Laparoscopic cholecystectomy under segmental thoracic spinal anaesthesia: a feasibility study

Background: Laparoscopic surgery is normally performed under general anaesthesia,but regional techniques have been found beneficial, usuallyin the management of patients with major medical problems. Encouragedby such experience, we performed a feasibility study of segmentalspinal anaesthesia in healthy patients. Methods: Twenty ASA I or II patients undergoing elective laparoscopiccholecystectomy received a segmental (T10 injection) spinalanaesthetic using 1 ml of bupivacaine 5 mg ml^–1 mixedwith 0.5 ml of sufentanil 5 µg ml^–1. Other drugswere only given (systemically) to manage patient anxiety, pain,nausea, hypotension, or pruritus during or after surgery. Thepatients were reviewed 3 days postoperatively by telephone. Results: The spinal anaesthetic was performed easily in all patients,although one complained of paraesthesiae which responded toslight needle withdrawal. The block was effective for surgeryin all 20 patients, six experiencing some discomfort which wasreadily treated with small doses of fentanyl, but none requiringconversion to general anaesthesia. Two patients required midazolamfor anxiety and two ephedrine for hypotension. Recovery wasuneventful and without sequelae, only three patients (all forsurgical reasons) not being discharged home on the day of operation. Conclusions: This preliminary study has shown that segmental spinal anaesthesiacan be used successfully and effectively for laparoscopic surgeryin healthy patients. However, the use of an anaesthetic techniqueinvolving needle insertion into the vertebral canal above thelevel of termination of the spinal cord requires great cautionand should be restricted in application until much larger numbersof patients have been studied.     

Fast-tracking (bypassing the PACU) does not reduce nursing workload after ambulatory surgery

Background. Postoperative day-case patients are usually allowedto recover from anaesthesia in a postanaesthesia care unit (PACU)before transfer back to the day surgical unit (DSU). Bypassingthe PACU can decrease recovery time after day surgery. Costsavings may result from a reduced nursing workload associatedwith the decreased recovery time. This study was designed toevaluate the effects of bypassing the PACU on patient recoverytime and nursing workload and costs. Methods. Two hundred and seven consenting outpatients undergoingday surgery procedures were enrolled. Anaesthesia was inducedand maintained with a standardized technique and the electroencephalographicbispectral index was monitored and maintained at 40–60during anaesthetic maintenance. At the end of surgery, patientswere randomly assigned to either a routine or fast-tracking(FT) group. Patients in the FT group were transferred from theoperating room to the DSU (i.e. bypassing the PACU) if theyachieved the FT criteria. All other patients were transferredto the PACU and then to the DSU. Nursing workload was evaluatedusing a patient care hour chart based on the type and frequencyof nursing interventions in the PACU and DSU. A cost associatedwith the nursing workload was calculated. Results. The overall time from end of anaesthesia to dischargehome was significantly decreased in the fast-tracking group.However, overall patient care hours and costs were similar inthe two recovery groups. Conclusion. Bypassing the PACU after these short outpatientprocedures significantly decreases recovery time without compromisingpatient satisfaction. However, the overall nursing workloadand the associated cost were not significantly affected.      

Analgesia for day-case shoulder surgery

Background. Single-shot nerve blocks provide excellent postoperativeanalgesia for a limited period and are increasingly used inday-case units. They allow early patient discharge followingpainful operative procedures that would otherwise require overnighthospitalization. We investigated the adequacy of analgesia athome after the block had worn off. Methods. A prospective audit by telephone 1 week after surgeryof 50 consecutive patients who had had a single-shot interscaleneblock for day-case shoulder arthroscopic surgery. Results. The mean length of adequate sensory block was 22.5h (9–48 h) after which 20% of patients had a maximum visualanalogue scale (VAS) score of 5/5. Most patients did not takeanalgesics as prescribed and two patients (5.4%) required additionalanalgesia from their family doctor or accident and emergencydepartment. Conclusions. We conclude that analgesia at home is often inadequateafter painful day-case surgical procedures if single-shot localanaesthetic blockade is used. Br J Anaesth 2004; 92: 414–15     

Assessment of sequelae at home following adenotonsillectomy. A basis for day-case management?

Adenotonsillectomy is traditionally performed as an in-patient procedure. Although day-case adenotonsillectomy is practised in some units in the USA, Canada, Finland and Israel, it is rarely practised in the UK. This study looks at a cohort of 100 consecutive children admitted for adenotonsillectomy and follows their progress after discharge. It also assesses parental attitudes to day-case surgery. The results highlight parental anxiety associated with day-case adenotonsillectomy. Only 28% of parents would have liked the procedure to be carried out on a day-case basis with 46% of parents considering a single night stay to be too short. More support must be given to parents in the UK if day-case adenotonsillectomy is to become an acceptable procedure.     

Postoperative nausea and vomiting in arthroscopic day-case surgery: a comparison between desflurane and isoflurane

We compared the postoperative effects, in particular nausea and vomiting, of two commonly used anaesthetic agents, isoflurane and desflurane, in patients undergoing day-case arthroscopic surgery. We found a significantly higher incidence of postoperative nausea and vomiting in those patients receiving desflurane. In our study, desflurane was associated with a higher incidence of peroperative respiratory complications, including airway irritability and coughing.     

Paediatric day-case surgery

Paediatric day surgery is common and increasingly more complex surgeries are being carried out on more complex children. The benefits to the child and parent include less disruption to daily routines and fewer psychological and emotional effects than an overnight stay would incur. The use of day-case services improves efficiency and is more cost effective for organizations. To deliver high-quality paediatric day surgery services there are several key components to address. This article discusses the role of preoperative assessment and the need to consider each case individually despite robust inclusion/exclusion criteria. Optimization of preoperative hydration, pain management and prevention of postoperative nausea and vomiting are highlighted as important factors to successful day-case surgery.     

Public hospital day-case surgery in a dedicated facility

Abstract
The first dedicated, public hospital day-case eye surgery unit opened in Melbourne in June 1987. This report details the mode of operation of this unit, and analyses the 218 procedures performed in the first 15 months of operation, and includes an assessment of the level of patient acceptance.     

A prospective audit of paediatric colonoscopy under general anaesthesia

Colonoscopy in children is frequently performed using intravenous sedation. Traditionally, there have been few advocates of general anaesthesia and some have regarded colonoscopy conducted in this way as potentially more hazardous. The aim of this study was to undertake a prospective audit of paediatric colonoscopy carried out under general anaesthesia. The details of all children referred for colonoscopy during a 3.5-y period were collected prospectively and the safety and efficacy of performing colonoscopy under general anaesthesia were analysed. A total of 250 colonoscopies was performed in 215 children of median age 10.7 y (range 5 months to 16 y) and ileoscopy was carried out in 164 of these cases. An increasing proportion of patients was investigated as day-cases, including most of the 56 who had additional procedures carried out under the same anaesthetic. There were no complications from the colonoscopy (including the 18 patients who underwent polypectomy). Only one procedure-related complication occurred and this was avoidable. These results confirm the safety of paediatric colonoscopy under general anaesthesia and demonstrate the advantages and feasibility of such an approach.     

Leg weakness is a complication of ilio-inguinal nerve block in children

Background. Ilio-inguinal nerve block is commonly used in childrento provide analgesia after surgery in the groin. Several casereports and clinical studies have described leg weakness afterthis technique and suggest that it may caused by inadvertentfemoral nerve block. No prospective studies describing the incidenceof this complication have been published. Methods. We carried out a prospective, observational study tofind out how many children had leg weakness after ilio-inguinalnerve block. We studied 200 children having day-case surgeryin the groin under a general anaesthetic with an ilio-inguinalnerve block. All children performed a simple leg-raising testwith each leg before induction of general anaesthesia with astandardized ilio-inguinal nerve block on the side of surgery.When the child was awake and comfortable after surgery, theyrepeated the leg-raising test. Results. Sixteen of 182 children (8.8%) had leg weakness aftersurgery on the side of the nerve block only, as detected bya leg-raising test. Conclusions. Leg weakness consistent with a femoral nerve blockoccurs after ilio-inguinal nerve block in approximately onein nine children. Br J Anaesth 2004; 92: 273–4     

Day-case pelvic osteotomy for developmental dysplasia of the hip

Purpose:In this article we report the results of a pilot study analysing the implications of performing pelvic osteotomies for developmental dysplasia of the hip (DDH) as a day case. We assess the advantages of performing paediatric pelvic osteotomies as day-case procedures from a financial perspective and from an in-patient bed resource point of view.Methods:This was a prospective cohort study analysing Salter and Pemberton pelvic osteotomies performed for DDH over a three-year period from 1st January 2017 to 30th September 2019. All patients residing within 50 km of the hospital were eligible for day-case procedures. All other cases were performed as in-patients. A detailed financial costing analysis was performed and the in-patient resources utilized were documented and compared between the two models of care.Results:In total, 84 Salter and Pemberton osteotomies were performed between 1st January 2017 to 30th September 2019. Of these cases, 35 were performed as day-case procedures. A total reduction in 70 in-patient bed days was reported. Total costs for a single in-patient requiring two nights of admission amounted to €5,752, whereas the discharge cost of a day case was reported at €2,670. The savings made by our institution amounted to €3,082 per day case. A total saving of €102,696 was made over three years. In all, seven day-case patients re-attended due to inadequate pain control. They required overnight admission and were discharged uneventfully the following day.Conclusion:Day-case pelvic osteotomies significantly reduce the number of in-patient bed days used in an elective paediatric orthopaedic setting. Significant financial savings in excess of €3,000 per case are possible. The introduction of day-case pelvic osteotomy procedures can significantly improve the cost-effectiveness of managing DDH provided there are clear protocols in place with close clinical follow-up.Level of evidence:IV