Factors influencing unexpected disposition after orthopedic ambulatory surgery.

STUDY OBJECTIVE: To analyze whether patient characteristics, ambulatory facility type, anesthesia provider and technique, procedure type, and temporal factors impact the outcome of unexpected disposition after ambulatory knee and shoulder surgery. DESIGN: Retrospective analysis of a national database. SETTING: Freestanding and hospital-based ambulatory surgery facilities. MEASUREMENTS: Ambulatory knee and shoulder surgery cases from 1996 and 2006 were identified through the National Survey of Ambulatory Surgery. The incidence of unexpected disposition status was determined and risk factors for such outcome were analyzed. MAIN RESULTS: Factors independently increasing the risk for unexpected disposition included procedures performed in hospital-based versus freestanding facilities [odds ratio (OR) 6.83 (95% confidence interval [CI] 4.34; 10.75)], shoulder versus knee procedures [OR 3.84 (CI 2.55; 5.77)], anesthesia provided by nonanesthesiology professionals and certified registered nurse-anesthetists versus anesthesiologists [OR 7.33 (CI 4.18; 12.84) and OR 1.80 (CI 1.09; 2.99), respectively]. Decreased risk for unexpected disposition was for procedures performed in 2006 versus 1996 [OR 0.15 (CI 0.10; 0.24)] and the use of anesthesia other than regional or general [OR 0.34 (CI 0.18; 0.68)]. CONCLUSIONS: The decreased risk for unexpected disposition associated with more recent data and with freestanding versus hospital-based facilities may represent improvements in efficiency, while the decreased odds for such disposition status associated with the use of other than general or regional anesthesia may be related to a lower invasiveness of cases. We found an increased risk of adverse disposition in cases where the anesthesia provider was a nonanesthesiology professional. No difference in this outcome was noted when an anesthesia care team provided care.

Do race, gender, and source of payment impact on anesthetic technique for inguinal hernia repair?

STUDY OBJECTIVE: To evaluate the potential differences in the type of anesthesia provided to patients of different race, gender, and source of payment undergoing inguinal hernia repair (IHR). DESIGN: Retrospective cohort study. SETTING: Ambulatory surgical centers/National Survey of Ambulatory Surgery. PATIENTS: 5810 patients older than 14 years who underwent IHR in an ambulatory surgical center. INTERVENTIONS: Inguinal hernia repair under different types of anesthesia. MEASUREMENTS: The association of race, gender, and source of payment with different types of anesthesia for IHR as determined by multivariate regression analysis. RESULTS: Significant discrepancies in the use of various anesthetics between patients of different race, gender, and source of payment were found. Patients identified as black and those of other minority groups were significantly more likely to receive general anesthesia compared with those identified as white (odds ratio [OR] 2.76, confidence interval [CI] 1.96-3.88 and OR 1.66, CI 1.14-2.42, respectively). Those identified as black were less likely to receive epidural anesthesia compared with their white counterparts (OR 0.36, CI 0.14-0.95). Women were less likely than men to undergo IHR with epidural anesthesia (OR 0.5, 95% CI 0.3-0.85). CONCLUSION: Significant discrepancies in the use of various anesthetics for IHR between patients of different race, gender, and insurance status were found. Despite limitations inherent to secondary data analysis, the findings raise the possibility that nonmedical factors may influence anesthetic management.

A case series of low-dose fenoldopam in seventy cardiac surgical patients at increased risk of renal dysfunction.

OBJECTIVE: To evaluate the usefulness of low-dose fenoldopam mesylate in patients at risk of developing renal dysfunction after cardiac surgery requiring cardiopulmonary bypass. DESIGN: A prospective, single-center, observational study. SETTING: University teaching hospital. PARTICIPANTS: Seventy patients scheduled for elective cardiac surgery with one or more predefined risk factors for renal dysfunction. INTERVENTIONS: After induction of anesthesia, fenoldopam (0.03 microg/kg/min) was administered throughout surgery and into the postoperative period, until the patient was stable and weaned from all other vasoactive agents. Perioperatively, fenoldopam was also used as a second-line antihypertensive agent as required. MEASUREMENTS AND MAIN RESULTS: No patient developed renal failure that required dialysis, whereas 7.1% (5/70) developed non-dialysis-dependent renal dysfunction. Four out of these 5 patients had 2 or more risk factors (9.5%). Higher preoperative creatinine levels, a history of hypertension, myocardial infarction within 5 days of surgery, and a preoperative diagnosis of chronic renal insufficiency were all good predictors of postoperative non-dialysis-dependent renal dysfunction. Discharge serum creatinine levels were lower than preoperative levels (1.16 +/- 0.36 mg/dL v 1.26 +/- 0.34 mg/dL, p < 0.05). CONCLUSION: These findings suggest that renal function was preserved in patients at increased risk for renal dysfunction after cardiac surgery when low-dose fenoldopam was used in the perioperative period. However, a randomized, controlled trial is required to establish efficacy.