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This is the first of two articles based on a presentation given at NATN Congress 2004. The presentation was given as the Daisy Ayris Memorial Lecture. In this article NATN archivist Nancy Cox describes her experiences working in the operating room beginning in the 1950s.
A patient's blind phakic eye with clear media, the subject of previous light exposure studies, was exposed for 60 minutes to light from a standard operating room microscope (Zeiss OpMi-6) filtered through an infrared filter. A typical acute photic retinopathy lesion was produced. Two and a half months later, the eye was exposed for 60 minutes to light filtered simultaneously through an ultraviolet filter and an infrared filter. Despite blocking both the ultraviolet and infrared light, and despite reducing the overall light energy by approximately one fourth because of the combination of filters, a typical acute photic retinopathy lesion was produced by the transmitted light, the energy of which was essentially all within the visible spectrum.
We developed an algorithm for processing networked vital signs (VS) to remotely identify in real-time when a patient enters and leaves a given operating room (OR). The algorithm addresses two types of mismatches between OR occupancy and VS: a patient is in the OR but no VS are available (e.g., patient is being hooked up), and no patient is in the OR but artifactual VS are present (e.g., because of staff handling of sensors). The algorithm was developed with data from 7 consecutive days (122 cases) in a 6 OR trauma center. The algorithm was then tested on data from another 7 consecutive days (98 cases), against patient in- and out-times captured by OR surveillance videos. When pulse oximetry, electrocardiogram, and temperature readings were used, OR occupancy was correctly identified 96% (95% confidence interval [CI] 95%-97%) and OR vacancy >99% of the time. Identified patient in- and out-times were accurate within 4.9 min (CI 4.2-5.7) and 2.8 min (CI 2.3-3.5), respectively, and were not different in accuracy from times reported by staff on OR records. The algorithm's usefulness was demonstrated partly by its continued operational use. We conclude that VS can be processed to accurately report OR occupancy in real-time.
Different operation theatres of the county of Gera were examined to quantify the exposition against halothane which is used as an inhalation narcotic, and also against ethanol. Besides the short time exposition (0.5 h) determined with gas sampling tubes the long time exposition (up to 8 h) was monitored personally by means of charcoal passive samplers. The analytical method of choice was gas chromatography, in the second case after thermal desorption of the enriched pollutants. Generally, the concentrations are lower than the MAKD if the workplace is equipped with an exhaust type NAREX 101. Without it the MAKD is reached quickly. A statistical evaluation of the results shows that there exist remarkable differences between as well the degree as the scattering of the individual exposition levels depending from the task in the operating theatre. Obviously the percentage of anesthesia using halothane is increasing.
Nosocomial infections may result from the reuse of surgical devices if adequate disinfection or sterilization measures are not employed. The first step of reprocessing occurs immediately after use in the operating room. This consists of cleaning and decontamination to eliminate organic material and to reduce the number of microorganisms, in order to protect personnel who subsequently manipulate these instruments and to facilitate the ultimate process of sterilization or disinfection. Instruments that cannot be sterilized must be submitted to "high level disinfection" to remove undesirable microorganisms. In order to guarantee the desired results of disinfection, it is very important to adopt reliable and effective protocols, chemical products with good germicidal properties and with minimal adverse effects on the personnel and the environment. The personnel involved in this delicate and important task must be thoroughly trained. If the above conditions are met, the infectious risk associated with reuse of surgical devices can be controlled.
The aim of this study was to evaluate the risks deriving from the interference by radio handsets (GSM cellular phones and UHF radios) with intensive-care and operating-room ventilators. Tests were conducted in three hospitals in Rome on 22 lung ventilators in accordance with the recommended practice ANSI C63.18-1997. When electromagnetic interference (EMI) effects occurred, the authors determined maximum interference distances. They also evaluated the distances at which the use of a given handset would result in a 5% and a 95% probability of interference. The degree of risk posed by each observed event was estimated, and safe distances are suggested. EMI events of varying degrees and natures were observed even with transmitters placed at a considerable distance. All observed effects were temporary. Only three ventilators of a certain model stopped working altogether and had to be reset.
Protocols regarding the treatment of cardiac arrest of the pediatric patient outside the operating room are continually being reviewed as knowledge regarding the pathophysiology of cardiac arrest and the pharmacologic properties of resuscitative drugs has progressed. The indications for treatment of cardiac arrest by the various resuscitative drugs, and techniques for obtaining access for the administration of these drugs are discussed.
Non-anesthetists usually provide sedation and anesthesia outside the operating room for emergency procedures. Techniques vary from no sedation to deep sedation using drugs with a good safety profile and few side effects. Newer methods of airway control may allow volatile agents such as sevoflurane to be used. Anesthetists may need to join sedation teams if they are to maintain control of their specialty.
A multicentric prospective trial was conducted to evaluate the frequency and kind of blood exposure in operating room. From march to june 1992, 3554 procedures were observed in 22 surgical units (visceral, orthopaedic and vascular), with 129 surgeons, 133 residents and 216 nurses. Statistic analysis was done on Epi Info 5 (CDC Atlanta) and EGRET (Statistic and Epidemiology Research Corporation, Seattle). 11.7% of procedures were the case for an incidental blood exposure: 4.2% for percutaneous exposure; 8.4% for cutaneous or mucosal exposure. Rates change with the surgical specialty. Surgeons were involved in 50.7% of percutaneous exposure and 58.7% of the cutaneous or mucosal exposures, especially when they were operators (respectively 2 and 5.6% person-act). A significative rate was founded between incidental blood exposure and the length of procedure, the sepsis character of the procedure, but not with emergency or number of globular units transfused. To diminish the incidental blood exposure and its risks, this data suggests three kinds of practice: a better work for vaccination; in our study 59% of surgeons declare an adequate vaccination against hepatitis B; a best operative hygiene, with knowing of risks factor of blood exposure, depending of the kind of procedure, changing between different units; the use of protections: non coated dressing, double gloving, ocular protection.
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The Japanese Society of Anesthesiologists (JSA) conducts an annual survey of life-threatening events in operating rooms (OR) in JSA Certified Training Hospitals (JSACTH) by sending and collecting confidential questionnaires. Etiologies of the incidents were divided into four categories: those totally attributable to anesthetic management (AM), those resulting from preoperative complications (PC), those resulting from intraoperative pathological events (IP) and those related to surgical procedures (SP). IP resulted from coronary ischemia not suspected preoperatively, arrhythmias, pulmonary embolism, and other conditions. Outcomes were judged on the 7th post-operative day. In the year 2002, questionnaires were sent to 844 JSACTHs, and a total of 1,461,020 cases of anesthesia were documented from 773 JSACTHs. Of these, 1,277,045 cases of anesthesia from 712 JSACTHs were available for analysis. Seven hundred thirty nine cardiac arrests (5.79 per 10,000 anesthetics) and 806 deaths (6.31 per 10,000 anesthetics) due to life-threatening events in the OR were reported. The incidence of cardiac arrest and mortality totally attributable to AM was 0.38 and 0.11 per 10,000 anesthetics. These values tended to decrease after 1994, except the mortality totally attributable to AM, which were almost at constant level during recent years. The summary of the study between 1999 and 2002 was as follows. Among 3,855,384 anesthetics, 2,443 cardiac arrests (6.34 per 10,000 anesthetics) and 2,638 deaths (6.85 per 10,000 anesthetics) due to life-threatening events in the OR were reported. PC, SP, IP and AM were responsible for 64.7, 23.9, 9.4, and 1.5% of deaths, respectively. The major cause of PC related deaths was preoperative hemorrhagic shock, followed by cardiovascular diseases such as myocardial ischemia and congestive heart failure. Excessive surgical bleeding comprised 70.2% of SP-related deaths. The major causes of IP-related death were myocardial ischemia, pulmonary embolism, and severe arrhythmias. The incidence of cardiac arrest and death totally attributable to AM was 0.47 and 0.10/10,000 anesthetics, respectively. Among patients with ASA-PS 1(E) and 2(E), AM-related deaths occurred at a rate of 0.04/10,000 anesthetics. Half of AM-induced deaths were caused by airway or ventilatory problems. Other causes of AM-related death were medication accidents and infusion/transfusion accidents. Considerable effort is required to reduce intraoperative life-threatening events caused by human error, hemorrhage, and cardiovascular diseases.
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OBJECTIVES: The aim of this study was to assess the level of occupational exposure to nitrous oxide (N(2)O) in operating rooms (ORs), as related to different ventilation and scavenging systems used to remove waste anaesthetic gases from the work environment. METHODS: The monitoring of N(2)O in the air covered 35 ORs in 10 hospitals equipped with different systems for ventilation and anaesthetic scavenging. The examined systems included: natural ventilation with supplementary fresh air provided by a pressure ventilation system (up to 6 air changes/h); pressure and exhaust ventilation systems equipped with ventilation units supplying fresh air to and discharging contaminated air outside the working area (more than 10 air changes/h); complete air-conditioning system with laminar air flow (more than 15 air changes/h). The measurements were carried out during surgical procedures (general anaesthesia induced intravenously and maintained with inhaled N(2)O and sevofluran delivered through cuffed endotracheal tubes) with connected or disconnected air scavenging. Air was collected from the breathing zone of operating personnel continuously through the whole time of anaesthesia to Tedlar((R)) bags, and N(2)O concentrations in air samples were analyzed by adsorption gas chromatography/mass spectrometry. RESULTS: N(2)O levels in excess of the occupational exposure limit (OEL) value of 180mg/m(3) were registered in all ORs equipped with ventilation systems alone. The OEL value was exceeded several times in rooms with natural ventilation plus supplementary pressure ventilations and twice or less in those with pressure/exhaust ventilation systems or air conditioning. N(2)O levels below or within the OEL value were observed in rooms where the system of air conditioning or pressure/exhaust ventilation was combined with scavenging systems. Systems combining natural/pressure ventilation with scavenging were inadequate to maintain N(2)O concentration below the OEL value. CONCLUSION: Air conditioning and an efficient pressure/exhaust ventilation (above 12 air exchanges/h) together with efficient active scavenging systems are sufficient to sustain N(2)O exposure in ORs at levels below or within the OEL value of 180mg/m(3).
As trauma systems develop, more patients can potentially benefit from immediate surgery. With in-house surgeons available, enthusiasm for direct transfer from the scene to the operating room (OR) has developed in many institutions. The purpose of this study was to define precisely which patients should be taken to the OR for resuscitation. Three hundred twenty-three patients were taken to the OR directly from the field during a 4-year period (6.9% of trauma activations). Indications included the following: (1) cardiac arrest--one vital sign present, (2) persistent hypotension despite field intravenous fluid, and (3) uncontrolled external hemorrhage. A board-certified surgeon and resuscitation team met the field transport team in the OR in all cases. Cardiopulmonary resuscitation for patients with blunt trauma was not accompanied by survival even with immediate surgery by a trained surgeon and it wastes valuable OR resources. Patients with prehospital hypotension unresponsive to fluid resuscitation indicate the need for rapid surgery. Patients with blunt injuries even with hypotension infrequently undergo operations in less than 20 minutes and can be resuscitated in traditional areas where better roentgenograms are obtained. Penetrating injuries to the chest and abdomen with hypotension are the primary indications for OR resuscitation. It can be anticipated with field communication and accompanied by enhanced survival.
BACKGROUND: Ineffective team communication is frequently at the root of medical error. The objective of this study was to describe the characteristics of communication failures in the operating room (OR) and to classify their effects. This study was part of a larger project to develop a team checklist to improve communication in the OR. METHODS: Trained observers recorded 90 hours of observation during 48 surgical procedures. Ninety four team members participated from anesthesia (16 staff, 6 fellows, 3 residents), surgery (14 staff, 8 fellows, 13 residents, 3 clerks), and nursing (31 staff). Field notes recording procedurally relevant communication events were analysed using a framework which considered the content, audience, purpose, and occasion of a communication exchange. A communication failure was defined as an event that was flawed in one or more of these dimensions. RESULTS: 421 communication events were noted, of which 129 were categorized as communication failures. Failure types included "occasion" (45.7% of instances) where timing was poor; "content" (35.7%) where information was missing or inaccurate, "purpose" (24.0%) where issues were not resolved, and "audience" (20.9%) where key individuals were excluded. 36.4% of failures resulted in visible effects on system processes including inefficiency, team tension, resource waste, workaround, delay, patient inconvenience and procedural error. CONCLUSION: Communication failures in the OR exhibited a common set of problems. They occurred in approximately 30% of team exchanges and a third of these resulted in effects which jeopardized patient safety by increasing cognitive load, interrupting routine, and increasing tension in the OR.
Over a 3-year-period, standard treatment with hydrostatic pressure from a contrast enema failed to reduce ileocolic intussusception in 31 of 62 children. With the child anesthetized in the operating room, a second contrast enema was given before laparotomy. Of the 31 intussusceptions, 21 (68%) were reduced without complication, thereby avoiding the discomfort, longer hospitalization, complications, and expense of surgery. Nine of the remaining 10 intussusceptions were difficult to reduce manually during surgery or required resection. The overall nonoperative reduction rate for the 3-year period was 84%; for the last 2 years it was 90%. Success with the second enema may be related to the effects of general anesthesia. In addition, partial reduction with the first enema may improve blood flow from the intussusceptum so that it becomes smaller and easier to reduce with the second enema. Because it can easily be added to standard management protocols without increased risk, routine use of this second enema with anesthesia is recommended.