Improved efficiency in providing blood to surgical patients using a novel approach to preadmission testing

Expansion of the preadmission process for same-day-admit (SDA) surgery patients through our Admissions Evaluation Center has provided an efficient and convenient means for complete patient evaluation up to 30 days in advance of surgery. Traditionally, collection of blood samples for the pretransfusion testing that is necessary to select compatible blood for transfusion occurs within 72 hours of admission, consistent with standards to ensure detection of red blood cell (RBC) alloantibodies formed as a result of recent transfusion or pregnancy. As a result, samples for many SDA patients were submitted Stat the morning of surgery, resulting in an unwieldy amount of testing and delay in blood availability. To address this problem, the time interval for collection of patient blood samples for pretransfusion testing was extended to 30 days prior to surgery. To ensure safety, this change required documentation of patient transfusion and pregnancy history at 2 specific timepoints. Input from a multidisciplinary team was vital to assess the process of blood ordering and administration and to determine the best means to accomplish these steps. Implementation of the new process resulted in a decreased number of emergent requests for compatibility testing, decreased delays in blood delivery, and elimination of canceled surgery due to cases with unexpected RBC antibodies.

Symptom distress and functional status changes during the first seven days after ambulatory surgery

In this study, we describe changes in symptom distress and functional status 24 h, 4 days, and 7 days after ambulatory surgery. Adult patients aged 18-64 yr, ASA physical status I-III, were studied. The General Symptom Distress Scale was used to score 11 general symptoms; scores range from 0 (no symptoms present) to 4 (symptoms present, constant, cannot be ignored, and, in a 24-h period, remained distressing for more than half the time). The Functional Status Questionnaire was used to evaluate basic and intermediate activities of daily living. Procedure-specific analyses of covariance were performed using multiple linear regression analyses. These models were used to obtain estimates of change while adjusting for preoperative index values of age, ASA physical status, type of anesthesia, and study site. Models for hernia (n = 41) and laparoscopy (n = 59) procedures used F statistics to test the overall significance of the model. Symptom distress persisted until the 7th postoperative day after ambulatory surgery. Patients experienced decreased functional status during the first 7 postoperative days, especially after hernia repair. Older laparoscopy patients tended to have more symptom distress and decreased functional status than younger patients. Only 22% of patients had returned to full- or part-time work by the 7th postoperative day. We conclude that although major morbidity is uncommon after ambulatory surgery, symptom distress and reduced functional status are common 7 days postoperatively.

IMPLICATIONS

Previous studies of patient status after ambulatory surgery have focused on mortality, major morbidity, and unanticipated hospitalization. In this study, we examined clinically significant but less life-threatening patient outcomes. Important problems in ambulatory surgery are posed by complications that occur at home. Careful assessment of discharge criteria is important to avoid these problems in this growing patient population.

Anaesthetic management for caesarean section in a patient with uncorrected truncus arteriosus

We describe the successful management of a 25-yr-old primigravida with uncorrected truncus arteriosus, requiring an urgent Caesarean section for delivery of a live infant and we discuss the rationale of using the chosen drug combination and the importance of adequate monitoring in selecting an anaesthetic technique based on the pathophysiology of the congenital cardiac lesion.

Effects of isoflurane on myocardial blood flow, function, and oxygen consumption in the presence of critical coronary stenosis in dogs

Because isoflurane has been reported to produce coronary steal, we studied 12 open chest, anesthetized (pentobarbital) dogs with critical stenosis (CS) of the left circumflex coronary artery (LCA). Sonomicrometers were implanted to measure systolic wall thickening, myocardial blood flow (MBF) was measured with microspheres (15 microns diameter), and regional venous sampling was performed to estimate regional oxygen extraction and myocardial oxygen consumption (MVO2). Anesthetic concentrations of isoflurane reduced arterial blood pressure dramatically, resulting in a maldistribution of MBF distal to the CS consistent with the pattern characterizing a transmural coronary steal effect. Elevation of arterial blood pressure with phenylephrine during high concentration isoflurane (1.7 +/- 0.1%) augmented MBF, but the maldistribution distal to the CS persisted. Despite the maldistribution, however, there was no indication of ischemia in the LCA region because systolic wall thickening, oxygen extraction, and MVO2 were not significantly different between the LCA and left anterior descending coronary artery (LAD) (control) areas. Because wall thickening, oxygen extraction, and MVO2 were markedly reduced by isoflurane in both the LCA and control areas, it was concluded that isoflurane substantially reduced myocardial oxygen requirements by inducing myocardial depression, reducing heart rate, and decreasing afterload. Consequently, the apparent maldistribution of LCA blood flow (coronary steal) was due to the hemodynamic and vasodilatory effects of isoflurane, but did not result in ischemia because the level of blood flow was at or above the requirements of the myocardium.