anesthesia for day surgery nov 2006

Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)

Anestes ia in day surgeryAnestes ia in day surgery

tecniche e farmacitecniche e farmaci

Claudio MelloniClaudio Melloni

Direttore Servizio di Anestes ia e Rianimazione Ospedale di FaenzaDirettore Servizio di Anestes ia e Rianimazione Ospedale di Faenza

CM 2001


Perché la amb surg ?

beneficio economico finanziario sotto pressione economica…………….

abbattimento dei costi riduz personale dei turni notturno/festivi possibile per miglioramento delle tecniche chir miglioramento tecniche anest


Problema

mantenimento qualità /riduz della spesa

i farmaci per anest rappresentano il 5-6% della spesa farmaceutica totale


Valutazione qualitativa:macroindicatori

(1) Mortalità/morbidità. (2) Prolungamento della degenza postop . (3) ricovero ospedaliero non programmato. (4) visite di controllo precoci/riammissione in

ospedale (5) soddisfazione del paziente


Mortalità e morbilità


Mortalità e morbilità

Misure piuttosto grossolane Warner MA, Shields SE, Shute CG. Major

morbidity and mortality within one month of ambulatory surgery and anesthesia. JAMA 1993; 270:1437±1441.

38 598 paz,4 decessi <30 gg :2 MI e 2 incidenti auto, 31 (0.08%) casi di morbilità maggiore;MI,emb polm,insuff

resp...


Nessun decesso perioperatorio

3 grossi studi da 6000 a 17600 paz;» Duncan PG, Cohen MM, Tweed WA, et al. The Canadian four-centre

study of anaesthetic outcomes: III. Are anaesthetic complications predictable in day surgical practice? Can J Anaesth 1992; 39:440-8.

» Osborne GA, Rudkin GE. Outcome after day-care surgery in a major teaching hospital. Anaesth Intensive Care 1993; 21:822-7.

Chung F, Mezei G. Intraoperative adverse events during ambulatory surgical procedures. Can J Anaesth 1997; 44:A70A.

Morbilità 4 % / 5 % secondo intervento ,ma includono anche le KO minori che non compromettono la vita del paz


Natof HE. Complications associated with ambulatory surgery. JAMA 1980;

244:1116-8.

Nessun decesso 106 patients (0,8 %) su 13 433 Ko chir Entro 15gg dall’intervento.


Modificazioni negli anni Ma

» aumento della complessità delle procedure» Aumento delle patologie coesistenti: comorbidità » Aumento dell’età media

Varranno le stesse cifre citate?


Complicanze maggiori nella casistica ambulatoriale della Mayo Clinic

(1994):3220 casi

PAZIENTI CON I.M: ETÀ,SEX

,ASA INTERV

ENTO FATTOR

I DI

RISCHIO

ANEST. T.PRESE

NTAZ. SINTOMI

54,F,II BIOPSIA

MAMM. IPERTENS A.G. INTRAOP EPA

62,M,II BIOPSIA

CORDE FUMO,CAD A.G. 6 H. IPOTENS

78,M,III CARPAL

TUNNEL NO REG 12 H DOL.TOR.

73,F,II BUNIONECT OBESITÀ REG 12 H SINCOPE 63,F,III CISTOSCOPIA COPD,IPERT A.G. 24 H DOL.TOR.

58,M.I ARTROSCOPI

A GINOCCHIO NO A.G. 36 H DOL.TOR.

74,M,III BIOPSIA

LINGUA FUMO,CAD MAC 36 H DOL.TOR.

85,M,III URETEROSCO

PIA DIABETE A.G. 42 H SINCOPE

48,F,II BIOPSIA

LGH.CERVIC MALIGNITÀ A.G. 48 H DOL.TOR.

66,M.I RILASC.TEND

IN. NO REG 3 GG. SINCOPE

83,F,II RIDUZ

FRATT.NASO NO A.G. 4 GG DOL TOR.

61,F,III LAPAROSCOPI

A ARITMIA,CADF

A.G. 7 GG. SINCOPE

70,M,II ERNIORRAFIA

INGUIN. IPERTENS A.G. 8 GG DOL.TOR.

6PAZEINT

I P COLONSC

OPIA NO MAC 11 GG NAUSEA


Complicanze maggiori nella casistica ambulatoriale della Mayo Clinic

(1994):9018 casi

0

0.005

0.01

0.015

0.02

0.025

0.03

0.035

%

MI def.CNS Emb.polm Ins.Resp

Frequenza


Deficit neurologici dopo anest.amb.in 6441 paz

età,sex,ASA

interv cofatt. anest. tempo sintom.

A.G. intrao 67,f,II aritm. 79,f,III lapar. mal.carot,i

pertens A.G. 12 h afasia

61,m,II graft cut. diab. reg 12 h confus. 72,m,I ernior. no A.G. 24 h. def.vista 60,f,II cisto mal.carot. A.G. 48 h emipl 71,m,II biops.

prost. mal.carot. MAC 7 gg afasia

74,m,II biops. lgh.cervic

aritm. A.G. 18 gg perdita memoria


Complicanze emboliche polmonari dopo anest.ambulat. su 9018 pazienti

età,sex,ASA

interv

cofatt.

anest.

tempo

sintom.

D&C fumo A.G. 24h. dispnea

56,m,II

ureterosc.

malign.

A.G. 24h dispnea

63,f,I imp.dent.

no A.G. 7 gg emoftoe

48,m,III

biops.axill.

malign.

A.G. 13 g dispnea

38,f,III biops.musc.

mal.neuromusxc.

MAC 22gg dispnea


Complicanze respiratorie su 9018 anest.ambulat.

età,sex.ASA

interv cofatt. anest occorr.

sintom

21,f,I tonsillect.

no A.G. intrao asp.polm

41,f,II biops.mamm.

ipertens A.G. 10 h asp.polm

68,m,II polipect.nas.

fumo A.G. 48 h tosse,febbre

82,f,III lapar. CAD A.G. 4 gg. asppolm.

71,m,II rip.tendon

obes. reg 5 gg tosse,febbre


Relazione fra ASA,morbidità e mortalità

0

10

20

30

40

50

ASA 1 ASA 2 ASA 3

da Warner,JAMA,1994

%tot

morbil(n)

mortalità

19614

14609

10867

% o num

%%

%

nn

4 morti

31 eventi patol,magg.


Incidenza delle complicanze in relazione

alle patologie

0.00

0.14

0.28

0.43

0.57

1.12

1.26

1.40

diabete COPD mal.card

da White,1994,Blckwell Sci.Pub.

asma

ipertens

%


Incidenza delle complicanze in relazione alla durata dell’anestesia

0

0.5

1

1.5

2

2.5

3

<1 h 1-2 h 2-3 h >3h

%


Incidenza delle complicanze secondo l’anestesia

somministrata:

00,10,20,30,40,50,60,70,80,9

1

loc solo reg.solo L o R +sed

A.G.

da White,1994,Blackwell Sci.Pub.


Quali sono le KO più frequenti della chir ambulat?

***************************************


Chung F, Mezei G, Tong D. Pre-existing medical conditions as predictors of adverse events in day-case surgery. Br J Anaesth 1999; 83:262±270.

Sono le condizioni preop che condizionano le Ko postop !


Complicanze cardiovascAnomalie pressione art:ipo/ipertens circa 2%, ma i

finlandesi 16%°di ipotensioni Disordini del

ritmo;bradicardia,tachicardia ,aritmie :finlandesi 14%» Differenze metodologiche

Complicazioni più frequenti nei pazienti che presentano già problemi cardiovascolari (ipertens;insuff cardiaca)» Duncan PG, Cohen MM, Tweed WA, et al. The Canadian four-centre study of anaesthetic

outcomes: III. Are anaesthetic complications predictable in day surgical practice? Can J Anaesth 1992; 39:440-8.

» Chung F, Mezei G. Intraoperative adverse events during ambulatory surgical procedures. Can J Anaesth 1997; 44:A70A.

» Heino A, Vainio J, Turunen M, Lahtinen J. Results of 500 general surgery patients operated on in the ambulatory surgical unit. Ann Chir Gynaecol 1992; 81:295-9.


Complicanze respiratorie Frequenza< 1 %. Laringospasmo,broncospasmo,con o senza

desaturazione » (ma anche con apnea ,aspirazione,pnx,EPA)

KO legate all’intubazione;difficile,esofagea,danni dentari:0,2 – 0,5 %

Caratteristiche dei pazienti strettamente legate:» Fumatori,obesi,asmatici da da 2 à 5 +


Le complicazioni postop sono predicibili?


Duncan PD, Reccan PG, Cohen MM, Tweed WA. The Canadian Four

Centre Study of anaesthetic outcomes: are anesthetic complications

predictable in day surgical practice? Can J Anesth 1992; 39:440±448.

6914 paz. Maggior parte giovani: 84.2% < 50 anni 3.1% anestesia a paz >70 ; 0.8% > 80 years of

age. Maggior parte di interventi donne giovani ASA I o

II 3% ASA III. > 75% dei paz nessuna patol preesist


Complicanze in 4 centri ospedalieri canadesi di day surgeryuncan PD, Reccan PG, Cohen MM, Tweed WA.The Canadian FourCentre Study of anaesthetic outcomes: are anesthetic complicationspredictable in day surgical practice? Can J Anesth 1992; 39:440±448

0

2

4

6

8

10

12

14

16

per

mille

frequenza

sbalzi pressaritmieintub diffprobl respmodificaz anestprobl attrezzincid farmaciICU adm

intraop


Complicanze in 4 centri ospedalieri canadesi di day

surgery Duncan PD, Reccan PG, Cohen MM, Tweed WA.The Canadian FourCentre Study of anaesthetic outcomes: are anesthetic complicationspredictable in day surgical practice? Can J Anesth 1992; 39:440±448

0

10

20

30

40

50

60

70

80

per m

ille

frequenza

sbalzi pressipotermiaPONVprobl respprobl renali/metabprobl muscpsicolustione

Nella PACU


Incidenza di complicanze postoperatorie all’intervista telefonica a 72 :25% dei pazienti Osp A,64% Osp C. Duncan PD, Reccan PG, Cohen MM, Tweed WA.The Canadian FourCentre Study of anaesthetic outcomes: are anesthetic complicationspredictable in day surgical practice? Can J Anesth 1992; 39:440±448


Incidenza di complicanze postoperatorie all’intervista telefonica a 72 h :risposte da 25% dei pazienti Osp

A,64% Osp C. Duncan PD, Reccan PG, Cohen MM, Tweed WA.The Canadian Four Centre Study of anaesthetic outcomes: are anesthetic complications,predictable

in day surgical practice? Can J Anesth 1992; 39:440±448

0

5

10

15

20

25

30

35

40

% OspA

Osp C


Relazione fra condizioni preop e KODuncan PD, Reccan PG, Cohen MM, Tweed WA.The Canadian Four Centre Study of

anaesthetic outcomes: are anesthetic complications,predictable in day surgical practice? Can J Anesth 1992; 39:440±448

Patologia di base complicanza

COPD Tratto resp inf

ipertens Instabilità press

neurol cardiache

COPD & ipertens cardiache

diabete cardiache

Insuff digiuno Probl pressori

obesità parecchie

Intub difficile Probl intubaz


Postoperative symtoms at telephone interview 24 hr. Chung F,Mezei G, Adverse outcomes in ambulatory anesthesia .Refresher Course

Outline.Can J Anesth 1999 / 46 / R18-R26 Chung F,Un V, Su J .Postoperative symptoms 24 hours after ambulatory anaesthesiaCAN J ANAESTH 1996 / 43: 11 /

0.0

5.0

10.0

15.0

20.0

25.0

30.0

%

pain at surgical site headache drowsiness dizziness ponv fever

778 pazienti

General surg 17.4% orthopaedic,

11.2%laparoscopic 9.4%.

laparoscopy 36.1%,

general surgery, 21.4%.

laparoscopy, 24.1%,general surgery, 16.1%.

1017 pazienti


% di interferenza con le normali attività quotidiane

nei pazienti con dolore > VAS 4 .Beauregard L, Pomp A,

Choinière M.Severity and impact of pain after day-surgery .Can J Anaesth 1998 / 45 / 304-11

0

20

40

60

80

100

24h 48h 7gg

livello di attivitàumorecamminolavororelaz.personalisonnopiaceri della vitaappetitoconcentraz.interferenza con 3 o + funzioni


Qualità della ripresa funzionale=soddisfazione del paziente

Physiologic endpoints

Psychosocial statusAdverse events

Differenti punti di vista:

PazienteOspedaleStruttura

Assicuraz…


Ma dove è la qualità??

Aprile 2001 Lavoro sul fast tracking di bambini a Washington 31% dei genitori riferiscono che il 40% dei loro

bambini è stato molto irrequieto dopo il fast tracking rispetto al 16%dei piccoli rimasti nella PACU….

Percio’……gli autori……. Concludono che il processo è fattibile e

tecnicamente vantaggioso per i piccoli!!!


Dove è la qualità???

1000 plastiche erniarie inguinale in anestesia locale non monitorizzata(ULA)

Anesth.Analg.2001;93:1373 940 questionari postop di ritorno:121 insoddisfatti principalmente a

causa del dolore intraop. Conclusioni:la plastica erniaria open puo essere

agevolmente effettuata in ULA;offre una sicura alternativa ad altre tecniche anestetiche con un acettabile grado di soddisfazione;anche se il sollievo intraop del dolore necessita di miglioramenti!!!!……..


Anche i migliori………..

Febbr 2001; il gruppo di Dallas paragona remifentanil con esmolol per la stabilità cardiovascolare durante laparoscopia ginecol.

:immaginate un poco….:il gruppo remifent accusa + nausea nel postop e quello esmolol necessita di due volte il dosaggio di idrossicodone postop….

Conclusioni:la tecnica è eccellente nell’80% dei casi……………


Apparenza vs sostanza

Viviamo forse in un mondo ove cio che è facilmente misurabile nasconde cio che è importante ???


Ricoveri ospedalieri non programmati

0.28-2.44% adulti;1% bambini» Fancourt-Smith PF, Hornstein J, Jenkins LG. Hospital

admissions from the day care centre of the Vancouver General Hospital. Can J Anaesth 1990; 37:699-704.

» Cause chir 0.22%» Cause anest:0.07%


Ripartizione delle complicanze che portano al ricovero non programmato

0

10

20

30

40

50

60

70

80

90

chir anest medic social

%

max

min

media

SanguinamentoKo chir

DolorePonv…..

Peggior condiz preesisDiabete,angina,OSA,Ko intraop;aritmie,MI,broncospasmo


Unplanned hospital admissionsDay Surgery Toronto Western Division

8/1017


Vuilleumier H, Halkic N.Laparoscopic cholecystectomy as a day surgery procedure: implementation and audit of 136 consecutive cases in a university hospital .World J Surg. 2004 Aug;28(8):737-40.

136 paz consecutivi:» dimissione:74% overnight stay;24% stesso giorno

3 ricoveri non programmati:» 2 PONV ed 1 caso di ematoma epatico

subcapsulare:diventano 3 su 33……….


Rognas LK, Elkjaer P. Anaesthesia in day case laparoscopic female sterilization: a comparison of two anaesthetic methods.Acta Anaesthesiol Scand. 2004 Aug;48(7):899-902.

0

2

4

6

8

10

12

14

%

pain PONV unplanned hospadmission

alfent

remifent

propofol + fentanyl/alfentanil, N2O and atracurium, vs TIVA with propofol + remifentanil.

Postop pain :high doses paracetamol + NSAID.

1.8% su 683 Sterilizzaz laparoscopiche


Tham C, Koh KF.Unanticipated admission after day surgery.Singapore Med J. 2002 Oct;43(10):522-6.

0

10

20

30

40

50

60

70

surgical anesth. social medical

75%prevenibili

10801 procedure;1.5% ricoveri non progr


Cause di ricovero non programmato post

colecistectomia laparoscopica .:Lau H, Brooks DC. Predictive factors for unanticipated admissions afterambulatory laparoscopic cholecystectomy. Arch Surg. 2001 Oct;136(10):1150-3

0123456789

10

pain ponv urin.retention pat prfeference medical observation

25/731=3.41%

1.36%

0.82%

0.68%

0.41%

Significant factors associated with unplanned admission :

operative duration >60 minutes thickened gallbladder wall on US

pathological findings. length of operation

the only independent predictive factor


0

2

4

6

8

10

12

pain ponv osservaz pt preference late finish ipossiemia ?? coledocolitiasi

134 VLC,28% ricoveri non programmati,fase sperimentale…

Calland JF, Tanaka K, Foley E, Bovbjerg VE, Markey DW, Blome S, Minasi JS, Hanks JB, Moore

MM, Young JS, Jones RS, Schirmer BD, Adams RB Outpatient Laparoscopic Cholecystectomy: Patient Outcomes After Implementation of a

Clinical Pathway


Armstrong M, Mark LJ, Snyder DS, Parker SD.Safety of direct laryngoscopy as an outpatient procedure. Laryngoscope. 1997 Aug;107(8):1060-5

589 direct laryngoscopies performed at a new outpatient surgery center.

9 unplanned admissions to the hospital:» 5 airway emergencies that developed within the first 30 min

after extubation:3 patients required reintubation before leaving the operating room.

On postoperative telephone follow-up, 9% complained of mild to moderate sore throat

no major complications after discharge risk of airway emergencies after direct laryngoscopy is

less than 1% in carefully selected patients


Groin hernia surgery: a systematic review.Cheek CM, Black NA, Devlin HB, Kingsnorth AN, Taylor RS, Watkin DF. The Royal College of Surgeons of England. Ann R Coll Surg Engl. 1998;80 Suppl S1-80 .

The main methodological shortcomings of the studies that have been performed are:

lack of agreed method for assessing severity of hernias;

failure to take confounding into account in non-randomised studies;

variation in length of follow-up; poor external validity; lack of objective measures of outcome; inadequate statistical power. These problems severely limit the conclusions that

can be drawn from the literature


Visite di ritorno non programmate


Visite di ritorno entro 1 mese/riammissioni in ospedale

Durante:» le prime 24-72 h: 4-8% di paz visitati da un medico(GP)

Nel primo mese: 12% Ricovero in ospedale:0.3%

» sanguinamento» Febbre» Infezione» Dolore» Deiscenza ferita» Ritenzione urinaria


Twersky R, Fishman D, Homel P. What happens after discharge? Return hospital visits after

ambulatory surgery. Anesth Analg 1997; 84:319±324

6243 paz 1.3 % rientri in osped entro 1 mese 5.4% in PS 4.6% ricoverati Interv e cause dei ricoveri:

» Varicocelectomia:» Idrocelectomia» D & C: 3 volte+

» Sanguinamenti! ²

8.3 volte


Interventi e dimissioni autori intervento dimissione riammissione Tot paz

De Waele Outpatient laparoscopic gastric banding: initial experience. Obes Surg. 2004 Sep;14(8):1108-10

Gastric banding laparosc

9.6 h no 10

Edwin Outpatient laparoscopic splenectomy: patient safety and satisfaction. Surg Endosc. 2004 Sep;18(9):1331-4.

Splenect video lap

2;16.6% 12

Athey. Day-case breast cancer axillary surgery.Ann R Coll Surg Engl. 200587(2):96-8.

Nodulect quadrantec +ascella

No drenaggio 9.7% 165

MacDonald Minimal impact urethroplasty allows same-day surgery in most patients. Urology. 2005 Oct;66(4):850-3.

Uretroplast ant 15% 54

Dieter RA JrRemote surgicenter experience with hernia repair. Int Surg. 2005 Jul-Aug;90(3 Suppl):S2-5.

ernioplast 6 paz:0.22% 2659


Morales R, Esteve N, Casas I, Blanco C. Why are ambulatory surgical patients admitted to hospital? Prospective study. Amb Surg 2002;

9:197±205.

. More extensive surgery than planned, and bleeding are the two most common.


Chirurgia di giorno e obesità

Linee guida dell’ UK Royal College of Surgeons 1992 :

Pazienti con BMI >30 non adatti per chir amb Inchiesta questionario postale UK:2004: 85% delle unità

trattato pazienti con BMI >30 » Atkins M, White J, Ahmed K. Day surgery and body mass index:

results of a national survey. Anaesthesia 2002; 57:180±182.

I dati di questa inchiesta postale suggeriscono che probabilmente I criteri di esclusione si applicano solo agli obesi patologici,cioè con >35 BMI.


Insoddisfazione del paziente

Con anest» Anest inadeguata durante mac» Ponv» Mal di gola» Associaz con il numero di sintomi sviluppati


Insoddisfazione dei pazienti Tong,D,Chung F,Wong D.Predictive Factors in Global and Anesthesia Satisfaction in Ambulatory Surgical Patients CLINICAL INVESTIGATION Anesthesiology, 87:856-64, 1997

Insoddisfatti 68 su 2,730 (2.5%) 9 scontenti dell’anestesia Scontento globale associato al numero dui sintomi

spiacevoli postop La preferenza personale per il ricovero costituisce la

causa più frequente di scontento con la chir Eventi avversi intra e postop sono le cause principali

di scontento con l’anestesia


Chung F,Mezei G. Adverse outcomes in ambulatory anesthesia .Refresher Course Outline.

Can J Anesth 1999 / 46 / R18-R26


PONV

Postoperative nausea & vomiting


Importanza dell’argomento PONV è :

» Un fattore limitante nella dimissione precoce» La I o II causa di ammissione ospedaliera non

programmata» PONV può :» Allungare la degenza postop» Accrescere il lavoro degli infermieri» Aumentare i costi totali dell’assistenza» Causare elevato discomfort» Contribuire alla mancanza di soddisfazione


Junger A, Klasen J, Benson M, et al. Factors determining length of stay ofsurgical day-case patients. Eur J Anaesthesiol 2001; 18:314±321

3152 paz ambulatory surgery all’Ospedale della Justus-Libig Università dal 1997.

Fattori importanti nel prolungamento della degenza :5.4% Hb Perdite ematiche Sesso femminile Età avanzata Durata chir Infusioni abbondanti Intubazione Anest.spinale

Oppioid intraop Rilassanti nondepolarizzanti Dolore + al VAS

PONV tempo di attesa prolungato preop


Allora,poichè sono gli interventi chirurgici a decidere nella maggior parte dei casi se il

paziente è gestibile in regime di day surgery……………


Quali procedure?

effettuabili in un tempo “ragionevole” non accompagnate da perdite ematiche o

idro-elettrolitiche importanti che non richiedono attrezzature

sofisticate o cure specializzate postop seguite da dolore postop.che può essere

tenuto sotto controllo dal paziente al proprio domicilio


quali pazienti?

sani solamente?ASA 1? ASA>1,ma con patologie stabilizzate collaboranti accompagnati a casa da un adulto

responsabile............... capaci di seguire le istruzioni pre e postop. problemi degli anziani


Criteri di selezione dei pazienti

fisici medici chirurgici sociali


laparo vs open

tempo operativo:+++

degenza osped:+ costo attrezz:+++ tempo apprendim:++ lavoro perduto:+ COSTI:??

+ +++ + + +++ ??


dalla laparocolecistectomia & dalla laparoscopia ginecologica ad altri interventi

chirurgici.............

erniolaparo.... appendicolaparo......colectomia. chir. pelvica---isterectomie

laparoscopiche.......... ablazione endometriale vs TAH:LASER microdiscectomia lombare uretroplastica transcistoscopica


Altri indicatori di qualità

Microindicatori?


Altre misure di qualità .nel postoperatorio

Dolore Ponv Sonnolenza Gir di testa Soddisfaz del paz Ripresa funzionale postop cefalea


Sintomi accusati dai pazienti a casa dopo interventi eseguiti in regime di day

surgery(da Wu et al.,Anesthesiology 2002).

dolorenauseavomitocefaleasonnolenzagir.di testafatica


Quali problemi preferirebbero evitare i pazienti

sottoposti a day surgery? (da Jenkins, K.; Grady, D.; Wong, J.;

Correa, R.; Armanious, S.; Chung, F.*Post-operative recovery: day surgery patients' preferences

Br. J. Anaesth. 2001; 86:272-274)

0

5

10

15

20

25

30

doloretossire sul tubo etvomitonauseadisorientamentomal di golabrividosonnolenzasete

Valori relativi !


Beauregard L, Pomp A, Choinière M. Severity and impact of pain after day-surgery

Can J Anaesth 1998 / 45 / 304-11

0102030405060708090

100

%

do

lore

PO

NV

gir

.tes

ta

son

no

len

za

cefa

lea

ma

l d

i g

ola

rau

ced

ine

fati

ca

I g.II gVII g


Applicazioni cliniche


Vantaggi dellla anestesia echirurgia ambulatoriali

Vantaggi dellla anestesia echirurgia ambulatoriali

diminuita separazione da casa/ambiente/lavoro..........diminuita separazione da casa/ambiente/lavoro..........

diminuzione delle infezioni ospedalierediminuzione delle infezioni ospedaliere

riduzione dei costiriduzione dei costi

maggiore flessibilitàmaggiore flessibilità

diminuzione delle liste di attesadiminuzione delle liste di attesa


Scopi della anestesia in day surgery( E NON SOLO DAYSURGERY....)

Scopi della anestesia in day surgery( E NON SOLO DAYSURGERY....)

Pre,intra e postop....Pre,intra e postop....

AnsiolisiAnsiolisi

SedazioneSedazione

AnalgesiaAnalgesia

IpnosiIpnosi

AmnesiaAmnesia

Protezione dall’insulto chirurgico e dai riflessi indesideratiProtezione dall’insulto chirurgico e dai riflessi indesiderati

Riduzione del rischio di reflusso gastrico acidoRiduzione del rischio di reflusso gastrico acido

Profilassi della nausea e del vomito,del dolore postop…..Profilassi della nausea e del vomito,del dolore postop…..


interventi possibili sotto MAC

sedazione +/-anestesia topica endoscopia GI,bronco,... ESWLT TVOC,IVFT radiologia diagnostica-terapeutica



sedazione +/-anestesia locale o blocchi regionali

angiografia,pacemaker,caterizzazione vascolare protratta,filtri venosi....

cure dentarie estrattive-conservative chirurgia oculare escissione di lesioni superficiali chirurgia dei seni e polipectomia artroscopia,tunnel carpale,chir .ortop.minore... septorinoplastica,chir.cosmetica vasectomia,orchidopessia D&C,chir perineale,procto inclusa



con sedazione e anestesia regionale

cistoscopia,TURP,TURV... artroscopia e chir ortop... D&C,isterectomia vaginale,chir perineale,plastiche vaginali... erniorrafia,emorroidectomia...


Patient satisfaction;la soddisfazione delpaziente.......

Patient satisfaction;la soddisfazione delpaziente.......

Patient satisfaction after anaesthesia and surgery: results of a prospective survey of 10 811 patients†Clinical Investigation Br. J. Anaesth. 2000; 84:6-10

Patient satisfaction after anaesthesia and surgery: results of a prospective survey of 10 811 patients†Clinical Investigation Br. J. Anaesth. 2000; 84:6-10

98% soddisfatti su 1050098% soddisfatti su 10500

fattori associati con la insoddisfazione:fattori associati con la insoddisfazione:

intraoperative awarenessintraoperative awareness

moderate or severe postoperative painmoderate or severe postoperative pain

severe nausea and vomitingsevere nausea and vomiting

other postoperative complicationsother postoperative complications


Criteri di scelta della tecnica anestetiaCriteri di scelta della tecnica anestetia

condizioni intraoperatorie ottimalicondizioni intraoperatorie ottimali

rapido ritorno di coscienzarapido ritorno di coscienza

effetti sedativi residui minimieffetti sedativi residui minimi

minimo disturbo delle condizioni cognitive postopminimo disturbo delle condizioni cognitive postop

assenza di effetti collaterali durante il I periodo diripresa;PONV minimi per precoce deambulazione e

dimissione

assenza di effetti collaterali durante il I periodo diripresa;PONV minimi per precoce deambulazione e

dimissione


Riprese "elementari"Riprese "elementari"

capacità di esprimere nome ecognome

capacità di esprimere nome ecognome

esecuzione di ordini sempliciesecuzione di ordini semplici

data del giornodata del giorno


criteri di dimissionecriteri di dimissione

capacità di stare sedutocapacità di stare seduto

capacità di assumere la posizione erettacapacità di assumere la posizione eretta

capacità di vestirsicapacità di vestirsi

capacità di camminarecapacità di camminare

capacità di berecapacità di bere

capacità di urinarecapacità di urinare

altre...................altre...................


Criteri di dimissioneCriteri di dimissione

segni vitali stabili >30 minsegni vitali stabili >30 min

assenza di nuovi sintomi postop.assenza di nuovi sintomi postop.

assenza di sanguinamento o secrezioni dalla incisioneassenza di sanguinamento o secrezioni dalla incisione

no PONV( o minima...)no PONV( o minima...)

funzione neurocircolatoria normale alle estremità dopo chirurgia degli artifunzione neurocircolatoria normale alle estremità dopo chirurgia degli arti

minimo capogiro in piediminimo capogiro in piedi

dolore sotto controllo con analgesici orali o altro...dolore sotto controllo con analgesici orali o altro...

minzione?(cistoscopia.....)minzione?(cistoscopia.....)

accompagnatore affidabileaccompagnatore affidabile


Score di dimissione


PADSS di Chung Practical issues in outpatient anaesthesia: Discharge criteria - a new trend .Chung, Frances. Department of Anaesthesia, University of Toronto, Toronto Hospital, University of Toronto, Toronto, Ontario, Canada.CAN J ANAESTH 1995 / 42: 11 / pp1056-9


MPADSS di Chung


Modified Aldrete Score


Patel RI,Verghese ST,Hannallah RS,Aregawi A,Patel K M..Fast-Tracking Children After Ambulatory Surgery Anesthesia and Analgesia 2001; 92:918-922


Patel RI,Verghese ST,Hannallah RS,Aregawi A,Patel K M..Fast-Tracking Children After

Ambulatory Surgery Anesthesia and Analgesia 2001; 92:918-922


Criteri dimissione di Oxford nel cestino di Vaio internet


Scelta della tecnicaScelta della tecnicaThe goal is to anaesthetize the patient for the shortest possible time with the

lowest concentration of anaesthetic.The goal is to anaesthetize the patient for the shortest possible time with the

lowest concentration of anaesthetic.

esigenze chirurgicheesigenze chirurgiche

considerazioni anesteticheconsiderazioni anestetiche

condizioni del pazientecondizioni del paziente

preferenze del pazientepreferenze del paziente


Scopi della tecnica di anestesia sceltaScopi della tecnica di anestesia scelta

condizioni intraop.ottimalicondizioni intraop.ottimali

rapida ripresa della coscienzarapida ripresa della coscienza

minimi strascichi sedativiminimi strascichi sedativi

minimo disturbo delle condizioni cognitve postop.minimo disturbo delle condizioni cognitve postop.

assenza di effetti collaterali(PONV...)assenza di effetti collaterali(PONV...)

possibilità di rapida dimissione e deambulazione precocepossibilità di rapida dimissione e deambulazione precoce

ripresa rapida delle normali attivitàripresa rapida delle normali attività


SicurezzaSicurezzaassenza di effetti collateraliassenza di effetti collaterali

rapidità induzionerapidità induzionePropofolPropofol

RemifentanilRemifentanil

rapido risvegliorapido risveglioPropofolPropofol

RemifentanilRemifentanil

minimi effetti cardiovascolariminimi effetti cardiovascolarimidazolammidazolam

modesta depressione respiratoriamodesta depressione respiratoriamidazolammidazolam

assenza di PONVassenza di PONVpropofolpropofol

midazolammidazolam

analgesia postoperatoriaanalgesia postoperatoriaKetorolacKetorolac

TramadolTramadol


Caratteristiche dei nuovi farmaciCaratteristiche dei nuovi farmaci

inizio e scomparsa di azione rapideinizio e scomparsa di azione rapide

assenza di residui o code anesteticheassenza di residui o code anestetiche

assenza di effetti collaterali(hangover)oassenza di effetti collaterali(hangover)o

nessuna necessità di antagonizzazione….nessuna necessità di antagonizzazione….

assenza di effetti collaterali;istaminoliberazione,effetti cardiovascolari…assenza di effetti collaterali;istaminoliberazione,effetti cardiovascolari…

predicibilità duratepredicibilità durate

sicurezzasicurezza

indipendenza da biotrasformazione da organi….indipendenza da biotrasformazione da organi….


Nuovi farmaciNuovi farmaciday anestesia-day surgeryday anestesia-day surgery

ipnotici & sedativiipnotici & sedativibarbiturici,propofolbarbiturici,propofol

benzodiazepinebenzodiazepine

analgesici,sistemici & localianalgesici,sistemici & localiderivati del fentanilederivati del fentanile

derivati amidiciderivati amidici

adiuvantiadiuvantiantiemeticiantiemetici

analgesici FANSanalgesici FANS

miorilassantimiorilassantibenzilisochinolinebenzilisochinoline

aminosteroideiaminosteroidei


DebateDebateGas vs TIVAGas vs TIVA

GasGas

advantagesadvantages

induction withoutveininduction withoutvein

easy maintenanceeasy maintenance

easy recoveryeasy recovery

familiar...familiar...

disadvantagesdisadvantages

pollutionpollution

Ponv...Ponv...

Point threePoint three


DebateDebateTIVATIVA

AdvantagesAdvantages

no pollutionno pollution

smoothemergence...smoothemergence...

postop.analgesiapostop.analgesia

smooth induction(after i.v...).smooth induction(after i.v...).

DisadvantagesDisadvantages

knowledge ofpk-pdknowledge ofpk-pd

less easyless easy

less reversibleless reversible


Le tecniche di sedazione

da sole in associazione a: anestesia locale:infiltrazione tissutale,della

cicatrice,topica(EMLA,spray,gel,pasta...) anestesia di nervi e/o plesso anestesia regionale e.v. A.R.spinale o peridurale


obbiettivi della sedazione

concetto di MAC ansiolisi sedazione analgesia (amnesia)



sedazione +/-anestesia topica endoscopia GI,bronco,... ESWLT TVOC,IVFT radiologia diagnostica-terapeutica



sedazione +/-anestesia locale o blocchi regionali

angiografia,pacemaker,caterizzazione vascolare protratta,filtri venosi.... cure dentarie estrattive-conservative chirurgia oculare escissione di lesioni superficiali chirurgia dei seni e polipectomia artroscopia,tunnel carpale,chir .ortop.minore... septorinoplastica,chir.cosmetica vasectomia,orchidopessia D&C,chir perineale,procto inclusa



con sedazione e anestesia regionale

cistoscopia,TURP,TURV... artroscopia e chir ortop... D&C,isterectomia vaginale,chir perineale,plastiche vaginali... erniorrafia,emorroidectomia...


definizione di MAC(ASA)

“circostanza in cui l’anestesista è chiamato per fornire un servizio anestetico specifico ad un paziente sottoposto a procedura di elezione durante la quale il paz.riceve o no anestesia locale .In tale caso l’anestesista offre un servizio specifico al paziente e controlla i suoi segni vitali ed è disponibile a somministrare anestetici o altre cure mediche come indicato”


definizione di MAC(ASA)

DEVE: essere stata effettuata una visita con valutazione preop; essere stata prescritta l’ assistenza anestetica necessaria; esservi una partecipazione personale o la direzione medica di

tutto il piano assistenziale; esservi la presenza fisica continua dell’anestesista o dello

specializzando o della infermiera sotto direzione medica esistere la vicinanza o nel caso della supervisione la disponibilità

dell’anestesista per la diagnosi o il trattamento delle emergenze


per la MAC:

monitoraggio usuale noninvasivo cardiovascolare e respiratorio

somministrazione di O2 se indicata somministrazione di terapia

farmacologica(sedativi,tranquillanti,antiemetici,narcotici,analgesici,betabloccanti,vasopressori,broncodilatatori,antiipertensivi)indicata.


Intubation without muscle relaxant

02468

1012141618

open midline closed

midaz 0.03 mg/kg e alfent 40 microgr/kg

eto 0.3eto 0.3 + lidoprop 2 mgprop + lidotps 4 mgtps + lidodtc/tps/scc


Intubation without muscle relaxant

02468

10121416

no movem 2 coughs cough + ormov+

midaz 0.03 mg/kg + alfentanil 40 microgr/kg

eto 0.3eto 0.3 + lidoprop 2 mgprop + lidotps 4tps + lidodtc/tps/scc


I miorilassantiI miorilassantisempre meno paralisi residue....sempre meno paralisi residue....

più sicurezzapiù sicurezza

Atracurium & VecuroniumAtracurium & VecuroniumFinalmente una nuova era dal'epoca della dtc e pancuronium...Finalmente una nuova era dal'epoca della dtc e pancuronium...

MivacuriumMivacuriumSicurezza nella ripresa,eccetto i deficit di pseudocolinesterasi...Sicurezza nella ripresa,eccetto i deficit di pseudocolinesterasi...

CisatracuriumCisatracurium Affinamento degli effefti collateraliAffinamento degli effefti collaterali

RocuroniumRocuronium onset rapidoonset rapido

rapacuroniumrapacuronium onset e offset rapidionset e offset rapidi


Benzilisochinolineaminosteroidi

Degradazione spontanea Metabolizzazione epatica

Glaxo Glaxo WellcomeWellcome

Organon Organon TeknikaTeknika


I miorilassanti oggi:

vecuronium atracurium mivacurium rocuronium cisatracuriumrapacurium

lib.istamina no si si no no no

ipotens no si si no no no

tachicardia no si si si no no

conservazione ok freddo freddo ok freddo ok

confezione polvere pronto pronto pronto pronto ?

laudanosina no si no no (si) no

metabolismo epatico Hoffman pseudocolinest epatico Hoffman epatico

escrez renale si no no si no si


Criteri di scelta dei miorilassanti in day surgery-

day anesthesia Conoscenza dei tempi chir e anest; dosi non >1-1.5 ED 95; monitoraggio ; vietati i miorilassanti a durata lunga: evitare antagonismo se possibile scelta fra:

» Rapacuronium,rocuronium vecuronium » mivacurium,atracurium,cisatracurium.


Quoziente di sicurezza:ED95 istaminoliberatrice/ED95 blocco nm.

0

1

2

3

4

5

6

7

8

safety factor

atracmivaccisatrac

??


Future trends

»fast onset & offset,senza cumulatività……..

»no metaboliti attivi»indipendente da organi»no effetti cardiovascolari»(selettivo per gruppi muscolari…)

Miraculorium


Antagonismo Ma se si dimostra che la

gammaciclòdestrina(SUGAMMADEX R )non ha effetti collaterali(diversamente da atropina e prostigmina….)

Poichè ingloba in pochi secondi la molecola del rocuronium e fa scomparire il blocco completamente…(appena meno specifica per il vecuronium)

La scelta degli aminosteroidei almeno in day surgery potrebbe divenire obbligata!


Analgesici oppioidiAnalgesici oppioididerivati fentaniliciderivati fentanilici

FentanilFentanil Il capostipiteIl capostipite

AlfentanilAlfentanil il figlio ,con la velocitàmancante al padreil figlio ,con la velocitàmancante al padre

RemifentanilRemifentanilUna nuova era:gli EMOUna nuova era:gli EMO

antagonismo sempre possibile con il Naloxone!antagonismo sempre possibile con il Naloxone!


Principali caratteristiche degli oppioidi

FARMACO ONSET(SEC) DURATA(MIN) METABOLISMO

Fentanil 240 30 epatico

Alfentanil 50 10 epatico

Sufentanil 180 15 epatico

Remifentanil 45 4 esterasi


Farmacodinamica dei principali oppioidi

0 50 100 150 200

onset

durata

tramadol

remifentanil

sufentanil

alfentanil

fentanil

sec

min


Concentrazioni plasmatiche (relative) di oppioidi

nel tempo dopo il bolo


IpnoticiIpnotici& sedativi......& sedativi......

PentotalPentotal Il gold standardIl gold standard

PropofolPropofol Il nuovo standardcinetico-dinamicoIl nuovo standardcinetico-dinamico

MidazolamMidazolamL'evoluzione delle BDZL'evoluzione delle BDZ


Propofol(diprivan)Propofol(diprivan)vantaggi & svantaggivantaggi & svantaggi

vantaggivantaggi

rapidorapido

noncumulativononcumulativo

duttileduttile

svantaggisvantaggi

costocosto

depressionecardiovascolaredepressionecardiovascolare

conservazioneconservazione


Confronto fra pentotal e propofol;punteggio da 0 a 100

pentotalpentotal propofolpropofol

rapiditàrapidità 3030 4545

dolore iniezionedolore iniezione 55 1010

depress.cardiovascdepress.cardiovasc 1010 1515

depress respdepress resp 1010 1515

cumulativitàcumulatività 5050 00

separazione sedaz-ipnosiseparazione sedaz-ipnosi 1010 100100

arteriolesivoarteriolesivo 100100 00

infus.continfus.cont 00 100100

antianalgesicoantianalgesico 2020 00


Sedativi-tranquillanti

Dal diazepam(Valium) al midazolam(Ipnovel,Dormicum)

possibilità di antagonismo! flumazenil (anexate).


Differenze nelle benzodiazepine

diazepam midazolam

irritazione venosa si, (*)no

trombosi si (*)no

emivita lunga breve

metaboliti attivi si no

amnesia si,+ si,++

infusione continua no si

somministrazione os,iv, os,iv,im,rect,nas

metabolismo epatico epatico*=corretti se in emulsione lipidica


Meccanismo di azione


Continuum

MACMAC

protezioneriflessi

protezioneriflessi

analgesiaanalgesia

sedazionesedazione

A.G.


AntiemeticiAntiemeticievoluzione del pensieroevoluzione del pensiero

metoclopramidemetoclopramidepreso dalla gastroenterologiapreso dalla gastroenterologia

droperidoldroperidol preso dagli antipsicotici....preso dagli antipsicotici....

ondansetronondansetronla nuova frontiera...la nuova frontiera...

granisetrongranisetron


PONVPONVfattori di rischiofattori di rischio

donnedonne

giovanigiovani

etàfertile

etàfertile

gravidegravide

postpartum

postpartum

interventiinterventi

muscoliextraoculari

muscoliextraoculari

orecchiomedio

orecchiomedio

pelvifemm.inlaparoscopia

pelvifemm.inlaparoscopia

deambulazioneprecoce

deambulazioneprecoce

bambinibambini

soggettia

cinetosi

soggettia

cinetosipregresso

PONVpregresso

PONV farmacifarmaci

oppioidioppioidi

anesteticiinalatori

anesteticiinalatori


PONVPONVRecettori coinvoltiRecettori coinvolti

CRTZCRTZ

5Ht35Ht3

H1H1AchAch

D2D2

ondansetronondansetron

granisetrongranisetron

tropisetrontropisetron

antistaminici::imedrinato,idrossizina,ciclizinaantistaminici::imedrinato,idrossizina,ciclizina

butirofenoni::droperidolbutirofenoni::droperidol

fenotiazinefenotiazine

scopolaminascopolamina

metoclopramidemetoclopramide

steroidisteroidi

Combinationtherapy

Combinationtherapy


Studi comparativi sulla incidenza di nausea(Raphael,1993) e

emesi(Alon,1992).

0

10

20

30

40

50

60

70

80

90

%

ondansetron droperidol 1.25 metoclopramide 10mg

Donne,RU.

emesis

nausea


Gli anestetici generaliGli anestetici generalievoluzione di una tradizione storicaevoluzione di una tradizione storica

isofluranoisofluranobuono per tutti gli usibuono per tutti gli usi

desfluranodesfluranola rapiditàla rapidità

sevofluranosevofluranoinduzione e risveglioinduzione e risveglio

N2ON2O potente analgesico,rapido,costa poco...potente analgesico,rapido,costa poco...


Dati sugli anestetici generali

ANESTETICO COEFF

.RIPARTIZIONE

SANGUE/GAS

MAC % METABOLISMO

%

DESFLURANE 0.45 6 0.02

SEVOFLURANE 0.65 2 3

N2O 0.47 105 0.004

ISOFLURANE 1.40 1.15 0.2

HALOTHANE 2.40 0.75 18


Solubilità e aumento della concentrazione alveolare (FA) rispetto a quella

inspirata(Fi)


Solubilità e eliminazione dell’anestetico ,espressa come

percentuale di Fa relativa all’ultima comcentrazione espirata Fao


Anestetici localiAnestetici locali

per infiltrazioneper infiltrazione

lidocainalidocaina meno tossica,meno costosa,capostipitemeno tossica,meno costosa,capostipite

mepivacainamepivacainapiù tossica,più costosa,ma durata maggiorepiù tossica,più costosa,ma durata maggiore

bupivacainabupivacainapiù tossica,più costosa,lunga duratapiù tossica,più costosa,lunga durata

ropivacainaropivacainameno tox,+ costosa,lunga duratameno tox,+ costosa,lunga durata

analgesia postop.analgesia postop.


Tabella comparativa degli A.L.

FARMACO ONSET DURATA DURATA CON

ADR

CONC.EQUIV

.

lidocaina 2 60 50% 0,5

mepivacaina 2 100 50 0,5

bupivacaina 5 180 100 0,20

ropivacaina 3 180 50 0,20


Interventi in day hospitalInterventi in day hospitale anestesia regionale corrispondente...e anestesia regionale corrispondente...

plastica erniainguinale

plastica erniainguinale

bloccoileoipogastrico-ileoinguinalebloccoileoipogastrico-ileoinguinale

RU,conizzazione,isteroscopiaRU,conizzazione,isteroscopiablocco paracervicaleblocco paracervicale

circoncisionecirconcisione blocco nn.dorsali delpeneblocco nn.dorsali delpene


Interventi in day hospitalInterventi in day hospital& anestesie regionali corrispondenti...& anestesie regionali corrispondenti...

interv.sull'arto inferiore(allucevalgo,caviglia..)

interv.sull'arto inferiore(allucevalgo,caviglia..)

blocchinn.femorale,surale,safeno,tibialepost....

blocchinn.femorale,surale,safeno,tibialepost....

interventi sulla mano eavambraccio

interventi sulla mano eavambraccio

blocco plesso brachialeascellare,blocchi deinn.mediano,radiale ,ulanre...

blocco plesso brachialeascellare,blocchi deinn.mediano,radiale ,ulanre...

interv sull'occhio(cataratta)interv sull'occhio(cataratta)Blocco retro & peribulbareBlocco retro & peribulbare

interv, dentariinterv, dentariblocchi tronculari,nn mascellare emandibolareblocchi tronculari,nn mascellare emandibolare


Interventi eseguibili con anestesia perinfiltrazione locale

Interventi eseguibili con anestesia perinfiltrazione locale

attenzione ai dosaggi totali......attenzione ai dosaggi totali......

CosmeticiCosmetici blefaroplastica,liposuzione...blefaroplastica,liposuzione...

ORLORL nasali,septoplastica...nasali,septoplastica...

escissione di masse e biopsieescissione di masse e biopsienodulectomie(mammella),nevi,.....nodulectomie(mammella),nevi,.....

artroscopieartroscopie ginocchio,spallaginocchio,spalla


Anestesia topicaAnestesia topicaattenzione ai dosaggi!attenzione ai dosaggi!

mistura eutectica diAL

mistura eutectica diAL

litotrissia,innesti cutaneilitotrissia,innesti cutanei

spray di lidocainaspray di lidocainabroncoscopia,endoscopiadigestiva...broncoscopia,endoscopiadigestiva...

lidocaina gel ocrema

lidocaina gel ocrema

circoncisione,uretroscopia,resezionitransuretrali vescicali...circoncisione,uretroscopia,resezionitransuretrali vescicali...


N.mediano

N.ulnare

Tendine flessore rad.carpo

Tendine m.palmare lungo

Tendine flessore ulnarecarpo


Analgesia postoperatoriaAnalgesia postoperatoriala capacità di controllare il dolore postop. costituisce la

differenza fra un intervento ambulatoriale e da ricoverato...la capacità di controllare il dolore postop. costituisce la

differenza fra un intervento ambulatoriale e da ricoverato...

oppioidi più potentioppioidi più potentilimitati all'immediato postoplimitati all'immediato postop

agonisti"deboli"agonisti"deboli" tramadol,codeinatramadol,codeina

FANSFANS Ketorolac,diclofenacKetorolac,diclofenac

FANS+ Agonisti deboliFANS+ Agonisti debolicodeina+paracetamolocodeina+paracetamolo


Analgesia postoperatoriaAnalgesia postoperatoriaproseguimento della tecnica di blocco...proseguimento della tecnica di blocco...

blocchiblocchi continui...continui...

instillazioneintraarticolareinstillazione

intraarticolareconAL,clonidina,combinazioniconAL,clonidina,combinazioni

infiltrazione dellaferita

infiltrazione dellaferita

erniainguinale,cicatrici,linee diincisione....

erniainguinale,cicatrici,linee diincisione....


Nuove metodiche di somministrazione

Infusione continua TCI BIS… servomeccanismi……..


Livelli plasmatici con boli

0

20

40

60

80

100

120

140

5 10 15 20 25 30 35 40 45 50 55 60

min

propofolremifentanilmaxmin

Finestra terapeutica

I boloII bolo


Livelli plasmatici con infusione continua

0

20

40

60

80

100

120

5 10 15 20 25 30 35 40 45 50 55 60

min

propofolremifentanilmaxmin

Finestra terapeutica


Essential intraoperative monitoringEssential intraoperative monitoringguidelinesguidelines

continuous presence of trained anesthesia personnelcontinuous presence of trained anesthesia personnel

continual assessment of ofcontinual assessment of of

oxygenationoxygenation

ventilationventilation

circulationcirculation

temperaturetemperature

clinical asessment+ standards of careclinical asessment+ standards of care

pulse oxymetrypulse oxymetry

capnographycapnography

NIBPNIBP

ECGECG

FiO2FiO2

disconnect alarmdisconnect alarm

thermometrythermometry


Basic physico-chemical properties of modern inhalational agents:

Low blood/ gas solubilities

»fast induction and emergence

No active metabolites Recovery times not dependent from

anesthesia duration


Inhalationinduction

Ideal characteristics for an inhaled agent useful for induction:

Low blood gas solubility Pleasant smell Nonirritating for the airway High potency sevoflurane ??


Context sensitive half time of

opioids(influence of P450 3A4 on alfentanil)


Inhalational anesthesia vs TIVAInhalational anesthesia vs TIVAsimilarities...similarities...

parameterparameter inhalation anesth.inhalation anesth. TIVATIVA

cont.adm.cont.adm. yesyes yesyes

methodmethod vaporizervaporizer syringe pumpsyringe pump

titrationtitration yesyes yesyes

how much?how much? MACMAC MIRMIR

transporttransport airwayairway i.v.i.v.

initinit overpressureoverpressure bolusbolus

basal analgbasal analg N2O/titrationN2O/titration analgesicsanalgesics

pre-intraop checkspre-intraop checks yesyes yesyes


Discharge of the patient vs homereadiness

Discharge of the patient vs homereadiness

ChungChung

patterns of home readinesspatterns of home readiness

persistent symptomspersistent symptoms

recurrence of painrecurrence of pain

PONVPONV

factors that delay dischargefactors that delay discharge

unavailability of escortsunavailability of escorts

Laparscopy,general surg,orthopedic surg


Anesthesia and factorsassociated with PONVAnesthesia and factorsassociated with PONV

GA> regGA> reg

etomidate,ketamine,(neostigmine),(N2O)etomidate,ketamine,(neostigmine),(N2O)

PAINPAIN

Sudden movementSudden movement

HypotensionHypotension

Gastric distentionGastric distention


PONVPONVCategories at riskCategories at risk

FemalesFemales young,pregnantyoung,pregnant

kinetosiskinetosis

certain operationscertain operations strabismus, innerear,pelvic laparoscopic ...strabismus, innerear,pelvic laparoscopic ...

diabeticsdiabetics


PONVPONVwe know the risk factorswe know the risk factors

Preventive strategyPreventive strategy non emetogenic drugs...non emetogenic drugs...

AntiemeticProphylaxisAntiemetic

ProphylaxisSelected at risk groupsSelected at risk groups

Immediate treatmentImmediate treatment in case ofoccurrence.....in case ofoccurrence.....


PONV prophylaxis and treatment

Droperidol 10 microgr/kg ev/im++ Ondansetron 4-8 mg ev(8 p.o.)++ Dexamethasone 4 mg ev+ Ephedrine 10 mg iv? Scopolamine 0.5 mg/62 hr patch ?? Metoclopramide 10 mg iv +/- Propofol 10-20 mg ev?? “setrons”++


Advantages of the LMA>TT

increased speed and ease of placement by inexperienced personnel;

increased speed of placement by anaesthetists; improved haemodynamic stability at induction and

during emergence; minimal increase in intraocular pressure following

insertion; reduced anaesthetic requirements for airway tolerance; lower frequency of coughing during emergence; improved oxygen saturation during emergence; lower incidence of sore throat in adults.


Advantages LMA>Face Mask

easier placement by inexperienced personnel;

improved oxygen saturation; less hand fatigue; improved operating conditions during

minor paediatric otological surgery.


Importare diapo LMA imbustata ed inserita….


Diapo dei monitoraggi


Disadvantages LMA> TT&FM

lower seal pressures higher frequency of gastric insufflation. The only disadvantage compared with

the FM was that oesophageal reflux was more likely.


In conclusionIn conclusionfor the success of day anesthesia & surgeryfor the success of day anesthesia & surgery

pk-pdfoundations

pk-pdfoundations

clinicalexperience

clinicalexperience

organizationorganization

continuousimprovementcontinuous

improvement

pk/pdfoundations

pk/pdfoundations

technology?technology?


Criteri di dimissioneCriteri di dimissionevalutazione della ripresa funzionalevalutazione della ripresa funzionale

segni vitali stabili per 30 minsegni vitali stabili per 30 minFC,PA,SaO2,coscienzaFC,PA,SaO2,coscienza

nessun nuovo sintomo postopnessun nuovo sintomo postopstatu quo ane.....statu quo ane.....

nessun sanguinamento dal sito op.nessun sanguinamento dal sito op.

nausea e/o vomito minimo per 30 minnausea e/o vomito minimo per 30 min

orientato nel tempo e spazio e alla personaorientato nel tempo e spazio e alla persona

minimo gir.di testa seduto o in piediminimo gir.di testa seduto o in piedi

dolore minimo & controllabile con analgesici oralidolore minimo & controllabile con analgesici orali

scorta per andare a casa....scorta per andare a casa....

Spec:capacità di mingere dopo cistoscopia,funz neurocirc.intatta dopo chir delle estremità....Spec:capacità di mingere dopo cistoscopia,funz neurocirc.intatta dopo chir delle estremità....

remitàremità


New frontiers in ambulatory anesthesiaNew frontiers in ambulatory anesthesiaday anesthesia-day surgeryday anesthesia-day surgery

new ideasnew ideas

new placesnew places

new equipmentnew equipment

new devicesnew devices

new drugsnew drugs

new physicians..............new physicians..............


Ottimizzazione della anestesia regionale

Nervi periferici o plessi: Puntura singola vs multipla Tecniche continue vs puntura singola Blocchi centrali Unilaterale vs bilaterale(minor impatto

emodinamico) Riduzione della dose di al?


Beauregard L, Pomp A, Choinière M. Severity and impact of pain after

day-surgery Can J Anaesth 1998 / 45 / 304-11

Purpose: To assess the intensity, duration and impact of pain after day-surgery interventions.

Predictors of pain severity were also evaluated along with the quality of analgesic practices and patent satisfaction.

Methods: Eighty-nine consecutive day-surgery patients completed self-administered questionnaires before leaving the hospital and at 24, 48 hr and seven days after discharge. The survey instrument was composed of 0–10 pain intensity scales, selected items of the Brief Pain Inventory, of the Patient Outcome Questionnaire and of the Barriers Questionnaire. Analgesic intake in hospital and at home was recorded along with the use of other pain control methods.

Results: Forty percent of the patients reported moderate to severe pain during the first 24 hr after hospital discharge. The pain decreased with time but it was severe enough to interfere with daily activities in a substantial number of patients. The best predictor of severe pain at home was inadequate pain control during the first few hours following the surgery. More than 80% of the participants were satisfied with their pain treatment. However, one patient in four (25%) needed contact with a health care provider because of pain at home. Many patients (33% to 51%) reported that instructions about pain control were either unclear or non-existent on several aspects. Medication use was low overall. Thirty-two percent of the patients did not take any pain medication during the first 24 hr after discharge although almost half of them (46%) rated their pain ³4. The most common concerns patients had about using pain medication were fear of drug addiction and side effects.

Conclusion: The severity and duration of pain after day-surgery should not be underestimated. Aggressive analgesic treatment during the hospital stay should be provided along with take-home analgesia protocols and comprehensive patient education programs.


Jenkins, K.; Grady, D.; Wong, J.; Correa, R.; Armanious, S.; Chung, F.* Post-operative recovery: day surgery

patients' preferences Br. J. Anaesth. 2001; 86:272-274

Due to the growing importance of quality assurance and cost containment in healthcare, eliciting patients' preferences for post-operative outcomes may be a more economical and reliable method of assessing quality. Three hundred and fifty-five day surgery patients completed a pre-operative written questionnaire to identify patients' preferences for avoiding 10 particular post-operative symptoms: pain, nausea, vomiting, disorientation, shivering, sore throat, drowsiness, gagging on the tracheal tube, thirst and a normal outcome. The two scoring methods used to evaluate preferences were priority ranking and relative value scores. The effects of age, gender, previous health status, type of surgery and previous experience of anaesthesia on patients' preferences were also examined. Avoiding post-operative pain, gagging on the tracheal tube and nausea and vomiting are major priorities for day-case patients. Anaesthetists should take patients' preferences into consideration when developing guidelines and planning anaesthetic care.


Myles, P. S.*; Williams, D. L.; Hendrata, M.; Anderson, H.; Weeks, A. M.

Patient satisfaction after anaesthesia and surgery: results of a prospective survey of 10 811

patients† Clinical Investigation Br. J. Anaesth. 2000; 84:6-

10

: Patient satisfaction after anaesthesia is an important outcome of hospital care. We analysed our anaesthetic database to identify potentially modifiable factors associated with dissatisfaction. At the time of analysis, our database contained information on 10 811 in-patients interviewed on the first day after operation. The major subjective outcome measure was patient satisfaction. We also measured other predetermined outcomes, such as nausea, vomiting, pain and complications. The overall level of satisfaction was high (96.8%); 246 (2.3%) patients were `somewhat dissatisfied' and 97 (0.9%) were `dissatisfied' with their anaesthetic care. After adjustment for patient and surgical factors, there was a strong relation between patient dissatisfaction and: (i) intraoperative awareness (odds ratio (OR) 54.9, 95% confidence intervals (CI) 15.7–191); (ii) moderate or severe postoperative pain (OR 3.94, 95% CI 3.16–4.91); (iii) severe nausea and vomiting (OR 4.09, 95% CI 3.18–5.25); and (iv) any other postoperative complications (OR 2.04, 95% CI 1.61–2.56). Several factors associated with dissatisfaction may be preventable or better treated.


Anesth Analg 1998; 87:816

Telephone follow-up after ambulatory surgery: a pilot study OUTPATIENT ANAESTHESIA AUTHOR(S): Vrehen, H. M.; Drege, E. J.; Oostveen, A. W.; Schipper, E.; Knape, J. T.A. Institute of Anesthesiology, University Hospital Utrecht, The Netherlands Br. J. Anaesth. 1999; 82:11 Objective: Nurses working at the postanesthesia care unit want to provide continued care after discharge of day surgery patients by means

of telephone follow-up. In a pilot study patients' experiences with postoperative care at the recovery room and the effects of a telephone follow-up service, were evaluated.

Patients and Methods: Over a 3 month period, 128 patients of different types of surgery were randomly selected for a telephone interview. After oral consent they were telephoned by a recovery room nurse within 24 hours after discharge from day surgery. A standardized questionnaire was used, consisting of 21 items inquiring about satisfaction with postoperative care at the recovery room, discharge preparation, the presence of postoperative symptoms that occurred at home, received and needed information about self care and recovery at home.

Results: Of the selected group 6 patients refused and 19 patients could not be contacted by telephone; 103 patients were interviewed. Most of the patients (96%) were satisfied with the postoperative care and support, 97% of the patients mentioned to appreciate the telephone follow-up. The day after surgery the main symptoms experienced by the patients were wound pain (49%), sour throat (19%) and headache (14%). A number of patients (19%) still had a feeling of drowsiness and dullness, an unforeseen symptom. Most of the patients (84%) were satisfied with the adequacy and clearness of the information provided by the nurses, as opposed to the information provided by the surgeon or anesthesiologist. Written information would have been appreciated by 35% of the patients. A number of patients (14%) needed information how to manage specific symptoms. In those cases advice or instruction was given over the telephone by the nurse. Most common concern of the patients was postoperative pain treatment.

Conclusion: Patients responded very positively to questions indicating satisfaction with postoperative care. During the first 24 hours after discharge most patients were feeling well with only little discomfort or complaints. Telephone follow-up provides continuity of care by offering the opportunity to the patient to ask questions about health care problems after day surgery. Following the pilot study results, the use of telephone follow-up will be considered for everyday practice after ambulatory surgery.


Pavlin, D. Janet, MD*; Rapp, Suzanne E., MD*; Polissar, Nayak L., PhD†‡;

Malmgren, Judith A., PhD§; Koerschgen, Meagan, BS*; Keyes,

Heidi, RN*Factors Affecting Discharge Time in Adult OutpatientsAnesth

Analg 1998; 87:816

Discharge time (total recovery time) is one determinant of the overall cost of outpatient surgery. We performed this study to determine what factors affect discharge time. Details regarding patients, anesthesia, surgery, and recovery were recorded prospectively for 1088 adult patients undergoing ambulatory surgery over an 8-mo period. The contribution of factors to variability in the discharge time was assessed by using multivariate linear regression analysis. In the last 4 mo of the study, nurses indicated the causes of discharge delays ³50 min in Phase 1 or ³70 min in Phase 2 recovery. When all anesthetic techniques were included, anesthetic technique was the most important determinant of discharge time (R2 = 0.10–0.15; P = 0.001), followed by the Phase 2 nurse. After general anesthesia, the Phase 2 nurse was the most important factor (R2 = 0.13; P = 0.01–0.001). In women, the choice of general anesthetic drugs was significant (R2 = 0.04; P = 0.002). The three most common medical causes of delay were pain, drowsiness, and nausea/vomiting. System factors were the foremost cause of Phase 2 delays (41%), with lack of immediate availability of an escort accounting for 53% of system-related delays. We conclude that efforts to shorten discharge time would best be directed at improving nursing efficiency; ensuring availability of an escort for the patient; and preventing postoperative pain, drowsiness, and emetic symptoms. The selection of anesthetic technique and anesthetic drug seems to be of selective importance in determining discharge time depending on patient gender and type of surgery. Implications: The relative importance of anesthetic and nonanesthetic factors were evaluated as determinants of discharge time after ambulatory surgery. Postoperative nursing care was the single most important factor after general anesthesia; anesthetic drugs, anesthetic technique, and prevention of pain and emetic symptoms were of selective importance depending on patient gender and type of surgery.


uncontrolled pain, nausea/vomiting, drowsiness, unresolved regional block, and inability to void. Pain, emetic symptoms, drowsiness, and voiding problems were also the most frequently identified symptoms associated with delayed discharge in the study by Chung . Inability to void as a cause of delay in our study was, in part, a result of the requirement that all patients void before discharge. It was most often observed after spinal anesthesia and hernia repair (18% and 23%, respectively). Subsequent studies have verified that urinary retention is relatively common after spinal-epidural anesthesia and hernia or perirectal surgery but is relatively rare after nonpelvic surgery performed with general or local anesthesia. Thus, the requirement that patients void before discharge may have unnecessarily delayed discharge in 5%–11% of patients in whom neither the type of anesthesia nor the type of surgery predisposed them to urinary retention.


This study was performed in a university teaching center, in which the duration of surgery is typically long compared with a private setting. However, because the duration of surgery was a relatively minor determinant of discharge time, it may have limited importance in determining outcome. The discharge times observed in our study after general anesthesia for laparoscopy (206 min) are similar to those reported by Chung et al. (201 min) and Rashiq et al. (160–205 min) ; for lower extremity surgery, our times were 176 min, compared with 208 min reported by Parnas et al. , 200–211 min reported by Linden and Enberg , and 95 min reported by Patel et al. ; for hernia surgery, comparable times were 302 min versus 206 min in the current study. This study may serve as a basis for indicating future directions of study with regard to discharge time after outpatient surgery.


Twersky R, Fishman D, Homel P. What happens after discharge? Return hospital visits after ambulatory surgery. Anesth Analg 1997; 84:319±324.

Tutti I paz rentrati nello stesso ospedale dopo chir amb entro 30 gg,sia in PS che nella ASU che come ricoverati

su 6243 paz in 1 anno 187 rientrati (2.99 %),dei quali 1.3% per KO 5.4% in PS e 4.6% riospedalizzati(ASU o ricoveri) Analisi multivariata condotta con 2 casi controllo per ciascun ricovero. urologia è l’unica specialità che predice il ricovero varicocelectomy and hydrocelectomy procedures were 8.3 times more likely patients undergoing dilation and curettage were three times as likely to return (CI

1.78–5.55; P = 0.0002). Bleeding was the most common reason for all hospital returns (41.5%), with 76.5% of

these patients treated and discharged through the ER. The increased likelihood of return visits after urology procedures warrants further evaluation. As patients with bleeding were most likely to return to the ER and discharged, more effective pre- and postprocedure patient education may further reduce this occurrence. Better informing patients regarding the prognosis of bleeding, and advising them of medical alternatives, could reduce inappropriate patient returns to the ER.


Ann R Coll Surg Engl. 2006 Mar;88(2):202-6. Links Day-case septoplasty and unexpected re-admissions at a dedicated day-case unit: a 4-year audit. Georgalas C, Obholzer R, Martinez-Devesa P, Sandhu G. The Royal National Throat, Nose and Ear Hospital, London, UK. [email protected] INTRODUCTION: Septal surgery has been identified as suitable for day-surgery, but is not widely

performed as such. Guidelines for day-surgery state that the unexpected admission rate should be 2-3%. Previous audits have not achieved this figure and septoplasty is not universally considered suitable for day-surgery. We have reviewed practice over 4 years in our institution to identify surgical and patient factors associated with unexpected admission following septoplasty. PATIENTS AND METHODS: A retrospective case note based audit of day-case septoplasty procedures reviewed at the end of each year between October 1998 and October 2002. RESULTS: A total of 432 septal surgery procedures were performed, comprising 378 septoplasties and 54 submucous resections. Thirty-eight patients were admitted, overwhelmingly because of haemorrhage in the immediate postoperative period, giving an overall admission rate of 8.8% within the first 24 h. Factors associated strongly with re-admission were the use of intranasal splints, the performance of revision surgery, submucous resection (as opposed to septoplasty) and, less so, the performance of additional procedures and the peri-operative administration of diclofenac. There was no correlation between unexpected admission and grade of surgeon, surgical technique or any of the patient factors analysed. CONCLUSIONS: The unexpected admission rate of septal surgery performed at our unit is above that recommended for day-case procedures, but is within the range previously published. Patient satisfaction with day-case septoplasty has been shown to be high. We believe that septoplasty should be performed in this setting but there is a significant chance that patients may need admission, and a pathway should be in place for this to occur with minimal disruption to the patient.


Dieter RA JrRemote surgicenter experience with hernia repair. Int Surg. 2005 Jul-Aug;90(3

Suppl):S2-5.

Northern Illinois Center for Surgery, Naperville, Illinois 60563, USA. A remote outpatient surgicenter was planned and constructed with

three partner groups-76 physicians and two competing hospitals. The CFS was opened in July 1994 and has since performed a large volume of procedures: >124,800 total and, in 2003, 14,900 cases. This multispecialty center during that same period of time (1994 to date) has performed 2659 hernia operations. Patients were discharged home in 1-2 hours after surgery to be followed as outpatients in the physician's office. Only six patients were admitted to the hospital. This efficient and economic model is well suited for hernia repair in the selected adult and pediatric patient population without a significant number of adverse events. The community has readily accepted this program for adult and pediatric hernia repair. Patients, family members, referring physicians, and participating physicians have endorsed and recommended the program.


MacDonald MF, Al-Qudah HS, Santucci RAMinimal impact urethroplasty allows same-day surgery in most patients. Urology. 2005 Oct;66(4):850-3.

Department of Urology, Wayne State University School of Medicine, Detroit, Michigan, USA. OBJECTIVES: To present our evaluation of the safety and feasibility of decreasing the

impact of anterior urethroplasty by minimizing the surgery time, maximizing adjuvant pain therapy, and using anesthetic agents that decrease the incidence and severity of side effects, which allows most patients to leave the hospital comfortably within 4 hours of surgery. METHODS: A retrospective chart review of 54 consecutive anterior urethroplasty patients from August 2000 to August 2004 (34 anterior anastomotic and 20 ventral onlay buccal mucosal graft urethroplasty) was performed. RESULTS: Historically, 27% of patients had undergone same-day surgery (SDS). After the initiation of minimal impact surgery and early discharge, 85% did so. All but one admission was planned (1 patient [2%] had hypotension in the recovery room and was admitted). No postoperative readmissions or emergency room visits occurred. The admitted patients had comparable stricture length to, but slightly older age (49 years compared with 42 years) than, the SDS patients. The perioperative complications were mild (small wound gap, small scrotal hematoma) and were seen in 5% of SDS patients and 0% of admitted patients. Late complications (chordee, mild erectile dysfunction, and urinary tract infection) were seen in 19% of SDS patients and 18% of admitted patients. The incidence of recurrences after a mean follow-up of 27 months was comparable (3% for the SDS and 6% for the admitted group). CONCLUSIONS: Decreasing the impact of urethroplasty surgery allows safe early discharge for most patients. Unexpected admissions were uncommon, and we continue to plan for admission only for the extremely elderly, those with severe comorbidities, and those expected to undergo lengthy (longer than 5 hours) surgery.


Athey N, Gilliam AD, Sinha P, Kurup VJ, Hennessey C, Leaper DJ. Day-case breast cancer axillary surgery.

Ann R Coll Surg Engl. 2005 Mar;87(2):96-8. University Hospital of North Tees, Stockton-on-Tees, Cleveland, UK.

[email protected] INTRODUCTION: The standard locoregional management of breast cancer is excision

of the primary tumour and axillary staging with suction drainage of the axilla. The objective of this study was to determine the safety, tolerability and efficacy of day-case surgery without suction drainage. PATIENTS AND METHODS: A review of complete, prospectively collected data was performed on all breast cancer patients (screening and symptomatic) planned to undergo day-case axillary surgery at a University Teaching Hospital between 2000 and 2002. Postoperative complications were recorded and the notes of patients not discharged on the day of their surgery were also examined to establish the reason for overnight stay. RESULTS:

165 patients underwent intended day-case axillary surgery (axillary dissection level 1/2; median age, 55 years; range, 39-76 years). Of these, 16 (9.7%) were admitted overnight usually due to over-running of theatre lists (n = 13; 81%). 29 patients (17.6%) underwent axillary dissection alone, the remainder had axillary surgery combined with wide local excision (median number of lymph nodes excised 11; range, 2-18). Complications included symptomatic seroma formation in 37 patients (22%) and wound infection in 16 patients (10%). CONCLUSIONS: Day-case axillary surgery can be performed safely with surgical morbidity comparing favourably to published work of 'traditional' axillary drainage following lymphadenectomy


Edwin B, Skattum X, Rader J, Trondsen E, Outpatient laparoscopic splenectomy: patient safety and satisfaction. Surg Endosc. 2004 Sep;18(9):1331-4.

hematological or neoplastic indications for splenectomy American Society of Anesthesiologists (ASA) I-III. They received general intravenous anesthesia with propofol and remifentanil and

were given keterolac, propacetamol, droperidol, and ondansetron as prophylaxis against postoperative pain and nausea

Laparoscopic splenectomy was performed via three trocars. The specimen was removed via an incision in the left iliac fossa. RESULTS: Ten of the 12 patients were discharged 3-6 h postoperatively; the other two were admitted primarily to hospital. One was readmitted due to a

fever, which was finally explained by measles. The median operative times was 58 min (range, 45-135). Patient satisfaction was excellent in nine and intermediate in two cases; it was poor in one case, due to postoperative pain. CONCLUSION: Laparoscopic splenectomy can be completed in a relatively short time; therefore, it is feasible, safe, and satisfactory for most patients as an outpatient procedure


De Waele B, Lauwers M, Van Nieuwenhove Y, Delvaux G. Outpatient laparoscopic gastric banding: initial experience. Obes Surg. 2004 Sep;14(8):1108-10Department of Surgery, VUB University Hospital, Brussels, Belgium.

Laparoscopic adjustable gastric banding (LAGB). BMI >35 kg/m2 with co-morbid conditions, living within a reasonable distance from the hospital, and adult

company at home. The patients were admitted at 0700 hours on the day of surgery, underwent laparoscopic placement of a

Lap-Band system and were discharged home that evening. RESULTS: 9 women and 1 man underwent outpatient LAGB. Mean age was 36 (range 18-52) years and mean BMI was 38.4 kg/m2 (range 35.1-43.3). Co-morbidities

included functional dyspnea (6), osteoarthritis (4), arterial hypertension (4), type 2 diabetes (2) and dyslipidemia (1). 7 patients had undergone previous abdominal surgery: cesarean section (4), appendectomy (3), cholecystectomy (1) and hysterectomy (1).

All patients had an American Society of Anesthesiologists (ASA) classification of II. The average operating time was 87 minutes (range 65-115). The mean time lapse between the end of the operation and discharge from hospital was 9.6 hours. There were no readmissions, and no complications were noticed at 1 month postoperatively. The patients' satisfaction with the ambulatory LAGB procedure was high. CONCLUSION: The present study demonstrates that LAGB for obesity may be performed on an

ambulatory basis without complications.


Duncan PD, Reccan PG, Cohen MM, Tweed WA. The Canadian FourCentre Study of anaesthetic outcomes: are anesthetic complicationspredictable in day surgical practice? Can J Anesth 1992; 39:440±448.

To understand better the factors important to the safety of anaesthesia provided for day surgical procedures, we analyzed the intraoperative and immediate postoperative course of patients at four Canadian teaching hospitals' day treatment centres. After excluding those who received only monitored anaesthesia care, there were 6,914 adult (non-obstetrical) patients seen over a twelve-month period in 1988–89. The rate of adverse outcome consequent to their care was identified by a comprehensive surveillance system which included review of anaesthetic records (four hospitals) and follow-up telephone calls (two hospitals). The relationship between adverse events and preoperative factors was determined by using a multiple logistic regression analysis that included age, sex, duration of the procedure and the hospital care. There were no deaths during the study period and major morbid events were infrequent. Patient preoperative disease was predictive of some intraoperative events relating to the same organ system, but not to events in the PACU. Some unexpected relationships emerged including preoperative hypertension being related to a greater risk of difficult intubation, and neurological disease to perioperative cardiac abnormalities. Patients judged obese, or inadequately fasted, were found to experience a greater rate of recovery problems as well as discomfort. While the low response rate (36%) to the telephone interviews created a sampling bias, the high rate of patient dissatisfaction among those reached is disconcerting. We conclude that day surgical patients with preoperative medical conditions, even when optimally managed, are at higher risk for adverse events in the perioperative period.


Duncan PD, Reccan PG, Cohen MM, Tweed WA. The Canadian Four

Centre Study of anaesthetic outcomes: are anesthetic complications

predictable in day surgical practice? Can J Anesth 1992; 39:440±448


6914 pazienti:da Duncan PD, Reccan PG, Cohen MM, Tweed WA.The Canadian Four Centre Study of anaesthetic outcomes: are

anesthetic complicationspredictable in day surgical practice? Can J Anesth 1992; 39:440±448

112 paz (1.6%) sbalzi pressori 74 aritmie transitorie:1.07 Intubazione difficile in 35 (0.5%) Altri eventi resp sfavorevoli in 87 (1.3%) 21 casi di modificazione di tecnica anest.:0.30 Probl meccanici o di attrezzature:6 casi 0.0087 Incidenti legati ai farmaci:4 casi 0.57 per mille 0.43

per mille 3 ammissioni alla ICU Eventi avversi intraop : 50 per 1000 anaest.


Rischio relativo di KO e condizioni preop


Relazione fra condizioni preop e KO

Patz con probl resp hanno un rischio alto di KO intraop,specie del tratto resp inf Gli iprtesi preoperative hypertensive disease were more likely to run into difficulties with

blood pressure control. Patients with preoperative hypertension were more likely to experience a difficult

intubation patients with preoperative neurological diseases were at risk for cardiac events. Patients with preoperative respiratory problems or hypertension were at higher risk for

cardiac events diabetics had four times the risk of blood pressure abnormalities. history of previous anaesthetic problems was not associated with any incremental risks history of cigarette smoking was only found to be a risk factor for lower respiratory events. Cases with inadequate fasting were at higher risk for problems with blood pressure

control cases where a difficult airway was anticipated were, as expected, at higher risk for

difficult intubation and respiratory related events. Patients judged obese were at higher risk for a number of problems. decreased risk of nausea or vomiting by those who smoked.


Prolungamento della degenza postop

Duration of postoperative stay or time to discharge is a commonly used outcome measure of ambulatory surgery and anesthesia and is considered to be an intermediateor surrogate measure of the `real' outcome such aspatient recovery [8]. While postoperative pain andnausea/vomiting were considered important factors forprolonged stay and unanticipated hospital admission,consequences of the surgical procedure are now the mostpredictive factors [9]. The rate of unanticipated hospitaladmission was 5.4% in a recent large-scale Germanstudy. Intraoperative hemoglobin concentration and blood loss were the best predictors of prolonged postoperativestay [10..].Duration of postoperative stay correlates with thefrequency of minor or moderately severe complications.Although these complications usually do not necessitatehospital admission, they can delay a patient's dischargeconsiderably. Discharge criteria include stable vital signs,orientation, freedom from excessive pain, absence ofnausea and vomiting and the availability of a responsibleescort. In addition, patients should be able to ambulateand, in certain circumstances, void and tolerate oralØuids. A postanesthesia discharge scoring system hasbeen devised by Chung and Chung in Toronto [11],which in a similar manner to the Aldrete scoring systemscores patients from 0 to 2 on Æve major criteria prior todischarge. The use of scoring systems can helpstandardize care and minimize the risk of unanticipatedadmission. General anesthesia is associated with a higherincidence of postoperative nausea and vomiting (PONV)(10±50%) and certain ear, nose and throat (ENT)orthopedic and urological procedures, which are frequentlymore painful than other surgical procedures, areassociated with more lengthy stay [10..].Excessive pain and PONV increase stay three to fourtimes. Other adverse events, including cardiovascularevents, drowsiness or dizziness, also prolong stay.Women are more likely to suffer from PONV thanmen [12]. Younger patients are more likely to suffer fromexcessive pain and PONV while the elderly are morelikely to experience cardiovascular adverse events.


8 Richardson MG, Wu CL, Hussain A. Midazolam premedication increases

sedation but does not prolong discharge times after brief outpatient general

anesthesia for laparoscopic tubal sterilization. Anesth Analg 1997; 85:301±

305. 9 Chung F, Ritchie E, Su J. Post-operative pain in

ambulatory surgery. Anesth Analg 1997; 85:808±816. . . 10.


Ricovero ospedaliero non programmato

The rate of unplanned hospital admissions following ambulatory surgery reØects the occurrence of intra- or postoperative complications. They mirror the frequency of severe complications, which prevent safe patient discharge after surgery and necessitate in-patient care. The rate of unanticipated admissions ranges from 0.3 to 1.4% [13]. The most frequent reason for unanticipated hospital admission (38±79%) is surgical complications [14]. Amongst these, excessive pain, bleeding, and surgical misadventure are the most frequent. Morales and colleagues [15.] reported in a prospective study of 3502 ambulatory patients that the majority of unanticipated admissions were due to postoperative surgical bleeding. Anesthesia-related complications, most frequently PONV, somnolence or dizziness, and less frequently aspiration, are the reasons for admissions in Ambulatory anaesthesia 648 10±26% or unanticipated hospital admissions. In 6±17% of cases, the patients are admitted for medical reasons. These medical admissions occur either because of presence or worsening of preexisting medical conditions, such as diabetes, angina and sleep apnea, or as a result of intraoperative or postoperative complications such as dysrhythmias, myocardial infarction or bronchospasm. A proportion of unanticipated hospital admissions (5±20%) occur for social reasons such as no available escort or inadequate home support. Patients undergoing painful surgery, such as ENT, neurological and orthopedic procedures, are about 4±30 times more likely to be admitted following surgery. The type and duration of surgery are also predictors of unanticipated hospital admission. Patients receiving general anesthesia are two to Æve times more likely to be admitted than patients without general anesthesia. The probability of admission increases with longer anesthesia, which correlates with the increased likelihood of intraoperative and postoperative problems as the duration of surgery increases. This may be due to surgical factors as well as anesthetic factors [5].


Fortier J, Chung F, Su J. Unanticipated admission after ambulatory surgery: a prospective study. Can J Anaesth 1998; 45:612±619.


1 Jarrett PEM. Day care surgery. Eur J Anaesthesiol 2001; 18:32±35. . 2 White PF, Watcha MF. Pharmacoeconomics in anaesthesia: what are the issues? Eur J Anaesthesiol 2001; 18:10±15. Newer more expensive drugs can provide cost saving in ambulatory anesthesia. . 3 Dahmen KG, Albrecht DM. An approach to quality management in anaesthesia: a focus on perioperative care and outcome. Eur J Anaesthesiol 2001; 18:4±9. The implications for perioperative care are explored following the German government's decision to change from fee-for-service reimbursement to fee per capita system. It is envisaged that traditional barriers between specialities treating a patient will be disrupted. 4 5 Chung F, Mezei G, Tong D. Pre-existing medical conditions as predictors of adverse events in day-case surgery. Br J Anaesth 1999; 83:262±270. 7 Atkins M, White J, Ahmed K. Day surgery and body mass index: results of a national survey. Anaesthesia 2002; 57:180±182. BMI patients in the 30±35 range are considered `obese'. Data from this postal survey suggest that day case exclusion criteria are now confined to the `morbid obese' (435 BMI) patients.


Discharge Criteria and Complications After Ambulatory Surgery AMBULATORY ANESTHESIA AUTHOR(S): Marshall, Scott I., FRCA; Chung, Frances, FRCPC Department of Anesthesia, The Toronto Hospital, University of

Toronto, Toronto, Ontario, Canada Accepted for publication December 3, 1998. Address correspondence to Dr. Frances Chung, Department

of Anesthesia, The Toronto Hospital, University of Toronto, 399 Bathurst St., Toronto, Ontario, Canada M5T 2S8. Address e-mail to [email protected].

Anesth Analg 1999; 88:508–17


In a recent study, 2730 patients completed a satisfaction survey, and only 2.5% were dissatisfied with the overall experience. Although only 1.1% expressed dissatisfaction with anesthesia, this was a powerful predictor of global dissatisfaction with ambulatory surgery . The most common reasons for dissatisfaction involved inadequate communication between the patient and the medical/nursing staff. Dissatisfaction with anesthesia was also related to the number of postoperative symptoms suffered.


Tong D, Chung F, Wong D. Predictive factors in anesthesia and nursing care satisfaction in patients undergoing ambulatory surgery. Anesthesiology 1997; 87:856-64. <ldn>!


Tong,D,Chung F,Wong D.Predictive Factors in Global and Anesthesia Satisfaction in Ambulatory Surgical Patients CLINICAL INVESTIGATION Anesthesiology, 87:856-64, 1997

Background: Patient satisfaction is one of the variables that affect the outcome of health care and the use of health-care services. As more procedures are performed on an ambulatory basis, the role of the anesthesiologist becomes more important. To improve the delivery of care, the predictors of dissatisfaction with the entire process (global dissatisfaction) of ambulatory surgery and with anesthesia itself must be identified. The authors conducted a hypothesis-generating study to identify predictors; specifically, they hypothesized that satisfaction with anesthesia was a predictor of global satisfaction with ambulatory surgery and that 24-h postoperative symptoms were a predictor of satisfaction with anesthesia.

Methods: The authors prospectively studied 5,228 consecutive patients having surgery in the ambulatory setting during a 1-yr period. Preoperative, intraoperative, and postoperative variables were gathered and patient satisfaction was assessed using a postoperative telephone questionnaire administered 24 h after operation in 2,730 respondents. Significant univariate variables and clinically important variables were entered into multiple logistic regression models. Qualitative data on dissatisfaction were obtained by asking patients' reasons for dissatisfaction.

Results: Sixty-eight of the 2,730 respondents (2.5%) had global dissatisfaction with ambulatory surgery. Nine of these patients were dissatisfied with anesthesia. Dissatisfaction with anesthesia was associated with a 12-fold increase in global dissatisfaction (P = 0.0001). Thirty-one of the 2,730 respondents (1.1%) were dissatisfied with anesthesia. An increasing number of symptoms occurring 24 h after operation was associated with an exp(0.28 ´ N)-fold increase in dissatisfaction with anesthesia for N number of symptoms (P = 0.0001). Qualitative data showed that the most common reason for global dissatisfaction with ambulatory surgery was personal preference for inpatient care (26%), whereas intraoperative and postoperative adverse outcomes were the major causes of dissatisfaction with anesthesia (88%).

Conclusions: Dissatisfaction with anesthesia is a predictor of global dissatisfaction with ambulatory surgery. An increasing number of symptoms 24 h after operation is a predictor of dissatisfaction with anesthesia. The rate of global dissatisfaction and anesthesia dissatisfaction is very low. The predictors from this model need to be validated by a second data set from either this or another center. Given the low rate of dissatisfaction, a focused study testing specific interventions to improve patient satisfaction would be difficult.


Bello per impostazione e discussione sullq filosofia

della amb surg e anesth…….

Is Outpatient Laparoscopic Cholecystectomy Safe and Cost-effective? : A Model to Study Transition of Care ECONOMICS AUTHOR(S): Fleisher, Lee A., M.D.*; Yee, Kelvin, M.D.†; Lillemoe, Keith D., M.D.‡; Talamini, Mark A., M.D.§; Yeo, Charles J., M.D.‡; Heath, Roberta, R.N.,

M.S.N.ï÷; Bass, Eric, M.D., M.P.H.,# Douglas S. Snyder, M.D.**; Parker, Stephen D., M.D.†† * Associate Professor of Anesthesiology and Critical Care Medicine, Joint Appointments in Medicine and Health Policy and Management. † Assistant Instructor. Current position: Anesthesiologist, Sinai Medical Center, Baltimore, Maryland. ‡ Professor of Surgery. § Associate Professor of Surgery. ï÷Director of Patient Care Services,Johns Hopkins Outpatient Center. #Associate Professor of Medicine. ** Assistant Professor of Anesthesiology. †† Associate Professor of Anesthesiology, Medical Director, Outpatient Surgery Program. Received from the Departments of Anesthesiology, Medicine, Surgery, and Health Policy and Management, Johns Hopkins Medical Institutions, Baltimore,

Maryland. Submitted for publication March 30, 1998. Accepted for publication January 25, 1999. Supported by a grant from the National Institutes of Health (CRC-RR00035) and by Glaxo Wellcome Pharmaceuticals, Research Triangle Park, North Carolina. Dr. Fleisher was supported by the Richard S. Ross Clinician Scientist Award. Presented in part at the Society of Ambulatory Anesthesia 1996 Annual Meeting, Boston, Massachussetts, May 2, 1996, and the American Society of Anesthesiologists October 21, 1996 Annual Meeting, New Orleans, Louisiana.

Address reprint requests to Dr. Fleisher: The Johns Hopkins Hospital, 600 North Wolfe Street, Carnegie 280, Baltimore, Maryland 21287. Address electronic mail to: [email protected]

ABSTRACT: Background: There is increasing pressure to perform traditional inpatient surgical procedures in an outpatient setting. The aim of the current trial

was to determine the safety and cost savings of performing laparoscopic cholecystectomy in an outpatient setting using a “mock” outpatient setting. Methods: Patients who were scheduled for laparoscopic cholecystectomy by four attending surgeons and for whom operating time was available in the

outpatient center were studied. All patients received a standardized anesthetic, including ondansetron, and were discharged from the outpatient postanesthesia care unit if appropriate. At discharge, all patients were admitted to a clinical research center where they were observed in a “mock home” setting and monitored for complications that would have necessitated readmission. A decision analysis was created assuming all patients underwent outpatient surgery with either direct admission or discharge to home and readmission if complications developed.

Results: Of 99 patients who were enrolled in this study, 96 patients would have met the discharge criteria for home. No major complications were observed in these 96 patients. Eleven patients experienced postoperative nausea and vomiting, 3 of whom required an additional 24 h of hospital observation. In the decision model, the optimal strategy would be to perform the procedure on an outpatient basis and readmit patients only for complications, with an average baseline cost savings of $742/patient.

Conclusions: The results show that outpatient laparoscopic cholecystectomy is safe and cost-effective in selected patients, and that the mock home setting provides a means of studying the safety of transition of care.

Anesthesiology 90:1746-55, 1999

anesthesia for day surgery nov 2006

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