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 1}Anesthetic/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 1}Anesthesiology & 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 1}Anesthesiology, 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 1}Department 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 1}Department 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 1}Day 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 1}Day 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.

 

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