A Description of Intraoperative and Postanesthesia Complication Rates

Incidence and Outcome of Reintubation in the Postanesthesia Care Unit: A Single-Center, Retrospective, Observational Matched Cohort Study in China

PURPOSE

To investigate the incidence and outcome of reintubation after planned extubation (RAP) in the postanesthesia care unit (PACU) in China.

DESIGN

A single-center, retrospective, 1:2 matched cohort study following the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Statement.

METHODS

Among 121,965 patients in the PACU, 14 patients with RAP were included in this study from January 1, 2017 to December 31, 2019. PACU length of stay, postoperative length of stay in hospital, inpatient healthcare costs, and outcomes were compared between the RAP and the matched groups.

FINDINGS

The incidence of RAP was 0.0115%. After propensity score matching, there were no statistically significant differences in age, sex, body mass index (BMI), elective/nonelective procedure, surgical classification, American Society of Anesthesiologists physical status, the duration of anesthesia, or the duration of surgical procedure between the two groups. PACU length of stay, postoperative length of stay in hospital, and inpatient healthcare costs significantly differed between the RAP group and the matched group (P < .01 for all). The percentage of patients with longer PACU length of stay in the RAP group was significantly higher than that in the matched group (92.86% vs 7.14%), with an odds ratio of 29.87 (95% confidence interval = 14.00-2,040.54, P < .001).

CONCLUSIONS

Despite its low incidence, RAP in the PACU may be associated with life-threatening and severe complications with longer PACU length of stay, unexpected intensive care unit admission, longer hospitalization length, longer postoperative length of stay in hospital, and increased inpatient health costs. Appropriate timing of extubation and monitoring in the PACU can effectively prevent the occurrence of RAP and improve patient prognosis.

Evaluation of Complication Development in General Surgery Patients Admitted to the Post Anesthesia Care Unit

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Incidence and factors associated with post-anesthesia care unit complications in resource-limited settings: An observational study

Background and aims

Postoperative complications are frequent encounters in the patients admitted to postanesthesia care units (PACU). The main aim of this study was to assess the incidence of complications and associated factors among surgical patients admitted in limited-resource settings of the PACU.

Methods

This is an observational study of 396 surgical patients admitted to PACU. This study was conducted from February 1 to March 30, 2021, in Ethiopia. Study participants' demographics, anesthesia, and surgery-related parameters, PACU complications, and length of stay in PACU were documented. Multivariate and bivariate logistic regression analyses, the odds ratio (OR), and 95% confidence interval (CI) were calculated. p-value < 0.05 was considered as statistically significant.

Results

The incidence of complications among surgical patients admitted to PACU was 54.8%. Of these, respiratory-related complications and postoperative nausea/vomiting were the most common types of PACU complications. Being a female (adjusted odds ratio [AOR] = 2.928; 95% CI: 1.899-4.512) was significantly associated with an increased risk of developing PACU complications. Duration of anesthesia >4 h (AOR = 5.406; 95% CI: 2.418-12.088) revealed an increased risk of association with PACU complications. The occurrences of intraoperative complications (AOR = 2.238; 95% CI: 0.991-5.056) during surgery were also associated with PACU complications. Patients who develop PACU complications were strongly associated with length of PACU stay for >4 h (AOR = 2.177; 95% CI: 0.741-6.401).

Conclusion

The identified risk factors for complications in surgical patients admitted to PACU are female sex, longer duration of anesthesia, and intraoperative complications occurrences. Patients who developed complications had a long time of stay in PACU. Based on our findings, we recommend the PACU team needs to develop area-specific institutional guidelines and protocols to improve the patients' quality of care and outcomes in PACU.

Incidence and predictive factors associated with hemodynamic instability among adult surgical patients in the post-anesthesia care unit, 2021: A prospective follow up study

Background

Hemodynamic instability, which is an independent predictor of long-term patient morbidity and duration of stay in the hospital, is a risk for patients in the post-anesthesia care unit. Multiple factors contribute to the development of postoperative hemodynamic instability. Prevention and treatment of these factors may reduce patients' hemodynamic instability, and its associated morbidity and mortality.

Objective

The aim of this study was to determine the incidence and factors associated with hemodynamic instability among adult surgical patients in the post-anesthesia care unit.

Method

An institution-based prospective follow up study was conducted from April 20, 2021 to June 28, 2021. Four hundred and seventeen (417) adult surgical patients were involved in this study. Descriptive and analytic statistics were used to describe our results. Both the bivariable and multivariable logistic regression with crude odds ratio and adjusted odds ratio were used with a 95% confidence interval to evaluate the strength of association. In multivariable regression, a p-value < 0.05 was considered as statistically significant.

Result

The overall incidence of hemodynamic instability was 59.47% (CI: 0.55, 0.64). The incidence of tachycardia, bradycardia, hypotension, and hypertension were 27.34%, 21.82%, 13.67%, and 15.35% respectively. Preoperative use of beta-blockers, ASA class III, procedure longer than 4 h, intraoperative hemodynamic instability, and regional anesthesia were significantly associated with hemodynamic instability in the post-anesthesia care unit.

Conclusion and recommendation

The incidence of hemodynamic instability in the post anesthesia care unit was high. Preoperative use of beta-blockers, intraoperative hemodynamic instability, and prolonged duration of procedures were predictors of hemodynamic instability after operation. Early detection and management of these perioperative risk factors is necessary to reduce hemodynamic instability in the post-anesthesia care unit.

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HDI is a common complication after surgery and anaesthesia

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It results in severe morbidity and mortality

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HDI is associated with multiple predictive factors

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Early detection and intervention of HDI improves outcome after surgery

Use of Emergency Manuals to Treat Delayed Emergence After Robotic-Assisted Cholecystectomy

Delayed emergence is defined as failure to regain consciousness 30 to 60 minutes after general anesthesia. Although incidence is low and difficult to accurately estimate, there is a wide differential diagnosis to be considered. Emergency manuals (EMs) are visual cognitive aids that can be used in the operating room to help manage intraoperative complications. They provide immediate access to evidence-based guidelines to optimize management of intraoperative complications. They are being increasingly implemented in the clinical setting and have been shown to improve patient safety. A case of a patient with delayed emergence after undergoing robotic-assisted cholecystectomy is described here. The delayed emergence section of the Stanford Anesthesia Emergency Model was referenced immediately and guided management of the patient. Utilization of an EM resulted in rapid return to baseline mental status. EMs allow health care providers to respond to intraoperative scenarios efficiently and effectively and ultimately improve patient care.

Effectiveness of Preoperative Visitation on Postanesthesia Complications

PURPOSE

The purpose of this study was to evaluate the effect of preoperative visitation on postanesthesia complications after hernia surgery.

DESIGN

In this quasi-experimental study, 70 patients receiving elective hernia surgery were purposefully selected.

METHODS

In the evening preceding surgery, the surgical technologist visited the patient in the surgical ward. Data were collected by checklist of vital signs and postanesthesia complications.

FINDINGS

A greater increase is observed in the systolic blood pressure of the experimental group at the moment of entering the postanesthesia care unit. A significant difference was found between groups in the intensity of postanesthesia agitation in the postanesthesia care unit patients, with a higher incidence among the experimental group.

CONCLUSIONS

According to the findings, preoperative education programs for operating room staff and other behavioral and mental interventions to manage surgery and its consequences in elective surgical patients is recommended.

Preoperative Screening for Obstructive Sleep Apnea and Outcomes in PACU

PURPOSE

Practice guidelines from the perianesthesia community suggest that preoperative identification of patients with obstructive sleep apnea (OSA) and standardized longer observation in postanesthesia care unit (PACU) promotes safety after general anesthesia. The purpose of this study was to determine if longer monitoring of patients with OSA in the PACU improves patient outcomes after general anesthesia.

DESIGN

Evidence-based best practices literature review.

METHODS

PACU patient charts were retrospectively analyzed for the presence of OSA diagnosis and screening scores. Information was compared with the postoperative oxygen saturation in PACU and nursing respiratory assessment documentation.

FINDINGS

Most patients (96.5%) did not experience oxygen desaturation regardless of OSA diagnosis or STOP (snore, tired, observed, pressure) score. There was no evidence extracted from this sample that suggested patients with OSA experienced a higher incidence of respiratory symptoms while in the PACU.

CONCLUSIONS

This study did not affirm that patients with OSA experienced a higher incidence of oxygen desaturation or respiratory symptoms despite receiving additional monitoring in PACU.

Use of low-dose neostigmine intravenously in the treatment of thyroid storm-induced severe tachycardia in patient during huge pelvic mass resection: A case report and review of literature

RATIONALE

Thyroid storm is a rare and life-threatening metabolic crisis because of an emergent release of excess thyroid hormone. Sinus tachycardia induced by excess thyroid hormone may result in congestive heart failure due to decreased diastolic filling time.

PATIENT CONCERNS

A controlled hyperthyroidism patient with severe sinus tachycardia.

DIAGNOSES

A controlled hyperthyroidism patient was induced thyroid storm during huge pelvic mass resection.

INTERVENTIONS

Application of low-dose neostigmine and β-antagonist esmolol to control the heart rate (HR) avoided hemodynamic collapse.

OUTCOMES

The patient improved dramatically following application of low-dose neostigmine instead of esmolol to control the HR avoided hemodynamic collapse.

LESSONS

Our case suggests that neostigmine, an acetylcholinesterase inhibitor, may warrant further investigation in patients with thyroid storm-induced severe sinus tachycardia.

Delayed Emergence From Anesthesia: A Simulation Case for Anesthesia Learners

INTRODUCTION

Delayed emergence is failure to regain consciousness following general anesthesia. It commonly involves altered mental status and respiratory compromise leading to increased morbidity, operating room delays, and increased cost. Causes include residual anesthetics, pharmacologic actions, surgical complications, neurologic events, endocrine disturbances, and patient-related factors. Pseudocholinesterase deficiency is an important consideration in delayed emergence. These patients are unable to effectively metabolize the muscle relaxants succinylcholine and mivacurium, leading to prolonged paralysis following administration.

METHODS

This simulation exercise is designed for medical students, student nurse anesthetists, and resident physicians. It is a 1-hour small-group learning activity centered upon a single patient encounter. We employ this exercise using an anesthesiology resident physician to proctor, a simulation technician to program and run, and a faculty anesthesiologist to mentor each session. It is intended to reinforce required reading assignments and improve the approach to delayed emergence from anesthesia. The debriefing includes discussion of risk-reduction strategies for incorporation in clinical practice. This exercise is easily reproduced using modern simulation mannequins without specialized programming.

RESULTS

Learners provided evaluations of their experience participating in the exercise, and resident physicians evaluated their experience proctoring the sessions. Responses were positive, and constructive criticism led to modifications to the exercise after development.

DISCUSSION

We use this exercise as an educational opportunity for medical students rotating clinically in our department. Medical students are paired with resident physicians for scenario development and work with faculty to produce valuable educational activities that benefit the entire department.

The impact of capnography monitoring among children and adolescents in the postanesthesia care unit: a randomized controlled trial

BACKGROUND

Pulse oximetry does not reliably recognize respiratory depression, particularly in the presence of supplemental oxygen. Capnography frequently detects hypoventilation and apnea among children recovering from anesthesia. Although children are routinely monitored with capnography during anesthesia, reducing the rate of adverse events, it is not routinely used in the postanesthesia care unit (PACU), where patients remain at risk for respiratory depression.

AIM

We hypothesized that children monitored with capnography would have more frequent staff interventions and fewer adverse events than children monitored with pulse oximetry alone.

METHODS

Otherwise healthy children of age 1-20 years undergoing general anesthesia for elective surgery were eligible for enrollment upon entering the pediatric PACU. Subjects were randomized as to whether PACU staff could view the capnography monitor (intervention group) or not (control group). All children received standard monitoring with pulse oximetry. Vital signs and patient interventions were recorded every 30 s by a portable monitor or a research associate.

RESULTS

Data from 201 children were analyzed. The rates of hypopneic hypoventilation [5% (95% CI: 2-8%) per minute vs 1% (95% CI: -1% to 3%) per minute, difference 4% (95% CI: 0.2-8%) per minute; P = 0.04] and apnea [11% (95% CI: 8-14%) per minute vs 1.5% (95% CI: -2% to 5%) per minute, difference 9% (5-14%) per minute; P < 0.001] decreased significantly faster in our intervention group as compared to the control group. The rates of bradypnea decreased faster in our control group [5% (95% CI: 2-8%) per minute vs 1% (95% CI: 0-4%) per minute, difference 4% per minute, 95% CI: 0-9%; P = 0.05]. Rates of respiratory events over time between groups were affected by the presence or absence of interventions. There were no differences in rates of hypoxemia between groups over time.

CONCLUSIONS

Children monitored with capnography have different rates of adverse respiratory events over time than children monitored solely with pulse oximetry. The addition of capnography improved the efficacy of staff interventions, however did not impact rates of oxygen desaturation.

Respiratory depression detected by capnography among children in the postanesthesia care unit: a cross-sectional study

BACKGROUND

Children are at risk for respiratory depression while recovering from anesthesia. Currently, monitoring children in the postanesthesia care unit (PACU) with pulse oximetry is recommended. However, pulse oximetry does not reliably recognize hypoventilation or apnea, particularly in the presence of supplemental oxygen. Capnography is a sensitive monitor of ventilation that is not often used in the PACU.

AIM

To determine the frequency of hypoventilation and apnea as detected by capnography among children in the PACU.

METHODS

In a cross-sectional study, capnography monitoring was applied to healthy children of age 1-17 years in the PACU of a tertiary care hospital. Staff was blinded to the capnography monitor; alarms were disabled. Staff provided routine care and monitoring with pulse oximetry to all patients. Vital signs, patient interventions, and medication administration were recorded by a research assistant every 30 s until all monitoring was discontinued by staff. Outcome measures included frequency of hypoventilation and apnea as measured by capnography and oxygen desaturations as measured by pulse oximetry, as well as staff interventions for these events.

RESULTS

Data from 194 children were analyzed. Capnography detected hypoventilation or apnea in 45.5% (95% CI 38.5%, 52.5%) of patients. Oxygen desaturations occurred in 19% (95% CI 13%, 24%) of patients. Interventions occurred in 9% (95% CI 5%, 13%) of patients. Patients who received narcotic medications were more likely to experience hypoventilation (OR 2.3, 95% CI 1.02, 5.3) and apnea (OR 2.7, 95% CI 1.1, 7). Hypoventilation was seen more often among children who received supplemental oxygen (OR 3.1, 95% CI 1.1, 12).

CONCLUSIONS

Hypoventilation and apnea are common among children in the PACU; however, few interventions occur to address these events. Routine monitoring with capnography may improve recognition of respiratory depression and enhance patient safety in the PACU.

[Anesthetic complications in a rehabilitation hospital: is the incidence related to the pre-anesthetic visit?]

INTRODUCTION

Approximately 234 million surgeries are done annually worldwide. There is a growing concern for the safety of the anesthetic act, and the pre-anesthetic consultation emerges as an important and widely recommended activity, used as a preventive measure for the emergence of a complication.

OBJECTIVES

To describe the complications related to anesthesia, to identify the factors that contribute to its appearance and to reflect on ways to improve clinical practice.

METHODS

700 patients, 175 cases and 525 controls, were evaluated over a period of 21 months. The data obtained through the pre-anesthetic consultation were evaluated descriptively and then tested with conditional univariate and multivariate logistic regression analysis.

RESULTS

175 cases of anesthesia-related complications (2.74%) out of 6365 anesthetic acts were evaluated. Hypotension was the most common complication (40 patients, 22.8%), followed by vomiting (24 patients, 13.7%) and arrhythmia (24 patients, 13.7%). Among the complications, 55% were due to patient conditions, 26% accidental, 10% predictable and 9% iatrogenic. The complications were classified as mild in 106 (61%), moderate in 63 (36%) and severe in six (3%) patients.

CONCLUSION

Patients with more impaired physical status (American Society of Anaesthesiology 3 and 4), with airway disease, tumor or parenchymal disease, diabetes or disorder of lipid metabolism, thyroid disease, former smokers and very prolonged anesthetic acts present a higher risk of anesthesia-related complications. Therefore, they should be actively investigated in the pre-anesthetic evaluation consultation.

Survey and management of anaesthesia related complications in PACU

It is the first prospective study about anaesthesia related postoperative complications conducted in Hamad General Hospital. Total 1128 adult patients admitted to the Post Anaesthesia Care Unit (PACU) during a period of three months were surveyed for anaesthesia related complications. Documented complications were found in 48 patients i.e. 4.25% of patients' population. The types of complications were related to the respiratory system, cardiovascular system, nausea/vomiting and body temperature in this descending order. Most of the complications happened to healthy ASA I and II patients. Factors that play major role in determining the immediate postoperative complications were the ASA status, the level of anaesthesia seniority attending the patient, the urgency and the nature of procedure. We tried to find other factors that may influence complications in addition, discussed below.

The occurrence of intra-operative hypotension varies between hospitals: observational analysis of more than 147,000 anaesthesia

BACKGROUND

Hypotension, a common intra-operative incident, bears an important potential for morbidity. It is most often manageable and sometimes preventable, which renders its study important. Therefore, we aimed at examining hospital variations in the occurrence of intra-operative hypotension and its predictors. As secondary endpoints, we determined to what extent hypotension relates to the risk of post-operative incidents and death.

METHODS

We used the Anaesthesia Databank Switzerland, built on routinely and prospectively collected data on all anaesthesias in 21 hospitals. The three outcomes were assessed using multi-level logistic regression models.

RESULTS

Among 147,573 anaesthesias, hypotension ranged from 0.6% to 5.2% in participating hospitals, and from 0.3% up to 12% in different surgical specialties. Most (73.4%) were minor single events. Age, ASA status, combined general and regional anaesthesia techniques, duration of surgery and hospitalization were significantly associated with hypotension. Although significantly associated, the emergency status of the surgery had a weaker effect. Hospitals' odds ratios for hypotension varied between 0.12 and 2.50 (P < or = 0.001), even after adjusting for patient and anaesthesia factors, and for type of surgery. At least one post-operative incident occurred in 9.7% of the procedures, including 0.03% deaths. Intra-operative hypotension was associated with a higher risk of post-operative incidents and death.

CONCLUSION

Wide variations remain in the occurrence of hypotension among hospitals after adjustment for risk factors. Although differential reporting from hospitals may exist, variations in anaesthesia techniques and blood pressure maintenance may also have contributed. Intra-operative hypotension is associated with morbidities and sometimes death, and constant vigilance must thus be advocated.

Response of hypotensive dogs to dopamine hydrochloride and dobutamine hydrochloride during deep isoflurane anesthesia

OBJECTIVE

To evaluate the dose-related cardiovascular and urine output (UrO) effects of dopamine hydrochloride and dobutamine hydrochloride, administered individually and in combination at various ratios, and identify individual doses that achieve target mean arterial blood pressure (MAP; 70 mm Hg) and cardiac index (CI; 150 mL/kg/min) in dogs during deep isoflurane anesthesia.

ANIMALS

10 young clinically normal dogs.

PROCEDURES

Following isoflurane equilibration at a baseline MAP of 50 mm Hg on 3 occasions, dogs randomly received IV administration of dopamine (3, 7, 10, 15, and 20 microg/kg/min), dobutamine (1, 2, 4, 6, and 8 microg/kg/min), and dopamine-dobutamine combinations (3.5:1, 3.5:4, 7:2, 14:1, and 14:4 microg/kg/min) in a crossover study. Selected cardiovascular and UrO effects were determined following 20-minute infusions at each dose.

RESULTS

Dopamine caused significant dose-dependent responses and achieved target MAP and CI at 7 microg/kg/min; dobutamine at 2 microg/kg/min significantly affected only CI values. At any dose, dopamine significantly affected UrO, whereas dobutamine did not. Target MAP and CI values were achieved with a dopamine-dobutamine combination at 7:2 microg/kg/min; a dopamine-related dose response for MAP and dopamine- and dobutamine-related dose responses for CI were identified. Changes in UrO were associated with dopamine only.

CONCLUSIONS AND CLINICAL RELEVANCE

In isoflurane-anesthetized dogs, a guideline dose for dopamine of 7 microg/kg/min is suggested; dobutamine alone did not improve MAP. Data regarding cardiovascular and UrO effects indicated that the combination of dopamine and dobutamine did not provide greater benefit than use of dopamine alone in dogs.