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Ambulatory gynaecological surgery: Risk and assessment

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Assessment of patients undergoing elective surgical procedures on an outpatient basis carries risks that range from mortality through non-lethal injuries to costs incurred for inappropriate testing. Ambulatory surgery accounts for over 60% of elective surgical procedures for most areas of the USA, Canada and Australia and a growing proportion of procedures in Europe and Asia. However, data to determine the true risk of these procedures are difficult to find due to standardized criteria for risk assessment and management. Nonetheless, this type of medical procedure, with appropriate preparation, is regarded as safe and standard. Assessment of patients undergoing these procedures must take into consideration the nature of the medical and surgical conditions. Diagnostic testing is only performed if the results might change the management of the patient. At present, the American Society of Anesthesiology (ASA) classification system and the ASA guidelines for pre-anesthesia evaluation serve as the most current examples of risk assessments and algorithms that can be used for appropriate management of patients undergoing elective surgical procedures.

Section snippets

Low intensity but not necessarily low risk

There is a common assumption that ambulatory procedures carry virtually no risk and therefore may be approached with less of a focus on safety or complications than is the case with inpatient procedures. Such a perspective is an invitation to disaster. Admittedly, the ability to determine the risks associated with ambulatory surgery is difficult. The purported low morbidity is compounded by the lack of prospective studies with sufficient numbers to determine the risk factors associated with

Philosophy: the value-added approach

Having established that ambulatory surgery is not, even in the most diligent circumstances, without risk, the issue of prospectively identifying and managing patients at risk assumes great importance. The pre-anaesthesia evaluation is that portion of the general process of pre-operative evaluation that is designed to address issues related to the peri-operative management of the surgical patient by anaesthetists. The term ‘pre-anaesthesia’ refers to those issues of unique concern to the

Risk classification

As the purpose of the pre-anaesthesia evaluation is to reduce adverse outcomes, a classification of risk is clearly the basis on which these considerations must be undertaken.

The first attempt to quantify risks associated with surgery was undertaken by Meyer Saklad4 in 1941 at the request of the American Society of Anesthesiology (ASA). This effort was the first by any medical specialty to stratify risk for its patients. Saklad's system analysed the basis of mortality secondary to anaesthesia

Patient and procedure selection

The nature of patient and procedure selection is a function of medical status, surgical procedure and, in the case of outpatient surgery, availability of appropriate postoperative assistance. Rapid changes in surgical technology, peri-operative care and postoperative management have narrowed the indications for postoperative admission of patients in previously higher risk categories. Decisions about appropriate patient management relate more to individual clinical, administrative and social

Time of the evaluation

It has been a common assumption that a pre-operative visit prior to the day of surgery confers some added measure of safety and comfort for patients. On the basis of this assumption, patients have routinely been asked to take the time and expense required to comply with such requirements while hospitals and anaesthetists have had to staff centres able to handle this demand.

However, the literature on the utility of pre-operative evaluation prior to the day of surgery is scant and, at best,

Personnel performing the evaluation

When not performed by anaesthetists or their associates, the assessment of patients with significant medical problems should be provided by the patient's primary care provider as the person most familiar with the patient's medical condition. The availability of facsimile transmission permits information to be sent to pre-operative evaluation centres in time for review. In order to prevent the occasional brief note on a prescription pad, a standard form for review should be provided that allows

Laboratory testing

Laboratory and other diagnostic tests associated with pre-operative evaluations represent one of the most costly issues associated with surgery. It is difficult to attach a precise cost to this activity. However, it is conservatively estimated that at least 10% of the over US$30 billion spent on laboratory testing each year is for pre-operative evaluation. The traditional system of the protocol ‘battery of tests’ evolved from a lack of clear definition of their role in pre-operative screening,

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