Planning for operating room efficiency and faster anesthesia wake-up time in open major upper abdominal surgery

Narrative Review of Prolonged Times to Tracheal Extubation After General Anesthesia With Intubation and Extubation in the Operating Room

This narrative review summarizes research about prolonged times to tracheal extubation after general anesthesia with both intubation and extubation occurring in the operating room or other anesthetizing location where the anesthetic was performed. The literature search was current through May 2023 and included prolonged extubations defined either as >15 minutes or at least 15 minutes. The studies showed that prolonged times to extubation can be measured accurately, are associated with reintubations and respiratory treatments, are rated poorly by anesthesiologists, are treated with flumazenil and naloxone, are associated with impaired operating room workflow, are associated with longer operating room times, are associated with tardiness of starts of to-follow cases and surgeons, and are associated with longer duration workdays. When observing prolonged extubations among all patients receiving general anesthesia, covariates accounting for most prolonged extubations are characteristics of the surgery, positioning, and anesthesia provider's familiarity with the surgeon. Anesthetic drugs and delivery systems routinely achieve substantial differences in the incidences of prolonged extubations. Occasional claims made that anesthesia drugs have unimportant differences in recovery times, based on medians and means of extubation times, are misleading, because benefits of different anesthetics are achieved principally by reducing the variability in extubation times, specifically by decreasing the incidence of extubation times sufficiently long to have economic impact (ie, the prolonged extubations). Collectively, the results show that when investigators in anesthesia pharmacology quantify the rate of patient recovery from general anesthesia, the incidence of prolonged times to tracheal extubation should be included as a study end point.

Factors Associated with Prolonged Extubation after Total Intravenous Anesthesia in Patients Undergoing Vestibular Schwannoma Resection

OBJECTIVE

To identify factors associated with prolonged tracheal extubation after vestibular schwannoma resection in patients receiving propofol-remifentanil-based total intravenous anesthesia (TIVA).

STUDY DESIGN

Single-center retrospective study of vestibular schwannoma resection performed by a single neurosurgeon between July 2018 and September 2021.

SETTING

Tertiary academic medical center.

PATIENTS

Adults receiving TIVA for vestibular schwannoma resection, classified according to extubation time: non-prolonged extubation (<15 min) and prolonged extubation (≥15 min).

MAIN OUTCOME MEASURES

Time from end of surgery to extubation, demographic parameters, intraoperative variables, and familiarity between the anesthesia provider and the neurosurgeon were analyzed. Predictors for prolonged extubation were analyzed via multivariate analysis. The primary outcome was the incidence of prolonged extubation. The secondary outcome was factors associated with prolonged tracheal extubation.

RESULTS

A total of 234 cases were analyzed. The median (interquartile range) extubation time was 9.4 minutes (7.2, 12.2 min). Extubation was prolonged in 39 patients (16.7%). Factors predicting prolonged extubation were significant blood loss (odds ratio [OR], 12.8; 95% confidence interval [CI], 2.6-61.7; p = 0.002), intraoperative neuromuscular blocking drug infusion (OR, 6.6; 95% CI, 2.8-15.7; p < 0.001), and lack of familiarity between the anesthesia provider and neurosurgeon (OR, 4.4; 95% CI, 1.5-12.3; p = 0.005).

CONCLUSION

Significant blood loss, intraoperative neuromuscular blocking drug infusion, and lack of familiarity between anesthesia provider and neurosurgeon were associated with prolonged extubation following TIVA for vestibular schwannoma resection.

Assessing the Environmental Carbon Footprint of Spinal versus General Anesthesia in Single-Level Transforaminal Lumbar Interbody Fusions

BACKGROUND

The U.S. health care sector produces approximately 10% of national greenhouse gas emissions, paradoxically harming human health. Neurosurgery is a resource-intensive specialty that likely contributes significantly, yet literature assessing this impact is absent. We investigate the difference in carbon emissions between spinal versus general anesthesia in lumbar spine surgery.

METHODS

A total of 100 patients underwent a single-level transforaminal lumbar interbody fusion (TLIF) from a single surgeon; 50 received spinal anesthesia and 50 received general anesthesia. Data were extracted from patient records. Amounts of anesthetics were calculated from intraoperative records and converted to carbon dioxide equivalents (CO₂e).

RESULTS

The median CO₂e for general anesthesia was 4725 g versus 70 g for spinal anesthesia (P = 7.07e-18). The mean CO₂e for general anesthesia was 22,707 g versus 63 g for spinal anesthesia. Desflurane use led to outsized carbon emissions. Carbon footprint comparisons are made with familiar units such as miles driven by a car, and are provided for a single TLIF, 50 TLIFs (single surgeon's cases in a year), and 488,000 TLIFs (annual spinal fusions in the United States).

CONCLUSION

This is one of the first known comparative carbon footprint studies performed in neurosurgical literature. We highlight the dramatic carbon footprint reduction associated with using spinal anesthesia and reflect a single neurosurgeon's change in practice from using only general anesthesia to incorporating the use of spinal anesthesia. Within general anesthesia patients, desflurane use was particularly harmful to the environment. We hope that our study will pave the way toward future research aimed at uncovering and reducing neurosurgery's environmental impact.

Benchmarking of Anesthesia and Surgical Control Times by Current Procedural Terminology (CPT®) Codes

Over half of hospital revenue results from perioperative patient care, thus emphasizing the importance of efficient resource utilization within a hospital's suite of operating rooms (ORs). Predicting surgical case duration, including Anesthesia-controlled time (ACT) and Surgical-controlled time (SCT) has been significantly detailed throughout the literature as a means to help manage and predict OR scheduling. However, this information has previously been divided by surgical specialty, and only limited benchmarking data regarding ACT and SCT exists. We hypothesized that advancing the granularity of the ACT and SCT from surgical specialty to specific Current Procedural Terminology (CPT^®) codes will produce data that is more accurate, less variable, and therefore more useful for OR schedule modeling and management. This single center study was conducted using times from surgeries performed at the University of Colorado Hospital (UCH) between September 2018 - September 2019. Individual cases were categorized by surgical specialty based on the specialty of the primary attending surgeon and CPT codes were compiled from billing data. Times were calculated as defined by the American Association of Clinical Directors. I² values were calculated to assess heterogeneity of mean ACT and SCT times while Levene's test was utilized to assess heterogeneity of ACT and SCT variances. Statistical analyses for both ACT and SCT were calculated using JMP Statistical Discovery Software from SAS (Cary, NC) and R v3.6.3 (Vienna, Austria). All surgical cases (n = 87,537) performed at UCH from September 2018 to September 2019 were evaluated and 30,091 cases were included in the final analysis. All surgical subspecialties, with the exception of Podiatry, showed significant variability in ACT and SCT values between CPT codes within each surgical specialty. Furthermore, the variances of ACT and SCT values were also highly variable between CPT codes within each surgical specialty. Finally, benchmarking values of mean ACT and SCT with corresponding standard deviations are provided. Because each mean ACT and SCT value varies significantly between different CPT codes within a surgical specialty, using this granularity of data will likely enable improved accuracy in surgical schedule modeling compared to using mean ACT and SCT values for each surgical specialty as a whole. Furthermore, because there was significant variability of ACT and SCT variances between CPT codes, incorporating variance into surgical schedule modeling may also improve accuracy. Future investigations should include real-time simulations, logistical modeling, and labor utilization analyses as well as validation of benchmarking times in private practice settings.

Colorectal Surgery in Critically Unwell Patients: A Multidisciplinary Approach

A proportion of patients require critical care support following elective or urgent colorectal procedures. Similarly, critically ill patients in intensive care units may also need colorectal surgery on occasions. This patient population is increasing in some jurisdictions given an aging population and increasing societal expectations. As such, this population often includes elderly, frail patients or patients with significant comorbidities. Careful stratification of operative risks including the need for prolonged intensive care support should be part of the consenting process. In high-risk patients, especially in setting of unplanned surgery, treatment goals should be clearly defined, and appropriate ceiling of care should be established to minimize care that is not in the best interest of the patient. In this article we describe approaches to critically unwell patients requiring colorectal surgery and how a multidisciplinary approach with proactive intensive care involvement can help achieve the best outcomes for these patients.

Comparison of Perioperative Active or Routine Temperature Management on Postoperative Quality of Recovery in PACU in Patients Undergoing Thoracoscopic Lobectomy: A Randomized Controlled Study

BACKGROUND

Whether intraoperative temperature management can help patients recover quickly in the postanesthesia care unit (PACU) still remains to be investigated. This study aimed to investigate the effect of intraoperative temperature management on the quality of postoperative recovery of patients who underwent pulmonary lobectomy in the PACU.

METHODS

Totally, 98 patients aged 45-60 years with a body mass index of 20-25 kg/m² who underwent elective thoracoscopic lobectomy were enrolled. Patients were categorized into two groups using a random number table: the conventional group received routine intervention to maintain normothermia (Group C, n = 49) and the aggressive group received integrated interventions (Group A, n = 49). In Group C, normothermic fluid was infused intravenously, the heating blanket was turned on when the intraoperative temperature was <35.0 °C, and the warming was stopped when the temperature reached 36.5 °C. In Group A, the fluid heated to 37 °C was infused intravenously, and the heating blanket was used intraoperatively. When the body temperature was >37 °C, the heating blanket was turned off, and when the body temperature was <36.5 °C, the heating blanket was turned on to continue heating.

RESULTS

Steward awakening scores at 1 min and 5 min after extubation and PaO₂ levels at 15 min after extubation were higher in Group A than in Group C (P < 0.05); incidence of chills, nausea, and vomiting in the PACU was lower in Group A than in Group C (P < 0.05); and length of stay in the PACU was shorter in Group A than in Group C (P < 0.05).

CONCLUSION

Aggressive intraoperative temperature management of patients undergoing thoracoscopic lobectomy can improve the quality of postoperative recovery in the PACU through a safe and smooth transition compared with routine insulation measures.

Activation of Orexinergic Neurons Inhibits the Anesthetic Effect of Desflurane on Consciousness State via Paraventricular Thalamic Nucleus in Rats

BACKGROUND

Orexin, a neuropeptide derived from the perifornical area of the hypothalamus (PeFLH), promotes the recovery of propofol, isoflurane, and sevoflurane anesthesias, without influencing the induction time. However, whether the orexinergic system also plays a similar role in desflurane anesthesia, which is widely applied in clinical practice owing to its most rapid onset and offset time among all volatile anesthetics, has not yet been studied. In the present study, we explored the effect of the orexinergic system on the consciousness state induced by desflurane anesthesia.

METHODS

The c-Fos staining was used to observe the activity changes of orexinergic neurons in the PeFLH and their efferent projection regions under desflurane anesthesia. Chemogenetic and optogenetic techniques were applied to compare the effect of PeFLH orexinergic neurons on the induction, emergence, and maintenance states between desflurane and isoflurane anesthesias. Orexinergic terminals in the paraventricular thalamic nucleus (PVT) were manipulated with pharmacologic, chemogenetic, and optogenetic techniques to assess the effect of orexinergic circuitry on desflurane anesthesia.

RESULTS

Desflurane anesthesia inhibited the activity of orexinergic neurons in the PeFLH, as well as the neuronal activity in PVT, basal forebrain, dorsal raphe nucleus, and ventral tegmental area, as demonstrated by c-Fos staining. Activation of PeFLH orexinergic neurons prolonged the induction time and accelerated emergence from desflurane anesthesia but only influenced the emergence in isoflurane anesthesia, as demonstrated by chemogenetic and pharmacologic techniques. Meanwhile, optical activation of orexinergic neurons exhibited a long-lasting inhibitory effect on burst-suppression ratio (BSR) under desflurane anesthesia, and the effect may be contributed by the orexinergic PeFLH-PVT circuitry. The orexin-2 receptor (OX2R), but not orexin-1 receptor (OX1R), in the PVT, which had been inhibited most significantly by desflurane, mediated the proemergence effect of desflurane anesthesia.

CONCLUSIONS

We discovered, for the first time, that orexinergic neurons in the PeFLH could not only influence the maintenance and emergence from isoflurane and desflurane anesthesias but also affect the induction under desflurane anesthesia. Furthermore, this specific effect is probably mediated by orexinergic PeFLH-PVT circuitry, especially OX2Rs in the PVT.

The effect of low flow anesthesia on hemodynamic and peripheral oxygenation parameters in obesity surgery

Objectives:

To investigate the effects of low-flow anesthesia on hemodynamic parameters and recovery from anesthesia in obese individuals undergoing laparoscopic surgery.

Methods:

This randomized-controlled and prospective study included 44 obese patients who underwent laparoscopic sleeve gastrectomy operation. The patients were randomly allocated into 2 groups as low-flow and high-flow anesthesia. Further, the groups compared in terms of hemodynamic parameters, anesthesia recovery times, operation times, and arterial blood gas parameters.

Results:

The groups were similar with respect to demographic data. Heart rate, peripheral oxygen saturation, arterial blood pressure measurements, end-tidal, and CO₂, lactate levels measurements were similar in both groups during the entire procedure. There was also no statistically significant difference in terms of arterial blood gas parameters or anesthesia recovery periods.

Conclusion:

Low-flow anesthesia in laparoscopic obesity surgery seems to be safer compared to high-flow anesthesia in terms of the adequacy of tissue perfusion, depth of anesthesia, and postoperative recovery.

Longer time to extubation after general anesthesia with desflurane in patients with obstructive respiratory dysfunction: a retrospective study

Background

The prospect of patients with obstructive respiratory dysfunction undergoing surgery has increased with the growth in the elderly population; however, there have been few investigations about the recovery profile from volatile anesthesia. This study aimed to investigate the impact of obstructive respiratory dysfunction on recovery from desflurane anesthesia.

Methods

A retrospective cohort study included patients who underwent orthopedic lower limb surgery between September 2018 and March 2020. Patients were divided into two groups: those whose preoperative forced expiratory volume in 1 s/forced vital capacity ratio was <70% (obstructive respiratory dysfunction group, n = 180) or ≥70% (control group, n = 45). Time from discontinuation of desflurane to extubation (extubation time) was compared between the two groups. Univariate and multivariable Cox regression models were used to compare odds ratios for prolonged extubation (≥10 min).

Results

A total of 45 patients with obstructive respiratory dysfunction and 180 control patients were eligible for analysis. Extubation time was significantly longer in patients in the obstructive respiratory dysfunction group than those in the control group. In the multivariable Cox model, male sex (HR = 2.00, 95% CI 1.12–3.57; P = 0.020) and obstructive respiratory dysfunction (HR = 2.07, 95% CI 1.05–4.08; P = 0.036) were associated with prolonged extubation.

Conclusions

This retrospective study indicated that extubation time was longer in patients with obstructive respiratory function than in patients without obstructive respiratory function. Male sex and obstructive respiratory function were factors that contributed to extubation time.

Effects of dexmedetomidine on immune function, renal function and inflammatory factors of patients undergoing percutaneous nephrolithotomy under general anesthesia

The present study was designed to determine the effects of dexmedetomidine on immune function, renal function and inflammatory factors in patients undergoing percutaneous nephrolithotomy under general anesthesia. A total of 177 patients with kidney calculi who underwent percutaneous nephrolithotomy in The Second Affiliated Hospital of Fujian Medical University were enrolled, in which 91 patients were treated with dexmedetomidine during surgery (research group) and 86 patients were not sedated during surgery (control group). The vital signs, renal function, inflammatory factors and immune function during surgery between the two groups were compared. Patients in the research group showed improved vital signs, renal function, inflammatory factors and immune function compared with the control group (P<0.05), and also experienced a significantly shorter hospitalization time (P<0.001). Therefore, the present results suggested that with a relatively high safety profile, use of dexmedetomidine for sedation can effectively protect renal and immune functions, and reduce the inflammatory response of patients during percutaneous nephrolithotomy. Thus, dexmedetomidine may have be potentially applied in clinical practice.

Prognostic significance of propofol-based intravenous anesthesia in early-stage lung cancer surgery

PURPOSE

The purpose of this study was to assess whether the anesthetic type is associated with the prognosis of pathological stage I non-small cell lung cancer (NSCLC).

METHODS

Clinicopathological data from 431 consecutive patients who underwent lobectomy for NSCLC between 2010 and 2016 were collected. Patients were classified into groups according to the type of anesthesia: propofol-based total intravenous anesthesia (TIVA) or inhalation anesthesia (INHA). We investigated the prognostic differences between these two groups.

RESULTS

A total of 72 patients in the TIVA group and 158 patients in the INHA group were eligible for the analysis. Recurrence was observed in 4 (5.6%) patients in the TIVA group and 19 (12.0%) patients in the INHA group (P = 0.159), and all-cause death occurred in 4 (5.6%) patients in the TIVA group and 24 (15.2%) patients in the INHA group (P = 0.049). The 5-year recurrence-free survival (RFS) and overall survival rates of the TIVA/INHA groups were 91.7%/77.4% and 94.4%/83.5%, respectively. TIVA was associated with a significantly better prognosis. A multivariable analysis of factors associated with RFS revealed that the type of anesthesia as a significant prognostic factor (P = 0.047).

CONCLUSION

Propofol-based TIVA was associated with a better prognosis in comparison to INHA in patients with surgically resected pathological stage I NSCLC.

Evaluation of Nursing Actions in Anesthesia Guided by the Patient Safety Checklist: Nursing in Anesthetic Procedure (PSC/NAP): A Cross-Sectional Study

PURPOSE

This study aimed to evaluate the implementation of nursing actions in anesthesia guided by the Patient Safety Checklist: Nursing Anesthetic Procedure and the difficulties in performing patient care.

DESIGN

A cross-sectional study.

METHODS

Nursing actions were evaluated in 282 anesthetic procedures of adult patients undergoing general anesthesia in three periods of anesthesia in a private hospital operating room in Brazil, from January to July 2018. The evaluated outcomes were the number of items performed by nurses during anesthesia periods and limitations for applying the Patient Safety Checklist: Nursing Anesthetic Procedure instrument.

FINDINGS

Execution of the nursing actions presented a mean percentage of 85.6, highlighting the anesthetic induction stage and differences between the periods before induction and reversal. The main items not performed in evaluating the nursing care in anesthesia were as follows: the anesthesia equipment test (84; 29.78%) in the preinduction period; the evaluation of adequate ventilation (132; 46.81%) in the induction period; and the tracheal aspiration assistance (62; 21.98%) during reversal. Receiving a call from another room with care interruption was highlighted among the nurses' justifications for not performing the activities and difficulty in continuing care because of shift change.

CONCLUSIONS

The execution of nursing care actions in anesthesia mainly occurred during the period related to induction, with limitations because of dimensioning of operating rooms and simultaneous procedures.

Propofol-based total intravenous anesthesia did not improve survival compared to desflurane anesthesia in breast cancer surgery

BACKGROUND

Breast cancer is the most common cancer in women and several perioperative factors may account for tumor recurrence and metastasis. The anesthetic agents employed during cancer surgery might play a crucial role in cancer cell survival and patient outcomes. We conducted a retrospective cohort study to investigate the relationship between the type of anesthesia and overall survival in patients who underwent breast cancer surgery performed by one experienced surgeon.

METHODS

All patients who underwent breast cancer surgery by an experienced surgeon between January 2006 and December 2010 were included in this study. Patients were separated into two groups according to the use of desflurane or propofol anesthesia during surgery. Locoregional recurrence and overall survival rates were assessed for the two groups (desflurane or propofol anesthesia). Univariable and multivariable Cox regression models and propensity score matching analyses were used to compare the hazard ratios for death and adjust for potential confounders (age, body mass index, American Society of Anesthesiologists physical status classification, TNM stage, neoadjuvant chemotherapy, Charlson Comorbidity Index, anesthesiologists, and functional status).

RESULTS

Of the 976 breast cancer patients, 632 patients underwent breast cancer surgery with desflurane anesthesia, while 344 received propofol anesthesia. After propensity scoring, 592 patients remained in the desflurane group and 296 patients in the propofol group. The mortality rate was similar in the desflurane (38 deaths, 4%) and propofol (22 deaths, 4%; p = 0.812) groups in 5-year follow-up. The crude hazard ratio (HR) for all patients was 1.13 (95% confidence interval [CI] 0.67-1.92, p = 0.646). No significant difference in the locoregional recurrence or overall 5-year survival rates were found after breast surgery using desflurane or propofol anesthesia (p = 0.454). Propensity score-matched analyses demonstrated similar outcomes in both groups. Patients who received propofol anesthesia had a higher mortality rate than those who received desflurane anesthesia in the matched groups (7% vs 6%, respectively) without significant difference (p = 0.561). In the propensity score-matched analyses, univariable analysis showed an insignificant finding (HR = 1.23, 95% CI 0.72-2.11, p = 0.449). After adjustment for the time since the earliest included patient, the HR remained insignificant (HR = 1.23, 95% CI 0.70-2.16, p = 0.475).

CONCLUSION

In our non-randomized retrospective analysis, neither propofol nor desflurane anesthesia for breast cancer surgery by an experienced surgeon can affect patient prognosis and survival. The influence of propofol anesthesia on breast cancer outcome requires further investigation.

Propofol-based Total Intravenous Anesthesia Is Associated with Better Survival Than Desflurane Anesthesia in Colon Cancer Surgery

WHAT WE ALREADY KNOW ABOUT THIS TOPIC

WHAT THIS ARTICLE TELLS US THAT IS NEW: BACKGROUND:: Previous research has shown different effects of anesthetics on cancer cell growth. Here, the authors investigated the association between type of anesthetic and patient survival after elective colon cancer surgery.

METHODS

A retrospective cohort study included patients who received elective colon cancer surgery between January 2005 and December 2014. Patients were grouped according to anesthesia received: propofol or desflurane. After exclusion of those who received combined propofol anesthesia with inhalation anesthesia or epidural anesthesia, survival curves were constructed from the date of surgery to death. After propensity matching, univariable and multivariable Cox regression models were used to compare hazard ratios for death. Subgroup analyses were performed for tumor-node-metastasis staging and postoperative metastasis.

RESULTS

A total of 706 patients (307 deaths, 43.5%) with desflurane anesthesia and 657 (88 deaths, 13.4%) with propofol anesthesia were eligible for analysis. After propensity matching, 579 patients remained in each group (189 deaths, 32.6%, in the desflurane group vs. 87, 15.0%, in the propofol group). In the matched analyses, the propofol-treated group had a better survival, irrespective of lower tumor-node-metastasis stage (hazard ratio, 0.22; 95% CI, 0.11 to 0.42; P < 0.001) or higher tumor-node-metastasis stage (hazard ratio, 0.42; 95% CI, 0.32 to 0.55; P < 0.001) and presence of metastases (hazard ratio, 0.67; 95% CI, 0.51 to 0.86; P = 0.002) or absence of metastases (hazard ratio, 0.08; 95% CI, 0.01 to 0.62; P = 0.016). Simple propensity score adjustment produced similar findings.

CONCLUSIONS

Propofol anesthesia for colon cancer surgery is associated with better survival irrespective of tumor-node-metastasis stage.

Nitrous oxide anesthetic versus total intravenous anesthesia for functional endoscopic sinus surgery

BACKGROUND

Functional endoscopic sinus surgery is a common procedure for sinonasal disease, frequently performed in the outpatient setting. General anesthesia maintained with total intravenous anesthesia (TIVA) with propofol has been shown to give superior surgical conditions compared to inhaled anesthetics. This study evaluated the effects of TIVA versus a predominantly nitrous oxide (N₂ O)-based anesthetic with a low-dose propofol and remifentanil infusion on sinus surgery.

METHODS

Patients were randomized to either a N₂ O-based (nitrous oxide with propofol and remifentanil) or TIVA (propofol and remifentanil without nitrous oxide) group. The surgeon was blinded to the anesthetic technique. Surgical field grading was performed in real time by the otolaryngologist every 15 minutes with the Boezaart grading system.

RESULTS

There were no statistically significant differences between the Boezaart scores, duration of surgery, or estimated blood loss between the two anesthetic techniques. However, the use of N₂ O provided a statistically significant, 38% reduction in time from surgery end to extubation. The TIVA group had significantly decreased mean and median pain scores in the post-anesthesia care unit (PACU). There was no difference in the rate of postoperative nausea and vomiting between the two groups.

CONCLUSION

A N₂ O-based anesthetic for functional endoscopic sinus surgery provides similar intraoperative and postoperative conditions when compared to TIVA, while being superior in terms of time to extubation. Although the TIVA group had significantly decreased pain scores, this did not lead to a decrease in pain medicine received in the PACU, and there was no difference between groups in time to discharge.

LEVEL OF EVIDENCE

1b Laryngoscope, 130:E299-E304, 2020.

Can high-volume teams of anesthesiologists and surgeons decrease perioperative costs for pancreatic surgery?

BACKGROUND

Pancreatic surgery outcomes are associated with surgeon and center experience. Anesthesiologists as potential value drivers for pancreatic surgery have not been explored. We sought to evaluate whether anesthesiologists impact perioperative costs for pancreatic surgery.

METHODS

Within an integrated health care system, 796 pancreatic surgeries (526 PDs and 270 DPs) were performed from January 2014 to June 2017. Mean direct operative and anesthesia costs driven by anesthesiologists (operating room (OR) time, anesthesia billing and anesthesia procedures) were determined for each case. The volumes of pancreatic cases per anesthesiologist were calculated, and those above the 75th percentile for volume (4 cases) were considered high-volume. A multivariable analysis of OR/anesthesia costs was performed.

RESULTS

Mean OR and anesthesia costs for PD were $7064 for low-volume anesthesiologists (LVA), higher than $5968 for high-volume anesthesiologists (HVA) (p < 0.001). By multivariable analysis, HVA were associated with decreased costs of $2278 (p < 0.001). Teams of HVA and high-volume surgeons (HVS) were also associated with decreased mean costs of $1790 (p = 0.04).

CONCLUSION

These data suggest that anesthesiologists experienced in the management of complex pancreatic operations such as PDs may contribute to improved efficiencies in care by reducing perioperative costs.

Clinical and pharmacogenetics associated with recovery time from general anesthesia

AIM

Delayed recovery from general anesthesia is a well-known complication that requires predictive tools and approaches. This study aimed to determine significant factors associated with postanesthesia recovery and to develop an algorithm for estimating recovery time from general anesthesia.

MATERIALS & METHODS

The genotypes of patients were determined by SNaPshot or ARMS-qPCR. The algorithm was developed via machine-learning and tested by the worm plot.

RESULTS

Results showed that OPRM1 rs1799971 (p = 0.006) and ABCG2 rs2231142 (p = 0.041) were significantly associated with recovery time. Ten factors after random forest and stepwise selection were associated with recovery time. Ten factors after random forest and stepwise selection were associated with recovery time. Meanwhile, seven factors were associated with delayed recovery.

CONCLUSION

This study demonstrated that both clinical and pharmacogenetic data are significantly associated with recovery from general anesthesia and provide the basis for pre-emptive prediction tools.

Early postoperative recovery in operating room after desflurane anesthesia combined with Bispectral index (BIS) monitoring and warming in lengthy abdominal surgery: a randomized controlled study

BACKGROUND

This study aimed to determine whether the use of desflurane (DES) anesthesia combined with bispectral index (BIS) monitoring and warming is effective in reducing anesthesia-controlled operating room time (ACT) in patients undergoing lengthy abdominal surgery.

METHODS

Seventy patients, 40 years of age or older, undergoing abdominal surgery expected to last three to five hours were randomly assigned to the DES group (n = 35) or the control group (n = 35). Patients in the DES group were maintained with desflurane anesthesia and received BIS monitoring and warming. Patients in the control group were given non-desflurane anesthesia for maintenance, and the usage of BIS monitoring and warming were not mandatory and determined by anesthesia care providers. Early postoperative recovery times were recorded.

RESULTS

The times to extubation (8.8 ± 8.5 vs 14.7 ± 13.7 min, P = 0.035), eye opening (8.4 ± 8.6 vs 14.4 ± 13.4 min, P = 0.028), responds on command (8.2 ± 8.5 vs 14.4 ± 13.0 min, P = 0.022), and the ACT (23.8 ± 11.4 vs 32.7 ± 15.4 min, P = 0.009) were significantly less in the DES group than that in the control group. The postanesthesia care unit (PACU) length of stay, incidence of prolonged extubation, and surgeon and anesthesiologist satisfaction were similar in two groups. Also, the result of multivariable linear regressions showed that patients who were younger, female, lower BMI and non-DES anesthesia regimen resulted in prolonged extubation.

CONCLUSIONS

Desflurane anesthesia combined with BIS monitoring and warming is associated with early postoperative recovery in lengthy abdominal surgery.

TRIAL REGISTRATION

ChiCTR-INR-17013333 . Date of registration: November 11, 2017.

Analysis of anesthesia-controlled operating room time after propofol-based total intravenous anesthesia compared with desflurane anesthesia in functional endoscopic sinus surgery

Anesthesia technique may contribute to the improvement of operation room (OR) efficiency by reducing anesthesia-controlled time. We compared the difference between propofol-based total intravenous anesthesia (TIVA) and desflurane anesthesia (DES) for functional endoscopic sinus surgery (FESS) undergoing general anesthesiaWe performed a retrospective study using data collected in our hospital to compare the anesthesia-controlled time of FESS using either TIVA via target-controlled infusion with propofol/fentanyl or DES/fentanyl-based anesthesia between January 2010 and December 2011. The various time intervals (surgical time, anesthesia time, extubation time, total OR stay time, post anesthesia care unit [PACU] stay time) and the percentage of prolonged extubation were compared between the 2 anesthetic techniques.We included data from 717 patients, with 305 patients receiving TIVA and 412 patients receiving DES. An emergence time >15 minutes is defined as prolonged extubation. The extubation time was faster (8.8 [3.5] vs. 9.6 [4.0] minutes; P = .03), and the percentage of prolonged extubation was lower (7.5% vs. 13.6%, risk difference 6.1%, P < .001) in the TIVA group than in the DES group. However, there was no significant difference between ACT, total OR stay time, and PACU stay time.In our hospital, propofol-based TIVA by target-controlled infusion provide faster emergence and lower chance of prolonged extubation compared with DES anesthesia in FESS. However, the reduction in extubation time may not improve OR efficiency.

Efficacy of sevoflurane as an adjuvant to propofol-based total intravenous anesthesia for attenuating secretions in ocular surgery

BACKGROUND

The incidence of nasal secretions into the operative field is as high as 5% in ophthalmic surgery under general anesthesia. It may induce postoperative endophthalmitis. Secretions under propofol-based total intravanous anesthesia (TIVA) are greater than sevoflurane anesthesia during surgery. Postoperative nausea and vomiting (PONV) after inhalational anesthesia is higher than TIVA and may increase intraocluar pressure. We investigated the effect of sevoflurane combination with propofol-based TIVA on nasopharyngeal secretions and PONV in ocular surgery.

METHODS

Fifty patients undergoing ocular operations were randomly assigned for propofol-based TIVA or propofol/sevoflurane anesthesia. In the TIVA group (n = 25), anesthesia was induced and maintained with propofol and fentanyl; in the propofol/sevoflurane group (n = 25), 1% sevoflurane anesthesia was added.

RESULTS

Nasopharyngeal excretion volume was significantly higher in the propofol-based TIVA group than in the propofol/sevoflurane group (31.0 ± 18.1 vs 13.7 ± 12.6 ml; P < .001). No significant difference in extubation time was noted (propofol-based TIVA: 6.4 ± 3.6 vs propofol/sevoflurane: 7.4 ± 3.0 minutes; P = .34). No postoperative endophthalmitis or PONV in both groups was observed.

CONCLUSION

Sevoflurane attenuated secretions under propofol-based TIVA and did not increase the incidence of PONV or prolonged extubation in ocular surgery.

Relationship between anesthesia and postoperative endophthalmitis: A retrospective study

Previous study showed that patients under general anesthesia (GA) had nasopharyngeal secretions on the face at the end of ocular surgery, especially in propofol-based total intravenous anesthesia (TIVA), it might induce postoperative endophthalmitis. Therefore, we conducted a retrospective study to compare the incidence of endophthalmitis after ocular surgery under topical, inhalation anesthesia, and propofol-based TIVA in our medical center from 2011 to 2015.A total of 21,032 patients were included, and we evaluated epidemiologic factors, systemic diseases, other ocular pathologic characteristics, complications during the surgery, technique of ocular surgery, method of antibiotic prophylaxis, vitreous culture, and vision outcome in these patients.Fifteen endophthalmitis cases among 21,032 operations reported, equaling an incidence of 0.071%. The incidence rates under topical, inhalation anesthesia, and propofol-based TIVA were 0.083%, 0.039%, and 0%, respectively (P = 0.39). Moreover, the risk of endophthalmitis under GA (0.024%) was significantly lower than topical anesthesia (0.083%) (P < 0.001). We also found that elder was the risk factor for endophthalmitis following ocular surgery.In conclusion, propofol-based TIVA or inhalation anesthesia did not increase the risk of endophthalmitis after ocular surgery. Thus, GA was not a risk factor for postoperative endophthalmitis. By contrast, elder was the risk factor for postoperative endophthalmitis.