Gabor Mezei

Can postoperative nausea and vomiting be predicted

BackgroundRetrospective [1] studies fail to identify predictors of postoperative nausea and vomiting (PONV). The authors prospectively studied 17,638 consecutive outpatients who had surgery to identify these predictors.MethodsData on medical conditions, anesthesia, surgery, and PONV were collected i

Factors contributing to a prolonged stay after ambulatory surgery

We identified predictors for prolonged postoperative stay after ambulatory surgery using multiple logistic regression models. We collected perioperative data for 16,411 ambulatory surgical patients. A log-transformed time to discharge variable was modeled by multiple linear regression, including patient-, anesthesia-, and surgery-specific variables. The impact of hypothetical elimination of perioperative adverse events on mean length of stay was also estimated. Separate analyses were performed among patients who received general anesthesia (GA) and monitored anesthesia care (MAC). Patients receiving GA stayed 50 min longer than patients receiving MAC. Patients receiving GA and undergoing strabismus, transurethral, or otorhinolaryngological/dental procedures had the longest postoperative stay. Among patients receiving GA, smokers had a 4% shorter stay compared with nonsmokers; among patients receiving MAC, those with congestive heart failure (CHF) had a 11% longer stay compared with patients without CHF. Postoperative nausea and vomiting, dizziness, excessive pain, and cardiovascular events predicted 22%‐79% increases in postoperative stay. The hypothetical elimination of all adverse events resulted in a 9.6% decrease in mean length of stay among patients receiving GA, but in only a 3.8% decrease among patients receiving MAC. The length of postoperative stay among ambulatory surgical patients is mainly determined by the type of surgery and by adverse events, such as excessive pain, postoperative nausea and vomiting, dizziness, drowsiness, and cardiovascular events. Patients with CHF and those who underwent long procedures had a higher risk of a prolonged stay. Appropriate prevention and management of postoperative symptoms could significantly decrease the length of stay among patients receiving GA. Implications: The length of postoperative stay among ambulatory surgical patients is mainly determined by the type of surgery and by adverse events, such as excessive pain, postoperative nausea and vomiting, dizziness, drowsiness, and untoward cardiovascular events. Patients with congestive heart failure and those who underwent long procedures had a higher risk of a prolonged stay. Appropriate prevention and management of postoperative symptoms could significantly decrease the length of stay among patients receiving general anesthesia.

Return Hospital Visits and Hospital Readmissions After Ambulatory Surgery

OBJECTIVE To determine the overall and complication-related readmission rates within 30 days after ambulatory surgery at a major ambulatory surgical center. SUMMARY BACKGROUND DATA Currently in North America, 65% of the surgical procedures are carried out in ambulatory settings. The safety of ambulatory surgery is well documented, with low rates of adverse events during or immediately after surgery. The consequences of ambulatory surgery during an extended period, however, have not been studied extensively. METHODS Preoperative, intraoperative, and postoperative data were collected on 17,638 consecutive patients undergoing ambulatory surgery at a major ambulatory surgical center in Toronto, Ontario. With the use of the database of the Ontario Ministry of Health, the authors identified all return hospital visits and hospital readmissions occurring in Ontario within 30 days after the ambulatory surgery. Return visits were categorized as emergency room visits, ambulatory surgical unit admissions, or inpatient admissions. The readmissions were categorized as those resulting from surgical, medical, or anesthesia-related complications or those not related to the ambulatory surgery. RESULTS One hundred ninety-three readmissions occurred within 30 days after ambulatory surgery (readmission rate 1.1%). Six patients returned to the emergency room, 178 patients were readmitted to the ambulatory surgical unit, and 9 patients were readmitted as inpatients. Twenty-five readmissions were the result of surgical complications, and one resulted from a medical complication (pulmonary embolism). The complication-related readmission rate was 0.15% (1 in 678 procedures). The complication rate was significantly higher among patients undergoing transurethral resection of bladder tumor (5.7%). No anesthesia-related readmissions or deaths were identified. CONCLUSIONS The rate of complication-related readmissions was extremely low (0.15%). This result further supports the view that ambulatory surgery is a safe practice.

Adverse outcomes in ambulatory anesthesia

ConclusionAmbulatory surgery, as currently practiced, has an excellent safety record. Major morbidity is infrequent, and death is extremely rare during or following ambulatory surgical procedures. Less serious, non lifethreatening perioperative adverse events, such as intraoperative cardiovascular events and, most frequently, postoperative excessive pain and PONV, occur with higher incidence. These minor adverse events could result in prolonged postoperative stay, unanticipated hospital admission, or hospital readmission, and they also affect patient satisfaction and postoperative functional level. The occurrence of these minor adverse events is now the major area of quality assessment and an area where improvement could be targeted. The goal of reducing the incidence of minor adverse events related to ambulatory surgery could be achieved by development of less invasive surgical techniques, the use of newer shorter acting anesthetic drugs with fewer side effects, and improved postoperative pain management.ConclusionLa chirurgie ambulatoire, tel qu’on la pratique, présente une fiche excellente concernant la sécurité. La morbidité grave est rare et la mortalité très rare pendant ou après les interventions chirurgicales ambulatoires. Les complications moins importantes, sans danger pour le patient, comme les troubles cardio-vasculaires peropératoires et, plus souvent, les douleurs intenses postopératoires et les NVPO, ont une plus grande occurrence. Ces incidents mineurs peuvent entraîner un séjour postopératoire prolongé, une admission non prévue à l’hôpital ou une réadmission, et ils peuvent aussi affecter la satisfaction du patient et son niveau fonctionnel postopératoire. L’occurrence de ces complications mineures est maintenant l’enjeu le plus important de l’évaluation de la qualité et de la recherche de solutions visant à l’améliorer. L’objectif de réduire l’incidence des complications mineures de la chirurgie ambulatoire peut être atteint en mettant au point des techniques chirurgicales moins effractives, en utilisant de nouveaux agents anesthésiques d’action rapide aux effets secondaires minimaux et en améliorant le traitement des douleurs postopératoires.

Prospective study on Incidence and Functional Impact of Transient Neurologic Symptoms Associated with 1% Versus 5% Hyperbaric Lidocaine in Short Urologic Procedures

Background The objectives of this study were to compare the incidence, onset, duration and pain scores of transient neurologic symptoms (TNS) with 1%versus 5% hyperbaric lidocaine in spinal anesthesia for short urological procedures in a large prospective study. This study would also evaluate patient satisfaction, and impact of TNS on functional recovery to assess the clinical significance of TNS. Methods This was a multicenter, double-blind, randomized controlled trial. Four hundred fifty-three patients undergoing short transurethral procedures were randomized to receive 1% or 5% hyperbaric lidocaine. Eighty milligrams of 1% or 5% hyperbaric lidocaine was administered. During the first 3 days after surgery, the presence of TNS, its intensity and duration, and patient functional level were recorded. An intention-to-treat analysis was used. Results There was no difference in the incidence of TNS (21%vs. 18%) between 1%versus 5% lidocaine. Patients with TNS had significantly higher pain scores (5.3 ± 3 vs. 2.3 ± 3) than patients without TNS during the first 24 h. This difference in pain scores persisted until 72 h postoperatively. There was a significant difference in the daily activities functional scores (2.2 ± 1 vs. 1.4 ± 0.8) of TNS versus non-TNS patients during the first 24 h postoperatively. Conclusions There was no difference in the incidence of TNS between the 1%versus 5% spinal lidocaine groups. Pain scores were higher in patients with TNS than those who did not have TNS. During the first 48 h postop, a small proportion of patients who had TNS experienced functional impairment of walking, sitting, and sleeping.

Can Postoperative Nausea and Vomiting Be Predicted

BACKGROUND Iletrospective studies fail to identify predictors of postoperative nausea and vomiting (PONV). The authors prospectively studied 17,638 consecutive outpatients who had surgery to identify predictors. METHODS Data on medical conditions, anesthesia, surgery, and PONV were collected in the post-anesthesia care unit, in the ambulatory surgical unit, and in telephone interviews conducted 24 h after surgery. Multiple logistic regression with backward stepwise elimination was used to develop a predictive model An independent set of patients was used to validate the model RESULTS Age (younger or older), sex (female or male), smoking status (nonsmokers or smokers), previous PONV, type of anesthesia (general or other), duration of anesthesia (longer or shorter), and type of surgery (plastic, orthopedic shoulder, or other) were independent predictors of PONV. A 10-yr increase in age decreased the likelihood of PONV by 13%. The risk for men was one third that for women. A 30-min increase in the duration of anesthesia increased the likelihood of PONV by 59%. General anesthesia increased the likelihood of PONV 11 times compared with other types of anesthesia. Patients with plastic and orthopedic shoulder surgery had a sixfold increase in the risk for PONV. The model predicted PONV accurately and yielded an area under the receiver operating characteristic curve of 0.785+/-0.011 using an independent validation set. CONCLUSIONS A validated mathematical model is provided to calculate the risk of PONV in outpatients having surgery. Knowing the factors that predict PONV will help anesthesiologists determine which patients will need antiemetic therapy.