Enhanced Recovery Programs in an Ambulatory Surgical Oncology Center.

Background: We describe the implementation of enhanced recovery after surgery (ERAS) programs designed to minimize postoperative nausea and vomiting (PONV) and pain and reduce opioid use in patients undergoing selected procedures at an ambulatory cancer surgery center. Key components of the ERAS included preoperative patient education regarding the postoperative course, liberal preoperative hydration, standardized PONV prophylaxis, appropriate intraoperative fluid management, and multimodal analgesia at all stages.

Methods: We retrospectively reviewed data on patients who underwent mastectomy with or without immediate reconstruction, minimally invasive hysterectomy, thyroidectomy, or minimally invasive prostatectomy from the opening of our institution on January 2016 to December 2018.

Association Between Local Anesthetic Dosing, Postoperative Opioid Requirement, and Pain Scores After Lumpectomy and Sentinel Lymph Node Biopsy with Multimodal Analgesia.

Background: Multimodal analgesia (MMA) during breast surgery reduces postoperative pain and opioid requirements, but the relative contribution of local anesthetic dosing as a component of MMA is not well defined among patients undergoing lumpectomy and sentinel lymph node biopsy (SLNB).

Patients And Methods: We identified consecutive patients who underwent lumpectomy and SLNB with MMA from 1/2019 to 4/2020. Univariable and multivariable linear and logistic regression were used to examine associations between local anesthetics, opioid requirements in the post-anesthesia care unit (PACU), and pain scores in the PACU and on postoperative day (POD) 1.

Association Between Electronic Patient Symptom Reporting With Alerts and Potentially Avoidable Urgent Care Visits After Ambulatory Cancer Surgery.

Importance: Increasingly complex surgical procedures are being performed in the outpatient setting, increasing the burden on patients and caregivers to manage their postoperative symptoms. Electronic patient-reported symptom tracking may reduce this burden and help patients distinguish between expected symptoms and those requiring intervention.

Objective: To determine whether electronic symptom reporting with clinical alerts for 10 days after ambulatory cancer surgery is associated with a reduction in potentially avoidable urgent care visits, defined as a visit not leading to admission.

Intraoperative Ketorolac is Associated with Risk of Reoperation After Mastectomy: A Single-Center Examination.

Background: Although ketorolac is an effective adjunct for managing pain in the perioperative period, it is associated with a risk of postoperative bleeding. This study retrospectively investigated the association between ketorolac use and both reoperation and postoperative opioid use among mastectomy patients.

Methods: The study identified all women undergoing mastectomy (unilaterally or bilaterally) at our ambulatory surgery cancer center from January 2016 to June 2019.

Routine Opioid Prescriptions Are Not Necessary After Breast Excisional Biopsy or Lumpectomy Procedures.

Background: Opioid analgesics are overprescribed after surgery. In August 2018, the authors replaced routine discharge opioid prescription with a nonsteroidal anti-inflammatory drug (NSAID) for patients who had a lumpectomy or excisional biopsy (lump/ex). This study compared patient-reported post-discharge pain scores for patients treated before and after the change in routine discharge medication.

Standardizing Opioid Prescriptions to Patients After Ambulatory Oncologic Surgery Reduces Overprescription.

Background: Overprescribing of opioids after surgery contributes to long-term abuse. Evaluating opioid prescription patterns and patient-reported opioid use offers an evidence-based method to identify potential overprescription. This quality improvement initiative aimed to reduce and standardize opioid prescriptions upon discharge from an ambulatory oncologic surgery center and evaluate the effect of this change on patients' subsequent opioid use and reported pain.

Complex Cancer Surgery in the Outpatient Setting: The Josie Robertson Surgery Center.

Minimally invasive operative techniques and enhanced recovery after surgery (ERAS) protocols have transformed clinical practice and made it possible to perform increasingly complex oncologic procedures in the ambulatory setting, with recovery at home after a single overnight stay. Capitalizing on these changes, Memorial Sloan Kettering Cancer Center's Josie Robertson Surgery Center (JRSC), a freestanding ambulatory surgery facility, was established to provide both outpatient procedures and several surgeries that had previously been performed in the inpatient setting, newly transitioned to this ambulatory extended recovery (AXR) model. However, the JRSC core mission goes beyond rapid recovery, aiming to be an innovation center with a focus on superlative patient experience and engagement, efficiency, and data-driven continuous improvement.

Impact of intraoperative remifentanil on postoperative pain and opioid use in thyroid surgery.

Background And Objectives: Remifentanil infusion is used as an intraoperative anesthetic for thyroidectomy, but has been associated with acute opioid tolerance and hyperalgesia. A national shortage of remifentanil provided an opportunity to study postoperative pain in patients undergoing thyroidectomy.

Methods: Retrospective review of prospectively collected data from an outpatient surgery center.

Effects of Midazolam on Postoperative Nausea and Vomiting and Discharge Times in Outpatients Undergoing Cancer-Related Surgery.

Midazolam, a short-acting benzodiazepine used for preoperative anxiolysis, may also have pharmacologic properties that could further reduce the incidence of postoperative nausea and vomiting (PONV) in high-risk patients when included in a multimodal antiemetic protocol. However, concerns remain that the sedating properties of midazolam will delay discharge after short outpatient procedures. A retrospective data analysis (N = 4,057) investigated effects of midazolam on postoperative antiemetic administration and length of stay following cancer-related outpatient procedures over 15 months.

Suitability of outpatient or ambulatory extended recovery cancer surgeries for obese patients.

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.

Enhanced Recovery Programs in Outpatient Surgery.

Although enhanced recovery pathways were initially implemented in inpatients, their principles are relevant in the ambulatory setting. Opioid minimization and addressing pain and nausea through multimodal analgesia, regional anesthesia, and robust preoperative education programs are integral to the success of ambulatory enhanced recovery programs. Rather than measurements of length of stay as in traditional inpatient programs, the focus of enhanced recovery programs in ambulatory surgery should be on improved quality of recovery, pain management, and early ambulation.

Outcomes and Safety Among Patients With Obstructive Sleep Apnea Undergoing Cancer Surgery Procedures in a Freestanding Ambulatory Surgical Facility.

Background: Patients with obstructive sleep apnea (OSA) may be at increased risk for serious perioperative complications. The suitability of ambulatory surgery for patients with OSA remains controversial, and several national guidelines call for more evidence that assesses clinically significant outcomes. In this study, we investigate the association between OSA status (STOP-BANG risk, or previously diagnosed) and short-term outcomes and safety for patients undergoing cancer surgery at a freestanding ambulatory surgery facility.

Assessing Rapidity of Recovery After Cancer Surgeries in a Single Overnight Short-Stay Setting.

Background: In the short-stay surgery setting, where patients remain in hospital for a single overnight at most, it is unclear as to whether postoperative length of stay is a good surrogate for assessing rapidity of recovery. We hypothesized that length of stay would be a function of time of surgery and would be a poorer marker of recovery than time of discharge.

Methods: A cohort of 891 mastectomy and 538 prostatectomy patients had a planned single overnight stay after surgery at an ambulatory surgical hospital during 2016.

Evaluating Patient-Centered Outcomes in Clinical Trials of Procedural Sedation, Part 2 Safety: Sedation Consortium on Endpoints and Procedures for Treatment, Education, and Research Recommendations.

The Sedation Consortium on Endpoints and Procedures for Treatment, Education, and Research, established by the Analgesic, Anesthetic, and Addiction Clinical Trial Translations, Innovations, Opportunities, and Networks, a public-private partnership with the US Food and Drug Administration, convened a second meeting of sedation experts from a variety of clinical specialties and research backgrounds to develop recommendations for procedural sedation research. The previous meeting addressed efficacy and patient- and/or family-centered outcomes. This meeting addressed issues of safety, which was defined as "the avoidance of physical or psychological harm.

Evaluating Patient-Centered Outcomes in Clinical Trials of Procedural Sedation, Part 1 Efficacy: Sedation Consortium on Endpoints and Procedures for Treatment, Education, and Research Recommendations.

The Sedation Consortium on Endpoints and Procedures for Treatment, Education, and Research, established by the Analgesic, Anesthetic, and Addiction Clinical Trial Translations, Innovations, Opportunities, and Networks public-private partnership with the US Food and Drug Administration, convened a meeting of sedation experts from a variety of clinical specialties and research backgrounds with the objective of developing recommendations for procedural sedation research. Four core outcome domains were recommended for consideration in sedation clinical trials: (1) safety, (2) efficacy, (3) patient-centered and/or family-centered outcomes, and (4) efficiency. This meeting identified core outcome measures within the efficacy and patient-centered and/or family-centered domains.

Office-based anesthesia: safety and outcomes.

The increasing volume of office-based medical and surgical procedures has fostered the emergence of office-based anesthesia (OBA), a subspecialty within ambulatory anesthesia. The growth of OBA has been facilitated by numerous trends, including innovations in medical and surgical procedures and anesthetic drugs, as well as improved provider reimbursement and greater convenience for patients. There is a lack of randomized controlled trials to determine how office-based procedures and anesthesia affect patient morbidity and mortality.

The risk of hypertension after preoperative discontinuation of angiotensin-converting enzyme inhibitors or angiotensin receptor antagonists in ambulatory and same-day admission patients.

Background: The continued use of angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin II subtype I receptor antagonists (ARBs) medications in the preoperative period has been reported to be associated with intraoperative hypotension that can be unresponsive to pressor drugs. As a result, several investigators suggested discontinuation of these medications before scheduled surgery but did not report on unintended consequences that might result from discontinuation. We conducted a prospective, single-blind, randomized trial to observe the effect of the medications on preoperative arterial blood pressure recordings in patients presenting for ambulatory and same-day surgery.

Anesthesia induction using video glasses as a distraction tool for the management of preoperative anxiety in children.

Background: Distraction technology suitable for the perioperative setting is readily available, but there is little evidence to show how it compares with oral midazolam in managing anxiety. Video glasses, which enable children to view and listen to cartoons and movies, may be used through the completion of inhaled induction. We compared the efficacy of oral midazolam and behavioral distraction with video glasses in managing preoperative anxiety in children.

Society for Ambulatory Anesthesia consensus statement on perioperative blood glucose management in diabetic patients undergoing ambulatory surgery.

Optimal evidence-based perioperative blood glucose control in patients undergoing ambulatory surgical procedures remains controversial. Therefore, the Society for Ambulatory Anesthesia has developed a consensus statement on perioperative glycemic management in patients undergoing ambulatory surgery. A systematic review of the literature was conducted according the protocol recommended by the Cochrane Collaboration.