Authors (including presenting author) :
Chan A(1),Chan PL(1),Wong KF(2)
Affiliation :
(1)Department of Anaesthesia and Operating Theatre, Tuen Mun Hospital
(2)Department of Surgery, Tuen Mun Hospital
Introduction :
Haemorrhoidectomy is usually performed under SA or GA, but PONV, motor weakness and POUR are common. PAB may be an alternative but was not widely performed in our locality. In mid-December 2020, we relocated our day surgery service from Pok Oi Hospital (POH) to Tin Shui Wai Hospital (TSH). During the period June to December 2020, only 2 patients in POH managed to be discharged without overnight hospital stay (6.1%). In terms of LOS, patients in POH stayed in the hospital for 2.4 days on average (SD 1.9). There were 2 unplanned admissions in POH (6.1%. In POH), which were due to PRB and POUR respectively, and were not related to same day discharge. We considered this to be unsatisfactory and used the opportunity to formulate a perioperative care bundle. This included performing the surgery under perianal block and a standardised post-operative analgesic regimen. We present the results of using this new care bundle over the period January to June 2021 and compare the data with the available data from POH in the form of an audit.
Objectives :
To assess the efficacy of the new perioperative care bundle in improving same day discharge rate, post-operative pain control, rate of post-operative urinary retention, nausea and vomiting by comparing it to previouis data from POH
Methodology :
Prior to the introduction of this care bundle, GA and SA were the main modes of anaesthesia, and analgesics were prescribed at surgeon's discretion. While for the new care bundle, it consisted of: 1) screening for day surgery eligibility in pre-operative anaesthetic clinic, 2) PAB as main anaesthesia, 3) standardised post-operative analgesics.
Anaesthesia was accomplished as the surgeon infiltrated the ischio-rectal fat in the peri-sphincteric space and the peri-anal skin by two jabs anterior and posterior to the anus (from Jinjil) with 40 mL of local anaesthetics containing 2% lignocaine with 1:200,000 adrenaline (up to 7mg/kg) and 0.5% levobupivacaine or 0.25% bupivacaine (up to 2mg/kg). Anaesthesia was supplemented with propofol, dexmedetomidine or fentanyl. Post-operatively, a standard set of regular and as-required oral analgesics, along with laxatives were prescribed. Follow-up was done by day ward nurse via phone on the first POWD.
Data were collected retrospectively for the period January to July 2021 and compared with previously unpublished data for POH for the period July to December 2020. Primary outcome included same day discharge rate. Secondary outcomes included post-operative pain score and proportion of patient in severe pain (i.e. Numeric Rating Scale or NRS >7) upon discharge from day ward and first post-operative working day (POWD), length of stay (LOS), POUR requiring intervention and unplanned admission rate within one week.
Data were analysed by SPSS 26 package. For comparison of NRS and LOS, student’s t test was used. For comparison of pain score in Verbal Descriptor Scale (VDS), proportion of patient in severe pain, same day discharge, unplanned admission and POUR, Chi-square or Fisher’s exact test were used. Patient demographics (age, sex, body mass index, ASA class) and peri-operative details (type of anaesthesia, post-operative oral analgesics, duration and type of operation) were controlled for by regression. P value smaller than 0.05 was considered statistically significant.
This audit was constructed in the format of SQUIRE guideline.
Result & Outcome :
It was found that the new care bundle significantly increased same day discharge rate and reduced POUR without a significant rise in unplanned admission rate. Therefore, we concluded that this care bundle is beneficial for ambulatory proctologic procedures.
