1
|
Pimentel MPT, Chung S, Ross JM, Wright D, Urman RD. Anesthesia-Related Closed Claims in Free-Standing Ambulatory Surgery Centers. Anesth Analg 2024; 139:521-531. [PMID: 38640080 DOI: 10.1213/ane.0000000000006700] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/21/2024]
Abstract
BACKGROUND As higher acuity procedures continue to move from hospital-based operating rooms (HORs) to free-standing ambulatory surgery centers (ASCs), concerns for patient safety remain high. We conducted a contemporary, descriptive analysis of anesthesia-related liability closed claims to understand risks to patient safety in the free-standing ASC setting, compared to HORs. METHODS Free-standing ASC and HOR closed claims between 2015 and 2022 from The Doctors Company that involved an anesthesia provider responsible for the claim were included. We compared the coded data of 212 free-standing ASC claims with 268 HOR claims in terms of severity of injury, major injuries, allegations, comorbidities, contributing factors, and financial value of the claim. RESULTS Free-standing ASC claims accounted for almost half of all anesthesia-related cases (44%, 212 of 480). Claims with high severity of injury were less frequent in free-standing ASCs (22%) compared to HORs (34%; P = .004). The most common types of injuries in both free-standing ASCs and HORs were dental injury (17% vs 17%) and nerve damage (14% vs 11%). No difference in frequency was noted for types of injuries between claims from free-standing ASCs versus HORs--except that burns appeared more frequently in free-standing ASC claims than in HORs (6% vs 2%; P = .015). Claims with alleged improper management of anesthesia occurred less frequently among free-standing ASC claims than HOR claims (17% vs 29%; P = .01), as well as positioning-related injury (3% vs 8%; P = .025). No difference was seen in frequency of claims regarding alleged improper performance of anesthesia procedures between free-standing ASCs and HORs (25% vs 19%; P = .072). Technical performance of procedures (ie, intubation and nerve block) was the most common contributing factor among free-standing ASC (74%) and HOR (74%) claims. Free-standing ASC claims also had a higher frequency of communication issues between provider and patient/family versus HOR claims (20% vs 10%; P = .004). Most claims were not associated with major comorbidities; however, cardiovascular disease was less prevalent in free-standing ASC claims versus HOR claims (3% vs 11%; P = .002). The mean ± standard deviation total of expenses and payments was lower among free-standing ASC claims ($167,000 ± $295,000) than HOR claims ($332,000 ± $775,000; P = .002). CONCLUSIONS This analysis of medical malpractice claims may indicate higher-than-expected patient and procedural complexity in free-standing ASCs, presenting patient safety concerns and opportunities for improvement. Ambulatory anesthesia practices should consider improving safety culture and communication with families while ensuring that providers have up-to-date training and resources to safely perform routine anesthesia procedures.
Collapse
Affiliation(s)
- Marc Philip T Pimentel
- From the Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Scott Chung
- From the Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Jacqueline M Ross
- Department of Patient Safety and Risk Management, The Doctors Company, Napa, California
| | - Daniel Wright
- Department of Patient Safety and Risk Management, The Doctors Company, Napa, California
| | - Richard D Urman
- Department of Anesthesiology, The Ohio State University, Columbus, Ohio
| |
Collapse
|
2
|
Shah S, Block-Wheeler N, Liu K, Weintraub MR, Williams WB. The Association of Body Mass Index and Early Outcomes Following Orthognathic Surgery. J Oral Maxillofac Surg 2024; 82:782-791. [PMID: 38643964 DOI: 10.1016/j.joms.2024.03.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Revised: 03/27/2024] [Accepted: 03/28/2024] [Indexed: 04/23/2024]
Abstract
BACKGROUND The existing data on the link between body mass index (BMI), operative characteristics, and surgical outcomes across orthognathic surgery are limited. PURPOSE The purpose was to measure the association between BMI and early postoperative outcomes in orthognathic surgery. STUDY DESIGN, SETTING, AND SAMPLE This is a retrospective cohort study of patients (n = 118) aged > 14 years undergoing bimaxillary orthognathic surgery between 2015 and 2018 by a single surgeon within the Kaiser Permanente Northern California-integrated healthcare system. Patients undergoing unilateral or additional procedures, history of prior orthognathic surgery, or pre-existing pain conditions were excluded. PREDICTOR VARIABLE The predictor variable was BMI measured as a continuous (kg/m2) and categorical variable (underweight/normal, overweight, obese). MAIN OUTCOME VARIABLE(S) The primary outcome variables were additional postoperative antibiotics, increased postoperative visits, wound dehiscence, and wound infection. The secondary outcome variables were total operative and anesthesia time. COVARIATES The demographic covariates included age, sex, and race/ethnicity. The clinical covariates included history of obstructive sleep apnea, Mallampati score, tobacco use, American Society of Anesthesia classification, thyromental distance, history of difficult intubation, and Angle's classification. ANALYSES Bivariate and multivariate analyses were performed to measure the associations between BMI and the primary and secondary outcomes. Multivariable logistic regression analyses were used to measure associations between BMI and the postoperative outcomes. Statistical significance was defined as P < .05. RESULTS The study sample was composed of 118 subjects with a mean age of 26.91 years (standard deviation 9.43). Forty-seven percent (n = 55) were male, and the mean BMI was 25.13 (standard deviation 5.19). BMI category was significantly associated with age, with increasing age associated with higher BMI category (P = .02). According to the bivariate and multivariable logistic regression analyses, controlling for age, race/ethnicity, BMI, and total operative time, increased total operative time was associated with additional postoperative antibiotics (odds ratio = 1.03, 95% confidence interval: 1.01, 1.05), and increased postoperative appointments (odds ratio = 1.02, 95% confidence interval: 1.01, 1.04). No significant association between BMI and other clinical or operative characteristics was seen aside from American Society of Anesthesia classification. CONCLUSION AND RELEVANCE Elevated BMI was not associated with worsened operative characteristics or postoperative outcomes. This supports the suitability of orthognathic surgery in a BMI-diverse population.
Collapse
Affiliation(s)
- Swapnil Shah
- Medical Student, Creighton University School of Medicine, Omaha, NE; Resident, Department of Head and Neck Surgery, Kaiser Permanente, Northern California, Oakland, CA.
| | - Nikolas Block-Wheeler
- Resident, Department of Head and Neck Surgery, Kaiser Permanente, Northern California, Oakland, CA
| | - Kalena Liu
- Resident, Department of Head and Neck Surgery, Kaiser Permanente, Northern California, Oakland, CA; Medical Student, City University of New York School of Medicine, New York, NY
| | - Miranda Ritterman Weintraub
- Research Manager, Department of Graduate Medical Education, Kaiser Permanente, Northern California, Oakland, CA
| | | |
Collapse
|
3
|
Caballero A, Tarascó J, Moreno P, López-Vendrell L, Pellitero S, Martínez E, Bonet G, Balibrea JM. Implementation of a same-day discharge bariatric surgery program and follow-up with a telemonitoring platform. Cir Esp 2023; 101:841-846. [PMID: 37783382 DOI: 10.1016/j.cireng.2023.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Accepted: 07/05/2023] [Indexed: 10/04/2023]
Abstract
INTRODUCTION Some groups have initiated outpatient bariatric surgery programs in selected patients, publishing good results after sleeve gastrectomy. Recent studies show that outpatient surgery is also feasible and safe in Roux-en-Y gastric bypass. The aim of this paper is to describe and analyze the results of our initial experience after the implementation of a same-day discharge bariatric surgery program using a telemonitoring system. METHODS We have completed a prospective, observational study with 14 consecutive, selected patients undergoing primary bariatric surgery (sleeve gastrectomy or Roux-en-Y gastric bypass) at a single center from April 2021 to February 2023, with home follow-up using the REVITA® telemonitoring platform (HI Iberia, S.A.) and the Home Hospitalization Unit. RESULTS From April 2021 to February 2023, 14 patients were selected for this program, which meant 7.3% of the total of 191 patients who underwent bariatric surgery during this period. Ten out of the 14 patients selected completed the circuit (71.4%), 4 of whom consulted the emergency department within the first 24 h (40%). There were no serious complications, readmissions or re-operations typical of bariatric surgery. The estimated savings per patient who completed the circuit was 762. CONCLUSION Bariatric surgery without hospital admission is feasible and safe in selected patients using a telemonitoring platform and with the support of a home hospitalization unit.
Collapse
Affiliation(s)
- Albert Caballero
- Unidad de Cirugía Endocrino-Metabólica y Bariátrica, Hospital Universitario Germans Trias i Pujol, Spain; Universitat Autònoma de Barcelona, Spain.
| | - Jordi Tarascó
- Unidad de Cirugía Endocrino-Metabólica y Bariátrica, Hospital Universitario Germans Trias i Pujol, Spain; Universitat Autònoma de Barcelona, Spain
| | - Pau Moreno
- Unidad de Cirugía Endocrino-Metabólica y Bariátrica, Hospital Universitario Germans Trias i Pujol, Spain; Universitat Autònoma de Barcelona, Spain
| | - Laura López-Vendrell
- Servicio de Cirugía General y Digestiva, Hospital Universitario Germans Trias i Pujol, Spain
| | - Sílvia Pellitero
- Servicio de Endocrinología, Nutrición y Dietética. Hospital Universitario Germans Trias i Pujol, Spain
| | - Eva Martínez
- Servicio de Endocrinología, Nutrición y Dietética. Hospital Universitario Germans Trias i Pujol, Spain
| | - Glòria Bonet
- Unidad de Hospitalización Domiciliaria, Hospital Universitario Germans Trias i Pujol, Spain
| | - José M Balibrea
- Unidad de Cirugía Endocrino-Metabólica y Bariátrica, Hospital Universitario Germans Trias i Pujol, Spain; Universitat Autònoma de Barcelona, Spain; Cátedra de Investigación en Cirugía iVascular-UAB, Spain
| |
Collapse
|
4
|
Tunruttanakul S, Tunruttanakul R, Prasopsuk K, Sakulsansern K, Trikhirhisthit K. Preoperative admission is non-essential in most patients receiving elective laparoscopic cholecystectomy: A cohort study. PLoS One 2023; 18:e0293446. [PMID: 37883351 PMCID: PMC10602302 DOI: 10.1371/journal.pone.0293446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Accepted: 10/12/2023] [Indexed: 10/28/2023] Open
Abstract
We evaluated conventional overnight-stay laparoscopic cholecystectomy, focusing on the preoperative admission day, to assess the feasibility of implementing daycare laparoscopic cholecystectomy, which is currently underutilized in developing and some Asian countries. We retrospectively reviewed elective laparoscopic cholecystectomy data from March 2020 to February 2022 at a 700-bed tertiary hospital in Thailand. Variables included age, sex, body mass index, comorbidities, American Society of Anesthesiologists status, presence of preoperative anesthesiology visit, laparoscopic cholecystectomy indications, additional intraoperative cholangiography, and surgery cancellations. The primary focus was on preoperative treatment and monitoring needs; secondary outcomes included morbidity, mortality within 30 days, and prolonged hospital stay (>48 hours). Statistical analysis was conducted using the Fisher exact test, t-test, and logistic regression. The study included 405 patients. Of these, 65 (16.1%) received preoperative treatment, with 21 unnecessary (over) treatments and six under-treatments. Based on the results, approximately 12.1% (n = 49) of patients may have theoretically required preoperative admission and treatment. Multivariable analysis showed that the increasing of comorbidities was significantly associated with preoperative management (odds ratio [95% Confidence interval]: 7.0 [2.1, 23.1], 23.9 [6.6, 86.6], 105.5 [17.5, 636.6]) for one, two, and three comorbidities, respectively), but factors such as age, obesity, and American Society of Anesthesiologists status were not. The cohort had 4.2% morbidity (2.2% medical complications), with no mortality. Surgery cancellations occurred in 0.5%. In conclusion, on the basis of our data, a small proportion (12.1%) of patients undergoing elective laparoscopic cholecystectomy may require preoperative admissions to receive the necessary treatment, and most (87.9%) preoperative admissions may not provide treatment benefit. The traditional admission approach was safe but required re-evaluation for optimal resource management.
Collapse
Affiliation(s)
| | | | - Kamoltip Prasopsuk
- Department of Anesthesiology, Regional Health Promotion Center 3, Nakhon Sawan, Thailand
| | | | - Kyrhatii Trikhirhisthit
- Department of Radiology, Division of Radiation Oncology, Sawanpracharak Hospital, Nakhon Sawan, Thailand
| |
Collapse
|
5
|
Hodgson JA, Cyr KL, Sweitzer B. Patient selection in ambulatory surgery. Best Pract Res Clin Anaesthesiol 2023; 37:357-372. [PMID: 37938082 DOI: 10.1016/j.bpa.2022.12.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2022] [Revised: 12/15/2022] [Accepted: 12/28/2022] [Indexed: 01/07/2023]
Abstract
Patient selection is important for ambulatory surgical practices. Proper patient selection for ambulatory practices will optimize resources and lead to increased patient and provider satisfaction. As the number and complexity of procedures in ambulatory surgical centers increase, it is important to ensure that patients are best cared for in facilities that can provide appropriate levels of care. This review addresses the multiple variables and resources that should be considered when selecting patients for anesthesia in ambulatory centers and offices.
Collapse
Affiliation(s)
- John A Hodgson
- Walter Reed National Military Medical Center and Uniformed Services University, 8901 Wisconsin Avenue, Bethesda, MD, 20889, United States.
| | - Kyle L Cyr
- Walter Reed National Military Medical Center and Uniformed Services University, 8901 Wisconsin Avenue, Bethesda, MD, 20889, United States.
| | - BobbieJean Sweitzer
- Medical Education, University of Virginia, Systems Director, Preoperative Medicine, Inova Health, 3300 Gallows Road, Falls Church, VA, 22042, United States.
| |
Collapse
|
6
|
Azizad O, Joshi GP. Day-surgery adult patients with obesity and obstructive sleep apnea: Current controversies and concerns. Best Pract Res Clin Anaesthesiol 2023; 37:317-330. [PMID: 37938079 DOI: 10.1016/j.bpa.2022.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Accepted: 11/28/2022] [Indexed: 12/02/2022]
Abstract
Obesity and obstructive sleep apnea are considered independent risk factors that can adversely affect perioperative outcomes. A combination of these two conditions in the ambulatory surgery patient can pose significant challenges for the anesthesiologist. Nevertheless, these patients should not routinely be denied access to ambulatory surgery. Instead, patients should be appropriately optimized. Anesthesiologists and surgeons must work together to implement fast-track anesthetic and surgical techniques that will ensure successful ambulatory outcomes.
Collapse
Affiliation(s)
- Omaira Azizad
- Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, TX, USA.
| | - Girish P Joshi
- Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, TX, USA
| |
Collapse
|
7
|
Modha K, Whinney C. Preoperative Evaluation for Noncardiac Surgery. Ann Intern Med 2022; 175:ITC161-ITC176. [PMID: 36343344 DOI: 10.7326/aitc202211150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
The previous In the Clinic that addressed preoperative evaluation for noncardiac surgery was published in December 2016. This update reaffirms much of the information in the previous version and provides new information that has accumulated since then. The goal of preoperative assessment is to identify the risk for postoperative complications so health care teams can more fully understand how to implement strategies to mitigate risks before and after the operation.
Collapse
Affiliation(s)
- Kunjam Modha
- Cleveland Clinic Foundation, Cleveland, Ohio (K.M.)
| | | |
Collapse
|
8
|
Medical disease and ambulatory surgery, new insights in patient selection based on medical disease. Curr Opin Anaesthesiol 2022; 35:385-391. [PMID: 35671030 DOI: 10.1097/aco.0000000000001132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Improvements in perioperative care contributed to enlarge the eligibility criteria for day case surgery and more and more patients with comorbidities may be concerned. However, underlying medical diseases may influence postoperative outcomes, and therefore, must be considered when selecting patients to undergo ambulatory surgery. RECENT FINDINGS To limit postoperative complications, rigid patient selection criteria are often applied in ambulatory surgery. In practice, however, most of these criteria predict the occurrence of treatable perioperative adverse events but not the need for unanticipated admission or readmission. SUMMARY The underlying medical diseases should not be considered as sole criteria but they should rather be regarded as a dynamic process, which includes the surgical procedure as well as the experience and expertise of the perioperative setting.
Collapse
|
9
|
First fully endoscopic metabolic procedure with NOTES gastrojejunostomy, controlled bypass length and duodenal exclusion: a 9-month porcine study. Sci Rep 2022; 12:21. [PMID: 34996894 PMCID: PMC8741923 DOI: 10.1038/s41598-021-02921-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Accepted: 11/18/2021] [Indexed: 01/14/2023] Open
Abstract
We conducted a pilot study of a potential endoscopic alternative to bariatric surgery. We developed a Natural Orifice Transluminal Endoscopic Surgery (NOTES) gastric bypass with controlled bypass limb length using four new devices including a dedicated lumen-apposing metal stent (GJ-LAMS) and pyloric duodenal exclusion device (DED). We evaluated procedural technical success, weight change from baseline, and adverse events in growing Landrace/Large-White pigs through 38 weeks after GJ-LAMS placement. Six pigs (age 2.5 months, mean baseline weight 26.1 ± 2.7 kg) had initial GJ-LAMS placement with controlled bypass limb length, followed by DED placement at 2 weeks. Technical success was 100%. GJ-LAMS migrated in 3 of 6, and DED migrated in 3 of 5 surviving pigs after mucosal abrasion. One pig died by Day 94. At 38 weeks, necropsy showed 100–240 cm limb length except for one at 760 cm. Weight gain was significantly lower in the pigs that underwent endoscopic bypass procedures compared to expected weight for age. This first survival study of a fully endoscopic controlled bypass length gastrojejunostomy with duodenal exclusion in a growing porcine model showed high technical success but significant adverse events. Future studies will include procedural and device optimizations and comparison to a control group.
Collapse
|
10
|
Huda A, Alharthi A, Mohammed A, Jamil M, Mehboob A. Evaluation of risk factors for unanticipated hospital admission following ambulatory surgery – An observational study. Saudi J Anaesth 2022; 16:419-422. [DOI: 10.4103/sja.sja_420_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2022] [Accepted: 06/01/2022] [Indexed: 11/04/2022] Open
|
11
|
Rajan N, Rosero EB, Joshi GP. Patient Selection for Adult Ambulatory Surgery: A Narrative Review. Anesth Analg 2021; 133:1415-1430. [PMID: 34784328 DOI: 10.1213/ane.0000000000005605] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
With migration of medically complex patients undergoing more extensive surgical procedures to the ambulatory setting, selecting the appropriate patient is vital. Patient selection can impact patient safety, efficiency, and reportable outcomes at ambulatory surgery centers (ASCs). Identifying suitability for ambulatory surgery is a dynamic process that depends on a complex interplay between the surgical procedure, patient characteristics, and the expected anesthetic technique (eg, sedation/analgesia, local/regional anesthesia, or general anesthesia). In addition, the type of ambulatory setting (ie, short-stay facilities, hospital-based ambulatory center, freestanding ambulatory center, and office-based surgery) and social factors, such as availability of a responsible individual to take care of the patient at home, can also influence patient selection. The purpose of this review is to present current best evidence that would provide guidance to the ambulatory anesthesiologist in making an informed decision regarding patient selection for surgical procedures in freestanding ambulatory facilities.
Collapse
Affiliation(s)
- Niraja Rajan
- From the Department of Anesthesiology and Perioperative Medicine, Penn State Health, Hershey, Pennsylvania
| | - Eric B Rosero
- Department of Anesthesiology and Pain Management, University of Texas Southwestern, Dallas, Texas
| | - Girish P Joshi
- Department of Anesthesiology and Pain Management, University of Texas Southwestern, Dallas, Texas
| |
Collapse
|
12
|
Hajmohamed S, Patel D, Apruzzese P, Kendall MC, De Oliveira G. Early Postoperative Outcomes of Super Morbid Obese Compared to Morbid Obese Patients After Ambulatory Surgery Under General Anesthesia: A Propensity-Matched Analysis of a National Database. Anesth Analg 2021; 133:1366-1373. [PMID: 34784321 DOI: 10.1213/ane.0000000000005770] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Patients with body mass index (BMI) ≥50 kg/m2, defined as super morbid obesity, represent the fastest growing segment of patients with obesity in the United States. It is currently unknown if super morbid obese patients are at greater odds than morbid obese patients for poor outcomes after outpatient surgery. The main objective of the current investigation is to assess if super morbid obese patients are at increased odds for postoperative complications after outpatient surgery when compared to morbid obese patients. METHODS The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database from 2017 to 2018 was queried to extract and compare patients who underwent outpatient surgery and were defined as either morbidly obese (BMI >40 and <50 kg/m2) or super morbidly obese (BMI ≥50 kg/m2). The primary outcome was the occurrence of medical adverse events within 72 hours of discharge. In addition, we also examine death and readmissions as secondary outcomes. A propensity-matched analysis was used to evaluate the association of BMI ≥50 kg/m2 versus BMI between 40 and 50 kg/m2 and the outcomes. RESULTS A total of 661,729 outpatient surgeries were included in the 2017-2018 NSQIP database. Of those, 7160 with a BMI ≥50 kg/m2 were successfully matched to 7160 with a BMI <50 and ≥40 kg/m2. After matching, 17 of 7160 (0.24%) super morbid obese patients had 3-day medical complications compared to 15 of 7160 (0.21%) morbid obese patients (odds ratio [OR; 95% confidence interval {CI}] = 1.13 [0.57-2.27], P = .72). The rate of 3-day surgical complications in super morbid obese patients was also not different from morbid obese patients. Thirty-five of 7160 (0.48%) super morbid obese patients were readmitted within 3 days, compared to 33 of 7160 (0.46%) morbid obese patients (OR [95% CI] = 1.06 [0.66-1.71], P = .80). When evaluated in a multivariable analysis as a continuous variable (1 unit increase in BMI) in all patients, BMI ≥40 kg/m2 was not significantly associated with overall medical complications (OR [95% CI] = 1.00 [0.98-1.04], P = .87), overall surgical complication (OR [95% CI] = 1.02 [0.98-1.06], P = .23), or readmissions (OR [95% CI] = 0.99 [0.97-1.02], P = .8). CONCLUSIONS Super morbid obesity is not associated with higher rates of early postoperative complications when compared to morbid obese patients. Specifically, early pulmonary complications were very low after outpatient surgery. Super morbid obese patients should not be excluded from outpatient procedures based on a BMI cutoff alone.
Collapse
Affiliation(s)
- Sherine Hajmohamed
- From the Department of Anesthesiology, The Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Deeran Patel
- From the Department of Anesthesiology, The Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Patricia Apruzzese
- Department of Anesthesiology, Rhode Island Hospital, Providence, Rhode Island
| | - Mark C Kendall
- From the Department of Anesthesiology, The Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Gildasio De Oliveira
- From the Department of Anesthesiology, The Warren Alpert Medical School of Brown University, Providence, Rhode Island
| |
Collapse
|
13
|
Ranum D, Beverly A, Shapiro FE, Urman RD. Leading Causes of Anesthesia-Related Liability Claims in Ambulatory Surgery Centers. J Patient Saf 2021; 17:513-521. [PMID: 29189439 DOI: 10.1097/pts.0000000000000431] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE We present a contemporary analysis of patient injury, allegations, and contributing factors of anesthesia-related closed claims, which involved cases that specifically occurred in free-standing ambulatory surgery centers (ASCs). METHODS We examined ASC-closed claims data between 2007 and 2014 from The Doctors Company, a medical malpractice insurer. Findings were coded using the Comprehensive Risk Intelligence Tool developed by CRICO Strategies. We compared coded data from ASC claims with hospital operating room (HOR) claims, in terms of injury severity category, nature of injury, nature of allegation, contributing factors identified, and contributing comorbidities and claim value. RESULTS Ambulatory surgery center claims were more likely to be classified as medium severity than HOR claims, more likely to involve dental damage or pain than HOR claims, but less likely to involve death or respiratory or cardiac arrest. Technical performance was the most common contributing factor: 47% of ASCs and 48% of HORs. Only 7% of allegations relating to technical performance were judged to be a direct result of poor technical performance. The most common anesthesia procedures resulting in ASC claims were injection of anesthesia into a peripheral nerve (34%) and intubation (29%). Obesity was the most common contributing comorbidity in both settings. Mean closed claim value was significantly lower for ASC than HOR claims, averaging US $87,888 versus $107,325. CONCLUSIONS Analysis of ASC and HOR claims demonstrates significant differences and several common sources of liability. These include improving strategies for thorough screening, preoperative assessment and risk stratifying of patients, incorporating routine dental and airway assessment and documentation, diagnosing and treating perioperative pain adequately, and improving the efficacy of communication between patients and care providers.
Collapse
Affiliation(s)
- Darrell Ranum
- From the Patient Safety, Northeast Region, The Doctors Company, Napa, California
| | - Anair Beverly
- Center for Perioperative Research, Brigham and Women's Hospital, Harvard Medical School
| | - Fred E Shapiro
- Department of Anesthesia and Critical Care, Beth Israel Deaconess Medical Center, Harvard Medical School
| | - Richard D Urman
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| |
Collapse
|
14
|
Abstract
The purpose of this American Society for Reproductive Medicine Practice Committee report is to provide clinicians with principles and strategies for the evaluation and treatment of couples with infertility associated with obesity. This revised document replaces the Practice Committee document titled "Obesity and reproduction: an educational bulletin" last published in 2015 (Fertil Steril 2015;104:1116-26).
Collapse
Affiliation(s)
-
- American Society for Reproductive Medicine, Birmingham, Alabama
| | | |
Collapse
|
15
|
Should there be a body mass index eligibility cutoff for elective airway cases in an ambulatory surgery center? A retrospective analysis of adult patients undergoing outpatient tonsillectomy. J Clin Anesth 2021; 72:110306. [PMID: 33905901 DOI: 10.1016/j.jclinane.2021.110306] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2021] [Revised: 03/30/2021] [Accepted: 04/18/2021] [Indexed: 02/08/2023]
Abstract
STUDY OBJECTIVE It is unclear what the body mass index (BMI) should be when performing surgery involving the airway at an outpatient surgery facility. The objective of this study was to evaluate the association of Class 3 obesity versus a composite cohort of Class 1 and 2 obesity with same-day hospital admission following outpatient tonsillectomy in adults. DESIGN Retrospective cohort study. SETTING Multi-institutional. PATIENTS Patients undergoing outpatient tonsillectomy. INTERVENTION None. MEASUREMENTS We used the National Surgical Quality Improvement Program (NSQIP) to analyze association of BMI to same-day admission and 30-day readmission following outpatient tonsillectomy from 2017 to 2019. We looked at six BMI cohorts: 1) ≥30 and < 40 kg/m2 (reference cohort), 2) ≥20 and < 30 kg/m2, 3) <20 kg/m2, 4) ≥40 and < 50 kg/m2, 5) ≥50 and < 60 kg/m2, and 6) ≥60 kg/m2. We used multivariable Poisson regression with robust standard errors and controlled for various confounders to calculate risk ratios (RR) and 99% confidence intervals (CI). MAIN RESULTS There were 12,287 patients included in the final analysis, at which 697 (5.7%) and 283 (2.3%) had a same-day admission or 30-day readmission, respectively. On Poisson regression with robust standard errors, the relative risks for BMI ≥40 kg/m2 and < 50 kg/m2, ≥50 kg/m2 and < 60 kg/m2, and ≥ 60 kg/m2 (BMI ≥30 kg/m2 and < 40 kg/m2 was the reference group) were 1.31 (99% CI 1.03-1.65, p = 0.03), 1.99 (99% CI 1.43-2.78, p = 0.002), and 1.80 (99% CI 1.00-3.25, p = 0.07), respectively. Furthermore, Class 3 obesity was not associated with 30-day readmission. CONCLUSION These results contribute data that may help practices - especially freestanding ambulatory surgery centers - decide appropriate BMI cutoffs for surgery involving the airway. Whether this is considered clinically significant enough to rule out eligibility will differ from practice-to-practice and will depend on surgical volume, resources available and financial interests.
Collapse
|
16
|
Nijland LMG, de Castro SMM, Vogel M, Coumou JWF, van Rutte PWJ, van Veen RN. Feasibility of Same-Day Discharge After Laparoscopic Roux-en-Y Gastric Bypass Using Remote Monitoring. Obes Surg 2021; 31:2851-2858. [PMID: 33821394 PMCID: PMC8021477 DOI: 10.1007/s11695-021-05384-z] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2021] [Revised: 03/24/2021] [Accepted: 03/24/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND Shortening of hospital stay to 1 night has not affected the short-term safety of patients undergoing laparoscopic Roux-en-Y gastric bypass (RYGB). Whether the RYGB is feasible in an ambulatory setting (same-day discharge) without overnight hospital stay remains to be answered. We aimed to evaluate the feasibility of same-day discharge after laparoscopic Roux-en-Y gastric bypass (RYGB) using additional live video consultation and remote monitoring. Same-day discharge (SDD) was defined as surgery without postoperative overnight hospital stay. METHODS This was a single-center prospective feasibility study in a selected group of patients undergoing a RYGB. Fifty patients undergoing a primary RYGB were selected and potentially treated following the SDD protocol. After SDD discharge patients were remotely monitored after surgery for 48 h using a medical device measuring vital signs three times a day. Video consultations were performed by a doctor twice a day for 2 postoperative days. Primary outcome was the success rate (%) of SDD. Secondary outcomes were emergency room presentations, readmissions, early complications (<30 days), and patient satisfaction. RESULTS A total of 50 patients were selected for the SDD treatment protocol between June 2020 and November 2020. An SDD success rate of 88 % (44/50 patients) was achieved. Five patients (10%) presented at the emergency room, 2 of whom (4%) were readmitted because of a complication within 30 days after surgery. Overall, patients who followed the SDD protocol reported high satisfaction scores. CONCLUSION A RYGB with SDD can be considered feasible using remote monitoring for a selected group of patients.
Collapse
Affiliation(s)
- Leontien M G Nijland
- Department of Surgery, OLVG, Amsterdam, The Netherlands. .,Obesity Center Amsterdam, OLVG, Jan Tooropstraat 164, 1061, AE, Amsterdam, The Netherlands.
| | | | - Marlou Vogel
- Department of Anesthesiology, OLVG, Amsterdam, The Netherlands
| | | | | | | |
Collapse
|
17
|
Abstract
PURPOSE OF REVIEW Implementation of enhanced recovery pathways have allowed migration of complex surgical procedures from inpatient setting to the outpatient setting. These programs improve patient safety and patient-reported outcomes. The present article discusses the principles of enhanced recovery pathways in adults undergoing ambulatory surgery with an aim of improving patient safety and postoperative outcomes. RECENT FINDINGS Procedure and patient selection is one of the key elements that influences perioperative outcomes after ambulatory surgery. Other elements include optimization of comorbid conditions, patient and family education, minimal preoperative fasting and adequate hydration during the fasting period, use of fast-track anesthesia technique, lung-protective mechanical ventilation, maintenance of fluid balance, and multimodal pain, nausea, and vomiting prophylaxis. SUMMARY Implementation of enhanced recovery pathways requires a multidisciplinary approach in which the anesthesiologist should take a lead in collaborating with surgeons and perioperative nurses. Measuring compliance with enhanced recovery pathways through an audit program is essential to evaluate success and need for protocol modification. The metrics to assess the impact of enhanced recovery pathways include complication rates, patient reported outcomes, duration of postoperative stay in the surgical facility, unplanned hospital admission rate, and 7-day and 30-day readmission rates.
Collapse
|
18
|
Affiliation(s)
- A. Wynn-Hebden
- University Hospitals of Leicester NHS Trust, Leicester, UK
| | - D.C. Bouch
- University Hospitals of Leicester NHS Trust, Leicester, UK
| |
Collapse
|
19
|
Rosero EB, Joshi GP. Finding the body mass index cutoff for hospital readmission after ambulatory hernia surgery. Acta Anaesthesiol Scand 2020; 64:1270-1277. [PMID: 32558921 DOI: 10.1111/aas.13660] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Revised: 05/29/2020] [Accepted: 06/11/2020] [Indexed: 12/22/2022]
Abstract
BACKGROUND The suitability of ambulatory surgery in obese patients remains controversial. This study aimed to investigate the "cutoff" value of body mass index (BMI) associated with increased likelihood of hospital readmissions within the first 24 hours of surgery in patients undergoing ambulatory hernia repair. MATERIALS AND METHODS The study used data from the 2012-2016 American College of Surgeons National Surgical Quality Improvement (ACS-NSQIP). Cochran Armitage trend tests were conducted to assess progression in rates hospital readmissions across categories of patient BMI. The minimum p-value method, Kolmogorov-Smirnov goodness of fit tests, logistic regression, and receiver-operating characteristic (ROC) curve analyses were used to investigate the cutoff of patient BMI indicative of increased likelihood of readmissions. RESULTS A total of 214,125 ambulatory hernia repair cases were identified. Of those, 908 patients (0.42%) had an unexpected hospital admission within the first 24 hours after surgery. The readmission rates did not significantly increase across the categories of BMI. However, some of the reasons for readmission significantly differed by BMI category. Logistic regression analysis revealed no statistically significant association between BMI and hospital readmissions (odds ratio [95% Cl], 0.96 [0.91-1.02] P = .179). An optimal BMI threshold predictive of an increased likelihood of hospital readmissions was not identifiable by any of the statistical methods used. CONCLUSIONS Although reasons for readmission differed by BMI category, there is no clear cutoff value of BMI associated with increased hospital readmission within the first 24 hours after surgery.
Collapse
Affiliation(s)
- Eric B. Rosero
- Department of Anesthesiology and Pain Management University of Texas Southwestern Medical Center Dallas TX USA
| | - Girish P. Joshi
- Department of Anesthesiology and Pain Management University of Texas Southwestern Medical Center Dallas TX USA
| |
Collapse
|
20
|
Rishel CA, Zhang Y, Sun EC. Association Between Preoperative Benzodiazepine Use and Postoperative Opioid Use and Health Care Costs. JAMA Netw Open 2020; 3:e2018761. [PMID: 33107919 PMCID: PMC7592026 DOI: 10.1001/jamanetworkopen.2020.18761] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
IMPORTANCE The association between preoperative benzodiazepine use and long-term postoperative outcomes is not well understood. OBJECTIVE To characterize the association between preoperative benzodiazepine use and postoperative opioid use and health care costs. DESIGN, SETTING, AND PARTICIPANTS In this cohort study, retrospective analysis of private health insurance claims data on 946 561 opioid-naive patients (no opioid prescriptions filled in the year before surgery) throughout the US was conducted. Patients underwent 1 of 11 common surgical procedures between January 1, 2004, and December 31, 2016; data analysis was performed January 9, 2020. EXPOSURES Benzodiazepine use, defined as long term (≥10 prescriptions filled or ≥120 days supplied in the year before surgery) or intermittent (any use not meeting the criteria for long term). MAIN OUTCOMES AND MEASURES The primary outcome was opioid use 91 to 365 days after surgery. Secondary outcomes included opioid use 0 to 90 days after surgery and health care costs 0 to 30 days after surgery. RESULTS In this sample of 946 561 patients, the mean age was 59.8 years (range, 18-89 years); 615 065 were women (65.0%). Of these, 23 484 patients (2.5%) met the criteria for long-term preoperative benzodiazepine use and 47 669 patients (5.0%) met the criteria for intermittent use. After adjusting for confounders, long-term (odds ratio [OR], 1.59; 95% CI, 1.54-1.65; P < .001) and intermittent (OR, 1.47; 95% CI, 1.44-1.51; P < .001) benzodiazepine use were associated with an increased probability of any opioid use during postoperative days 91 to 365. For patients who used opioids in postoperative days 91 to 365, long-term benzodiazepine use was associated with a 44% increase in opioid dose (additional 0.6 mean daily morphine milligram equivalents [MMEs]; 95% CI, 0.3-0.8 MMEs; P < .001), although intermittent benzodiazepine use was not significantly different (0.0 average daily MMEs; 95% CI, -0.2 to 0.2 MMEs; P = .65). Preoperative benzodiazepine use was also associated with increased opioid use in postoperative days 0 to 90 for both long-term (32% increase, additional 1.9 average daily MMEs; 95% CI, 1.6-2.1 MMEs; P < .001) and intermittent (9% increase, additional 0.5 average daily MMEs; 95% CI, 0.4-0.6 MMEs; P < .001) users. Intermittent benzodiazepine use was associated with an increase in 30-day health care costs ($1155; 95% CI, $938-$1372; P < .001), while no significant difference was observed for long-term benzodiazepine use. CONCLUSIONS AND RELEVANCE The findings of this study suggest that, among opioid-naive patients, preoperative benzodiazepine use may be associated with an increased risk of developing long-term opioid use and increased opioid dosages postoperatively, and also may be associated with increased health care costs.
Collapse
Affiliation(s)
- Chris A. Rishel
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California
| | - Yuting Zhang
- Melbourne Institute: Applied Economic & Social Research, Faculty of Business & Economics, University of Melbourne, Melbourne, Victoria, Australia
| | - Eric C. Sun
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California
- Department of Health Research and Policy, Stanford University School of Medicine, Stanford, California
| |
Collapse
|
21
|
|
22
|
Obesity and unanticipated hospital admission following outpatient laparoscopic cholecystectomy. Surg Endosc 2020; 35:1348-1354. [DOI: 10.1007/s00464-020-07514-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2019] [Accepted: 03/14/2020] [Indexed: 10/24/2022]
|
23
|
Perioperative Risks Are Similar for Normal versus Selected High-Body Mass Index Patients Undergoing Outpatient Hand and Elbow Surgery. Plast Reconstr Surg 2020; 144:836e-840e. [PMID: 31688759 DOI: 10.1097/prs.0000000000006152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Many ambulatory surgery centers use body mass index as a screening tool to make admissions decisions because of complication risks associated with high-body mass index patients. The objective of this investigation was to evaluate perioperative complications in a cohort of high-body mass index patients undergoing hand and elbow surgery at an ambulatory surgery center. The authors' hypothesis was that anesthesia-related complications for this cohort would be similar to those of a normal-body mass index group. METHODS The authors retrospectively reviewed data from all hand and elbow procedures performed on patients with a high body mass index (>40 kg/m). One hundred eighty-nine high-body mass index patients and 189 normal-body mass index patients were included in the analysis. RESULTS The average weight-based dosage of propofol was similar in both groups but was lower in the high-body mass index group for midazolam and fentanyl. Two high-body mass index patients had oxygen desaturations in the postanesthesia care unit. No patients developed complications related to anesthesia. In the high-body mass index group, one patient developed hypotension in the postanesthesia care unit, was admitted to the emergency room for monitoring, but was discharged the following morning. CONCLUSIONS Outpatient hand surgical care of high-body mass index patients can be performed safely. Body mass index alone should not be considered as an absolute contraindication for surgery. Careful patient selection, evaluation of comorbidities, and close involvement of the anesthesia and medical teams are critical. CLINICAL QUESTION/LEVEL OF EVIDENCE Risk, II.
Collapse
|
24
|
The association of body mass index with same-day hospital admission, postoperative complications, and 30-day readmission following day-case eligible joint arthroscopy: A national registry analysis. J Clin Anesth 2020; 59:26-31. [DOI: 10.1016/j.jclinane.2019.06.012] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Revised: 05/08/2019] [Accepted: 06/02/2019] [Indexed: 11/19/2022]
|
25
|
Joshi GP, Benzon HT, Gan TJ, Vetter TR. Consistent Definitions of Clinical Practice Guidelines, Consensus Statements, Position Statements, and Practice Alerts. Anesth Analg 2019; 129:1767-1770. [PMID: 31743199 DOI: 10.1213/ane.0000000000004236] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
An evidence-based approach to clinical decision-making for optimizing patient care is desirable because it promotes quality of care, improves patient safety, decreases medical errors, and reduces health care costs. Clinical practice recommendations are systematically developed documents regarding best practice for specific clinical management issues, which can assist care providers in their clinical decision-making. However, there is currently wide variation in the terminology used for such clinical practice recommendations. The aim of this article is to provide guidance to authors, reviewers, and editors on the definitions of terms commonly used for clinical practice recommendations. This is intended to improve transparency and clarity regarding the definitions of these terminologies.
Collapse
Affiliation(s)
- Girish P Joshi
- From the Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Honorio T Benzon
- Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Tong J Gan
- Department of Anesthesiology, Stony Brook University, Stony Brook, New York
| | - Thomas R Vetter
- Department of Surgery and Perioperative Care, Dell Medical School at University of Texas, Austin, Texas
| |
Collapse
|
26
|
Rodriguez LV. Anesthesia for Ambulatory and Office-Based Ear, Nose, and Throat Surgery. Otolaryngol Clin North Am 2019; 52:1157-1167. [PMID: 31551126 DOI: 10.1016/j.otc.2019.08.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
With today's technological advances in outpatient surgery, anesthetic technique does not differ significantly between inpatient and outpatient settings. It is important to decide which setting is most appropriate for the patient based on the surgeon's ability, the patient's comorbidities, the facility resources, and the staff who will provide care for the patient. Matching all of the above can lead to good outcomes, less complications, and a good patient experience.
Collapse
Affiliation(s)
- Leopoldo V Rodriguez
- Society for Ambulatory Anesthesiology (SAMBA); ASA Committee on Ambulatory Surgical Care; Surgery Center of Aventura, Aventura, FL, USA; Envision Physician Services, 7700 West Sunrise Boulevard, Plantation, FL 33322, USA.
| |
Collapse
|
27
|
Cok OY, Seet E, Kumar CM, Joshi GP. Perioperative considerations and anesthesia management in patients with obstructive sleep apnea undergoing ophthalmic surgery. J Cataract Refract Surg 2019; 45:1026-1031. [PMID: 31174989 DOI: 10.1016/j.jcrs.2019.02.044] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Accepted: 02/20/2019] [Indexed: 11/26/2022]
Abstract
Obstructive sleep apnea (OSA) is a disorder characterized by breathing cessation caused by obstruction of the upper airway during sleep. It is associated with multiorgan comorbidities such as obesity, hypertension, heart failure, arrhythmias, diabetes mellitus, and stroke. Patients with OSA have an increased prevalence of ophthalmic disorders such as cataract, glaucoma, central serous retinopathy (detachment of retina, macular hole), eyelid laxity, keratoconus, and nonarteritic anterior ischemic optic neuropathy; and some might require surgery. Given that OSA is associated with a high incidence of perioperative complications and more than 80% of surgical patients with OSA are unrecognized, all surgical patients should be screened for OSA (eg, STOP-Bang questionnaire) with comorbidities identified. Patients suspected or diagnosed with OSA scheduled for ophthalmic surgery should have their comorbid conditions optimized. This article includes a review of the literature and highlights best perioperative anesthesia practices in the management of ophthalmic surgical patients with OSA.
Collapse
Affiliation(s)
- Oya Y Cok
- Baskent University, School of Medicine, Department of Anesthesiology and Reanimation, Adana Education and Research Centre, Adana, Turkey
| | - Edwin Seet
- Department of Anaesthesia, Khoo Teck Puat Hospital, Singapore
| | - Chandra M Kumar
- Department of Anaesthesia, Khoo Teck Puat Hospital, Singapore.
| | - Girish P Joshi
- University of Texas Southwestern Medical Center, Dallas, Texas, USA
| |
Collapse
|
28
|
Abstract
Obesity and obstructive sleep apnea (OSA) are often associated with increased perioperative risks and challenges for the anesthesiologist. This article addresses the current controversies surrounding perioperative care of morbidly obese patients with or without OSA scheduled for ambulatory surgery, particularly in a free-standing ambulatory center. Topics discussed include preoperative selection of obese and OSA patients for ambulatory surgeries, intraoperative methods to reduce perioperative risk, and appropriate postoperative care.
Collapse
Affiliation(s)
- Gaganpreet Grewal
- University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390-9068, USA.
| | - Girish P Joshi
- University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390-7208, USA
| |
Collapse
|
29
|
Suitability of outpatient or ambulatory extended recovery cancer surgeries for obese patients. J Clin Anesth 2019; 58:111-116. [PMID: 31154282 DOI: 10.1016/j.jclinane.2019.05.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Revised: 04/25/2019] [Accepted: 05/01/2019] [Indexed: 02/06/2023]
Abstract
STUDY OBJECTIVE An increasing number of overweight and obese patients are presenting for ambulatory surgical procedures and may be at risk of complications including longer surgeries, longer length of stay (LOS), and possible increase in unanticipated return visits or hospital admissions. DESIGN Observational study using prospectively-collected data. SETTING Freestanding and hospital-based ambulatory surgery facilities. PATIENTS AND INTERVENTIONS 13,957 patients underwent ambulatory cancer surgery procedures at the Josie Robertson Surgery Center (JRSC) since opening in 2016, and 4591 patients eligible for ambulatory surgery at JRSC underwent surgery at the main hospital during the same timeframe. MEASUREMENTS We assessed whether BMI was associated with increased operative time, post-operative LOS, hospital transfer after surgery, or hospital readmission or urgent care center visits within 30 days. Using multivariable logistic regression, we assessed whether BMI was associated with decision to do surgery at JRSC controlling for age, ASA score and surgical service. MAIN RESULTS While higher BMI was associated with a higher rate of transfer out of JRSC (p = 0.014), the difference in rate was small (mean risk 0.8% for BMI 25 vs 1.3% for BMI 40, difference in risk 0.52%, 95% CI 0.05%, 1.0%). We found no evidence that higher BMI increased the risk of urgent care visits or readmissions within 30 days or outpatient LOS (p = 0.7 for all). There was a statistically but not clinically significant difference in operative time for outpatient procedures (p = <0.0001), with a mean operative time of 59 vs 63 min for BMI 25 vs 40. Ambulatory extended recovery patients with higher BMI had shorter operative times (p < 0.0001). Patients with higher BMI were not significantly less likely to undergo surgery at JRSC (84% vs 83% vs 82% probability of treatment at JRSC for BMI 25, BMI 40 or BMI 50, respectively, p = 0.089). CONCLUSIONS Ambulatory cancer surgeries can be performed safely among clinically eligible patients. Patients with BMI up to 50 or more can be treated safely in an ambulatory setting if they otherwise meet eligibility criteria.
Collapse
|
30
|
Schoenfeld D, Zhou T, Stern JM. Outcomes for Patients Undergoing Ambulatory Percutaneous Nephrolithotomy. J Endourol 2019; 33:189-193. [PMID: 30489147 DOI: 10.1089/end.2018.0579] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
INTRODUCTION Multiple studies have concluded that ambulatory percutaneous nephrolithotomy (aPCNL) is safe. However, selection criteria remain vague and no investigators have assessed the practicality of using various post-procedural drainage strategies in the ambulatory setting. In this study we establish a set of inclusion and exclusion criteria for aPCNL, compare outcomes between aPCNL patients and those admitted following PCNL, and incorporate a variety of "exit" strategies including Double-J stent, ureteropelvic junction (UPJ) stent and totally tubeless techniques. METHODS We developed inclusion and exclusion criteria to determine patient eligibility for aPCNL. Between January 2014 and December 2016, 52 out of 145 patients met criteria for aPCNL and 47 of these patients were ultimately discharged on the same day. Forty-seven of the remaining 98 patients who were admitted following PCNL were randomly selected as a control group. Primary outcomes included stone-free status, emergency department (ED) visits and hospital readmissions within the 6-week post-operative period. Statistical analysis was performed using Student's t-tests, chi square tests, and Fischer's exact tests. RESULTS Both groups had similar age (P = 0.91), sex (P = 0.68), body mass index (P = 0.91), and stone burden (P = 0.12). Patients in the ambulatory group had a lower Charlson Comorbidity score (aPCNL CCS = 0.11, inpatient PCNL CCS = 0.62, P = 0.002). Seventy three percent of ambulatory patients and 62% of standard PCNL patients had no residual stone burden 6 weeks following PCNL (P = 0.33). The average residual stone fragment in our ambulatory and standard PCNL group was 3.5 and 3.2 mm, respectively. Five patients (11%) from the aPCNL group and 4 (9%) from the standard PCNL group presented to the ED (P = 0.76). One aPCNL (2%) and three standard PCNL (6%) patients were re-admitted to the hospital (P = 0.62). CONCLUSIONS In this study we establish specific inclusion and exclusion criteria for aPCNL. Using these criteria we then demonstrated the practicality of using various exit strategies to facilitate aPCNL. Future randomized control trials would be beneficial in confirming the safety and efficacy of aPCNL in select patients.
Collapse
Affiliation(s)
- Daniel Schoenfeld
- Department of Urology, Montefiore Medical Center, Albert Einstein College of Medicine , Bronx, New York
| | - Tian Zhou
- Department of Urology, Montefiore Medical Center, Albert Einstein College of Medicine , Bronx, New York
| | - Joshua M Stern
- Department of Urology, Montefiore Medical Center, Albert Einstein College of Medicine , Bronx, New York
| |
Collapse
|
31
|
Improving outcomes in ambulatory anesthesia by identifying high risk patients. Curr Opin Anaesthesiol 2018; 31:659-666. [DOI: 10.1097/aco.0000000000000653] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
|
32
|
Lee JW. Considerations in treating obese patients in office-based anesthesia. Minerva Anestesiol 2018; 84:1318-1322. [DOI: 10.23736/s0375-9393.18.12670-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
|
33
|
Rapp DE, Mills JT, Smith-Harrison LI, Smith RP, Costabile RA. Effect of body mass index on recurrence following urethroplasty. Transl Androl Urol 2018; 7:673-677. [PMID: 30211058 PMCID: PMC6127538 DOI: 10.21037/tau.2018.06.07] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Background Limited investigation exists to understand whether obesity affects outcomes of urethral reconstruction. We sought to assess whether body mass index (BMI) is an independent predictor for stricture recurrence following urethroplasty. Methods We performed a retrospective review of patients undergoing urethroplasty between 2007–2014, identifying 137 patients for study inclusion. Data collected included BMI and patient demographic and surgical characteristics, including age, stricture length and location, etiology, and urethroplasty technique. Stricture-free survival analysis was performed using Kaplan-Meier method. Logistic regression was performed to assess predictors for stricture recurrence using both univariate and multivariate models. Results Mean patient age and follow-up was 46.7 (±16.4) years and 91.8 (±30.5) months, respectively. A recurrence rate of 17% was identified, with a mean time to recurrence of 29 months. There was no difference when comparing the mean BMI in patients with and without recurrence (28.9 vs. 30.4 kg/m2, respectively) (P=0.4). A higher rate of stricture recurrence was seen when comparing the cohort with a BMI <25 kg/m2 versus remaining cohorts (BMI: 25–30 kg/m2; BMI >30 kg/m2). However, in univariate and multivariate analysis, BMI failed to demonstrate statistical significance as a predictor for urethroplasty outcome. On multivariate analysis, fasciocutaneous repair type was predictive of stricture recurrence. No additional potential predictors assessed were found to be significant. Conclusions In the present study, BMI did not independently predict for stricture recurrence following urethroplasty.
Collapse
Affiliation(s)
- David E Rapp
- Department of Urology, University of Virginia, Charlottesville, VA, USA
| | - James T Mills
- Department of Urology, University of Virginia, Charlottesville, VA, USA
| | | | - Ryan P Smith
- Department of Urology, University of Virginia, Charlottesville, VA, USA
| | | |
Collapse
|
34
|
Bennitz JD, Manninen P. Anesthesia for Day Care Neurosurgery. CURRENT ANESTHESIOLOGY REPORTS 2018. [DOI: 10.1007/s40140-018-0284-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
|
35
|
|
36
|
Braaten KP, Urman RD, Maurer R, Fortin J, Goldberg AB. A randomized comparison of intravenous sedation using a dosing algorithm compared to standard care during first-trimester surgical abortion. Contraception 2018; 97:490-496. [DOI: 10.1016/j.contraception.2018.01.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2017] [Revised: 01/23/2018] [Accepted: 01/24/2018] [Indexed: 01/21/2023]
|
37
|
Morbid obesity, sleep apnea, obesity hypoventilation syndrome: Are we sleepwalking into disaster? ACTA ACUST UNITED AC 2017. [DOI: 10.1016/j.pcorm.2017.11.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
|
38
|
De Oliveira GS, McCarthy RJ, Davignon K, Chen H, Panaro H, Cioffi WG. Predictors of 30-Day Pulmonary Complications after Outpatient Surgery: Relative Importance of Body Mass Index Weight Classifications in Risk Assessment. J Am Coll Surg 2017; 225:312-323.e7. [DOI: 10.1016/j.jamcollsurg.2017.04.013] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2017] [Revised: 04/04/2017] [Accepted: 04/11/2017] [Indexed: 10/19/2022]
|
39
|
|
40
|
Billing P, Billing J, Kaufman J, Stewart K, Harris E, Landerholm R. High acuity sleeve gastrectomy patients in a free-standing ambulatory surgical center. Surg Obes Relat Dis 2017; 13:1117-1121. [DOI: 10.1016/j.soard.2017.03.012] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2016] [Revised: 02/17/2017] [Accepted: 03/10/2017] [Indexed: 10/19/2022]
|
41
|
Value of endometrial thickness assessed by transvaginal ultrasound for the prediction of endometrial cancer in patients with postmenopausal bleeding. Arch Gynecol Obstet 2017. [PMID: 28634754 DOI: 10.1007/s00404-017-4439-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
PURPOSE Histological confirmation of endometrial cancer by dilatation/curettage (D/C) in women with postmenopausal bleeding (PMB) can be challenging due to anesthesiological and/or surgical risks. Thus, less invasive methods for diagnostics are required to identify patients with minimal risk for endometrial cancer (EC) to avoid unnecessary surgical intervention. The objective of this single-center cohort study was to assess the diagnostic validity of transvaginal ultrasound (TVUS) measurements of endometrial thickness (ET) in patients with PMB for the detection of EC. METHODS A retrospective analysis of data from patients presenting between January 2005 and August 2014 at the Department of Obstetrics and Gynecology, University Hospital Ulm, Germany, with PMB and subsequent D/C was performed. Complete data with TVUS documentation of ET and histological results of tissue samples were available from 254 patients. In addition, data on age, body mass index (BMI), ASA-score, diabetes, hypertension, and hematological laboratory values (for a smaller subsample) were recorded. To identify independent risk factors, a multivariate logistic regression with endometrial cancer as binary response variable (yes/no) was performed. Diagnostic efficacy data for different ET cutoff points (≤1 to ≤26 mm) were obtained by a receiver operator characteristic (ROC) curve analysis. RESULTS The multivariate logistic regression revealed a significant independent predictive value for age and ET. However, none of the analyzed ET cutoff points showed optimal diagnostic validity, as all cutoff points with sensitivity rates above 90% (≤1 to ≤5 mm) had false positive rates of 70% and higher. CONCLUSIONS There is no ET cutoff point that provides good diagnostic accuracy and/or reliably excludes the presence of endometrial cancer in patients with PMB. Thus, our data analysis supports the actual German approach of histological evaluation of any PMB to confirm or exclude EC.
Collapse
|
42
|
Malchow RJ, Gupta RK, Shi Y, Shotwell MS, Jaeger LM, Bowens C. Comprehensive Analysis of 13,897 Consecutive Regional Anesthetics at an Ambulatory Surgery Center. PAIN MEDICINE 2017; 19:368-384. [DOI: 10.1093/pm/pnx045] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
|
43
|
Variables Influencing the Depth of Conscious Sedation in Plastic Surgery: A Prospective Study. Arch Plast Surg 2017; 44:5-11. [PMID: 28194341 PMCID: PMC5300924 DOI: 10.5999/aps.2017.44.1.5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2016] [Revised: 10/20/2016] [Accepted: 10/20/2016] [Indexed: 11/17/2022] Open
Abstract
Background Conscious sedation has been widely utilized in plastic surgery. However, inadequate research has been published evaluating adequate drug dosage and depth of sedation. In clinical practice, sedation is often inadequate or accompanied by complications when sedatives are administered according to body weight alone. The purpose of this study was to identify variables influencing the depth of sedation during conscious sedation for plastic surgery. Methods This prospective study evaluated 97 patients who underwent plastic surgical procedures under conscious sedation. Serum aspartate aminotransferase (AST), alanine aminotransferase (ALT), creatinine, and glucose levels were measured. Midazolam and ketamine were administered intravenously according to a preset protocol. Bispectral index (BIS) recordings were obtained to evaluate the depth of sedation 4, 10, 15, and 20 minutes after midazolam administration. Associations between variables and the BIS were assessed using multiple regression analysis. Results Alcohol intake and female sex were positively associated with the mean BIS (P<0.01). Age was negatively associated with the mean BIS (P<0.01). Body mass index (P=0.263), creatinine clearance (P=0.832), smoking history (P=0.398), glucose (P=0.718), AST (P=0.729), and ALT (P=0.423) were not associated with the BIS. Conclusions Older patients tended to have a greater depth of sedation, whereas females and patients with greater alcohol intake had a shallower depth of sedation. Thus, precise dose adjustments of sedatives, accounting for not only weight but also age, sex, and alcohol consumption, are required to achieve safe, effective, and predictable conscious sedation.
Collapse
|
44
|
Mull HJ, Rivard PE, Legler A, Pizer SD, Hawn MT, Itani KMF, Rosen AK. Comparing definitions of outpatient surgery: Implications for quality measurement. Am J Surg 2017; 214:186-192. [PMID: 28233538 DOI: 10.1016/j.amjsurg.2017.01.021] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2016] [Revised: 01/09/2017] [Accepted: 01/19/2017] [Indexed: 01/08/2023]
Abstract
BACKGROUND Adverse event (AE) rates in outpatient surgery are inconsistently reported, partly because of the lack of a standard definition of outpatient surgery. We compared the types and rates of surgical procedures defined by two national healthcare agencies: Health Care Cost Institute (HCCI) and the Healthcare Cost and Utilization Project (HCUP) and considered implications for quality measurement. METHODS We used HCCI and HCUP definitions to identify FY2012-14 VA outpatient surgeries. RESULTS There were six times as many HCCI surgeries as HCUP (6,575,830 versus 1,086,640). Ninety-nine percent of HCUP-defined surgeries were also identified by HCCI. More HCUP surgeries had higher average Medicare Relative Value Units then HCCI surgeries [5.3 (SD = 4.4) versus 1.6 (SD = 2.3) RVUs]. CONCLUSIONS Rates and types of procedures vary widely between definitions. Quality measurement using HCCI versus HCUP may produce significantly lower AE rates because many of the surgeries included reflect low complexity and potentially low risk of AEs.
Collapse
Affiliation(s)
- Hillary J Mull
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, MA, USA; Department of Surgery, Boston University School of Medicine, Boston, MA, USA.
| | - Peter E Rivard
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, MA, USA; Healthcare Administration, Sawyer Business School Suffolk University, Boston, MA, USA
| | - Aaron Legler
- Partnered Evidence-based Policy Resource Center (PEPReC), Department of Veterans Affairs, Boston, MA, USA
| | - Steven D Pizer
- Partnered Evidence-based Policy Resource Center (PEPReC), Department of Veterans Affairs, Boston, MA, USA; Northeastern University School of Pharmacy, Boston, MA, USA
| | - Mary T Hawn
- Department of Surgery, Stanford University School of Medicine, Stanford, CA, USA; Center for Surgical, Medical Acute Care Research and Transitions (C-SMART), Birmingham VA Medical Center, Birmingham, AL, USA
| | - Kamal M F Itani
- Department of Surgery, Boston University School of Medicine, Boston, MA, USA; Department of Surgery, VA Boston Healthcare System, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Amy K Rosen
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, MA, USA; Department of Surgery, Boston University School of Medicine, Boston, MA, USA
| |
Collapse
|
45
|
Stenglein J. Morbid Obesity. Anesthesiology 2017. [DOI: 10.1007/978-3-319-50141-3_31] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
|
46
|
Kulkarni S, Harsoor SS, Chandrasekar M, Bhaskar SB, Bapat J, Ramdas EK, Valecha UK, Pradhan AS, Swami AC. Consensus statement on anaesthesia for day care surgeries. Indian J Anaesth 2017; 61:110-124. [PMID: 28250479 PMCID: PMC5330067 DOI: 10.4103/ija.ija_659_16] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
The primary aim of day-care surgery units is to allow for early recovery of the patients so that they can return to their familiar 'home' environment; the management hence should be focused towards achieving these ends. The benefits could include a possible reduction in the risk of thromboembolism and hospital-acquired infections. Furthermore, day-care surgery is believed to reduce the average unit cost of treatment by up to 70% as compared to inpatient surgery. With more than 20% of the world's disease burden, India only has 6% of the world's hospital beds. Hence, there is an immense opportunity for expansion in day-care surgery in India to ensure faster and safer, cost-effective patient turnover. For this to happen, there is a need of change in the mindset of all concerned clinicians, surgeons, anaesthesiologists and even the patients. A group of nine senior consultants from various parts of India, a mix of private and government anaesthesiologists, assembled in Mumbai and deliberated and discussed on the various aspects of day-care surgery. They formulated a consensus statement, the first of its kind in the Indian scenario, which can act as a guidance and tool for day-care anaesthesia in India. The statements are derived from the available published evidence in peer-reviewed literature including guidelines of several bodies such as the American Society of Anesthesiologists, British Association of Day Surgery and International Association of Ambulatory Surgery. The authors also offer interpretive comments wherever such evidence is inadequate or contradictory.
Collapse
Affiliation(s)
- Satish Kulkarni
- Lilavati Hospital and Research Centre, Mumbai, Maharashtra, India
| | - S S Harsoor
- Department of Anaesthesiology, Bangalore Medical College and Research Centre, Bengaluru, Karnataka, India
| | - M Chandrasekar
- Aarogyasri Trust, Government of Telangana, Hyderabad, Telangana, India
| | - S Bala Bhaskar
- Department of Anaesthesiology and Critical Care, Vijayanagar Institute of Medical Sciences, Bellary, Karnataka, India
| | - Jitendra Bapat
- Hinduja Hospital and Medical Research Centre, Mumbai, Maharashtra, India
| | | | - Umesh Kumar Valecha
- Department of Anaesthesiology, BLK Super Specialty Hospital, New Delhi, India
| | | | | |
Collapse
|
47
|
Airway Surgery in the Ambulatory Setting. CURRENT ANESTHESIOLOGY REPORTS 2016. [DOI: 10.1007/s40140-016-0183-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
|
48
|
|
49
|
Fully Ambulatory Laparoscopic Sleeve Gastrectomy: 328 Consecutive Patients in a Single Tertiary Bariatric Center. Obes Surg 2015; 26:1429-35. [DOI: 10.1007/s11695-015-1984-0] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
|
50
|
Controversies in perioperative anesthetic management of the morbidly obese: I am a surgeon, why should I care? Obes Surg 2015; 25:879-87. [PMID: 25726320 DOI: 10.1007/s11695-015-1635-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Over the last four decades, as the rates of obesity have increased, so have the challenges associated with its anesthetic management. In the present review, we discuss perioperative anesthesia management issues that are modifiable by the early involvement of the surgical team. We sum up available evidence or expert opinion on issues like patient positioning, postoperative analgesia, and the effect of continuous positive airway pressure (CPAP) ventilation on surgical anastomosis. We also address established predictors of higher perioperative risk and suggest possible management strategies and concerns of obese patients undergoing same day procedures. Finally, a generalized pharmacological model relevant to altered pharmacokinetics in these patients is presented.
Collapse
|