Purpose
Recovery and discharge following ambulatory surgery are important components of the ambulatory surgery experience. This review provides contemporary perspectives on the issues of discharge criteria, fast-tracking, patient escort requirements, and driving after ambulatory anesthesia.

/pdf/factors-affecting-recovery-and-discharge-following-4xmyoiixr9.pdf

Factors affecting recovery and discharge following ambulatory surgery

IMPLICATIONS: In this study, although 41%-94% of the patients were fast-track eligible after laparoscopic surgery, only 35%-53% of the patients actually bypassed the postanesthesia care unit (PACU) because of anesthetic-related factors and surgical complications. Residual sedation was the most common anesthetic-related cause of failure to bypass thePACU.

Fast-tracking after outpatient laparoscopy: reasons for failure after propofol, sevoflurane, and desflurane anesthesia.

https://www.jopan.org/article/S1089-9472(01)20782-5/pdf

Fast-tracking after ambulatory surgery

Objetivo: Estudar as alteracoes da ventilacao e volumes pulmonares e da forca muscular respiratoria no pos-operatorio de colecistectomia por via laparoscopica. Tipo de estudo: Estudo prospectivo. Material e metodos: Foram avaliados 20 pacientes provenientes da enfermaria de gastrocirurgia da Unifesp, com media de idade 42,7 anos, sendo 7 (35%) homens e 13 (65%) mulheres. No periodo pre-operatorio todos foram submetidos a um questionario clinico, exame fisico, radiografia de torax, espirometria. No pre e no pos-operatorio foram obtidas as medidas da forca muscular respiratoria (pressoes inspiratoria e expiratoria maximas), da ventilacao pulmonar (volume corrente e volume minuto), da capacidade vital, a oximetria de pulso e o indice diafragmatico (ID). Este indice e capaz de refletir o movimento toracoabdominal, determinado pelas mudancas nas dimensoes ântero-posteriores da caixa toracica (CT) e do abdome (AB) e foi calculado utilizando-se a seguinte formula: ID = D AB/D AB + D CT. Resultados: Observou-se que os pacientes evoluiram no primeiro dia de pos-operatorio com diminuicao media significante de 26% do volume corrente, de 645ml ± 220ml para 475ml ± 135ml; 20% do volume minuto, de 15,0L ± 4,5L para 11,9L ± 3,6L; 36% da capacidade vital, de 2,7L ± 0,6L para 1,74L ± 0,7L; 47% da pressao inspiratoria maxima, de -75 ± -22cm/H2O para -40 ± 17cm/H2O; 39% da pressao expiratoria maxima, de +90 ± 28cm/H2O para +55 ± 28cm/H2O e 36% do indice diafragmatico, de 0,60 ± 0,10 para 0,39 ± 0,14 (p < 0,05). O volume corrente, o volume minuto e a pressao expiratoria maxima retornaram aos seus valores basais no 3o dia de pos-operatorio; a capacidade vital, pressao inspiratoria maxima e o indice diafragmatico retornaram aos seus valores basais entre o 4o e o 6o dia de pos-operatorio. Dos vinte pacientes, somente um apresentou atelectasia como complicacao pulmonar, tendo evoluido bem com as medidas habituais de fisioterapia respiratoria. Conclusao: Concluimos que os pacientes submetidos a colecistectomia por via laparoscopica apresentam no 1o dia de pos-operatorio diminuicao significante dos volumes pulmonares e da forca muscular respiratoria. Porem, quando comparados com dados de literatura, o retorno aos valores pre-operatorios e mais rapido na cirurgia por via laparoscopica (3o e 4o dias de pos-operatorio) do que na cirurgia abdominal convencional.

Alterações funcionais respiratórias na colecistectomia por via laparoscópica

The EAES Clinical Practice Guidelines on the Pneumoperitoneum for Laparoscopic Surgery (2002)

BACKGROUND Respiratory function and pulmonary gas exchange are affected in laparoscopic procedures where a pneumoperitoneum is introduced using CO2. Previous studies have shown differing results concerning pulmonary gas exchange during laparoscopic procedures: Whereas in patients undergoing isoflurane anaesthesia decreases in PaO2 are demonstrated, this factor remains unchanged in patients undergoing propofol anaesthesia. In the present study, the effects of propofol on pulmonary gas exchange were compared with those of isoflurane in patients undergoing elective laparoscopic cholecystectomy in a prospective randomised manner. METHODS Twenty ASA patients with physical status I and II were divided randomly between isoflurane (IG) and propofol groups (PG). After induction of anaesthesia patients were moderately hyperventilated. Respirator settings remained unchanged during pneumoperitoneum (PP) until 10 min after deflation of the peritoneal cavity. Blood gas analyses were performed at 5 time points: 15 min after induction of anaesthesia (giving pre-PP values), immediately before carbon dioxide insufflation (0 min PP), after both 30 and 60 min of PP and 10 min post PP. Inspiration plateau pressure (Pplat), compliance of the respiratory system, and both ins- and expiratory gas concentrations were continuously recorded by an Ultima V monitor (Datex Corp., Helsinki, Finland). The difference between arterial and end-tidal CO2 partial pressure (P(a-et)CO2) was calculated so as to allow assessment of physiological dead space by the modified Bohr equation. RESULTS Pulmonary gas exchange differed significantly after 30 min of PP between the IG and the PG. At this time, PaO2 was 19.5 +/- 2.9 kPa (mean +/- SD) in the IG and 23.1 +/- 1.8 kPa in the PG (P < 0.01), whereas PaCO2 was 5.5 +/- 0.37 kPa in the IG and 4.9 +/- 0.27 kPa in the PG (P < 0.01). These discrepancies remained until after carbon dioxide desufflation. At 10 min post PP, PaO2 was 18.3 +/- 2.6 kPa in the isoflurane group and 21.9 +/- 2.2 kPa in the propofol group (P < 0.01), whereas PaCO2 was 5.4 +/- 0.46 kPa in the IG and 4.8 +/- 0.22 kPa in the PG (P < 0.01). During carbon dioxide insufflation the P(a-et)CO2 increased significantly in the IG from 0.47 +/- 0.13 kPa to 0.76 +/- 0.37 kPa (P < 0.05), while the values in the PG remained constant. CONCLUSION This study demonstrates that pulmonary gas exchange in patients with laparoscopic cholecystectomy is affected by the choice of anaesthetic procedure. During and after laparoscopic cholecystectomy using isoflurane as the anaesthetic, the PaCO2 is significantly higher and the PaO2 significantly lower than they are with propofol.

Effects of propofol vs isoflurane on respiratory gas exchange during laparoscopic cholecystectomy

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Effects of propofol vs isoflurane on respiratory gas exchange during laparoscopic cholecystectomy