Post-COVID-19 elective surgery and transformation: exploring the role of ambulatory spinals in the high-risk patient population

ABSTRACT

At Whipps Cross Hospital, multi-morbid (high-risk) patients undergoing urological surgery are routinely listed on the surgical inpatient pathway. The 'Getting it right first time' [1] review of anaesthesia recommended day-case surgery as the default for suitable procedures, to help with waiting lists as well as to provide patients with a safe environment. To improve patient choice and postoperative outcomes, an ambulatory spinal pathway was piloted. Methods An earlier scoping exercise identified a pool of urology high-risk patients who could potentially benefit from an ambulatory spinal pathway. Based on this, prilocaine use for ambulatory spinal anaesthetic was provisionally approved by the drugs and therapeutic committee. A pilot ambulatory pathway was put in place, which helped identify suitable patients. The pilot pathway was limited to a select group of anaesthetists to minimise variations. Postoperatively, patients were followed up at 3 and 24 h and assessed for postoperative nausea, vomiting, pain, mobilisation, neurological symptoms and cognitive impairment. Results The total number of patients was 19. Mean ASA was 2.9. Average age was 74 years. The mean dose of hyperbaric prilocaine 2% used was 2.9 ml, 21% of cases utilised additional intrathecal additives. Regarding intra-operative analgesia, only paracetamol was used in 15% of cases. There were no conversions to general anaesthetic. The most common procedure was a cystoscopy with or without biopsy (42%). With comorbidities, diabetes mellitus was the most common (58%), followed by cardiac disease (53%) and respiratory disease (42%). At 3 h, 100% of patients were eating and all sensation had returned, 0% had cognitive impairment, 47% were sitting out and 42% mobilising. Sixteen per cent had hypotension and 5% had pain at rest. At 24 h, 0% had cognitive impairment, 50% had required analgesia and 84% were mobilising. All patients reported they would have a spinal anaesthetic again in the future. Discussion With an ageing population, who have multiple comorbidities, there is huge benefit regarding providing the choice of a spinal anaesthetic rather than general anaesthetic, which allows patients to go home the same day. This will not only provide financial savings to the service provider but also help clear the backlog of surgeries due to the COVID-19 pandemic and enhance patient recovery.