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Schultz MJ, Thalody HS, Lutz RW, Cheesman QT, Ong AC, Post ZD, Ponzio DY. Older Age, Male Sex, and Early Start Time Lengthen the Recovery Room Stay Following Total Joint Arthroplasty in an Ambulatory Surgical Center. HSS J 2024; 20:63-68. [PMID: 38356749 PMCID: PMC10863596 DOI: 10.1177/15563316231208977] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Accepted: 06/19/2023] [Indexed: 02/16/2024]
Abstract
Background Total joint arthroplasty (TJA) performed in the ambulatory surgical center (ASC) has been shown to be safe and cost-effective for an expanding cohort of patients. As criteria for TJA in the ASC become less restrictive, data guiding the efficient use of ASC resources are crucial. Purpose We sought to identify factors associated with length of stay in the recovery room after primary total hip arthroplasty (THA) and total knee arthroplasty (TKA) performed in the ASC. Methods We conducted a retrospective review of 411 patients who underwent primary THA or TKA at our institution's ASC between November 2020 and March 2022. We collected patient demographics, perioperative factors, success of same-day discharge (SDD), and length of time in the recovery room. Results Of 411 patients, 100% had successful SDD. The average length of time spent in recovery was 207 minutes (SD: 73.9 minutes). Predictors of longer time in recovery were increased age, male sex, and operative start time before 9:59 am. Body mass index, preoperative opioid use, Charlson Comorbidity Index, type of surgery (THA vs TKA), urinary retention risk, and type of anesthesia (spinal vs general) were not significant predictors of length of time in the recovery room. Conclusion In this retrospective study, factors associated with increased length of time in the recovery room included older age, male sex, and operative start time before 9:59 am. Such factors may guide surgeons in determining the optimal order of cases for each day at the ASC, but further prospective studies should seek to confirm these observations.
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Affiliation(s)
| | | | | | | | - Alvin C Ong
- Rothman Orthopaedic Institute, Egg Harbor Township, NJ, USA
| | - Zachary D Post
- Rothman Orthopaedic Institute, Egg Harbor Township, NJ, USA
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2
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Baek J, Kim YM. The Impact of Parental Presence on Emergence Delirium in Pediatric Patients After General Anesthesia: A Systematic Review and Meta-analysis. J Perianesth Nurs 2024:S1089-9472(23)00987-5. [PMID: 38219079 DOI: 10.1016/j.jopan.2023.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Revised: 09/20/2023] [Accepted: 10/01/2023] [Indexed: 01/15/2024]
Abstract
PURPOSE This study reviewed existing literature on parental presence in cases of pediatric patients after general anesthesia and explored its effect on emergence delirium (ED) in the postanesthesia care unit (PACU). DESIGN Systematic review and meta-analysis. METHODS After protocol registration, we searched the PubMed, EMBASE, CINHAL, Web of Science, SCOPUS, and CENTRAL databases. Two authors independently searched and selected the relevant studies, assessed their risk of bias, and abstracted the data. The primary outcome was ED, and the additional outcome was pain. We provided the narrative synthesis and meta-analysis results. FINDINGS Of the 296 articles retrieved, 6 were included in the narrative synthesis, and 5 were used for the meta-analysis. Four studies were randomized controlled trials, and two studies were nonrandomized controlled trials. There were 348 pediatric patients in the parental presence group and 314 pediatric patients in the usual care group. Parental presence effectively reduced the ED score (mean difference, -0.58; 95% confidence interval [CI], -0.84 to -0.31; P < .001). The ED incidence rate (log odds ratio, -0.58; 95% CI, -1.24 to 0.09; P = .090) and pain score (standardized mean difference, -0.24; 95% CI, -0.57 to 0.10; P = .163) were lower in the parental presence group than in the usual care group. However, the differences were not statistically significant. CONCLUSIONS The presence of parents in the PACU can reduce ED in pediatric patients. Therefore, parental presence may be a useful intervention in the PACU.
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Affiliation(s)
- Jihyun Baek
- College of Nursing, Jeonbuk National University, Jeonju-si, Jeollabuk-do, Republic of Korea; Research Institute of Nursing Science, Jeonbuk National University, Jeonju-si, Jeollabuk-do, Republic of Korea; Biomedical Research Institute, Jeonbuk National University Hospital, Jeonju-si, Jeollabuk-do, Republic of Korea
| | - Young Man Kim
- College of Nursing, Jeonbuk National University, Jeonju-si, Jeollabuk-do, Republic of Korea; Research Institute of Nursing Science, Jeonbuk National University, Jeonju-si, Jeollabuk-do, Republic of Korea; Biomedical Research Institute, Jeonbuk National University Hospital, Jeonju-si, Jeollabuk-do, Republic of Korea.
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3
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O'Brien JM, McKay WPS, McDonald M. Identifying behaviors that characterize emergence delirium: An observational study. Paediatr Anaesth 2023. [PMID: 37096364 DOI: 10.1111/pan.14678] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 04/04/2023] [Accepted: 04/06/2023] [Indexed: 04/26/2023]
Abstract
BACKGROUND Diagnostic criteria for emergence agitation are sensitive but not specific; they misclassify patients who are angry or upset as having emergence delirium. AIMS The aim of this three-phase study was to determine expert agreement on the behaviors that differentiate children with emergence delirium from those without. METHODS In the first phase of this observational study, pediatric dental patients were video recorded while awakening from anesthesia. In the second phase, salient 10 s segments of the recordings showing patient activity were shown to an expert audience of pediatric dentists, anesthesiologists and Post Anesthetic Care nurses, who scored the recordings as showing or not showing "true emergence delirium." In phase 3, the video segments were assessed by three research assistants using a behavior checklist for features that discriminate between those scored "true emergence delirium" and those scored "NOT true emergence delirium" by the experts. RESULTS One hundred and fifty-four pediatric dental patients were included. Subsequently, an expert audience consisting of 10 anesthesiologists, 12 anesthesiology residents, 3 pediatric dentists, and 4 experienced Post Anesthesia Care Unit nurses rated each 10-second video segment. This resulted in three groups of patients: a group for whom all experts agreed was "True emergence delirium" (n = 33; CI 21 to 45), a group for whom all agreed was "Not True emergence delirium" (n = 120; CI 107 to 133), and a group where experts disagreed (n = 11; CI 4 to 18). Three research assistants then completed a behavior checklist for each of the 33 "True emergence delirium" video segments and matched "Not True" controls. Twenty-four behaviors were identified as significantly different between videos scored True emergence delirium and those scored Not True emergence delirium. Research assistants reached almost perfect agreement (0.81-1.00) on one behavior, and substantial agreement (0.61-0.80) on seven behaviors that characterized "True emergence delirium." CONCLUSIONS Eight behaviors that differentiate pediatric dental patients with emergence delirium from those without were found. These discriminators may be used to develop a scale that will lead to better diagnosis and treatment of emergence delirium.
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Affiliation(s)
- Jennifer M O'Brien
- Department of Anesthesiology, Perioperative Medicine and Pain Management, University of Saskatchewan, Saskatoon, Canada
| | - William P S McKay
- Department of Anesthesiology, Perioperative Medicine and Pain Management, University of Saskatchewan, Saskatoon, Canada
| | - Marguerite McDonald
- Department of Anesthesiology, Perioperative Medicine and Pain Management, University of Saskatchewan, Saskatoon, Canada
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4
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Conti D, Pandolfini L, Ballo P, Falsetto A, Zini C, Goti M, Cappelli V, Pissilli G, Laessig R, Scatizzi M, Pavoni V. The Role of the Recovery Room in Improving Adherence During an Enhanced Recovery After Surgery (ERAS) Implementation Program for Colorectal Surgery: A Single-Center Retrospective Analysis. J Perianesth Nurs 2023; 38:232-235. [PMID: 36241540 DOI: 10.1016/j.jopan.2022.04.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2022] [Revised: 04/25/2022] [Accepted: 04/30/2022] [Indexed: 03/27/2023]
Abstract
PURPOSE The purpose of thisstudy was to evaluate the clinical impact of the Recovery Room (RR) in an Enhanced Recovery After Surgery (ERAS) pathway in colorectal surgery. DESIGN Single-center retrospective study. METHODS From November 2019 until September 2021, a total of 149 consecutive patients that underwent to colon-rectal surgery were enrolled. The patients were divided into two study groups: RR Group if admitted to RR after surgery, and no-Recovery Room (NRR) Group if monitored directly on the ward, bypassing the RR. The postoperative ERAS items adherence was assessed in the two study groups. FINDINGS Final analysis included 119 patients in the RR Group and 30 patients in NRR Group. Patients that started clear liquid oral intake within two hours postoperatively were 118 in the RR group and 19 in the NRR group (99.1% vs 63.3%, P < .001). A total of 98 patients and 18 patients were mobilized on day 0 in the RR group and in NRR group, respectively (84.4% vs 15.5%, P < .05). In the RR group, postoperative adherence to the ERAS protocol components was higher in comparison with the NRR group (P < .003); adherence to the all protocol components was also higher (P < .004). CONCLUSIONS Among patients undergoing colorectal surgery admitted to RR after surgery, the RR nurse guaranteed effective patient assistance and ensured appropriate compliance to the postoperative ERAS items.
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Affiliation(s)
- Duccio Conti
- Anaesthesia and Intensive Care Unit, Santa Maria Annunziata Hospital, Bagno a Ripoli, Florence, Italy.
| | - Lorenzo Pandolfini
- General Surgery Unit, Santa Maria Annunziata Hospital, Bagno a Ripoli, Florence, Italy
| | - Piercarlo Ballo
- Cardiology Unit, Santa Maria Annunziata Hospital, Bagno a Ripoli, Florence, Italy
| | - Alessandro Falsetto
- General Surgery Unit, Santa Maria Annunziata Hospital, Bagno a Ripoli, Florence, Italy
| | - Chiara Zini
- Department of Radiology, Santa Maria Annunziata Hospital, Bagno a Ripoli, Florence, Italy
| | - Marta Goti
- Department of Clinical Nursing, Santa Maria Annunziata Hospital, Bagno a Ripoli, Florence, Italy
| | - Valentina Cappelli
- Department of Clinical Nursing, Santa Maria Annunziata Hospital, Bagno a Ripoli, Florence, Italy
| | - Gaia Pissilli
- Department of Clinical Nursing, Santa Maria Annunziata Hospital, Bagno a Ripoli, Florence, Italy
| | - Romana Laessig
- General Surgery Unit, Santa Maria Annunziata Hospital, Bagno a Ripoli, Florence, Italy
| | - Marco Scatizzi
- General Surgery Unit, Santa Maria Annunziata Hospital, Bagno a Ripoli, Florence, Italy
| | - Vittorio Pavoni
- Anaesthesia and Intensive Care Unit, Santa Maria Annunziata Hospital, Bagno a Ripoli, Florence, Italy
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5
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Vetter L, Camenzind E. [Patient handover from anaesthesia to postanaesthesia unit: An analysis of the current situation in three Swiss hospitals]. Pflege 2023; 36:87-94. [PMID: 35301868 DOI: 10.1024/1012-5302/a000876] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Patient handover from anaesthesia to postanaesthesia unit: An analysis of the current situation in three Swiss hospitals Abstract: Background: Patient handovers carry a risk of inadequate or missing communication of important information that can jeopardize patient safety. To increase patient safety, protocols for processes and contents of a structured patient handover were created. Aim: To assess the current status of patient handovers from anaesthesia staff to recovery room nurses. Method: After a literature search an observation protocol for patient handovers according to the SBAR concept (von Dossow & Zwißler, 2016) was developed. Using this checklist, non-participant observations were conducted in three Swiss hospitals and evaluated with statistical analysis. Results: A total of 98 observations were made. The report receiving person felt integrated into the handover and received the necessary information. Deficiencies in patient identification and a joint control of lines after surgical interventions could be identified. The subjectively rated quality of patient handover did not differ between the three hospitals (X2(2)=,927, p=,629) and also not according to the time of day (X2(2)=3,604, p=,216). There was also no difference between the subjective quality of the handover and the delivering professional group (X2(3)=4,507, p=,212). Conclusions: The subjective quality of patient handover did not differ between the three hospitals. However, the patient handover protocols need to be adapted to ensure that patient identification and a joint assessment including control of lines and drains are performed.
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Affiliation(s)
- Luzia Vetter
- Klinik für Anästhesie, Luzerner Kantonsspital, Luzern, Schweiz
| | - Elena Camenzind
- Universitätsklinik für Anästhesiologie und Schmerztherapie, Inselspital, Bern, Schweiz
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6
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Gnatta JR, Cavassana TM, Nascimento ASD, Poveda VDB. Instruments to Identify Delirium in Patients Recovering From Anesthesia: A Scoping Review. J Perianesth Nurs 2022; 37:961-965.e7. [PMID: 35760717 DOI: 10.1016/j.jopan.2021.12.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Revised: 12/06/2021] [Accepted: 12/26/2021] [Indexed: 11/15/2022]
Abstract
PURPOSE To identify the validated instruments used for screening and detecting postoperative delirium (POD) during Post Anesthesia Recovery (PAR) period, and the incidence and associated risk factors with POD. DESIGN A scoping review. METHODS The study search occurred in May 2021 in the PubMed, Embase, Scopus, CINAHL, Web of Science and LILACS databases. Primary studies that used validated instruments for screening and detecting POD in the PAR period were included. FINDINGS A total of 38 articles were included. The most used instruments were CAM-ICU, Nu-DESC, and RASS. The instruments that screened and detected delirium earliest were the Nu-DESC and CAM-ICU. POD incidence was up to 20% in more than half of the included studies. Cardiovascular comorbidities, chronic kidney disease, low functional reserve, chronic obstructive pulmonary disease and postoperative pain were among the primary risk factors. CONCLUSION The instrumentsshowing the greatest accuracy for screening and detecting POD in the PAR period were the Nu-DESC and CAM-ICU.
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Affiliation(s)
- Juliana Rizzo Gnatta
- Medical Surgical Department, School of Nursing, University of Sao Paulo, Brazil; The Brazilian Centre of Evidence-based Healthcare: A JBI Centre of Excellence (JBI Brazil)
| | | | | | - Vanessa de Brito Poveda
- Medical Surgical Department, School of Nursing, University of Sao Paulo, Brazil; The Brazilian Centre of Evidence-based Healthcare: A JBI Centre of Excellence (JBI Brazil)
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7
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Fletcher LR, Coulson TG, Story DA, Hiscock RJ, Marhoon N, Nazareth JM. The association between unanticipated prolonged post-anaesthesia care unit length of stay and early postoperative deterioration: A retrospective cohort study. Anaesth Intensive Care 2022; 50:295-305. [PMID: 35549560 DOI: 10.1177/0310057x211059191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
This study aimed to investigate whether there was an association between an unanticipated prolonged post-anaesthesia care unit (PACU) length of stay and early postoperative deterioration, as defined as the need for a rapid response team activation, within the first seven days of surgery. We conducted a single-centre retrospective cohort study of adult surgical patients, who stayed at least one night in hospital, and were not admitted to critical care immediately postoperatively, between 1 July 2017 and 30 June 2019. A total of 11,885 cases were analysed. PACU length of stay was significantly associated with rapid response team activation on both univariate (odds ratio (OR) per increment 1.57, 95% confidence intervals (CI) 1.45 to 1.69, P < 0.001) and multivariate analysis (OR per increment 1.41, 95% CI 1.28 to 1.55, P < 0.001). Patients who stayed less than one hour were at low risk of deterioration (absolute risk 3.7%). In patients staying longer than one hour, the absolute increase in risk was small but observable within six hours of PACU discharge. Compar\ed to a one-hour length of stay, a five-hour stay had a relative risk of 4.9 (95% CI 3.7 to 6.1). Other factors associated with rapid response team activation included non-elective surgery (OR 1.78, P < 0.001) and theatre length of stay (OR per increment 1.61, P < 0.001). PACU length of stay was also independently associated with predefined complications and unplanned intensive care unit admission postoperatively. In our cohort, an unanticipated prolonged PACU length of stay of over one hour was associated with an increased incidence of rapid response team activation in the first seven days postoperatively.
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Affiliation(s)
- Luke R Fletcher
- Department of Anaesthesia, Austin Health, Heidelberg, Victoria, Australia.,Data Analytics Research and Evaluation Centre (DARE), Austin Health and The University of Melbourne, Heidelberg, Victoria, Australia
| | - Timothy G Coulson
- Department of Anaesthesia, Austin Health, Heidelberg, Victoria, Australia.,Department of Anaesthesiology and Perioperative Medicine, Alfred Health and Monash University.,Department of Critical Care (DoCC), University of Melbourne, Melbourne, Victoria, Australia
| | - David A Story
- Department of Anaesthesia, Austin Health, Heidelberg, Victoria, Australia.,Department of Anaesthesiology and Perioperative Medicine, Alfred Health and Monash University
| | - Richard J Hiscock
- Department of Epidemiology and Preventive Medicine, Monash University, Clayton, Victoria, Australia.,Department of Anaesthesia, Mercy Hospital for Women, Heidelberg, Victoria, Australia
| | - Nada Marhoon
- Data Analytics Research and Evaluation Centre (DARE), Austin Health and The University of Melbourne, Heidelberg, Victoria, Australia
| | - Justin M Nazareth
- Department of Anaesthesia, Austin Health, Heidelberg, Victoria, Australia.,Department of Anaesthesiology and Perioperative Medicine, Alfred Health and Monash University.,Translational Obstetrics Group, The Department of Obstetrics and Gynaecology, Mercy Hospital for Women, Heidelberg, Victoria, Australia
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8
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Ludbrook GL, Leaman E. Cost-Effectiveness in Perioperative Care: Application of Markov Modeling to Pathways of Perioperative Care. Value Health 2022; 25:215-221. [PMID: 35094794 DOI: 10.1016/j.jval.2021.07.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Revised: 06/23/2021] [Accepted: 07/30/2021] [Indexed: 06/14/2023]
Abstract
OBJECTIVES This study aimed to evaluate the application of cost-effectiveness modeling to redesign of perioperative care pathways, from a hospital perspective. METHODS A Markov cost-effectiveness model of patient transition between care locations, each with different characteristics and cost, was developed. Inputs were derived from clinical trials piloting a preoperative call center and a postoperative medium-acuity care unit. The effect chosen was days at home (DAH) after surgery, reflecting quality of in-hospital care, acknowledged financially by fundholders, and relevant to consumers. Cost was from the hospital's perspective. A model cycle time of 4 hours for 30 days reflected relevant timelines and costs. RESULTS A Markov model was successfully created, accounting for the care locations in the 2 pathways as model states and accounting for consequences and costs. Cost-effectiveness analysis allowed the calculation of an incremental cost-effectiveness ratio comparing these pathways, providing a mean incremental cost-effectiveness ratio of -$427 per additional DAH, where incremental costs and DAH were -$644 and +1.51, respectively. Probabilistic sensitivity analysis suggested the new pathway had a 61% probability of reduced costs and a 74% probability of increased DAH and a 58% probability this pathway was dominant. Tornado analysis revealed the major contributor to increased costs as intensive care unit stay and the major contributor to decreased costs as ward stay. For the new pathway, the probability of transfer from ward to home and the probability of staying at home had the greatest impact on DAH. CONCLUSIONS These data suggest Markov modeling may be a useful tool for the cost-effectiveness analysis of initiatives in perioperative care.
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Affiliation(s)
- Guy L Ludbrook
- Department of Anaesthesia, Royal Adelaide Hospital and Discipline of Acute Care Medicine, University of Adelaide, Adelaide, South Australia, Australia.
| | - Esrom Leaman
- Department of Anaesthesia, Royal Adelaide Hospital and Discipline of Acute Care Medicine, University of Adelaide, Adelaide, South Australia, Australia
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9
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Ji J, Gu X, Xiao C. Comparison of Perioperative Active or Routine Temperature Management on Postoperative Quality of Recovery in PACU in Patients Undergoing Thoracoscopic Lobectomy: A Randomized Controlled Study. Int J Gen Med 2022; 15:429-436. [PMID: 35046704 PMCID: PMC8760972 DOI: 10.2147/ijgm.s342907] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Accepted: 12/23/2021] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Whether intraoperative temperature management can help patients recover quickly in the postanesthesia care unit (PACU) still remains to be investigated. This study aimed to investigate the effect of intraoperative temperature management on the quality of postoperative recovery of patients who underwent pulmonary lobectomy in the PACU. METHODS Totally, 98 patients aged 45-60 years with a body mass index of 20-25 kg/m2 who underwent elective thoracoscopic lobectomy were enrolled. Patients were categorized into two groups using a random number table: the conventional group received routine intervention to maintain normothermia (Group C, n = 49) and the aggressive group received integrated interventions (Group A, n = 49). In Group C, normothermic fluid was infused intravenously, the heating blanket was turned on when the intraoperative temperature was <35.0 °C, and the warming was stopped when the temperature reached 36.5 °C. In Group A, the fluid heated to 37 °C was infused intravenously, and the heating blanket was used intraoperatively. When the body temperature was >37 °C, the heating blanket was turned off, and when the body temperature was <36.5 °C, the heating blanket was turned on to continue heating. RESULTS Steward awakening scores at 1 min and 5 min after extubation and PaO2 levels at 15 min after extubation were higher in Group A than in Group C (P < 0.05); incidence of chills, nausea, and vomiting in the PACU was lower in Group A than in Group C (P < 0.05); and length of stay in the PACU was shorter in Group A than in Group C (P < 0.05). CONCLUSION Aggressive intraoperative temperature management of patients undergoing thoracoscopic lobectomy can improve the quality of postoperative recovery in the PACU through a safe and smooth transition compared with routine insulation measures.
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Affiliation(s)
- Junhui Ji
- Anesthesiology Department, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, People's Republic of China
| | - Xiafang Gu
- Anesthesiology Department, The No.2 People's Hospital of Suzhou Xiangcheng District, Suzhou, Jiangsu, People's Republic of China
| | - Chengjiao Xiao
- Anesthesiology Department, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, People's Republic of China
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10
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West N, Görges M, Poznikoff A, Whyte S, Malherbe S. Association of dexmedetomidine with recovery room and hospital discharge times: A retrospective cohort analysis. Paediatr Anaesth 2021; 31:1170-1178. [PMID: 34292656 DOI: 10.1111/pan.14257] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Revised: 07/02/2021] [Accepted: 07/17/2021] [Indexed: 12/21/2022]
Abstract
BACKGROUND Dexmedetomidine is a useful anesthetic adjunct, increasingly popular during pediatric surgery and procedural sedation. Its half-life of 2-3 hours might prolong recovery and discharge times when compared with an un-supplemented propofol anesthetic. This may create an additional burden in a busy post-anesthetic care unit (PACU). AIM To investigate whether intraoperative adjuvant dexmedetomidine delays PACU discharge in patients undergoing propofol anesthesia for day surgery or procedural investigations with minimal anticipated post-procedural pain. METHODS We conducted a retrospective review of outpatient procedures performed during a six-month period including pediatric patients, ASA physical status I-III, who underwent intravenous anesthesia with propofol and remifentanil for magnetic resonance imaging (MRI), strabismus repair, upper gastrointestinal endoscopy, or combined upper/lower gastrointestinal endoscopy. Patients receiving a sedative premedication, long-acting opioids, or volatile anesthetics for maintenance of anesthesia, were excluded. Duration of PACU stay was compared for patients who did or did not receive intraoperative dexmedetomidine in the four procedure groups. RESULTS Charts were reviewed for 359 patients; 130 (36%) received dexmedetomidine. Median differences in duration of PACU stay for dexmedetomidine versus non-dexmedetomidine cases were: 5 minutes (95%CI 0 to 10, p=0.037) for MRI; 5 minutes (95%CI -3 to 15, p=0.258) for strabismus surgery; 7 minutes (95%CI 3 to 10, p<0.001) for upper endoscopy; and 5 minutes (95%CI 1 to 12, p=0.021) for combined upper/lower endoscopy. Linear regression (F=61.1, adjusted R2 =0.40) indicated a significant relationship between dexmedetomidine dose (estimate 14.6 minutes per μg/kg, 95%CI 8.2 to 21.1, p<0.001) and duration of PACU stay. CONCLUSION We found evidence for a small association of intraoperative dexmedetomidine with duration of recovery from propofol anesthesia for a set of common outpatient procedures, with a potential dose relationship equivalent to approximately 15 minutes delay per μg/kg dexmedetomidine administered. Future research into the benefits of dexmedetomidine in pediatric anesthesia should further evaluate this relationship.
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Affiliation(s)
- Nicholas West
- BC Children's Hospital Research Institute, Vancouver, BC, Canada
| | - Matthias Görges
- BC Children's Hospital Research Institute, Vancouver, BC, Canada.,Department of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia, Vancouver, BC, Canada
| | - Andrew Poznikoff
- Department of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia, Vancouver, BC, Canada.,Department of Anesthesia, BC Children's Hospital, Vancouver, BC, Canada
| | - Simon Whyte
- BC Children's Hospital Research Institute, Vancouver, BC, Canada.,Department of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia, Vancouver, BC, Canada.,Department of Anesthesia, BC Children's Hospital, Vancouver, BC, Canada
| | - Stephan Malherbe
- Department of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia, Vancouver, BC, Canada.,Department of Anesthesia, BC Children's Hospital, Vancouver, BC, Canada
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11
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Schad S, Booke H, Thal SC, Bentley AH, Booke M. The Recovery Room: Transition from a Sleepy Postoperative Unit to a Vibrant and Cost-Effective Multipurpose Perioperative Care Unit. Clinicoecon Outcomes Res 2021; 13:893-896. [PMID: 34707381 PMCID: PMC8542462 DOI: 10.2147/ceor.s331681] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Accepted: 09/21/2021] [Indexed: 12/04/2022] Open
Abstract
The anesthesiologist, who traditionally was solely responsible for the intra- and postoperative care of patients, has undergone a transformation over the last decades and has emerged as a specialist for perioperative medicine. This includes preoperative assessment, preoperative stabilization of emergent cases, pre- or postoperative initiation of regional blocks, postoperative recovery and if needed postoperative intensive care outside the intensive care unit. A traditional recovery room, designated to take care of patients emerging from anesthesia only, no longer matches the modern anesthesiologist’s demands. However, a traditional recovery room can easily be transformed into a vibrant multi-purpose perioperative care unit. Especially in smaller hospitals, this serves to match the anesthesiologist’s demands without the financial burden of separate units for each task. On the contrary, it allows to transform the recovery room from a mandatory, but costly postoperative unit into a highly productive and demanding perioperative unit, allowing for extra revenues without corresponding costs. Worldwide, operating rooms are linked to an adjacent recovery room allowing patients to emerge from anesthesia until they fulfill the criteria to be transferred either to the regular ward or, in case of outpatient surgery, to be discharged home. Running these recovery rooms, however, is expensive due to the required technical equipment and the monthly costs of highly qualified anesthesia personnel. Despite these financial burdens, such recovery rooms are still mandatory to ensure full recovery after anesthesia and surgery. In most countries, there is no (full) reimbursement for providing recovery rooms, turning them into fiscally deficient units in most hospitals. However, recovery rooms can be further developed allowing hospitals to improve their caseloads, reduce turnover times in the operating room, and even help to manage a shortage of beds in the intensive care unit. In this paper, we describe the potential transformation from a traditional recovery room to a multi-purpose perioperative high-tech unit.
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Affiliation(s)
- Stefan Schad
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, Kliniken-MTK, Academic Hospital of the Goethe-University Frankfurt, Frankfurt, Germany
| | - Hendrik Booke
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe University, Frankfurt, Germany
| | - Serge C Thal
- Department of Anesthesiology, HELIOS University Hospital Wuppertal, Witten/Herdecke University, Wuppertal, Germany
| | - Alexander H Bentley
- Department of Anesthesiology, HELIOS University Hospital Wuppertal, Witten/Herdecke University, Wuppertal, Germany
| | - Michael Booke
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, Kliniken-MTK, Academic Hospital of the Goethe-University Frankfurt, Frankfurt, Germany
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12
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Lee HJ, Cho Y, Joo H, Jeon JY, Jang YE, Kim JT. Comparative study of verbal rating scale and numerical rating scale to assess postoperative pain intensity in the post anesthesia care unit: A prospective observational cohort study. Medicine (Baltimore) 2021; 100:e24314. [PMID: 33578527 PMCID: PMC10545085 DOI: 10.1097/md.0000000000024314] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Revised: 08/07/2020] [Accepted: 12/23/2020] [Indexed: 11/26/2022] Open
Abstract
ABSTRACT Postsurgical patients usually have difficulty in answering the self-report pain scales due to the residual effects of anesthetic or sedative agents in the post-anesthesia care unit (PACU). A comparative analysis of pain assessment tools used in the PACU is lacking.In this prospective observational study, we compared the intensity of pain using the 11-point numeric rating scale (NRS) and the 4-category verbal rating scale (VRS) thrice, 5 minutes after PACU admission, 20 minutes after the first assessment, and just before discharge from the PACU in 200 patients undergone surgery. Spearman rank correlation analysis was used to investigate the correlation between 2 scales, and the weighted kappa (κ) coefficient was performed to evaluate inter-scale reliability. Response rates of the 2 scales were also compared.VRS and NRS were highly correlated during all 3 comparisons (r = 0.767, 0.714, and 0.653, respectively; P < .0001). Each category of VRS showed a statistically significant difference in pain intensity measured by NRS during all 3 assessments. Inter-scale reliability had a fair strength of agreement for all 3 measurements (weighted κ = 0.519, 95% CI: 0.421-0.618; weighted κ = 0.511, 95% C.I: 0.409-0.613; weighted κ = 0.452, 95% C.I: 0.352-0.551, respectively). VRS showed a higher response rate for PACU patients compared to NRS in all 3 measurements (96% vs 77.5%, 99% vs 81.5%, and 96.5% vs 86.5%, respectively; P < .0001).In the PACU, VRS is a reasonable and practical pain intensity measurement tool for postsurgical patients, considering the high correlation between VRS and NRS, and a higher response rate.
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Affiliation(s)
- Ho-Jin Lee
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital
| | - Yongjung Cho
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Hyundeok Joo
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Jae Yeong Jeon
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Young-Eun Jang
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital
| | - Jin-Tae Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital
- Seoul National University College of Medicine
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Ludbrook G, Lloyd C, Story D, Maddern G, Riedel B, Richardson I, Scott D, Louise J, Edwards S. The effect of advanced recovery room care on postoperative outcomes in moderate-risk surgical patients: a multicentre feasibility study. Anaesthesia 2020; 76:480-488. [PMID: 33027534 DOI: 10.1111/anae.15260] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/28/2020] [Indexed: 01/03/2023]
Abstract
Postoperative complications are common and may be under-recognised. It has been suggested that enhanced postoperative care in the recovery room may reduce in-hospital complications in moderate- and high-risk surgical patients. We investigated the feasibility of providing advanced recovery room care for 12-18 h postoperatively in the post-anaesthesia care unit. The primary hypothesis was that a clinical trial of advanced recovery room care was feasible. The secondary hypothesis was that this model may have a sustained impact on postoperative in-hospital and post-discharge events. This was a multicentre, prospective, feasibility before-and-after trial of moderate-risk patients (predicted 30-day mortality of 1-4%) undergoing non-cardiac surgery and who were scheduled for postoperative ward care. Patients were managed using defined assessment checklists and goals of care in an advanced recovery room care setting in the immediate postoperative period. This utilised existing post-anaesthesia care unit infrastructure and staffing, but extended care until the morning of the first postoperative day. The advanced recovery room care trial was deemed feasible, as defined by the recruitment and per protocol management of > 120 patients. However, in a specialised cancer centre, recruitment was slow due to low rates of eligibility according to narrow inclusion criteria. At a rural site, advanced recovery room care could not be commenced due to logistical issues in establishing a new model of care. A definitive randomised controlled trial of advanced recovery room care appears feasible and, based on the indicative data on outcomes, we believe this is warranted.
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Affiliation(s)
- G Ludbrook
- Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, Australia
| | - C Lloyd
- Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, Australia
| | - D Story
- Centre for Integrated Critical Care, University of Melbourne, Melbourne, Australia
| | - G Maddern
- Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, Australia
| | - B Riedel
- Department of Anaesthetics, Peri-operative and Pain Medicine, the Peter MacCallum Cancer Centre, University of Melbourne, Melbourne, Australia
| | - I Richardson
- Department of Anaesthetics, Peri-operative and Pain Medicine, the Peter MacCallum Cancer Centre, University of Melbourne, Melbourne, Australia
| | - D Scott
- School of Medicine, Western Sydney University, Sydney, Australia
| | - J Louise
- Adelaide Health Technology Assessment, University of Adelaide, Adelaide, Australia
| | - S Edwards
- Adelaide Health Technology Assessment, University of Adelaide, Adelaide, Australia
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Liu S, Wang Z, Xiong J, Wan L, Luo A, Wang X. Continuous Analysis of Critical Incidents for 92,136 Postanesthesia Care Unit Patients of a Chinese University Hospital. J Perianesth Nurs 2020; 35:630-634. [PMID: 32778494 DOI: 10.1016/j.jopan.2020.03.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2019] [Revised: 02/22/2020] [Accepted: 03/02/2020] [Indexed: 11/30/2022]
Abstract
PURPOSE To determine the spectrum of critical incidents in postanesthesia care unit (PACU) and the possible prediction and prevention of the worse scenario-associated critical incidents. DESIGN A retrospective observational study. METHODS The critical incidents in PACU comprising 92,136 patients were recorded. The incidents included the following disorders: delayed recovery, pain, bleeding, hypothermia, unplanned transfer to intensive care unit, shivering, agitation, nausea and vomiting, and respiratory or cardiovascular-related critical incidents. We then performed descriptive analyses and t test or χ2 test on the collected data. FINDINGS A total of 1,760 critical incidents were recorded in 1,417 patients among 92,136 patients. Most critical incidents were associated with the patients after general anesthesia and general or gynecologic surgery. The most common critical incidents noted in the present study were pain, followed by cardiovascular-related and respiratory-related incidents. The average length of stay in PACU was 61.50 ± 44.40 minutes for the patients with critical incidents and 28.50 ± 19.40 minutes for the patients without critical incidents. CONCLUSIONS Critical incidents lead to longer length of stay in the PACU. Regular inspection and immediate response for critical incidents in the PACU is essential for the maintenance of the quality of the immediate postoperative care.
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Affiliation(s)
- Shangkun Liu
- Department of Anesthesiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei Province, China
| | - Zhenxing Wang
- Department of Anesthesiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei Province, China
| | - Juan Xiong
- Department of Anesthesiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei Province, China
| | - Li Wan
- Department of Anesthesiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei Province, China
| | - Ailin Luo
- Department of Anesthesiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei Province, China
| | - Xueren Wang
- Department of Anesthesiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei Province, China.
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Lloyd C, Ludbrook G, Story D, Maddern G. 'Organisation of delivery of care in operating suite recovery rooms within 48 hours postoperatively and patient outcomes after adult non-cardiac surgery: a systematic review'. BMJ Open 2020; 10:e027262. [PMID: 32139478 PMCID: PMC7059488 DOI: 10.1136/bmjopen-2018-027262] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
CONTEXT Postoperative recovery rooms have existed since 1847, however, there is sparse literature investigating interventions undertaken in recovery, and their impact on patients after recovery room discharge. OBJECTIVE This review aimed to investigate the organisation of care delivery in postoperative recovery rooms; and its effect on patient outcomes; including mortality, morbidity, unplanned intensive care unit (ICU) admission and length of hospital stay. DATA SOURCES NCBI PubMed, EMBASE and Cumulative Index to Nursing and Allied Health Literature. STUDY SELECTION Studies published since 1990, investigating health system initiatives undertaken in postoperative recovery rooms. One author screened titles and abstracts, with two authors completing full-text reviews to determine inclusion based on predetermined criteria. A total of 3288 unique studies were identified, with 14 selected for full-text reviews, and 8 included in the review. DATA EXTRACTION EndNote V.8 (Clarivate Analytics) was used to manage references. One author extracted data from each study using a data extraction form adapted from the Cochrane Data Extraction Template, with all data checked by a second author. DATA SYNTHESIS Narrative synthesis of data was the primary outcome measure, with all data of individual studies also presented in the summary results table. RESULTS Four studies investigated the use of the postanaesthesia care unit (PACU) as a non-ICU pathway for postoperative patients. Two investigated the implementation of physiotherapy in PACU, one evaluated the use of a new nursing scoring tool for detecting patient deterioration, and one evaluated the implementation of a two-track clinical pathway in PACU. CONCLUSIONS Managing selected postoperative patients in a PACU, instead of ICU, does not appear to be associated with worse patient outcomes, however, due to the high risk of bias within studies, the strength of evidence is only moderate. Four of eight studies also examined hospital length of stay; two found the intervention was associated with decreased length of stay and two found no association. PROSPERO REGISTRATION NUMBER This protocol is registered on the International Prospective Register of Systematic Reviews (PROSPERO) database, registration number CRD42018106093.
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Affiliation(s)
- Courtney Lloyd
- Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia
| | - Guy Ludbrook
- Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia
| | - David Story
- Perioperative and Pain Medicine Unit, Melbourne Medical School, The University of Melbourne, Parkville, Victoria, Australia
| | - Guy Maddern
- Discipline of Surgery, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia
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Jenkins BN, Fortier MA, Stevenson R, Makhlouf M, Lim P, Converse R, Kain ZN. Changing healthcare provider and parent behaviors in the pediatric post-anesthesia-care-unit to reduce child pain: Nurse and parent training in postoperative stress. Paediatr Anaesth 2019; 29:730-737. [PMID: 31012505 DOI: 10.1111/pan.13649] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2018] [Revised: 04/02/2019] [Accepted: 04/14/2019] [Indexed: 12/28/2022]
Abstract
BACKGROUND Children who undergo surgery experience significant pain in the post anesthesia care unit. Nurse and parent behaviors in the post anesthesia care unit directly impact child postoperative pain. Therefore, we have developed and evaluated (Phase 1) and then tested (Phase 2) the feasibility of a new intervention (Nurse and Parent Training in Postoperative Stress) to alter parent and nurse behaviors in a way consistent with reducing child postoperative pain. METHODS In Phase 1, a multidisciplinary team of experts (physicians, nurses, and psychologists) developed an empirically-based intervention which was then evaluated by experienced nurses (N = 8) and parents (N = 9) during focus groups. After revising the intervention based on focus group feedback, it was tested in Phase 2 using a pre-post study design. Nurses (N = 23) who worked in the recovery room were recruited to be part of both pre- and post-intervention data collection periods. Parents were recruited to be part of either the pre- (N = 52) or post-intervention (N = 60) data collection periods. Nurses and parent-child dyads were recorded in the post anesthesia care unit and videos were coded for the desired (ie, behaviors that may decrease child pain) and non-desired (ie, behaviors that may increase child pain) behaviors. Pain data was collected from the children's medical records to assess pain after surgery. The intervention was given to the nurses and parents in the post-intervention data collection period. RESULTS Nurses significantly increased their rate of desired behaviors by 231% (P = 0.001; Somer's D = 1) and significantly decreased their rate of non-desired behaviors by 62% (P = 0.004, Somer's D = -0.88, 95% CI [-1.74, -0.03]). Parents significantly increased their rate of desired behaviors by 124% (P = 0.033). Moreover, the intervention significantly decreased child pain in the post anesthesia care unit (b = -2.19, SE = 0.63, z = -3.46, P = 0.001, 95%CI [-3.43, -0.95]). CONCLUSION The intervention was effective in changing nurse and parent behaviors as well as child pain after surgery.
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Affiliation(s)
- Brooke N Jenkins
- Department of Psychology, Chapman University, Orange, California.,Center on Stress and Health, University of California, Irvine, Orange, California.,Department of Anesthesiology and Perioperative Care, University of California, Irvine, California
| | - Michelle A Fortier
- Center on Stress and Health, University of California, Irvine, Orange, California.,Department of Anesthesiology and Perioperative Care, University of California, Irvine, California.,Sue & Bill Gross School of Nursing, University of California, Irvine, California.,Children's Hospital of Orange County, Orange, California
| | - Robert Stevenson
- Center on Stress and Health, University of California, Irvine, Orange, California.,Department of Anesthesiology and Perioperative Care, University of California, Irvine, California
| | - Mai Makhlouf
- Center on Stress and Health, University of California, Irvine, Orange, California.,Department of Anesthesiology and Perioperative Care, University of California, Irvine, California
| | - Paulina Lim
- Center on Stress and Health, University of California, Irvine, Orange, California.,Department of Anesthesiology and Perioperative Care, University of California, Irvine, California
| | - Remy Converse
- Center on Stress and Health, University of California, Irvine, Orange, California.,Department of Anesthesiology and Perioperative Care, University of California, Irvine, California
| | - Zeev N Kain
- Center on Stress and Health, University of California, Irvine, Orange, California.,Department of Anesthesiology and Perioperative Care, University of California, Irvine, California.,Children's Hospital of Orange County, Orange, California.,Yale Child Study Center, Yale University, New-Haven, Connecticut
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17
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Hesse S, Kreuzer M, Hight D, Gaskell A, Devari P, Singh D, Taylor NB, Whalin MK, Lee S, Sleigh JW, García PS. Association of electroencephalogram trajectories during emergence from anaesthesia with delirium in the postanaesthesia care unit: an early sign of postoperative complications. Br J Anaesth 2019; 122:622-34. [PMID: 30915984 DOI: 10.1016/j.bja.2018.09.016] [Citation(s) in RCA: 111] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2017] [Revised: 08/21/2018] [Accepted: 09/11/2018] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Postoperative delirium is associated with an increased risk of morbidity and mortality, especially in the elderly. Delirium in the postanaesthesia care unit (PACU) could predict adverse clinical outcomes. METHODS We investigated a potential link between intraoperative EEG patterns and PACU delirium as well as an association of PACU delirium with perioperative outcomes, readmission and length of hospital stay. The risk factors for PACU delirium were also explored. Data were collected from 626 patients receiving general anaesthesia for procedures that would not interfere with frontal EEG recording. RESULTS Of the 626 subjects enrolled, 125 tested positive for PACU delirium. Whilst age, renal failure, and pre-existing neurological disease were associated with PACU delirium in the univariable analysis, the multivariable analysis revealed the importance of information derived from the EEG, anaesthetic technique, anaesthesia duration, and history of stroke or neurodegenerative disease. The occurrence of EEG burst suppression during maintenance [odds ratio (OR)=1.86 (1.13-3.05)] and the type of EEG emergence trajectory may be predictive of PACU delirium. Specifically, EEG emergence trajectories lacking significant spindle power were strongly associated with PACU delirium, especially in cases that involved ketamine or nitrous oxide [OR=6.51 (3.00-14.12)]. Additionally, subjects with PACU delirium were at an increased risk for readmission [OR=2.17 (1.13-4.17)] and twice as likely to stay >6 days in the hospital. CONCLUSIONS Specific EEG patterns were associated with PACU delirium. These findings provide valuable information regarding how the brain reacts to surgery and anaesthesia that may lead to strategies to predict PACU delirium and identify key areas of investigation for its prevention.
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Özelsel TJP, Kim S, Buro K, Tsui B. Elevated Waste Anaesthetic Gas Concentration in the Paediatric Post-Anaesthesia Care Unit. Turk J Anaesthesiol Reanim 2018; 46:362-366. [PMID: 30263859 DOI: 10.5152/tjar.2018.35683] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2017] [Accepted: 05/13/2018] [Indexed: 11/22/2022] Open
Abstract
Objective Exposure to waste anaesthetic gas (WAG) is a recognised occupational hazard for health care professionals (HCP). In recovery rooms, scavenging and ventilation systems differ from those in the operating room, raising the question as to how efficient they are. This study aims to measure the levels of ambient sevoflurane over the course of consecutive workdays in the paediatric recovery room of a tertiary academic centre. Methods The following is a descriptive-analytic study of ambient air sevoflurane levels measured using a MIRAN® 205B Series SapphIRe portable ambient air analyser. Samples were obtained between 7:30 am and 6:30 pm for two non-consecutive weeks on consecutive weekdays in our paediatric recovery room area. Results The ambient air levels of sevoflurane exceeded the ceiling concentration of 0.5 ppm recommended by the National Institute for Occupational Safety and Health on all days of measurement. The concentration of sevoflurane in ambient air correlates directly with the number of patients present. Conclusion Even in a modern recovery room constructed according to current building standard and code, ambient air levels of WAG exceed the recommendations. Future research and practice standards are needed to reduce this occupational exposure. Disregarding whether chronic exposure to WAG is harmful, we have shown that HCP working in recovery rooms are chronically exposed to concentrations which exceed recommended levels. Strategies are needed to reduce ambient levels of WAG in post-anaesthesia care units.
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Affiliation(s)
| | - Sam Kim
- Department of Anaesthesia and Pain Medicine, University of Alberta, Edmonton, Canada
| | - Karen Buro
- Department of Mathematics and Statistics, Macewan University, Edmonton, Canada
| | - Ban Tsui
- Department of Anaesthesiology, Perioperative and Pain Medicine, Stanford University, Palo Alto, USA
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Donahue S, DiBlasi RM, Thomas K. Humidification of Blow-By Oxygen During Recovery of Postoperative Pediatric Patients: One Unit's Journey. J Perianesth Nurs 2018; 33:964-971. [PMID: 29402527 DOI: 10.1016/j.jopan.2017.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Revised: 10/30/2017] [Accepted: 11/04/2017] [Indexed: 11/19/2022]
Abstract
PURPOSE To examine the practice of nebulizer cool mist blow-by oxygen administered to spontaneously breathing postanesthesia care unit (PACU) pediatric patients during Phase one recovery. DESIGN Existing evidence was evaluated. Informal benchmarking documented practices in peer organizations. An in vitro study was then conducted to simulate clinical practice and determine depth and amount of airway humidity delivery with blow-by oxygen. METHODS Informal benchmarking information was obtained by telephone interview. Using a three-dimensional printed simulation model of the head connected to a breathing lung simulator, depth and amount of moisture delivery in the respiratory tree were measured. FINDINGS Evidence specific to PACU administration of cool mist blow-by oxygen was limited. Informal benchmarking revealed that routine cool mist oxygenated blow-by administration was not widely practiced. The laboratory experiment revealed minimal moisture reaching the mid-tracheal area of the simulated airway model. CONCLUSIONS Routine use of oxygenated cool mist in spontaneously breathing pediatric PACU patients is not supported.
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Jain A, Muralidhar V, Aneja S, Sharma AK. A prospective observational study comparing criteria-based discharge method with traditional time-based discharge method for discharging patients from post-anaesthesia care unit undergoing ambulatory or outpatient minor surgeries under general anaesthesia. Indian J Anaesth 2018; 62:61-65. [PMID: 29416152 PMCID: PMC5787893 DOI: 10.4103/ija.ija_549_17] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Background and Aims: Mostly, institutions in India have single post-anaesthesia care unit (PACU) which follows traditional time-based discharge (TBD) method. Recently, it has been classified into PACU Phase I and Phase II, and criteria-based discharge (CBD) method has been used. This study primarily compares CBD versus TBD methods in moving patients through PACU, and other non-clinical factors causing delay in shifting. Methods: One hundred patients, aged 18–65 years, American Society of Anesthesiologist's physical status I and II, scheduled for elective minor surgeries under general anaesthesia were studied. White's fast-track score in operating room (OR) and modified Aldrete's score (CBD time) in PACU were recorded. Patients were scheduled to discharge at 60 min based on TBD method. The mean CBD time and actual discharge time from PACU were statistically compared with TBD time. Other non-clinical factors delaying the discharge were also studied. Results: Eighty-five percent of patients achieved acceptable White's fast-track score in OR. The TBD time (60 min) was compared with the mean CBD time (10.70 ± 2.56 min) and actual discharge time (79.75 ± 12.98 min), which were found to be statistically significant. Primarily, anaesthesiologists' busy schedule was accountable for delay in discharge. Conclusion: The study concluded that in patients undergoing ambulatory minor surgeries, discharge times based on Criterion Based Discharge scoring systems such as modified Aldrete's and White's-fast are significantly lower in PACU Phase I as compared to the traditional Time Based Discharge method.
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Affiliation(s)
- Anuj Jain
- Department of Anaesthesia and Critical Care, Indraprastha Apollo Hospitals, New Delhi, India
| | - Varadarajan Muralidhar
- Department of Anaesthesia and Critical Care, Indraprastha Apollo Hospitals, New Delhi, India
| | - Sanjeev Aneja
- Department of Anaesthesia and Critical Care, Indraprastha Apollo Hospitals, New Delhi, India
| | - Anil Kumar Sharma
- Department of Anaesthesia and Critical Care, Indraprastha Apollo Hospitals, New Delhi, India
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Koivula-Tynnilä H, Axelin A, Leino-Kilpi H. Informational Privacy in the Recovery Room-Patients' Perspective. J Perianesth Nurs 2017; 33:479-489. [PMID: 30077292 DOI: 10.1016/j.jopan.2016.12.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2016] [Revised: 12/06/2016] [Accepted: 12/11/2016] [Indexed: 10/19/2022]
Abstract
PURPOSE To describe patients' perceptions of informational privacy and factors promoting it in the recovery room. DESIGN A descriptive semistructured qualitative interview study. METHODS The study was conducted in 2013, and the data were analyzed with inductive content analysis. Adult surgical recovery room patients (n = 17) were recruited with purposive sampling at the Department of Ear, Nose and Throat diseases in a university hospital in Finland. FINDINGS Informational privacy was described as control of patients' health information maintained by the health care professionals and the patients. Informational privacy was especially important in relation to other patients. Health care professionals and patients' attitude, behavior, and knowledge of informational privacy, barriers of hearing and seeing, societal rules, and the electronic patient data system promoted informational privacy. CONCLUSIONS Informational privacy in relation to other patients could be improved in the recovery room, for example, by developing patient health information transmission and architectural solutions.
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Hayhoe S, Pallett S, Zani J, Trott J. Reduction of Postanesthetic Pediatric Distress: A Coordinated Approach. J Perianesth Nurs 2018; 33:312-318.e1. [PMID: 29784261 DOI: 10.1016/j.jopan.2016.11.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2016] [Revised: 07/11/2016] [Accepted: 11/20/2016] [Indexed: 11/20/2022]
Abstract
PURPOSE Preoperative anxiety in children is associated with postoperative distress in recovery. Both are predictors of long-term maladaptive behavior. Remedies have been suggested to modify individual risk factors, but overall strategy is lacking. DESIGN An approach to anxiety reduction coordinated throughout the hospital experience has been developed in our day-stay pediatric surgical unit. METHODS There is a preadmission familiarization visit. On admission, time is spent in a playroom with other children. Anxiety is recorded using the modified Yale Preoperative Anxiety Scale. Children are distracted with an activity book during propofol induction. They are allowed to wake naturally, and emergence state is scored. FINDING The incidence of emergence distress is low in our study. Of 68 children, only one exhibited emergence delirium and three had inconsolable crying. CONCLUSIONS Important elements in reducing emergence distress are preadmission visit, use of a playroom, effective analgesia, anesthetic maintenance without short-acting volatiles, and undisturbed recovery with a parent present for reassurance.
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Abstract
INTRODUCTION We reviewed patients with critical incidents that occurred in the post-anaesthesia care unit (PACU) at a major tertiary hospital, and assessed the effect of these incidents on PACU length of stay and discharge disposition. METHODS A retrospective review was conducted of patients in the PACU over a two-year period from 24 June 2011 to 23 August 2013. Data on critical incidents was recorded in the administrative database using a standardised data form. RESULTS There were 701 incidents involving 364 patients; 203 (55.8%) patients had American Society of Anesthesiologists (ASA) physical status I or II. The most common critical incidents were cardiovascular-related (n = 293, 41.8%), respiratory (n = 155, 22.1%), neurological (n = 52, 7.4%), surgical (n = 47, 6.7%) and airway-related (n = 34, 4.9%). There were two incidents of cardiac arrest and 25 incidents of unexpected reintubations. Many patients (n = 186, 51.2%) stayed for over four hours in the PACU due to critical incidents and 184 (50.5%) patients required a higher level of care postoperatively than initially planned. Some patients (n = 34, 9.3%) returned to the operation theatre for further management. A proportion of patients (n = 64, 17.6%) had unplanned intensive care unit admissions due to adverse events in the PACU. CONCLUSION A wide spectrum of critical incidents occur in the PACU, many of which are related to the cardiovascular and respiratory systems. Critical incidents have a major impact on healthcare utilisation and result in prolonged PACU stays and higher levels of postoperative care than initially anticipated.
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Affiliation(s)
| | | | - Shin Yi Ng
- Department of Anaesthesia, Singapore General Hospital, Singapore
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Conti D, Ballo P, Buoncristiano U, Secchi S, Cecconi P, Buoncristiano M, Boccalini R, Mondaini N, Pedullà A. Clinical utility of an undersized nurse-operated recovery room in the postoperative course: results from an Italian community setting. J Perianesth Nurs 2015; 29:185-90. [PMID: 24856335 DOI: 10.1016/j.jopan.2013.07.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2012] [Revised: 05/22/2013] [Accepted: 07/15/2013] [Indexed: 11/30/2022]
Abstract
PURPOSE In Europe, standardized criteria for recovery room (RR) requirements have not been established. The purpose of this study was to examine the clinical utility of an undersized nurse-operated RR in an Italian community hospital. DESIGN Single-center observational study. METHODS A total of 1,945 consecutive surgical patients admitted to the RR at the study institution between September 31, 2009, and August 31, 2011, were included in the study. A control group of surgical patients not admitted to the RR, matched for age, gender, American Society of Anesthesiologists score, and type of surgery were also considered. The prevalence of early adverse events occurring within 3 hours of the end of surgery was compared between the two groups. FINDINGS Patients admitted to the RR (mean age, 73.6 ± 14.2 years; 42.2% male; and 76.3% having major surgery) showed lower prevalences of hypotension (P < .0001), hypertensive response (P < .0001), new arrhythmias requiring intervention (P = .0036), and oxygen desaturation (P < .0001) in comparison with the control group. No differences in the proportions of patients experiencing postoperative nausea and vomiting, shivering, bleeding, and respiratory events were found. The Numeric Rating Scale for pain was also significantly lower at 2 hours in the study group as compared to the control group (1 [0 to 5] vs 3 [1 to 7]; P < .0001). CONCLUSION In this Italian community setting, an undersized nurse-operated RR contributed to a reduced prevalence of adverse postoperative events.
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Sakai RL, Abrão GMG, Ayres JFV, Vianna PTG, de Carvalho LR, Castiglia YMM. Prognostic factors for perioperative pulmonary events among patients undergoing upper abdominal surgery. SAO PAULO MED J 2007; 125:315-21. [PMID: 18317600 PMCID: PMC11020569 DOI: 10.1590/s1516-31802007000600003] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2006] [Revised: 10/17/2007] [Accepted: 10/19/2007] [Indexed: 12/11/2022] Open
Abstract
CONTEXT AND OBJECTIVE The significant relationship between upper abdominal surgery and early (perioperative) pulmonary events was investigated among patients with preoperative pulmonary conditions undergoing general anesthesia. DESIGN AND SETTING Retrospective study for which data were obtained prospectively from 1999 to 2004, at a tertiary university hospital. METHODS We retrospectively studied 3107 patients over 11 years old presenting American Society of Anesthesiologists (ASA) status I, II or III who underwent upper abdominal surgery under general anesthesia and were discharged to the recovery room. The preoperative conditions analyzed using logistic regression were: age, sex, ASA physical status, congestive heart failure, asthma, chronic obstructive pulmonary disease (COPD), respiratory failure and smoking. The outcomes or dependent variables included intraoperative and postoperative events: bronchospasm, hypoxemia, hypercapnia, prolonged intubation and airway secretion. RESULTS Among these patients (1500 males, 1607 females, mean age 48 years, 1088 ASA I, 1402 ASA II and 617 ASA III), there were 80 congestive heart failures, 82 asthmatics, 122 with COPD, 21 respiratory failures and 428 smokers. Logistic regression analysis showed that female sex (p < 0.001), age over 70 years (p < 0.01), smoking (p < 0.001) and COPD (p < 0.02) significantly influenced pulmonary event development, particularly hypoxemia and bronchospasm, at both times but not in the same patients. Asthma and congestive heart failure cases did not present pulmonary events in the recovery room. CONCLUSION In upper abdominal surgery under general anesthesia, female sex, age over 70, smoking and COPD were independent risk factors for intra and postoperative pulmonary events.
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Affiliation(s)
- Rafael Luis Sakai
- Department of Anesthesiology, Faculdade de Medicina de Botucatu, Universidade Estadual Paulista (Unesp), Botucatu, São Paulo, Brazil
| | - Graciela Maria Gera Abrão
- Department of Anesthesiology, Faculdade de Medicina de Botucatu, Universidade Estadual Paulista (Unesp), Botucatu, São Paulo, Brazil
| | - José Franscisco Vasques Ayres
- Department of Anesthesiology, Faculdade de Medicina de Botucatu, Universidade Estadual Paulista (Unesp), Botucatu, São Paulo, Brazil
| | - Pedro Thadeu Galvão Vianna
- Department of Anesthesiology, Faculdade de Medicina de Botucatu, Universidade Estadual Paulista (Unesp), Botucatu, São Paulo, Brazil
| | - Lídia Raquel de Carvalho
- Department of Anesthesiology, Faculdade de Medicina de Botucatu, Universidade Estadual Paulista (Unesp), Botucatu, São Paulo, Brazil
| | - Yara Marcondes Machado Castiglia
- Department of Anesthesiology, Faculdade de Medicina de Botucatu, Universidade Estadual Paulista (Unesp), Botucatu, São Paulo, Brazil
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Gali B, Whalen FX, Gay PC, Olson EJ, Schroeder DR, Plevak DJ, Morgenthaler TI. Management plan to reduce risks in perioperative care of patients with presumed obstructive sleep apnea syndrome. J Clin Sleep Med 2007; 3:582-588. [PMID: 17993039 PMCID: PMC2045705] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
STUDY OBJECTIVES Obstructive sleep apnea (OSA) has been associated with increased perioperative morbidity and mortality. We initiated a protocol designed to screen patients preoperatively and monitor them postoperatively. The goal was to identify patients who were at risk for oxygen desaturation after discharge from the postanesthesia recovery room (PACU). METHODS Patients without previously diagnosed OSA presenting to the preoperative evaluation clinic were assessed over a 10.5-month period using a validated prediction rule to identify patients thought to be at high risk of OSA (sleep apnea clinical score, SACS > or = 15). Following surgery, patients were monitored in the PACU for significant respiratory events: apnea, increased FiO2 requirement, pain-sedation mismatch, or episodes of desaturation. Patients were placed in 3 groups based on their SACS and the presence or absence of recurrent PACU respiratory events (group 1: SACS < 15, no recurrent events; group 2: SACS > or =15, no recurrent events; and group 3: SACS > or = 15, recurrent events.) The number of oxygen desaturations > or = 4% per hour, the oxygen desaturation index (ODI), was calculated for each patient for 24 to 48 hours after PACU discharge. An ODI > 10 was the threshold chosen to indicate a high frequency of oxygen desaturation. RESULTS The percentage of patients with ODI > 10 differed significantly across the 3 study groups (12%, 37%, and 57%, for groups 1-3, p = 0.005). Mean ODI in group 1 was significantly different from groups 2 and 3 (5.8 compared to 10.0 group 2 and 11.4 group 3 with p = 0.001). CONCLUSIONS We have shown that combining preoperative screening is useful for identifying patients at risk for oxygen desaturation after PACU discharge.
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Affiliation(s)
- Bhargavi Gali
- Department of Anesthesiology, Mayo Clinic, Rochester, MN 55905, USA.
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