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PubMed1975

Alteration of warfarin kinetics in man associated with exposure to an operating-room environment.

The plasma half-life of warfarin (mean +/- SE) in five normal, nonmedicated control subjects given a single 40 mg/m2 oral dose of warfarin was 38.8 +/- 4.1 hours. It was essentially the same (37.7 +/- 2.6 hours) in these subjects when determined again four months later. The effect of the single dose of warfarin on prothrombin complex activity (prothrombin response) was determined by calculating the area under the curve obtained by plotting prothrombin time (seconds) versus time after the warfarin dose (hours). The prothrombin response in control subjects was 1670 +/- 64 sec-hr initially and essentially the same at the end of the four-month interval (1730 +/- 96 sec-hr). Plasma warfarin half-life and prothrombin response in seven anesthesiology residents were 32.1 +/- 3.6 hours and 1337 +/- 78 sec-hr at the start of their training period, i.e., before working in the operating room. Four months later, their plasma warfarin half-lives were significantly prolonged (49.3 +/- 4.8 hours) and the prothrombin responses were significantly greater (1552 +/- 22 sec-hr) compared with their initial values. The alteration of warfarin kinetics appeared to be due mainly to inhibition of warfarin metabolism, presumably related to the repeated exposure of these subjects to an operating room environment.

Administration, Oral↗
PubMed2003

Microbiological evaluation of various parameters in ophthalmic operating rooms. The need to establish guidelines.

PURPOSE: Postoperative infections can be caused by a contaminated environment, unsterile equipment, contaminated surfaces, and infected personnel as well as contaminated disinfectants. In order to establish guidelines for microbiological monitoring, a detailed microbiological surveillance was carried out in an ophthalmic hospital. METHOD: Over a period of 21 months, we assessed environmental Bacteria Carrying Particle(BCP) load and surface samples weekly (n = 276); the autoclaving system once a month and repeated whenever the process failed (n = 24); the air conditioning filters for fungal growth once in four months (n = 15), and the disinfectant solution for contamination once in two months (n = 10). Additionally, the personnel involved directly in surgery were screened for potential pathogens such as Staphylococcus aureus and beta haemolytic streptococci. RESULT: On 14 (5.07%) occasions the environment in the operating rooms had a significant risk of airborne infections. Sterilisation of instruments in the autoclaves was unsatisfactory on 4 (16.66%) occasions. Samples from the filters of the air-conditioning units yielded potentially pathogenic fungi on 3 (20%) occasions. Personnel sampling revealed that 5 (8.77%) individuals harboured beta haemolytic Streptococci in the throat and 4 (7.01%) harboured S. aureus in the nasal cavity. The samples of disinfectant in use were not contaminated. CONCLUSION: There is a need to standardise microbiological evaluation protocols for operating rooms.

Disinfection↗
PubMedDate not supplied

Hepatitis and operating-room personnel: an approach to diagnosis and management.

Hepatitis represents a common problem in operating room (OR) personnel. The differential diagnosis is usually narrowed to viral hepatitis versus halothane-associated hepatitis. While specific immunologic technics are available to diagnose viral hepatitis, halothane hepatitis cannot presently be unequivocally diagnosed with available clinical, biochemical, immunologic, or pathologic technics. Suggestions for management of OR personnel with hepatitis can only be based on insufficient evidence at present. The authors have initiated a prospective study to help clarify this situation.

Acute Disease↗
PubMed2005

Cerebral monitoring in the operating room and the intensive care unit: an introductory for the clinician and a guide for the novice wanting to open a window to the brain. Part I: The electroencephalogram.

While there is an increasing body of knowledge in regard to central nervous system function and/or the mode of action of centrally active agents on neuronal function, little is done to develop new techniques on how to measure such changes. Also, monitoring of the cardiovascular system in the past has made extensive progress especially when it comes to evaluate the failing heart. In contrast monitoring of the central nervous system is only done in rare cases where operative procedures likely impede nervous function integrity. Since in the past decade the aging population undergoing operation has rise considerably, the risk of cerebral malperfusion or minute signs of degradation of the aging central nervous system (CNS) to anesthetics and agents being used in the operation room (OR) or the intensive care unit (ICU), needs continuous monitoring of an organ which presents the highest vulnerability and is likely to deteriorate faster than the cardiovascular system. In spite the rapid improvement in technology regarding the electroencephalogram (EEG) and evoked potential monitoring, physicians still are reluctant to use a technology on a routine base, which will give them insight information into brain function and activity. Such "windows to the brain" now not just are reserved to specialists working in the area of neurology and/or psychiatry. More so, cerebral monitoring is getting an integrated part in the overall therapy in patients undergoing operation or who need ventilatory support in the ICU as it effects the well-being and the outcome. The present book therefore, is intended for the practitioners who work with the patient, guide the clinician in his decision making and outlining those situations where cerebral monitoring presents an integrated part in the diagnosis and therapy of patient care. Without going too much into the technical details, representative cases underline the potential use of cerebral monitoring in the underlying clinical situation where either the patient presents borderline perfusion of the CNS, undergoes vascular surgery, or where monitoring of cerebral function in the intensive care in a head trauma patients is an integrated part in therapy. The book therefore is meant for all those clinicians who have to deal with the CNS in a day-to-day situation. This may be the anesthesiologist, the surgeon, the intensive care therapist, the nurse anesthetist as well as all other medical personal involved in intensive care therapy. The aim of the book therefore is to outline the possibilities, the limitations, and the options for therapy when the windows to the brain are opened, how to interpret the data in the light of other physiological parameters and aid the user in the technical details of how to avoid artifacts in recording which may have an impact on final decision making. Therefore, emphasis is placed on the electrode placement, artifact and electrical noise reduction, as well as data interpretation so that cerebral function diagnosis can be made on reliable grounds. The following serves as an introduction to and as a reference guide for Cerebral Monitoring in the OR and the ICU: Gives complete coverage of EEG power spectra analysis. Describes in detail the EEG machines available to be used in the OR and ICU setting. Describes in detail the major features of EEG power spectra and evoked potential measurements, including amplifiers, filter setting and microprocessor algorithm for data reduction. Gives suggestions for assessing and improving signal quality, including noise and artifact rejection, which usually are encountered in the operation room and the intensive care unit, both of which can be considered as electrically contaminated. Gives examples of EEG power spectra and evoked potential monitoring related to different types of anesthesia, in coma, after head trauma, and for the detection of ischemic events. In addition, gives complete coverage of those machines being available for the OR and the ICU, including a list of parameters regarding latency and amplitude in evoked potential As an introductory, recommendations are given for the novice to start cerebral monitoring and guide the beginner in setting up cerebral monitoring in the clinical environment.

Artifacts↗
PubMed2001

Operating room design for minimally invasive surgery.

Adapting the modern operating room (OR) for minimally invasive surgery (MIS) is a challenge that begins with the more general problem of designing the OR. Apart from the scarcity of practical publications and details in this area, the highly technical nature of many of the issues, and the difficulty of communicating them, often result in mistakes being made in planning at a very simple level. Three specific ways of improving communication in planning are: using a checklist, sharing a planning handbook among the intended users, and modifying architects' drawings to 1:10 scale floor plans with movable cut-outs to represent equipment and staff.

Journal Article↗
PubMed2000

Transmission of viral disease in the operating room setting.

The transmission of viral disease in the operating room is an evolving problem. Advances in transfusion medicine have made blood supply safer than ever, whereas changes in transfusion practice have minimized the amount of blood transfused. The epidemiology of viral infection is changing in both the general population and among healthcare workers. Vaccination and prevention hold the key to future risk reduction for patients and providers.

Journal Article↗
PubMed2001

[Perioperative mortality and morbidity for the year of 1999 in 466 Japanese Certified Anesthesia-training Hospitals: with special reference to ASA-physical status--report of Committee on Operating Room Safety of Japan Society of Anesthesiologists].

Perioperative mortality and morbidity in Japan for the year 1999 were studied retrospectively. Committee on Operating Room Safety of the Japan Society of Anesthesiologists (JSA) sent confidential questionnaires to 774 Certified Training Hospitals of JSA and received answers from 60.2% of the hospitals. We analyzed their answers with special reference to ASA physical status (ASA-PS). The total number of anesthetics analyzed was 655, 644. Mortality and morbidity due to all kinds of causes including anesthetic management, intraoperative events, co-existing diseases, and operation were as follows. The incidence of cardiac arrest (per 10,000 anesthetics) was 0.68, 3.76, 14.37, 67.03, 0.36, 4.68, 27.96, 206.30 in patients with ASA-PS of I, II, III, IV, I E, II E, III E, and IV E, respectively. The incidences of critical events including cardiac arrest, severe hypotension, and severe hypoxemia were 8.93, 26.99, 71.30, 188.52, 8.68, 31.27, 136.16, and 790.92 in patients with ASA-PS of I, II, III, IV, I E, II E, III E, and IV E, respectively. The mortality rates (death during anesthesia and within 7th postoperative day) after cardiac arrest were 0.16, 0.94, 5.71, 33.51, 0.00, 1.46, 16.41 and 167.76 per 10,000 anesthetics in patients with ASA-PS of I, II, III, IV, I E, II E, III E, and IV E, respectively. The overall mortality rates were 0.24, 1.66, 12.16, 67.03, 0.00, 3.51, 34.65 and 417.14 in patients with ASA-PS of I, II, III, IV, I E, II E, III E, and IV E, respectively. Overall mortality and morbidity were higher in emergency anesthetics than in elective anesthetics. ASA-PS correlated well with overall mortality and with morbidity, regardless of etiology. The incidences of cardiac arrest totally attributable to anesthesia were 0.24, 0.45, 1.47, 8.38, 0.36, 1.75, 2.43 and 11.34 in patients with ASA-PS of I, II, III, IV, I E, II E, III E, and IV E, respectively. The incidences of all critical events totally attributable to anesthesia were 4.92, 8.81, 14.74, 20.95, 4.34, 11.40, 15.80 and 22.67 in patients with ASA-PS of I, II, III, IV, I E, II E, III E, and IV E, respectively. The mortality rates after cardiac arrest totally attributable to anesthesia were 0.00, 0.00, 0.61 and 4.53 in patients with ASA-PS of I-IV, I E-II E, III E, and IV E, respectively. The overall mortality rates totally attributable to anesthesia were 0.00, 0.04, 0.18, 0.00, 0.00, 0.61 and 4.53 in patients classified to ASA-PS of I, II, III, IV, I E-II E, III E, and IV E, respectively. Only one death, due to overdose of anesthetics, was reported among patients with good physical status (ASA-PS of I, II, II E and II E). Anesthetic management was mainly responsible for critical events in patients with good physical status, while co-existing diseases were in those with poor physical status. The major co-existing diseases or conditions leading to critical events were heart diseases in elective anesthetics, and hemorrhagic shock in emergency anesthetics. We reconfirmed that ASA-PS is beneficial to predict perioperative mortality and morbidity. It also seems likely that we should make much more efforts to reduce anesthetic morbidity in patients with good physical status, and to improve preanesthetic assessment and preparation of cardiovascular conditions in those with poor physical status.

Anesthesiology↗
PubMed2005

Preoperative clinic visits reduce operating room cancellations and delays.

BACKGROUND: Anesthesiologist-directed preoperative medicine clinics are used to prepare patients for the administration of anesthesia and surgery. Studies have shown that such a clinic reduces preoperative testing and consults, but few studies have examined the impact of the clinic on the day of surgery. The authors tested whether a visit to an anesthesia preoperative medicine clinic (APMC) would reduce day-of-surgery case cancellations and/or case delays. METHODS: The authors conducted a retrospective chart review of all surgical cases during a 6-month period at the University of Chicago Hospitals. Case cancellations and rates of first-start case delay over the 6-month period were cross-referenced with a database of APMC attendees in both the general operating rooms and the same-day surgery suite. The impact of a clinic visit on case cancellation and delay in both sites were analyzed separately. RESULTS: A total of 6,524 eligible cases were included. In the same-day surgery suite, 98 of 1,164 (8.4%) APMC-evaluated patients were cancelled, as compared with 366 of 2,252 (16.2%) in the non-APMC group (P < 0.001). In the general operating rooms, 87 of 1,631 (5.3%) APMC-evaluated patients were cancelled, as compared with 192 of 1,477 (13.0%) patients without a clinic visit (P < 0.001). For both operating areas, APMC patients had a significantly earlier room entry time than patients not evaluated in the APMC. CONCLUSIONS: An evaluation in the APMC can significantly impact case cancellations and delays on the day of surgery.

Adult↗
PubMed1986

Improving the operating room to increase revenues.

Hospitals often overlook the potential to increase revenues by improving operating rooms and attracting additional surgery. Administrators should respond to surgeons' dissatisfaction with services despite limitations and ambiguities imposed by the surgical suite's chain of command. Directors of surgery can overcome formal authority problems by establishing informal relationships with the chiefs of surgery and anesthesia. Monthly reports to administration on quality and performance standards can avoid difficulties and prompt timely solutions. Satisfied surgeons will increase admissions by directing elective surgery patients to the hospital. Administrators can conduct interviews with all surgical personnel or use questionnaires to identify problems, potential new surgeons, and suggestions for improvement. Other tasks are to analyze each surgical section's functions, accumulate data by specialty and surgeon to plan daily schedules, evaluate organization and staffing, and evaluate instrumentation and supplies. Block scheduling and surgical acuity systems help establish controls in these areas. Feedback systems ensure that personnel remain sensitive to surgeons' needs. A nurse should be assigned to each surgeon to communicate information about patients, and surgeons should be encouraged to complete forms after each surgery to identify deficiencies in procedures. Other incentives for surgeons include favorable OR scheduling arrangements, purchase of special equipment, and package pricing for certain procedures.

Anesthesia Department, Hospital↗
PubMed2000

Port-access minimally invasive cardiac surgery increases surgical complexity, increases operating room time, and facilitates early postoperative hospital discharge.

BACKGROUND: Proposed advantages of port-access cardiac surgery have yet to be substantiated. The authors retrospectively compared patients undergoing port-access cardiac surgery with a matched group undergoing conventional cardiac surgery. METHODS: Forty-six patients who underwent port-access cardiac surgery were matched with 46 who underwent conventional cardiac surgery. Absolute criteria for matching included morning-of-surgery admission, procedure undergone, and care being delivered by one of two surgeons. If possible, matching included care delivered by one of two anesthesiologists. Patients were matched as closely as possible for preoperative demographic and clinical characteristics. RESULTS: All 46 pairs of patients were matched for procedure and admitted the morning of surgery. All 92 operations were performed by one of two surgeons, and 89% were performed by one of two anesthesiologists. Preoperative demographic and clinical characteristics were equivalent between groups. Compared with conventional cardiac surgery, port-access cardiac surgery increased surgical complexity (it almost tripled cardiopulmonary bypass time during coronary artery bypass grafting and increased it almost 40% during mitral valve procedures) and increased total operating room time (P < 0.0001). Port-access cardiac surgery had no beneficial effect on earlier postoperative extubation, decreased incidence of atrial fibrillation, or intensive care unit time, yet it decreased postoperative duration of stay (P = 0.029, all patients), a benefit observed primarily in patients undergoing coronary artery bypass grafting (P = 0.002). CONCLUSIONS: This retrospective analysis revealed that port-access cardiac surgery increases surgical complexity, increases operating room time, has no effect on earlier postoperative extubation or decreased incidence of atrial fibrillation or intensive care unit time, and may facilitate postoperative hospital discharge (primarily in patients undergoing coronary artery bypass grafting). Properly designed prospective investigation is necessary to ascertain whether port-access cardiac surgery truly offers any benefits over conventional cardiac surgery.

Adult↗
PubMed2004

Tensions influencing operating room team function: does institutional context make a difference?

BACKGROUND: A recent study of operating room (OR) team communication in a large, urban hospital described recurrent tension catalysts and a preliminary theory of team members' interpretive processes. To determine to what extent these findings were transferable to other institutional contexts, we conducted a validation study in 2 small, academic hospitals in a mid-size city. METHODS: Eight focus groups and 8 interviews were conducted with 6 general surgeons, 22 OR nurses, 5 anaesthesiologists and 10 trainees. Observations of 10 surgeons and their team members were conducted over 4 months. Data were analysed by applying thematic codes derived from previous research and engaging a grounded theory process to reveal additional, emergent themes. RESULTS: Observed tension catalysts were consistent with those described previously. However, 'higher tension' events occurred in only 70% of procedures in the smaller institutional context, as compared with at least 1 such event in all procedures in the larger setting. Interpretive processes were similar in teams from large and small institutional contexts. Team members referenced professional roles to interpret discourse, and they displayed recurrent role disagreements. Role perception influenced the motivations individuals attributed to colleagues' discourse, which influenced interpretations and reactions. CONCLUSIONS: Overall tension levels are lower in OR teams in smaller institutions; however, tension catalysts and interpretive processes appear similar to those in larger settings. Consistency in tension catalysts and interpretive processes across contexts allows us to begin to model theoretical principles of OR team communication, enabling the development of generic communication curricula applicable in a wide variety of institutional contexts.

Canada↗
PubMed1996

The operating room of the future.

As more and more care moves to the home setting, the ability to undergo a surgical procedure from the comfort of your own home may not be that far away. As for the operating room itself, patient care will be radically different than it has been in the past. Radiologists, assisted by computers and robots, may be performing procedures on patients "anesthetized" by acupuncture, therapeutic touch and aromatherapy in a totally bloodless environment.

Forecasting↗
PubMed2006

Transmission of group A Streptococcus limited to healthcare workers with exposure in the operating room.

BACKGROUND: Nosocomial transmission of group A Streptococcus (GAS) has been well described. A recent report of an outbreak investigation suggested that transmission can be extensive and that standard infection control measures may not be adequate to prevent transmission from patients with severe, invasive disease to healthcare workers (HCWs). OBJECTIVE: A case of pharyngitis in an HCW caring for a patient with GAS pharyngitis and necrotizing fasciitis prompted an investigation of the extent and risk factors for nosocomial transmission of GAS. SETTING: A 509-bed, tertiary care center in Portland, Oregon with 631,100 patient visits (hospital and clinic) and 11,500 employees in the year 2003. METHODS: HCWs with exposure to the index patient ("contacts") were identified for streptococcal screening and culture and completion of a questionnaire regarding the location and duration of exposure, use of personal protective equipment, and symptoms of GAS infection. RESULTS: We identified 103 contacts of the index patient; 89 (86%) submitted oropharyngeal swabs for screening and culture. Only 3 (3.4%) of contacts had a culture that yielded GAS; emm typing results and pulsed-field gel electrophoresis patterns of GAS isolates from 2 HCWs were identical to those for the isolate from the index patient. Both HCWs were symptomatic, with febrile pharyngitis and reported prolonged contact with the open wound of the patient in the operating room. CONCLUSIONS: In this investigation, nosocomial transmission was not extensive, and standard precautions provided adequate protection for the majority of HCWs. Transmission was restricted to individuals with prolonged intraoperative exposure to open wounds. As a result, infection control policy for individuals was modified only for HCWs with exposure to GAS in the operating room.

Adult↗
PubMed2004

Fungal endophthalmitis caused by Paecilomyces variotii following cataract surgery: a presumed operating room air-conditioning system contamination.

PURPOSE: To report a case of delayed fungal endophthalmitis by Paecilomyces variotii following uncomplicated cataract surgery. To our knowledge this is the first reported case of postoperative endophthalmitis by this species. METHODS: We report the longterm clinical follow-up of an 83-year-old female who underwent uncomplicated sutureless, small-incision cataract surgery. She developed recurring uveitis 4 months after surgery. Vitreous tap and finally complete vitrectomy with removal of the capsular bag including the intraocular lens were performed. Fungi were studied by histopathology and culture. RESULTS: At histopathological examination, the fungi were found to be closely related with the capsular bag. A few mononuclear inflammatory cells were encountered. At culture, Paecilomyces variotii, a common ubiquitous non-pathogenic saprophyte, was identified. Despite systemic, intravitreal and topical antifungal therapy after vitrectomy the uveitis recurred several times, but no fungal organisms were isolated from the repeat intraocular specimen. At 18 months postoperatively the subject's visual acuity was finger counting at 2 metres. At the time of surgery the operating room air-conditioning system was undergoing repairs. Cases of fungal endophthalmitis after contamination from air-conditioning ventilation systems have been reported before, but none of the cases reported have been caused by P. variotii. CONCLUSION: P. variotii, a non-pathogenic environmental saprophyte, may be disastrous if introduced into the eye. International recommendations on the environmental control of the operating room air-conditioning ventilation system should be strictly followed. No intraoperative surgery should be undertaken while the air-conditioning system is undergoing repairs or service.

Aged↗
PubMedDate not supplied

An ethnographic study of differentiated practice in an operating room.

An ethnographic study was conducted to investigate implementation of the clinical nurse III or team leader (TL) role as part of a newly executed nursing differentiated practice model. The six TLs studied were employed in the operating room (OR). Through participant observation, interviews, and document analysis, the TL role--as well as perceptions of the role by the TLs and OR staff--were studied. Problems related to performance of the role and its evolutionary process were delineated. Data analysis involved identifying categories and subcategories of data and developing a coding system to identify themes. Salient themes were related to the culture of the OR. Because of the OR's highly technical environment, the TLs defined their roles in relation to the organizational and technical needs of their surgical service. Refinement of surgeon "preference cards" and "instrument count sheets" was considered the initial priority for the TLs. Various controllable and uncontrollable factors were identified that affected implementation of the new TL role. Findings suggest that introduction of the role requires insight into setting and an emphasis on staging and orientation of employees to the new role.

Anthropology, Cultural↗
PubMed2003

Achieving operating room efficiency through process integration.

As healthcare organizations look for ways to gain new efficiencies and reduce costs, they are examining surgical services with a critical eye. In many cases, the operating room (OR) was not included in enterprisewide reengineering efforts, thereby limiting the positive impact of those efforts. Healthcare organizations are recognizing that every point along the patient care continuum is interrelated. To truly maximize reengineering efforts, they need to integrate the entire process and information flow within the OR and across the enterprise.

Appointments and Schedules↗
PubMed1982

Concentrations of methoxyflurane and nitrous oxide in veterinary operating rooms.

The surgical rooms of 14 private veterinary practices were monitored to determined methoxyflurane (MOF) concentrations during surgical procedure under routine working conditions. The average room volume for these 14 rooms was 29 m3. The average MOF value for all rooms was 2.3 ppm, with a range of 0.7 to 7.4 ppm. Four of the 14 rooms exceeded the maximum recommended concentration of 2 ppm. Six rooms which had 6 or more air changes/hr averaged 1.1 ppm, whereas 8 rooms with less than 6 measurable air changes/hr averaged 3.2 ppm. Operating rooms that had oxygen flows of more than 1,000 cm3/min averaged 4.4 ppm, whereas those with flows of less than 1,000 cm3/min averaged 1.5 ppm. The average time spent during a surgical procedure using MOF, for all 14 facilities, was 2 hours. Nitrous oxide (N2O) concentrations were determined in 4 veterinary surgical rooms. The average N2O concentration for 3 rooms without waste anesthetic gas scavenging was 138 ppm. Concentration of N2O in the waste anesthetic gas-scavenged surgical room was 14 ppm, which was below the maximum recommended concentration of 25 ppm.

Air Pollution↗