Alan P. Marco

Recovery from outpatient laparoscopic tubal ligation is not improved by preoperative administration of ketorolac or ibuprofen.

The analgesic efficacy of a single dose of ketorolac or ibuprofen given preoperatively was assessed in healthy outpatients undergoing general anesthesia for laparoscopic tubal ligation. Fifty patients were randomized to receive either ketorolac 60 mg intravenously (i.v.), ibuprofen 800 mg orally, or placebo in a double-blind manner. Anesthesia was induced with fentanyl 2 micrograms/kg, thiopental 5 mg/kg, and either vecuronium 0.1 mg/kg or succinylcholine 1.5 mg/kg i.v. and was maintained with nitrous oxide 67% in oxygen and isoflurane. Patients were assessed at 15-min intervals in the postanesthesia care unit (PACU) and treated for pain with i.v. morphine by protocol. Patients were evaluated for pain, analgesic requirements, side effects, and recovery times. After discharge, patients completed questionnaires to assess pain, analgesic use, and side effects 6 and 24 h postoperatively. Parenteral morphine was required in 80% of patients in the control group, and 73% of patients in both treatment groups, and the difference was not statistically significant. The dose of parenteral morphine required in the PACU was not different between the control (7 +/- 1.2 mg), ibuprofen (5.7 +/- 1.4 mg), and ketorolac (6.1 +/- 1.4 mg) groups. There was no difference between groups in terms of pain visual analog scale (VAS) scores, fatigue VAS scores, recovery times, or the incidence of postoperative nausea and vomiting. The preoperative administration of either parenteral ketorolac or oral ibuprofen did not decrease postoperative pain or side effects when compared to placebo in this outpatient population.

Influence of form structure on the anesthesia preoperative evaluation

STUDY OBJECTIVE To determine the impact of changes in form design on the capture of administrative and clinical data elements. DESIGN Randomized retrospective chart review. SETTING Academic health center. PATIENTS Patients undergoing surgical procedures in the operating rooms at Medical College Hospital. INTERVENTION The principal intervention was the implementation of a newly designed anesthesiology preoperative evaluation form with the intent to improve data capture. MEASUREMENTS Charts were reviewed for the presence or absence of the following indicators: Addressograph Stamp, Proposed Surgery, Current Medications, Medication Doses/Frequency, Allergies, ASA Physical Status, Anesthesia Plan, Attending Note, and fasting (NPO) Status. MAIN RESULTS Completion of Proposed Surgery and ASA Physical Status was lower for the structured form. Completion of Attending Notes was higher with the new form. Medication Doses were more often completed, but they remained below desired levels on the new form. CONCLUSIONS Design of a form can have a significant impact on the completion rate of form elements. Visual cues such as a labeled space for medication doses may improve the completion of these elements. Design layout can also have an influence on completion. In this case, changes to the layout may have impeded the completion rate for ASA Physical Status.

Rationale for anesthesia groups to run additional flexible operating rooms for multiple surgeons who have scheduled more than 8 hours of cases.

In this month’s issue, Sessler et al. show absence of an association between the time of day at which scheduled (elective) general surgery and orthopedic procedures start and both 30-day risk-adjusted mortality and incidence of in-hospital complications. For start times between 7:00 am and 5:00 pm, the confidence intervals for the odds ratios were narrow (i.e., unlikely that absence of an association was attributable to a type II error). These results are especially important because they differ from recent findings in gastrointestinal endoscopy. Sessler et al. also show no difference in patient outcome between July and August, when there are new trainees, and other months. In this Editorial, we review research in operating room (OR) management to help readers apply the results obtained by Sessler et al. to managerial decision-making. We apply the authors’ findings to the various decisions that may be made, from decisions made on the day of surgery to decisions made several months before surgery. On the day of surgery, urgent (add-on) cases are scheduled. The findings by Sessler et al. do not apply in this setting, because they studied scheduled cases. There may be provider fatigue and/or resource availability late at night affecting patient outcome, as detected for some transplantation procedures. Weeks to days before the day of surgery, cases are scheduled into allocated OR time. The decision is made rationally by not scheduling a case into overutilized OR time unless there is insufficient remaining allocated time for the case. Issues regarding patient outcome related to the time of day do not arise in the decision. A few months before the day of surgery (e.g., before staff scheduling is done), allocated OR time is calculated based on forecasted workload. This decision is made based on the total workload, not case start times. The results of Sessler et al. do not apply to this decision either. Several months before the day of surgery, surgeons’ block times can be readjusted (e.g., days of the week that they operate). Because such decisions do not change mean start times or numbers of first case starts, these decisions too are unaffected by the Sessler et al. results. Several months before the day of surgery, additional block time may be planned for one or more surgeons in the hope of future growth in the surgeon’s OR workload. That decision frequently does change the duration of the workday (e.g., cases scheduled up to 6:00 pm instead of up to 3:30 pm) and could be influenced by the findings of Sessler et al. However, in practice, the decision should not be affected. Sessler et al. pooled procedures (see the authors’ Fig. 1). Their confidence intervals for odds ratios were narrow when pooled, unlike what the result would be for each specified procedure and/or surgeon. Although quality can be built into the contribution margin per OR hour analysis, either as increased utility (revenue) or as reduced cost, the resulting confidence intervals by surgeon for contribution margin per OR hour would be impractically wide. The potential incremental increase in margin from increasing block time to one specified surgeon would thus be offset by a large increase in risk that the realized contribution margin per OR hour would be significantly different from the expected value. The analysis would result in the surgeon not being allocated additional block time, in lieu of the alternative (salvage) decision to allocate the additional block time as first-come, first-scheduled unblocked open OTHER overflow time. Several months before the day of surgery, the decision may be made to open another such OTHER flexible OR. This is the decision to which the results of Sessler et al. do apply. Opening such an OR at a facility with many cases starting beyond an 8-hour workday will result in fewer cases starting that late. The value of the findings of Sessler and colleagues is in showing that patient outcome is unlikely to be affected by this decision. Therefore, the decision to run longer days versus more ORs can be made balancing (a) the cost of longer days, (b) the cost of opening one or more OR(s), and (c) the reduction in surgeons’ waiting times from scheduled start times achieved by adding first case starts. From the *Department of Anesthesia, University of Iowa, Iowa City, Iowa; and †Department of Anesthesiology, University of Toledo, Toledo, Ohio.

Cross-Industry Benchmarking: Is it Applicable to the Operating Room?

The use of benchmarking has been growing in nonmedical industries. This concept is being increasingly applied to medicine as the industry strives to improve quality and improve financial performance. Benchmarks can be either internal (set by the institution) or external (use others performance as a goal). In some industries, benchmarking has crossed industry lines to identify breakthroughs in thinking. In this article, we examine whether the airline industry can be used as a source of external process benchmarking for the operating room.

Informed Consent for Surgical Anesthesia Care: Has the Time Come for Separate Consent?

Alan P. Marco, MD, MMM In this issue of the journal, Marcucci et al. present 2 patients whose ability to give informed consent for surgical procedures differed from their ability to grant such consent for anesthesia. The report by Marcucci et al. raises several interesting questions, the foremost being “Is it time for separate consent for anesthesia care?” The answer is a resounding “Yes!” However, practical application of this recommendation requires thoughtful consideration. The legally recognized concept of consent for medical care has its origins at the beginning of the 20th century in the case of Schloendorff v Society of New York Hospital in which a woman who had agreed to undergo surgery underwent additional procedures without proper consent. This landmark case established that patients have the right to accept or refuse treatment, and Judge Cardoza wrote: “Every human being of adult years and sound mind has a right to determine what shall be done with his own body; and a surgeon who performs an operation without his patient’s consent commits an assault for which he is liable in damages.” However, the legal term “informed consent” did not come into use until 1957 in the case of Salgo v Stanford. In general, informed consent for medical interventions must include the nature of the proposed intervention, the alternatives to it, the risk and benefits of the proposed intervention as well as the alternatives, an assessment of the patient’s ability to understand the discussion, and the patient’s voluntary acceptance of the proposed intervention. Marcucci et al. bring to light important distinctions about the patient’s ability to understand various components of the proposed interventions and how different aspects of impairment affect the ability of the anesthesiologist to obtain “informed” consent. This gives rise to the fundamental question of whether there should be separate anesthesia consent. Based on the above cited cases, there is a clear need for a separate consent procedure for anesthesia care. In fact, whereas many people question the need for separate consent, we as a profession have been obtaining separate consent for anesthesia for decades. The true questions concern the nature of that consent and its documentation. Assessment of capacity is an essential element of proper informed consent. In order for a patient (or surrogate) to give proper informed consent, the patient must have the capacity to make judgments, weighing the information provided within his or her own value system. Competency, often misquoted in the medical community, is a related but distinct legal term. Most adults are assumed to be competent unless evidence to the contrary is present. Minors, with certain state-defined exceptions, are deemed by law to not be competent. However, the high school senior who is a national debate semifinalist undoubtedly has the capacity to make an informed decision, yet may not be recognized as competent by the court. Physicians have a duty to disclose information to the patient. The extent of the disclosure can be summarized by 3 perspectives. Jurisdictions apply different standards in case law. One commonly recognized standard is the reasonable physician standard wherein the disclosure is based on what a “reasonable physician” would believe to be material. This may be problematic in some circumstances, if physicians erroneously judge the patient’s need for information. For example, a survey of vascular surgeons From the Department of Anesthesiology, University of Toledo, Toledo, Ohio. Accepted for publication September 18, 2009. Supported by departmental sources. Address correspondence and reprint requests to Alan P. Marco, MD, MMM, Department of Anesthesiology, University of Toledo, Mail Stop 1137, 3000 Arlington Ave., Toledo, OH 43617-2598. Address e-mail to alan.marco@utoledo.edu. Copyright

Influencing Physician Performance

For physicians to change their behavior, they must internalize the need for change. One way to do this is to get the physicians to agree to the improvement. In this study, surgeons were asked to agree that documentation is important. When surgeons who agreed that documentation is important were compared with those who did not express agreement, those who agreed were more likely to provide the required clinical documentation. Furthermore, they showed improvement in their percentage of cases with the required documentation when compared to themselves over time. Simple strategies such as asking for a private commitment to change can enhance competency with documentation requirements.

Peripheral nerve blockade in a patient with Charcot-Marie-Tooth disease.

CAN J ANESTH 55: 10 www.cja-jca.org October, 2008 rhythm (Hr 70–80 beats·min–1) with a stable BP (110–140 mmHg systolic), and he did not receive any specific treatment. Two hours after IC administration, residual neuromuscular block was reversed with neostigmine 3 mg iv and glycopyrrolate 0.6 mg iv, and the patient’s trachea was extubated when he was awake. At this point, the patient became tachycardic (Hr in the 120s beats·min–1) and he developed deeply inverted T waves (not further characterized) without concurrent angina. He was treated with esmolol 40 mg iv and metoprolol 5 mg iv in divided doses. A cardiologist was consulted postoperatively, and the patient was admitted to a cardiac telemetry unit. Myocardial infarction was ruled out by three sets of cardiac enzymes over the next 24 hr. Subsequently, a transthoracic echocardiogram revealed an essentially normal heart with an ejection fraction of 66% and no segmental wall motion abnormalities. A pharmacological cardiac stress test (adenosine Tc-99m sestamibi) was negative for inducible ischemia. On postoperative day four, he was discharged home in good condition. In both cases described, a second-degree AVB appeared immediately after the administration of IC, suggestive of a direct causative relation. Other possible etiologies are less likely: (1) Vagal reflexes induced by peritoneal traction should have resolved after the surgeons were notified and had ceased manipulation; (2) A high spinal level is also improbable in case 1, given the documented T6 sensory level and the fact that the event occurred 72 min after the subarachnoid block was placed; (3) Also unlikely is a baroreceptor reflex (although hypertension is commonly seen after administration of IC,2 no increase in BP was recorded, in either case, on the automated anesthesia records prior to the development of AVB). Moreover, in the second case, the AVB occurred in the absence of sinus bradycardia.3 In conclusion, this report aims to alert to the possibility that intraoperative administration of IC may induce the development of AVB. Although the events were relatively inconsequential in the two cases presented, serious complications may occur if progression to complete AVB occurs, or, as in the first case, as a consequence of tachycardia induced by its pharmacological treatment.

Cerebral oximetry and an unanticipated circulatory arrest

I read the letter regarding the impending collapse of academic anaesthesia with considerable interest (Jackson et al. Anaesthesia 2003; 58: 911–2). As I am a clinical anaesthetist who does quite a bit of research ‘on the side’, I feel I can speak with a certain amount of authority on the issues raised, and perhaps suggest alternative solutions to the rather drastic measures proposed. In any case, their proposals are, in my view, impractical and unlikely to improve the lot of academic departments. There is no doubt that clinical academic departments in all specialties are suffering as a result of changes in funding, training, and the focus of Universities. There is also no doubt that anaesthesia has suffered disproportionately. One does not have to look very far to see why. The collective perception of research by anaesthetists themselves must take some of the blame. The following views are repeatedly expressed to me: 1 Anaesthesia is a service speciality and doesn’t have time for research 2 Anaesthesia is very safe and cannot be improved upon, so clinical research is pointless 3 Basic science is too difficult for anaesthetists to understand 4 Trainees have no interest in research, and in any case it is no longer a career issue. I will deal with each of these in turn. If you think of yourself as a servant, you will be treated as a servant. There is no doubt that the more assertive approach in recent years by the Royal College of Anaesthetists and the Association of Anaesthetists has vastly improved ‘in-theatre’ standards. Trivial operations are no longer performed at bizarre times of night, and consultant cover for trainees has improved beyond recognition in the past 20 years. Nevertheless, Trusts view anaesthetists simply as a means to an end – getting the patients to lie still long enough for the surgeon to perform the operation and thereby reduce the waiting lists. If we offer ourselves up merely as ‘bums on seats’, and perform no other extracurricular activity apart from occasional College activities, we can hardly expect our peers, the local hospital management, major research-funding bodies, or even the Government, to take much notice of what we say. ‘Nobody asked the anaesthetists’ is a frequent complaint. The current controversy surrounding the means of insertion of central lines is a good example. Did anyone from NICE ask you what you thought about it? We only have ourselves to blame. Anaesthesia of itself causes very little major morbidity or mortality in this country. However, in my view, this does not mean we can sit back and let the surgeons take all the blame, tempting as that may be. I have attended several national surgical meetings, and it always strikes me that the surgeons are continually frustrated by complex perioperative issues that limit the type of patient that can undergo a particular operation, and ⁄ or affect outcome. By this I mean such things as nutritional status, preand postoperative fluid balance, pulmonary embolus, wound infection and dehiscence, and MRSA to name but a few. You may think surgeons are a law unto themselves and should sort out their own problems, but I would contend that we are all professionals who have a collective responsibility for the welfare of any patient that we take to theatre. We need to work out how to provide the most relevant pre-operative care, how to maximise intra-operative management, and how to speed their recovery. We are part of the team that brought them into hospital. We have an obligation to get them out., The excuse that basic science is too difficult for anaesthetists to understand is put to me very frequently, and is possibly the scariest. With a very few notable exceptions, the majority of anaesthetic Specialist Registrars are convinced that science is an impenetrable jungle. Many of their consultant colleagues express similar views. In these attitudes, we are no better than the general public. The standard of scientific knowledge and understanding in this country is a national disgrace. Why are we following this herd? Medical schools recruit people with the highest science A-level grades in the country. We need to find out what happens next that turns these bright young people into trainees that are happy to give potent vasopressors without having the faintest idea how they work. Jackson et al. are quite right that we are in danger of turning

Anesthetic Problems: Venous Air Embolism, Airway Difficulties, and Massive Transfusion

Perioperative anesthetic complications require the coordinated efforts of both the surgical and anesthesia teams. These complications, or their sequelae, have significant influence on the care of the patient in the preoperative, intraoperative, and postoperative periods.

Wind Disasters: A Comprehensive Review of Current Management Strategies

Wind disasters are responsible for tremendous physical destruction, injury, loss of life and economic damage. In this review, we discuss disaster preparedness and effective medical response to wind disasters. The epidemiology of disease and injury patterns observed in the early and late phases of wind disasters are reviewed. The authors highlight the importance of advance planning and adequate preparation as well as prompt and well-organized response to potential damage involving healthcare infrastructure and the associated consequences to the medical response system. Ways to minimize both the extent of infrastructure damage and its effects on the healthcare system are discussed, focusing on lessons learned from recent major wind disasters around the globe. Finally, aspects of healthcare delivery in disaster zones are reviewed.