Summary Day surgery provides high quality and efficient care for a wide variety of surgical procedures. Patients appreciate the rapid recovery and effective analgesia, while the health service benefits from a streamlined service with lower costs. Despite the numerous advantages, day surgery practices vary enormously and many patients are still denied this excellent form of care. Fundamental to improving this situation is a change in emphasis, with day surgery becoming the default option for many surgical procedures – rather than being applied selectively – with inpatient care being used only where specifically indicated. Appropriate patient preparation is facilitated by consultant‐led, nurse‐run preassessment using modern selection criteria; only conditions which will still cause problems a few hours beyond the end of the operation should be barriers to day surgery. Preassessment also provides an excellent opportunity to begin patient education and ensures that pre‐existing pathology is optimally treated. Efficient day surgery is best delivered by a specialised, dedicated, multi‐disciplinary team, but consultant anaesthetists have a major role to play in co‐ordinating policies and providing leadership. Individual anaesthetists should develop techniques that allow their patients to undergo day surgery with minimum stress, maximum comfort and the optimal chance of early discharge. Improving day surgery rates is a win–win situation, with both clinical and financial benefits.
The efficacy of preoperative fasting is reduced in the presence of any factor which delays gastric emptying. We examined the association between anxiety and gastric emptying in adult patients undergoing elective surgery. Immediately before operation, 21 patients completed both a Spielberger state trait inventory (used to quantify current anxiety state (STAIs) and anxiety predisposition (STAIt)), and the Amsterdam preoperative anxiety and information scale (used to quantify anxiety and need for information). Gastric emptying was measured using the paracetamol absorption technique. Four to 10 weeks later, gastric emptying and STAI were measured again. Patients were more anxious before than after operation (STAIs = mean 35.4 (SD 10.9) and 25 (4.1), respectively; P = 0.0004). Neither anxiety state (P = 0.40) nor measures of anxiety relative to anxiety predisposition (P = 0.86) influenced gastric emptying (as measured by area under the paracetamol absorption-time curve). This contrasts with previous findings that anxiety in patients with low anxiety predisposition scores delays gastric emptying.
Day surgery and gastroenterologyDay surgery encompasses all surgical specialities and is an accepted mode of delivering surgical care. In the UK day surgery accounts for 30/O of all elective surgical cases; this is expected to increase to 50% in the near future.' In our institution the high level (90%) of patient acceptability for day surgery has led to an increased patient demand for the service. Gastroenterological surgery, which includes endoscopy, constitutes a significant proportion of the current activity and promises to be the speciality that will contribute most to the predicted increase in day surgery. In this review we examine the reasons for the increase in day surgery, the adaptations required in providing a day surgery service, the types of gastroenterological procedures being performed, and finally those procedures that may be performed in the future.Increase in day surgery activity Day surgery has been practised in this country since the beginning of the century when it was recognised that there were psychological and medical benefits to be gained from early discharge from hospital.2 It was not until the 1970s, however, that there was renewed interest in day surgery, when reports of the technical feasibility and benefits of day surgery were published by enthusiasts.3The main reason for the present increase in day surgery is the allocation of additional resources for providing dedicated facilities and personnel by health services keen on promoting day surgery. This has been driven by economic considerations, as day surgery is thought to be more cost effective and efficient than inpatient treatment, thus allowing closure of some inpatient facilities.4 The cost per general surgical patient in our day care unit is £471 compared with £571 for an inpatient stay of 48 hours. This represents a saving of 21% which is achieved in a unit adapted from existing facilities.5 Therefore, careful planning is required if the purpose built day facilities are to achieve the desired levels of usage and efficiency to justify the considerable capital expenditure. Considerable organisation is involved in the delivery of a successful day surgery service.9 Dedicated theatre lists are required so that the more complicated procedures can be performed in the morning to allow patients sufficient time to recover from surgery and be fit for discharge. Placing such patients on routine lists often leads to their delay or cancellation when inpatient procedures run over time.The general anaesthetic agents used for day surgery must allow rapid postoperative recovery and minimal postoperative nausea. We have found that the use of locoregional anaesthesia has benefits which include eliminating the risks and side effects of general anaesthesia and providing better perioperative analgesia than narcotic analgesics.Meticulous haemostasis is important as even slight bleeding provokes anxiety, which may prevent the patient from being discharged.10 Subcuticular sutures are used as they are more comfortable and do not need removing. Appropriat...
Purpose: A decrease in the rate of gastric emptying can delay resumption of enteral feeding, alter bioavailability of orally administered drugs, and result in larger residual gastric volumes, increasing the risk of nausea and vomiting. We compared the effects of I) intrathecal bupivacaine (17.5 mg) and 2) the combination of intrathecal morphine (0.6 mg) and intrathecal bupivacaine (17.5 mg) on the rate of gastric emptying in patients undergoing elective hip arthroplasty. Me~o~: Twenty four fasting ASA I-3 patients were randomly assigned, in a double blind manner, to receive intrathecal hyperbaric bupivacaine (17.5 mg), either alone (group I), or followed by intrathecal morphine (0.6 mg) (group 2). Gastric emptying was measured (using an acetaminophen absorption technique), twice in each patient; preoperatively, and approximately one hour postoperatively. Gastric emptying parameters are: AUC (area under the plasma acetaminophen concentration time curve), maximum plasma acetaminophen concentration (Cmax), and time to Cmax (tCmax), analyzed using paired Student's t tests. ~.~lts: Gastric emptying rates were reduced in both group I (AUC= 14.98 (3.8) and I 1.05 (4.6) pre-and postoperatively, respectively) and group 2 (AUC= 13.93 (3.59) and 6.4 (3.42) pre-and postoperatively, respectively); the magnitude of the reduction was greater in group 2 {AUC (P = 0.04), Cmax (P=0.05), tCmax (P = 0.13)}. Conck~ion: The combination of intrathecal morphine (0.6 mg) and intrathecal bupivacaine (I 7.5 mg) delays gastric emptying postoperatively.Objectff : Une r~duction de la vitesse de vidange gastrique peut retarder la reprise de I'alimentation ent~rale, modiffer la biodisponibilit~ des m~dicaments administr& oralement et provoquer de plus grands volumes gastriques r&iduels, ce qui peut accro~re le risque de naus&s et de vomissements. Nous avons compar~ les effets de I) la bupivaca~ine intrath&ale ( 17,5 mg) et 2) la combinaison de morphine intrath&ale (0,6 mg) et de bupivaca'ine intrath&ale (17,5 mg) sur la vitesse de vidange gastrique chez des patients qui subissent une arthroplastie de la hanche. M&J~ode : Vingt-quatre patients ~ jeun, ASA 1-3, ont ~t~ r~partis au hasard et en double aveugle. IIs ont re~u de la bupivaca'l'ne hyperbare intrath&ale (17,5 mg), soit seule (groupe I), solt suivie de morphine intrath&ale (0,6 mg, groupe 2). I'&acuation gastrique a ~t~ mesur& ~ deux reprises (selon la technique d'absorption de I'ac~ta-minoph~ne), avant I'op~ration et environ une heure apr&. Les param~tres ~taient : I'aire sous la courbe (ASC) de la concentration plasmatique d'ac~taminoph~ne en fonction du temps, la concentration plasmatique maximale d'ac&a-minoph~ne (C~x) et le temps auquel on observe la concentration maximale (tCm~), analys& au moyen des tests t de Student pour des &hantillons appari~s. Ra~lta~ : Les vitesses de vidange gastrique ont ~t~ r~duites chez les patients des deux groupes; I (ASC= 14,98 (3,8) et I 1,05 (4,6) avant et apr~s I'op&ation, respectivement) et 2 (ASC= 13,93 (3,59) et 6,4 (3,42) avant et apr& I'op~ra...
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