Richard L. Fishman

Successful strategies for improving operating room efficiency at academic institutions.

In this prospective study, we evaluated the etiology of operating room (OR) delays in an academic institution, examined the impact of multidisciplinary strategies to improve OR efficiency, and established OR timing benchmarks for use in future OR efficiency studies.OR times and delay etiologies were collected for 94 cases during the initial phase of the study. Timing data and delay etiologies were analyzed, and 2 wk of multidisciplinary OR efficiency awareness education was conducted for the nursing, surgical, and anesthesia staff. After the education period, timing data were collected from 1787 cases, and monthly reports listing individual case delays and timing data were sent to the Chiefs of Service. For the first case of the day, patient in room, anesthesia ready, surgical preparation start, and procedure start time were significantly earlier (P < 0.01) in the posteducation period compared with the preeducation period, and the procedure start time for the first case of the day occurred, on average, 22 min earlier than all other procedures. For all cases combined, turnover time decreased, on average, by 16 min. Unavailability of surgeons, anesthesiologists, and residents decreased significantly (P < 0.05) as causes of OR delays. Anesthesia induction times were consistently longer for the vascular and cardiothoracic services, whereas surgical preparation time was increased for the neurosurgical and orthopedic services (P < 0.05). Identification of the etiology of OR inefficiency, combined with multidisciplinary awareness training and personal accountability, can improve OR efficiency. The time savings realized are probably most cost-effective when combined with more flexible OR staffing and improved OR scheduling. Implications: We achieved significant improvements in operating room efficiency by analyzing operating room data on causes of delays, devising strategies for minimizing the most common delays, and subsequently measuring delay data. Personal accountability, streamlining of procedures, interdisciplinary team work, and accurate data collection were all important contributors to improved efficiency. (Anesth Analg 1998;86:896-906)

The effect of bupivacaine skull block on the hemodynamic response to craniotomy.

The placement of pointed cranial pins into the periosteum is a recognized acute noxious stimulation during intracranial surgery which can result in sudden increases in blood pressure and heart rate, causing increases in intracranial pressure.A skull block (blockade of the nerves that innervate the scalp, including the greater and lesser occipital nerves, the supraorbital and supratrochlear nerves, the auriculotemporal nerves, and the greater auricular nerves) may be effective in reducing hypertension and tachycardia. Twenty-one patients were allocated in a prospective, double-blind fashion to a control group or a bupivacaine group. After a standardized induction and 5 min prior to head pinning, a skull block was performed. Patients in the control group received a skull block of normal saline, while the bupivacaine group received a skull block with 0.5% bupivacaine. Systolic (SAP), diastolic (DAP), mean arterial pressure (MAP), heart rate (HR), and end-tidal isoflurane were recorded at the following times: 5 min after the induction of anesthesia, during performance of the skull block, during head pinning, and 5 min after head pinning. Significant increases in SAP of 40 +/- 6 mm Hg, DAP of 30 +/- 5 mm Hg, MAP of 32 +/- 6 mm Hg, and HR of 22 +/- 5 bpm occurred during head pinning in the control group, while remaining unchanged in the bupivacaine group. These results demonstrate that a skull block using 0.5% bupivacaine successfully blunts the hemodynamic response to head pinning. (Anesth Analg 1996;83:1256-61)

The Effects of Desmopressin and 6% Hydroxyethyl Starch on Factor VIII: C

In moderate doses of 20 mL/kg (1.2 g/kg), hydroxyethyl starch (HES) 6% decreases factor VIII:C activity. Desmopressin (DDAVP) increases circulating levels of factor VIII:C by stimulating the release of factor VIII:C from peripheral storage sites. The objective of this study was to monitor the changes in factor VIII:C associated with sequential HES and DDAVP administration. Thirty patients undergoing surgical procedures with a predicted blood loss of less than 750 mL were enrolled. After induction of anesthesia, HES was administered, 20 mL/kg, to a maximum of 1500 mL, at a rate to meet intraoperative fluid requirements. Patients then randomly received either a 10-mL solution containing 0.3 micro gram/kg of DDAVP (Group 1) or 10 mL of normal saline (Group 2). After HES administration, factor VIII:C levels decreased significantly, to 69% of baseline, in both groups. After study drug administration, factor VIII:C in Group 1 increased significantly to 135% of baseline at 30 min and 115% of baseline at 60 min while in Group 2 average factor VIII:C levels remained below baseline at 30 and 60 min. DDAVP produced an increase in factor VIII:C activity despite HES administration and should be considered a treatment option for the mild coagulopathy infrequently associated with HES administration. (Anesth Analg 1996;83:804-7)

Tranexamic Acid Reduces Bleeding After Cardiopulmonary Bypass When Compared to Epsilon Aminocaproic Acid and Placebo

Abstract Perioperative bleeding following coronary artery bypass grafting (CABG) is associated with increased blood product usage. Although aprotonin is effective in reducing perioperative blood loss, excessive cost prohibits routine utilization. Epsilon aminocaproic acid (EACA) and tranexamic acid (TA) are inexpensive antifibrinolytic agents, which, when give prophylactically, may reduce blood loss. The present study was undertaken to compare the efficacy of TA and EACA in reducing perioperative blood loss. Methods: The study population consisted of first‐time CABG patients. Patients were allocated in a prospective double‐blind fashion: (1) group EACA (loading dose 150 mg/kg, continuous infusion 10 mg/kg per hour for 6 hours, N = 20); (2) group TA (loading dose 15 mg/kg, continuous infusion 1 mg/kg per hour for 6 hours, N = 20); (3) control group (infusion of normal saline for 6 hours, N = 19). Results: Treatment groups were similar preoperatively. No significant difference in intraoperative blood loss or perioperative use of blood products was noted. D‐dimer concentration was elevated in the control group compared to the EACA and TA groups (p < 0.05). Group TA had less postoperative blood loss than the EACA and control groups at 6 and 12 hours postoperatively (p < 0.05). TA had reduced total blood loss (600 ± 49 mL) postoperatively compared to EACA (961 ± 148 mL) and control (1060 ± 127mL, p < 0.05). Conclusion: TA and EACA effectively inhibited fibrinolytic activity intraoperatively and throughout the first 24 hours postoperatively. TA was more effective in reducing blood loss postoperatively following CABG. This suggests that TA may be beneficial as an effective and inexpensive antifibrinolytic in first‐time CABG patients.

Intravenous sedation for placement of automatic implantable cardioverter-defibrillators

OBJECTIVE To evaluate a change in anesthetic technique for transvenous placement of the automatic implantable cardioverter-defibrillator (ICD). DESIGN Retrospective study. SETTING A university hospital. PARTICIPANTS Twenty-eight patients who underwent placement of ICDs. INTERVENTIONS Thirteen patients had the ICD placed via the transvenous approach with general anesthesia (group GA). Fifteen patients had the ICD placed via the transvenous approach with intravenous sedation (group IV). MEASUREMENTS AND MAIN RESULTS Intraoperative systolic and diastolic blood pressures were significantly higher in group IV compared with group GA. The ICD was successfully placed in all patients in both groups. There were no intraoperative complications noted in either group during induction of fibrillation and defibrillation, and there was no recall by any patient in either group. The average hospital stay was significantly less in group IV (1.8 days) compared with group GA (3.4 days). CONCLUSIONS Intravenous sedation for the placement of ICDs is a safe and effective technique. Patients who had their ICD placed while receiving intravenous sedation experienced higher intraoperative blood pressures and were discharged from the hospital earlier than those patients who received general anesthesia.

Independent placement of a bronchial blocker for single-lung ventilation : An alternative method for the difficult airway

F unctional separation of the lungs may be accomplished by double-lumen (DL) endotracheal intubation, bronchial blockade with the Univent tube (Fuji Systems Corp., Tokyo, Japan), bronchial blockade independent of a single-lumen tube (SLT), or endobronchial intubation with a SLT. In patients with abnormal upper airways who require one-lung ventilation, DL tube placement may not be possible. Nasotracheal intubation and one-lung ventilation using a Univent tube has been previously reported (1). However, Univent placement in small patients may be traumatic because of the large outer diameter of these tubes. The short length of a conventional SLT also prohibits endobronchial intubation via the nasal route. Recently, we managed a patient with restricted mouth opening requiring nasotracheal intubation and lung separation for thoracoscopy with an independent bronchial blocker placed outside a SLT.

The incidence of complications after the double-catheter technique for cannulation of the right internal jugular vein in a university teaching hospital.

P atients at risk for major intraoperative blood loss and hemodynamic instability often require two central venous catheters. There are no studies that compare the complication rate of single cannulation of a central vein with the rate associated with double cannulation of the same vein with two catheters in close proximity to each other. We have used the double cannulation of the right internal jugular vein (RIJV) for the last 3 yr in patients who may require both the monitoring of pulmonary artery pressures and large volume transfusions. Our recently reported avulsion of the right facial vein during double cannulation of the RIJV (1) prompted us to evaluate prospectively the efficacy and safety of double versus single cannulation of the RIJV in a university teaching hospital setting.

Avoiding an Impairment of Factor VIII: C by Using Hydroxyethyl Starch with a Low In Vivo Molecular Weight

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