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Arora V, Tuttle K, Borisovskaya A. Postanesthesia Recovery Unit Optimization for Patients With Postictal Agitation Secondary to Electroconvulsive Therapy. J ECT 2023; 39:91-96. [PMID: 36215424 DOI: 10.1097/yct.0000000000000891] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/08/2023]
Abstract
OBJECTIVES The occurrence of postictal agitation (PIA) can rapidly alter and intensify the level of care that electroconvulsive therapy (ECT) patients require during their recovery in the postanesthesia care unit (PACU). This operational analysis was undertaken to determine the impact PIA has on phase 1 PACU resources. METHODS This operational analysis was undertaken at the Seattle Division of the US Department of Veterans Affairs Puget Sound Health Care System. From August 2019 to April 2020, we prospectively collected data on the recovery from ECT of 61 unique patients who underwent a total of 334 ECT sessions. Utilization of PACU resources was assessed by determining the PACU length of stay (LOS), onset of PIA, severity of PIA, and duration of agitation in encounters complicated by PIA. RESULTS Seventy-nine occurrences of PIA occurred during the 334 ECT encounters. The mean ± SD PACU LOS was longer in encounters complicated by the occurrence of PIA compared with those not complicated by PIA (72 ± 32 and 59 ± 18 minutes respectively; P -value <0.05). Postanesthesia care unit LOS and mean duration of agitation increased as severity of PIA increased. CONCLUSIONS The occurrence of PIA can rapidly alter and intensify the level of care that ECT patients may require. Postictal agitation has a significant impact on the phase 1 PACU LOS of patients undergoing ECT. Phase 1 PACU staffing models should factor in the acute and prolonged care needs of patients who develop PIA during the recovery from ECT.
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Affiliation(s)
- Vivek Arora
- From the VA Puget Sound Health Care System, Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA
| | - Kelsey Tuttle
- General Psychiatry Residency, School of Medicine, University of Utah, Salt Lake City, UT
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Kesarimangalam MHP, Hegde PM. Identification of Risk Factors Contributing to Prolonged Stay in the Post-anaesthesia Care Unit at a Tertiary Care Hospital in Abu Dhabi, United Arab Emirates. Cureus 2023; 15:e35741. [PMID: 36879586 PMCID: PMC9984308 DOI: 10.7759/cureus.35741] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/03/2023] [Indexed: 03/06/2023] Open
Abstract
INTRODUCTION Post-anesthesia care units (PACU) were developed to reduce postoperative morbidity and mortality and the ideal duration of postoperative stay has been proposed as two hours; however, the incidence and risk factors for prolonged stay are variable. The objective of this study was to assess the incidence of prolonged length of stay in the post-anesthesia care unit at Sheikh Khalifa Medical City (SKMC), Abu Dhabi, United Arab Emirates, and identify the risk factors contributing to it. METHODS AND MATERIALS This is a retrospective observational study of patients who stayed in the PACU for more than two hours. A total of 2387 patients, both male and female, who underwent surgical procedures between May 2022 to August 2022 at SKMC and were admitted to the PACU after surgery were included in the study and their data were analyzed. RESULTS Of the 2387 patients who underwent surgical procedures, 43 (1.8%) had prolonged stays in the PACU. Of these, 20 (47%) were adult cases and 23 (53%) were pediatric cases. The main reasons for the delay in discharge from PACU in our study were the non-availability of ward beds (25.5%), followed by pain management (18.6%). CONCLUSIONS We recommend improving the communication between different specialties, restructuring staffing, implementing changes in perioperative management, and changing operating room scheduling to prevent avoidable reasons contributing to a prolonged stay in the PACU.
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Magnitude and associated non-clinical factors of delayed discharge of patients from post-anesthesia care unit in a comprehensive specialized referral hospital in Ethiopia, 2022. Ann Med Surg (Lond) 2022; 82:104680. [PMID: 36268286 PMCID: PMC9577618 DOI: 10.1016/j.amsu.2022.104680] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Revised: 09/06/2022] [Accepted: 09/10/2022] [Indexed: 11/21/2022] Open
Abstract
Background Patients are kept in the post anesthesia care unit until their condition is stabilized before transfer to the clinical areas. Prolonged length of stay in the PACU leads to increased health care cost and patient dissatisfaction. Objective The aim of this study was to determine the magnitude and to identify the non-clinical factors that lead to delay discharge from the post anesthesia care unit. Method This prospective observational study was conducted from April 1, 2022 to June 5, 2022. Patients were considered ready for discharge after they had achieved a satisfactory discharge score. The data obtained were presented as descriptive statistic and were analyzed using SPSS version 20. Results A total of 307 patients admitted to in the post anesthesia care were included in this study with a response rate of 100%. Majority of patients, 188 (61.2%), had prolonged length of stay in the PACU because of non-clinical factors. The most common non-clinical factor for delayed discharge was unavailability of beds in the respective ward (n = 69, 22.5%) followed by lack of available hospital patient transport (n = 34, 11.1%). Conclusion and recommendations: The proportion of delayed discharge of patients from the post anesthesia care unit (PACU) was significant. Non-clinical related delays contributed for a considerable extension of a patient's time in PACU. Delay discharge for non-medical reasons put patients at unnecessary risk for hospital-acquired infections and prolonged hospital stay and increased health care costs. Thus, understanding and addressing the causes of delayed discharge from PACU is essential. The proportion of delayed discharge of patients from the post anesthesia care unit was significant. Non-clinical factors contributed for an extended stay in the post anesthesia care unit. Prolonged length of stay in the PACU may lead to increased health care cost and patient dissatisfaction. Understanding and addressing the causes of delayed discharge in PACU improves patient flow and reduces length of stay.
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Mihalj M, Corona A, Andereggen L, Urman RD, Luedi MM, Bello C. Managing bottlenecks in the perioperative setting: Optimizing patient care and reducing costs. Best Pract Res Clin Anaesthesiol 2022; 36:299-310. [DOI: 10.1016/j.bpa.2022.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Accepted: 05/27/2022] [Indexed: 10/18/2022]
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Deng J, Balouch M, Albrink M, Camporesi EM. Sugammadex Reduces PACU Recovery Time after Abdominal Surgery Compared with Neostigmine. South Med J 2021; 114:644-648. [PMID: 34599343 DOI: 10.14423/smj.0000000000001304] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE This study blindly evaluated sugammadex compared with neostigmine on length of stay in the postanesthesia care unit (PACU). METHODS Fifty patients undergoing elective laparoscopic cholecystectomy or abdominal wall hernia repair consented to receive either sugammadex (2 mg/kg) or neostigmine (0.07 mg/kg) for the reversal of rocuronium neuromuscular blockade. Reversal agents were administered during surgical closing, and the train of four was measured until a twitch ratio of T4:T1 ≥ 0.9 was obtained to signify a robust reversal. Postreversal outcomes also were measured during PACU stay. Aldrete scores, pain visual analog scale score, and nausea were measured during the PACU stay. RESULTS Patients receiving sugammadex experienced a shorter PACU stay at the time of discharge than patients receiving neostigmine, by an average of 12 minutes (P < 0.05). CONCLUSIONS Sugammadex patients had a significantly shorter PACU stay.
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Affiliation(s)
- Jin Deng
- From the Morsani College of Medicine, University of South Florida, Tampa, TEAMHealth Anesthesia, Tampa, Florida, and the Division of General Surgery, Tampa General Hospital, Tampa, Florida
| | - Maha Balouch
- From the Morsani College of Medicine, University of South Florida, Tampa, TEAMHealth Anesthesia, Tampa, Florida, and the Division of General Surgery, Tampa General Hospital, Tampa, Florida
| | - Michael Albrink
- From the Morsani College of Medicine, University of South Florida, Tampa, TEAMHealth Anesthesia, Tampa, Florida, and the Division of General Surgery, Tampa General Hospital, Tampa, Florida
| | - Enrico M Camporesi
- From the Morsani College of Medicine, University of South Florida, Tampa, TEAMHealth Anesthesia, Tampa, Florida, and the Division of General Surgery, Tampa General Hospital, Tampa, Florida
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Laporta ML, O'Brien EK, Stokken JK, Choby G, Sprung J, Weingarten TN. Anesthesia Management and Postanesthetic Recovery Following Endoscopic Sinus Surgery. Laryngoscope 2020; 131:E815-E820. [PMID: 32652629 DOI: 10.1002/lary.28862] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Revised: 05/19/2020] [Accepted: 05/21/2020] [Indexed: 11/09/2022]
Abstract
OBJECTIVES Delayed anesthesia recovery following endoscopic sinus surgery (ESS) can be an indicator of immediate complications and negatively impact healthcare efficiency. This study aims to examine clinical factors with a focus on improving clinical practice. METHODS Medical records of patients undergoing ESS under general anesthesia from 2014 to 2018 were reviewed. Based on the interquartile range of anesthesia recovery for the cohort, patients in the upper quartile were categorized as "prolonged" and the lowest three quartiles as "goal" recovery. Patient and surgical characteristics were investigated. RESULTS Analyzing 416 patients who underwent ESS, the median anesthesia recovery time was 48 [35-66] minutes. Prolonged recovery was associated with higher body mass index (odds ratio 1.50 [95% confidence interval 1.03-2.18] per 10 kg/m2 , P = .03) and surgical duration (1.37 [1.10-1.72] per hour, P < .01). Inversely, goal recovery was associated with preoperative acetaminophen (0.61 [0.38-0.98], P = .04) and intraoperative remifentanil (0.55 [0.32-0.93], P = .03). Patients with prolonged recovery had higher rates of severe pain (33 (31.7%) vs. 25 (8.0%), P < .01), respiratory depression (7 [6.7] vs. 2 [0.6], P < .01), oversedation (39 [37.5] vs. 39 [12.5], P < .01), and the need for rescue opioids (52 [50] vs. 71 [22.8], P < .01). In addition to reduced postanesthesia recovery time, patients who were administered preemptive acetaminophen had lower rates of severe pain (OR 0.55 [0.31-0.98], P = .04) and nausea and vomiting (0.39 [0.17-0.87], P = .02). CONCLUSION Our findings substantiate the use of acetaminophen and remifentanil in ESS, facilitating anesthesia recovery. Broadly consideration of preemptive acetaminophen could further increase postoperative comfort in ESS. LEVEL OF EVIDENCE 4 - Retrospective. Laryngoscope, 131:E815-E820, 2021.
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Affiliation(s)
- Mariana L Laporta
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Erin K O'Brien
- Department of Otolaryngology, Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Janalee K Stokken
- Department of Otolaryngology, Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Garret Choby
- Department of Otolaryngology, Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Juraj Sprung
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Toby N Weingarten
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, U.S.A
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Elsharydah A, Walters DR, Somasundaram A, Bryson TD, Minhajuddin A, Gabriel RA, Grewal GK. A preoperative predictive model for prolonged post-anaesthesia care unit stay after outpatient surgeries. J Perioper Pract 2020; 30:91-96. [PMID: 31135281 DOI: 10.1177/1750458919850377] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
STUDY OBJECTIVE To create a preoperative predictive model for prolonged post-anaesthesia care unit (PACU) stay for outpatient surgery and compare with an existing (University of California-San Diego, UCSD) model. DESIGN Retrospective observational study. SETTING Post-anaesthesia care unit. Patients: Outpatient surgical patients discharged on the same day in a large academic institution. Preoperative data were collected. The study period was three months in 2016. Measurements: Prolonged PACU stay defined as a length of stay longer than the third quartile. We utilized multivariate regression analyses and bootstrapping statistical techniques to create a predictive model for prolonged PACU stay. Main results: Four strong predictors for prolonged PACU stay: general anaesthesia, obstructive sleep apnoea, surgical specialty and scheduled case duration. Our model had an excellent discrimination performance and a good calibration. CONCLUSION We developed a predictive model for prolonged PACU stay in our institution. This model is different from the UCSD model probably secondary to local and regional differences in outpatient surgery practice. Therefore, individual practice study outcomes may not apply to other practices without careful consideration of these differences.
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Affiliation(s)
- Ahmad Elsharydah
- Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Daren R Walters
- Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Alwin Somasundaram
- Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Trenton D Bryson
- Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Abu Minhajuddin
- Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, TX, USA
- Department of Clinical Sciences, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Rodney A Gabriel
- Department of Anesthesiology, University of California, San Diego, San Diego, CA, USA
- Department of Biomedical Informatics, University of California, San Diego, San Diego, CA, USA
| | - Gaganpreet K Grewal
- Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, TX, USA
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Anesthesia recovery after ophthalmologic surgery at an ambulatory surgical center. J Cataract Refract Surg 2019; 45:823-829. [PMID: 31146933 DOI: 10.1016/j.jcrs.2019.01.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Revised: 01/09/2019] [Accepted: 01/10/2019] [Indexed: 12/17/2022]
Abstract
PURPOSE To examine anesthesia recovery duration after ophthalmologic procedures performed at an ambulatory surgical center (ASC) and provide information that could be used to increase postanesthesia recovery unit efficiency. SETTING Ambulatory surgical center at tertiary medical center, Rochester, Minnesota, USA. DESIGN Retrospective case series. METHODS Health records of adult patients having ophthalmologic procedures at an ASC from July 1, 2010, through September 30, 2016 were reviewed, and anesthesia recovery duration was calculated. Potential associations were assessed between clinical factors and prolonged recovery (upper 10th percentile of recovery duration by anesthesia type [general, intravenous sedation, or topical]). RESULTS Among 20 116 procedures, the median recovery was 36 minutes (interquartile range [IQR], 28 to 48); general anesthesia had the longest recovery (79 minutes; IQR, 52 to 104 minutes) (P < .001). Recovery was longest for orbitotomy and strabismus procedures and shortest for cataract procedures. Female sex, obstructive sleep apnea, greater disease burden, longer procedures, and intraoperative fentanyl administration were associated with prolonged recovery. Patients with prolonged recovery had more severe pain episodes (pain score ≥7 [scale 0 to 10]; 138 patients [6.9%] versus 140 [0.8%]; P < .001) and received opioid analgesics during recovery (278 patients [13.8%] versus 293 [1.6%]; P < .001). Prolonged recovery involved higher rates of emergency department visits and hospitalizations in the first 48 postoperative hours and higher 30-day mortality rates. CONCLUSIONS Anesthesia recovery after ophthalmologic procedures at an ASC was associated primarily with the procedure and anesthesia type. Prolonged recoveries were associated with intraoperative fentanyl use, severe postoperative pain, and postoperative opioid requirements.
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Kratt KM, Bothun ED, Kruthiventi SC, Portner ER, Sprung J, Weingarten TN. Postoperative Nausea and Vomiting and Phase I Post-anesthesia Recovery After Strabismus Operations. J Pediatr Ophthalmol Strabismus 2019; 56:151-156. [PMID: 31116861 DOI: 10.3928/01913913-20190208-03] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Accepted: 01/07/2019] [Indexed: 11/20/2022]
Abstract
PURPOSE To ascertain postoperative nausea and vomiting (PONV) rates in adult patients after strabismus operations and assess causes for prolonged post-anesthesia recovery. METHODS This was a retrospective observational study of consecutive adult patients who underwent strabismus operations at one institution from January 1, 2010, to May 31, 2017. The anesthetic records were abstracted and PONV rates were ascertained. On the basis of the cohort's 75th percentile of anesthesia recovery duration, patients were categorized into goal recovery (lower three quartiles) and prolonged recovery (upper quartile). Multivariable logistic regression analyses were performed to assess associations between clinical characteristics and prolonged recovery. RESULTS A total of 794 adult patients who underwent strabismus surgery were identified. PONV was present in 31 (3.9%) patients. The median (interquartile range) post-anesthesia recovery was 45 minutes (range: 33 to 63 minutes). Prolonged recovery was associated with long-term benzodiazepine use (odds ratio [OR]: 3.07; 95% CI [confidence interval]: 1.23 to 7.80; P = .02). Patients with prolonged recovery had higher rates of PONV (15 [7.2%] vs 16 [2.7%], P = .007), oversedation (107 [51.4%] vs 226 [38.6%], P = .001), and postoperative analgesic administration (138 [66.4%] vs 222 [37.9%], P < .001). Inverse associations were found between desflurane and oversedation (OR: 0.63; 95% CI: 0.45 to 0.86; P = .004) and between acetaminophen administration and postoperative analgesic administration (OR: 0.57; 95% CI: 0.38 to 0.86; P = .007). CONCLUSIONS Adult patients undergoing general anesthesia for strabismus surgery had a low PONV rate. However, the presence of PONV was associated with delayed recovery room discharge. Other factors associated with prolonged Phase I recovery were long-term benzodiazepine use and longer operations, which likely resulted in an increased need for anesthetic agents and therefore more intense postoperative sedation. [J Pediatr Ophthalmol Strabismus. 2019;56(3):151-156.].
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Reis P, Lopes AI, Leite D, Moreira J, Mendes L, Ferraz S, Amaral T, Abelha F. Predicting mortality in patients admitted to the intensive care unit after open vascular surgery. Surg Today 2019; 49:836-842. [DOI: 10.1007/s00595-019-01805-w] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Accepted: 03/23/2019] [Indexed: 01/22/2023]
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Factors associated with trauma patients' length of stay at Role 2 facilities in Afghanistan, October 2009 to September 2014. J Trauma Acute Care Surg 2018; 85:S140-S144. [DOI: 10.1097/ta.0000000000001843] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Reis PV, Sousa G, Lopes AM, Costa AV, Santos A, Abelha FJ. Severity of disease scoring systems and mortality after non-cardiac surgery. BRAZILIAN JOURNAL OF ANESTHESIOLOGY (ENGLISH EDITION) 2018. [PMID: 29628154 PMCID: PMC9391813 DOI: 10.1016/j.bjane.2017.11.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Background Mortality after surgery is frequent and severity of disease scoring systems are used for prediction. Our aim was to evaluate predictors for mortality after non-cardiac surgery. Methods Adult patients admitted at our surgical intensive care unit between January 2006 and July 2013 was included. Univariate analysis was carried using Mann–Whitney, Chi-square or Fisher's exact test. Logistic regression was performed to assess independent factors with calculation of odds ratio and 95% confidence interval (95% CI). Results 4398 patients were included. Mortality was 1.4% in surgical intensive care unit and 7.4% during hospital stay. Independent predictors of mortality in surgical intensive care unit were APACHE II (OR = 1.24); emergent surgery (OR = 4.10), serum sodium (OR = 1.06) and FiO2 at admission (OR = 14.31). Serum bicarbonate at admission (OR = 0.89) was considered a protective factor. Independent predictors of hospital mortality were age (OR = 1.02), APACHE II (OR = 1.09), emergency surgery (OR = 1.82), high-risk surgery (OR = 1.61), FiO2 at admission (OR = 1.02), postoperative acute renal failure (OR = 1.96), heart rate (OR = 1.01) and serum sodium (OR = 1.04). Dying patients had higher scores in severity of disease scoring systems and longer surgical intensive care unit stay. Conclusion Some factors influenced both surgical intensive care unit and hospital mortality.
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Affiliation(s)
- Pedro Videira Reis
- Hospital de São João, Serviço de Anestesiologia, Porto, Portugal; Universidade do Porto, Faculdade de Medicina, Porto, Portugal
| | - Gabriela Sousa
- Hospital de São João, Serviço de Anestesiologia, Porto, Portugal
| | | | - Ana Vera Costa
- Universidade do Porto, Faculdade de Medicina, Porto, Portugal
| | - Alice Santos
- Hospital de São João, Serviço de Anestesiologia, Porto, Portugal
| | - Fernando José Abelha
- Hospital de São João, Serviço de Anestesiologia, Porto, Portugal; Universidade do Porto, Faculdade de Medicina, Porto, Portugal.
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Reis PV, Sousa G, Lopes AM, Costa AV, Santos A, Abelha FJ. [Severity of disease scoring systems and mortality after non-cardiac surgery]. Rev Bras Anestesiol 2018; 68:244-253. [PMID: 29628154 DOI: 10.1016/j.bjan.2017.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2015] [Accepted: 11/22/2017] [Indexed: 10/17/2022] Open
Abstract
BACKGROUND Mortality after surgery is frequent and severity of disease scoring systems are used for prediction. Our aim was to evaluate predictors for mortality after non-cardiac surgery. METHODS Adult patients admitted at our surgical intensive care unit between January 2006 and July 2013 was included. Univariate analysis was carried using Mann-Whitney, Chi-square or Fisher's exact test. Logistic regression was performed to assess independent factors with calculation of odds ratio and 95% confidence interval (95% CI). RESULTS 4398 patients were included. Mortality was 1.4% in surgical intensive care unit and 7.4% during hospital stay. Independent predictors of mortality in surgical intensive care unit were APACHE II (OR=1.24); emergent surgery (OR=4.10), serum sodium (OR=1.06) and FiO2 at admission (OR=14.31). Serum bicarbonate at admission (OR=0.89) was considered a protective factor. Independent predictors of hospital mortality were age (OR=1.02), APACHE II (OR=1.09), emergency surgery (OR=1.82), high-risk surgery (OR=1.61), FiO2 at admission (OR=1.02), postoperative acute renal failure (OR=1.96), heart rate (OR=1.01) and serum sodium (OR=1.04). Dying patients had higher scores in severity of disease scoring systems and longer surgical intensive care unit stay. CONCLUSION Some factors influenced both surgical intensive care unit and hospital mortality.
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Affiliation(s)
- Pedro Videira Reis
- Hospital de São João, Serviço de Anestesiologia, Porto, Portugal; Universidade do Porto, Faculdade de Medicina, Porto, Portugal
| | - Gabriela Sousa
- Hospital de São João, Serviço de Anestesiologia, Porto, Portugal
| | | | - Ana Vera Costa
- Universidade do Porto, Faculdade de Medicina, Porto, Portugal
| | - Alice Santos
- Hospital de São João, Serviço de Anestesiologia, Porto, Portugal
| | - Fernando José Abelha
- Hospital de São João, Serviço de Anestesiologia, Porto, Portugal; Universidade do Porto, Faculdade de Medicina, Porto, Portugal.
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Decreasing Postanesthesia Care Unit to Floor Transfer Times to Facilitate Short Stay Total Joint Replacements. J Perianesth Nurs 2018; 33:109-115. [PMID: 29580590 DOI: 10.1016/j.jopan.2016.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2016] [Revised: 08/16/2016] [Accepted: 08/20/2016] [Indexed: 11/23/2022]
Abstract
PURPOSE We describe a process for studying and improving baseline postanesthesia care unit (PACU)-to-floor transfer times after total joint replacements. DESIGN Quality improvement project using lean methodology. METHODS Phase I of the investigational process involved collection of baseline data. Phase II involved developing targeted solutions to improve throughput. Phase III involved measured project sustainability. FINDINGS Phase I investigations revealed that patients spent an additional 62 minutes waiting in the PACU after being designated ready for transfer. Five to 16 telephone calls were needed between the PACU and the unit to facilitate each patient transfer. The most common reason for delay was unavailability of the unit nurse who was attending to another patient (58%). Phase II interventions resulted in transfer times decreasing to 13 minutes (79% reduction, P < .001). Phase III recorded sustained transfer times at 30 minutes, a net 52% reduction (P < .001) from baseline. CONCLUSIONS Lean methodology resulted in the immediate decrease of PACU-to-floor transfer times by 79%, with a 52% sustained improvement. Our methods can also be used to improve efficiencies of care at other institutions.
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Gabriel RA, Waterman RS, Kim J, Ohno-Machado L. A Predictive Model for Extended Postanesthesia Care Unit Length of Stay in Outpatient Surgeries. Anesth Analg 2017; 124:1529-1536. [DOI: 10.1213/ane.0000000000001827] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
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Siddiqui NT, Yousefzadeh A, Yousuf M, Kumar D, Choudhry FK, Friedman Z. The Effect of Gabapentin on Delayed Discharge from the Postanesthesia Care Unit: A Retrospective Analysis. Pain Pract 2017; 18:18-22. [PMID: 28371158 DOI: 10.1111/papr.12575] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2016] [Revised: 12/13/2016] [Accepted: 01/28/2017] [Indexed: 11/29/2022]
Abstract
BACKGROUND Enhanced recovery after surgery programs has incorporated gabapentin as part of a multimodal analgesia protocol. The preemptive use of gabapentin was found to be beneficial due to its opioid-sparing effect. However, excessive sedation and delayed discharge from postanesthesia recovery units are of concern. The aim of this study was to investigate whether preoperative gabapentin increased the length of stay in the recovery unit. METHODS This retrospective cross-sectional study was carried out over a period of 2 months in the postanesthesia care unit (PACU) of a tertiary care hospital in Canada. Two hundred and twenty-eight consecutive patients who underwent elective surgical procedures and who required a longer than 2-hour stay in the PACU were included. Prolonged stays caused by respiratory inadequacy, hemodynamic instability, nausea, vomiting, pain, and loss of consciousness were recorded. The data were collected from patients' charts and nursing flow sheets. RESULTS All patients were grouped into those who received 300 mg gabapentin (n = 108), 600 mg gabapentin (n = 41), and no gabapentin (n = 139). No significant difference was observed between the groups in terms of opioid consumption, respiratory inadequacy, nausea, vomiting, and hemodynamic parameters. Gabapentin administration groups had significantly lower postoperative pain scores (P < 0.001). Decreased level of consciousness occurred significantly more often in a dose-dependent fashion in the gabapentin groups and led to a longer stay in the PACU (P < 0.001). CONCLUSION In the setting of enhanced recovery after surgery, gabapentin did reduce pain scores, but at the cost of delayed discharge from the recovery room. Future studies are needed to evaluate the efficacy of gabapentin in this setting.
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Affiliation(s)
- Naveed T Siddiqui
- Department of Anesthesia and Pain Management, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Amir Yousefzadeh
- Department of Anesthesia and Pain Management, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Maaz Yousuf
- Department of Anesthesia and Pain Management, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Dileep Kumar
- Department of Anesthesia and Pain Management, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Farah K Choudhry
- Department of Anesthesia and Pain Management, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Zeev Friedman
- Department of Anesthesia and Pain Management, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
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Weingarten TN, Hawkins NM, Beam WB, Brandt HA, Koepp DJ, Kellogg TA, Sprung J. Factors associated with prolonged anesthesia recovery following laparoscopic bariatric surgery: a retrospective analysis. Obes Surg 2015; 25:1024-30. [PMID: 25392076 DOI: 10.1007/s11695-014-1468-7] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Phase I postanesthesia recovery is often prolonged after laparoscopic bariatric surgery. We hypothesized that postoperative respiratory depression is a major contributor to this delayed recovery. METHODS Medical records of all patients who had a laparoscopic bariatric surgical operation from January 1, 2009, to December 31, 2012, were reviewed for clinical, anesthetic, and postanesthesia variables. Recoveries were defined as discharge from the recovery room in ≤90 min and in >90 min (prolonged postanesthesia recovery). We compared characteristics of patients without prolonged recovery to those with prolonged recovery. RESULTS Of 781 bariatric patients, 304 (38.9 %) had prolonged recovery. These patients had more respiratory depression (29 vs 6 patients), more postoperative nausea and vomiting (106 vs 92 patients), more treatments of hypertension in the recovery room (49 vs 33 patients), and more opioid treatment (median intravenous morphine equivalents [interquartile range], 10.0 [3.0-15.0] vs 5.0 [0.0-10.5]) (P < 0.001 for all). On multivariable analysis, preoperative history of hypertension (P = 0.03), fewer prophylactic antiemetics received (P = 0.02), and longer surgical duration (P = 0.03) were associated with prolonged postanesthesia recovery. CONCLUSIONS Inadequate antiemetic prophylaxis and the treatment of postoperative hypertension were associated with prolonged postanesthesia recovery. Surprisingly, diagnosis of obstructive sleep apnea was not associated with prolonged recovery, which may be attributable to use of continuous positive airway pressure devices following emergence from anesthesia. Prolonged recovery in patients treated for hypertension may be related to institutional guidelines that require additional monitoring time after these medications are administered.
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Affiliation(s)
- Toby N Weingarten
- Department of Anesthesiology, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA,
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Effects of changes in intraoperative management on recovery from anesthesia: a review of practice improvement initiative. BMC Anesthesiol 2015; 15:54. [PMID: 25902828 PMCID: PMC4410739 DOI: 10.1186/s12871-015-0040-x] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2014] [Accepted: 04/17/2015] [Indexed: 12/03/2022] Open
Abstract
Background Our anesthetic practice was hindered by inadequate postanesthesia care unit space resulting in operating room inefficiencies. In response, an anesthetic protocol designed to reduce the duration of postanesthesia stay by decreasing residual anesthetic sedation and postoperative nausea and vomiting (PONV) was introduced. Here the impact of this practice change is analyzed. Methods The protocol encouraged desflurane use instead of isoflurane, triple antiemetic prophylaxis, and discouraged midazolam. Records of patients undergoing general anesthesia from calendar-matched epochs were reviewed. Epoch I included a 6-month period prior to implementation of the practice change (October 1, 2009, to March 31, 2010) and Epoch II included 6 months following the practice change (October 1, 2010, to March 31, 2011). Results General anesthesia was administered to 2,936 and 3,137 patients during Epochs I and II, respectively. Midazolam decreased from 57.4% to 24.0%, isoflurane from 50.8% to 5.7%, desflurane increased from 25.6% to 77.0%, and antiemetic prophylaxis from 6.5% to 50.8%. Median [IQR] recovery time decreased from 72 [50, 102] to 62 [44, 90] minutes, P <0.001. Supplemental analyses found antiemetic prophylaxis was associated with PONV reduction (OR = 0.47, 95% CI 0.38 –0.58, P < 0.001). When compared to isoflurane, desflurane was associated with a decreased rate of respiratory depression (OR = 0.72, 95% CI 0.55-0.93, P = 0.013). Patients administered midazolam trended towards higher rate of respiratory depression (OR = 1.27, 95% CI 1.00–1.60, P = 0.050). Conclusions Introduction of an anesthetic protocol that was designed to attenuate adverse anesthetic effects was associated with a reduction of anesthetic recovery time.
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Frictions as barriers to perioperative alignment: results from a latent class analysis. Qual Manag Health Care 2014; 23:188-200. [PMID: 24978168 DOI: 10.1097/qmh.0000000000000038] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The quality of the relationship between the sterile processing department (SPD) and the operating room (OR) is an important determinant of OR safety and performance. In this article, the concept of "friction" refers to the SPD behaviors and attributes that can negatively affect OR performance. Panels of SPD professionals initially were asked to identify and operationally define different ways in which behaviors of a hospital's SPD could compromise OR performance. A national convenience sample of OR nurses (N=291) rated 14 frictions in terms of their agreement or disagreement that each had a negative effect on OR performance in their hospital. Overall, more than 50% of the entire sample agreed that 2 frictions, "SPD does not communicate effectively with the OR" (55%) and "SPD inventories are insufficient for surgical volume" (52%), had negative effect on OR performance. However, a latent class analysis revealed 3 distinct classes of nurses who varied with respect to their level of agreement that SPD-OR frictions negatively affected OR performance. The observed heterogeneity in how different groups of nurses viewed different frictions suggests that effective efforts aimed at reducing performance-limiting frictions should be customized so that resources can be used where they are most needed.
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Lalani SB, Ali F, Kanji Z. Prolonged-Stay Patients in the PACU: A Review of the Literature. J Perianesth Nurs 2013; 28:151-5. [DOI: 10.1016/j.jopan.2012.06.009] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2011] [Revised: 03/30/2012] [Accepted: 06/19/2012] [Indexed: 10/26/2022]
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Abstract
BACKGROUND AND OBJECTIVE A Pre-operative Therapeutic Intensity Score (P-TIS) was developed to quantify intensity of pre-operative care. Its association with post-operative ICU admission was explored. METHODS P-TIS assigns 1-4 points to therapeutic interventions and diagnostic procedures based on care intensity. P-TIS was evaluated using elective (n = 716) and emergency (n = 289) surgery patients entering the post-anaesthesia care unit (PACU) or directly admitted to ICU. RESULTS P-TIS has chronic (interventions >48 h before surgery, e.g. chronic dialysis therapy: 3 points, oral antibiotics: 1 point) and acute (interventions within 48 h of surgery, e.g. intra-aortic balloon: 4 points, urinary catheter insertion: 1 point) components. Acute P-TIS provided quantitative information, not provided by other methods, about care intensity immediately before surgery. High acute P-TIS were observed in elective patients with high chronic P-TIS and ASA classifications (3 and 4) and emergency surgery and trauma. The higher acute P-TIS, the more likely emergency patients are to receive post-operative ICU rather than intermediate or routine floor care (odds ratio 1.18, P < 0.001). Adding surgical complexity improved acute P-TIS's ability to predict post-operative ICU care in elective patients. CONCLUSION P-TIS quantifies the intensity of chronic and acute pre-operative care. Acute P-TIS predicted receipt of post-operative ICU care, especially in emergency surgery.
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When is it time to go? The difficulty of intensive care unit discharge decisions at times of high census or admission demand*. Crit Care Med 2009; 37:2982-3. [DOI: 10.1097/ccm.0b013e3181b39edd] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Weissman C, Klein N. Who receives postoperative intensive and intermediate care? J Clin Anesth 2008; 20:263-70. [PMID: 18617123 DOI: 10.1016/j.jclinane.2007.11.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2006] [Revised: 11/02/2007] [Accepted: 11/19/2007] [Indexed: 11/29/2022]
Abstract
STUDY OBJECTIVES To examine the effects of preoperative and intraoperative factors that determine whether to provide postoperative intensive or intermediate care. DESIGN Prospective observational study. SETTING Tertiary-care university hospital. PATIENTS 3,066 ASA physical status I, II, III, and IV adult patients, 1,233 of whom were transferred to floor or the ambulatory surgery unit after a short postoperative recovery room stay (group 1), whereas the other 1,883 were admitted to intermediate and intensive care areas (group 2). INTERVENTIONS None. MEASUREMENTS Demographic and clinical information including preoperative medical history, extent of intraoperative care, and postoperative course were collected. Intraoperative activities were examined with the Operative Complexity Score and the Intraoperative Therapeutic Intensity Score. RESULTS Almost all patients undergoing complex surgery (cardiac surgery and neurosurgery) received postoperative intermediate or intensive care, even if they had no significant underlying systemic diseases (ASA physical status I and II). Patients with severe underlying diseases (ASA physical status III and IV), but who underwent less extensive surgery, tended to receive intensive and intermediate care. Postoperative mechanical ventilation was associated with receipt of intensive rather than intermediate care. Interestingly, 10% of the elective surgery patients in group 2 unexpectedly received intensive or intermediate care because of intraoperative and immediate postoperative complications. CONCLUSIONS Receipt of postoperative intermediate and intensive care is associated with distinct patterns of preoperative and intraoperative factors.
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Affiliation(s)
- Charles Weissman
- Department of Anesthesiology and Critical Care Medicine, Hadassah-Hebrew University Medical Center, Jerusalem 91120, Israel.
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Weissman C, Klein N. The importance of differentiating between elective and emergency postoperative critical care patients. J Crit Care 2008; 23:308-16. [PMID: 18725034 DOI: 10.1016/j.jcrc.2007.10.039] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2006] [Revised: 10/05/2007] [Accepted: 10/11/2007] [Indexed: 12/16/2022]
Abstract
PURPOSE The purpose of the study is to demonstrate the importance of separately analyzing data on elective and emergency surgery patients admitted postoperatively to intensive and intermediate care units. MATERIALS AND METHODS A prospective observational study was performed in a tertiary care university hospital to assess the demographic and clinical differences between emergency and elective surgical patients (>14 years old). Group 1 included patients transferred to a floor bed or the ambulatory surgery unit for discharge home after a short stay (<12 hours) in the postanesthesia care unit. Group 2 patients were admitted to the cardiothoracic intensive care unit (ICU), neurosurgical ICU, general ICU, or for an extended intermediate care postanesthesia care unit stay (>12 hours). RESULTS In groups 1 (n = 1059), there were significant differences between the elective and emergency patients. Emergency, as compared with elective group 2 (n= 1883) patients, experienced more severe preexisting illnesses (ie, had higher American Society of Anesthesiology classifications), underwent different and shorter operations, required prolonged postoperative mechanical ventilation, required longer ICU stays, and had higher mortality. CONCLUSIONS Substantial differences between elective and emergency surgery patients have important implications when conducting and reporting research on the nature, extent, and outcome of postoperative ICU care.
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Affiliation(s)
- Charles Weissman
- Department of Anesthesiology and Critical Care Medicine, Hadassah-Hebrew University Medical Center, Hebrew University-Hadassah School of Medicine, Jerusalem, Israel
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