Median Anesthesia Time Research Articles

Influence of Patient and Hospital Characteristics on Anesthesia Time in Medicare Patients Undergoing General and Orthopedic Surgery

Procedure time is a clinically important variable that is often analyzed when studying quality and efficiency. Norms for procedure length have not been reported from Medicare data sets, nor has the influence of patient and hospital characteristics on procedure time been estimated using Medicare data. The authors obtained Medicare claims on all patients aged 65-85 years who underwent general surgical and orthopedic surgical procedures in Pennsylvania. Anesthesia procedure time was estimated from anesthesia time units bills supplied from Medicare on 20 common general and orthopedic surgery procedures, and models to determine the influence of hospital and patient characteristics were developed. Of the 77,638 patients, 31,472 had general surgery and 46,166 underwent orthopedic procedures. The median anesthesia time for general surgery was 133 min, and for orthopedic surgery it was 146 min. After adjusting for principal procedure, hospital, and physiologic severity, covariates associated with increased anesthesia time included: multiple procedure on same day + 18.3 min (P < 0.0001); transfer-in + 6.7 min (P = 0.0002); black race + 5.5 (P < 0.0001); coagulation disorders + 4.9 (P = 0.0012); and paraplegia + 4.5 (P = 0.0006). Lower-income black patients had significantly longer procedure times than lower-income white patients (+ 7 min; P < 0.0001). Among the 15 hospitals with the largest black surgical populations, 5 hospitals had statistically significant procedure lengths for black versus white patients, ranging from + 9 to + 16 min. In addition to variation by patient comorbidities and procedure, anesthesia procedure time varies with hospital, medical history, and sociodemographic characteristics.

Postoperative alopecia areata: Is pressure-induced ischemia the only cause to blame?

Introduction Postoperative alopecia areata (PAA) following surgery has been reported, especially after certain gynecologic and cardiac procedures; however, no cases have been reported after liver transplant (LT). Localized pressure associated with prolonged anesthesia is usually blamed. Herein we report a few cases of PAA encountered especially in relation to LT procedures. Objective To report our PAA cases, identifying possible contributing risk factors. Methods Between April 2001 and May 2003 the data on eight PAA cases were analyzed for age, sex, type of surgery, duration of anesthesia, type of head support, periods of hypotension, and psychiatric comorbidity. Results Median age of affected patients was 27 years (10 to 44) and the male/female ratio 3/5. The type of surgery included: two LT recipients, two LT donors, three cardiac valve replacements, and one coronary bypass surgery. Median anesthesia time was 6 hours (3 to 12). Sponge or jelly donut was used for head support with frequent change of its position as per protocol. There were no significant periods of hypotension. Surprisingly, almost all patients had a documented psychiatric comorbidity, mainly anxiety, adjustment/adaptation, or mood disorders. Conclusions PAA is a rare complication following certain surgeries including both donor and recipient LT procedures. Although pressure-induced ischemia is the most likely etiological factor, we believe that psychiatric comorbidity plays a major role in its development. Therefore, preoperative thorough psychiatric counseling in addition to frequent intraoperative head repositioning will help to avoid this minor but distressing postoperative complication.

Image-guided craniotomy for cerebral metastases: techniques and outcomes.

The purpose of the present study was to analyze the outcomes after craniotomies for brain metastases in a modern series using image-guided technologies either in the regular operating room or in the intraoperative magnetic resonance imaging unit. Neurosurgical outcomes were analyzed for 49 patients who underwent 55 image-guided craniotomies for excision of brain metastases during a 5-year period. Tumors were located in critical and noncritical function regions of the brain. A total of 23 craniotomies for tumors in critical brain were performed using intravenous sedation anesthesia; craniotomies for noncritical function brain regions were completed under general anesthesia. The patients were also divided into Radiation Therapy Oncology Group recursive partitioning analysis (RPA) classes on the basis of age, Karnofsky Performance Scale scores, state of primary disease, and presence or absence of extracranial metastases. There was no perioperative mortality. Gross total resection, as verified by postoperative contrast-enhanced computed tomography or magnetic resonance imaging, was achieved in 96% of patients. The median anesthesia time was 4.25 hours, and the median length of hospital stay was 3 days. In 51 symptomatic cases, there was complete resolution of symptoms in 70% (n = 36), improvement in 14% (n = 7), and no change in 12% (n = 6) postoperatively. No patient who was neurologically intact preoperatively deteriorated after surgery, and 93% of patients maintained or improved their functional status. Only two patients (3.6%) with significant preoperative deficits had increased long-term deficits postoperatively. The mean follow-up was 1 year, and the local recurrence rate was 16%. The median survival of the entire group was 16.23 months (17.5 mo in RPA Class I, 22.9 mo in RPA Class II, and 9.8 mo in RPA Class III). Gross total resection of brain metastases, including those involving critical function areas, can be safely achieved with a low morbidity rate using contemporary image-guided systems. RPA Class I and II patients with controlled primary disease benefit from aggressive treatment by surgery and radiation.

Holmium:Yttrium-aluminum-garnet laser cystolithotripsy of large bladder calculi

Objectives Patients with large bladder calculi (4 cm or larger) have traditionally been managed with open cystolithotomy. Endoscopic management with cystolitholapaxy or electrohydraulic lithotripsy risks complications. In an effort to spare patients the morbidity of open cystolithotomy, the results of holmium:yttriumaluminum-garnet (YAG) laser cystolithotripsy for bladder calculi 4 cm or larger were reviewed. Methods Consecutive patients with bladder calculi of 4 cm or larger were managed with holmium:YAG laser cystolithotripsy. Laser energy was delivered using either the 365-μm end-firing fiber or the 550-μm sidefiring fiber. Results Fourteen consecutive patients were managed with holmiumrYAG cystolithotripsy. All patients were rendered stone free, regardless of stone composition or size. Median anesthesia time was 57 minutes. Twelve of 14 patients were discharged by the first postoperative day. The procedure times normalized for stone size (mean ± standard deviation) for the end-firing versus the side-firing fibers were 13 ± 6 min/cm versus 6 ± 1 min/cm, respectively; P = 0.04. Conclusions Holmium:YAG laser cystolithotripsy of large bladder calculi is effective, technically facile, and safe. The 550-μm side-firing fiber may be better suited for large bladder calculi compared with the 365-μm end-firing fiber. Holmium:YAG cystolithotripsy may obviate open cystolithotomy in selected patients.

Laparoscopic-assisted reversal of Hartmann's procedure: a simplified technique and audit of twelve cases.

Laparoscopic-assisted reversal of Hartmann's procedure was performed in 12 patients over a 2-year period. The group comprised three patients with colonic carcinoma and nine with diverticular disease, their mean age being 62 years (range 40-73). In all twelve cases, intestinal continuity was successfully restored, without conversion to open surgery, in a median anesthetic time of 165 min (range 110-240). One patient required a temporary defunctioning colostomy and two other patients had three complications. The median postoperative hospital stay was 8 days (range 5-12). We report a retrospective audit of this consecutive series of 12 patients, showing that laparoscopic-assisted reversal of Hartmann's is technically feasible. We also give details of the morbidity associated with the technique.

Laparoscopic right and left adrenalectomies. Surgical procedures.

Laparoscopic approach for adrenalectomy was recently described and the operative technique is not yet well defined. Twenty-seven laparoscopic adrenalectomies were performed between 1992 and 1995. There were 18 women and nine men ranging in age from 31 to 70 years (mean, 50.8 years). The surgical procedure was a lateral decubitus transperitoneal flank approach in 26 patients, and a retroperitoneal approach in one. Twelve right and 15 left glands were removed. Adrenal diseases were primary aldosteronism in 20 patients, nonfunctional adenoma in four patients, Cushing adenoma in two, and an adrenal cyst in one. Median adrenal gland size was 2.0 cm (range 0.5-8 cm). Five patients were converted to laparotomy (18%)-for dissection problems in four and for an unrecognized gland in one. The median anesthesia time was 200 min and the median surgical time was 140 min. Operative morbidity was one adrenal vein injury sectioned close to the vena cava. The hemorrhage was controlled by laparoscopic suturing without conversion. This patient required a three-unit blood transfusion. No mortality occurred and postoperative morbidity was one minor chest infection. The median postoperative in-hospital stay was 4.6 days (range 2-8) for nonconverted patients. Laparoscopic adrenal gland removal is safe and offers fast recovery and short in-hospital stay. Laparoscopic adrenalectomy combines the advantages of both the conventional anterior and posterior approach.

Laparoscopic pelvic lymph node dissection, laparoscopically assisted seminal vesicle mobilization, and total perineal prostatectomy versus radical retropubic prostatectomy for prostate cancer

Objectives The outcomes of patients with prostate cancer who were candidates for radical prostatectomy were compared with patients who underwent either: (1) radical retropubic prostatectomy (RRP); or (2) laparoscopic pelvic lymph node dissection, laparoscopically assisted seminal vesicle mobilization, and total perineal prostatectomy (LN-SV-TPP). Methods The staging, surgical, and early postoperative characteristics of 10 consecutive patients treated by RRP were compared with 12 consecutive patients who underwent LN-SV-TPP. Results Patients who underwent LN-SV-TPP versus RRP had respective median blood loss of 450 versus 1250 ce ( P = 0.001), median anesthesia time of 330 versus 287.5 minutes ( P = 0.05), median surgical time of 237.5 versus 237.5 minutes ( P = 0.6), median units transfused of 0 versus 1 ( P = 0.05), median time to ambulation of 1 versus 2 days ( P = 0.002), median time to oral intake of 1 versus 3.5 days ( P < 0.001), median hospital stay of 3 versus 6 days ( P < 0.001), and median morphine requirements of 44 versus 119 mg (P < 0.001). Conclusions LN-SV-TPP is less morbid than RRP concerning blood loss, blood transfusions, pain, and postoperative recovery. Compared with LN-SV-TPP, RRP is faster and is particularly indicated for ease of performing a nerve-sparing radical prostatectomy.

The use of short-induction nitrous oxide and oxygen with Penthrane; a new concept in pediatric oral surgical anesthesia

Abstract 1. 1. The inhalant drug, methoxyflurane, a fluorinated ether marketed as Penthrane, is the newest member of the halogen family of anesthetic agents. It is the first clinically useful, nonexplosive ether to be introduced. It is described physically as a clear liquid with a high boiling point, a low saturated vapor pressure, and a pleasant odor. In addition to its nonflammable properties, the drug is stable in the presence of air, alkali, light, and moisture, and it can be used safely in a closed-circuit system. 2. 2. We initiated the use of Penthrane early in 1963, subsequent to a number of previously published reports which evaluated clinical experience with this agent. Our own clinical experience has substantiated specific advantages which we consider to be of merit in the administration of pediatric analgesia and anesthesia for office oral surgical procedures. These advantages include (1) rapid induction; (2) early and profound relaxation of extremities; (3) ease of administration with reference to procedure and equipment; (4) the safety factor attendant to the administration of inhalants with low saturated vapor pressure wherein precipitous induction, initial overdose, and early saturation levels are difficult to produce; (5) apparent lack of associated hepatocellular toxicity, cardiovascular alterations, or measurable effect on the coagulation mechanism; (6) pharmacological compatibility with other drugs ordinarily employed during the conduct of anesthesia; (7) good early analgesia in the light planes, which then extends into emergence; and (8) rapid recovery. 3. 3. For purposes of general evaluation, therefore, we instituted an analysis of Penthrane and nitrous oxide-oxygen anesthetic in a randomly selected series of 301 pediatric oral surgical patients. In the series analysis, the median induction time was 3 minutes. The median total Penthrane time was also 3 minutes, and the median total anesthesia time was 5 minutes. The median recovery time was 3 minutes, and the median recovery-room time was 17 minutes. Vomiting incidence was 7.6 per cent. 4. 4. We have used Penthrane for more than 3,000 office procedures and have found that it has several favorable characteristics which make it applicable to outpatient anesthesia. We believe Penthrane to be a very effective and useful general anesthetic for use in the oral surgery office because of its inherent properties of rapid induction, safety , and rapid recovery .