Evaluation of risk of dehiscence in dogs and cats after gastrotomy.

Professor Emeritus in Pediatrics and Anesthesiology. Received from the Department of Pediatrics and Anesthesiology, The George Washington University Medical Center, Washington, District of Columbia.I am honored to have been selected to deliver the 40th Annual Emery A. Rovenstine Memorial Lecture. At previous Rovenstine lectures, I learned about his pioneering efforts as the Director of the Anesthesia Service at Bellevue Hospital (New York City, New York) where he served from 1935 to 1960; his Presidency of the American Society of Anesthesiologists (ASA), 1943–1944; and as the recipient of the ASA's Distinguished Service Award in 1957. In the past year, however, two outstanding articles have been written that present material I was unaware of.Lucien Morris, M.D. (Professor Emeritus, Medical College of Ohio, Toledo, Ohio) authored the fascinating article “Ralph M. Waters’ Legacy: The Establishment of Academic Anesthesia Centers by the ‘Aqualumni’.”1The ’aqualumni,’ is defined as Waters’ own trainees. The article was written to commemorate the 75th Anniversary of Waters accepting an academic appointment to the medical faculty of the University of Wisconsin (Madison, Wisconsin).I found particularly interesting the section describing Professor Waters’ concern that when Dr. Rovenstine, one of his aqualumni, went to Bellevue Hospital, New York University (NYU, New York City, New York), he might not have sufficient staff to establish a new academic training center for anesthesia. As a result, Waters split his Wisconsin group, sending both staff and residents to New York City to ensure the success of Dr. Rovenstine at NYU. Waters had enough confidence in Dr. Rovenstine to predict that he would succeed. He would not disappoint Dr. Waters.David Waisel, M.D. (Department of Anesthesia, Children's Hospital, Boston, Massachusetts) provided a comprehensive review of “The Role of World War II and The European Theater of Operations in the Development of Anesthesiology as a Physician Specialty in the USA.”2In 1942, Waters and Rovenstine and others teamed up to train “90-day wonders” in 12-week courses “to prepare medical officers to take charge of the anesthesia sections of the various types of hospitals of the U.S. Army.” Courses were given at several institutions, including Bellevue, and were developed by the Subcommittee on Anesthesia of the National Research Council. The latter was chaired by Dr. Waters. Dr. Rovenstine was the Secretary. Many future anesthesiologists were attracted to the specialty as a result of their initial exposure to the field in World War II and the influence of role models such as Dr. Rovenstine.Although I did not know Dr. Rovenstine personally, I was trained by another aqualumnus of Dr. Waters, Robert D. Dripps, M.D. (Professor and Chair, Department of Anesthesiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania). Dr. Dripps was interested in attracting medical students into the field of Anesthesiology. One of his efforts led to the establishment of the ASA Preceptorship Program and the Committee on which I first served the ASA.In the 36 yr in which I have been involved in the activities of the ASA, 20 yr have been spent on developing guidelines for sedation for nonanesthesiologists. It has been the most challenging, frustrating, and contentious issue I have had to address.Even though ASA's efforts have been exemplary, the results have been misunderstood by not only the groups we have attempted to educate but also by our own members. I have decided to set the record straight by discussing the history of “ASA's Efforts in Developing Guidelines for Sedation and Analgesia for Nonanesthesiologists.” Some of the comments that follow are my own thoughts and interpretations; however, most of the statements are documented in the literature or are part of my own collection of documents. The latter will be donated to the Wood Library Museum (Park Ridge, Illinois) together with the script of this lecture.The formal process of ASA's evidence-based guideline development for members did not begin until 1990, and for nonanesthesiologists, in 1993. Other specialty groups began setting guidelines earlier and their efforts must be acknowledged before proceeding with ASA's efforts. It is not intended to provide a comprehensive or complete review of these accomplishments but rather to attempt to chronicle the background from which ASA developed some of its interest.Driscoll 3describes one of the anesthetic eras, “conscious and unconscious sedation,” as beginning in 1970. He notes that, previously, the use of diazepam along with local analgesia was relatively uncomplicated. However, soon meperidine, atropine, fentanyl, methohexital, and a host of other drugs were also added. Polypharmacy posed a potential problem.In 1972, “Guidelines for Teaching the Comprehensive Control of Pain and Anxiety in Dentistry” were published. 4These guidelines established a standard for training all dental personnel in this area of patient management. 5Apparently the dental profession continued to strive for a balance between minimizing fear and anxiety and maximizing safety. To resolve some of the issues, The National Institutes of Health (NIH), The Food and Drug Administration, and The NIH Office of Medical Applications of Research (Bethesda, Maryland) convened a Consensus Development Conference on Anesthesia and Sedation in the Dental Office. 6A host of experts, including anesthesiologists, agreed on developing answers to frequently asked questions. Although the principles and definitions described in the document are not necessarily original (but undoubtedly originated in the dental literature), they do represent important features, which continue to be emphasized, and must not be ignored. Several of these are as follows:From time to time, other Dental groups, such as The American Dental Association (Chicago, Illinois) and American Association of Oral and Maxillofacial Surgeons (Rosemont, Illinois), have issued comprehensive guidelines for sedation and anesthesia; however their design and content are beyond the scope of this discussion.My involvement with the formulation of guidelines related to sedation began in 1983 as a member of the Committee of the Section on Anesthesiology, American Academy of Pediatrics (AAP) (Elk Grove Village, Illinois). Sedation guidelines were developed by the AAP primarily because of the reporting of a number of deaths in dental offices. 7In 1985, The Committee on Drugs, Section on Anesthesiology, AAP, in conjunction with The American Academy of Pediatric Dentistry (Chicago, Illinois), published Guidelines for the Elective Use of Conscious Sedation, Deep Sedation, and General Anesthesia in Pediatric Patients. 8In this document, the three states were defined as were the requirements for selection of patients, personnel, monitoring procedures, facility, equipment, and recovery care. The definition of conscious sedation included the patient's ability to maintain a patent airway and that this be retained independently and “continuously.” It also noted that “the drugs and techniques used should carry a margin of safety wide enough to render unintended loss of consciousness unlikely.”Although a number of anesthesiologists, including myself, were members of one of the committees drafting the Guidelines, the ASA was not officially involved. As a matter of fact, in its 1985 Annual Report, the ASA Committee on Pediatric Anesthesia stated “members of the committee, as well as others within the ASA, were interested and concerned with (these) guidelines …”*As a result, the 1985 ASA House of Delegates instructed the ASA Committee on Standards of Care to review the Guidelines and report back to the March Board of Directors. At the time of the referral, I was the Chair of this Committee. An official reply was drafted and specifically addressed items of concern, such as the requirement for the use of intravenous (IV) injections in patients undergoing Deep Sedation and General Anesthesia. †This was subsequently “clarified” by the AAP making it permissible for personnel expert in securing IV access in infants and children to be immediately available. Both the Committee on Pediatric Anesthesia and Standards of Care agreed that many portions of the AAP Guidelines were well designed but believed that it was “essential—that future undertakings of this type and importance have official input from the ASA.”In 1992, the AAP published a revision of the 1985 Guidelines. 9In this document, it was noted that “regardless of the intended level of sedation or route of administration, the sedation of a patient represents a continuum—and a patient may move easily from a light level of sedation to obtundation.” It also added that “the practitioner should be prepared to increase the level of vigilance corresponding to that necessary—” if the patient becomes more deeply sedated. Use of pulse oximetry was required for both conscious and deep sedation. (Note: I have not attempted to describe this important document in its entirety.) The 1992 Guidelines were reviewed and suggestions made by the ASA's Committees on Pediatric Anesthesia and Standards of Care before the document was published. Their contributions were acknowledged by the AAP.Several articles have been written that describe the evolution of the development of the AAP's Guidelines. 10,11Of particular interest to me are several references to the reason that ASA “renewed” its interest in the revised (1992) Guidelines. Striker and Coté11state, “at the time of revision, the Committee on Drugs felt it important to once again work with the ASA, since during the intervening years from the original guidelines, The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) (Oakbrook Terrace, Illinois) took the torch of responsibility.” Further, “with renewed interest (in part because of the JCAHO), the ASA Committee on Standards reviewed each iteration of the revised pediatric guidelines.”These statements clearly imply that ASA was complacent until JCAHO provided the impetus for ASA to get moving. Nothing could be further from the truth. To the contrary, ASA had taken a different path in generating guidelines for sedation and, as early as 1985 through our liaison activities with JCAHO, we were able to convince them to incorporate the concept of sedation into their accreditation standards. ASA's initial concern and involvement related to deaths outside the operating room when nonanesthesiologists sedated adult patients with a new drug, midazolam (VERSED®, Hoffman–La Roche Laboratories, Nutley, NJ).In 1985, the Food and Drug Administration approved the use of midazolam, and in 1986, it was marketed in the United States. Midazolam was reported to be twice as potent as diazepam. 12There were warnings from abroad that the comparative potency with diazepam was underestimated. 13Midazolam had certain advantages over diazepam—water solubility, less venous irritation, potent amnesia, and “short” duration of action. As a result, its use was embraced by a variety of types of practitioners who administered sedation.Bailey et al. 14demonstrated in human volunteers that the combination of midazolam with fentanyl in reasonable doses produced hypoxemia. Subsequently, they cited data from the Department of Health and Human Services, Office of Epidemiology and Biostatistics, Center for Drug Evaluation and Research, Data Retrieval Unit, in which 86 deaths were collected in the United States after the use of midazolam. 15All but 3 occurred outside the operating room “in clinical situations where patients are typically unattended by anesthesia personnel.” Seventy-eight percent of these deaths were associated with oxygenation or ventilation difficulties, and in 57% of these respiratory deaths, various opioids were used.Bailey et al. 15also noted that endoscopists were beginning to document the risk of hypoxemia in their environment. Further, most of these midazolam-associated adverse drug reaction reports involved care outside the operating room, where standards for the assessment of ventilation and oxygenation had not been defined and therefore were variable.In 1986, the ASA published its first standards for its members—Standards for Basic Intraoperative Monitoring. These applied not only to the states of general and regional anesthesia but also to “Monitored Anesthesia Care” or “MAC.” The latter term was also introduced in 1986 and applies to the service provided by the anesthesia care team in which the same level of care is provided with sedation/analgesia as with general or regional anesthesia. In the 1986 Standards, the use of pulse oximetry was encouraged.In 1988, the package insert for midazolam HCl (VERSED®) was modified to state the “clinical experience has shown VERSED® to be 3–4 times as potent per mg. as diazepam. Because serious and life-threatening cardiorespiratory adverse events have been reported, provision for monitoring, detection, and correction of these reactions must be made for every patient to whom VERSED® injection is administered, regardless of age or health status” (injection, package insert, Hoffmann–La Roche, Nutley, NJ).In the early 1980s, the section in the JCAH manual titled “Anesthesia Services” focused primarily on organization; staffing; safety (electrical and explosion hazards); delivery of care (e.g. , written guidelines for use of all general anesthetics); and quality and appropriateness of care. In 1982, the ASA developed a liaison with the JCAH (no “O” at that time). Representation was established in the Hospital Professional and Technical Advisory Committee (HPTAC), and in the Ambulatory Health Care Professional and Technical Advisory Committee (AHCPTAC). 16ASA's representatives, Eli Brown, M.D. (then, Professor and Chair, Department of Anesthesiology, Wayne State University, Detroit, Michigan) and Harry Wong, M.D. (then, Medical Director and President of the Medical Staff, Salt Lake Surgical Center, Salt Lake City, Utah) brought to the JCAH their concerns with the deaths occurring outside the operating room when potent sedatives with or without narcotics were administered by the “operating practitioner” to patients who were not adequately monitored. Largely due to their influential efforts, in 1985 the JCAH drafted proposed Standards for Surgery and Anesthesia services that addressed the surgical and anesthesia care of patients wherever they receive care in a hospital and to reflect current practices in the delivery of surgery and anesthesia care.In 1986, a draft was sent for “field review” to 1951 organizations and individuals. This led to the landmark language of the 1988 Standards for Surgical and Anesthesia Services (SA).“The standards in this chapter apply to services for all patients who (1) receive general, spinal, or other major regional anesthesia or (2) undergo surgery or other invasive procedures when receiving general, spinal, or other major regional anesthesia and/or intravenous, intramuscular, or inhalation sedation/analgesia that, in the manner used in the hospital, may result in the loss of the patient's protective reflexes. Invasive procedures include, but are not necessarily limited to, percutaneous aspirations and biopsies, cardiac and vascular catheterizations, and endoscopies.”‡The Director of Anesthesia's clinical and administrative responsibilities included “assuring” the effective monitoring and evaluation of the quality of appropriateness of anesthesia care provided by individuals in any department/service of the hospital, including—dental, emergency, etc. Requirements for assuring the availability of continuing medical education programs, monitoring the quality and appropriateness of anesthesia services, and other key items were included. The Standards required that “patients with the same health status and condition receive a comparable level of quality of surgery and anesthesia care throughout the hospital.” Obviously, the standard applied to adults and children and was promulgated by an accrediting organization that required conformance or else “deemed status” might not be attained.The endoscopists, in particular, were very alarmed by this development and considered the whole issue to be a turf battle between them and the anesthesiologists. They objected to being placed under the category of “surgical and anesthesia services.” In 1988, I replaced Eli Brown, M.D. (then, Professor and Chair, Department of Anesthesiology, Wayne State University, Detroit, Michigan) as ASA's liaison with the JCAH HPTAC. At the request of Jim Roberts, M.D. (Vice President, JCAH), I met with him and a representative of the endoscopy community, David Fleisher, M.D. (Division of Gastroenterology, Georgetown University Hospital, Washington, DC). After a lengthy discussion, Dr. Roberts confirmed that the language in the JCAH Standards for Surgery and Anesthesia Services was intended to promote safety and uniformity in the quality of care and that, indeed, the requirements applied to endoscopists using sedation that “in the manner used—may result in the loss of protective reflexes.”One of the results of this meeting was the establishment of a dialogue between the endoscopists and anesthesiologists at a national level. In 1989 and 1992, I was invited to address the conventions of the American Society of Gastrointestinal Endoscopists (ASGE) (May, 1989, Washington, DC, and May, 1992, San Francisco, California). In 1989, The Society of Ambulatory Anesthesiologists (SAMBA invited the Chair of the Standard's Committee, ASGE, to SAMBA's annual meeting; April, 1989, San Antonio, Texas). Anesthesiologists and endoscopists began a dialogue but disagreed on several key issues: (1) the level of sedation for which the JCAH Standards applied, and (2) the use of the pulse “the role of pulse oximetry and monitoring during procedures is and The was that the of monitoring should be to the patient's risk of and the type and duration of the 1990, the JCAHO added to the for Anesthesia the requirement for the Director of Anesthesia Services to or through a with of other that provide anesthesia services in the formulation of and material that to provide quality of anesthesia services throughout the hospital.” language including to and the quality and appropriateness of anesthesia care in any department/service in the hospital requirement to was by many anesthesiologists as an to and procedures and to be for the activities of practitioners who outside their without the to their To to the of of Anesthesia were also to official ASA to incorporate into their and procedures for sedation. In an attempt to this issue and to our I authored an article for the ASA Anesthesia Services in other Hospital this I that the JCAHO standards only required that the Director of Anesthesia be for the of the members of to practitioners not with the ASA that could be used as the for and procedures such as Standards for Basic Intraoperative were many other events occurred in the of the language of the JCAHO Standards between and it to that and within ASA and between our organization and other In one by JCAHO of the definition of anesthesia care was and It the under which the sedation standards applied including or without for which is a reasonable that in the manner the sedation/analgesia will result in the loss of protective for a of a of In other if the and techniques used were not to a loss of consciousness for a of a of patients, sedation as used in the manner would not the with the Standards for Anesthesia endoscopists were The Board that during IV conscious sedation by most endoscopists, protective are not in a of JCAHO to the continued to , that in most procedures are and that cardiorespiratory are to this JCAHO revision, an ASA member to the President of the ASA is the of by the I am and to be a member of a which did not the role of patient's The ASA was I in on Accreditation for new language was by the of the JCAHO, the Board of without the or of the and without the field to JCAHO from ASA and The Society for Ambulatory Anesthesia were This that, if had been from our at the their might have been or modified by the two , Standards and Committee and The Board of 1985 and we learned many from Guidelines and Standards by other organizations and input from our members about they to their and related to the development of and procedures for the of nonanesthesiologists who provided sedation outside the operating began ASA's efforts to establish its own Guidelines for this The of 1989, The for Health Care and In 1990, President of the ASA, was by the Office of the for and in Health for Health Care and Research Department of Health and Human Services of new to and clinical The were to be from of the expert and of health care In ASA established the Committee on under the of M.D. (then, President for University of Medical the process that ASA for guideline development is the are beyond the scope of this it to the original members of the Committee and the of the two initial and of the were on the in The who the was Office of the for Department of Health and Human The Guidelines were to be 1992, was in of the development of an ASA to be titled or for nonanesthesiologists. President, Anesthesia (Park Ridge, Illinois), that the development of Standards, Guidelines, and/or should be the of the not He also noted in anesthesia it will be considered by the other specialty involved. by the is to have it at the level of the for Health Care and President, to President, ASA, took and to that they the they ASA would was not In ASA selected members of a and as its Chair, M.D. (Professor of Anesthesiology and University of of Dr. and I described the of the process in an article on Analgesia and Sedation by this article are several to its the on the guidelines from selected in the field of and from other in which sedation and analgesia is The draft was also to anesthesiologists and invited of specialty groups of nonanesthesiologists at several In the included as a M.D. (Department of Gastroenterology, an who was officially by The Guidelines for Sedation and Analgesia by was approved by the ASA House of Delegates and in was published in the Anesthesiology. Guidelines were also by the with the to the document to our for their in their President, to ASA, After yr of dialogue and on the to the sedated ASA and had Guidelines were by the ASA material was by Roche and and the was by in this material was a which was part of the ASA under the of the Committee on and the it that ASA had produced an evidence-based which would be embraced by all this was not the ASA's initial did not address the state of In its of it is stated that “patients is from a are sedated to a by The was on the state patients to procedures cardiorespiratory and the ability to to and/or pediatric anesthesiologists that most pediatric patients, a level of deep the new AAP (1992) sedation guidelines will the ASA and that less personnel and less monitoring and recovery are associated with the state of “conscious in current all sedation is conscious regardless of the of sedation procedures or procedures complete (e.g. , or be in a who is the is The of the of a state of conscious sedation in which pediatric patients are to in the of is were that the ASA was developing guidelines for nonanesthesiologists in to their turf and that, in the the to be a of by the without the of specialty groups was also JCAHO was of adverse events associated with the use of sedation by nonanesthesiologists outside the operating room environment. of the related to practitioners the of sedation provided and not the monitoring and efforts liaison to the JCAHO are members of the ASA Committee on and Administration the Chair, M.D. Memorial Healthcare of In to JCAHO staff in the Standards, Dr. a to address a report of the ASA Committee on Standards of Care to monitoring the of the House of Delegates of the definition of to a of the President

Practice Advisory for Preanesthesia Evaluation

Practice Advisory for the Perioperative Management of Patients with Cardiac Rhythm Management Devices: Pacemakers and Implantable Cardioverter–Defibrillators

Practice advisory for preanesthesia evaluation: a report by the American Society of Anesthesiologists Task Force on Preanesthesia Evaluation.

Practice Advisory for Perioperative Visual Loss Associated with Spine Surgery

Anesthesia for Office-Based Surgery: Are We Paying Too High a Price for Access and Convenience?

Retrospective cohort study. The objective of this study was to characterize the costs associated with American Society of Anesthesiologists (ASA) class, and to determine the extent to which ASA status is a predictor of increased cost and LOS following lumbar laminectomy and fusion (LLF). Spinal fusion accounts for the highest hospital costs of any surgical procedure performed in the United States, and ASA (American Society of Anesthesiologists) status is a known risk factor for cost and length of stay (LOS) in the orthopedic literature. There is a paucity of literature that directly addresses the influence of ASA status on cost and LOS following LLF. This is a retrospective cohort study of an institutional database of patients undergoing single-level LLF at an academic tertiary care facility from 2006 to 2016. Univariate comparisons were made using χ tests for categorical variables and t tests for continuous variables. Multivariate linear regression was utilized to estimate regression coefficients, and to determine whether ASA status is an independent risk factor for cost and LOS. A total of 1849 patients met inclusion criteria. For every one-point increase in ASA score, intensive care unit (ICU) LOS increased by 0.518 days (P < 0.001), and hospital length of stay increased by 1.93 days (P < 0.001). For every one-point increase in ASA score, direct cost increased by $7474.62 (P < 0.001). ASA status is a predictor of hospital LOS, ICU LOS, and direct cost. Consideration of the ways in which ASA status contributes to increased cost and prolonged LOS can allow for more accurate reimbursement adjustment and more precise targeting of efficiency and cost effectiveness initiatives. 3.

Background: To reduce morbidity and mortality associated with anesthetic procedures in cats, it is important to carry out a thorough pre-anesthetic evaluation. The surgical risk depends on several factors related to the patient, the surgical procedure, and the anesthetic used. Evaluation of perioperative mortality and the identification of the main factors of death reduce mortality rates. This research was conducted to evaluate and obtain the classification of physical status and anesthetic risk in cats submitted for surgical procedures.Materials, Methods &amp; Results: Ninety-two cats were classified into anesthetic categories according to the American Society of Anesthesiologists (ASA) classification. The group consisted of 62 females (67.39%) and 30 males (32.61%). In the ASA classification, the emergency qualifier was added, resulting in 52.17% (48/92) of the total number of surgeries being considered as emergencies. The ASA I patients constituted the majority of the study sample (33.69%, 31/92). There were no deaths among ASA I patients. The ASA II patients represented 20.65% (19/92), with surgeries divided into non-emergency (42.10%, 8/19) and emergency (57.89%, 11/19). All ASA II patients had mild localized infections, and there were no deaths. ASA III patients constituted 28.26% (26/92) of the study sample and had moderate systemic alterations. Surgeries in this group were also classified as emergency (24/26, 92.30%) or non-emergency (2/26, 7.69%). There was one postoperative death in this group. The ASA IV patients represented 17.39% (16/92) of the study sample. The emergency surgeries (81.25%, 13/16) had a greater percentage than the elective surgeries. In this group, two deaths occurring in the immediate postoperative period. The overall mortality for the entire study sample was 3.26% (3/92).Discussion: The majority of the surgeries were emergency surgeries, indicating that, in the feline specie, in the service analyzed, most owners seek medical treatment under these conditions. In these situations, there is a need for rapid intervention since there is a high probability of immediate adverse consequences with the added risk of death. The results obtained from the ASA I patients are expected in animals of this classification, whose prognosis is considered excellent. The patients ASA II included six patients with obstructive lower urinary tract disease (OLUTD) that progressed to ASA III and IV, proving that patients with OLUTD need urgent attention. Some animals ASA III entered this classification because they presented anemia. These clinical sign was considered of great importance since the reduction of circulating red blood cells reduces tissue oxygenation, thereby increasing surgical risk due to hypovolemic shock. The one death in the ASA III group occurred in the postoperative period, and necropsy indicated septicemia, which has a high mortality rate. ASA IV patients were placed in this category due to serious diseases such as neoplasms accompanied by secondary infection, urolithiasis with post-renal azotemia, OLUTD with azotemia, and pyometra. All deaths in the ASA IV group occurred in the immediate postoperative period. Recent data suggest that the postoperative period is the period associated with the highest risk of mortality. This may have been a reason for these deaths, along with the fact that all these patients were emergency patients, because in such procedures, the risk of death is much higher in patients undergoing emergency surgeries than in those undergoing elective surgeries. Starting by the patients classified as ASA grade III, the mortality was higher, as well as in cases of emergency. The overall mortality rate was high, with a higher risk during the immediate postoperative period. It is recommended that felines be carefully monitored postoperatively to reduce mortality rates.

Guidelines for sedation and anesthesia in GI endoscopy

What's New in Hip Replacement.

To describe a referral hospital population of dogs and cats receiving red blood cell (RBC) transfusions during general anaesthesia (GA). Retrospective cohort study. Cats and dogs. Between 2016 and 2021, animals that received RBC products during GA were identified using clinical records. Signalment, physical examination and clinical pathology findings, reason for GA, blood product details and timing of transfusion in relation to commencement of GA, American Society of Anesthesiologists (ASA) status and survival to discharge were collected. Normality was assessed using the Shapiro-Wilks test. Pearson's chi-squared or Wilcoxon-Mann-Whitney U tests was used to investigate the relationship between underlying disease, timing of transfusion and ASA status on survival; p < 0.05. A total of 2137 animals received RBC transfusions during the study period. Of these, 332 occurred under GA and 244 patients were excluded, leaving 88 animals that met the study criteria. These comprised 18 cats and 70 dogs. The most common reason for RBC transfusion under GA was for surgical management of a haemoabdomen (23/88). Animals were significantly more likely to survive if their ASA status was I or II (p= 0.031). Overall survival was not affected by transfusion start time; however, animals with ASA status of IV or V were significantly more likely to survive when RBC transfusion was started before GA (p < 0.001). There was no significant difference in survival (p= 0.876), or length of hospital stay (p= 0.854) based on volume of RBC product administered. No transfusion reactions were identified in this group of animals in this study. Overall survival was 79.5%. Noncritical animals (ASA I and II) were more likely to survive in this population, but more compromised animals (ASA IV and V) benefitted from starting the transfusion prior to GA.

Practice guidelines for sedation and analgesia by non-anesthesiologists.

This is a case study with exploratory character, descriptive and comparative, and a fieldwork with a quantitative approach. It aims to classify the surgeries in categories according to the number of nursing hours in operating rooms, subsidizing the dimensioning of the nursing staff in operating rooms. It was performed in a large general private Hospital in Sao Paulo. The sample was constituted of 140 patients, divided into 14 groups, 10 patients on each group. To organize the groups it was taken on account the patient’s physical condition, according to the American Society of Anesthesiologists (ASA), the anesthetic complexity, according to the Brazilian Medical Association (BMA), the sort of surgical anesthetic procedure: invasive, or minimally invasive (MI) and elective surgeries. According to the patient’s physical condition, groups were constituted with ASA1, ASA2 and ASA3. ASA 4 was put away because there were no cases, and ASA 5 and ASA 6 were put away because they were urgency or emergency surgeries. As to the anesthetic complexity, surgeries were classified as presenting small complexity, mean complexity, large complexity and special complexity. Therefore groups were symbolized as: 1S, 1M, 1L, 1S, 2S, 2M, 2L, 2S, 3M, 3L, 3S, 1SMI, 1MMI AND 2AMI. Data were collect inside the operating rooms, by means of organized observation, according to a guide presenting items referring to the surgery characteristics, human resources, patient’s physical condition and surgical anesthetic procedures. Data analysis was performed according to the surgical patient’s characteristics, hours taken by human resources and by the patient, procedures and material resources employed. In the comparison among groups, the characterization of the surgical patient led to the following results: as to gender, 83 (59,29%) female and 57 (40,71%) male, the higher age frequency was between 30 and 40 years in 34 (24,29%) of the patients. The most frequent surgical specialties were otorhinolaryngology and traumatology in 23 (16,43%), gynecology and obstetrics in 21 (15%) and orthopedics and traumatology in 21 patients (15%). General anesthesia prevailed in 75 (53,58%) of the patients. Concerning the systemic disorders that characterize the ASA, cardiovascular disorders prevailed in 52 (65%) of the patients, 40 (50%) presenting systemic arterial hypertension and 16 (20%) presenting diabetes Mellitus. As to the hours taken, the average hours taken by patients was: 3,40 hours of nursing (NH); 0,10 hours of nurse (NeH); 3,28 hours of nursing assistant (NaH); 6,14 hours of medical staff (MSH); 1,12 hours of surgery (SH), 1,95 hours of operating room (ORH); 0,21 hours of anesthetic preparation (APH) and 0,16 hours of surgery preparation (SPH). For one SH, the average hours taken for each patient was: 3,54 NH; 0,14 NeH; 3,40 NaH; 3,08 MSH and 0,54 SH. Concerning to the procedures taken, the average of invasive procedures was 2,04 and non-invasive procedures 5,70; total procedures 7,74. The average material resources used for anesthesia was 4,19 equipment and for surgery 2,76 equipment; total 6,95 equipment. In the statistical analysis of groups referring to the ASA, according to the anesthetic complexity, results evidenced that small and mean anesthetic complexity presented no significant difference, and were inferior to large and special complexity in variables NH, NaH and MSH; as to the anesthetic complexity according to the ASA the results evidenced that there were almost none difference among the ASA. In the group of minimally invasive surgeries, there was difference only in the material resources, that were superior according to the anesthetic complexity and in the analysis comparing groups of invasive and minimally invasive surgeries with similar anesthetic complexity and ASA the results evidenced that groups of invasive surgeries were significantly inferior in the studied variables in relation to groups of minimally invasive surgeries. Therefore, this study concludes that the NH are related to the anesthetic complexity, and the more complex the anesthetic surgical procedure, the more nursing hours are taken. The relation of NH taken with the patient’s physical condition was not observed. Thus a classification of surgeries in categories was done, according to the necessary nursing hours for one hour of operating room, that is: standard nursing cares, 1,41 hours; complex nursing cares, 1,99 hours and differentiate nursing cares, 1,78 hours.

Patients with obstructive sleep apnea are at risk for perioperative morbidity. The authors used a screening prediction model for obstructive sleep apnea to generate a sleep apnea clinical score (SACS) that identified patients at high or low risk for obstructive sleep apnea. This was combined with postanesthesia care unit (PACU) monitoring with the aim of identifying patients at high risk of postoperative oxygen desaturation and respiratory complications. In this prospective cohort study, surgical patients with a hospital stay longer than 48 h who consented were enrolled. The SACS (high or low risk) was calculated; all patients were monitored in the PACU for recurrent episodes of bradypnea, apnea, desaturations, and pain-sedation mismatch. All patients underwent pulse oximetry postoperatively; complications were documented. Chi-square, two-sample t test, and logistic regression were used for analysis. The oxygen desaturation index (number of desaturations per hour) was calculated. Oxygen desaturation index and incidence of postoperative cardiorespiratory complications were primary endpoints. Six hundred ninety-three patients were enrolled. From multivariable logistic regression analysis, the likelihood of a postoperative oxygen desaturation index greater than 10 was increased with a high SACS (odds ratio = 1.9, P < 0.001) and recurrent PACU events (odds ratio = 1.5, P = 0.036). Postoperative respiratory events were also associated with a high SACS (odds ratio = 3.5, P < 0.001) and recurrent PACU events (odds ratio = 21.0, P < 0.001). Combination of an obstructive sleep apnea screening tool preoperatively (SACS) and recurrent PACU respiratory events was associated with a higher oxygen desaturation index and postoperative respiratory complications. A two-phase process to identify patients at higher risk for perioperative respiratory desaturations and complications may be useful to stratify and manage surgical patients postoperatively.

ABSTRACTIntroduction and Hypothesis: Sacrospinous ligament fixation(SSLF) is a commonly used surgical procedure in pelvic organ prolapse due to high treatment success rates. Many intraoperative and postoperative anesthesia-related obstacles may be encountered by the elderly population. Local anesthesia alone or with intravenous sedation may provide simple, cheap, and safe anesthesia. For elderly patients at high risk for general anesthesia according to the American Society of Anesthesiologists(ASA), it is better to operate through the vaginal route under local anesthesia. To perform minimal invasive SSLF surgery, the Pelvic Floor Repair Tissue Fixing Anchor, which is a target-specific system, can be used. In this prospective observational study, evaluation was made of elderly patients who underwent SSLF under local anesthesia. Materials and Methods: The study included 11 patients evaluated as high risk for general and regional anesthesia who underwent SSLF under local anesthesia as pelvic organ prolapse surgery. All operations were performed by a single experienced surgeon using 1% lidocaine infiltration and the Pelvic Floor Repair Tissue Fixing Anchor system. Results: The mean age of the patients was 69.6 years. Stage IV prolapse was determined in 7 (63.6%) patients, 4 (36.3%) had a history of hysterectomy, 5 (45.4%) were classified as ASA 3, and 6 (54.6%) as ASA 4. No complications occurred and patients were followed up for 24 months. In two patients, recurrence of POP was observed at postoperative 8 and 10 months, respectively. Conclusions: The results of this study demonstrated the surgical and anesthetic safety of SSLF under local anesthesia for pelvic organ prolapse in elderly patients.