Anaesthesia
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In 1994, 66% of all surgery in the USA was performed as ambulatory surgery. Day surgery is also expanding to other countries worldwide. To provide safe anaesthesia and good outcomes for longer and more extensive operations performed in ambulatory facilities, patients must be carefully evaluated before surgery, their home readiness must be assessed, and they must fully understand all relevant information. ⋯ If a patient does not have an escort home, the surgical procedure should be cancelled or the patient admitted to the hospital. As the number of patients and complexity of scheduled surgical procedures increases, the outcome of day surgery will increasingly depend on the anaesthetist's skills. The recently introduced short-acting drugs may further improve the outcome after day surgery by facilitating rapid recovery and an early return to normal daily activities.
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Several factors have to be considered in determining the cost of applying a new inhalational anaesthetic such as desflurane into clinical practice. Factors beyond the immediate control of the anaesthetic practitioner include the price set by the manufacturer (although this may be influenced by economic and political pressures), and the physical-pharmacological properties of the anaesthetic (e.g. vaporization, potency, solubility). The anaesthetic practitioner can minimise cost by applying lower inflow rates. ⋯ The use of lower inflow rates presupposes that such rates do not allow the production of toxic compounds in recirculating gases. Modern equipment makes low-flow anaesthesia reliable and easy to control, and as desflurane is not degraded by the standard carbon dioxide absorbents, its use in low-flow systems is effective and economical. These cost considerations do not take into account the savings that may result from a more rapid recovery from anaesthesia, nor do they take into account the increased expense of capital equipment needed to apply a new anaesthetic.
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Although many anaesthesia machines are equipped with circle rebreathing systems, inhalational anaesthesia remains frequently performed using relatively high fresh-gas flows. The major advantages of rebreathing techniques can be achieved only if the fresh-gas flow is reduced to 1 l.min-1 or less. Although there are potential risks associated with low-flow anaesthesia, modern anaesthesia machines meet all the technical requirements for the safe use of low-flow techniques if they are used in conjunction with equipment for monitoring inhaled and exhaled gas concentrations; these monitors are already increasingly available and, in the near future, are likely to become an obligatory safety standard in many countries. For both economic and ecological reasons, the use of new inhalational anaesthetics, with low tissue solubility and low anaesthetic potency, can be justified only if the efficiency of administration is optimised by using low-flow anaesthetic techniques.