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PubMed1996

Prevention of pain on injection of propofol: a comparison of lidocaine with alfentanil.

We undertook a randomized, placebo-controlled, double-blind study to compare the use of alfentanil 1 mg and lidocaine 40 mg for the reduction of pain during injection of propofol. Eighty-nine patients were randomly allocated to one of three groups: Group L, lidocaine 40 mg added to 180 mg propofol; Group A, alfentanil 1 mg 30 s prior to propofol; or Group P, placebo (normal saline). The incidence of pain in the placebo group was 67%. Both treatment groups had a significantly lower incidence of pain than the placebo group (P < 0.002). There was no significant difference in the incidence of pain between the groups receiving lidocaine or alfentanil (13% and 24%, respectively). There was no significant difference in the induction dose of propofol between the groups. Fifty-two percent of patients who experienced pain at induction had recall of that pain in the recovery room. Alfentanil 1 mg and lidocaine 40 mg are both effective in reducing pain during injection of propofol.

Adolescent↗
PubMedDate not supplied

Building a quality culture through small and large successes.

Total quality management (TQM) is a unifying business strategy for achieving and sustaining growth. TQM proceeds, step by step, project by project, to transform the organization into one smoothly working, quality-focused team. For successful implementation of TQM, the small projects are every bit as important as the large ones. The simple, accessible successes validate the skills that employees are acquiring and encourage them to try more complex, long-term endeavors. This article discusses several TQM projects conducted at Baptist Medical Center in Columbia, SC: streamlining medical records processing (a large project that freed up millions of dollars in cash flow); improving the reliability of all hospital equipment; and ongoing small successes in the recovery room. Although the dollar value of the projects varied considerably, all were critical to creating a culture of total quality management at Baptist Medical Center.

Cost Savings↗
PubMed1985

Noise in acute patient care areas.

This study was designed to describe the level of sound in acute patient care areas. A convenience sample of 25 subjects from four intensive care and two general care units within three hospitals in a large metropolitan area was studied. Continuous decibel levels [dB(A)] and equivalent continuous sound pressure levels [LEQ] were measured for 24 continuous hours. Two 3-hour observations were made to assess the sources of sound, and patients were interviewed to determine their perceptions of sound effects. Continuous high noise levels were found in the larger hospital's open heart recovery room and intensive care units [48.5-68.5 dB(A), 15-minute LEQ], lower levels in the smaller hospital's intensive care units [32.5-57 dB(A)] and varying levels in the general ward areas [34.25-62.5 dB(A)]. Decibel levels generated from equipment reached 90 dB(A) in some instances. Patients' perceptions ranged from content to highly perturbed. Although some sources of noise were not immediately changeable, other were adaptable, preventable, or reducible.

Canada↗
PubMed1981

Studies in fentanyl-supplemented anaesthesia: awareness and effect of naloxone on early post-operative recovery.

Ninety-nine unselected patients were given a standardized general anaesthetic with fentanyl 1.5 microgram . kg-1 every 30 minutes and were randomly divided into three equal groups; Group I patients received naloxone 0.1 mg. Group II naloxone 0.2 mg and Group III naloxone 0.4 mg intravenously at the end of the operation and after the reversal of neuromuscular blockade. After naloxone the level of consciousness lightened and the response to stimulus increased: the changes were significant in all three groups and the actual changes were significantly greater in Groups II and III compared with Group I. In the Recovery Room there was no significant difference among the Groups for shivering, nausea, vomiting or pain. The incidence of operative awareness was one per cent and that of dreaming eight per cent and this was unrelated to naloxone dosage. Patient acceptance was high, seven patients not wanting this type of anaesthesia again due to (a) light premedication (inherent in the study design), two patients; (b) nausea and vomiting, four patients; and (c) slow awakening, one patient.

Anesthesia↗
PubMed1998

Comparison of immediate recovery period among young, middle-aged and elderly patients.

We reported the immediate recovery period of 705 consecutive patients post general or head-neck-breast surgery, 590 were looked after in the recovery room (RR) and 115 were admitted into the intensive care unit (ICU) right after surgery. Group I were "young" (aged 15-45 years), group II were "middle aged" (46-60 years) and group III were "elderly" (> 60 years). Twenty-seven per cent of the elderly patients were sent to the ICU, whereas, 8.4 per cent of the young and 14.7 of the middle-aged group were looked after in the ICU. In RR patients, the young group were in better ASA class and had significantly fewer underlying diseases than the middle-aged and elderly groups; the most common of which were hypertension, diabetes and anemia. Elderly patients spent a significantly longer time in the RR than the young group but the risk of complication was not different. The most frequent complication was pain and elderly patients more frequently suffered from pain than the young group. Post-anesthetic recovery score (after Aldrete and Kroulik) was lower in the elderly on arrival and at 15, 30, 60 minutes in the RR but there was no clinical significance. In ICU patients, the 3 groups' intubation rates were not different and although the duration of intermittent positive pressure ventilation and duration of stay in the ICU were longest in the elderly group, there was no statistically significant difference. The mortality rate was highest in the elderly. We concluded that elderly patients had a worse immediate recovery period.

Adolescent↗
PubMed1977

The diffusion of hospital technologies: some econometric evidence.

This paper examines the diffusion of five hospital technologies that have spread widely since 1950: the postoperative recovery room, the intensive care unit, the respiratory therapy department, diagnostic radioisotope facilities, and electroencephalograph. The regressions show that the logistic function describes the diffusion of hospital innovations as well as it does the diffusion of innovations in other industries, that the rates of diffusion for these technologies fall within the range established by work on other industries, and that the rates for technologies that were not yet widespread in the middle 1960s increased with the advent of Medicare and Medicaid.

Costs and Cost Analysis↗
PubMed1996

Bolus metoclopramide does not enhance morphine analgesia after cesarean section.

Intravenous metoclopramide potentiates the analgesic effects of opioids in postoperative patients. We speculate that increased spinal concentrations of acetylcholine from metoclopramide-induced acetylcholinesterase inhibition is the mechanism responsible for enhanced morphine analgesia from metoclopramide. Sixty patients undergoing elective cesarean section with subarachnoid anesthesia were randomized to receive either 20 mg metoclopramide or saline intravenously 30-60 min prior to subarachnoid injection. Prior to subarachnoid injection of local anesthetic, 2 mL of cerebrospinal fluid (CSF) was aspirated for cholinesterase activity measurement. Visual analog scale (VAS) scores for pain were obtained prior to drug administration, at first patient request for analgesia, and at discharge from the postanesthesia care unit. Total morphine use was recorded in the recovery room and for 24 h postoperatively. There were no significant differences in VAS scores, morphine use, or CSF cholinesterase activity between groups. CSF cholinesterase activity was similar to values in nonpregnant patients demonstrated previously. This study failed to confirm the morphine-enhancing action of 20 mg intravenous metoclopramide in postoperative patients. Furthermore, this dose of metoclopramide does not inhibit CSF acetylcholinesterase.

Acetylcholine↗
PubMed1998

Pulse oximetry: an added criterion for discharge from the post-operative care unit.

Based on the observation that the degree of wakefullness measured by Post Anesthetic Recovery (PAR) score in some patients does not correlate with their oxygen saturation, the authors decided to carry on a study to validate that assumption. Three hundred patient ASA I & II were studied. Oxygen saturation and PAR score were recorded from the time of arrival till their discharge by the recovery room staff nurses. Thirty one patients out of one three hundred (10%) were found to be hypoxic (saturation < 95%) despite their high PAR score. The degree of wakefullness as measured by PAR scores cannot be used to establish an end point for oxygen supplementation. Oxygen supplementation and SpO2 monitoring are recommended in all patients recovering from anesthesia.

Adolescent↗
PubMedDate not supplied

A regional pain management audit.

An audit was carried out in the Northern and Yorkshire region to assess postoperative pain management outcomes. Pain scores were measured in the recovery room at 24 hours and at seven days postoperatively, at rest and on movement. A verbal numerical rating score (VNRS) tool was used. Data was also collected on the modalities of pain management. The results show that a large percentage of patients reported unacceptable levels of pain despite changes in practice and the development of acute pain management teams. Epidural infusion was the most effective modality and intramuscular opioid with non steroidal anti-inflammatory drugs (NSAIDs) and codeine were shown to be more effective than patient-controlled analgesia. Sites with pain management teams did not provide better pain management for postoperative patients.

Analgesics↗
PubMed1995

Death associated with anaesthesia and surgery in Finland in 1986 compared to 1975.

Mortality associated with anaesthesia and surgery in Finland in 1986 was studied using a retrospective method and was compared with the results of a similar study performed in 1975. The total number of procedures was 325,585. 570 patients fulfilled one of the three criteria: 1. The patient died within three days of a procedure needing anaesthesia. 2. The patient died more than three days after a procedure needing anesthesia, but had suffered a cardiac arrest or been resuscitated, or there was a surgical or an anaesthesiological complication contributing to the death. 3. The patient suffered a major handicapping neurological (or other) deficit, which was associated with anaesthesia, or there was a surgical or an anaesthesiological complication possibly contributing to the death or handicap (no patients). The number of consultant anaesthesiologists had more than doubled since 1975. At the same time there was also a significant increase in recovery room and intensive care facilities. Surgery was the main contributing factor in the death of 22 (frequency 0.68/10,000 procedures), and anaesthesia in the death of five (frequency 0.15/10,000 procedures) patients. The role of surgery had decreased to about one third and the role of anaesthesia to less than one tenth as the main cause of death associated with anaesthesia and surgery compared to the year 1975. 95.3% of all the patients died mainly because of co-existing medical or surgical disease.

Adolescent↗
PubMed1994

How noisy are anaesthesia and intensive care medicine? Quantification of the patients' stress.

The minimum and maximum sound pressure levels (Lmin, Lmax) were measured, and the energy equivalent sound pressure level (Leq) and the impulse rated Leq (LAlm) were ascertained in the surgical intensive care unit and the anaesthetic and recovery room. Frequency analyses were also made of the noise from various pieces of equipment. The LAlm was never below 60 dB(A)--the wake-up threshold in man--comprising strong narrow-band impulses with Lmax more than 100 dB(A) primarily from instrument alarms. When several instruments were alerted at the same time, a broad-band noise resulted which was based on their various spectral peaks. Whilst the maximum sound level of the technical equipment was high, it was surpassed by avoidable background noise caused by the staff (e.g. falling bucket lid: 94.7 dB(A)). No relationship was found between acoustic parameters and intended type of anaesthesia or surgery. Sound level was low in dangerous situations and high during routine work.

Acoustics↗
PubMedDate not supplied

Costs incurred by outpatient surgical centers in managing postoperative nausea and vomiting.

STUDY OBJECTIVE: To estimate the financial costs incurred by outpatient surgical centers in managing postoperative nausea and vomiting (PONV). DESIGN: Prospective, observational study. SETTING: 6 hospital-based outpatient surgery centers. PATIENTS: 211 adult patients undergoing outpatient surgery for laparoscopy, dilatation and curettage, knee arthroscopy, or hernia repair. MEASUREMENTS AND MAIN RESULTS: Of the 211 patients studied, 34 experienced PONV in the recovery room. For those patients experiencing PONV, personnel, supply, and drug costs for management of this condition averaged $14.94 per patient. In addition, PONV increased the centers' operating costs by delaying patient discharge by an average of 24 minutes. A minimum estimate of this cost, based on nurses' wage rates, was $7.12. This estimate is appropriate only for short-run considerations in outpatient surgery centers that operate at low capacity. An appropriate valuation for long-run considerations and for centers operating near capacity is based on the revenue that centers lose as a result of extended stays. Lost revenue was estimated to be $415 per patient experiencing PONV. CONCLUSIONS: PONV substantially increases the costs incurred by outpatient surgical centers.

Adult↗
PubMed1991

Effect of an automated sink on handwashing practices and attitudes in high-risk units.

OBJECTIVE: To assess the effects of an automated sink on handwashing practices and attitudes of staff. DESIGN: Quasi-experimental crossover design. SETTING: Two high-risk patient care areas, one postanesthesia recovery room (Site 1), and one neonatal intensive care unit (Site 2) in two tertiary care hospitals. PARTICIPANTS: All patient care staff on study units; approximately 55 individuals. INTERVENTIONS: An automated sink was installed to replace one handwashing sink for about five weeks; the sink was then crossed-over for an equivalent time period to the other location. Handwashing practices of all unit staff were observed in three two-hour observation periods/week. Questionnaires were distributed to staff two weeks after sink installation and at the study's end. RESULTS: One thousand, six hundred ten handwashes were observed. Handwashing practices differed significantly by site. For both sites, hands were washed significantly better but significantly less often with the automated sink (all p less than .001). Staff expressed negative attitudes, however, about certain features of the sink, and these negative attitudes increased over the study period. CONCLUSIONS: Automated devices must be flexible enough to allow adjustments based on staff acceptance. Application of new technology to improve hand hygiene requires a multifaceted approach to behavior change.

Anesthesia Recovery Period↗
PubMed2001

Chest radiograph interpretation skills of anesthesiologists.

OBJECTIVE: To assess the skills of anesthesiologists in the interpretation of chest radiographs. DESIGN: Randomized evaluation conducted among anesthesiologists and radiologists. SETTING: Postgraduate Assembly of the New York State Society of Anesthesiologists in 1999, and the Department of Radiology, New York University Medical Center. PARTICIPANTS: A total of 61 anesthesiologists (48 attending physicians; 13 residents); control group of 8 radiology residents (all participants volunteered). INTERVENTIONS: After completing a demographic survey, participants were asked to review a series of 10 chest radiographs. A brief clinical scenario accompanied each radiograph. No time limit was set for these interpretations. MEASUREMENTS AND MAIN RESULTS: The demographic characteristics of the anesthesiology participants included university faculty (46%), private group practitioners (41%), independent practitioners (11%), and 1 participant with an unspecified type of practice. Additional training among the participants included internal medicine (31%), surgery (19%), and pediatrics (3%); 34% did not specify any additional training. Of the participants, 92% were involved in cases requiring general anesthesia; 96% managed patients in the recovery room; and 34% managed patients in the intensive care unit. Of participants, 80% usually order chest radiographs, but only 42% interpret the films themselves. Misdiagnosed radiographs included pneumothorax by 11% of participants, free air under the diaphragm by 41%, bronchial perforation from a nasogastric tube by 28%, right mainstem intubation by 20%, superior vena cava perforation from a central venous catheter by 31%, normal film by 75%, negative pressure pulmonary edema by 16%, left lower lobe collapse by 80%, pulmonary infarction from a pulmonary artery catheter by 29%, and tension pneumothorax by 41%. Overall scores of the attending physicians were not significantly different from that of residents (p > 0.05). The control group of radiology residents scored significantly better (mean, 83.7; p = 0.009) than the anesthesia residents (mean, 62.8) and anesthesia attending physicians (mean, 62.5). CONCLUSION: Anesthesiologists are deficient in skills for the interpretation of chest radiographs. The skill level of university-based physicians is not greater than physicians in private practice, and skill level does not improve with level of training or experience. Most anesthesiologists rely on radiologists for interpretative results. Further training during the residency years may help improve diagnostic skills.

Anesthesiology↗
PubMed1997

[Intravenous sedation in implantology].

Local or block anesthesia can be used satisfactorily in many implant procedures. However, when advanced implant techniques or pre-prosthetic reconstruction surgery of the maxillofacial bones are required, local or regional anesthesia is insufficient. The "day-hospital" concept is a rational approach which meets the requirements for anesthesia and deep sedation with criteria for patient safety and comfort while guaranteeing optimal operating conditions. Intravenous sedation, both "conscious" and "deep" sedation, is a very well adapted form of anesthesia for implant recipients. Local or block anesthesia is enhanced or reinforced prior to surgery by the intravenous administration of a sedative and anxiolytic agent (single-drug concept), such as a benzodiazepine, associated or not with a morphinomimetic agent and an antihistaminic substance (multiple-drug concept). The main goal is to maintain spontaneous respiration while obtaining postoperative amnesia of the entire procedure. Mandatory use of a pulse oximeter has greatly contributed to improved safety of intravenous sedation, essentially indicated for operations not lasting more than 2 and a half hours in patients in good general health (scoring 1 or 2 in the American Society of Anesthesiology (ASA) classification) and with a low risk of postoperative complications. This concept requires an adapted technical facility. The operating theatre should have all the equipment necessary for cardiovascular, neurological and respiratory emergency care. The postoperative recovery room should also be equipped with cardiovascular monitoring devices and be able to accommodate an intensive care unit. Under these strict rules, short duration surgical procedures (< 150') can be performed : 1) with the best conditions of medical safety, 2) with improved operating conditions for the implant surgeon (the patient responds immediately to vocal orders when necessary) while asepsis is maintained as easily as with general anesthesia, 3) with better conditions for postoperative care and patient comfort (the anesthetist is continuously present). 4) better psychological conditions for the patient who will be discharged the same day, 5) with total amnesia of the entire surgical procedure, 6) elimination of a usually disproportionately long hospitalization. Day hospitalization also helps contain health care costs by cutting out the need for overnight care and accommodation. We underline the safety of current intravenous sedation techniques and present two series of data related to the use of this technique by an anesthetist and an operating surgeon in a day hospital from 1986 to 1995.

Ambulatory Surgical Procedures↗
PubMed1996

Indications for intensive care unit care after carotid endarterectomy.

OBJECTIVES: To describe the complications of carotid endarterectomy and the interventions performed in the intensive care unit (ICU) after carotid endarterectomy. To identify preoperative and recovery room (RR) risk markers for these complications and interventions. DESIGN: A retrospective case study. SETTING: The ICU of a university hospital. PATIENTS: One hundred and one patients who required carotid endarterectomy over a 15-month period. INTERVENTION: Carotid endarterectomy (bilateral procedures in 11 patients). OUTCOME MEASURES: Demographic data including Goldman's cardiac risk index and the therapeutic intervention scoring system (TISS) score to measure the risk of complications. RESULTS: Most of interventions conducted in the RR and ICU were to control high blood pressure. In the RR, three patients experienced a neurologic event, one patient was reintubated for vocal cord paralysis and one had electrocardiographic abnormalities. Overall, 5 of the 101 patients had neurologic complications and 2 suffered a myocardial infarction. Two patients died, one as a result of a massive stroke and the other of myocardial infarction with cardiogenic shock. The mean (and standard deviation) TISS. score in the ICU was 12.6 (3.8). Analysis of all events in the RR was not predictive of events in the ICU. However, the absence of major complications in the RR had a negative predictive value of 97%. CONCLUSIONS: The decision to admit patients to the ICU after carotid endarterectomy should be based on major complications occurring in the RR. A low TISS score and low incidence of complications does not warrant routine admission.

Aged↗
PubMed1999

[Quantification of postoperative vigilance by evoked potentials].

OBJECTIVE: Patients will be discharged from the postoperative recovery room mostly on subjective clinical assessment. In this study an approach to a more quantitative judgment of postoperative vigilance is made by recording the P300-latency and neuropsychological tests. METHODS: 22 adult patients undergoing a disc operation were examined. For induction of anesthesia thiopental (4-5 mg/kg), fentanyl (0.1 mg) and a musclerelaxant (atracurium 0.4 mg/kg or succinylcholine 1-2 mg/kg after precurarisation with atracurium 5 mg) were given. Anesthesia was then continued with enflurance (1.0-1.2 MAC) in a mixture of 67% nitrous oxide in oxygen. If postoperative analgesia was needed, piritramid was injected in boli à 3-6 mg. The P300 was acoustically stimulated with an oddball-paradigm and recorded at Fz and Cz. Afterwards the latencies were measured and compared with a vigilance score composed of clinical parameters and neuropsychological tests. Recordings were done preoperatively and every 30 minutes up to 2 hours postoperatively. A correlation between P300-latencies and vigilance score was made with the coefficient of Spearman. Comparison of pre- and postoperative values was managed by using Wilcoxon test for matched pairs with Bonferroni-correction. RESULTS: Immediately after operation, P300 was obtained only in 8 patients (36%). The latencies were delayed (394 +/- 35 ms versus 326 +/- 12 ms preoperatively). During follow-up patients recovered and 2 hours postoperatively only one patient had no P300. At the end of the examination period P300-latencies of most patients had not yet reached the preoperative levels. The vigilance score in parallel showed decreases immediately after the operation and increases later on. However there were discrepancies between P300 latencies and neuropsychological findings, in some cases possibly due to the sedative effects of postoperative analgetics. CONCLUSION: Recording of P300-latencies showed remarkable cognitive deficits because of subclinical anesthesia hangover even 2 hours after a routine inhalational anesthesia. It is a good quantifiable method for assessment of postoperative vigilance. In some cases P300-latency is a more sensitive parameter for vigilance phenomena than clinical and neuropsychological scores.

Adult↗