Susan Harvey

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)

Individualized outcome feedback produces voluntary antiemetic prescribing practice changes

STUDY OBJECTIVE To determine the impact of individualized outcome feedback on antiemetic prescribing practices and compare outcomes of a cost-effective, standardized antiemetic protocol (PROT) to that of customized antiemetic therapy (NONPROT). DESIGN Prospective, observational study with randomized component. SETTING Postanesthesia care unit (PACU) of an academic medical center. PATIENTS 3027 consecutive ASA physical status I, II, and III patients receiving general anesthesia. INTERVENTIONS Patients were randomized to receive 0.625 mg droperidol or 4 mg ondansetron for postoperative nausea and/or vomiting (PONV) from a protocol, or received customized antiemetic therapy. MEASUREMENTS AND MAIN RESULTS Incidence of PACU PONV, selection of PROT versus NONPROT, patient satisfaction, and use of PONV prophylaxis were measured and indexed by an attending anesthesiologist in a monthly report for 4 months. Monthly expenditures for antiemetic therapy prior to, during, and after the study were collected. Literature on PONV outcomes, appropriate timing, and selection of PONV prophylaxis was distributed. The NONPROT group was slightly older than the PROT group; otherwise, demographics were similar between all groups. The incidence of PONV did not differ between the PROT and NONPROT groups (11% vs. 10%), and the incidence of PONV in patients receiving prophylaxis was higher in both groups (17% PROT vs. 15% NONPROT). Patients receiving ondansetron as a first-line drug required rescue therapy less often (5%) than those receiving droperidol (14%); however, patient satisfaction was indistinguishable among all groups. During the study, the use of prophylaxis decreased 47% without an increase in PONV, and PROT selection increased 54%. CONCLUSIONS Individualized outcome feedback produced a 48% reduction in monthly expenditures for ondansetron and droperidol, which was sustained after the study. Patients satisfaction between ondansetron 4 mg and droperidol 0.625 mg given in the PACU did not differ in spite of a slightly greater efficacy of ondansetron as a first-line drug.

Continuous spinal anesthesia for cesarean section in a parturient with severe preeclampsia

Epidural anesthesia is a widely accepted technique for cesarean section in the preeclamptic patient with normal coagulation. Regional anesthetic techniques avoid the hazards associated with tracheal intubation in the preeclamptic or eclamptic patient. To date, continuous spinal anesthesia in the preeclamptic parturient has not been described. We present a case in which continuous spinal anesthesia was administered for cesarean section in a morbidly obese parturient with severe preeclampsia. Continuous spinal anesthesia was successfully administered without significant hemodynamic consequences or maternal or fetal morbidity. This case suggests that continuous spinal anesthesia may be a viable alternative anesthetic technique for operative delivery in the preeclamptic parturient when epidural anesthesia cannot be established.

Stability of meperidine in an implantable infusion pump using capillary gas chromatography-mass spectrometry and a deuterated internal standard.

A capillary gas chromatographic-mass spectrometric (GC MS) method is described for the analysis of meperidine using 3,3,5,5-[2H4]-meperidine as an internal standard. Chromatography was performed on a (5% phenyl) methylpolysiloxane column (30 m x 0.32 mm I.D., 0.25 microm film thickness) operated at 195 degrees C; helium carrier gas-50 cm/s(-1), tR = 2.3 min. Ionization was by electron impact (EI) and detection by selected ion monitoring of the molecular ions. The method provided high response linearity (mean r = 0.9982) and precision (< 6.5% C.V.). Application of this method to a pilot study of aqueous meperidine x HCl (10 mg/ml(-1)) stability in a surgically implantable infusion pump at 37 degrees C for 90 days revealed no demonstrable drug degradation.

Superior Vena Cava Compression During Posterior Spinal Fusion for Idiopathic Scoliosis: A Case Report

Known complications of prone positioning for spinal surgery include visual impairment, blindness, meralgia paresthetica, and elevated intra-abdominal pressure1-3. There are a plethora of positioning frames and tables available for spinal surgery. Much of the focus in positioning the patient is to leave the abdomen hanging freely in order to reduce intra-abdominal pressure. Elevated abdominal pressures have been shown to lead to elevated inferior vena cava pressure, which results in increased blood loss during surgery4,5. In this report, we discuss a patient who had temporary compression of the superior vena cava caused by prone positioning on the patient chest pad of the Jackson spinal table during surgery. The patient and her family were informed that data concerning the case would be submitted for publication, and they consented. A sixteen-year-old postmenarchal female had a 45° left lumbar curve and a 45° right thoracic curve that, despite bracing when the patient was younger, had continued to progress and were no longer balanced. The trunk had shifted to the left and the patients head was no longer centered over the pelvis (Fig. 1-A). She was experiencing increasing lumbar back pain and reported having difficulties with balance. After discussion of the risks and benefits of operative compared with nonoperative treatment for idiopathic scoliosis, the patient and her family selected operative intervention. Fig. 1-A Preoperative posteroanterior radiograph. Fig. 1-B One-year postoperative posteroanterior radiograph. In the operating room, general endotracheal anesthesia was induced. Intraoperative monitoring of somatosensory evoked potentials (SSEP) and motor evoked potentials commenced immediately after induction. Anesthesia was maintained with propofol and remifentanil intravenous infusions and low-dose sevoflurane (0.2 MAC [minimum alveolar concentration]). The maintenance anesthetic was adjusted and maintained at a constant rate prior to the onset of the critical surgical period. Invasive arterial pressure monitoring …