or below with an age range of 26 to 79 years (mean 53). The average surgical and PACU times were 96 and 249 minutes respectively. Post-operative complications including unplanned admission within 72 hours are listed below. Of the 62 procedures preformed, there was a 17.7% incidence of nausea, an 8.1% incidence of nausea and vomiting and one admission. The admission was for post-operative bleeding in a patient who was later diagnosed with a bleeding diathesis.

Conclusion: Our review of 62 outpatient mastectomies (17.7% with immediate reconstruction) demonstrates a low complication rate with no major morbidity and one readmission within 72 hours after surgery. We therefore continue to support the practice of outpatient total mastectomy in the appropriate and motivated patient and believe it is reasonable to offer the option of immediate reconstruction.

POST OPERATIVE COMPLICATIONS (n=62)
	NUMBER	PERCENT
UNPLANNED ADMISSION WITHIN 48 HOURS	1	1.6
NAUSEA	11	17.7
NAUSEA AND VOMITING	5	8.1
HEMODYNAMIC INSTABILITY	0	0
PAIN SCORE > 3 AT DISCHARGE	0	0

P-29

TWO YEARS’ EXPERIENCE WITH 1% CHLOROPROCAINE FOR SPINAL ANESTHESIA IN AMBULATORY ANESTHESIA

Timo A. R. Palas. ¹Department of Anesthesia, Linde Hospital, 2503 Biel, Switzerland.

INTRODUCTION Chloroprocaine (cp) has been in clinical anesthesia practice for 50 years. Well known applications are epidural anesthesia and peripheral nerve blocks. In Switzerland 0.5% chloroprocaine is also registered for intravenous regional anesthesia (IVRA). Due to its properties of fast onset, low toxicity and rapid break down, it also should be ideal in intrahecal anesthesia for short surgical procedures. Since 2001 we have used an isobaric, additive free 1% cp solution in clinical outpatient settings.

METHODS after an informed consent 300 outpatients for various surgical (urology, surgery, gynecology/obstetrics, orthopedic surgery) procedures were selected to have spinal cp for the operation. The maximum time for surgery was not to exceed 45 minutes. A 27G pencil-point spinal needle (PENCAN®, Braun-Medical) was used. 30-40mg was injected. Postoperatively all patients were monitored to the point of full mobilization. Patients were asked for pain during injection, pain or paresthesias during recovery, PONV and urinary retention. Also any sort of an allergic reaction was recorded. When leaving the hospital patients were informed to contact the anesthesia department if any side effects or questions should occur.

RESULTS There were not any signs of TRI (transient radicular irritation) during injection of the local anesthetic drug, nor during recovery. The onset time was less than 5 minutes. After 60 minutes from injection all patients could already move their legs. 90 minutes after spinal anesthesia all patients could stand up. Surgical anesthesia was complete in all cases. None of the patients called to complain of side effects.

DISCUSSION A long search for a short acting local anesthetic drug for intrathecal anesthesia has been going on. With an additive free 1% isobaric chloroprocaine solution we probably have found our goal. TRI has been described with lidocaine (1) and even with bupivacaine (2). Previous studies have postulated of neurologic deficits following intrathecal 2-chloroprocaine injection (3). Wang showed later that it was actually the sodium bisulfite in the solution that was responsible for the neurological problems (4). It seems that an additive free, isobaric 1% chloroprocaine could be the ideal future local anesthetic drug for short surgical procedures.

REFERENCES 1. Anesth Analg 1993; 76; 1154-7 2. Reg Anesth 1996; 21: 26-9 3. Anesth Analg 1980; 59: 452-4 4. Anesth Analg 1984; 63 (4): 445-7

P-30

OSSEOUS RECONSTRUCTIVE ANKLE SURGERY- IMPACT OF ANESTHETIC AND ANALGESIC TECHNIQUES ON RECOVERY AND AMBULATORY TRANSITION

Daniel Kendall,¹ Edward Yaghmour,¹ Mark C. Kendall,¹ Radha Sikhani,¹ Robert J. McCarthy.¹ ¹Anesthesiology, Northwestern University, Feinberg School of Medicine, Chicago, IL.

Introduction: Reconstructive ankle surgery (RAS) requiring osseous manipulation produces moderate/severe postoperative pain. General and central neuroaxial anesthesia (spinal/epidural) supplemented with opioids may produce several side effects. A single injection sciatic nerve block (SNB) using long acting local anesthetic provides extended postoperative analgesia permitting ambulatory transition with high patient satisfaction (1, 2). The present prospective, study evaluated the perioperative analgesia and recovery profiles of patients receiving general or spinal anesthesia versus single injection extended SNB for osseous RAS.

Methods: IRB approval was obtained for this 2 phase study. Phase 1 patients gave written informed consent and received SNB plus sedation (Group 1). Phase 1 patients had a SNB with 25-35 ml of 0.625% levobupivacaine plus 1:200,000 epinephrine. Additional femoral or saphenous nerve block was performed as needed. Postoperatively patient received a standardized oral analgesic regimen consisting of oxycodone hydrochloride 20-30 mg every 12 hours, supplemented with hydrocodone 5mg with acetaminophen 325mg every 4-6 hours for breakthrough pain, and rofecoxib 25mg every 12 hours. Twenty-fours hours following surgery patients were questioned by a trained observer not involved in clinical care of the patient regarding the duration of analgesia as well their satisfaction with the perioperative anesthesia and analgesia. Phase 2 involved retrospective review of medical records of 30 patients who received general or spinal anesthesia (Group 2) for osseous reconstructive surgery. The Mann-Whitney U test and c² statistic were used to compare demographic and recovery parameters between groups. A P<0.05 was required to reject the null hypothesis.

Results: Demographic parameters were comparable in the two groups. Of the 70 patients in Group 1, 5 patients required rescue popliteal block; in all cases, surgery was completed under SNB plus sedation. Postoperative analgesia duration with SNB was 19 ± 6 hours. The table presents recovery parameters between the two study groups. The total opioid analgesic dose is presented as morphine equivalents in mg.

Conclusions: The important finding of this study was that in comparison to general or spinal anesthesia, SNB for osseous RAS provided a significant reduction in emetic sequelae, recovery room admissions, and the need for IV opioids as well as 24 hour opioid requirements. SNB provided effective perioperative analgesia (19 ± 6 hours) with high patient satisfaction (97% rated satisfaction ³ 8 on a scale of 0-10 with 0 = very unsatisfied, 10 = very satisfied).

References:

1. Rongstad K, Mann RA, Prieskorn D et al: Foot & Ankle International, 1996; 17: 378-82.

2. Hansen E, Eshelman MR, Cracchioloa III A: Foot & Ankle International, 2000; 21: 38-44.

Demographic and Recovery Parameters
	Group 1 (SNB) n=70	Group 2 (Gen/SP) n=30
Age (y)	43±14	42±11
Gender (% Male)	59	60
Weight (kg)	84±16	89±21
Surgical duration (min)	88±31*	105±36
Ankle reconstruction (%)	43	41
Fracture fixation (%)	57	59
Recovery room bypass (%)	96*	0
Ambulatory discharge (%)	66*	10
Post op IV opioids (%)	0*	90
Nausea (%)	47	67
Vomiting (%)	23*	63
Antiemetic intervention (%)	4*	63
24 hr morphine equivalent (mg) (median; range)	18 (0-62)*	30 (14-97)

SNB- Sciatic nerve block, Gen/Sp- General or Spinal Anesthesia; * = different from Group 2, (P<0.05)

P-31

ROLE OF HEATED AND HUMIDIFIED INTRAPERITONEAL GASES DURING LAPAROSCOPIC SURGERY - EFFECT ON TEMPERATURE CONTROL, POSTOPERATIVE PAIN, AND RECOVERY TIMES

Mohamed A. Hamza,¹ Alejandro Recart,¹ Babatunde Ogunnaike,¹ Paul F. White.¹ ¹Department of Anesthesiology & Pain Management, University of Texas Southwestern Medical Center, Dallas, TX, United States.

Introduction. Intraoperative hypothermia occurs commonly during major laparoscopic surgery procedures. Controversy exists regarding the efficacy of heated and humidified intraperitoneal gases in maintaining core body temperature. Therefore, we designed a sham-controlled study to evaluate the effect of the Insuflow® gas warming and humidification device on perioperative body temperatures, postoperative analgesic requirements, and recovery times. The hypothesis being tested was that the use of the active (versus sham) device would reduce intraoperative heat loss, decrease postoperative pain, and facilitate the recovery process.

Methods. 44 morbidly obese patients undergoing elective laparoscopic Roux-en-Y procedures under a standardized general anesthetic technique were randomly assigned to either a control (Sham) group receiving an ‘inactive’ Insuflow device, or an active (Insuflow) group receiving warmed and humidified intraperitoneal gases. Esophageal (core) temperature was measured intraoperatively and tympanic membrane temperature was measured postoperatively. No other active warming devices (e.g., forced air, IV fluid warmer) were used during surgery. Pain scores were assessed using an 11-point verbal rating scale, with 0=none to 10=maximal at 15 min intervals in the postoperative period. In addition, the postoperative opioid analgesic requirement, incidence of postoperative nausea and vomiting, as well as the quality of recovery using an 18-point questionnaire were recorded on the day of surgery, as well as on postoperative days #1(POD 1), #2 (POD 2) and #3 (POD 3). * p-value <0.05 vs Sham group.

Results: The demographic characteristics were comparable in both treatment groups (Table 1). Use of the active Insuflow device was associated with significantly higher core body temperatures at the end of surgery and after one hour of air insuflation. Two patients in Sham group (vs none in the Insuflow group) developed intraoperative hypothermia (temperature < 34 C) and were "rescued" by forced air warming. Although pain scores and opioid analgesic requirements in the PACU were significantly lower in the Insuflow group, there were no significant differences in their nausea scores . The length of stay in the PACU was shorter in the Insuflow (vs Sham) group (83±30 vs 107±69 min). However, this difference was not statistically significant due to the high degree of interpatient variability. Finally, the patients in Insuflow group reported a better quality of recovery on postoperative day #2.

Table 1
	SHAM	INSUFLOW
Number	21	23
Age (yr)	45 ± 12	44 ± 10
Weight (kg)	128 ± 17	125 ± 15
Surgery time (min)	132 ± 48	120 ± 24
Propofol (mg)	181 ± 32	182 ± 27
Desflurane (ET%)	4.5 ± 1.2	4.9 ± 1.1
Fentanyl (mg)	469 ± 147	393 ± 115
Total intravenous fluid (ml)	4836 ± 990	4217 ± 1093
Fogging of lens (1-5) †	2 (1-2)	2 (2-3)
Temperature at start of Insuflow	36.1 ± 0.4	36 ± 0.5
Temperature at end of surgery	35 ± 0.5	35.5 ± 0.6*
Max. pain scores (0-10), 45 min PACU	5 (4-5)	4 (0-5)*
Max. nausea scores (0-10)	0 (0-2)	0 (0-3)
Duration of PACU stay (min)	107 ± 69	83 ± 30
PACU morphine (mg)	9.9 ± 6	5.4 ± 5*
Quality of recovery @ 24 h (1-18)	12 (10-13)	12 (10-14)
Quality of recovery @ 48 h (1-18)	13 (11-15)	14 (14-16)*
Total hospital stay (day)	2 (2-3)	2 (2-2)

Values are means ± SD, medians (inter-quartile range), numbers (n), and percentages (%) † Scale 1=best to 5=worst

Conclusions: The Insuflow device may be a useful alternative to other active warming devices (e.g., forced air and IV fluid warming) for maintaining temperature during laparoscopic surgery. These preliminary findings suggest that the device may also be associated with lower pain scores in the early postoperative period and shorter recovery times. However, further larger scale studies are needed comparing this device to other active warming devices, as well as evaluating the Insuflow device in combination with the other commonly used warming modalities.

P-32

THE IMPACT OF OBESITY ON THE PLANNING OF AMBULATORY SURGERY LISTS

Simon Yarrow, Vivian Addy. ¹Nuffield Department of Anaesthetics, John Radcliffe Hospital, Oxford, United Kingdom.

Obesity has traditionally been regarded as a contraindication to ambulatory surgery (1) although recent large studies have suggested that the incidence of untoward events is no higher in these patients (2). In our institution, there is a reluctance to perform ambulatory surgery on the obese because of a perception that the challenging nature of surgery and anaesthesia in these patients means that more time is required, with an impact on the planning of operating lists. This prospective study was designed to assess the validity of this assumption.

METHOD

During the two periods of the study (18.3.02 - 4.4.02 and 5.8.02 - 20.9.02), 264 patients presented to the Gynaecology Day Services Unit. Height and weight are routinely measured on all patients, from which body mass index (BMI) could be calculated. Each patient’s progress through the system is recorded in real time on a computorised data collection system, allowing calculation of anaesthetic time (the interval between induction and entry into theatre), surgical time (interval between start and end of surgery), emergence time (interval between end of surgery and start of the next case), recovery time (interval between entry to the post-anaesthesia care room and discharge to the ward) and total time (interval between start of anaesthetic and discharge). These times could then be related to the patient’s BMI.

RESULTS

Of the 264 patients, body mass index could not be calculated on 18; no times were recorded on 4; 4 cases were performed with local anaesthesia. The data for the remaining 238 patients is shown in the table.

Body Mass Index	< 20	20 - 25	25 - 30	30 - 35	> 35
Anaesthetic Time	4 (3-6), n=16	5 (3-6), n=95	5 (4-7), n=59	5 (3-8), n=36	10 (5-12), n=15
Surgical Time	13 (10-16), n=20	13 (8-21), n=99	12 (8.5-22.5), n=73	16 (9-19), n=37	21 (12-32), n=16
Emergence Time	8 (4-14), n=15	8 (5-10), n=66	7.5 (4.5-11), n=51	8.5 (6.5-11.5), n=22	8 (5.5-14.5), n=11
Recovery Time	30 (25-40), n=21	30 (23-36.5), n=105	29 (21-33), n=76	24 (19.5-38.5), n=39	26 (20-40.5), n=11
Total Time	58 (48-70), n=16	58.5 (49-72), n=96	54.5 (45.5-75), n=61	53 (41-74), n=36	76.5 (56-97), n=16

Times in minutes (median + interquartile range)

Times are in minutes (median and interquartile range) and were analysed using the Kruskal Wallis test. Unfortunately, not every time could be calculated for every patient, owing to omissions in the routine input of data into the database. The process of induction of anaesthesia took significantly longer in patients with a BMI > 35 kg.m^-2 (p<0.01) although the absolute difference was only approximately 5 minutes. The total time for the procedure was also significantly longer (p<0.05) with an absolute difference of approximately 20 minutes. There were no significant differences in surgical time, emergence time or recovery time between the groups. The proportion of patients in each group undergoing laparoscopic surgery was similar (data not shown).

CONCLUSIONS

This data supports the view that obesity alone should not preclude ambulatory surgery. The perception that obese patients take longer to anaesthetise is correct, but the absolute difference in time is small. It would seem prudent to place obese patients early on an operating list to ensure efficient use of theatre time.

REFERENCES

1 Royal College of Surgeons of England. Guidelines for Day Case Surgery, March 1992

2 Davies et al Anaesthesia 2001; 56: 1112-5

P-33

THE INDUCTION DOSE-EFFECT OF PROPOFOL IN ADDITION TO LOW-DOSE ROCURONIUM ON TRACHEAL INTUBATING CONDITIONS FOR DAY-CASE TONSILLECTOMZ IN CHILDREN

Dubravka Bartolek,¹ Zoran Lajtman,¹ Katarina Sakic.² ¹Anesthesiology and Othorynolaryngology, Clinic Hospital Merkur, Zagreb, Croatia.

Tonsillectomy in children is a surgical procedure performed in general anesthesia on a day-case basis. Minimal postoperative morbidity as well as successful postoperative outcome depend not only on patient selection with optimaization of preoperative function but also on appropiate choice of anesthetic technique and good selection of anesthetic agents. Induction and maintenance of day-case anesthesia, especially in children has centered on rapid- and short-acting drugs combination of the hypnotic, opioid and one non-depolarizing short-acting or low-dose intermediate-acting muscle relaxants that allow rapid induction and recovery.We investigated the effect of different induction doses of propofol accompanied by low-dose rocuronium on intubating conditions and hemodynamic changes in day-case tonsillectomy in children. The protocol of the study was approved by the Ethic Committee of the Merkur University Hospital and written informed consent obtained from the parents. Three hundred children of both sexes ranging in age 6-9 years, classified as ASA grades I or II were included in a prospective, double-blinded clinical study during a one year period. The children were randomized to the three groups of one hundred children each. Groups were comparable in demographic data. One hour prior to anesthesia children were premedicated with midazolam 0.5 mg kg ^-1orally and a 5% eutectic mixture of lidocaine and prilocaine (EMLA) was placed over a promising peripheral vein. In thirty children anesthesia was induced with propofol in a dose of 2.0 (Group A), 2.5 (Group B) or 3.0 mg kg^-1(Group C) preceded by alfentanyl (0.02 mg kg^-1) 5 minutes before. Muscle relaxation was achieved with low-dose rocuronium (1.5 x ED₅₀; 0.45 mg kg ^-1). The intubating conditions were assessed using a four-point scoring system by Helbo-Hansen based on the difficulty of laryngoscopy( 1=easy, 2=regular, 3=difficult, 4=impassible), presence of vocal cord movement (1=open, 2=moving, 3=closing, 4=closed) and the intensity of coughing (1=none, 2=slight, 3=moderate, 4=severe). The adequate intubating conditions were accepted if score in three variables was equal or less than 2, and inadequate if it was greater than 2. Neuromuscular transmission was monitored by means of acceleromyography with supramaximal train-of-four stimulation of the ulnar nerve with the frequency of 1Hz. X ²Fisher’s exact test was used for nominal variables and one-way ANOVA, post-hoc test were used for numerical variables. Repeated measures of ANOVA was used to analyse haemodynamic variables during the time. Onset time of neuromuscular block did not differ between groups (A=3.2 +/-0.4, B=3.1 +/- 0.4 and C=3.1 +/-0.4 minutes (p>0.05). The adequate intubating conditions (AIC) were significantly better with 2.5 (97%) and 3.0 (99%) then with 2.0 mg kg^-1of propofol (p<0.05). Although, we recorded significant higher fair laryngoscopy, movement of vocal cords and slight coughing with 2.5 (4%, 7% and 3%) than with 3.0 mg kg^-1of propofol (0%, 1% and 0%)(p<0.05) there was no statistical difference in AIC (p>0.05). The mean arterial blood pressure decreases significantly immediately after induction of 3.0 mg kg^-1of propofol (12% versus 2.0 mg kg^-1=2% and 2.5 mg kg^-1=4%)(p<0.05). We conclude that induction dose of 2.5 mg kg^-1of propofol with low-dose rocuronium improved AIC in short elective day-case surgery where neuromuscular block is required.

References

1. Collins L, Prentice J, Vaghadia H. Tracheal intubation og outpatients with and without muscle relaxants. Can J Anesth 2000;47:427-432.

2. Erhan E, Ugur G, Alper I et al. Tracheal intubation without muscle relaxants: remifentanil or alfentanil in combination with propofol. Europan J Anaesth 2003;20:37-43.

3. Moore EW, Pollard BJ, Elliott RE. Anaesthetic agents in paediatric day case surgery: do they affect outcome? European J Anaesth 2002;19:9-17.

P-34

COMPARISON OF SMART CAPNOLINE O2 NASAL CANNULA AND STANDARD NASAL O2 CANNULA FOR RESPIRATORY MONITORING IN SEDATED PATIENTS

Roger Mattison,¹ Colleen Dingmann,¹ Leslie Jameson.¹ ¹Department of Anesthesiology, University of Colorado Health Science Center, Denver, CO.

End tidal (ET) CO₂ monitoring is commonly used for early detection of hypoventilation in sedated patients. Increasingly complex procedures are performed utilizing a combination of analgesic and hypnotic agents to achieve sedation. Sedation, often administered by nonanesthesiologists, reduces consciousness and respiratory effort. Decreases in SpO₂ are late and dangerous signs of hypoventilation. Changes in capnography, as measured by respiratory rate, ET CO2 value and capnographic conformation, can be the early indicator of significant hypoventilation. In a sedated patient the standard ET CO2 sampling device is a nasal cannula (SNC) delivering O2 into one nostril and aspirating respiratory gas from the other. TheSmart CapnoLine O2 cannula (Oridion, Needham, MA) (ONC) is designed to aspirate respiratory gas and to deliver oxygen from several seperate locations. This study compared SNC and ONC for detection of respiratory depression in sedated surgical patients in an outpatient surgery center.The hypothesis was that ONC with its multiple sampling ports would be more sensitive at detecting depressed ventilatory activity than SNC.

Methods. With IRB approval and with informed consent 110 patients were randomly assigned to control (SNC) (n=54) and the ONC groups (n=56). The cannula to be used was attached to an RGM 5250 (Ohmeda, Louisville, CO). MAC sedation was provided with midazolam, fentanyl and/or propofol, ad lib by the attending anesthesiology team, to patients undergoing a variety of minor surgery procedures. Supplimentary anesthesia may have been provided by regional or field block. Patient age, gender, ASA classification, surgical procedure and body mass index (BMI) were recorded. At 0 (without sedation), 5, 15, 30, and 45 minutes (or end of procedure) ET CO2 value, presence of waveform, observed respiration without ET CO2 waveform (NC apnea), respiratory rate, oxygen saturation, airway support intervention manuever(s), and sedation score were recorded. SNC and ONC groups were compared using Chi-square and ANOVA with p<.05 significant.

Results. There were no differences between the mean SNC and ONC groups in age (54.46 ±16.54 and 48.04±16.44 years), gender ratio (female/male=37/17 and 42/14), or mean BMI (26.68±5.53 and 26.72±7.09 kg/m². Distribution of sedation over time and initial ET CO2 (t=0) measurements were the same for each group. Hypoventilation occured in both groups. ONC ETCO2 was lower during sedation (ET CO2 28.87±6.99 at sedation level 1-2 and 27.16±9.48 at sedation level ³3 while SNC ETCO2 was higher (33.74±6.32 and 36.52±6.82 respectively). Difference between groups was significant (p<.001). Respiratory changes with deeper sedation were detected by NC apnea using ONC (4 episodes/16 patients at level 1 vs 10/21 at level ³4) and SNC (1/19 and 11/24). The differences in NC apnea between levels of sedation were significant (p<.01in both groups) but the difference between cannula was not. There were no differences in the presence of waveform respiration without ETCO2, respiratory rate, oxygen saturation, or ETCO2 at sedation levels 1,2,or3 for either cannula. BMI alone did not effect the detection of hypoventilation. ORC or SNC groups did not differ in SpO2 at any measurement point but clinically insignificant decreases in SpO2 did correlate to hypoventilation.

Conclusions. During sedation for surgical procedures a period of attenuated conscious often ensues requiring ETCO2 monitoruing to provide early detection of hypoventilation. Our study showed no better detection of decreased or increased CO2 using the design with dual nasal sampling ports plus an oral sampling port. The oxygen delivery fenestrations in this cannula design may have artifactually lowered the CO2 in end tidal sampling. Our conclusion is that the three port cannula offers no clear advantage over the conventional design.

P-35

"DOES PREEMPTIVE ANALGESIA REALLY WORK? A COMPARISON OF OXYCONTIN, ROFECOXIB AND PLACEBO UNDERGOING ELECTIVE LAPAROSCOPIC CHOLECYSTECTOMY"

Swapna Chaudhuri,^{TTUHSC-El
Paso} Kallol Chaudhuri,^{TTUHSC-El Paso} Emmett L. McGuire,^{TTUHSC-El Paso} José Rivera, ^{UTAustin&ElPaso} James Boone. ^{TTUHSC-El Paso} ¹Anesthesiology, Texas Tech University Health Science Center, El Paso, TX, United States.

Introduction: Recently, there has been renewed interest regarding the role of preemptive analgesia with long acting oral medication in the management of postoperative pain (1, 2). The purpose of this study was to compare the postoperative analgesic effects of Oxycontin, rofecoxib and placebo in patients undergoing outpatient laparoscopic cholecystectomy.

Methods: Following approval from the Institutional Review Board, a randomized double-blinded placebo controlled study was undertaken in ASA I and II patients scheduled for elective laparoscopic cholecystectomy. Group 1 (n=23) received 10 mg of Oxycontin, Group 2 (n=25) received 50 mg of rofecoxib, and Group 3 (n=23) received the placebo tablet. Exclusion criteria included patients less than 18 years or more than 65 years of age, patients with history of hypersensitivity to codeine, pregnancy, renal or hepatic disease, substance abuse, patients who had received any pain medications within 24 hours before surgery, and conversion to open cholecystectomy. All patients were administered their medications orally, approximately 60 minutes prior to surgical incision. Induction of general anesthesia was accomplished with propofol (1.5-2 mg/kg), fentanyl (2 mcg/kg) and cisatracurium (0.2 mg/kg) or rocuronium (0.6 mg/kg). Following intubation of the trachea, general anesthesia was maintained with O₂:N₂O (50:50) and isoflurane (0.6-1.2%), together with intermittent boluses of fentanyl and muscle relaxant. Patients did not receive any other analgesics during surgery, nor was any local anesthetic infiltrated at the sites of surgical incisions at any time during the procedure. In the postanesthesia care unit (PACU), pain and sedation levels were assessed every half-hour until discharge. Total dosage of morphine administered to each patient for breakthrough pain was recorded, and the number of patients requiring morphine treatment was documented in each group.

Results: The average total dose of morphine required for each patient was 2.8 mg, 4.8 mg and 3.4 mg in the Oxycontin, rofecoxib and placebo groups respectively. However, using analysis of variance testing, no statistical difference was observed among the three groups (p>0.05). With regards to incidence of breakthough pain, 13/23 patients in Group 1, 7/25 in Group 2, and 10/23 in Group 3, did not require any supplemental morphine in the PACU. Furthermore, there was no obvious difference in pain scores among the three groups; however, there appeared to be a trend for greater morphine requirement in the rofecoxib group.

Discussion: This study raises some questions regarding the efficacy of oral preemptive analgesia with Oxycontin (10 mg) or rofecoxib (50 mg) in the management of postoperative pain following laparoscopic cholecystectomy.

References:

1. Can J Anesth 41:98-101, 1994.

2. Anesth Analg 94:55-59, 2002.

P-36

PAIN 24 HOURS AFTER AMBULATORY SURGERY. CAN WE DO BETTER?

Brid McGrath, Frances Chung, Hany Elgendy, Damon Kamming. ¹Department of Anesthesia, Toronto Western Hospital, University of Toronto, Toronto, ON, Canada.

Introduction: We investigated the severity of pain at 24 hrs after ambulatory surgery and determined the most painful procedures. The need for further advice, clarity of postoperative instructions and overall patient satisfaction was also examined.

Methods: Approval of the institutional ethics committee was obtained, and 12,085 consecutive ambulatory patients were studied over a 17-month period. For treatment of postoperative moderate to severe pain, intravenous fentanyl 25mcg was titrated until the patient was comfortable. Mild postoperative pain was treated with acetaminophen or acetaminophen with codeine 30mg. Take home prescriptions were for acetaminophen or acetaminophen with codeine 30mg. 5,703 patients were successfully telephoned 24 hrs after surgery. Patients were asked to grade their pain using the 10-point self-assessing scale (0=no pain, 10=worst pain. Data was analyzed in 2 groups, those with moderate pain to severe pain (pain score 4-10) and those with no or mild pain.

Results: 30% of patients (1495/5703) had moderate to severe pain. Patients who had undergone neurosurgery or general surgery had the highest incidence of moderate to severe pain (figure1). Microdiscectomy, laparoscopic cholecystectomy, shoulder, elbow/hand, ankle, inguinal hernia and knee surgery were the individual procedures causing the most pain at 24 hrs postoperatively (figure2).13.2% of patients needed medical advice by telephone, 1.4% made an unplanned visit to a doctor while the unanticipated admission rate was 0.08%(table1). Commonest reasons for seeking advice included pain, prescription advice, wound oozing and bleeding.

88% of patients with moderate-severe pain indicated that instructions for taking pain medications were absolutely clear. 86% of these patients felt that instructions to alter dosage and timing of analgesics to augment pain relief were absolutely clear. 98% found the postoperative instruction sheets and advice helpful. 99% of patients indicated staff listened and answered their queries. Overall satisfaction of care received was excellent (78.2%), good (21.2%), fair (0.5%) and poor (0.2%).

Discussion: Despite 30% of patients having moderate-severe pain at 24hrs, overall satisfaction ratings were high. As pain is one of the commonest reasons for delayed discharge and readmission¹ postoperative prescribing and analgesic instructions need to be absolutely clear and tailored according to type of surgery. Effective analgesia will allow continual development in the field of ambulatory surgery.

References: Anesth Analg 1995; 80:896-902

Requirement for further medical intervention
	Number	Percentage
Advice from calling nurse	499	9.8
Telephone call to doctor	170	3.4
Unplanned visit to doctor	38	0.7
Visit to Emergency Department	36	0.7
Unplanned hospital admission	4	0.08

P-37

THE USE OF DOPPLER ULTRASOUND FOR FEMORAL NERVE BLOCKS IN MORBIDLY OBESE PATIENTS

Ramprasad Sripada, Jafrul S. Islam. ¹Department of Anesthesiology, Saint Louis University, Saint Louis, MO, United States.

Abstract: Using a Doppler ultrasound pencil probe in 15 morbidly obese patients weighing 200 to 500 lbs, it became easy to identify the arterial structure within the femoral sheath, and the position of femoral nerve just lateral to it. With the use of the technique described in the report successful block was achieved in a single attempt in all patients.

Introduction: When performing a femoral nerve block, it is imperative to administer the correct dose of local anesthetic to the target nerve without incurring any damage to the nerve and its related structures. Currently, regional blocks are achieved by using needles, guided mostly by knowledge of anatomy and electrical nerve stimulation or elicitation of paresthesias and by visualization of nerves with an Ultrasound if available. The conventional technique of femoral nerve block relies on feeling the pulsatile femoral artery as a reference point as it emerges through the femoral sheath. The nerve is then localized by muscle twitch with a stimulator. Identification of the femoral artery and the nerve may require several attempts because of variations in surface anatomy. In most morbidly obese patients, it is difficult to feel the femoral arterial pulse. The patient, especially when obese often poorly tolerate the procedure because of the associated discomfort of the nerve searching procedure in the supine position. As such some anesthesiologists avoid using the block. We describe a technique using a Doppler ultrasound flow detector¹ in morbidly obese patients that accurately determines the entry point of the block needle for rapid localization of the nerve.

Method: Patients were placed in supine position after pre-medication with midazolam and fentanyl. After routine aseptic skin preparation, a sterile pencil Doppler probe (8.0 MHz probe, model 811-BL, Park Medical Electronics, Oregon) was used to locate the position of the femoral artery². The Femoral nerve was localized with help of the nerve stimulator approximately 1 cm lateral to the position of the ultrasound probe along the inguinal crease. A 5 cm insulated nerve stimulator needle was inserted through the skin perpendicularly approximately 1.0 cm lateral to the artery until twitches were elicited. Once the nerve was identified, the block needle was held firmly while 25cc of a 1:2 mixture of 0.5% levobupivacaine and 2% lidocaine was injected after negative aspiration for blood. Complete block occurred within 10 to 20 minutes.

Results: With conventional technique, identification of the femoral artery by palpation was not feasible in these obese patients. Using the Ultrasonic Doppler Flow detector made it easy to locate the femoral artery in all cases. In all of the 15 patients a block at a point 0.5 to 1 cm lateral to the maximal impulse was successful after a single attempt with no arterial punctures. Patients tolerated the procedure well and none required reinsertion of the needle as compared to conventional way where several attempts may be required to locate the femoral artery and the femoral nerve. Additionally, in some instances, one may have to abort the procedure due to inability to locate the nerve. In our group of patients, the time required for the placement of the blocks was between 10 to 15 minutes. Experience of the anesthesiologist did not affect the procedure.

Discussion: Use of femoral nerve blocks is limited by the experience of anesthesiologist and body habitus. Ultrasonic Doppler can be a useful aid in identifying vascular structures, especially for patients with distorted or altered anatomy as in our cohort with morbid obesity. The use of ultrasound-guided nerve blocks under visualization has been described recently. Advantages of the ultrasonic flow Doppler in nerve blocks are i) portable, ii) a handy pencil-probe, iii) readily available in the absence of an expensive ultrasound for visualization of nerves, iv) inexpensive, v) useful in teaching trainees³ and vi) does not require expertise. Using ultrasonic Doppler, such complications as accidental puncture of blood vessels and repeated attempts at locating the perivascular sheath can be prevented. A randomized study is necessitated.

References:

1. Regional Anesthesia 1991Sep-Oct; 16(5): 282- 4.

2. British Journal of Anesthesia 1978; 50(9): 965-7.

3. Regional Anesthesia Pain Medicine 2002 Jul-Aug; 27(4): 444-5.

P-38

A QUALITY-CONTROL SURVEY USING 2 DIFFERENT ANAESTHETIC TECHNIQUES IN DAY CASE SURGERY

Gerda Egedorf, Hanne Kragh, Kurt Feddersen. ¹Dept of Anesthesia, Fyns Hospital, DK-5700 Svendborg, Denmark.

In this survey we focused on possible relationsships between 2 anaesthetic regimes on postoperative outcome parameters. 300 questionnaires were handed out, 255 usable responses form the basis for this analyses.

Patients were asked choose between induction by intravenous propofol + remifentanil (gr. A) or by sevoflurane inhalation and supplementary i.v. remifentanil (gr. B). 208 patients had previously had general anaesthesia.

169 patients were given i.v. induction (A) and the remaining 86 were given inhalation (B). Routine day case surgery - gynaecology, ENT, orthopaedics and general surgery - was performed.

On arrival at the PACU 5 patients (3%) in group A and 10(12%) in group B complained of PONV but only 2 and 4 asked for treatment. At the telephone interview 24 – 48 hours after discharge this problem was negligible.

47(28%) patients in A and 42(49%) in group B sensed an unpleasant smell or taste during induction and in the PACU, but it had disappeared at the time of the telephone interview.

39(23%) of the patients in A and 19(22%) of the patients in B complained of pain related to the position of the i.v. line.

Postoperative pain was treated with paracetamol, if necessary in combination with codeine, and lornoxicam (NSAID). Opioids were not used. At discharge VAS score was < 2.

At the telephone interview 38 patients in A had no pain at all and the remaining gave an average VAS score of 1.8; 6 patients had slight PONV and 27 minor headache and/or dizziness; 22 needed to consult medical staff regarding their problems. In group B 16 patients had no pain and the remaining patients gave an average VAS score of 3.6; 13 had slight PONV and 9 headache and/or dizziness; 10 needed contact to professionals after discharge.

Our survey found that >95% of the patients rate day care treatment acceptable.

Discussion: This survey allows us to describe the span of postoperative events related to anaesthesia and surgery in the PACU and after discharge. 2 different induction methods were used. Bad taste or smell is a known side effect to sevoflurane but was tolerated by all. Surprisingly, a large number of patients having had i.v induction felt a similar sensation. We anticipated pain in the i.v.-line arm in group A and were surprised that a number of the group B patients also complained of this. This side effect may be significant, as it is identical in A and B.

The profile of side effects differs between the groups, and this should be explained to the patient in order to give him sufficient basis for choosing between the methods. Although most patients had had general anaesthesia previously, 25% chose induction by sevoflurane, a method not normally used in our region/country.

The patient’s freedom of choice might be a mutual advantage in so far as he feels co-responsible for the course of recovery. The narrow range in inductions agents is easier for him to overlook - and for the staff, in order to advice on and relate to side effects. This may be mirrored in the low incidence of PONV as we used the full effect of lornoxicam and avoided the use of opiods. In general, the patients did well 24 – 48 hours post operatively and only had minor problems related to the day case treatment as such. However, we had not fully appreciated the need for professional contact after discharge, in particular during the first 24 hours. We conclude that preoperative information regarding possible postoperative events in general and complications specifically related to surgery and anaesthesia is mandatory in maintaining quality control and high patient satisfaction

P-39

OUTPATIENT SPINAL SURGERY

W.Bradley Worthington.¹ ¹St.Thomas Outpatient Neurosurgery Center, St.Thomas Healthcare Services, Nashville, TN.

Outpatient neurosurgery{OPNS} has traditionally encompassed peripheral nerve decompression and biopsy procedures.Novel strategies providing improved anesthesia recovery,postoperative analgesia ,decreased nausea/vomiting and streamlined patient flow,have allowed our facility to offer an expanded variety and complexity of spinal procedures. We present our experience caring for patients undergoing anterior cervical fusion with instrumentation{ACDF} as an example of our inpatient to outpatient transition.

The St. Thomas Outpatient Neurosurgery Center (STOPNC) is a JCAHO accredited free-standing facility in Nashville, Tennessee, jointly owned by St. Thomas Healthcare and Neurological Surgeons, P.C. Neurological Surgeons, P.C. is a horizontally integrated private practice neurosurgical group.

In 2001 and 2002 STOPNC performed a total of 7,836 outpatient procedures, 2,323 OPNS and 5,513 pain management procedures. In 2002 the facility performed 331 outpatient ACDFs.

During the preconstruction phase of our facility we sought input from neurosurgeons, anesthesiologists, operating room and perioperative nurses, as well as architects, interior designers, and life safety consultants. The result of our effort is an aesthetically pleasing ,functional,and convenient outpatient facility.

In reviewing the processes associated with traditional hospital based outpatient neurosurgical procedures we identified fourteen steps in patient flow through seven different environments. We utilize uniquely designed, staffed and equipped patient care sites reducing patient flow to two environments. This scheme allows total patient care by two nurses, a perioperative R.N. and an intraoperative R.N., from admission to discharge.

Table 1 shows the total number of OPNS performed in 2002.All patients undergoing ACDF had neuroanatomic and /or neurodiagnostic corroboration of cervical neurocompressive lesions failing to respond to ample non-surgical interventions. These patients included ASA 1 and 2 patients and carefully screened ASA 3 patients having stable conditions.

Of the 331 ACDF procedures in 2002 there was one superficial skin infection (.3% infection rate).There were two direct admissions to the adjacent hospital.One patient was observed in an emergency room for painful postoperative urinary retention and discharged. In the remaining 328 patients there were no complications.

We reassessed our anesthetic and postoperative analgesia techniques to promote fast recovery and overcome the traditional obstacles to OPNS. We have found the use of NSAIDS,Central Alpha-2-agonists, and NMDA receptor antagonists critical to our success in avoiding intravenous opioids. We also utilize a cocktail consisting of dilute local anesthetic, NMDA receptor antagonists, and NSAID to infiltrate the surgical field in all patients undergoing OPNS providing impressive control of postoperative incisional pain allowing early ambulation.

Table 2 shows admission to discharge times for one and two level ACDF surgery.Level I recovery to discharge is a rapid process. The majority of our patients meet or exceed level I discharge requirements within five minutes of extubation. Level II monitoring and staffing criteria continues until the patient is ambulatory, well hydrated, voids, and voices adequate analgesia with minimal nausea and vomiting."Door-to-door" times for 1 level ACDF procedures averaged 6:25,2 level ACDF 7:08{3 hour monitoring post extubation by policy}.

Patient volume at STOPNC is increasing due to improved patient satisfaction and convenience. Revamped anesthesia and analgesia techniques have enhanced and accelerated postoperative recovery and discharge allowing OPNS to be performed safely and efficiently in a specially designed and staffed outpatient facility.

P-40

EFFECTS OF MUSIC DURING SURGERY IN DAY CASE PATIENTS

Anne-Lise Flintegaard, Gerda Egedorf, Kurt Feddersen. ¹Dept of Anesthesia, Fyns Hospital, DK-5700 Svendborg, Denmark.

Day case surgery has evolved into a highly specialised medical service to patients and it is sensitive to side effects and complications. Every effort is focused on patient safety, quality in service and compliance after discharge. This relies on a holistic view on the treatment in which factors other than strictly medically related may come into focus. The influence of music on psychological functions as well as on medical data and response to pain is reported positive. We have earlier conducted a pilot study on this thesis with promising results.

In this survey of 257 (213 female; 44 male) patients could listen to music (CD-player, headphones, New Age Music) or prefer not to. 82 requested music, and 175 preferred no music. Patients underwent typical day case operations in gynaecology, ENT, orthopaedic and general surgery. Anaesthesia was by sevoflurane and remifentanil or propofol and remifentanil for induction and maintained by sevoflurane and remifentanil. Pain treatment was by paracetamol with or without codeine and lornoxicam, NSAID, on indication.

About 60% selected i.v. induction. Demographic data were identical in the two groups. Duration of anaesthesia and surgery was much the same in the groups, and there was no difference in lowest systolic BP, diastolic BP and HR. Pain VAS score at discharge was 1.5, PONV VAS score was 0.2 in both the music group and the no-music group. In the telephone interviews 24 – 48 after discharge the highest pain VAS score was 4.1 versus 3.1. There were no PONV problems, headaches or dizziness. 10% in the music group and 14% in the no-music group felt they needed professional advice on medical issues.

Discussion. Music is widely considered to be a good ‘adjuvant’ given to patients in relation to anaesthesia and surgery as well as in the post operative period, but no reports have – so far - provided any convincing evidence regarding clinical practise.

We have earlier conducted a pilot study on this topic and found promising results on patient compliance and satisfaction primarily regarding their need for nursing care. In this survey we studied hard medical data during surgery as well as immediate and late postoperative pain and PONV. We found no influence on haemo-dynamic parameters or on pain and PONV scores, which was to be expected according to other reports. This could be owing to our method, as music was offered - as part of our everyday routine - only minutes before induction. However, we still consider music to play an important role in the concept of day case treatment, in particular in the field of nursing care. Patients’ feedback is convincing - they feel confident and relaxed. Music could be offered to each patient on arrival in the department or as background music to all patients. Later, before surgery, specific music should be offered to the patient and continued throughout surgery and into the PACU by means of for instance a CD-player with headphones.

P-41

Title: FEMORAL AND POPLITEAL NERVE BLOCKS IN A PATIENT WITH MODERATE HEMOPHILIA A

Ramprasad Sripada, Joseph Reyes. ¹Department of Anesthesiology, Saint Louis University School of Medicine, Saint Louis, MO, United States.

Introduction: Bleeding disorders such as Hemophilia A have traditionally been considered contraindications to regional anesthetic techniques. Furthermore, there are few reports in the recent literature regarding performing regional anesthetics in patients with Hemophilia A¹. We present a case in which a patient request for regional anesthetic challenged such traditional contraindications.

Case Report: A 44 year old Caucasian male with a history of moderate hemophilia A and hemophiliac arthropathy of his left tibiotalar and subtalar joints presented to the OR for elective tibiotalo-calcaneal fusion. The patient had previously undergone bilateral total knee replacements, along with a unilateral total elbow replacement in the past, all done under general anesthetic. On pre-anesthetic evaluation, the patient cited problems with moderate to severe post-operative nausea and vomiting, and severe post operative pain following previous administrations of general anesthesia, and requested a regional anesthetic for the surgery. The patient was fully aware of his condition, and was cognizant of the increased risks associated with regional techniques due to his hemophilia A. After discussion and informed consent was obtained a left femoral and a left Popliteal Nerve block was planned for both surgery and postoperative pain control. In the preoperative area, the patient received a bolus dose of 5000 units of Factor VIII, and after an adequate level of Factor VIII (100 %) was confirmed by the lab, the femoral / popliteal block was performed. Standard monitoring including ECG and pulse oximetry were placed, and the patient was given 2L 02 via nasal cannula. The patient was positioned prone for the popliteal nerve block. After sterile preparation and draping, popliteal nerve block was performed using a #22 gauge insulated stimulating needle. After obtaining muscle twitch at 0.4 milliamps, 30 cc of a mixture of 2% lidocaine and 0.5% levo-bupivicaine (1:2) was injected without difficulty. The patient was then positioned supine for left femoral nerve block. A #22 gauge insulated stimulating needle was again used to elicit quadricep muscle twitch at 0.4 milliamps. 15 cc of 2% lidocaine and 0.5% levo-bupivicaine (1:2), were injected without difficulty. There was no evidence of bleeding or other complication at either block site. The patient tolerated the procedure well, and exhibited signs of both femoral and popliteal blockade prior to entering the OR. The block served as the main anesthetic for the surgery, augmented with mild sedation with propofol, midazolam and fentanyl. To maintain adequate Factor VIII level, an intraoperative bolus of factor VIII (approximately 1200 units) was given. On postoperative evaluation, the patient exhibited no complications from the regional blockade, and reported a period of sixteen hours of pain relief from the block. The patient indicated a high level of satisfaction with the technique.

Discussion: Hemophilia has been traditionally considered a contraindication for regional anesthesia. Furthermore, there are few reported descriptions in the literature of regional techniques performed on these patients. Patients with a history of mild to moderate hemophilia A are considered surgical candidates if an adequate level²(factor VIII c range for blood group A, 60-200 U/DL) of Factor VIII is obtained prior to surgery and maintained in the immediate postoperative period. This particular patient’s request for a regional anesthetic for his surgery presented us with a dilemma. The patient, due to his hemophilia A, would be at increased risk for bleeding if a femoral / popliteal block were to be performed. However, it was felt that if adequate Factor VIII levels were obtained prior to the block, the risk of bleeding secondary to block placement would not be as great. Additional considerations for proceeding with this nerve block were the use of stimulator technique to decrease the risk for bleeding, and the block sites were both easily accessible such that bleeding from these sites should it occur would be controllable.

Reference: 1. Anesthesia and Analgesia 1979 vol. 58 #2:133-35.

2. Cecil Textbook of Medicine. Philadelphia, WB Saunders, 1996.

P-42

DAY CASES VIDEOLAPAROSCOPIC COLECISTECTOMY. PRELIMINARY RESULTS OF A PROSPECTIVE STUDY

Roberta E. Monzani, Riccardo Rosati, Stefano Bona, Uberto R. Fumagalli, Mauro Zago, Simone Celotti, Massimo Motta. ¹Day Hospital Chirurgico, Istituto Clinico Humanitas, Rozzano, Milano, Italy.

Although ambulatory videolaparoscopic cholecystectomy (VLC) has been reported by several authors in the last years, patient selection, postoperative care and discharge criteria are not univocally described.

An open prospective non controlled trial was performed on non acute VLC.

Coledocolithyasis, major associated procedures and clinical, social and geographical non satisfactory criteria were considered the exclusion parameters.

All patients were administered LMW heparin and one shot antibiotic prophylaxys (cephalosporine) before surgery.

Premedication with atropine, benzodiazepine and antiemetic drugs was followed by surgery under intravenous GA only (TIVA).

A four-port (2 5mm and 2 10mm) surgical technique was used with previous injection of local anaesthetic at port sites. Retrograde colecistectomy by diathermic coaugulation and routine intraoperative colangiography were performed. Layers suture closed the 10mm portals only.

Postoperatively intravenous fluid was administered with analgesic and antiemetic drugs. Life parameters were recorded hourly.

Discharge was allowed when stable parameters, pain control (on VAS scale), diuresis, feeding and deambulation were observed at least 6 hrs after surgery.

Patients were instructed for home pain and vomit control and given a pain score questionnaire. Patients were telephone monitored on the 1^st and 2^nd PO days and followed up at 7 days.

From Feb 2002 to Jan 2003, 50 patients were included in the study. There were 13 males and 37 females with a mean age of 41.9 yrs (22-70).Nineteen pts had previous appendecectomy and/or gynecological procedures. Of the 49 pts with symptomatic cholelithiasis, 3 had previous acute cholecystytis and one underwent endoscopic papillosphinterotomy due to jaundice. One pt had suspected gallbladder adenoma.

Thirty-two patients were ASA anaesthetic II and 17 ASA I.

Mean surgical time was 58 min (range 30-115). Mean anaesthetic time was 84 min with a similar range.

Five patients did not meet discharge criteria and were converted to inpatients.

VAS lower than 5, at 6 hrs from surgery was measured in 91,8% of pts, at 7 hrs in 95.9% and at 8hrs 100% of the patients were pain-free.

Postoperative morbidity was 0% and no readmissions was recorded during the 7day F.U.

Activities of daily life were resumed after 3 days and pts returned to work after a mean 6 days PO.

Good patient satisfaction was recorded in 94,6%; nevertheless, 21,6% would have preferred a longer hospital stay; 89,2% would recommend ambulatory VLC.

These preliminary data do not allow a statistical evaluation of results. Nevertheless videolaparoscopic colecystectomy (VLC) as day case seems to be a safe, feasible and satisfactory procedure.

Our results suggest that in consideration of the low risk and good patient acceptance, selection criteria may become wider, therefore reducing the impact of hospitalization and costs. Dedicated setting and specific anesthesiology and nursing protocols are mandatory to support this activity. General hospital facility must be readily available.

Patient Safety and Quality Improvement

Poster Presentations

P-43

DOES NASAL / ORAL CAPNOGRAPHY ACCURATELY DETECT APNEA DURING MONITORED ANESTHESIA CARE?

Roy G. Soto,¹ Eugene S. Fu, Hector Vila, Jr., Rafael V. Miguel. ¹Department of Anesthesiology, University of South Florida College of Medicine, Tampa, FL.

Introduction: Detection of apnea or airway obstruction is essential when potent sedatives are employed. Pulse oximetry, routinely used during monitored anesthesia care (MAC), is a reliable estimate of arterial blood oxygenation; however, detection of apnea or airway obstruction can be delayed, especially if patients are breathing supplemental oxygen.¹ Reliability of nasal capnography to monitor apnea and airway obstruction has not been examined in MAC/sedated patients breathing with and without supplemental oxygen.

Methods: Patients undergoing MAC with a variety of sedative agents were included in the study. Anesthesia care provider used standard ASA monitoring and was blinded to other monitoring. Nasal / oral capnography and thoracic impedance monitoring were monitored by a trained observer blinded to other monitoring. Apnea or airway obstruction for 20s detected by the nasal capnograph or impedance monitor triggered notification of the anesthesia provider, unless the event was not already noted and corrected. Measurement data observed at varied supplemental oxygen were compared with repeated measures analysis of variance and Tukey’s HSD post hoc test. Logistic regression analysis was used to examine potential moderators of apnea.

Results: Ten (26%) of the 39-patients studied developed 20s of apnea, none detected by the anesthesia provider. There was no difference in detection via capnograph versus thoracic impedance monitoring. Logistic regression analysis revealed no independent variables predictive of apnea. There were no significant alterations in heart rate or arterial blood pressure throughout study (Table). SpO₂decreased to below 90% in only one patient during one apneic episode.

Discussion: Capnography is not a mandatory ASA standard monitor for MAC procedures, nor is it required for sedation performed outside of the operating theater. This pilot study discovered that apnea of at least 20s is relatively common during MAC. Although these episodes were undetected with routine monitoring, they were reliably detected by capnography. By design, we only studied apnea episodes lasting 20s. Presumably, unrecognized episodes of much greater duration can occur without capnography. Monitoring of end-tidal CO₂ may be an important means of improving safety in patients undergoing MAC/sedation. Utility of our results must be examined in a suitably designed outcome study.

Reference:

1. Anesth Analg 1999;88:S39.

Variables reflecting cardiopulmonary function with varied oxygen flow rate by nasal cannula.
Variables	Baseline	0 L/min O₂	2 L/min O₂	4 L/min O₂	6 L/min O₂
Episodes of Apnea	NA	2	4	3	1
SpO₂ (%)	97±2	97±2	98±2⁺*	99±2⁺*	99±3⁺*
PetCO₂ (mmHg)	42±10	45±10	43±12	38±13	36±14⁺*
Respiratory Rate (/min)	19±4	16±5	19±6	17±5	16±6
Heart Rate (/min)	77±10	78±13	78±15	77±12	77±13
Mean arterial blood pressure (mmHg)	95±24	96±16	96±20	96±17	97±16

*P<.05 v. Baseline; ⁺P<.05 v. 0 L/min O₂

P-44

COLONOSCOPY: PERFORMANCE MEASUREMENT STUDY

Sam J. W. Romeo, Deborah Connah, Marilee Ball, Diane Burns, John Johanson, Nancy Norman, Thomas J. Ustach, Dennis Worthington, Naomi Kuznets,¹ AAAHC Institute for Quality Improvement Colonoscopy Work Group & Performance Measurement Initiative. ¹AAAHC Institute for Quality Improvement, AAAHC Institute for Quality Improvement, Wilmette, IL, United States.

Colonoscopy is the second most frequently performed ambulatory procedure, with 1.1 million cases reported in 1996.¹ The intent of the report is to provide organizations with alternatives in practice to provide better value. The AAAHC Institute for Quality Improvement, via the 42 participating organizations, collected real-time data, in February-April 2002, on 952 colonoscopies. Participating organizations were single (69%)/multi-specialty (26%)/office-based (5%); annual colonoscopy volume ranged from 160-11,944. 74% of cases included ASA classification; 38% were ASA 1 and 53% ASA 2. Aspects of process/outcomes studied included: procedure times; use of multiple operating rooms (ORs); procedure preparation, indications, and findings; intraoperative complications; anesthetic technique, administrator, designated monitor; colonoscope sterilization; and patient outcomes. 10 selected findings follow (the entirety of the report will be available for review at the session). 1-Preprocedure, procedure, and discharge times varied greatly, with overall facility times ranging from 75-175 minutes (min). 2- The 8 organizations with more than 1 OR per endoscopist had better preprocedure times (26 v 37 min) and a narrower range in preprocedure (44 v 57 min) and procedure (52 v 99 min) times. 3-Most organizations were using polyethylene glycol (PEG) solutions (35%) or phosphosoda (49%) for bowel preparation. 4-Unexplained gastrointestinal bleeding (25%), "routine screening" (22%), and colonic neoplasm (17%) were the 3 most frequent indications for colonoscopy. 5-54% of the 859 polyps and 29% of the 184 other abnormalities found were distal to the splenic flexure. 6-7% of cases were complicated (please see graph). 7- 3 patients did not receive anesthesia; the rest were administered IV sedation (97%) and general anesthesia (3%). Endoscopists, RNs, and both comprised 70% of anesthesia administrators. 80% of designated monitors were RNs (66%), CRNAs (7%), CGRNs (4%), and CGRNs/RNs (3%); anesthesiologists were 9%. Please see graph for anesthesia costs. 8-Most (81%) organizations used a high level disinfectant to disinfect their colonoscopes. 9-Most (96%) patients were completely/very satisfied with their procedures and would have a colonoscopy again. 10- Patients with high levels of discomfort during the procedure, although small in number/proportion, were disproportionately those who would not have another colonoscopy, had more indications for the procedure and findings/biopsies/removals, and were less likely to have had pre-operative anesthesia. It is concluded that organizations that have demonstrated and validated differences in clinical practice can have similar outcomes, but at a dramatically different cost. ¹Vital Health Stat. 1998. 13(139).

P-45

KNEE ARTHROSCOPY WITH MENISCECTOMY

Sam J. W. Romeo, Deborah Connah, Betty Bozzuto, Jack Egnatinsky, John T. Henley, Naomi Kuznets,¹ AAAHC Institute for Quality Improvement ASC Work Group and Performance Measurement Initiative. ¹AAAHC Institute for Quality Improvement, AAAHC Institute for Quality Improvement, Wilmette, IL, United States.

Knee arthroscopy is a high volume procedure; 250,000 procedures were performed in 1996, almost all (96%) ambulatory.¹ The intent of the report is to provide organizations with alternatives in practice to provide better value. The AAAHC Institute for Quality Improvement, via 25 participating organizations, collected real-time data, in July-November 2002, on 542 knee arthroscopies (KAs) with meniscectomies. Participating organizations were multispecialty (52%)/single specialty (36%)/office-based (12%); annual KA volume ranged from 23-550. 94% of cases included ASA classification; 47% were ASA 1; 45% ASA 2. Among the processes/outcomes studied were: procedure times; intraoperative complications; anesthetic technique; supply/equipment cost; preoperative testing; and patient outcomes. 10 selected findings follow (the entirety of the report will be available for review at the session). 1-Preprocedure, procedure, turnover, and discharge times varied greatly, with overall facility times ranging from 41-106 minutes. Discharge time appeared to vary with anesthetic used (see graph). 2-Complicated/nonroutine cases included a hospital transfer associated with general anesthesia and a malfunctioning pump. 3-Anesthestic technique used-please see attached graph. 4-48% of organizations required preprocedure testing; the majority individualized testing by gender, age, medications, etc. 5-The most common test required was an EKG, per patient age/history. 6-Four organizations required pregnancy testing. 7-Cost associated with skin prep, drapes, pump cassettes, and shaver blades/wands varied greatly. 8-Despite staff considering 50%, patients believed 94%, of cases started on time (please see graph). 9-Of those patients who recalled (76%), all stated they were comfortable during their procedures.10-Of those not walking within 72 hours of surgery, a disproportionately large group (52% vs 9% of all patients) did not feel that their discharge instructions were clear. It is concluded that organizations that have demonstrated and validated differences in clinical practice can have similar outcomes, but at a dramatically different cost. ¹Vital Health Stat. 1998. 13(139).

P-46

LAPARASCOPIC SUBTOTAL HYSTERECTOMY. A DAY SURGERY PROCEDURE?

Marianne Jungersen,¹ Bjoern Busund,¹ Anton Langebrekke,¹ Olav Istre,¹ Edda Steen-Hansen.¹ ¹Out-Patient Surgery Unit, Ullevaal University Hospital, N-0407 Oslo, Norway.

Introduction:The intention of this pilot study was to investigate the feasibility to perform laparascopic subtotal hysterectomy (LASH) in a special designed unit for day surgery. Furthermore the study was established to validate the importance of motivated staff and modern endoscopic equipment.

Material and Results: 15 women with a mean-age of 43 (ranging from 33 to 47) underwent LASH as a day surgical procedure. The criteria for inclusion were surgical indications for subtotal hysterectomy, a normal large to moderately enlarged uterus, ASA 1 or ASA 2, adult company for the first 24 hours after discharge, and additional consent to day surgery treatment.

In an anaesthetic regime of propofol and remifentanil the operation lasted on average 40 minutes (between 30 and 72 min.) with no complications. Perioperativ also were given dexamethason 4 mg, pro-paracetamol 2 g, ketrolac 30 mg, droperidol 1.25 mg, ondansetron 4 mg in addition to bupivacain injected into the wounds.

A visual analogue scale 0-100 was used to measure and record pain levels. At 2 hours post-operativ VAS were recorded at an average of 30 (range 10-55), 4 hours an average of 20 (2-40) and on discharge an average of 10 (0-60). There was no nausea recorded. The patients spend 5.2-7.5 hours in the department after finished surgery.

Before discharge all patients spoke with the surgeon and received verbal as well as written instructions from a nurce. Patients were instructed where to contact with questions or in the event of complications. Additionally a copy of the surgeons` operative description and the surgeons`mobile telephone number were given to the patient.

At the 3 week follow-up there had been 1 post-operativ re-admission to hospital. When questioned on satisfaction with the procedure the score on VAS 0-100 was median 100 (average 83).14 of 15 would recommend LASH as a day surgery.

Conclusion: Certain conditions should be mandatory if LASH should be undertaken as a day surgical procedure. The staff should be experienced within day surgery, and the operating theatre must have specialised instruments and equipment. The anaesthetic should be fully tailored to day surgery, inclusive of good prophylactic routines for pain and nausea control, a fast wake-up time and minimal side effects. There should be well-established information and follow-up routines so patients feel safe and in control if complications arise.

The patients in the pilot are highly satisfied and would recommend others to undergo LASH as day surgery. The pilot project has shown that laparascopic subtotal hysterectomy is suitable as a day surgery procedure within the safety parameters.

P-47

AMBULATORY SURGERY PATIENTS MAY BE DISCHARGED BEFORE VOIDING AFTER UNILATERAL SPINAL ANESTHESIA

Gabriele Armellin,¹ Ugo Baccaglini,² Umberto Vacalebre,¹ Attilio Nosadini,² Patrizia Pavei,² Giampiero Giron.¹ ¹1)Anesthesia and Intensive Care - 2)General Surgery, University of Padova, Padova, Italy.

Background: Voiding before discharge is usually required after outpatient spinal anesthesia because of concern about bladder overdistention and dysfunction. Mulroy et al. (1) showed that urinary retention is a low risk after short-acting, low-dosage spinal or epidural anesthesia and hence patients may be safely discharged before voiding. We evaluated 3134 outpatients submitted to unilateral spinal anesthesia with hyperbaric bupivacaine to know if patients discharge before voiding is safe after a unilateral block obtained with a long-acting local anesthetic as well.

Methods: We retrospectively evaluated a five-year period in which 3134 outpatients were submitted to unilateral spinal anesthesia for ambulatory vein stripping, knee surgery and hernia repair. Patients demographics and operative characteristics are shown in Table 1. Spinal blocks were performed with different dosages of hyperbaric bupivacaine 0.5 or 1%. Every anesthetist was free to choose the bupivacaine concentration and the dosage he preferred. The usual lateral position midline injection was used for all the patients.

Results: Patient data and operative characteristics are shown in table 1. 11 patients were removed from the study because they required a second injection for the failure of the former one. Despite the use of high dosages in most patients (table 2) and the use of a long-acting local anesthetic, only four patients required bladder catheterization for urinary retention (table 3)

Discussion: Inability to void may often delay discharge after ambulatory surgery (2). Normal bladder function requires active contraction of the detrusor muscle of the bladder but neuraxial blockade interferes with detrusor contraction. Sometimes, bladder overdistension is caused by fluid overload and happens before the end of action of spinal block. The low rate of temporary bladder catheterization in our study is likely to be the result of different recovery of bladder function due to the different extent of a unilateral spinal block. Moreover, the more restricted spinal blockade also produces a more stable cardiovascular profile so volume expansion to treat hypotension is rarely required (3). In conclusion, hyperbaric bupivacaine 0.5 or 1% appears to be a suitable local anesthetic for ambulatory unilateral spinal anesthesia. Patients can be discharged safely with instructions to return to hospital if urinary retention develops later.

References: 1)Mulroy MF et al. Anesthesiology 2002;97:315-319. 2)Pavlin DJ et al. Anesth Analg 1998;87:816-826 3)Fanelli G et al Can J Anesth 2000;47:746-751

Patients and operative data
		mean ±SD or %
age (years)		50.3 ±12.5
weight (kg)		71.5 ±12.5
height (cm)		167.6 ±8.54
sex (%female)		59.5
vein stripping (%)		79.7
hernia repair (%)		14.5
knee surgery (%)		5.8
Spinal anesthesia data
				mean ±SD or %
bupivacaine 1%				87.1
bupivacaine 0.5%				12.9
dose (mg)				8.2±1.7
high dosage blocks (> 10 mg)				29.7
time to void (min)				256±54
Patients with urinary retention
sex (M/F)	age (years)		surgical procedure		bupivacaine concentration	bupivacaine dose (mg)	lumbar space
F	28		vein stripping		0.5%	9	L3L4
M	49		vein stripping		1%	8	L2L3
F	61		vein stripping		1%	9	L1L2
M	62		hernia repair		1%	10	L2L3

P-48

INCIDENCE OF POST-OPERATIVE VOMITING (POV) AFTER AMBULATORY STRABISMUS SURGERY IN CHILDREN

Jules Gamache,¹ Sean Clinefelter,¹ Andreas H. Taenzer,¹ Timothy Dutton.¹ ¹Anesthesiology, Maine Medical Center, Portland, ME, United States.

Background: Historically, strabismus surgery is associatied with a high incidence (approx. 40-85%) (1) of POV.

Methods: In a retrospective analysis of an ongoing QA project we investigated the incidence of and contributing factors to POV in 270 patients over 36 months. All patients underwent general anesthesia (GA), with an LMA, after mask induction with sevoflurane in O2 or N2O/O2 and IV placement. GA was maintained with volatile agents (sevoflurane, isoflurane), N2O or a propofol infusion. Anti-emetic strategies varied between anesthesiologists, but included fluid loading, omission of N2O, FiO2>50%, propofol infusion, 5HT3-antagonists (ondansetron 0.1 mg/kg) and steroids (dexamethasone 0.1 mg/kg). Less commonly administered agents were droperidol (prior to the FDA advisory) and metoclopramide. None of the patients was intubated or received neuro-muscular blockade (NMB). POV was tracked while the patents remained in the ambulatory center and during a 24-hour follow-up phone call. Only patients for whom all data were available were included in the analysis.

Results: Only 8 out of 270 patients had any POV episode either during their stay in the ambulatory center or during the 24-hour follow-up period.. None of the anti-emetic strategies reached statistical significance as a risk factor for POV.

Of note, out of the 75 patients that received neither a 5HT-antagonist nor a steroid, only one patient had POV.

Discussion: We conclude that POV is rare in outpatient strabismus surgery independent of anti-emetic strategy. This is in obvious contrast to many other studies. We cannot say conclusively that the avoidance of NMB is the reason for our remarkably low incidence of POV (NMB is not currently practiced at our institution for strabismus surgery). It is, however, the only obvious difference in patient management compared to most published reports.

References:

(1) Cote CJ, Todres ID, Goudsouzian NG, Ryan JF: A Practice of Anesthesia for Infants and Children, 3rd edition. Philadelphia, WB Saunders, 2001, p. 488.

Administration of 5HT3-antagonist/Steroid
Steroid		5HT3-antagonist	Both	Neither
16		49	130	75
Summary of patients with POV
Age	Maintenance				Intra-op anti-emetic
7	N2O/Isoflurane				5HT3
8	N2O/Sevoflurane				Both
4	Propofol/N2O/Isoflurane				Both
2	N2O/Isoflurane				Both
9	Isoflurane				Both
1	Isoflurane				Neither
8	Isoflurane				Both
9	N2O/Isoflurane				Both/Metoclopramide

P-49

BRONCHOMEDIASTINOSCOPY AS A ROUTINE AMBULATORY PROCEDURE FOR ASA CLASS 3 AND 4 PATIENTS

Kirsten Knage,¹ Mikael Regnèr,¹ Andreas Agger,² Birgitte N. Hansen,¹ Helle Ørding.¹ ¹Department of Anesthesiology, Vejle Hospital, 7100-DK Vejle, Denmark.

Introduction

Mediastinoscopy is used to sample mediastinal lymph nodes in the diagnosing and staging of bronchopulmonary cancer and for diagnosing other conditions.

Mediastinoscopy as an ambulatory procedure has been documented to be a low-risk procedure (mortality rates 0-0,5 % and complication rates 1,1- 5,2 %). The feasibility is reported to be 80-99%.We have found little documentation of performing mediastinoscopy as an ambulatory procedure in physical high-risk patients, i.e. the American Society of Anesthesia (ASA) class 3 and 4 patients.

In Vejle Hospital, Denmark, bronchomediastinoscopy has been a routine ambulatory procedure since 1996. We have gradually included more patients in poor physical condition. Today ambulatory bronchomediastinoscopy is performed on patients classified as ASA class 1 to 4.

The aim of the study was to evaluate the safety and the feasibility of bronchomediastinoscopy as an ambulatory procedure for ASA class 3 and 4 patients.

Patients and Methods

A prospective study of a consecutive series of patients having performed an ambulatory bronchomediastinoscopy in the hospital’s ENT outpatient unit during a period of 11 months.

The patients were referred by the hospital’s pulmonologist. A preoperative assessment of each patient was made by an anesthesiologist.

Patients enrolled in the study had to comply with the following:

1) A stable physical condition. 2) Written informed consent. 3) Company by an adult during the first postoperative night.

Patients requiring hospitalization for treatment or other investigations were not included.

The procedure was performed under general anesthesia with propofol, remifentanil, rocuronium, and air/nitrous oxide in oxygen. Postoperative analgesia consisted of paracetamol and keterolac/ibuprofen. Fiberoptic bronchoscopy was done via a laryngeal mask airway. After the bronchoscopy, the patients were intubated and a transcervical mediastinoscopy performed.

The Ethical Committee of the Region approved the study.

Results

92 patients were included. Mean age was 62,5 years (range 22-82). 35 were females and 57 males. 29 (31%) were ASA 1-2, 53 (58%) ASA 3, and 10 (11%) ASA 4. The average recovery time was 3h 9min (range 1h 25min – 6h 29min).

85 patients (92 %) were discharged from the ambulatory unit as planned. There was no difference concerning ASA status between the group of patients discharged and the group of patients hospitalized.

Five nonfatal complications (5,4 %) were encountered. During the operation 2 patients (ASA 3) got a pleural tear and 1 patient (ASA 3) a penetration of the trachea. One patient (ASA 4) had diagnosed pneumonia. All of the complications were diagnosed before discharge and the patients became hospitalized. One patient (ASA 3) developed supraventricular arrhythmias. He was medically stabilized and discharged without problems. There was no correlation between the number of patients with complications and their ASA status.

Tree patients returned in the evening and were hospitalized. One male (ASA class 3) with urinary retention and 2 patients (ASA class 2 and 3) because of feeling unwell. No specific medical problems were found.

There was no operative mortality.

Discussion

In this prospective study of patients classified as ASA class 1 to 4, having performed an ambulatory bronchomediastinoscopy, we found a higher complication rate than reported by other authors. One ASA 4 patient had pneumonia. Tree ASA 3 patients had complications related to the surgical procedure itself, but not specific to the ambulatory concept. All of the complications were diagnosed before the patients would have been discharged and no serious late problems developed.

92 % of the patients were discharged.

Conclusion

The study confirms the feasibility of bronchomediastinoscopy as a routine ambulatory procedure even for ASA class 3 and 4 patients. The procedure can be performed safely provided a hospital back-up function is available.

The study was financed by the Hospital’s Fund for Research and Development.

References

1.Ann Thorac Surg 1991 Nov;52(5):1122-6.

2.J Thorac Cardiovasc Surg 1993 Oct;106(4):686-8.

3.Ann Thorac Surg 1994 Jul;58(1):176-8.

4.Arch Bronconeumol 1998 Mar;34(3):119-22.

5.Ugeskr Laeger 2001 Jul 2;163(27):3802-5.

6.Acta Oncol 2001;40(1):79-82.

P-50

EFFICACY AND SAFETY OF A MULTI-MODAL FAST-TRACK RECOVERY STRATEGY IN PATIENTS UNDERGOING LAPAROSCOPIC NEPHRECTOMY

Dajun Song, Alex Recart, Paul F. White. ¹Anesthesiology and Pain Management, UT Southwestern Medical Center at Dallas, Dallas, TX, United States.

INTRODUCTION: The length of the hospital stay after laparoscopic nephrectomy is normally 2 to 3 days. Factors which preclude an earlier discharge include organ dysfunction (i.e., urinary incontinence, ileus), pain, postoperative nausea and vomiting and generalized fatigue. The objective of this study was to evaluate the effect of a multimodal perioperative approach (1) which includes preemptive pain relief, supplementary use of local anesthesia, GI supplements, early enteral nutrition and mobilization. We hypothesized that the application of this fast-track (FT) rehabilitation program would facilitate recovery and reduce the length of the hospital stay.

METHODS: Following institutional approval and informed consent, 20 patients undergoing unilateral laparoscopic nephrectomy procedures were randomly assigned to receive either the conventional postoperative care (Control) or the FT postoperative care paradigm used at this teaching hospital. All patients received a standardized anesthetic technique consisting of propofol, fentanyl, desflurane and nitrous oxide. Patients assigned to the FT group were premedicated with rofecoxib 50 mg po, colace 100 mg po, and ranitidine 150 mg po, as well as given prophylactic antiemetic therapy with a combination of droperidol, 0.625 mg iv, dexamethasone, 4 mg iv and ondansetron, 4 mg iv. In addition, 0.25% bupivacaine was irrigated into the renal fossa prior to closure. After surgery, intravenous morphine was administered for postoperative pain control in all patients. However, patients in the FT group received rofecoxib 50 mg qd po and acetaminophen 800 mg q6h po., while patients in Control group were administered standard opioid-containing oral analgeics as a suppliment to the iv morphine. Early nutrition and forced mobilization recovery program were implemented in the FT group only. Postoperative pain and nausea, need for rescue analgesics and antiemetics, were evaluated every hour for the first 6 h and then subsequently every 6 h for 48 h after surgery. Times from the end of surgery to PACU and home discharge were recorded. In addition, patient satisfaction with postoperative pain control (score of 0-100) and quality of recovery (score of 0-18) were assessed at the time of discharge. Data were analyzed using t-test, Kruskal-Wallis test and chi-square test, with p<0.05 considered statistically significant (mean±SD).

RESULTS: Demographic data were similar in both study groups. Patients in the FT group were discharged earlier both from the PACU (75±25 vs.106±51 min) and from hospital (59±12 vs. 39±11 h) compared to Control group (p<0.05). Postoperative nausea scores were lower in the FT (1.6±3.2) vs. Control group (3.4±3.1) during the first 48 h after surgery. In addition, patients in the FT group received less morphine than the Control group during the first two postoperative days (16±18 vs. 42±32 mg, p<0.05). Patient satisfaction with pain control was higher (p<0.05) in the FT group then the Control group (100±0 vs. 93±7). However, the quality of recovery scores were similar in both groups.

CONCLUSIONS: The multimodal recovery program led to a reduced hospital stay and less morphine consumption in patients undergoing laparoscopic nephrectomy. Improvement in postoperative recovery and, perhaps reduction in hospital costs, can be achieved by early aggressive perioperative management of common postoperative complications in this patient population. With further optimization of the fast-tracking recovery program, it should be possible to perform these procedures in an ambulatory setting in future.

REFERENCES: (1) Kehlet H. Mogensen T. Br J Surg 1999;86 (2):227-30

We have not received any educational grants to fund this study.

P-51

PREOPERATIVE ROFECOXIB IMPROVES RECOVERY AFTER OUTPATIENT HERNIORRHAPHY

Jun Tang,¹ Hong Ma,¹ Paul F. White,¹ Ronald H. Wender,¹ Alan Zaentz.¹ ¹Department of Anesthesiology, UT Southwestern Medical Center at Dallas, Dallas, TX, United States.

Introduction: Concerns regarding the side effects of opioid, analgesics has lead to increasing interest in the use of non-opioid analgesics as part of a multimodal regimen to control pain after ambulatory surgery. Rofecoxib, a COX-2 inhibitor, has been shown to produce comparable analgesic effects to conventional NSAIDs when administered for the treatment of acute pain. However, the effect of rofecoxib on recovery has not been evaluated when administered for preemptive analgesia in the ambulatory setting. Therefore, we designed this randomized, double-blinded, placebo-controlled study to assess the analgesic efficacy of rofecoxib when administered for premedication prior to outpatient hernia surgery.

Methods: 60 healthy consenting outpatients undergoing inguinal hernia repair with a local anesthetic-based anesthesia technique were randomly assigned to one of two study groups (n=30/each): Control (Placebo), and Rofecoxib (rofecoxib 50 mg). The first oral dose of the study medication was administered 30 min before surgery, and a second dose of the same medication was taken the first morning after surgery. Verbal pain scores were assessed at regular postoperative intervals, with 0=none, 1=mild, 2=moderate, and 3=severe. Recovery times, quality of recovery (0-18), the need for rescue analgesics, maximum pain score (0=none, 1=mild, 2=moderate, 3=severe), and postoperative side effects were also recorded. Follow-up evaluations were performed via telephone at 24 h after surgery to assess patient global evaluation of the study medication (0=poor, 1=fair, 2=good, 3=very good, 4=excellent), and the need for oral opioid-containing pain medication after discharge. A p-value <0.05 was considered statistically significant. (* p<0.05 vs Control)

Results: The two study groups were comparable with respect to demographic characteristics, duration of surgery, and intraoperative anesthetic drugs. The early recovery profiles with respect to the times to sitting up, tolerating oral fluids, standing up, ambulating, "fitness" for discharge, and actual discharge were significantly decreased in patients who received premedication with rofecoxib. Rofecoxib also significantly reduced the requirements for rescue pain medication during the 24 h study period, and was more effective in management of postoperative pain without increasing side effects (e.g., bleeding, nausea, vomiting).

Conclusion: Rofecoxib, 50 mg oral, was highly effective in improving pain management and the quality of recovery after outpatient inguinal hernia repair surgery when administered preoperatively and the first postoperative day without increasing intraoperative blood loss or postoperative wound complications.

	Control	Rofecoxib
Age (yrs)	43±14	45±13
Weight (kg)	71±9	73±11
Surgery time (min)	42±15	41±20
Orientation (min)	12±11	10±10
Sitting up (min)	53±27	32±18*
Tolerating oral fluids (min)	60±26	40±17*
Standing up (min)	101±40	77±32*
Ambulating alone (min)	102±41	81±31*
"Fit" for discharge (min)	115±43	84±31*
Actual discharge (min)	126±44	88±30*
Quality of recovery (n)	17 (13-18)	18 (14-18)*
Pain medication used before discharge
Vicodin pills (n)	0.5 (0-2)	0 (0-2)
Hydromorphone (mg)	0.13±0.29	0.04±0.21
Oral analgesic after discharge (n)	9 (1-33)	0 (0-20)*
Maximum pain during the study period (n)	2 (1-3)	1 (0-3)*
Global evaluation of the study medication (n)	1 (0-3)	3 (1-4)*
Blood loss during surgery (ml)	6±2	6±2
Nausea and vomiting <24h (%)	21	14

P-52

MAJOR EAR SURGERY PERFORMED AS A DAY-CASE: IS IT VIABLE?

Nigel D. Padgham. ¹Otolaryngology-Head&Neck Surgery, East Kent Hospitals NHS Trust, Ashford, Kent, United Kingdom.

Aim

To assess the acceptability of major ear operations performed as a day-case by comparison of the views of patients treated by the same surgeon in dedicated day-case and inpatient settings.

Method

With hospital (trust) ethical committee approval, a postal survey was carried out to assess patients’ experiences and attitudes to surgery in two different hospital settings. In the first there were adjacent day-surgery and short-stay inpatient wards allowing flexible admissions. In the second there was a dedicated day-surgery unit but no in-patient ORL beds within the hospital, allowing no opportunity for an overnight stay without transfer to a unit 20 miles (32km) away.

All patients treated in both settings over a two year sample period were included. Major ear surgery was defined as all ear procedures of tympanoplasty, cortical mastoidectomy, modified radical and combined approach tympanomastoidectomy. Stapedectomy was excluded as it was only performed at the site where overnight admission was possible.

Patients

From a total of 184 patients 127 questionaires were returned. 77 questionnaires were returned from the day-surgery / short stay unit patients. 50 questionnaires were returned from the day surgery unit patients.

Results

The response rate was 69% (some required follow-up mailling)

No significant differences were found in satisfaction levels for pain, nausea, dizziness, or length of stay.

Significantly more patients in the day-surgery group returned to normal activity before those treated as inpatients. x² (p<0.005)

Significantly more in-patients felt better or cured. x² (p<0.05)

P-53

A SIMPLE DATABASE FOR USE IN AN ASC FOR TRACKING AND MANAGEMENT OF OUTCOME DATA FOR SURGICAL AND ANESTHESIA PATIENTS

Douglas G. Merrill,¹ Kristine D. Ogden.¹ ¹Anesthesiology, The Virginia Mason Medical Center and Clinics, Seattle, WA.

Concurrent recording of data for evaluation of clinical outcomes allows effective management of CQI efforts. Trends in clinical care must be identified and correlated with processes, procedures and practitioners. This allows informed evaluation and identification of problems and their correction.

Using Microsoft Access®, a database was created and placed on a workstation in the PACU of a four O.R. ASC. Expense for programming expertise (less than 20 hours) and for a licensed copy of MS Access ($273.00) are estimated at approximately $1,900, although both were already available to the ASC through its parent corporation, without additional charge. HIPPA compliance was insured via password protection and "scrubbed" reporting. Acceptance by the PACU RNs was rapid.

Patients were enrolled in the database as they were admitted to PACU. Data were entered concurrently by the treating RN. Patient outcome data was collected both the day of surgery and the next working day (phone contact). Data sets chosen for this initial trial included Score on Admission to PACU, Incidence of PONV either in PACU or at home, Time in PACU, and Patient Rating of Satisfaction with Overall Experience at the ASC. The database, although simply constructed, allows outcome evaluation and linkage to the surgery type, anesthesia technique, and the various providers. Data has been collected since March 2002. Data shown is for 04/01/02 through 01/09/03.

Sample tables here portray information easily elicited via the use of "queries" in Access, which may be used for identifying trends in care. For instance, time in PACU by PACU RN (Table 2) correlates well with the Medical Director’s impression of individual RN’s skills in "fast-tracking" and has aided "objective" mentoring by "RN D" of RNs "B" and "C". As well, differences in PONV rates attendant to anesthetic technique (Table 1) has been communicated to incoming pre-operative patients. Patients have stated that this information has provided them added confidence in their decisions on anesthetic type.

Additionally, "modules" of more extensive questioning can be temporarily added to the database for two or three month evaluations of special questions (e.g., "Would you choose the same anesthetic?"). This simple design allows directed studies without burdening PACU RNs with too much data entry.

Staff acceptance and satisfaction with the project is high. Data are shared in an anonymous fashion. Possible problems include a higher patient census that might not allow RNs to enter data concurrently. Potential solutions include data entry by a unit clerk, which would also allow the data to be entered with less bias than that attendant to RN entry. Future direction includes electronic record-keeping which would allow this data to be collected/entered only once (bedside hand-held devices).

In summary, this is a relatively inexpensive and flexible solution to the need to collect concurrent outcome data on patient outcomes in a PACU.

PACU Outcomes by Anesthesia Type
Anesth Type	Total performed	# with nausea	# with emesis	Time in PACU (mean)	Excellent/good patient rating
Epidural	19	3 (16%)	0 (0%)	100 minutes	17 (89%)
General ET	358	46 (13%)	17 (4.7%)	85 minutes	280 (78%)
General no ET	314	11 (3.5%)	2 (0.6%)	62 minutes	248 (79%)
LMAC	87	0 (0%)	0 (0%)	42 minutes	68 (78%)
Regional	60	4 (6.6%)	0 (0%)	66 minutes	44 (67%)
Spinal	174	10 (5.7%)	2 (1.1%)	86 minutes	140 (80%)

79% rated good or excellent, 21% no opinion or unable to reach

PACU Outcomes by PACU RN
PACU RN	# of patients		% with nausea			% with emesis		Mean time PACU		Excellent/good patient rating
RN A	332		5.7			1.8		74.5 minutes		78.3%
RN B	174		12.1			1.7		80.6 minutes		80.5%
RN C	171		9.4			4.7		87.1 minutes		77.8%
RN D	163		6.1			1.2		65.7 minutes		78.5%
RN E	39		5.1			0		62.1 minutes		84.6%
RN F	30		3.3			0		71.7 minutes		86.7%
RN G	27		3.7			0		75.6 minutes		74.1%
PACU Outcomes by Anesthesiologist
Anesth. MD		# of patients		Mean arrival score	% with nausea		% with emesis		Time in PACU (mean)		Excellent/good patient rating
MD A		646		7.3	6.5		2.0		74.9		79.4%
MD B		106		7.0	7.5		2.8		79.6		77.4%
MD C		29		6.4	6.9		0		83.8		69.0%
MD D		20		7.4	5.0		0		83.0		70.0%
MD E		19		6.8	21.1		5.3		86.3		84.2%
MD F		19		7.6	10.5		0		73.2		78.9%

Top 6 providers by number of cases/9 months

P-54

RESULTS FROM 2 YEARS EXPERIENCE OF A PORTUGUESE DAY SURGERY UNIT BASED ON CLINICAL INDICATORS

Ana Cardoso, Evangelina Dias, Fátima Malafaia, Domingos Marques, Paulo Lemos. ¹Anaesthetics Department, Hospital Geral Santo António, Oporto, Portugal.

AIM:The great development of Ambulatory Surgery (AS) all over the world based on clinical, economic and social advantages, has to be guide by qualitative issues in order to be successful and promote high-quality health care services. The goal of the present study is to establish and evaluate some clinical indicators at our Day Surgery Unit (DSU).

MATERIALS AND METHODS: We established in January 2001, 3 clinical indicators to evaluate prospectively our practice from the quality point of vue: 1. Cancellation of booked procedures; 1.1. Failure to attend the DSU; 1.2. Cancellation after arrival at the DSU; 2. Unplanned return to the operating room on the same day; 3. Unplanned overnight admission.

RESULTS: We analysed prospectively all patients scheduled for day surgery at our DSU between January 2001 and December 2002. From the 2,434 patients included only 2,194 (90,14%) were submitted for the day surgery proposed. The reasons for cancellation of booked procedures are pointed out on table 1.

Our 2,194 patients had a mean age of 39,07 years old (from a minimum of 6 months old to a maximum of 88 years old, and a standard deviation of 16,9 years old). 152 patients submitted to the surgery were classified as ASA III (6,9%), and we considered more complex surgery (hemi-tyroidectomy, laparoscopic cholescystectomy, lumbar hernia repair, craneoplasty) in 5,2% of the total procedures.

We had no mortality and we recorded a low morbidity rate. Three patients (0,14%) reported severe pain (visual analogue scale ranging from 7 to 10) but none had to be admitted after proper treatment, and in 71 patients (3,24%) we had post-operative nausea and vomiting causing the admission of 3 of them. We noticed some haemorrhage in 27 patients (1,23%) that led to the admission of 10 of them.

Seven patients (0,32%) had to return to the operating room on the same day of the surgery, and 24 patients (1,09%) had an overnight admission owing to: a) surgical reasons - 18; b) anaesthetic / medical reasons - 4; social / administrative reasons - 2.

CONCLUSIONS: Accordingly to the results obtained we might say that our pre-admission clinical indicators reflect some inefficiency in our organisation. In fact with so many cancellations of patients scheduled for surgery we realise the significant wastage of operating time at the theatre and human resources dedicated to it. However we can say that we are effective in our practice and few patients needed to be overnight admitted. There is still reasons to careful evaluate the sentinel event that is the unplanned return to the operating room on the same day, as 7 patients were a high figure (although it was a small sample for a rare indicator). Periodical clinical indicators evaluation hopefully will allow us to improve the quality and efficiency of our clinical care at our DSU and the satisfaction of our patients in the future.

REFERENCES:

1. Roberts L. Ambulatory Surgery 1994;2:5-6.

2. Roberts L. Ambulatory Surgery 1994;2:223-226.

3. Rudkin GE. In Practical Anaesthesia and Analgesia for Day Surgery, Bios Scientific Publishers, 1997; pag. 228-229.

Cancellation booked procedures
Clinical Indicators	No of patients	%
1. Failure to attend the DSU	124	5,09
a) with previous contact	25
b) without any information at all	99
2. Cancellation after arrival at the DSU	116	4,77
a) pre-existing medical condition	20
b) acute medical condition	25
c) organisational reasons	53
d) other reasons	18
Total	240	9,86

P-55

A TEN -YEARS EXPERIENCE OF AMBULATORY PEDIATRIC SURGERY IN FREE STANDING PEDIATRIC SURGICAL UNITS: REPORT OF THE " PROFESSIONAL ORGANIZATION OF SETTLED PEDIATRIC SURGEONS OF GERMANY ( BNKD )"

Christian J. Deindl, Thomas A. Angerpointner. ¹Free Standing Pediatric Surgical Unit and Ambulatory Pediatric Surgical Center, Professional Organization of Settled Pediatric Surgeons of Germany (BNKD), Berlin Grazer Damm, Germany.

Ambulatory pediatric surgery is definded as the performance of operations which normaly were carried out with a hospital stay until several days. Until to the late 60 ies and early 70 ies of the last century the home care of operated patients was changed by the increasing number of hospitals and accompanied by a long duration of hospitalization and very restricted visiting possibilities. The results of modern psychology and knowledges about psychological problems especially in operated children were the reasons because pediatric surgeons were the first who reduced the duration of hospitalization after routine-operations. They introduced the so called one day surgery in SO-ME pediatric surgical centers and departements. Nearly in the same time only a few pioneering pediatric surgeons founded their own free standing pediatric surgical units and began to operate children in their ambulatory operation centers. This was the beginning of ambulatory pediatric surgery since the last 10 to 15 years an increasing establishment of this kind of ambulatory surgery has been taken. The logical consequence of this developement was the taking over of one day surgery in the hospitals by free settled pediatric surgeons . In Germany 97 % of all ambulatory operations are currently carried out in free standing, privately financed units and only 3% in the hospitals. However, soon it was clear, that it was necessary to found a conclusion especially for settled pediatric surgeons. 1993 a working group of settled German pediatric surgeons was founded by 22 foundation members. Since four years now there is existing a " Professional Organization of Settled Pediatric Surgeons of Germany (BNKD)". Our organization currently comprises 66 settled specialized pediatric surgeons, who are working in 53 free standing units under strong clinicl conditions and together with experienced pediatric anesthesiologists. The members of BNKD represent nearly one third of all specialized pediatric surgeons. Normaly about of 70 % of all routine-operations in the pediatric age can be performed on an ambulatory basis in an appropriately equipped ambulatory surgical center. The collection of the annual statistic of BNKD is the basis for demonstration the possibilities in ambulatory surgery: 1: soft tissue tumors , nevi etc; 2. Head,face and neck: auricular dysplasia or fistula, ankyloglossum, diastema, cervical fistula or cyst, torticollis; 3. Thoracal and abdominal wall, abdomen and proctology: umbilical, epigastric and inguinal hernia, appendectomy, pilonidal sinus, anal fissure or fistula, hemorrhoids, rectal polyp, minimal invasive surgery(mic); 4. Genitals: phimosis, paraphimosis, penil skin anormalies, meatal stenosis, maldescended testis, hydrocele, recurrent maldescended testis or inguinal hernia, orchiectomy; 5. Extremities and traumatology: ganglion, baker`s cyst, scar correlation, syndactylia, hexadactylia, exostosis, osteotomy, repositions of fractures or luxations, osteosynthesis, tendon and ligament repair, removal of osteosynthesis material, extended soft tissúe injuries; 6. Septic surgery. The collect annual number of operations performed by members of BNKD was in 1993 19500 and in 2002 64500. Generally in the last 10 years 430 000 operations were carried out in free standing pediatric surgical units . 80% of them that means over 350 000 operations - were carried out under general anesthesia on an average 1200 operations were performed in each unit every year. Following operations were the most : 95161 circumcisons ; 71185 herniorhaphies; 41377 excisions of soft- tissue tumors; 22816 orchidopexies; 18145 repairs of umbilical hernia; 19164 hydroceles ; 3856 removal of osteosynthesis material; 4285 ganglia and Baker´s cysts; 3318 proctological interventions and 4891 cases by hand surgery. During the last years the incidence of early and late complications is below 1 % and shows the qualitative and technical standards on our discipline. So it can finally be stated, that ambulatory pediatric surgery in a free standing unit of a specialiced pediatric surgeon is a safe, efficient and cost -effective kind of modern pediatric surgery.

P-56

QUALITY OF LIFE AFTER OUTPATIENT LAPAROSCOPIC CHOLECYSTECTOMY

Gunn Goksoeyr,¹ Erik Trondsen.¹ ¹Out-Patient Surgery Unit, Ullevaal University Hospital, Oslo, Norway.

Introduction: Between 1994 and January 2003; 1021 outpatient elective laparoscopic cholecystectomy have been performed (OLC) in our out patient surgery unit. Follow-up included telephone interview first postoperative day, and counseling patients report further concerns or problems back the unit. In order to validate this practice a new study on the outcome after outpatient laparoscopic cholecystectomy was initiatet, focusing on the patient satisfaction, tolerance for outpatient treatment, frequencies of complications and quality of life during the first weeks postoperatively.

Patients and methods: During a period of eleven months, from December 2001 until November 2002, 100 patients were operatet with OLC. 85 females and 15 males Aged 20 - 81 years Patients were interviwed by telephone according to a standardized formula the first day postoperatively, and then after one week and six weeks. The ASA grade of the patients were 62% grade 1, 35% grade 2 and 3% grade 3. Total intravenous general anasthesia with infusion of propfol and remifentalin were used. Additionally ketorolac, paracetamol and droperidol and ondansetron were administrated as prophylaxis against postoperative pain and nausea.

Results: None of the procedures were converted to open operation. 93 patients were discharged according to plan the same day and 7 patients hospitalized in the ward. Readmission of 5 patients (4 due to pain and one of them due to a postoperative wound abcess) were needed. Of the seven patients primarily admitted one patient revealed a perforation of the small bowel (primarely admitted) and consequently a laparotomi was performed. Otherwise no infectious complications took place. Pain and nausea was infrequent. 80% patients were fully mobilized on the first day postoperatively, and after six weeks 90% of the patients returned to normal activity. Of the 55 patients who needed sick leave the median needed time to return tom work were ten days (median). The postoperative course was as expected or even better than expected in 80% of the patients on the one-week interview. On the six weeks follow-up 95% of the patients reported better or as expected postoperative course. 85% of the patients felt safe after the discharge, 3 were indifferent, and 2 felt some unsafe. Outpatient treatment was the preference of 88% the patients and another five would select one night in ward if they should choose a similar surgical procedure in the future.

Conclusions: Patient satisfaction with OLC seems excellent; they felt safe and well cared for. Few admissions in the ward were needed and readmissions rate were low. Only one infectious complication was seen. Most patients had returned to normal activity after six weeks. Nevertheless, routines for handling of postoperative complications and problems occuring after discharge are mandatory.

P-57

TUMESCENT LIPOSUCTION

Sam J. W. Romeo, Deborah Connah, William P. Coleman III, Sue Ellen Cox, Richard L. Dolsky, Gerald Edds, Roy C. Greykin, C. William Hanke, Lorraine Jordan, Naomi Kuznets,¹ AAAHC Institute for Quality Improvement Tumescent Liposuction Work Group and Performance Measurement Initiative. ¹AAAHC Institute for Quality Improvement, AAAHC Institute for Quality Improvement, Wilmette, IL, United States.

Liposuction became the most commonly performed aesthetic procedure in the 1990s.^1,2,3The intent of the report is to provide organizations with alternatives in practice to provide safest care/best value. The AAAHC Institute for Quality Improvement, via 39 participating organizations, collected real-time data, February 2001 to August 2002, on 688 tumescent (oral/intramuscular medications only) liposuction cases. Participating organizations were single specialty centers (12%)/office-based (88%); annual liposuction case volume ranged from 10-468. 86% of cases included ASA classification; 93% ASA 1 and 6% ASA 2. Among the processes/outcomes studied were: complicated cases; preoperative medications; amount of tumescent fluid (TF) infused; lidocaine concentration/dose; amount of extracted supranatant fat/fluid (SFF); estimated cost per case; and patient outcomes. 10 selected findings follow (the entirety of the report will be available for review at the session). 1-The clinical complication rate was .7%. 2-Sedatives, anti-anxiety, and/or analgesics medications were commonly used preinfiltration. 3-TF infused per case-please see graph. 4-TF lidocaine concentration varied from .004% to .5 %; the median was .075%. 5-Lidocaine doses could be calculated for 75% of cases-please see graph. 6-SFF extracted was listed for 87% of cases-please see graph. 7-Estimated cost per case of medications, supplies, staff, and facilities varied greatly. 8-96% of patients responded to a 1 week postoperative survey. Of those that recalled their procedures (95%), 75% had an intraoperative comfort rating of no or minimal discomfort. 9-59% of patients responded to a 6 month postoperative survey; 91% were positive about their decision to have liposuction. 10-At 6 months, 84% were satisfied overall with their results. It is concluded that organizations that have demonstrated and validated differences in clinical practice can have similar outcomes, but at a dramatically different cost. ¹Dermatologic Clinics. 1999. 17(4):729-734. ²Aesthetic Plast Surg. 1999. 23(5):307-311. ³ Plast Reconstr Surg. 1998. 101(4):1103-1116.

P-58

INCIDENCE, INTENSITY AND PREDICTIVE FACTORS OF POSTDISCHARGE SYMPTOMS, ONE WEEK SURVEY OF 2732 OUTPATIENTS

Kristiina Mattila,¹ Juhani Toivonen,² Leena Janhunen,¹ Per H. Rosenberg,³ Markku Hynynen.¹ ¹Department of Anesthesia and Intensive Care, Helsinki University Central Hospital,Jorvi Hospital, Espoo, Finland; ²Department of Anesthesia, South Carelian Central Hospital, Lappeenranta, Finland; ³Department of Anesthesia and Intensive Care, Helsinki University Central Hospital, Helsinki, Finland.

Introduction The well-being of patients after discharge is an important criteria of quality. Minor postoperative symptoms are reported to occur frequently after ambulatory surgery.¹ Postdisharge symptoms are seldom serious, but they can be unpleasant and distressing, lengthen the time to recovery and normal activity and even increase costs after surgery. Previous large studies on postoperative symptoms have mainly concentrated on the predischarge and immediate postoperative period. The purpose of this study was to define prospectively the incidence and intensity of postoperative symptoms during the first week following surgery in a large, mixed outpatient population and to determine the effects of demographic and clinical variables on minor morbidity.

Patients and Methods The study was carried out at the ambulatory surgery units of Jorvi Hospital, Helsinki University Central Hospital, Espoo and South Carelian Central Hospital, Lappeenranta. Both units care for a similar mixed outpatient population. Approvals of the Institutional Ethics Committees were obtained. The study was observational with no changes in standard care and written consent was not required. Consecutive patients or parents of children were given questionnaires in envelopes with prepaid postage. The intensity of defined symptoms was graded daily for a period of eight days using a four point scale. Incidence and intensity of symptoms in adults and children ( age <15 years) on the evening after discharge, on the first, third and seventh postoperative days were analyzed. The effect of age, ASA class, gender, duration of surgery, type of anesthesia and type of surgery on the occurrence of individual symptoms was determined using Multinominal Logistic Regression analysis and reported by Odd’s ratio and its 95% confidence interval. Wald.P-level < 0.05 was considered significant. In adults also the effect of Body Mass Index (BMI), smoking- history and positioning during surgery were assessed.

Results Seventy percent of the patients responded. Incisional pain in spite of medication and drowsiness were the most commonly reported symptoms, occurring in 52% of all the patients. Hoarseness was reported by 43%, bleeding by 39%, sore throat by 38%, dizziness and headache by 24%, nausea by 21%, rise in temperature by 13%, difficulties in voiding by 10% and vomiting by 7% of all patients during the surveillance time. One tenth of patients reported no symptoms. BMI and ASA class did not have significant effect on the occurrence of any of the analyzed symptoms. In the adult group age over 65 years decreased the risk of several symptoms, while in children age over 7 years increased the risk. Risk of nausea was 3.2 -fold compared to children aged under 3 years. Compared to orthopedics gastroenterological surgery increased the risk of pain 1.8-fold. Following vascular surgery and gynecological procedures risk of pain was decreased. Longer duration of surgery increased the risk of pain and nausea in all patients. In adults general anesthesia increased the risk of sore throat 20-fold and risk of vomiting 4.3-fold when compared with local anesthesia. In adults female gender increased the risk of vomiting, nausea, dizziness, headache and drowsiness over two-fold. Also girls were more prone to experience dizziness, drowsiness, headache and sore throat.

Conclusion For most patients recovering from ambulatory surgery and anesthesia is not symptom-free and uneventful. Taking risk factors in consideration can help in tailoring even better ambulatory care.

¹Anesthesiology 2002; 994 - 1003

P-59

NURSES VS CLINICIANS - WHO COMES OUT ON TOP IN PRE-OPERATIVE ASSESSMENT?

Christine Downey,¹ Peter J. Thomson,¹ Ian R. Fletcher.¹ ¹Oral & Maxillofacial Surgery, Newcastle Dental Hospital, Newcastle upon Tyne, NE2 4BW, United Kingdom.

A nurse-led pre-admission clinic (PAC) was introduced in 1996 within the Oral Surgery Day Unit at Newcastle Dental Hospital to help reduce patient failures and cancelled operations on the day of admission. Using an established code of practice and anaesthetic guidelines, PAC has also improved pre-operative patient assessment and education prior to surgery.

Anecdotally, our impression is that patients often reveal more details of their medical histories during nurse PAC consultations than when first interviewed by clinicians at out-patients. In this study, therefore, we reviewed the clinical records of 57 consecutive patients attending for day case dento-alveolar surgery and compared medical histories obtained by clinicians with those recorded by nurses. Of particular interest was who best identified conditions likely to interfere with surgery?

Results showed that in 39% of cases, nurse-led PAC interview revealed additional information which had not been recorded by clinicians, most frequently cardiovascular disorders (7 patients), arthritis (5 patients) and drug allergies (2 patients). Anaemia, pancreatitis, epilepsy, recurrent epistaxis and, surprisingly, a history of fractured mandible were other conditions only identified following nurse consultation.

Medical history taking by nurses at PAC thus provides an important screening function prior to successful ambulatory surgery.

P-60

DAY CARE NURSING OF PATIENTS UNDERGOING RECONSTRUCTIVE MIDDLE EAR SURGERY. A FOLLOW-UP STUDY

Mariana Nordensvärd, Åsa Lindersson, Annika Näzell, Elin Rapp. ¹Hand ,Plastic and ENT Centre, Day-Surgery Unit, Uppsala, Sweden.

Background

The number of ambulatory patients undergoing middle ear surgery has increased in recent years. In Uppsala we perform most of the middle ear surgery in local anesthesia. We have found that the follow-up telephone call to the patients the day after surgery improved the patients’ well being. In the ENT clinic at Uppsala University Hospital no studies have yet been performed concerning the patients status and well being at longer time after surgery. We therefore performed this study.

Aim/Method:

The aim was to study the patients’ experience after having undergone ambulatory hearing improvement middle ear surgery. We used a questionnaire to find out how the patients experience the time directly after the surgery and some time after. The participation the questionnaire is on an elective basis and the answers were treated confidentially. The questions were focused on pain, dizziness and nausea. The questionnaires were sent to 58 patients (age 18 to 76 years). The answers are compared with the answers from the postoperative telephone call the day after surgery. The overall aim with the study is to guaranty a high quality and to improve the nursing care after surgery and to improve adequate information to the patient.

Results

The follow-up telephone call made to the patient the day after surgery has shown that 87% of the patients felt "no problems" by the time of the phone call; 11% felt "minor problems" and 2% "major problems". The patients’ "minor or major problems" were complaining of dizziness and/or nausea.

16% of the patients said that they had nausea and 11% had been vomiting once or several times after leaving the hospital.

79% had no pain at all (VAS 0-2), 14% had a little pain (VAS 3), 7% had moderate or fairly troublesome pain (VAS 4-6) none had troublesome pains (VAS more than 6).

66% answered that the effect of the analgesics was very good and 2% said that the effect was unsatisfactory. 32% didn’t need any painkiller at all.

Conclusion

At present time our waiting list for middle ear surgery is long, about two years. The ambulatory unit in Uppsala has capacity to take care of several more patients. We like to make sure that our nursing care quality is satisfying. The phone calls to the patients the day after surgery, has shown good results concerning nursing. With a questionnaire to the patients we decided to find out if the patients are still satisfied with the nursing and the operation after some time has passed. The results of this examination will help us to understand the need of further improvements in order to fully optimize patient care and nursing.

P-61

BRONCHOMEDIASTINOSCOPY AS AN AMBULATORY PROCEDURE SEEN FROM THE PATIENTS PERSPECTIVE

Mikael Regnér,¹ Kirsten Knage,¹ Andreas Agger,² Berit Dichmann,¹ Helle Ørding.¹ ¹Department of Anesthesiology, Vejle Hospital, Vejle, 7100-DK Vejle, Denmark.

Introduction

Investigation for bronchopulmonary cancer in Vejle County, Denmark, comprises bronchomediastinoscopy under general anesthesia as an ambulatory procedure for patients classified according to The American Society of Anesthesia (ASA) as class 1 to 4.

We have found little documentation of the patients’ possible discomfort and satisfaction with the ambulatory mode of procedure.

The purpose of this prospective study was:

To investigate the incidence of postoperative pain, nausea, and possible aggravation of coughing, dyspnea, and expectoration following bronchomediastinoscopy.

To asses the patients’ satisfaction regarding time of discharge and having bronchomediastinoscopy performed as an ambulatory procedure.

Patients and Methods

During 11 months 92 patients had ambulatory bronchomediastinoscopy performed in the hospital’s ENT outpatient unit.

Inclusion criteria were:

Stable medical condition

Informed consent to participation

An accompanying adult available for transportation and staying overnight with the patient

The procedure was performed under general anesthesia. Postoperative analgesia consisted of paracetamol and keterolac / ibuprofen. The patients were discharged when they were alert, stable and able to walk.

The patients completed a questionnaire concerning nausea, dyspnea, coughing, expectoration, and pain due to surgery. There were 4 alternative reply options (Likert scale): none (1), slight (2), moderate (3), severe (4) The questionnaire was filled in before surgery and 3 and 24 hours postoperatively. The following day the patients were questioned via telephone about their satisfaction regarding time of discharge and having bronchomediastinoscopy performed as an ambulatory procedure.

The Ethical Committee of the Region approved the study.

For statistical evaluation pared Student’s t test was used with P < 0.05 considered significant.

Results

Patient demography: 35 females, 57 males, mean age 62,5 years (range 22-82), 29 (31%) ASA 1-2, 53 (58%) ASA 3, 10 (11%) ASA 4.

82 patients completed the study as planned, 7 patients were admitted to the hospital, and 3 patients dropped out of the study.

Average scores concerning discomfort associated with the procedure are shown in the table.

Patient discomfort
	Nausea	Dyspnea	Coughing	Expectoration	Pain
Preoperatively	1.04	1.40	1.99	1.73	1.24
3 h postoperatively	1.04	1.30	1.93	1.23*	2.04*
24 h postoperatively	1.07	1.47	1.82	1.61	2.01*

* marks a statistically significant change from the preoperative value

72 patients (88 %) were satisfied with time of discharge.

75 patients (91 %) were satisfied having bronchomediastinoscopy performed as an ambulatory procedure.

Discussion

As expected the patients scored little to moderate surgical pain 3 and 24 h after surgery.

Nausea and coughing were similar to preoperative values.

Seven of the 82 patients completing the study would have preferred to stay 2 or 3 hours more and 7 additional patients would have preferred to be hospitalized overnight.

These patients were similar to the satisfied patients concerning ASA class.

Conclusion

This study including mildly to seriously ill patients, ASA class 1-4, confirms that bronchomediastinoscopy under general anesthesia as an ambulatory procedure gives a high degree of satisfaction and only little postoperative discomfort.

Funding sources

Vejle Hospital’s Fund for Research and Development.

P-62

FOLLOW-UP AFTER AMBULATORY SURGERY: TELEPHONE OR DIRECT INTERVIEW

Yuriko Teratani,¹ Atsuko Yamaguchi,¹ Akiko Eto,¹ Gotaro Shirakami.¹ ¹Day Surgery Unit, Kyoto University Hospital, Kyoto, Japan.

INTRODUCTION: Telephone interview after ambulatory surgery is a commonly used tool for postoperative management including evaluation of the patient’s postoperative condition, teaching reinforcement and acquisition of performance feedback. However, it is controversial whether the nurse can ascertain the patient’s post-discharge safety and satisfaction by telephone without direct patient observation. To investigate whether the postoperative telephone call is really adequate, we studied post-discharge symptoms, resumption of normal activity levels (RNA), patient satisfaction and Nursing Outcomes Classification (NOC) in patients who were followed up by a telephone call or a direct meeting after ambulatory hysteroscopic surgery.

METHODS: This study was approved by the Ethical Committee of our institute and obtained an informed consent from each patient. Two hundred forty-five adult female patients who had undergone hysteroscopic surgery under general anesthesia in our Day Surgery Unit (DSU) were divided into two groups. They were interviewed by a registered nurse using the same questionnaire either by telephone call (n=82, Group T) or a direct meeting (n=163, Group D) on the next day of surgery. The questions included post-discharge symptoms, patient’s self-rated RNA ("If you were to score your present physical status between zero (not recovered at all) and ten (fully recovered and normally active), which score would you give?"), patient satisfaction ("If you required surgery again, which would you choose inpatient surgery or outpatient surgery similar to this time?" -yes, no or did not say which). A nurse reviewed the nursing outcome for patient’s post-discharge safety and satisfaction using NOC (1: unsafe, 2: poor, 3: incomplete, 4: good, 5: excellent). A supervisor nurse audited the records, finally.

RESULT: Patient age in Group T (46 +/- 13, mean +/- SD, yr) was not different from that in Group D (45 +/- 12 yr). Distribution of American Society of Anesthesiologists Physical Status Classification (ASA PS) in Group T was almost similar to that in Group D (ASA PS-I 46/37 %, PS-II 46/60 % and PS-III 7/2 % in Group T/D). Incidence of post-discharge symptoms in Group T/D was almost equal: sore throat 41/44 %, drowsiness 22/39 %, genital bleeding