Ambulatory surgery in proctology: retrospective analysis of 1 031 cases

Introduction: The number of ambulatory surgeries accomplished in hospitals, as in private clinics, grows each day, with this increase having been observed principally in the last two decades. In many countries, such as France, ambulatory surgeries have predominated in relation to those in hospitals. Objective: To evaluate retrospectively 1 031 cases of patients operated on in the Ambulatory Surgery Service of CH. in the School of Medicine at Botucatu. Material and method: Retrospectively, 1 031 clinical cases of orificial pathologies operated on in the service were studied, analyzing the distribution by age group, sex, pathologies and postoperative complications. Result: We note predominance of patients aged less than 45 years (56.6%), discrete prevalence of males (51.2%), with hemorrhoidal disease (60%) being the principal affliction, with pain and bleeding being the most frequent complications (3.2%). Conclusions: The results obtained demonstrate that ambulatory procedures in proctology can be accomplished in a safe and systematic manner at low cost with advantages and fewer complications in relation to procedures completed in a hospitalization regime.

Postoperative pain management after ambulatory surgery. A survey of anaesthesiologists

Data on practice and quality of postoperative pain treatment by anaesthesiologists after ambulatory surgery are sparse. The current survey enrolled anaesthesiologists in private practice who were responsible for pain therapy after ambulatory surgery. The aim of this investigation was to evaluate the implementation of the German S3 guidelines for acute and postoperative pain therapy in the outpatient setting.

Hospital and Ambulatory Surgery Center Payment Manual

This manual contains the policy governing the billing and payment of hospitals and ambulatory surgery centers for services rendered under the Workers’ Compensation Act. The payment rates listed herein are deemed by the Commission to be fair and reasonable.

How ophthlamic day surgery patients convalesce at home : an exploration of the salient issues

Cataract surgery is the most commonly performed surgical procedure in Australia. In the next 10-15 years, the number of people needing this surgery is expected to double, This article is based on a study, which explored the types and levels of symptoms experienced by patients post-ophthalmic surgery. Patients were asked to complete two instruments: a 'Postoperative Symptoms Diary' and a follow up 'Telephone Survey Questionnaire'. Eight males and 15 females (n = 23) with a mean age of 80.5 years were recruited. The findings revealed that patients' symptom levels decreased over time, except for tiredness and moving around which increased slightly on Day 4 post-operatively. A carer was required for an average of 2.3 days. This study highlighted the discrepancies in current day surgery literature, which recommend that a carer is needed during only the first 24 hours post-operatively.

Hospital and Ambulatory Surgical Center Payment Manual

This manual contains the policy governing the billing and payment of hospitals and ambulatory surgery centers for services rendered under the Workers’ Compensation Act. The payment rates listed herein are deemed by the Commission to be fair and reasonable.

Opportunity cost of unavailable surgical instruments in Australian hospitals

Hospitals invest considerable resources organizing operating suites and having surgeons and theatre staff available on an agreed schedule. A common impediment to efficiency is perioperative delay,including delays getting to the operating room or during the operation. Perioperative delays entail significant costs for hospitals,wasting staff time and operating theatre resources. They may also affect patient outcomes; prolonged surgery is a predictor for unanticipated admission following elective ambulatory surgery...

Studies on the assessment of the adequacy of anesthesia

Several hypnosis monitoring systems based on the processed electroencephalogram (EEG) have been developed for use during general anesthesia. The assessment of the analgesic component (antinociception) of general anesthesia is an emerging field of research. This study investigated the interaction of hypnosis and antinociception, the association of several physiological variables with the degree of intraoperative nociception, and aspects of EEG Bispectral Index Scale (BIS) monitoring during general anesthesia. In addition, EEG features and heart rate (HR) responses during desflurane and sevoflurane anesthesia were compared. A propofol bolus of 0.7 mg/kg was more effective than an alfentanil bolus of 0.5 mg in preventing the recurrence of movement responses during uterine dilatation and curettage (D C) after a propofol-alfentanil induction, combined with nitrous oxide (N2O). HR and several HR variability-, frontal electromyography (fEMG)-, pulse plethysmography (PPG)-, and EEG-derived variables were associated with surgery-induced movement responses. Movers were discriminated from non-movers mostly by the post-stimulus values per se or normalized with respect to the pre-stimulus values. In logistic regression analysis, the best classification performance was achieved with the combination of normalized fEMG power and HR during D C (overall accuracy 81%, sensitivity 53%, specificity 95%), and with the combination of normalized fEMG-related response entropy, electrocardiography (ECG) R-to-R interval (RRI), and PPG dicrotic notch amplitude during sevoflurane anesthesia (overall accuracy 96%, sensitivity 90%, specificity 100%). ECG electrode impedances after alcohol swab skin pretreatment alone were higher than impedances of designated EEG electrodes. The BIS values registered with ECG electrodes were higher than those registered simultaneously with EEG electrodes. No significant difference in the time to home-readiness after isoflurane-N2O or sevoflurane-N2O anesthesia was found, when the administration of the volatile agent was guided by BIS monitoring. All other early and intermediate recovery parameters were also similar. Transient epileptiform EEG activity was detected in eight of 15 sevoflurane patients during a rapid increase in the inspired volatile concentration, and in none of the 16 desflurane patients. The observed transient EEG changes did not adversely affect the recovery of the patients. Following the rapid increase in the inhaled desflurane concentration, HR increased transiently, reaching its maximum in two minutes. In the sevoflurane group, the increase was slower and more subtle. In conclusion, desflurane may be a safer volatile agent than sevoflurane in patients with a lowered seizure threshold. The tachycardia induced by a rapid increase in the inspired desflurane concentration may present a risk for patients with heart disease. Designated EEG electrodes may be superior to ECG electrodes in EEG BIS monitoring. When the administration of isoflurane or sevoflurane is adjusted to maintain BIS values at 50-60 in healthy ambulatory surgery patients, the speed and quality of recovery are similar after both isoflurane-N2O and sevoflurane-N2O anesthesia. When anesthesia is maintained by the inhalation of N2O and bolus doses of propofol and alfentanil in healthy unparalyzed patients, movement responses may be best avoided by ensuring a relatively deep hypnotic level with propofol. HR/RRI, fEMG, and PPG dicrotic notch amplitude are potential indicators of nociception during anesthesia, but their performance needs to be validated in future studies. Combining information from different sources may improve the discrimination of the level of nociception.

Factores asociados al dolor crónico posoperatorio en pacientes llevados a herniorrafia inguinal

Introducción: La herniorrafia inguinal se asocia hasta en un 50% de los casos con dolor crónico posoperatorio (DCP), y en algunos puede ser incapacitante. En este estudio se evaluaron los factores asociados al DCP en pacientes llevados a herniorrafia inguinal. Métodología: Se realizó un estudio de cohorte multicéntrico. Se obtuvo información sociodemográfica y de antecedentes personales. Se determinó la presencia e intensidad de dolor agudo posoperatorio (DAP) y se evaluaron los factores asociados al DCP con seguimiento a los dos meses del posoperatorio. Se establecieron asociaciones con la prueba chi cuadrado. Mediante una regresión lineal se evaluó el papel de los factores de confusión. Resultados: Se analizaron 108 pacientes. 54.7% presentaron DCP. La edad menor de 40 años, el DAP no controlado, el DAP severo, y el dolor no controlado entre la primera y tercera semanas del POP se relacionaron con mayor riesgo de DCP. La edad mayor a 65, el uso de opioides intratecales, la visualización y preservación de los nervios durante la cirugía, y el uso de tres o más analgésicos intravenosos con bloqueo ilioinguinal/iliohipogástrico fueron factores protectores. Discusión: El DCP es frecuente en nuestro medio. La prevención y manejo eficientes del DAP utilizando analgesia multimodal, el uso de opioide intratecal, y la identificación y preservación de los nervios en el área quirúrgica ayudan a prevenir el desarrollo de DCP. Estudios de este tipo realizados a una escala más grande, permitirán identificar otros factores relacionados con esta patología. Palabras clave: Dolor crónico postoperatorio, herniorrafia inguinal, inguinodina, factores asociados.

Excision of an atypical case of palatal bone exostosis: a case report.

Bone exostosis has long been described in the literature, appearing in most cases as a torus palatinus or mandibularis. These two variations are relatively common and affect approximately 30% of the world's population. Incidence is even higher when human skulls are examined post mortem, indicating that in some cases the exostosis is small and cannot be seen under the soft tissue. Removal of an exostosis is usually associated with the construction of a prothesis, but in rare cases such as the present, the lesion enlarges enough to affect speech and feeding. Few studies have reported the removal of such a large exostosis, and all were conducted in a hospital environment. In this case, complete removal was successfully conducted in an ambulatory clinic under local anesthesia.

Clonidina como medicação pré-anestésica em facectomias: Comparação entre as doses de 100 μg e 200 μg

BACKGROUND AND OBJECTIVES: The objective of the present study was to evaluate the degree of sedation, intraocular pressure, and hemodynamic changes with premedication with low doses of oral clonidine, 100 μg and 200 μg, in outpatient cataract surgeries. METHODS: This is a randomized, double-blind, clinical study undertaken at the Universidade Federal de São Paulo with 60 patients of both genders, physical status ASA 1 and 2, ages 18 to 80 years. Patients were separated into three groups: placebo, clonidine 100 μg, and clonidine 200 μg. Intraocular pressure, heart rate, and blood pressure besides assessment of sedation were measured before and 90 minutes after the administration of clonidine. Sedation levels were classified according to the Ramsay sedation scale. RESULTS: Patients who received placebo and 100 μg of clonidine did not show reduction in heart rate, while a reduction in heart rate was observed in patients who received 200 μg of clonidine, and this difference was statistically significant. Patients who received 200 μg of clonidine also had a reduction in systolic and diastolic blood pressure (p < 0.05). One patient who received 200 μg of clonidine developed severe hypotension, with systolic pressure < 80 mmHg. Patients treated with clonidine had a reduction in intraocular pressure (p < 0.05). Ninety minutes after the oral administration of placebo and 100 μg and 200 μg of clonidine, 25%, 60%, and 80% of the patients respectively were classified as Ramsay 3 or 4. CONCLUSIONS: Clonidine 100 μg can be indicated as premedication for fasciectomies, being effective in sedation and reduction of intraocular pressure, without adverse effects on blood pressure and heart rate.

Ensaio randomizado, duplo-cego e controlado de anestesia tópica induzida por iontoforese de lidocaína

Introduction: Needle infi ltration of local anesthetic is a painful procedure, thus, a topical anesthetic is a comfortable alternative; however, it is diffi cult to deliver transcutaneous polar drugs. Iontophoresis is a noninvasive technique that uses electrical current for releasing electrically charged drugs through biological membranes. Objective: To evaluate the anesthesia induced by iontophoresis of lidocaine for a standardized painful stimulus. Material and methods: Randomized, controlled, double-blind study, involving 10 volunteers under the anesthetic effects of topical application of lidocaine gel 2% and noradrenaline 1:50,000, with or without iontophoresis of 1.85 milliamps for 13 minutes. Pain sensitivity was evaluated by the prick of a 21G needle in the arms posterior region, using a visual numerical scale. Results: Patients mean age was 50.8 ± 11.4 years. Nine of them were women. All had previously received infi ltrative anesthesia. Iontophoresis was well tolerated by volunteers. The median pain scores were 0 and 3 for the arm that received the iontophoresis and for the one that did not receive, respectively (p < 0.01). Conclusion: The anesthetic effect in the region subjected to iontophoresis suggests an effi cient and comfortable method for promoting local anesthesia in the surgical approach of pediatric, hyperalgic, or needlephobic patients.

Internamento não planejado após cirurgia ambulatorial: estudo retrospectivo

Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES)

Criteria for the request of preoperative tests among oral and maxillofacial surgeons

Objective: The aim of this study was to analyze the criteria employed for the requesting of preoperative tests among maxillofacial surgeons. Materials and methods: Thirty maxillofacial surgeons working in Aracaju (Brazil) received a questionnaire to fill out. The study inquired about the practice of requesting preoperative tests for healthy patients scheduled to undergo elective surgery. Results: Most of the surgeons interviewed requested tests that are not recommended for the case in question. The highest frequency of requests was a complete blood count, coagulation test, blood glucose test and chest radiograph. Conclusion: The absence of strict rules for the requesting of preoperative tests causes uncertainty and a lack of criteria regarding pre-surgical conduct. It was not possible to clearly define the criteria used by surgeons for requesting such tests, as the clinical characteristics of the hypothetical case presented suggest a smaller number of tests. (C) 2011 European Association for Cranio-Maxillo-Facial Surgery.

Cirurgia intra-renal retrógrada para o tratamento da litíase : um procedimento de ambulatório?

Trabalho Final do Curso de Mestrado Integrado em Medicina, Faculdade de Medicina, Universidade de Lisboa, 2014

Satisfação dos utentes de uma unidade de cirurgia de ambulatório de um hospital central : contributo para melhor cuidar

Enquadramento: O carácter inovador da Cirurgia de Ambulatório reside no seu modelo organizativo específico, centrado no doente, que o envolve num circuito independente do de internamento, procurando-se ganhos em eficiência e em qualidade e obtendo-se níveis de maior humanização e satisfação dos utentes e seus familiares. Objetivos: Analisar de que forma as variáveis sociodemográficos influenciam a qualidade percebida dos utentes de uma Unidade de Cirurgia de Ambulatório de um Hospitalar Central; verificar se existem efeitos significativos das variáveis circunstanciais na qualidade percebida dos utentes de uma Unidade de Cirurgia de Ambulatório de um Hospitalar Central; verificar a existência de efeitos significativos das variáveis sociofamiliares na qualidade percebida nos utentes. Métodos: Estudo quantitativo, com corte transversal, descritivo e correlacional; enquadra-se num estudo descritivo analítico-correlacional porque o mesmo tem por objetivo explorar as relações entre variáveis e descrevê-las. Os dados foram colhidos junto dos utentes tendo como base escalas e questionários. A amostra é não probabilística por conveniência, constituída por 140 utentes de uma Unidade de Cirurgia de Ambulatório de um Hospitalar Central, na maioria, do sexo masculino (60,7%), com uma idade mínima de 19 anos e uma máxima de 94 anos, ao que corresponde uma idade média de 58,01 (±19.26 anos). Foi aplicado um Questionário de caracterização sociodemográfica e sociofamiliar, incluindo-se o Questionário (Medical Outcomes Study Social Support Survey) MOS-SSS (Fachado et al., 2007) e o Questionário Service Quality (SERVQUAL) (Parasuraman et al., 1988). Resultados: Os utentes do sexo feminino manifestam mais satisfação em relação à UCA (cortesia/empatia p=0.000; compreensão do utente p=0.000; fiabilidade p=0.005; acessibilidade p=0.010; qualidade global p=0.001; os utentes idosos obtiveram valores mais elevados em quase todas as dimensões e na qualidade global (aspetos físicos p=0.006); os participantes com o ensino básico manifestaram mais satisfação (fiabilidade p<0,016); os que possuem um rendimento familiar até 1000€ apresentaram maior nível de satisfação (cortesia/empatia p=0,033); os utentes que não se deslocam em meio de transporte próprio atribuem mais qualidade à UCA (fiabilidade p=0,028); aqueles cuja residência está situada a uma distância superior a 15 km do hospital revelam índices mais elevados de qualidade (cortesia/simpatia p=0.037; compreensão do utente p=0.044; fiabilidade p=0.022; acessibilidade p=0.001; qualidade global p=0.013); os participantes cuja distância de casa ao centro de saúde é superior a 9 km revelam mais satisfação (fiabilidade p=0.038); os utentes com tempos de espera para a cirurgia entre 6-12 meses atribuem mais qualidade à UCA (cortesia/empatia p=0.000; compreensão do utente p=0.011; fiabilidade p=0.007; acessibilidade p=0.001; qualidade global p=0.001). Conclusão: A maioria dos utentes atribui qualidade à UCA, tendo em conta a cortesia/empatia, a compreensão do utente, fiabilidade, acessibilidade e aspetos físicos, pode afirmar-se que a referida Unidade adequa os serviços prestados às suas necessidades, garantindo, deste modo, a satisfação dos utentes. Palavras-chave: Cirurgia de Ambulatório; Satisfação dos utentes; Qualidade; Atendimento.