Anesthesia Preparation Time Research Articles

Use of multidisciplinary positive deviance seminars to improve efficiency in a high-volume arthroplasty practice: a pilot study.

Positive deviance (PD) seminars, which have shown excellent results in improving the quality of surgical practices, use individual performance feedback to identify team members who outperform their peers; the strategies from those with exemplary performance are used to improve team members' practices. Our study aimed to use the PD approach with arthroplasty surgeons and nurses to identify multidisciplinary strategies and recommendations to improve operating room (OR) efficiency. We recruited 5 surgeons who performed high-volume primary arthroplasty and had participated in 4-joint rooms since 2012, and 29 nurses who had participated in 4-joint rooms and in at least 16 cases in our data set. Three 1-hour PD sessions were held in February and March 2021: 1 with surgeons, 1 with nurses, and 1 with both surgeons and nurses to select recommendations for implementation. The sessions were led by a member of the nonorthopedic surgical faculty who was familiar with the subjects discussed and with PD seminars. To determine the success of the recommendations, we compared OR efficiency before and after implementation. We defined success as performance of 4 joint procedures within 8 hours. Eleven recommendations were recorded from the session with nurses and 7 from the session with surgeons, of which 11 were selected for implementation. During the month after implementation, there were great improvements across all time intervals of surgical procedures, with the greatest improvements seen in mean anesthesia preparation time in the room (4.51 min [26.3%]), mean procedure duration (9.75 min [14.0%]) and mean anesthesia finish time (5.78 min [44.0%]) (all p < 0.001). The total time saved per day was 49.84 minutes; this led to a success rate of 69.0%, a relative increase of 73.8% from our 2012-2020 success rate of 39.7% (p < 0.001). The recommendations and increased motivation owing to the individualized feedback reduced time spent per case, allowing more days to finish on time. Positive deviance seminars offer an inexpensive, efficient and collegial means for process improvement in the OR.

A Canadian centre's experience with prone retroperitoneoscopic adrenalectomy.

Minimally invasive adrenalectomy is the standard of care for the surgical management of benign adrenal disease. The transperitoneal laparoscopic approach (TLA) is the most common approach used worldwide; however, many centres have adopted a posterior retroperitoneoscopic approach (PRA), as it is reported to offer several advantages. We describe our experience with PRA. We performed a retrospective review of the charts of patients who underwent minimally invasive adrenalectomy via PRA or TLA performed by a single endocrine surgeon between September 2010 and December 2019 at a tertiary academic centre in British Columbia, Canada. Patient and tumour characteristics, operative times and postoperative outcomes were compared between the 2 groups. During the study period, 58 patients underwent adrenalectomy via PRA, and 41 underwent adrenalectomy via TLA. The median American Society of Anesthesiologists score was higher in the TLA group than the PRA group (3.0 v. 2.6, p = 0.02). Adrenal glands were heavier in the TLA group than the PRA group (mean 63.4 g v. 19.2 g, p < 0.001). The mean anesthesia preparation time was shorter with PRA than with TLA (51.5 min v. 63.7 min, p < 0.001), as was mean operative time (77.9 min v. 118.4 min, p < 0.001) and mean hospital length of stay (2 d v. 4 d, p < 0.001). There was no difference in the complication rate between the 2 groups. Our study shows that PRA offers shorter operative time and length of stay for appropriately selected patients. Thus, it has become the preferred approach at our centre for minimally invasive adrenalectomy.

941 The Effect of COVID-19 on Orthopaedic Trauma Theatre Efficiency and Surgical Training in the North and East of Scotland Major Trauma Centres – a Year On

Abstract Aim To determine the orthopaedic trauma theatre efficiency in two large major trauma centres (MTCs) in Scotland before and after the outbreak of Coronavirus disease (COVID-19) pandemic. Method All trauma patients presented to the North and East of Scotland's MTCs prior to the outbreak of COVID-19 (7th May to 7th June 2019), during the first peak of COVID-19 (7th May to 7th June 2020), after Aerosol Generating Procedures updates (7th November to 7th December 2020) and the ‘new normal’ (7th May to 7th June 2021) were retrospectively reviewed. Training opportunities and theatre time were compared. The Kruskall-Wallis test was used. Results There were no significant differences in the length of hospital stay (p=0.117, 0.065) and time from injuries and surgery within groups in both MTCs (p=0.508, 0.384). The pandemic has negatively affected the anaesthetic and surgical preparation time, time between end of procedure and send for next case, and turnover time, with more profound effect on the North of Scotland's MTC. The trainee's involvement as main surgeon had decreased with the outbreak of the pandemic, with the junior trainees being affected most severely in North of Scotland. The time taken for patient to arrive to theatre after sending and total downtime were twice as long in the North of Scotland. Conclusion The COVID-19 pandemic has negatively impacted the orthopaedic trauma theatre efficiency and training opportunities. Actions should be taken to improve the turnover time to maximise theatre efficiency while prioritizing training opportunities.

The Effect of Humanized Nursing Intervention Guided by Computed Tomography Images on Elderly Patients Undergoing Anesthesia for Femur Intertrochanteric Fractures under Intelligent Reconstruction Algorithm.

This research was aimed at analyzing the effect of humanized nursing intervention combined with computed tomography (CT) imaging in the surgical anesthesia of femur intertrochanteric fractures (FIF) in the elderly. An image reconstruction algorithm was proposed based on nonlocal mean (NLM) algorithm, which was named as ONLM, and its performance was analyzed. A total of 114 elderly patients with FIF were equally and randomly divided into a humanized nursing group (57 cases) and a routine nursing group (57 cases). They were performed with CT imaging scan based on the ONLM algorithm, and the clinical indicators of the two groups of patients were recorded. The root mean square error (RMSE) and mean absolute error (MAE) of the CT images constructed using the ONLM algorithm were significantly lower than those using NLM algorithm, edge filtering algorithm, and total variation model, while the peak signal-to-noise ratio (PSNR) was the opposite (P < 0.05). The operation time, hospitalization days, intraoperative blood loss, postoperative drainage, and anesthesia preparation time of patients in the humanized nursing group were significantly lower than those in the routine nursing group. The number of patients with excellent Harris scores in the humanized nursing group was higher than that in the routine nursing group, and the number of patients with poor Harris scores was lower (P < 0.05). The language pain score, facial pain score, and visual analog simulation (VAS) scores of patients in the humanized nursing group were significantly lower than those in the routine nursing group. The numbers of postoperative hip varus and fracture nonunion cases in the humanized nursing group were significantly more than those in the routine nursing group. In short, CT images constructed by the ONLM showed higher performance than those by the traditional algorithm. In addition, CT images constructed by ONLM combined with humanized nursing intervention could more effectively improve the cooperation of patients with surgical anesthesia, reduce surgical pain and fear of patients, improve the prognosis of patients, and lower the occurrence of adverse events.

Prospective Elective Neurosurgical Theater Utilization Audit in Pakistan: Problems in a Public Tertiary Care Hospital and Proposed Solutions from Lower-Middle-Income Country.

Background In lower-middle-income countries such as Pakistan, public hospitals provide free healthcare but suffer from poor management and misgovernance, negatively impacting service provision. One aspect of this is operating theater time (OTT) utilization. In a 1,600-bed hospital with a 22 million catchment population, we noticed significant delays and inadequate OTT efficiency at the neurosurgery department of Jinnah Hospital, Lahore, Punjab, Pakistan. This audit aimed to analyze the neurosurgical OTT utilization, identify delays, and highlight managerial deficiencies and areas for improvement while comparing our workflow with contemporary international literature. Materials and Methods We prospectively audited OTT utilization at the neurosurgical department. All elective surgeries from January to April 2021 were included to identify delays concerning patient transfer, anesthesia team arrival, preparation and intubation time, operative time, and anesthesia extubation time. Results Fifty-six per cent of OTT was utilized operating. Sources of delay included the delayed arrival of anesthesia team (4.7%) and the delay in transferring patients to OT (9.7%). Anesthesia intubation and preparation time accounted for 23% of OT utilization and was significantly longer than the comparable international studies. Extubation time accounted for 5.7% of OT utilization. The issues surrounding transfer delays and prolonged anesthesia time were discussed, with strategies to address them developed with close vital input from our anesthesia colleagues and ward staff. Conclusion Gross delays relatively simple in nature were identified due to poor management and less than ideal interspecialty coordination. Most delays were avoidable and can be addressed by proper planning, optimization of patient transfer and resources, and, most importantly, improved communication between surgeons, anesthetists, and ward staff. This can ensure optimal use of theater time and benefit all specialties, including ancillary staff, and, most importantly, the patient. A reaudit is warranted to assess the impact of interventions on OTT utilization.

Anesthetic Management and Outcomes of Patients With Epidermolysis Bullosa: Experience at a Tertiary Referral Center.

Epidermolysis bullosa (EB) is a group of rare epithelial disorders caused by abnormal or absent structural proteins at the epidermal-dermal junction. As a result, patients experience blisters and wounds from mild shearing forces. Some forms of EB are complicated by resultant scarring and contractures. The perioperative anesthetic management of patients with EB is complex and requires a systems-based approach to limit harm. We reviewed our experience with providing general anesthesia to patients at our tertiary EB referral center, including adverse events related to anesthetic care, outcomes in the immediate perioperative period, and details of anesthetic management. We retrospectively reviewed the charts of all patients with EB anesthetized at the Children's Hospital Colorado between January 2011 and December 2016. A subset of pediatric anesthesiologists cared for all patients using a standardized clinical care pathway. Patient demographics, detailed anesthetic methods, immediate perioperative outcomes, and adverse events were characterized. Over a 6-year period, 37 patients underwent 202 general anesthetics. Most patients (75.7%) had dystrophic EB (DEB). Female patients comprised 48.6%. The majority (56.7%) traveled >50 miles to receive care, and many (35.1%) traveled >150 miles for their care. Common adaptations to care included avoidance of electrocardiogram leads (88.6%) and temperature probes (91.6%). Nasal fiberoptic intubation (n = 160) was performed, or natural airway/mask (n = 27) was maintained for most patients. Supraglottic devices were not used for airway management during any of the anesthetics. Anesthesia preparation time was longer (average 25.8 minutes [standard deviation {SD} = 12.7]) than our average institutional time (14 minutes). Succinylcholine was never used, and nondepolarizing muscle relaxants were used in only 1.5% of patient encounters. Blood was transfused in 16.3% of cases and iron infused in 24.8%. Average length of stay in the postanesthesia care unit was comparable to our institutional average (average 40.1 [SD = 28.6] vs 39 minutes). New skin or mucosal injury occurred in 8 encounters (4%), and desaturation occurred in 43 cases (21.3%). There were no major adverse events. By using a specialized team and a standardized clinical care pathway, our institution was able to minimize adverse events caused by the anesthetic and surgical care of patients with EB. We recommend natural airway or nasal fiberoptic airway management, meticulous avoidance of shear stress on the skin, and a multidisciplinary approach to care. Supportive therapy such as perioperative blood transfusions and iron infusions are feasible for the treatment of chronic anemia in this population.

Orthopaedic Trauma Theatre Efficiency in the COVID-19 Pandemic: Are We Returning to Normality?

BackgroundRecent studies have shown a decline in theatre efficiency and productivity coinciding with the coronavirus disease 2019 (COVID-19) pandemic. In this study, we evaluate trauma theatre task efficiency in three different time periods (April 2019, April 2020, and November 2020), and analyse if productivity has altered since the start of the pandemic.MethodsThe records of a total of 320 patients who underwent orthopaedic trauma surgery at a large district general hospital in April 2019, April 2020 (during the first wave of the pandemic) and November 2020 (during the second wave of the pandemic) were analysed. Primary outcomes measured include time to get to the theatre, anaesthetic preparation time, the sum of time of anaesthesia and surgical preparation time, duration of surgery and time to transfer to recovery. Patient demographics as well as the type of surgery were also analysed.ResultsThe time to get to the theatre and anaesthetic preparation time significantly increased in April 2020 (p<0.05) but fell in November 2020 with no significant difference in comparison to before the pandemic in April 2019 (p>0.05). The duration of surgery and time to transfer to recovery significantly increased in April 2020 (p<0.05) and though reduced in November 2020, was still significantly greater in comparison to April 2019 (p<0.05). In April 2020, the proportion of patients aged 18-65 was just 26% as compared to 35% in April 2019. This figure rose again to 45% in November 2020. The number of hip fracture procedures remained similar during the three time periods, with 32, 32 and 36 hip fracture operations in April 2019, April 2020 and November 2020, respectively.ConclusionWhile operating theatres' efficiency decreased during the first wave of the COVID-19 pandemic, it increased again in the second wave, coming close to the ‘normal’ levels before the pandemic struck.

Increased maternal body mass index is associated with prolonged anaesthetic and surgical times for caesarean delivery but is partially offset by clinician seniority and established epidural analgesia.

BackgroundObesity is associated with higher surgical and anaesthetic morbidity and difficulties.AimsWe aimed to investigate associations between maternal body mass index (BMI) and the in‐theatre time taken to produce an anaesthetised state or to perform surgery for caesarean delivery.Materials and MethodsUsing the Strengthening the Reporting of Observational Studies in Epidemiology guidelines, we identified all women who underwent caesarean section at a single institution (2009–2015). The prospectively collected data arising from antenatal and peripartum care were analysed. Generalised linear regression was used to examine associations between maternal BMI and the time taken to anaesthetise the mother and the duration of surgery.ResultsOf a total of 24 761 caesarean deliveries, 5607 (22.7%) women were obese at antenatal registration. In‐theatre anaesthetic preparation (18 vs 32 min, P < 0.001) and surgical duration (38 vs 52 min, P < 0.001) were longer in women with BMI ≥50 kg/m2 (BMI‐50) than those with normal BMI (BMI‐N). This difference remained significant after controlling for antenatal, intra‐operative and immediate postoperative variables. Modifiable variables were identified that may mitigate the effects of severe obesity. Senior obstetric and anaesthetic care were both independently associated with a significant reduction in mean in‐theatre anaesthetic preparation time and surgical duration, by 11 and three minutes respectively (P < 0.001), while epidural top‐up significantly lessened mean anaesthetic in‐theatre preparation duration by seven minutes (P < 0.001).ConclusionsObese women had greater anaesthesia and surgery time, but the effect may potentially be mitigated by provision of care by experienced staff and prior establishment of epidural analgesia.

A comparative study looking at trauma and orthopaedic operating efficiency in the COVID-19 era

BackgroudCOVID-19 has led to a reduction in operating efficiency. We aim to identify these inefficiencies and possible solutions as we begin to pursue a move to planned surgical care. MethodsAll trauma and orthopaedic emergency surgery were analysed for May 2019 and May 2020. Timing data was collated to look at the following: anaesthetic preparation time, anaesthetic time, surgical preparation time, surgical time, transfer to recovery time and turnaround time. Data for 2019 was collected retrospectively and data for 2020 was collected prospectively. ResultsA total of 222 patients underwent emergency orthopaedic surgery in May 2019 and 161 in May 2020. A statistically significant increase in all timings was demonstrated in 2020 apart from anaesthetic time which demonstrated a significant decrease. A subgroup analysis for hip fractures demonstrated a similar result. No increase in surgical time was observed in hand and wrist surgery or for debridement and washouts.Although the decrease in anaesthetic time is difficult to explain, this could be attributed to a reduction in combined anaesthetic techniques and possibly the effect of fear. The other increases in time demonstrated can largely be attributed to the PPE required for aerosol generating procedures and other measures taken to reduce spread of the virus. These procedures currently form a large amount of the orthopaedic case load. ConclusionCOVID-19 has led to significant reductions in operating room efficiency. This will have significant impact on waiting times. Increasing frequency of regional anaesthesia concurrently with non-aerosol generating surgeries may improve efficiency.

COVID-19 pandemic and hip fractures: impact and lessons learned.

AimsThe coronavirus disease (COVID)-19 pandemic forced an unprecedented period of challenge to the NHS in the UK where hip fractures in the elderly population are a major public health concern. There are approximately 76,000 hip fractures in the UK each year which make up a substantial proportion of the trauma workload of an average orthopaedic unit. This study aims to assess the impact of the COVID-19 pandemic on hip fracture care service and the emerging lessons to withstand any future outbreaks.MethodsData were collected retrospectively on 157 hip fractures admitted from March to May 2019 and 2020. The 2020 group was further subdivided into COVID-positive and COVID-negative. Data including the four-hour target, timing to imaging, hours to operation, anaesthetic and operative details, intraoperative complications, postoperative reviews, COVID status, Key Performance Indicators (KPIs), length of stay, postoperative complications, and the 30-day mortality were compiled from computer records and our local National Hip Fracture Database (NHFD) export data.ResultsHip fractures and inpatient falls significantly increased by 61.7% and 7.2% respectively in the 2020 group. A significant difference was found among the three groups regarding anaesthetic preparation time, anaesthetic time, and recovery time. The mortality rate in the 2020 COVID-positive group (36.8%) was significantly higher than both the 2020 COVID-negative and 2019 groups (11.5% and 11.7% respectively). The hospital stay was significantly higher in the COVID-positive group (mean of 24.21 days (SD 19.29)).ConclusionCOVID-19 has had notable effects on the hip fracture care service: hip fracture rates increased significantly. There were inefficiencies in theatre processes for which we have recommended the use of alternate theatres. COVID-19 infection increased the 30-day mortality and hospital stay in hip fractures. More research needs to be done to reduce this risk.Cite this article: Bone Joint Open 2020;1-9:530–540.

Use of erector spinae fascial plane blocks in open pancreatic surgery

Presenter: Hannah Wilcox | University of New Mexico Health Sciences Center Background: Bilateral erector spinae fascial plane blocks (ESPB) are a novel method of regional analgesia. The use of ESPB in abdominal surgery has sparked interest as an adjunct to opioid-sparing post-operative pain regimens. In this study, we describe our initial experience of ESPB in open pancreatectomy procedures. Methods: A retrospective analysis of a prospectively-maintained database was performed of all patients from August 2018 to March 2019 who received bilateral-ESPB for post-operative pain control after open pancreatectomy. Ultrasound-guided ESPB at the T7 or T8 level was performed in a cranial to caudal direction with infiltration of liposomal bupivacaine. Patient demographics, intraoperative and postoperative factors, including quality end points and intravenous morphine milligram equivalent (MME) requirements, were examined. Results: Twenty-nine patients met inclusion criteria, including 21 pancreaticoduodenectomy and 8 distal pancreatectomy patients. All incisions were via midline laparotomy. Diagnosis in 15 patients (52%) was ductal adenocarcinoma. Mean patient age was 66 years, and 48% were male (n=14). Average patient BMI was 28.7. Mean anesthesia preparation time was 82 minutes. Return of bowel function was a mean of 3.5 days post-operatively and urinary catheter removal was 1.8 days. Median hospital length of stay was 6.5 days. Seven patients were readmitted within 30 days of surgery (24%) and there were no deaths. Ten patients (34%) had complications within 30 days of surgery which included 3 superficial site infections, 2 organ space infections, 1 patient with atrial fibrillation, 1 patient with bleeding and 3 other causes. There were no recorded adverse events related to the ESPB procedure. No patients required rescue thoracic epidural catheter placement or intravenous patient controlled analgesia (PCA). Mean MME for first 72 hours after surgery was 40 mEq and 82 mEq for the entire inpatient stay. Nine patients received a mean of 18 mEq of opioid medications in the first 24 hours after surgery, followed by no further opioids. Three patients did not require any opioids after surgery. Conclusion: ESPB presents an effective and safe mode of regional analgesia in patients undergoing open pancreatectomy and shows promise as a key element in opioid-sparing post-operative pain regimens. The expanded role of ESPB in major abdominal surgery warrants further investigation.

Effect of PM2.5 on inflammatory factors and pathology of nasal mucosa in a rat model of allergic rhinitis

Objective: To investigate the effect of PM2.5 exposure on nasal inflammatory cytokines and nasal mucosal pathology in a rat model of allergic rhinitis (AR). Methods: Twenty-four healthy female SD rats were randomly divided into 3 groups by random number table method, with 8 rats in each group: normal control group (NC group), ovalbumin (OVA) induced AR model (AR group), and AR model group inhaled to PM2.5 at 200 μg/m(3), 3 h/d, for 30 d (ARE group). Nasal symptoms including sneezing, nasal rubs and nasal secretion were recorded. Levels of OVA specific IgE in serum, interleukin 6 (IL-6) and tumor necrosis factor-ɑ (TNF-ɑ) in nasal irrigating solution were measured by enzyme-linked immunosorbent assay (ELISA). The histopathological changes of nasal mucosa were observed by HE staining. SPSS 17.0 software was used to analyze the data. Results: The number of sneezing, nasal rubs and the amount of nasal secretion in the ARE group were significantly higher than that in the AR group and the NC group (number of sneezing (15.38±1.68) times/15 min vs (11.63±1.13) times/15 min vs (1.75±0.71) times/15 min, number of nasal rubs (27.75±2.12) times/15 min vs (21.25±2.96) times/15 min vs (5.25±1.04) times/15 min, amount of nasal secretion (18.90±2.07) mg vs (13.83±1.81) mg vs (3.78±0.41) mg, F values was 236.089, 224.139, 183.971, respectively, all P<0.001). Statistically significant differences in OVA specific IgE, IL-6 and TNF-ɑ levels were observed in ARE group exceeded AR group and NC group (OVA specific IgE (25.42±2.51) ng/ml vs (18.07±1.07) ng/ml vs (1.47±0.26) ng/ml, IL-6 (123.30±18.86) pg/ml vs (63.49±11.29) pg/ml vs (16.87±3.29) pg/ml, TNF-ɑ (162.50±38.15) pg/ml vs (72.96±11.28) pg/ml vs (27.52±4.15) pg/ml, F values was 481.604, 138.277, 63.938, respectively, all P<0.001). HE staining showed that the nasal epithelial cells of NC group were intact and neatly arranged. Nasal mucosa epithelial cells were arranged in disorder in AR group, with tissue structure swelling. Partial shedding of nasal epithelial cells, mucosal basement membrane thickening, submucosal tissue interstitial edema, vasodilation and gland hyperplasia were found in ARE group. Conclusion: An increase inflammatory factors level such as IL-6 and TNF-ɑ aggravates pathological damage of nasal mucosa in a rat model of AR by exposure to PM2.5.

Epidural analgesia versus fascial plane blocks: a critical appraisal in the context of hepatopancreaticobiliary enhanced recovery pathways

Background: Epidural analgesia (EA) is an effective method to both control post-operative pain and reduce perioperative complications after major abdominal surgery. However, with the introduction of Enhanced Recovery (ER) pathways, potential side effects associated with EA such as hypotension and oliguria are in conflict with core ER endpoints. Novel methods, collectively named facial plane blocks (FPB), offer a promising alternative, providing effective pain control while negating unwanted side effects associated with EA. This study compares EA to FPB in hepatopancreatobiliary surgery in an established ER practice. Methods: Data for 34 patients who underwent open liver, pancreas, or extrahepatic biliary surgery were prospectively acquired and retrospectively analyzed. Patients were randomly assigned into two arms, EA and FPB. The FPB group included three methods: transversus abdominis, quadratus lumborum, and erector spinae blocks. The route was based on the anesthesia provider’s preference. EA and FBP groups were compared on continuous variables (e.g. age, BMI) with Wilcoxon-Mann-Whitney test, binary variables (e.g. sex) with Fisher’s exact test, and categorical variables with >2 categories (e.g. ethnicity) were compared with chi-squared test. Results: 19 patients received EA and 15 FPB. There were no differences regarding age, sex, ethnicity, indication for surgery (benign vs. malignant), ECOG performance status and BMI between EA and FPB groups. The pre-incision anesthesia preparation time (73 vs 50 min, for the EA and FPB respectively; p < 0.001) and procedure time for the analgesia intervention (21 vs 13 min; p = 0.02) were both shorter in the FPB arm. Mean intraoperative intravenous colloid infusion was 296ml in the EA group vs 95ml in the FPB group (p = 0.03). Post-operatively, arterial hypotension (systolic blood pressure < 90 mmHg) was observed in 54% of EA vs 8% of the FPB patients (p = 0.03). FPB was also favorable in regards to Foley catheter removal and time to first ambulation, both being achieved 24 hours earlier. There was no statistically significant differences in pain scores between the two arms. Post-operative complications were not noted to differ between the two groups. Conclusion: In major open abdominal operations, there were no significant differences in pain scores or complications between FPB and EA. Our data suggest superiority of the former in several key ERAS endpoint domains. These outcomes will be further validated in a prospective randomized fashion. Of additional interest are the economic implications of FPB, potentially positively affecting operating room time and utilization.

The effect of an orthopedic specialty hospital on operating room efficiency in shoulder arthroplasty

Operating room (OR) time is a major cost to the health care system. Therefore, increasing OR efficiency to save time may be a cost-saving tool. This study analyzed OR efficiency in shoulder arthroplasty at an orthopedic specialty hospital (OSH) and a tertiary referral center (TRC). All primary shoulder arthroplasties performed at our OSH and TRC were identified (2013-2015). Manually matched cohorts from the OSH and TRC were compared for OR times. Three times (minutes) were recorded: anesthesia preparation time (APT; patient in room to skin incision), surgical time (ST; skin incision to skin closed), conclusion time (CT; skin closed to patient out of room). There were 136 primary shoulder arthroplasties performed at the OSH and matched with 136 at the TRC. OSH and TRC patients were similar in age (P = .95), body mass index (P = .97), Charlson Comorbidity Index (P = 1.000), sex (P = 1.000), procedure (P = 1.000), insurance status (P = .714), discharge destination (P = .287), and diagnoses (P = .354). These matched populations had similar ST (OSH: 110.0 ± 26.6 minutes, TRC: 113.4 ± 28.7 minutes; P = .307). APT (39.2 ± 8.0 minutes) and CT (7.6 ± 3.8 minutes) were shorter in the OSH patients than APT (46.3 ± 8.8 minutes; P < .001) and CT (11.2 ± 4.7 minutes; P < .001) in TRC patients. Total nonoperative time (sum of APT and CT) at the OSH (46.8 ± 8.9 minutes) was shorter than at the TRC (57.5 ± 10.4 minutes; P < .001). Despite similar patient populations and case complexity, the OR efficiency at an OSH was superior to a TRC. Further analysis is needed to determine the financial implications of this superior OR efficiency.

Attempted Development of a Tool to Predict Anesthesia Preparation Time From Patient-Related and Procedure-Related Characteristics

Operating room (OR) utilization generally ranges from 50% to 75%. Inefficiencies can arise from various factors, including prolonged anesthesia preparation time, defined as the period from induction of anesthesia until patients are considered ready for surgery. Our goal was to use patient-related and procedure-related factors to develop a model predicting anesthesia preparation time. From the electronic medical records of adults who had noncardiac surgery at the Cleveland Clinic Main Campus, we developed a model that used a dozen preoperative factors to predict anesthesia preparation time. The model was based on multivariable regression with "Least Absolute Shrinkage and Selection Operator" and 10-fold cross-validation. The overall performance of the final model was measured by R, which describes the proportion of the variance in anesthesia preparation time that is explained by the model. A total of 43,941 cases met inclusion and exclusion criteria. Our final model had only moderate discriminative ability. The estimated adjusted R for prediction model was 0.34 for the training data set and 0.27 for the testing data set. Using preoperative factors, we could explain only about a quarter of the variance in anesthesia preparation time-an amount that is probably of limited clinical value.

Cervical plexus anesthesia versus general anesthesia for anterior cervical discectomy and fusion surgery: A randomized clinical trial.

Both general anesthesia (GA) and cervical plexus anesthesia (CPA) can be used for anterior cervical discectomy and fusion (ACDF) surgery. The aim of this study was to evaluate the influence of anesthetic techniques on perioperative mortality and morbidity in patients undergoing cervical surgery.From January 2008 to December 2015, 356 patients who underwent 1-level ACDF for cervical spinal myelopathy were prospectively reviewed. They were assigned to receive GA (group A) and CPA (group B). The analgesic efficacy of the block was assessed by anesthesia preparation time, the maximum heart rate, and mean arterial blood pressure changes compared with the baseline, time of postoperative revival, and duration of recovery stay. Duration of surgery, blood loss, and anesthesia medical cost were also recorded. Numerical rating scale (NRS) was used to evaluate pain at different time points. Postoperative nausea and vomiting (PONV) was assessed, and postoperative average administered dosages of meperidine and metoclopramide were also recorded. The spinal surgeon satisfaction, anesthetist satisfaction, and patient satisfaction were assessed.Both the anesthesia induction time and postoperative revival time were longer in group A than that in group B; both the duration of surgery and recovery stay were also longer in group A than that in group B, whereas there was no difference in blood loss between the 2 groups. The average dosage of both meperidine and metoclopramide was more in group A than that in group B, and the anesthesia medical cost was greater in group A than that in group B. There were no significant differences in baseline data of systolic blood pressure, diastolic blood pressure, and heart rate between the 2 groups. But the intraoperative data of systolic blood pressure, diastolic blood pressure, and heart rate were higher/larger in group B than that in group A. In group A, there was no complaint of pain in the surgery procedure, but the pain increased after GA, with highest degree at 8 hours postoperation; then the pain degree decreased, and the NRS was 1 at 24 hours postoperation. In group B, intraoperative pain was NRS 4, and pain degree decreased from 4 hours postoperation; the NRS was 2 at 24 hours postoperation. The incidence of severe PONV was higher in group A than that in group B. There was no significant difference in the spinal surgeon satisfaction and anesthetist satisfaction for the anesthetic techniques. There was significant difference in patient satisfaction between the 2 groups, with high satisfaction for GA.General anesthesia is superior to CPA in maintaining better intraoperative hemodynamic stability and providing high patient satisfaction with no intraoperative pain for patients receiving ACDF, but it entails longer surgery and anesthesia time, and requires more postoperative analgesic and anesthesia cost.

Initial experience with percutaneous coronary sinus catheter placement in minimally invasive cardiac surgery in an academic center.

BackgroundPlacement of a percutaneous coronary sinus catheter (CSC) by an anesthesiologist for retrograde cardioplegia in minimally invasive cardiac surgery is relatively safe in experienced hands. However, the popularity of its placement remains limited to a small number of centers due to its perceived complexity and potential complications.MethodsWe retrospectively reviewed all cardiac cases performed by one surgeon between December 2009 and April 2012. The reviewed cases were divided into two groups: cardiac cases with percutaneous CSC placement (CSC group) and cardiac cases without placement (control group). Anesthesia preparation time (APT) was then compared between the CSC group and control group. In the CSC group, cases were further divided into two groups. One group contained cases with an APT of less than 90 min (success group) and the other contained cases with an APT greater than or equal to 90 min or cases with CSC placement failure (delay/failure group). Patients’ characteristics, type of surgery, and transesophageal echocardiography (TEE) findings were compared between the two groups (success group vs. delay/failure group) to identify variables associated with prolongation of the APT or CSC placement failure.ResultsPercutaneous CSC placement was required in 83 cases (CSC group). The catheter was successfully placed in 74 of those cases. We experienced one complication, coronary sinus injury after multiple attempts at placing the catheter. The mean APT was 102 ± 31 min in the CSC group (n = 81) and 42 ± 15 min in the control group (n = 285). We could not identify any variables associated with prolongation of the APT or catheter placement failure.ConclusionsThe success rate of the placement was 89.1 % in our academic center. On average, placing the CSC added approximately one additional hour to the APT. This time is not an accurate representation of true catheter placement time, as it included time for preparation of the CSC, TEE, and fluoroscopy. We experienced one documented complication (coronary sinus injury), which was immediately diagnosed by TEE and fluoroscopy in the operating room. No variables associated with prolongation of APT or CSC placement failure were identified.Electronic supplementary materialThe online version of this article (doi:10.1186/s12871-016-0203-4) contains supplementary material, which is available to authorized users.

Working toward benchmarks in orthopedic OR efficiency for joint replacement surgery in an academic centre.

The introduction of 4-joint operating rooms (ORs) to meet provincial wait time targets represented a major change in practice, providing an opportunity to optimize patient care within an OR time allotment of 8 hours. We reviewed our success rate completing 4 joint replacements within 8 hours and defined benchmarks for successful completion. We reviewed the surgeries performed in the 4-joint ORs between May and October 2012. Using prospectively collected data from the Surgical Information Management System, each surgery time was divided into the following components: anesthesia preparation time (APT), surgical preparation time (SPT), procedure duration, anesthesia finishing time (AFT) and turnover time. We defined success as 4 joint replacements being completed within the allotted time. We reviewed 49 4-joint OR days for a total of 196 joint surgeries. Of the 49 days, 24 (49%) were successful. Only 2 surgeons had a success rate greater than 50%. Significant predictors of success were APT (odds ratio 1.09, 95% confidence interval [CI] 1.02-1.16), procedure duration (odds ratio 1.02, 95% CI 1.00-1.05) and AFT (odds ratio 1.19, 95% CI 1.06-1.34). We calculated probabilities for each component and derived benchmark times corresponding to the probability of 0.60. These benchmarks were APT of 9 min, SPT of 14 min, procedure duration of 68 min, AFT of 4 min and turnover of 15 min. We established benchmark times for the successful completion of 4 primary joint replacements within an 8-hour shift. Targeted interventions could maximize OR efficiency and enhance multidisciplinary care delivery.

Anesthesia Preparation Time Is Not Affected by the Experience Level of the Resident Involved During His/Her First Month of Adult Cardiac Surgery

This study was designed to answer the question of whether the experience level of the resident on his/her first month of adult cardiothoracic anesthesiology has an impact on operating room efficiency in a large academic medical center. Traditionally, the resident's 1st month of cardiac anesthesia had been reserved for the clinical anesthesia (CA)-2 year of training. This study analyzed the impact on operating room efficiency of moving the 1st month of cardiac anesthesia into the CA-1 year. The authors hypothesized that there would be no difference in anesthesia preparation times (defined as the interval between "in-room" and "anesthesia-ready" times) between CA-1 and CA-2 residents on their 1st month of cardiac anesthesia. This study was retrospective and used an electronic anesthesia information management system database. This study was conducted on care provided at a single 450-bed academic medical center. This study included 12 residents in their 1st month of cardiac anesthesia. The anesthesia preparation time (defined as the interval between "in-room" and "anesthesia-ready" times) was measured for cases involving residents on their first month of cardiac anesthesia. Anesthesia preparation times for 6 CA-1 resident months and 6 CA-2 resident months (100 adult cardiac procedures in total) were analyzed (49 for the CA-1 residents and 51 for the CA-2s). There were no differences in preparation time between CA-1 and CA-2 residents as a group (p = 0.8169). The CA-1 residents had an unadjusted mean (±standard error) of 51.1 ± 3.18 minutes, whereas the CA-2 residents' unadjusted mean was 50.2 ± 2.41 minutes. Adjusting for case mix (valves v coronary artery bypass graft surgery), the CA-1 mean was 49.1 ± 5.22 minutes, whereas the CA-2 mean was 49.1 ± 4.54 minutes. These findings suggest that operating room efficiency as measured by the anesthesia preparation time may not be affected by the level of the resident on his/her 1st month of adult cardiac anesthesia.

The influence of various anesthesia techniques on postoperative recovery and discharge criteria among geriatric patients

OBJECTIVE:We aim to compare selective spinal anesthesia and general anesthesia with regard to postoperative recovery and fast‐track eligibility in day surgeries.MATERIALS AND METHOD:Sixty geriatric outpatient cases, with ASA II‐III physical status and requiring short‐duration transurethral intervention, were enrolled in the study. The cases were split into 2 groups: as general anesthesia (Group GA) and selective spinal anesthesia (Group SSA). Group GA (n = 30) received propofol 2 mg kg‐1 (until loss of eyelash reflex), remifentanil induction 0.5‐1 µg kg‐1, and laryngeal mask. Maintenance was achieved by 4‐6% desflurane in 60% N2O and 40% O2 along with remifentanil infusion at 0.05 µg /kg‐1 /min‐1. Drugs were discontinued after the withdrawal of the ureteroscope, and extubation was carried out with 100% O2. Group SSA (n = 30) received 0.5% spinal anesthesia via L4‐5 space by 0.5% hyperbaric bupivacaine 5 mg. Anesthesia preparation time, time to surgical anesthesia level, postoperative fast‐tracking, and time to White‐Song recovery score of 12, were noted. In the operating room, we evaluated hemodynamics, nausea/vomiting, surgeon and patient satisfaction with anesthesia, perioperative midazolam‐fentanyl administration, postoperative pain, and discharge time.RESULTS:Anesthesia preparation time, length of surgery, anesthesia‐related time in the operating room, time to sit, and time to walk were significantly low in Group GA (p<0.05), whereas time to fast‐track eligibility, length of stay in the PACU, discharge time, and other parameters were similar in both of the groups.CONCLUSION:While anesthesia preparation time, length of surgery, start time of surgery, time to sit, and time to walk were shorter in the General Anesthesia group, time to fast‐track eligibility, phase 1 recovery time, and discharge time were similar among patients subjected to selective spinal anesthesia.