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High-flow nasal cannula oxygen therapy versus conventional oxygen therapy in patients undergoing bronchoscopy: a retrospective study

BackgroundPatients undergoing bronchoscopy, particularly those with pre-existing hypoxemia, face a significant risk of further deterioration in their oxygen saturation levels. This heightened risk necessitates the provision of supplemental oxygen therapy throughout the procedure, rendering it mandatory. High-flow nasal cannula (HFNC) has been widely employed in the management of hypoxemic acute respiratory failure (ARF) in adults. Based on this, HFNC has been used in endoscopic procedures, but there are still few studies on HFNC in fiberoptic bronchoscopy (FOB) patients. The purpose of this study was to evaluate the comparative efficacy of HFNC with nasal cannula oxygen in maintaining adequate oxygen saturation during fiberoptic bronchoscopy in patients with pre-existing hypoxemia.MethodsWe retrospectively investigated 232 patients with hypoxemia who underwent bronchoscopy between January 2018 to August 2023 who received either HFNC or nasal cannula oxygen supplementation. The control group received nasal cannula oxygen, and the observation group received HFNC. The changes of oxygen saturation, heart rate, blood pressure and adverse events during the operation were compared between the two groups.ResultsThe patients were divided into the HFNC (n = 78) and nasal cannula oxygen (n = 154) groups. During FOB, although the lowest oxygen saturation (SpO2) was similar in both groups (intraoperative minimum SpO2 was defined as the lowest value of SpO2 occurring between the start of anesthesia and the end of the operation), the occurrence of the lowest SpO2 < 90% was significantly lower in the HFNC group (3.8% vs. 17.5%, p = 0.003). No serious complications were reported in either group, however, the overall incidence of general adverse events was 7.7% and 20.1% in the HFNC and conventional oxygen therapy (COT) groups, respectively (p = 0.015). Multifactorial analysis showed that higher arterial partial pressure of oxygen versus the fraction of inspired oxygen (PaO2/FiO2; P/F) was a protective factor against desaturation events (p = 0.032, OR = 0.990, 95% CI: 0.982–0.999). In patients with baseline PaO2/FiO2 ≥ 200 mmHg, the HFNC group exhibited smoother vital sign changes from pre-procedure to the end of bronchoscopy, although there were no significant differences between the two groups regarding the rates of deoxygenation events as well as adverse events.ConclusionThe use of HFNC therapy can effectively reduce the incidence of SpO2 < 90% during bronchoscopy in patients with hypoxemia. Additionally, HFNC significantly reduces the overall incidence of adverse events compared to COT. In patients with milder hypoxemia, its advantages in maintaining operational stability during bronchoscopy should not be overlooked.

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Background. Regional anesthesia has become widely used in routine anesthesiology practice, it is considered a safer method of anesthesia in older patients and those with concomitant pathology. Nevertheless, both general and regional anesthesia have side effects on the cardiovascular system. The cardiotoxic effect of anesthesia in one way or another is present with any variant of anesthesia. One of the most transparent signs is rhythm alterations on the ECG. These changes can occur not only intraoperatively, but also in the early postoperative period, have an asymptomatic clinical course. But the presence of these signs can have a negative impact on the patient’s prognosis. That is why we performed daily Holter monitoring for patients undergoing trauma surgery. The purpose of the study was to compare regional and general anesthesia as a risk factor for perioperative rhythm disturbances. Materials and methods. It was a 2-group observational study that included 120 trauma patients undergoing surgery using general (group GA) or regional anesthesia (group RA). Postoperative Holter monitoring lasted 24 hours. Further analysis of the recording included the assessment of the presence of ischemic changes or extrasystoles. Results. The incidence of ST-depression episodes within 24 perioperative hours was 10 % in the GA group compared to 3 % in the RA group. In the GA group, the percentage of extrasystole was significantly higher compared to the RA group: 1.5 ± 2.1 % versus 0.7 ± 1.3 % (p = 0.0145). An increase in Qtd was significantly higher in the GA group 15 minutes after the start of anesthesia (51.31 ± 23.09) compared to the RA group (40.70 ± 19.97; p = 0.008). At the same time, QT dispersion was statistically significantly higher in the RA group 1 hour after the start of anesthesia compared to the GA group — 38.22 ± 12.30 versus 50.1 ± 19.5 (p = 0.04). The QT interval was significantly longer in the GA group 15 minutes after the start of anesthesia: 440.00 ± 33.09 versus 400.70 ± 23.18 in the RA group (p = 0.04). One hour after the start of anesthesia, QTt was longer in the RA group: 390.22 ± 23.60 versus 410.1 ± 30.1 in the GA group (p = 0.05). Conclusions. Regional anesthesia has less hemodynamic effects and is the method of choice in patients with cardiovascular comorbidity. However, given the risk of cardiotoxicity due to the resorptive effect of the local anesthetic, in older patients and with existing risk factors, it is crucial to account for the arrhythmogenic effects of local anesthetics and adjust the dosage accordingly.

Comparison of intranasal versus intravenous dexmedetomidine in postoperative pain control in traumatic mandibular fractures surgery: a randomized clinical trial

Objective: Effective pain management in mandibular fractures is crucial due to the complications associated with opioids, such as respiratory depression and re-intubation. Non-opioid methods are therefore important. This study aims to compare the effectiveness, safety, and efficiency of intranasal (IN) versus intravenous (IV) dexmedetomidine (Dex) for reducing acute pain following mandibular surgery. Methods: This study was a randomized, double-blind clinical trial. All patients underwent general anesthesia, laryngoscopy, and intubation in a standardized manner. For the IN administration group, Dex was prescribed at a dose of 0.2 µ/kg (in the form of drops) half an hour before the start of anesthesia. For the IV administration group, Dex was administered at a dose of 0.5 µ/kg intravenously over ten minutes, half an hour before anesthesia. During the first 24 hours after surgery, pain intensity and the total amount of opioid medication (measured in mg of pethidine) were recorded for each patient. Results: There was no significant difference in pain intensity between the two groups in the post-anesthesia care unit (P=0.898), one hour (P=0.052) and 24 hours post-surgery (P=0.898). However, pain intensity was significantly lower in the IN Dex group at the second (P=0.044), fourth (P=0.041), sixth (P=0.048), and twelfth (P=0.025) hours. Total pethidine injected in the IN Dex group was significantly lower than in the IV Dex group (P=0.041). Conclusion: This study underscores the efficacy of IN Dex as a viable alternative for postoperative pain management in traumatic mandibular fracture surgeries

The impact of diurnal variations on emergence delirium following general anesthesia and surgery in children.

Emergence delirium (ED) is a widely recognized issue that prolongs mechanical ventilation and post-anesthesia care unit (PACU) resuscitation time, consequently increasing hospital costs and mortality. Postoperative disturbance in circadian rhythms, commonly leading to sleep disorders, has been identified as a significant risk factor for ED. However, the influence of surgery timing (morning vs. afternoon) on the incidence of ED in pediatric patients undergoing general anesthesia remains unknown. Patients aged 2-6 years who were operated on under general anesthesia with a bispectral index value between 50 and 60 were categorized based on anesthesia start time into either the morning surgery group (Group M, 8:00-12:00) or the afternoon surgery group (Group A, 13:00-17:00). The primary outcome was the post-extubation incidence of ED assessed by the Cornell Assessment of Pediatric Delirium (CAPD) score. Secondary outcomes included extubation time, duration of PACU stay, and adverse postoperative events and complications. We recruited a total of 560 patients, 280 in group M and 280 in group A. Compared to Group M, Group A exhibited a significantly higher incidence of ED (p < 0.001), elevated CAPD scores (p < 0.001), and prolonged PACU stays (p < 0.001). Notably, there was no significant difference in extubation time and anesthesia-related adverse events or other postoperative complications between the groups. Our study highlights that the time of surgery significantly affects the incidence of ED, CAPD scores, and PACU stay duration in children. Further validation of these findings may guide future strategies to reduce ED.

The Importance of Surgical Cutting Time as a Key Performance Indicator Alongside Touchtime Utilisation in Operating Theatre Efficiency Optimisation.

Aims The Getting It Right First Time(GIRFT) programme has set targets to achieve 85% touchtime utilisation by 2024/25. Touchtime utilisation is a measure of theatre productivity, defined as the time from the start of anaesthesia to the time a patient leaves the theatre for all cases on a defined theatre list as a percentage of total available theatre time. No published evidence examines touchtime utilisation as a measure of theatre efficiency and its correlation with surgical cutting time. This study aims to determine if there is a statistical relationship between touchtime utilisation and surgical cutting time, and whether the use of touchtime utilisation is sufficient to inform about surgical productivity. Methods A retrospective analysis of two orthopaedic theatres spanning 100 days at both a major trauma centre and an elective hospital in London was performed. Electronicrecords identifiedanaesthetic start time, knife-to-skin time, end-of-procedure time, and patient-leaving-theatre time. Time intervals were calculated and the relationship between touchtime utilisation and surgical cutting time was assessed using Pearson's correlation coefficient (r). Results The mean total touchtime was 403 minutes (SD, 84 minutes) at the major trauma centre and 383 minutes (SD, 103 minutes) at the elective hospital. The mean total surgical cutting time was 259 minutes(SD, 72 minutes) at the major trauma centre and 233 minutes (SD, 75 minutes) at the elective hospital, from a total available time of 510 minutes per list. There was a significant correlation between touchtime and surgical cutting time at both hospitals (elective hospital: r (198) = 0.815, p < 0.001; major trauma centre: r (198) = 0.892, p < 0.001). The mean touchtime utilisation was 79.31% for the major trauma centre and 75.20% for the elective hospital; however, the mean total surgical cutting time was 51% and 46%, respectively, of total available time. Conclusion Despite a good correlation between touchtime and surgical cutting time, the range between these measures suggests that using touchtime utilisation alone to measure theatre efficiency may not sufficiently inform about efficient practices. We suggest complementing touchtime utilisation data with surgical cutting time may provide more information to contextualise efficiencies or inefficiencies in an operating theatre.

A Retrospective Comparative Study of the Frequency of Hypotension in Pediatric Cardiac Catheterization under General Anesthesia: Remimazolam versus Sevoflurane

ObjectiveTo compare the incidence of hypotension between remimazolam and sevoflurane under general anesthesia for cardiac catheterization of congenital heart disease. DesignRetrospective observational study. SettingA single university hospital with 300 pediatric cardiac catheterizations by general anesthesia performed annually. ParticipantsPatients younger than 15 years who underwent cardiac catheterization under general anesthesia between March 1, 2021, and December 31, 2022. Exclusion criteria: general anesthesia maintained with other than remimazolam or sevoflurane, the administration of remifentanil, ASA score of 4–5, emergency procedures, and no direct arterial pressure measurement. InterventionsGeneral anesthesia was maintained with remimazolam or sevoflurane. Measurements and Main Results309 patients were analyzed, 28 in the remimazolam group and 281 in the sevoflurane group. Propensity score matching adjusted for confounding factors resulted in 28 patients in each arm, with no apparent differences in background factors. Hypotension was defined as a time-averaged area of systolic arterial pressure falling below 80% of the baseline from the start of anesthesia to the end of procedure that was > 1. Significance level: p < 0.05. The incidence of hypotension was 39.3% in the Remimazolam and 46.4% in the Sevoflurane with no significant difference (p=0.79), although the ratio of median systolic arterial pressure to the baseline was significantly higher in the Remimazolam: 91.4 (SD: 15.2)% vs 83.2 (SD: 11.4)% in the Sevoflurane (p=0.03). ConclusionsRemimazolam did not result in lower hypotension incidence than sevoflurane during pediatric cardiac catheterization for congenital heart disease, while maintaining significantly higher blood pressure overall.

Appendicectomy pathway: Insights from electronic medical records of a local health district in Australia

BackgroundThis study aims to identify the common pathways of appendicectomy, the most common emergency surgery in Australia’s public hospitals and any variations within a regional public health district in New South Wales, Australia. MethodsWe analyzed the electronic medical records of 3,943 patients who underwent appendicectomy between January 2014 and July 2020 at 2 hospitals in the Illawarra Shoalhaven Local Health District, New South Wales, Australia, using the PM2 approach for surgical pathway identification and subsequent statistical analyses. ResultsAmong 3,943 patients, 3,606 (91.5%) followed an 11-step main pathway: (1) emergency department admission, (2) surgery booking, (3) anesthesia start, (4) operating room entry, (5) surgery start, (6) surgery end, (7) anesthesia end, (8) operating room discharge, (9) postanesthesia care unit admission, (10) postanesthesia care unit discharge, and (11) hospital discharge. The median length of stay was 48.13 hours (interquartile range 32.74). The main pathway differed from either variation 1 (n = 246, 6.2%) or variation 2 (n = 30, 0.8%) only in the timing and location of anesthesia administration or conclusion. Variation 3 (n = 26, 0.7%) included patients who underwent appendicectomy twice, whereas variation 4 (n = 25, 0.6%) included patients booked for surgery before emergency department admission through community doctor referrals. Thirteen exceptional cases experienced combinations of the aforementioned pathways. The length of stay and phase durations varied between the main pathway and these variations. ConclusionThe appendicectomy pathway was largely standardized across the studied hospitals, with the location of anesthesia administration or conclusion affecting specific stages but not the overall length of stay. Only a complex 2-surgery pathway increased length of stay.

Peculiarities of anesthesia for caesarean section in patients with gestational diabetes mellitus

BACKGROUND: Women with gestational diabetes mellitus are at high risk of operative delivery. Meanwhile, hyperglycemia affects the metabolism of narcotic analgesics, while increasing their need. Thus, the anesthesiologist is faced with the question of what method of anesthesia to choose for a particular cesarean section. AIM: The aim of this study was to estimate the features of the perioperative period of cesarean section in patients with gestational diabetes mellitus. MATERIALS AND METHODS: This prospective, controlled, single-center study enrolled 101 patients who were delivered by planned cesarean sections from April to November 2023. Group 1 included patients with gestational diabetes mellitus on diet therapy (n = 28), group 2 comprised patients with gestational diabetes mellitus on insulin therapy (n = 29), and group 3 (control) included women with a normal pregnancy without carbohydrate metabolism disturbances (n = 44). RESULTS: The highest initial values of mean arterial pressure were in group 2 and amounted to 91.8 ± 7.0 mmHg. In group 1, the mean arterial pressure was within 89.1 ± 6.4 mmHg, and in group 3, that was 85.9 ± 9.1 mmHg, which was significant (p 0.05). The sympathetic block developed longer in patients of group 2. In group 1, the sensory block was recorded at the ThIV–ThV level after 10.1 minutes and the motor block (Bromage score 3) after 12.2 minutes compared to 7.8 and 8.6 minutes, respectively, in group 2, and 4.5 and 5.1 minutes, respectively, in group 3. In group 2, authors observed the most rapid regression of the block (79.4 minutes after the injection of local anesthetic), which required an earlier start of the transversus abdominis plane block (after 65.3 minutes). The sympathetic block regressed after 86.2 and 138.1 minutes in patients of groups 1 and 3, respectively (p 0.05), when the transversus abdominis plane block was performed. Thus, immediately after cesarean section, women with gestational diabetes mellitus (especially on insulin therapy) had a higher need for analgesics than those without gestational diabetes mellitus. CONCLUSIONS: During cesarean section under spinal anesthesia in patients with gestational diabetes mellitus, the rate of development of the sympathetic block is reduced (especially in women who received insulin therapy). At the same time, block regression in these patients occurs much faster, which requires an earlier start of postoperative anesthesia. An increased need for systemic analgesics has been demonstrated during the postoperative period in women with gestational diabetes mellitus, mainly with insulin therapy.

Association between perioperative flurbiprofen administration and acute kidney injury (AKI) in spine surgery: a retrospective cohort study

BackgroundThe association between nonsteroidal anti-inflammatory drugs (NSAIDs) and postoperative acute kidney injury (AKI) remains controversial, with limited studies specifically examining flurbiprofen. Therefore, this research aimed to investigate the association between intraoperative flurbiprofen administration and postoperative AKI.MethodsWe retrospectively identified a cohort of patients at the Third Xiangya Hospital of Central South University. A total of 3882 adult patients undergoing spinal surgery between January 1, 2012, and July 31, 2018, were included and classified into two groups: those receiving flurbiprofen (50 or 100 mg once, 5 min after anesthesia start) and those not receiving flurbiprofen. The primary endpoint was the incidence of AKI.ResultThe flurbiprofen group (4.4%) had a lower incidence of AKI compared to the non-flurbiprofen group (6.5%, P < 0.001). After adjusting for potential confounding variables, the multivariable regression analysis showed that the flurbiprofen group had a 49% reduced risk of postoperative AKI (OR 0.51; 95% CI 0.31 to 0.82) compared to the non-flurbiprofen group. Subgroup analysis indicated that flurbiprofen injection was associated with a reduced incidence of postoperative AKI in patients without diabetes (OR 0.61; 95% CI 0.19 to 0.74), surgical times of 2–5 h (OR 0.54; 95% CI 0.23 to 0.75), and preoperative anemia (OR 0.57; 95% CI 0.21 to 0.74).ConclusionThe study concluded that perioperative flurbiprofen treatment was associated with a lower risk of postoperative AKI in adult patients undergoing spinal surgery.

Peri-anesthetic Environmental and Occupational Exposure to Desflurane Waste Anesthetic Gas in a Large Animal Veterinary Hospital.

The goals were to determine the environmental levels of desflurane waste anesthetic gas and the desflurane occupational exposure of operating room staff during the anesthesia of large animal veterinary patients. Active environmental sampling was performed using single-beam infrared spectrophotometry. Passive sampling with dosimeter badges was used to measure the occupational exposure of anesthesia and operating room staff. Higher concentrations of desflurane (n = 16) were measured at all recovery timepoints relative to the concentrations measured at all locations and timepoints at the start of anesthesia and surgery ( P < 0.05). Time-weighted average desflurane concentrations from dosimeter badges (n = 310) were higher for anesthesia staff than for other operating room personnel ( P < 0.0001). The anesthetic recovery of large animal patients is a period of increased exposure to desflurane waste anesthetic gas for veterinary staff.

Perioperative Hypothermia in Elderly Patients During Pelvic Floor Reconstruction Surgery: An Observational Study.

The potential predictors of pelvic floor reconstruction surgery hypothermia remain unclear. This prospective cohort study was aimed at identifying these predictors and evaluating the outcomes associated with perioperative hypothermia. Elderly patients undergoing pelvic floor reconstruction surgery were consecutively enrolled from April 2023 to September 2023. Perioperative temperature was measured at preoperative (T1), every 15min after the start of anesthesia (T2), and 15min postoperative (T3) using a temperature probe. Perioperative hypothermia was defined as a core temperature below 36°C at any point during the procedure. Multivariate logistic regression analysis was conducted to determine factors associated with perioperative hypothermia. A total of 229 patients were included in the study, with 50.7% experiencing hypothermia. Multivariate analysis revealed that the surgical method involving pelvic floor combined with laparoscopy, preoperative temperature < 36.5°C, anesthesia duration ≥ 120min, and the high levels of anxiety were significantly associated with perioperative hypothermia. The predictive value of the multivariate model was 0.767 (95% CI, 0.706 to 0.828). This observational prospective study identified several predictive factors for perioperative hypothermia in elderly patients during pelvic floor reconstruction surgery. Strategies aimed at preventing perioperative hypothermia should target these factors. Further studies are required to assess the effectiveness of these strategies, specifically in elderly patients undergoing pelvic floor reconstruction surgery.

Comparison of the genotoxicity of propofol and desflurane using the comet assay in the lymphocytes of patients who underwent lumbar discectomy: A randomized trial.

To compare the genotoxic effects of desflurane and propofol using comet assay in patients undergoing elective discectomy surgery. This was a randomized controlled study. Patients who underwent elective lumbar discectomy under general anesthesia with propofol or desflurane were included in the study. Venous blood samples were obtained at 4 different time points: 5 minutes before anesthesia induction (T1), 2 hours after the start of anesthesia (T2), the first day after surgery (T3), and the fifth day following surgery (T4). Deoxyribonucleic acid damage in lymphocytes was assessed via the comet assay. A total of 30 patients, 15 in each group, were included in the analysis. The groups were similar in terms of age and gender distribution. There were no significant differences in demographics, duration of surgery, total remifentanil consumption, and total rocuronium bromide consumption. The comet assay revealed that head length, head intensity, tail intensity, tail moment at T1 were similar in the desflurane and propofol groups. Head length, tail length and tail moment measured in the desflurane group at T4 were significantly higher compared to the propofol group. Tail lengths of the desflurane group at T1, T2 and T3 were significantly higher than the corresponding values in the propofol group. Propofol and desflurane do not appear to induce DNA damage in lymphocytes. However, when the quantitative data were compared, it was determined that propofol had relatively lower genotoxic potential than desflurane.ClinicalTrials.gov Reg. No.: NCT05185167.

Time Is Ovary: Assessment of Current Latencies and Areas for Improvement in the Initial Assessment of Ovarian Torsion [ID 2683553

INTRODUCTION: Ovarian torsion is a gynecologic emergency with potential complications including reduced ovarian function, ovarian necrosis, and peritonitis. There are few studies that examine the effect of time from initial presentation to surgery on ovarian preservation. METHODS: We conducted an IRB-waived retrospective review of patients cared for at a single academic center from August 2018 to August 2023. The SlicerDicer tool in Epic was used to identify diagnostic laparoscopy performed by gynecologists for suspicion of ovarian torsion (n=60). We extracted times of key events and calculated corresponding latencies, including from initial presentation to examination, imaging, gynecologic consultation, and start of anesthesia. Patient characteristics, imaging findings, and surgical outcomes were noted. RESULTS: Patients undergoing diagnostic laparoscopy for suspected ovarian torsion were age 33 years on average. A pelvic examination was performed on initial evaluation in 20% of patients. Torsion was confirmed in 58% of patients (n=35), and 40% of these patients underwent oophorectomy. The average ovarian volume for patients with confirmed torsion was 241 and 57 cm3 in patients without torsion (P=.01, two-sample t-test). Although not statistically significant, patients who underwent oophorectomy experienced a longer time from presentation to anesthesia (n=14; 516 minutes) compared to those who underwent ovarian preservation procedures (n=21; 474 minutes). CONCLUSION: Patients with confirmed torsion had higher ovarian volumes on ultrasound. Interventions to reduce latencies may include strategies to expedite imaging results and fast-tracking consultation for patients with higher ovarian volumes.

Anesthesia start time documentation accuracy where peripheral nerve block is the primary anesthetic.

When used as the primary anesthetic, nerve blocks are not billed as separate procedures. In this scenario, the anesthesia start (AStart) time should include the block procedural time. We measured how often AStart time was documented before the nerve block was placed in the preoperative area, and compared cases where a block team performed the nerve block and cases where the intraoperative anesthesia attending supervised the nerve block. We hypothesized that the involvement of a regional anesthesia team would lead to more accurate documentation of AStart. We also estimated the lost revenue due to inaccurate start time documentation. The study population were patients undergoing surgery with a peripheral nerve block as the primary anesthetic. For this analysis, AStart occurring less than 10 min before the in-operating room time was defined as potentially inaccurate. Lost potential revenue was estimated by taking the difference between the documented time of local anesthetic administration and the documented AStart time. A total of 745 cases were analyzed. Overall, 439 cases (58%) cases were identified as having potentially inaccurate start times. There were higher rates of inaccurate AStart documentation by the block team (316/482, 65.5%) compared with blocks supervised by the in-room anesthesia attendings (123/263, 46.7%, p<0.001). Overall, the estimated loss in billable revenue during the study period was a total of $70 265. The performance of primary regional anesthesia procedure by a block team increased the incidence of inaccurate documentation and uncaptured potential revenue. There is need for education about accurate nerve block documentation for anesthesiologists, especially when separate teams are used.

Evaluation of the early use of norepinephrine in major abdominal surgery on medical and surgical postoperative complications: study protocol for a randomised controlled trial (EPON STUDY)

BackgroundPost-induction anaesthesia often promotes intraoperative hypotension (IOH) that can worsen postoperative outcomes. This study aims to assess the benefit of norepinephrine versus ephedrine at the induction of anaesthesia to prevent...

Improving Anesthesia Start Time Documentation Through a Departmental Education Initiative at Yale New Haven Hospital, New Haven, United States.

Background Reimbursement for anesthetic services in the United States utilizes a formula that incorporates procedural and patient factors with total anesthesia time. According to the Centers for Medicare & Medicaid Servicesand the American Society of Anesthesiologists, the period of billable time starts when the anesthesia practitioner assumes care of the patient and may include transport to the operating room from the preoperative holding area. In this report on a quality improvement effort, we implemented a departmental education initiative aimed at improving the accuracy of anesthesia start-time documentation. Methods Utilizing de-identified, internal data on surgical procedures at Yale New Haven Hospital (YNHH), New Haven, United States, the difference between documented anesthesia start and patient in-room time was determined for all cases. Those with a difference between 0-1 minute were assumed "likely underbilled," and the total revenue lost for these cases was estimated using a weighted average of institutional reimbursement per unit of time. A monthly, department-wide educational email was then introduced to inform practitioners about the guidelines around start-time documentation, and the percentage of "likely underbilled" cases and lost revenue estimates trended over a one-year period. Results Baseline data in December 2020 showed that of the 6,877 total surgical cases requiring anesthesia at YNHH, 55.1% (N=3,790) had an anesthesia start to in-room time of 0-1 minute, which were considered "likely underbilled." The average start-to-in-room time for properly recorded cases (44.9%, N=3,087) was 4.42 minutes. The baseline revenue lost in December 2020 for underbilled cases was estimated at $52,302. Over the one-year quality improvement initiative, the proportion of underbilled cases showed a downward trend, decreasing to 29.2% of total cases by November 2021. The estimate of revenue lost due to underbilling also showed a downward trend, decreasing to $29,300 in November 2021. Conclusion This quality improvement study demonstrated that a relatively simple, department-wide educational email sent monthly correlated with an improvement in anesthesia start-time documentation accuracy and a reduction in estimated revenue lost to underbilling over a one-year period.

Effects of positive end expiratory pressure during laryngeal mask airway anesthesia on respiratory parameters and abdominal pain in cataract surgery

Introduction: The purpose of this study was to evaluate the effects of positive end expiratory pressure (PEEP) on respiratory parameters and abdominal pain in patients ventilated with a laryngeal mask during cataract surgery. Methods: This clinical trial study included 80 patients in need of cataract surgery (40 in the group without PEEP and 40 in the group with PEEP at 5 cmH2O) who underwent laryngeal mask ventilation during general anesthesia. The parameters of dynamic compliance, pressure peak (Ppeak), tidal volume, SpO2, EtCO2, heart rate, non-invasive blood pressure, and abdominal pain were recorded at intervals of 1, 5, 10, and 20 minutes after the start of anesthesia and were compared between the two groups. Results: Respiratory parameters, heart rate and systolic and diastolic blood pressure were not significantly different between two groups, and only the mean tidal volume at 5, 10, and 20 minutes was significantly higher in the group without PEEP. Conclusion: Application of 5 cmH2O PEEP during ventilation with laryngeal mask in patients undergoing cataract surgery had no significant effect on improving respiratory parameters and pain in the gastric area.

Prophylactic effect of chamomile on post-dural puncture headache in women undergoing elective cesarean section: A randomized, double blind, placebo-controlled clinical trial

BackgroundPost-dural puncture headache (PDPH) is a common complication after spinal anesthesia, affecting patient recovery. This study evaluated the prophylactic effect of topical chamomile ointment on PDPH in women undergoing elective cesarean section. MethodsIn a randomized, double-blind, placebo-controlled clinical trial 148 pregnant women were randomized into two parallel groups and received 3cc of the chamomile or the placebo ointment on the forehead of the participants 20 minutes before the start of spinal anesthesia, and then 2 and 4 hours after that. The primary outcomes were the incidence rate of headache, and its severity assessed by a numeric rating scale (NRS), while secondary outcomes included analgesic consumption, frequency of nausea/vomiting, and adverse events. ResultsChamomile ointment exhibited significant preventive effects on PDPH incidence compared to placebo. The chamomile group demonstrated lower rates of PDPH at 6 hours (3.5% vs. 7.18%, p = 0.021) and 12 hours (7.6% vs. 20%, p = 0.028) after spinal anesthesia. Analgesic consumption, frequency of nausea/vomiting, and adverse events were comparable between the groups. ConclusionTopical chamomile ointment demonstrated significant preventive effects on PDPH incidence compared to placebo. Chamomile ointment could be a promising adjunctive approach to prevent PDPH, enhancing patient comfort and potentially reducing the need for analgesics. Further investigation is needed to explore its mechanisms and broader applications.

EFFECT OF MANNITOL ON ELECTROLYTES AND ITS RELATION WITH KIDNEY INJURY IN CARDIOPULMONARY BYPASS

The optimal composition of the priming solution used in cardiopulmonary bypass (CPB) during human cardiac surgery is still uncertain. Mannitol is a common component of CPB priming solutions, but its efficacy is debated. To clarify the effect of mannitol on CPB prime solutions, a prospective, randomized, double-blind trial was conducted on 40 patients with sound cardiac and renal functions who were undergoing coronary artery bypass grafting. The trial included two groups: one received Ringer's acetate-based prime (n = 20), and the other received a combination of Ringer's acetate and 200 mL mannitol as prime (n = 20). The study examined changes in renal-related parameters, electrolytes, osmolality, and acid-base balance. Interestingly, no significant differences in osmolality were observed between the Mannitol and Ringer's acetate groups. However, the Mannitol group showed a significant decrease in sodium levels from 138.7±2.8 mmol/L at the start of anesthesia to 133.9±2.6 mmol/L after the initiation of CPB (p &lt;0.001). Renal parameters remained consistent across groups, except for a temporary effect of mannitol on post-surgery urine output (p = 0.003). In conclusion, this study found no significant differences in osmolality between Ringer's acetate-based prime and Mannitol-based prime in individuals with healthy cardiac and renal function. However, the addition of mannitol to the prime resulted in a significant, albeit short-term, reduction in sodium levels. These findings contribute to the ongoing discourse on optimizing CPB prime solutions, especially in cardiac surgical procedures involving mannitol inclusion.

FTP7.7 Does bilateral combined Transversus Abdominis Plane (TAP) and rectus sheath block reduce postoperative pain after “hot laparoscopic cholecystectomy” compared to trocar site local anaesthetic infiltration?

Abstract Introduction Post-operative pain is the commonest reason for prolonged hospital stay and readmission following laparoscopic cholecystectomy. We aim to assess whether bilateral transversus abdominis plane (TAP) and rectus sheath block reduces post-operative pain compared to local anaesthetic (LA) wound infiltration following “hot” laparoscopic cholecystectomies. Methods Prospective study involving 15 patients who underwent laparoscopic cholecystectomy in dedicated “hot lists” between October and December 2022. Post-operative pain scores were recorded 4 hours, 3 days, and 5 days post-procedure. Pain scores of patients who received bilateral TAP and rectus sheath blocks were compared with those who received LA wound infiltration with 0.5% Levobupivacaine. Results 9 patients received TAP and rectus sheath blocks, and 6 patients received LA infiltration. The time from start of anaesthesia to start of surgery in the TAP block group was significantly higher than the LA group (P=0.039). There was no statistical difference in pain scores on the pain analogue scale (1-10) between groups at 4 hours (P=0.73), 3 days (P=0.27), or 5 days (P=0.33) post-surgery. There was no statistical difference between the 2 groups in length of hospital stay post-procedure (P=0.75), or in re-admission rates due to poorly controlled post-operative pain (P=0.58). Conclusion Bilateral TAP and rectus sheath blocks do not significantly reduce pain post “hot laparoscopic cholecystectomy” any more than LA wound infiltration. Given the extra time taken to perform TAP and rectus sheath blocks, a larger study population would be required to more reliably assess their benefits, given the importance of avoiding overrunning of the “hot list”.