Postanesthesia Care Unit Length Research Articles

Nalbuphine in Pediatric Emergence Agitation Following Cochlear Implantation: A Randomized Trial.

To investigate the effects of nalbuphine on emergency agitation (EA), which affects up to 80% of the children following otolaryngology procedures, in children undergoing cochlear implantation. A prospective double-blinded randomized controlled clinical trial was conducted between November 2020 and October 2022. Eligible children, aged 6 months to 3 years old, were randomly assigned to either 0.1 mg/kg, 0.15 mg/kg, 0.2 mg/kg nalbuphine or 0.9% saline groups. EA was defined by the Pediatric Anesthesia Emergence Delirium (PAED) score ≥10. Extubation time, post-anesthesia care unit (PACU) length of stay, severe EA (PAED ≥ 15), peak PAED score, the Faces, Legs, Activity, Cry, and Consolability (FLACC) scale, Ramsay sedation score, and adverse events were also recorded. A total of 104 children were enrolled, with 26 children in each group. Nalbuphine significantly reduced the EA occurrence from 73.1% in the saline group to 38.5%, 30.8%, and 26.9% in the 0.1 mg/kg, 0.15 mg/kg, and 0.2 mg/kg nalbuphine groups, respectively (P < 0.001), without affecting the extubation time and PACU length of stay. More children (34.6%) in the 0.9% saline group experienced severe EA. Higher dose nalbuphine (0.15 mg/kg, 0.2 mg/kg) showed lower peak PAED score, better analgesia and sedation effect compared with 0.1 mg/kg nalbuphine and saline groups. However, 0.2mg/kg nalbuphine caused undesired over-sedation in two (7.7%) children. No other adverse events were reported. Young children undergoing cochlear implantation surgery were at a high risk of EA and postoperative pain, while 0.2 mg/kg nalbuphine might be an ideal candidate for EA and pain prevention when used under close monitoring. ChiCTR2000040407.

Implementation of Continuous Capnography Protocol in a Postanesthesia Care Unit for Adult Patients at High-risk of Postoperative Respiratory Depression

PurposeThis project aimed to implement a continuous capnography protocol in the postanesthesia care unit (PACU) for postoperative adult patients who are at high risk for respiratory failure. DesignA preintervention and postintervention quality improvement design with retrospective chart reviews evaluated patient demographics (age, weight, body mass index [BMI], perioperative fluid intake and output, use of intraoperative positive-end expiratory pressure), length of surgery, average length of PACU stay, incidence of respiratory events, and adherence to a PACU capnography protocol. MethodsPreimplementation data were collected from retrospective chart reviews over a 3-month period. A continuous capnography protocol was implemented for same-day surgery patients with a BMI of 35 kg/m2 or greater and who received general anesthesia. Postimplementation data were collected over 3 months in addition to adherence to the capnography protocol. This was presented using descriptive statistics. FindingsAge, length of surgery, weight, BMI, perioperative fluid intake and output, and use of positive-end expiratory pressure did not impact PACU length of stay. The average PACU length of stay decreased from 76.76 to 71.82 minutes postimplementation but was not statistically significant (P = .470). The incidence of respiratory events was 6% (n = 3). After the implementation of the continuous capnography protocol, adherence to the continuous capnography monitoring was 86% (n = 43). ConclusionsPatients who are at high risk for postoperative respiratory failure may benefit from continuous capnography monitoring in the PACU. Capnography monitoring may decrease PACU length of stay and provide earlier detection of pending respiratory depression or failure than pulse oximetry alone.

Using Clinical-based Discharge Criteria to Discharge Patients After Endoscopy Procedures Under Drug-induced Intravenous Sedation in the Outpatient Care Unit: An Observational Study

PurposeTo verify the feasibility of clinical-based discharge (CBD) criteria and to find out the reasons for the delayed discharge of outpatients after endoscopy procedures under drug-induced intravenous sedation. DesignA prospectively observational study conducted at a tertiary endoscopy center. MethodsMedical records were collected from outpatients admitted for endoscopy procedures under drug-induced intravenous sedation from June 1, 2021 to December 30, 2021. Patients were scheduled to discharge at least 30 minutes based on the time-based discharge (TBD) method. Postanesthetic discharge scoring system in the outpatient post-anesthesia care unit (PACU) recorded the time of patients discharged home on the CBD criteria. Postoperative complications were recorded in the PACU and within 24 hours after discharge. Multivariate analysis was applied to identify the factors relating to late discharges. Findings10,597 patients were safely and successfully discharged home, and we were informed of no serious emergency or accidental readmissions to the hospital. The mean CBD time (21.77 ± 11.35 minutes) was compared with the TBD time (30 minutes) and actual TBD discharge time (61.56 ± 4.93 minutes), which were statistically significant, without changes in the patient's vital signs (P < .01). Primarily, further univariate and multivariate analyses showed that abdominal pain and fatigue were key factors accountable for delay in PACU discharge (P < .05). ConclusionsThe study concluded that in patients undergoing ambulatory endoscopy procedures with drug-induced intravenous sedation, discharge times based on physiological scoring systems can efficiently and safely guide ambulatory patient discharge as compared to the traditional TBD method. Postoperative fatigue and pain were the main factors affecting patients discharge associated with a relatively long PACU length of stay.

The Effect of Different Propofol-Ketamine Combinations on Emergence Delirium in Children Undergoing Adenoidectomy and Tonsillectomy Surgery

PurposeEmergence delirium (ED) after sevoflurane anesthesia remains a serious issue in children. We aimed to compare different ratios of propofol-ketamine combinations to determine a better option for preventing ED. DesignA prospective, randomized clinical trial. MethodsIn this study, 112 children aged between 3 and 12 years who underwent adenoidectomy and tonsillectomy were recruited. Propofol 1 mg kg−1 + ketamine 1 mg kg−1 (1:1 ratio), propofol 1.5 mg kg−1 + ketamine 0.75 mg kg−1 (2:1 ratio), propofol 2 mg kg−1 + ketamine 0.66 mg kg−1 (3:1 ratio), and propofol 3 mg kg−1 were applied at induction of anesthesia for Groups I, II, III, and IV, respectively. Fentanyl 1 mcg kg−1 and rocuronium 0.6 mg kg−1 were applied at induction, and anesthesia was maintained with sevoflurane and O2/N2O mixture for all participants. Intravenous morphine 0.1 mg kg−1 was applied for postoperative analgesia in the last 10 minutes of surgery. ED was defined as a Watcha score of ≥3. Demographics, hemodynamics, extubation time, Watcha scores, the Face, Legs, Activity, Cry, and Consolability scores, length of stay in the postanesthesia care unit (PACU), rescue analgesic requirement, and postoperative complications were recorded. FindingsED was significantly higher at 10 and 20 minutes in Group IV. Eighteen children experienced ED in PACU, (3, 2, 2, and 11 children in Groups I, II, III, and IV, respectively). Face, Legs, Activity, Cry, and Consolability scores were significantly different at all times. Rescue analgesics were required by 3 children (10.7%) in Group I, 2 (7.1%) in Group II, 2 (7.1%) in Group III, and 10 (35.7%) in Group IV (P = .012). The PACU stay was 21.9 ± 6.4 in Group I, 18.7 ± 6.3 in Group II, 16.7 ± 5.8 in Group III, and 17.4 ± 5.8 in Group IV. Nystagmus was observed in three children in Group I. ConclusionsTo addition of ketamine to propofol during the induction of sevoflurane anesthesia can reduce the ED and analgesic requirements in children. A propofol-to-ketamine ratio of 3:1 provided better postoperative recovery with less pain and ED, without prolonging the PACU length of stay.

Respiratory Depression Following Intraoperative Methadone: A Retrospective Cohort Study.

Methadone is used as a perioperative analgesic in the management of postoperative pain. Despite positive outcomes from randomized trials favoring methadone, concerns about its safety persist, particularly regarding respiratory depression (RD) and excessive sedation. In this study, we compared the incidence of naloxone administration between patients administered intraoperative methadone and those administered intraoperative morphine as a measure of severe RD. Time spent at the postanesthesia care unit (PACU) was used as a proxy variable for excessive sedation. This was a retrospective cohort study including all patients aged ≥18 years who underwent surgery between March 2019 and March 2023 at Aarhus University Hospital, Denmark. We assessed the association between intraoperative administration of either methadone or morphine and postoperative naloxone administration within the first 24 hours using logistic regression (primary outcome). An analogous linear regression model was used for the secondary outcome of time spent in the PACU after surgery. Patients were weighted using propensity scores to adjust for potential confounding variables. A total of 14,522 patients were included in the analysis. Among the 2437 patients who received intraoperative methadone, 15 (0.62%) patients received naloxone within the first 24 hours after surgery compared to 68 of 12,0885 (0.56%) who received intraoperative morphine. No statistical difference was observed in the odds of naloxone administration between patients administered methadone or morphine (adjusted odds ratio 95% confidence interval [CI], 1.21 [0.40-2.02]). Patients who were administered intraoperative methadone had a mean PACU length of stay (LOS) of 334 minutes (standard deviation [SD], 382) compared to 195 minutes (SD, 228) for those administered intraoperative morphine. The adjusted PACU LOS of patients administered intraoperative methadone was 26% longer compared to those administered intraoperative morphine (adjusted ratio of the geometric means 95% CI, 1.26 [1.22-1.31]). The incidence of naloxone administration to treat severe RD was low. No difference was observed in the odds of naloxone administration to treat severe RD between patients administered intraoperative methadone or intraoperative morphine. Intraoperative methadone was associated with longer stays at the PACU; however, this result should be interpreted with care. Our findings suggest that intraoperative methadone has a safety profile comparable to that of morphine with regard to severe RD.

Comparison of Remimazolam Tosilate and Propofol Sedation on the Early Postoperative Quality of Recovery in Patients Undergoing Day Surgery: A Prospective Randomized Controlled Trial.

Remimazolam tosilate is a novel ultrafast-acting benzodiazepine that has a rapid emergence even after continuous infusion when using flumazenil. So far, relatively few articles are still focusing on the quality of recovery after general anesthesia with remimazolam, especially in day surgery. This study aimed to compare the early postoperative quality of recovery of remimazolam tosilate with flumazenil and propofol in patients undergoing day surgery. 137 patients scheduled for day surgery were randomly divided into the remimazolam tosilate or propofol group. The primary endpoint was the incidence of overall recovery assessed with the early postoperative quality of recovery scale (PostopQRS) on postoperative day 1 (POD 1). The Richmond Agitation-Sedation Scale (RASS) scores in the post-anesthesia care unit (PACU), extubation time, postoperative recovery profiles, and perioperative data were documented. Any adverse events were recorded. The incidence of overall recovery on POD1 was 47.7% in the remimazolam tosilate group and 65.1% in the propofol group (odds ratio, 0.52; 95% confidence interval (CI) 0.26 to 1.06; P = 0.072). In general, the overall recovery of the PostopQRS increased over time, and its interaction between time and group was significant (P = 0.003). Among the five dimensions of PostopQRS, there exist statistical differences between groups including emotional state and cognitive recovery. Upon arrival at the PACU, the remimazolam group was more sedated and took longer to recover to a RASS score similar to propofol. The frequency of application of vasoactive drugs during anesthesia was similar in both groups (P = 0.119). Despite rapid emergence with remimazolam after flumazenil reversal, re-sedation (10.8%) or somnolence (60%) in the PACU was observed, and the length of PACU stay in patients treated with remimazolam tosilate was longer than that of the propofol (35 min vs 30 min, P<0.001). General anesthesia with remimazolam tosilate in conjunction with flumazenil reversal permits rapid recovery of consciousness in day surgery, but there was a notable occurrence of re-sedation or somnolence observed in PACU.

Use and Clinical Relevancy of Pericapsular Nerve Block (PENG) in Total Hip Arthroplasty: A Systematic Review and Meta-analysis.

Ultrasound-guided pericapsular nerve group (PENG) block is an emerging regional anesthesia technique that may provide analgesia for patients undergoing total hip arthroplasties (THA). There are clinical studies comparing this fascial plane block to other established methods; however, evidence on the actual efficacy of this block for THA continues to evolve. Available clinical studies conducted over the past 4 years were reviewed to evaluate the analgesic efficacy and effectiveness of PENG block in patients undergoing THAs. A meta-analysis of randomized controlled trials (RCTs) in patients undergoing THA, where PENG block was compared to no block, placebo/sham block (injection with saline), or other analgesic techniques including suprainguinal fascia iliaca block (FIB), or periarticular infiltration (PAI) was performed. Our primary outcome was opioid consumption during the first 24 hours. Secondary outcomes were postoperative rest and dynamic pain scores at 6-12, 24 and 48 hours, block performance time, sensory-motor assessment, quadriceps weakness, the incidence of postoperative falls, first analgesic request, block and opioid-related complications, surgical complications, patient satisfaction scores, postanesthesia care unit length of stay, hospital length of stay, and functional and quality of life outcomes. We included 12 RCTs with a total of 705 patients. Data showed that PENG block decreased 24-hour oral morphine milligram equivalent consumption by a mean difference (MD) of 3.75mg (95% CI: -5.96,-1.54; P =0.0009). No statistically significant differences in rest or dynamic pain were found, except for a modest MD reduction in dynamic pain score of 0.55 points (95% CI: -0.98, -0.12; P =0.01), measured 24 hours after surgery in favor of PENG block. Our systematic review and meta-analysis suggest that PENG block provides better analgesia, measured as MME use, in the first 24 hours after THA, with no real impact on postoperative VAS scores. Despite statistical significance, the high heterogeneity across RCTs implies that PENG's benefits may not surpass the minimal clinically important difference threshold for us to recommend PENG as best practice in THA.

Association of dexmedetomidine use with haemodynamics, postoperative recovery, and cost in paediatric anaesthesia: a hospital registry study

BackgroundDexmedetomidine utilisation in paediatric patients is increasing. We hypothesised that intraoperative use of dexmedetomidine in children is associated with longer postanaesthesia care unit length of stay, higher healthcare costs, and side-effects. MethodsWe analysed data from paediatric patients (aged 0–12 yr) between 2016 and 2021 in the Bronx, NY, USA. We matched our cohort with the Healthcare Cost and Utilization Project-Kids’ Inpatient Database (HCUP-KID). ResultsAmong 18 104 paediatric patients, intraoperative dexmedetomidine utilisation increased from 51.7% to 85.7% between 2016 and 2021 (P<0.001). Dexmedetomidine was dose-dependently associated with a longer postanaesthesia care unit length of stay (adjusted absolute difference [ADadj] 19.7 min; 95% confidence interval [CI]: 18.0–21.4 min; P<0.001, median length of stay of 122 vs 98 min). The association was magnified in children aged ≤2 yr undergoing short (≤60 min) ambulatory procedures (ADadj 33.3 min; 95% CI: 26.3–40.7 min; P<0.001; P-for-interaction <0.001). Dexmedetomidine was associated with higher total hospital costs of USD 1311 (95% CI: USD 835–1800), higher odds of intraoperative mean arterial blood pressure below 55 mm Hg (adjusted odds ratio [ORadj] 1.27; 95% CI: 1.16–1.39; P<0.001), and higher odds of heart rate below 100 beats min−1 (ORadj 1.32; 95% CI: 1.21–1.45; P<0.001), with no preventive effects on emergence delirium requiring postanaesthesia i.v. sedatives (ORadj 1.67; 95% CI: 1.04–2.68; P=0.034). ConclusionsIntraoperative use of dexmedetomidine is associated with unwarranted haemodynamic effects, longer postanaesthesia care unit length of stay, and higher costs, without preventive effects on emergence delirium.

Spinal versus general anesthesia for hip arthroscopy—a pandemic (COVID) and epidemic (opioid) driven study

ABSTRACT The purpose of this study is to compare general anesthesia (GA) to spinal anesthesia (SA) for hip arthroscopy, based on measurable perioperative parameters. The pandemic signaled a change from GA to SA, and thus a retrospective review was performed of the first 120 consecutive SA cases compared to the last 120 GA cases prior to the pandemic. Demographic data included age, sex, BMI, preop narcotic usage and procedure performed. The groups were compared for post-anesthesia care unit length of stay, entry and discharge visual analog scale (VAS) scores, morphine mg equivalent usage, need for regional blocks and untoward events. Additionally, the length of time from entry to the operating room until completion of induction anesthesia was compared. Demographically, the groups were virtually identical. SA used significantly less morphine mg equivalent (6.0 versus 8.1; P = 0.005), had more needing no narcotics (17 versus 7; P = 0.031), fewer requiring blocks (1 versus 14; P = 0.001) and lower entry VAS scores (5.2 versus 6.2; P = 0.003). Five early SA patients required catheterization for urinary retention, and this was avoided later in the study by having patient void on call to operating room and avoiding anticholinergic agents. Completion of induction anesthesia was 0.8 min longer for SA. Hip arthroscopy can be effectively performed with either GA or SA. SA results in statistically significant better post-anesthesia care unit pain control, reflected by lower entry VAS, less need for narcotics and fewer requiring regional blocks compared to GA. Urinary retention, a potential problem of SA, is minimized with routine precautions.

Impact of Replacing Fentanyl With Hydromorphone as the First-Line Postoperative Opioid Among Patients Undergoing Outpatient Cancer Surgery

In response to a nationwide fentanyl shortage, our institution assessed whether changing our first-line postoperative intravenous opioid from fentanyl to hydromorphone impacted patient outcomes. The primary research aim was to evaluate the association between first-line opioid and rapidity of recovery. The study team retrospectively obtained data on all consecutive patients extracted from the electronic medical record. The rapidity of recovery was defined as the time from entry into the postanesthesia care unit to the transition to Phase 2 for ambulatory extended recovery patients and as the length of total postanesthesia care unit stay for outpatients. Following intent-to-treat-principles, we tested the association between study period and rapidity of recovery (a priori clinically meaningful difference: 20minutes) using multivariable linear regression, adjusting for anesthesia type (general vs monitored anesthesia care), American Society of Anesthesiologst physical status (ASA) score (1-2 vs 3-4), age, service, robotic procedure, and surgery start time. Ambulatory extended recovery patients treated in the hydromorphone period had, on average, a 0.25minute(95% confidence interval [CI] -6.5, 7.0), nonstatistically significant (P>.9) longer time to transition. For outpatient procedures, those who received hydromorphone had, on average, 8.5-minute longer stays (95% CI 3.7-13, P<.001). Although we saw statistical evidence of an increased risk of resurgery associated with receiving hydromorphone (0.5%; 95% CI -0.1%, 1.0%; P=.039 on univariate analysis), the size of the estimate is clinically and biologically implausible and is most likely a chance finding related either to multiple testing or confounding. The multidisciplinary team concluded that the increase in postoperative length of stay associated with hydromorphone was not clinically significant and the decrease waste of prefilled syringes outweighed the small potential increased risk of resurgery compared to the shorter-acting fentanyl. We will therefore use hydromorphone moving forward.

Psychometric evaluation of the modified quality of recovery score for the postanaesthesia care unit (QoR-PACU2)—A prospective validation study

BackgroundTo date, there is no instrument to adequately assess self-reported quality of recovery (QoR) in the post-anesthesia care unit (PACU). We previously developed the QoR-PACU, a 13-item questionnaire specifically applicable to the PACU. The feasibility, acceptance, and validity of the QoR-PACU were promising. However, measures of reliability were slightly lower than expected. MethodsWe modified the QoR-PACU and evaluated its psychometric properties in a cohort of adult patients scheduled for non-cardiac surgery with general anesthesia. The modified QoR-PACU (termed QoR-PACU2) was administered before surgery and postoperatively in the PACU at the time of the decision to discharge. ResultsA total of 307 patients were included in the final analysis. Postoperative QoR-PACU2 sum scores differed across categories of sex, perioperative and surgical risk, and modes of airway management. The duration of anesthesia and surgery, maximum pain intensity and analgesic requirement in the PACU, and length of PACU stay were all inversely correlated with QoR in the PACU. Cronbach’s alpha was 0.70 (95%CI: 0.66–0.75). The intra-class correlation coefficient was 0.86 (95%CI: 0.70–0.94, p < 0.001) for intra-rater reliability (n = 24) and 0.94 (95%CI 0.90 to 0.97, p < 0.001) for inter-rater reliability (n = 31). Cohen’s effect size was 0.68 and the standardized response mean was 0.57. ConclusionThe QoR-PACU2 assesses self-reported QoR after surgery in the PACU. Measures of feasibility, validity, and reliability were consistently high. Measures of responsiveness were moderate, which might be attributable to the heterogeneity of the study population. Future studies should include aspects of ethnicity and cross-cultural applicability.

Impact of dexmedetomidine use on pediatric PACU length of stay and practice patterns: A single center study

BackgroundDexmedetomidine has been increasingly incorporated in pediatric anesthesia owing to its opioid sparing analgesic effect. In theory, dexmedetomidine may lower the use of intraoperative and postoperative opioids but increase post anesthesia care unit (PACU) patient recovery time. In 2020, the Anesthesia Department of Albany Medical Center implemented an opioid reducing initiative with dexmedetomidine incorporation as a major strategy. As such, we have carried out this retrospective study to examine the effect of dexmedetomidine on pediatric PACU length of stay (LOS) across a blend of invasive surgical procedures requiring general anesthesia. MethodsThe present study is a single-institution, retrospective chart review of children undergoing invasive procedures requiring general anesthesia at an academic center during 2021 and 2022. Convenience sampling of the first 200 patients from each of those years was analyzed (n=400). Here, we compared PACU LOS between patients who did or did not receive dexmedetomidine using the propensity-score matching treatment effects analysis. We also examined changes in perioperative medication patterns between patients who did versus did not receive dexmedetomidine. Results344 patients over the study period met inclusion criteria. The matched cohort consisted of 118 patients without dexmedetomidine administration and 122 patients with dexmedetomidine administration. The average treatment effect for administration of dexmedetomidine was an increase in PACU LOS of 19.4 min (p < 0.001). Dosages and proportion of patients receiving intraoperative or postoperative opioids did not significantly change during the study period. ConclusionsIn our center, dexmedetomidine use in pediatric procedures with general anesthesia was associated with prolonged recovery times, without a corresponding reduction in opioid use. Further investigations are therefore warranted to understand the role of dexmedetomidine as an anesthetic adjunct and in multimodal pain management.

Postanesthesia Care Unit and Anesthetic Management Outcomes Among Patients Undergoing Noncardiac Surgery: Differences by Race and Ethnicity

To investigate the association of patient race and ethnicity with postanesthesia care unit (PACU) outcomes in common, noncardiac surgeries requiring general anesthesia. Single tertiary care academic medical center retrospective matched cohort. We matched 1:1 1836 adult patients by race and/or ethnicity undergoing common surgeries. We compared racial and ethnic minority populations (62 American Indian, 250 Asian, 315 Black or African American, 281 Hispanic, and 10 Pacific Islander patients) to 918 non-Hispanic White patients. The primary outcomes were: the use of an appropriate number of postoperative nausea and vomiting (PONV) prophylactics; the incidence of PONV; and the use of a propofol infusion as part of the anesthetic (PROP). Secondary outcomes were: the use of opioid-sparing multimodal analgesia, including the use of regional anesthesia for postoperative pain control; the use of any local anesthetic, including the use of liposomal bupivacaine; the duration until readiness for discharge from the PACU; the time between arrival to PACU and first pain score; and the time between the first PACU pain score of ≥4 and administration of an analgesic. Logistic and linear regression were used for relevant outcomes of interest. Overall, there were no differences in the appropriate number of PONV prophylactics, nor the incidence of PONV between the two groups. There was, however, a decreased use of PROP (OR=0.80; 95% CI: 0.69, 0.94; P=.005), PACU length of stay was 9.56minutes longer (95% CI: 2.62, 16.49; P=.007), and time between arrival to PACU and first pain score was 2.30minutes longer in patients from racial and ethnic minority populations (95% CI: 0.99, 3.61; P=.001). There were no statistically significant differences in the other secondary outcomes. The rate of appropriate number of PONV prophylactic medications as well as the incidence of PONV were similar in patients from racial and ethnic minority populations compared to non-Hispanic White patients. However, there was a lower use of PROP in racial and ethnic minority patients. It is important to have a health equity lens to identify differences in management that may contribute to disparities within each phase of perioperative care.

The effect of multimodal care based on Peplau’s interpersonal relationship theory on postoperative recovery in lung cancer surgery: a retrospective analysis

BackgroundLung cancer remains a major global health concern due to its high incidence and mortality rates. With advancements in medical treatments, an increasing number of early-stage lung cancer cases are being detected, making surgical treatment the primary option for such cases. However, this presents challenges to the physical and mental recovery of patients. Peplau known as the “mother of psychiatric associations” has formulated a theory of interpersonal relationships in nursing. Through effective communication between nurses and patients over four periods, she has established a good therapeutic nurse-patient relationship. Therefore, this study aimed to explore the effect of perioperative multimodal nursing based on Peplau’s interpersonal relationship theory on the rehabilitation of patients with surgical lung cancer.MethodsWe retrospectively analyzed 106 patients with non-small cell lung cancer who underwent thoracoscopic lobectomy at our department between June 2021 and April 2022. Patients were categorized into two groups according to the different nursing intervention techniques. The Peplau’s group comprised 53 patients who received targeted nursing interventions, and the control group comprised 53 patients who received conventional nursing care. We observed the patients’ illness uncertainty, quality of life, and clinical symptoms in both groups.ResultsPatients in the Peplau’s group had significantly lower illness uncertainty scores and a significantly higher quality of recovery than those in the control group. However, there were no significant differences in length of post-anesthesia care unit stay, complication rates, and visual analog scores between both groups.ConclusionThe multimodal perioperative nursing based on Peplau’s interpersonal relationship theory not only reduces the illness uncertainty of patients with lung cancer surgery and improves their QoR but also expands the application of this theory in clinical practice, guiding perioperative nursing of patients with lung cancer.ImplicationsThese findings provide practical information for standardized care in a hectic anesthetic care setting.ImpactThe assessed anesthesia nursing model helps reduce uncertainty and promote early recovery in patients with cancer at various stages of their disease, which expands the scope of therapeutic practice and existing theories. It also serves as a guide for care in the anesthesia recovery room.Reporting methodWe adhered to the relevant Equator guidelines and the checklist of items in the case–control study report.Patient or public contributionPatients cooperated with medical staff to complete relevant scales.

Acupuncture as a Complementary Treatment Modality in the Post-Anesthesia Care Setting: A Feasibility Study.

Introduction: Postoperative pain management and postoperative nausea and vomiting are a persistent challenge for both health care providers and patients. Acupuncture is an effective and safe modality for the management of pain and nausea, and has the potential to play a key role in postoperative pain management. This study explores the utility and feasibility of acupuncture in the immediate postoperative setting. Methods: In a retrospective case-control study, 22 patients who underwent elective surgeries and received acupuncture in the post-anesthesia care unit (PACU) were compared with 88 case controls. Indications for acupuncture therapy included persistent pain, nausea, or anxiety. Patient satisfaction and symptom improvement after acupuncture were assessed. PACU nurses and patients were queried on their perspectives on using this therapy. Demographic data, perioperative opioid consumption, pain score in the PACU, incidence of postoperative nausea, PACU length of stay, and unintended hospital admission were assessed. The groups with/without acupuncture were compared using Wilcoxon rank sum test or Fisher's exact test as appropriate. Results: A total of 78.9% of patients receiving acupuncture felt improvement in their symptoms. 94.7% of recovery nurses who cared for patients who received acupuncture felt that it was helpful and 78.9% did not believe it was disruptive. Patients who opted for acupuncture had a statistically significant higher overall median (interquartile range) pain score in the PACU (7.0 [5.2, 9.5] vs. 5.0 [3.0, 7.0], p = 0.009) and higher postoperative opioid consumption (22.5 [9.8, 44.8] vs. 15.0 [0.0, 30.0], p = 0. 03). There was no difference between total perioperative opioid consumption between groups (p = 0.94). Conclusions: Most patients who received acupuncture therapy in the PACU were satisfied with their therapy and would recommend it to future patients undergoing surgery. Most recovery nurses felt it was helpful, was not disruptive, and would like to see it utilized in the PACU.

Methadone for Emergence Delirium in Ambulatory Pediatric Strabismus Surgery.

Background: Emergence delirium in children following strabismus surgery is a distressing and potentially dangerous condition and is likely attributable to visual disturbances, pain, and anesthetic gases. We explored whether a single intraoperative dose of methadone could reduce emergence delirium. Methods: Our study was an institutional review board-approved prospective, controlled, before-and-after investigation. Inclusion criteria were age <18 years and American Society of Anesthesiologists (ASA) classification 1 or 2. Patients were excluded for obesity, documented sleep apnea, significant neurologic disease, or inpatient status. Control group patients were recruited sequentially, and the anesthetic was performed per preference. The study group was recruited similarly and received an intravenous dose of methadone 0.15 mg/kg at induction. The primary outcome was peak score on the Pediatric Anesthesia Emergence Delirium (PAED) scale. Secondary outcomes included time to anesthetic emergence, postoperative pain scores, postanesthesia care unit (PACU) length of stay, and postdischarge respiratory complications. Results: Forty-nine control group and 55 study group patients were recruited. No significant differences were found between groups for age, sex, weight, ASA classification, or duration of surgery. The control group received more preoperative midazolam, intraoperative fentanyl, and intraoperative ketorolac. Compared to the control group, the study group had 42% and 85% reductions in peak and severe PAED scale scores, respectively, in the PACU and required less rescue pain medications. Anesthetic emergence time and length of stay were not different between the groups. No significant postoperative complications occurred. Conclusion: Emergence delirium following outpatient pediatric strabismus surgery was substantially mitigated by the use of intraoperative methadone without affecting PACU throughput. No significant complications occurred. Further study is warranted to corroborate routine use of this drug for emergence delirium.

Recovery and safety with prolonged high-frequency jet ventilation for catheter ablation of atrial fibrillation: A hospital registry study from a New England healthcare network

Study objectiveTo investigate post-procedural recovery as well as peri-procedural respiratory and hemodynamic safety parameters with prolonged use of high-frequency jet ventilation (HFJV) versus conventional ventilation in patients undergoing catheter ablation for atrial fibrillation. DesignHospital registry study. SettingTertiary academic teaching hospital in New England. Patients1822 patients aged 18 years and older undergoing catheter ablation between January 2013 and June 2020. InterventionsHFJV versus conventional mechanical ventilation. MeasurementsThe primary outcome was post-anesthesia care unit (PACU) length of stay. In secondary analyses we assessed the effect of HFJV on intra-procedural hypoxemia, defined as the occurrence of peripheral hemoglobin oxygen saturation (SpO2) <90%, post-procedural respiratory complications (PRC) as well as intra-procedural hypocarbia and hypotension. Multivariable negative binomial and logistic regression analyses, adjusted for patient and procedural characteristics, were applied. Main results1157 patients (63%) received HFJV for a median (interquartile range [IQR]) duration of 307 (253–360) minutes. The median (IQR) length of stay in the PACU was 244 (172–370) minutes in patients who underwent ablation with conventional mechanical ventilation and 226 (163–361) minutes in patients receiving HFJV. In adjusted analyses, patients undergoing HFJV had a longer PACU length of stay (adjusted absolute difference: 37.7 min; 95% confidence interval [CI] 9.7–65.8; p = 0.008). There was a higher risk of intra-procedural hypocarbia (adjusted odds ratio [ORadj] 5.90; 95%CI 2.63–13.23; p < 0.001) and hypotension (ORadj 1.88; 95%CI 1.31–2.72; p = 0.001) in patients undergoing HFJV. No association was found between the use of HFJV and intra-procedural hypoxemia or PRC (p = 0.51, and p = 0.97, respectively). ConclusionAfter confounder adjustment, HFJV for catheter ablation procedures for treatment of atrial fibrillation was associated with a longer length of stay in the PACU. It was further associated with an increased risk of intra-procedural abnormalities including abnormal carbon dioxide homeostasis, as well as intra-procedural arterial hypotension.

Early observations with an ERAS pathway for thyroid and parathyroid surgery: Moving the goalposts forward

BackgroundEnhanced recovery after surgery pathways have become the standard of care in various surgical specialties. In this study, we discuss our initial experience with a staged enhanced recovery after surgery pathway in endocrine surgery and assess the impact of this pathway on select perioperative outcomes and unanticipated admissions. MethodsWe collected information regarding all thyroid/parathyroid surgeries performed by endocrine surgeons at our institution before and after the implementation of the multi-intervention enhanced recovery after surgery pathway. We compared relevant outcomes for all cases 1 year before (n = 479) and 1 year after (n = 166) implementation of the pathway. We also compared outcomes between enhanced recovery after surgery patient groups with varying levels of enhanced recovery after surgery compliance. ResultsEnhanced recovery after surgery was associated with a significant decrease in total length of stay (9.2 vs 7.5 hours, P < .0001). Whereas there was no significant decrease in all-cause unanticipated postoperative admissions, there was a decrease in patient-initiated admissions in the Enhanced recovery after surgery group. There was also a significant decrease in mean postoperative morphine milligram equivalents (14.4 vs 16.2 vs 24.8, P = .0015), average daily morphine milligram equivalents (25.6 vs 45.6 vs 53, P < .0001), and average daily pain scores (1.89 vs 2.38 vs 2.74, P = .0045) in the Enhanced recovery after surgery group (particularly with increasing Enhanced recovery after surgery compliance). There were no significant differences in the requirement for postoperative antiemetics or in the post-anesthesia care unit length of stay. ConclusionThis study demonstrates a significant benefit from Enhanced recovery after surgery pathways for thyroidectomies and parathyroidectomies, even with initial data and a staggered roll-out plan. Further directions include a follow-up study once we reach a higher level of institutional compliance with all components of the Enhanced Recovery After Surgery pathway and a prospective trial to identify the relative significance of different portions of the Enhanced Recovery after Surgery pathway, particularly the superficial cervical plexus block.

Efficacy of Electronic Reminders in Increasing the Enhanced Recovery After Surgery Protocol Use During Major Breast Surgery: Prospective Cohort Study

Background Enhanced recovery after surgery (ERAS) protocols are patient-centered, evidence-based guidelines for peri-, intra-, and postoperative management of surgical candidates that aim to decrease operative complications and facilitate recovery after surgery. Anesthesia providers can use these protocols to guide decision-making and standardize aspects of their anesthetic plan in the operating room. Objective Research across multiple disciplines has demonstrated that clinical decision support systems have the potential to improve protocol adherence by reminding providers about departmental policies and protocols via notifications. There remains a gap in the literature about whether clinical decision support systems can improve patient outcomes by improving anesthesia providers’ adherence to protocols. Our hypothesis is that the implementation of an electronic notification system to anesthesia providers the day prior to scheduled breast surgeries will increase the use of the already existing but underused ERAS protocols. Methods This was a single-center prospective cohort study conducted between October 2017 and August 2018 at an urban academic medical center. After obtaining approval from the institutional review board, anesthesia providers assigned to major breast surgery cases were identified. Patient data were collected pre- and postimplementation of an electronic notification system that sent the anesthesia providers an email reminder of the ERAS breast protocol the night before scheduled surgeries. Each patient’s record was then reviewed to assess the frequency of adherence to the various ERAS protocol elements. Results Implementation of an electronic notification significantly improved overall protocol adherence and several preoperative markers of ERAS protocol adherence. Protocol adherence increased from 16% (n=14) to 44% (n=44; P&lt;.001), preoperative administration of oral gabapentin (600 mg) increased from 13% (n=11) to 43% (n=43; P&lt;.001), and oral celebrex (400 mg) use increased from 16% (n=14) to 35% (n=35; P=.006). There were no statistically significant differences in the use of scopolamine transdermal patch (P=.05), ketamine (P=.35), and oral acetaminophen (P=.31) between the groups. Secondary outcomes such as intraoperative and postoperative morphine equivalent administered, postanesthesia care unit length of stay, postoperative pain scores, and incidence of postoperative nausea and vomiting did not show statistical significance. Conclusions This study examines whether sending automated notifications to anesthesia providers increases the use of ERAS protocols in a single academic medical center. Our analysis exhibited statistically significant increases in overall protocol adherence but failed to show significant differences in secondary outcome measures. Despite the lack of a statistically significant difference in secondary postoperative outcomes, our analysis contributes to the limited literature on the relationship between using push notifications and clinical decision support in guiding perioperative decision-making. A variety of techniques can be implemented, including technological solutions such as automated notifications to providers, to improve awareness and adherence to ERAS protocols.

Use of IV Lidocaine Infusion Postoperatively Within the ERAS Surgical Population

PurposeThe aim of this project was to investigate whether opioid pain scores, postoperative opioid requirements, and postanesthesia care unit (PACU) length of stay were impacted when comparing a 24-hour intravenous lidocaine infusion versus postoperative discontinuation of the lidocaine infusion. DesignA retrospective chart review was used both before and after the discontinuation of postoperative lidocaine infusions for a quality improvement project. MethodsThe project was carried out in the adult surgery PACU setting at a level 1 trauma center between April 2021 and September 2021. The sample included 100 adult patients who fell under surgical specialties that used enhanced recovery after surgery protocol. After approval was obtained, data was collected via an electronic chart review using an evaluation tool created by the project team. FindingsBetween the five surgical specialties used for this review, the PACU length of stay variable was reduced only in the gynecology oncology service (P= .041). Additionally, the postoperative opioid requirements were significantly reduced in the surgical oncology service (P = .02). Comparing the groups as a whole, 50 participants who had a 24-hour continuous lidocaine infusion and 50 participants whose lidocaine infusion was discontinued before PACU admission had no statistically significant values with pain scores, postoperative opioid requirements, and PACU length of stay. ConclusionsResults indicate that a 24-hour lidocaine infusion did not impact this patient population’s pain scores, postoperative opioid requirements, or PACU length of stay.