Management of Preoperative Anemia

Anemia is the most common modifiable risk factor for postoperative morbidity and mortality. Early identification and optimal management are key to restore iron stores and ensure its resolution before surgery. Several therapies have been proposed to treat anemia in the perioperative period, such as iron supplementation and erythropoiesis-stimulating agents, though it remains unclear which is the most optimal to improve clinical outcomes. This article summarizes the most updated evidence on perioperative management of anemia and denotes differences among the international guidelines to reflect the conflicting evidence in this field and the need for further research in specific areas.

Preoperative Code Status Discussion Workflows: Targets for Improvement in Multidisciplinary Pathways

CONTEXT

Discussion of perioperative code status is an important element of preoperative care and a component of the American College of Surgeons' Geriatric Surgery Verification (GSV) program. Evidence suggests code status discussions (CSDs) are not routinely performed and are inconsistently documented.

OBJECTIVES

Because preoperative decision making is a complex process spanning multiple providers, this study aims to utilize process mapping to highlight challenges associated with CSDs and inform efforts to improve workflows and implement elements of the GSV program.

METHODS

Using process mapping, we detailed workflows relating to (CSDs) for patients undergoing thoracic surgery and a possible workflow for implementing GSV standards for goals and decision-making.

RESULTS

We generated process maps for outpatient and day-of-surgery workflows relating to CSDs. In addition, we generated a process map for a potential workflow to address limitations and integrate GSV Standards for Goals and Decision Making.

CONCLUSION

Process mapping highlighted challenges associated with the implementation of multidisciplinary care pathways and indicated a need for centralization and consolidation of perioperative code status documentation.

Preoperative Management of Medications for Rheumatologic and HIV Diseases: Society for Perioperative Assessment and Quality Improvement (SPAQI) Consensus Statement

Perioperative medical management is challenging because of the rising complexity of patients presenting for surgical procedures. A key part of preoperative optimization is appropriate management of long-term medications, yet guidelines and consensus statements for perioperative medication management are lacking. Available resources use recommendations derived from individual studies and do not include a multidisciplinary focus on formal consensus. The Society for Perioperative Assessment and Quality Improvement identified a lack of authoritative clinical guidance as an opportunity to use its multidisciplinary membership to improve evidence-based perioperative care. The Society for Perioperative Assessment and Quality Improvement seeks to provide guidance on perioperative medication management that synthesizes available literature with expert consensus. The aim of this consensus statement is to provide practical guidance on the preoperative management of immunosuppressive, biologic, antiretroviral, and anti-inflammatory medications. A panel of experts including hospitalists, anesthesiologists, internal medicine physicians, infectious disease specialists, and rheumatologists was appointed to identify the common medications in each of these categories. The authors then used a modified Delphi process to critically review the literature and to generate consensus recommendations.

Efficacy of an Online Curriculum for Perioperative Goals of Care and Code Status Discussions: A Randomized Controlled Trial

BACKGROUND

Preoperative goals of care (GOC) and code status (CS) discussions are important in achieving an in-depth understanding of the patient's care goals in the setting of a serious illness, enabling the clinician to ensure patient autonomy and shared decision making. Past studies have shown that anesthesiologists are not formally trained in leading these discussions and may lack the necessary skill set. We created an innovative online video curriculum designed to teach these skills. This curriculum was compared to a traditional method of learning from reading the medical literature.

METHODS

In this bi-institutional randomized controlled trial at 2 major academic medical centers, 60 anesthesiology trainees were randomized to receive the educational content in 1 of 2 formats: (1) the novel video curriculum (video group) or (2) journal articles (reading group). Thirty residents were assigned to the experimental video curriculum group, and 30 were assigned to the reading group. The content incorporated into the 2 formats focused on general preoperative evaluation of patients and communication strategies pertaining to GOC and CS discussions. Residents in both groups underwent a pre- and postintervention objective structured clinical examination (OSCE) with standardized patients. Both OSCEs were scored using the same 24-point rubric. Score changes between the 2 OSCEs were examined using linear regression, and interrater reliability was assessed using weighted Cohen's kappa.

RESULTS

Residents receiving the video curriculum performed significantly better overall on the OSCE encounter, with a mean score of 4.19 compared to 3.79 in the reading group. The video curriculum group also demonstrated statistically significant increased scores on 8 of 24 rubric categories when compared to the reading group.

CONCLUSIONS

Our novel video curriculum led to significant increases in resident performance during simulated GOC discussions and modest increases during CS discussions. Further development and refinement of this curriculum are warranted.

Development of an Automated Technology Platform for Preoperative Triage and Patient Preparation

A proof of concept study was conducted to implement an automated preoperative triage and preparation service with 2 components: (1) triage between preoperative visits and phone screens, and (2) delivery of preoperative instructions to patients. The study enrolled 2604 patients, of whom 75.7% completed the preoperative triage questionnaire and 47.6% were triaged to preoperative phone screens. For the preoperative preparation component, 90.8% of patients viewed surgery preparation instructions, and average patient satisfaction score was 9.3/10. An automated preoperative triage and preparation service can facilitate preoperative triage using patient self-reported information and guide patient preparation with instructions delivered at relevant times.

Management of a surgical patient with a label of penicillin allergy: narrative review and consensus recommendations

Unsubstantiated penicillin-allergy labels are common in surgical patients, and can lead to significant harm through avoidance of best first-line prophylaxis of surgical site infections and increased infection with resistant bacterial strains. Up to 98% of penicillin-allergy labels are incorrect when tested. Because of the scarcity of trained allergists in all healthcare systems, only a minority of surgical patients have the opportunity to undergo testing and de-labelling before surgery. Testing pathways can be modified and shortened in selected patients. A variety of healthcare professionals can, with appropriate training and in collaboration with allergists, provide testing for selected patients. We review how patients might be assessed, the appropriate testing strategies that can be used, and the minimum standards of safe testing.

Preoperative Cardiac Stress Tests Ordered in the Preoperative Evaluation Clinic: A Retrospective Review of Ordering Patterns

Background

The role of anesthesiologists has expanded from operating rooms to preoperative evaluation clinics. This role involves performing preoperative cardiovascular evaluation and optimization of patients before elective surgery, which can include ordering cardiac stress tests. We aimed to study the ordering patterns by anesthesiologists for preoperative cardiac stress tests, focusing on whether societal and institutional guidelines and recommendations were used. Choice of type of cardiac stress test was also examined.

Methods

A single center retrospective chart review from December 1, 2005 to May 31, 2015 was performed on 492 patients who had a cardiac stress test ordered by an anesthesiologist. Patients were categorized by indication for ordering the cardiac stress test based on societal practice guidelines, institutional guidelines or other relevant reasons at the time of patient encounter. Those “other” category cardiac stress tests were assessed for indication and evaluated by physician peer review to see if there was peer agreement for being appropriately ordered. Exercise electrocardiography (ECG) cardiac stress tests ordered were evaluated for appropriateness based on baseline resting ECG findings. Patients with left bundle branch block (LBBB) or right ventricular (RV) pacing were evaluated for appropriateness of proper cardiac stress test modality based on whether a pharmacological vasodilator cardiac stress test was ordered.

Results

Analysis of the cardiac stress tests ordered showed that 43% were ordered according to American College of Cardiology/American Heart Association guidelines, 29% were ordered according to institutional guidelines, and 28% were categorized as “other”. Of the 28% “other” cardiac stress tests, 53% were in agreement for ordering by peer review. Sixty-four exercise ECG cardiac stress tests were ordered, of which 58% were appropriate based on having no baseline resting ECG abnormalities. Fifty-one patients were identified as having a resting ECG of LBBB or RV pacing of which 41% had an appropriate pharmacological vasodilator cardiac stress tests ordered.

Conclusions

Anesthesiologists order most preoperative cardiac stress tests according to professional societal or institutional guidelines (72%), yet they are not always choosing the best modality of cardiac stress test. A significant portion of cardiac stress tests are ordered (28%) based on clinical judgment, likely due to the lack of guidelines and recommendations being all-encompassing on many commonly encountered preoperative patient situations.

Application of Kern's 6-Step Approach in the Development of a Novel Anesthesiology Curriculum for Perioperative Code Status and Goals of Care Discussions

BACKGROUND

Code status discussions, goals of care discussions, and shared decision-making in the perioperative setting are of great importance. As perioperative physicians, anesthesiologists are uniquely poised to handle these discussions. Yet formal training for anesthesiology residents in how to approach these scenarios is currently lacking.

METHODS

Using Kern's 6-step approach to curriculum development, we describe an innovative curriculum for anesthesiology residents designed to teach the necessary skills to successfully conduct code status and goals of care discussions and to assess its efficacy.

RESULTS

Our curriculum is composed of the following educational components: (1) formal, online learning modules, (2) selected journal articles describing code status and goals of care discussions skills and communication strategies, and (3) 2 objective-structured clinical examination experiences, with 1 occurring prior to and the other occurring after completion of the educational content. The educational content focuses on evidence-based best practices content covering professional guidelines, current literature, shared decision-making, and effective communication strategies. We also describe the potential methodology to evaluate the effectiveness of our proposed educational interventions.

CONCLUSION

Using Kern's framework, we developed a curriculum focusing on code status discussions, goals of care discussions, and shared decision-making in the perioperative setting which provides trainees with the opportunity to practice communication skills and receive feedback from a standardized patient through participation in an objective structured clinical examination.

Factors associated with the use of cognitive aids in operating room crises: a cross-sectional study of US hospitals and ambulatory surgical centers

Background

Operating room (OR) crises are high-acuity events requiring rapid, coordinated management. Medical judgment and decision-making can be compromised in stressful situations, and clinicians may not experience a crisis for many years. A cognitive aid (e.g., checklist) for the most common types of crises in the OR may improve management during unexpected and rare events. While implementation strategies for innovations such as cognitive aids for routine use are becoming better understood, cognitive aids that are rarely used are not yet well understood. We examined organizational context and implementation process factors influencing the use of cognitive aids for OR crises.

Methods

We conducted a cross-sectional study using a Web-based survey of individuals who had downloaded OR cognitive aids from the websites of Ariadne Labs or Stanford University between January 2013 and January 2016. In this paper, we report on the experience of 368 respondents from US hospitals and ambulatory surgical centers. We analyzed the relationship of more successful implementation (measured as reported regular cognitive aid use during applicable clinical events) with organizational context and with participation in a multi-step implementation process. We used multivariable logistic regression to identify significant predictors of reported, regular OR cognitive aid use during OR crises.

Results

In the multivariable logistic regression, small facility size was associated with a fourfold increase in the odds of a facility reporting more successful implementation (p = 0.0092). Completing more implementation steps was also significantly associated with more successful implementation; each implementation step completed was associated with just over 50% higher odds of more successful implementation (p ≤ 0.0001). More successful implementation was associated with leadership support (p < 0.0001) and dedicated time to train staff (p = 0.0189). Less successful implementation was associated with resistance among clinical providers to using cognitive aids (p < 0.0001), absence of an implementation champion (p = 0.0126), and unsatisfactory content or design of the cognitive aid (p = 0.0112).

Conclusions

Successful implementation of cognitive aids in ORs was associated with a supportive organizational context and following a multi-step implementation process. Building strong organizational support and following a well-planned multi-step implementation process will likely increase the use of OR cognitive aids during intraoperative crises, which may improve patient outcomes.

Electronic supplementary material

The online version of this article (10.1186/s13012-018-0739-4) contains supplementary material, which is available to authorized users.

Electronic Care Coordination From the Preoperative Clinic

Fragmented and variable perioperative care exposes patients to unnecessary risks and handoff errors. The perioperative surgical home aims to optimize quality, value-based care. We performed a retrospective evaluation of how a preoperative assessment center could coordinate care through e-mails sent to a patient's healthcare team that initiate discussion on critical clinical information. During 100 clinic days on which 8122 patients were evaluated, 606 triggered e-mails, with a potential impact on 19 elements across the perioperative care spectrum. Four cases were canceled, and 42 cases were rescheduled. By fostering information exchange, these communications could advance patient-centered, value-enhanced quality and safety outcomes.

An Agenda for Improving Perioperative Code Status Discussion

Code status discussions (CSDs) clarify patient preferences for cardiopulmonary resuscitation in the event of cardiac or respiratory arrest. CSDs are a key component of perioperative care, particularly at the end of life, and must be both patient-centered and shared. Physicians at all levels of training are insufficiently trained in and inappropriately perform CSD; this may be particularly true of perioperative physicians. In this article, we describe the difficulty of achieving a patient-centered, shared perioperative CSD in the case of a medical professional with a do-not-resuscitate order. We provide a brief background in cardiopulmonary resuscitation, do-not-resuscitate, and CSD before proposing an agenda for improving perioperative CSD.

A Model for Better Leveraging the Point of Preoperative Assessment: Patients and Providers Look Beyond Operative Indications When Making Decisions

Previous literature on preoperative evaluation focuses on the impact on the day of surgery cancellations and delays; however, the framework of cancellations and delays at the time of the elective outpatient preoperative anesthesia visit has not been categorized. We describe the current model in the preoperative clinic at Brigham and Women's Hospital, examining the pattern of cancellations at the time of this preoperative visit and the framework used for categorizing the issues involved. Looking at this broader framework is important in an era of patient-centered care; we seek to identify targets to modify the preoperative assessment and adequately assess and capture the spectrum of issues involved. Elective cases evaluated in the preoperative clinic were reviewed over 10 months. Characteristics of cancelled and noncancelled cases were compared. In-depth analysis of issues related to cancellation was done; 1-year follow-up was completed. Cancellation patterns included categories encompassing clinical, financial, alignment with patient values and goals, compliance, and social issues. The period of preoperative assessment can therefore be leveraged to review a number of domains that can adversely affect surgical outcomes and improve patient-centered care. Also, our framework allows the institution to benchmark these patterns over time; increases in cancellations at the time of the preoperative anesthesia clinic visit for specific categories can prompt an opportunity to examine and improve preoperative workflow.

Controversies in anaesthesia for noncardiac surgery in older adults

As the population of the world is rapidly ageing, the amount of surgery being performed in older patients is also increasing. Special attention is required for the anaesthetic and perioperative management of these patients. The clinical and non-clinical issues specific to older surgical patients are reviewed, with a special emphasis on areas of debate related to anaesthesia care in this group. These issues include the role of frailty and disability in preoperative assessment, choice of anaesthesia technique for hip fracture, postoperative delirium, and approaches to shared decision-making before surgical procedures.

Preoperative Laboratory Testing

Routine preoperative testing is not cost-effective, because it is unlikely to identify significant abnormalities. Abnormal findings from routine testing are more likely to be false positive, are costly to pursue, introduce a new risk, increase the patient's anxiety, and are inconvenient to the patient. Abnormal findings rarely alter the surgical or anesthetic plan, and there is usually no association between perioperative complications and abnormal laboratory results. Incidental findings and false positive results may lead to increased hospital visits and admissions. Preoperative testing needs to be done based on a targeted history and physical examination and the type of surgery.

Impact of information technology on preoperative scheduling systems: a pilot study modeling scheduling systems in the preoperative clinic

BACKGROUND

Scheduling systems that consider volume and patient acuity are crucial to maximize the use of resources during preoperative assessments. Identifying patients with specific needs and developing resource-efficient pathways to address these needs is essential to achieve a high-value framework. At our facility, we triage patients for assessment by phone or in-person visit. Significant variation in lengths of visits results in longer waiting times and inefficient scheduling of clinical and space resources. Developing a schedule that included appointments of shorter and longer lengths based on patient triage factors could optimize resource use.

METHODOLOGY

We utilized a survey methodology to determine clinical and non-clinical factors that clinicians identified as important determinants of visit length.

RESULTS

Within the system-based issues, incomplete information given to the patient during the surgical office visit and the need for additional phone calls to outside medical facilities for information gathering afforded the longest mean appointment time lengths. Within patient-based issues, new clinical findings discovered during the visit and patients who lacked social support demonstrated the longest mean appointment times.

CONCLUSIONS

Both clinical and non-clinical issues contribute to visit length; a proper understanding of both can assist in developing evidence-based scheduling that maximizes value for both the patient and the system, as well as optimizing patient experience and outcomes.

Measuring critical deficits in shared decision making before elective surgery

OBJECTIVE

Identifying patient factors correlated with specific needs in preoperative decision making is of clinical and ethical importance. We examined patterns and predictors of deficiencies in informed surgical consent and shared decision-making in preoperative patients.

METHODS

Validated measures were used to survey 1034 preoperative patients in the preoperative clinic after signed informed consent. Principal component analysis defined correlated groupings of factors. Multivariable analysis assessed patient factors associated with resultant groupings.

RESULTS

13% of patients exhibited deficits in their informed consent process; 33% exhibited other types of deficits. Informed consent deficits included not knowing the procedure being performed or risks and benefits. Other deficits included not having addressed patient values, preferences and goals. Non-English language and lower educational level were factors correlated with higher risk for deficits.

CONCLUSION

Deficits exist in over a third of patients undergoing preoperative decision-making. Sociodemographic factors such as language and educational level identified particularly vulnerable groups at risk for having an incomplete, and possibly ineffective, decision-making process.

PRACTICE IMPLICATIONS

Interventions to identify vulnerable groups and address patient centered surgical decision making in the pre-operative setting are needed. Focused interventions to address the needs of at-risk patients have potential to improve the surgical decision-making process and reduce disparities.

Anaphylaxis in the clinical setting of obstetric anesthesia: a literature review

The prevalence of anaphylaxis occurring during pregnancy is approximately 3 cases per 100,000 deliveries. The management of anaphylaxis occurring during the third trimester of pregnancy may be challenging because of the additive effects of aortocaval compression and cardiovascular disturbances of anaphylaxis. In this review, we identify the clinical signs of anaphylaxis occurring during labor and cesarean delivery, discuss the more common allergens that cause anaphylaxis during this clinical setting, and develop a rational approach to the identification of the offending allergen. We also suggest strategies for the management of anaphylaxis occurring during the third trimester of pregnancy, including the prompt administration of epinephrine and emergency cesarean delivery in cases of severe reactions. Evidence is limited to case reports and extrapolation from nonfatal and fatal cases, interpretation of pathophysiology, and consensus opinion.

Simulation-based trial of surgical-crisis checklists

BACKGROUND

Operating-room crises (e.g., cardiac arrest and massive hemorrhage) are common events in large hospitals but can be rare for individual clinicians. Successful management is difficult and complex. We sought to evaluate a tool to improve adherence to evidence-based best practices during such events.

METHODS

Operating-room teams from three institutions (one academic medical center and two community hospitals) participated in a series of surgical-crisis scenarios in a simulated operating room. Each team was randomly assigned to manage half the scenarios with a set of crisis checklists and the remaining scenarios from memory alone. The primary outcome measure was failure to adhere to critical processes of care. Participants were also surveyed regarding their perceptions of the usefulness and clinical relevance of the checklists.

RESULTS

A total of 17 operating-room teams participated in 106 simulated surgical-crisis scenarios. Failure to adhere to lifesaving processes of care was less common during simulations when checklists were available (6% of steps missed when checklists were available vs. 23% when they were unavailable, P<0.001). The results were similar in a multivariate model that accounted for clustering within teams, with adjustment for institution, scenario, and learning and fatigue effects (adjusted relative risk, 0.28; 95% confidence interval, 0.18 to 0.42; P<0.001). Every team performed better when the crisis checklists were available than when they were not. A total of 97% of the participants reported that if one of these crises occurred while they were undergoing an operation, they would want the checklist used.

CONCLUSIONS

In a high-fidelity simulation study, checklist use was associated with significant improvement in the management of operating-room crises. These findings suggest that checklists for use during operating-room crises have the potential to improve surgical care. (Funded by the Agency for Healthcare Research and Quality.).

Crisis checklists for the operating room: development and pilot testing

BACKGROUND

Because operating room crises are rare events, failure to adhere to critical management steps is common. We sought to develop and pilot a tool to improve adherence to lifesaving measures during operating room crises.

STUDY DESIGN

We identified 12 of the most frequently occurring operating room crises and corresponding evidence-based metrics of essential care for each (46 total process measures). We developed checklists for each crisis based on a previously defined method, which included literature review, multidisciplinary expert consultation, and simulation. After development, 2 operating room teams (11 participants) were each exposed to 8 simulations with random assignment to checklist use or working from memory alone. Each team managed 4 simulations with a checklist available and 4 without. One of the primary outcomes measured through video review was failure to adhere to essential processes of care. Participants were surveyed for perceptions of checklist use and realism of the scenarios.

RESULTS

Checklist use resulted in a 6-fold reduction in failure of adherence to critical steps in management for 8 scenarios with 2 pilot teams. These results held in multivariate analysis accounting for clustering within teams and adjusting for learning or fatigue effects (11 of 46 failures without the checklist vs 2 of 46 failures with the checklist; adjusted relative risk = 0.15, 95% CI, 0.04-0.60; p = 0.007). All participants rated the overall quality of the checklists and scenarios to be higher than average or excellent.

CONCLUSIONS

Checklist use can improve safety and management in operating room crises. These findings warrant broader evaluation, including in clinical settings.

Anesthesia in the patient with multiple drug allergies: are all allergies the same?

PURPOSE OF REVIEW

During the preoperative evaluation, patients frequently indicate 'multiple drug allergies', most of which have not been validated. Potential allergic cross-reactivity between drugs and foods is frequently considered as a risk factor for perioperative hypersensitivity. The aim of this review is to facilitate the recognition of risk factors for perioperative anaphylaxis and help the management of patients with 'multiple drug allergies' during the perioperative period.

RECENT FINDINGS

Neuromuscular blocking agents (NMBAs) and antibiotics are the most common drugs triggering perioperative anaphylaxis. Quaternary ammonium ions have been suggested to be the allergenic determinant of NMBAs. Even though the 'pholcodine hypothesis' has been suggested to explain the occurrence of NMBA-induced allergy, this concept remains unclear. Although many practitioners believe that certain food allergies present an issue with the use of propofol, there is no role to contraindicate propofol in egg-allergic, soy-allergic or peanut-allergic patients. IgE-mediated hypersensitivity has been reported with seafood and iodinated drugs, IgE-mediated hypersensitivity has been reported with seafood and iodinated drugs, but there is no cross-reactivity between them. The allergenic determinants have been characterized for fish, shellfish and povidone iodine and remain unknown for contrast agents.

SUMMARY

There are many false assumptions regarding drug allergies. The main goal of this article is to review the potential cross-reactivity among specific families of drugs and foods in order to facilitate the anesthetic management of patients with 'multiple drug allergies'.

The role of testing in the preoperative evaluation

Preoperative laboratory and electrocardiographic testing should be driven by the patient's history and physical examination and the risk of the surgical procedure. A test is likely to be indicated only if it can correctly identify abnormalities and will change the diagnosis, the management plan, or the patient's outcome. Needless testing is expensive, may unnecessarily delay the operation, and puts the patient at risk for unnecessary interventions. Preoperative evaluation centers can help hospitals standardize and optimize preoperative testing while fostering more consistent regulatory documentation and appropriate coding for reimbursement.

Neuromuscular blockade, reversal agent use, and operating room time: retrospective analysis of US inpatient surgeries

PURPOSE

Reducing operating room (OR) time is of interest to hospital administrators because of high costs of OR utilization. Neuromuscular blocking agents (NMBAs) induce muscle relaxation during surgery. Several acetylcholinesterase inhibitors are used to reverse neuromuscular blockade to shorten recovery time. This study explored the relationship between elapsed OR time and the use of specific NMBAs and reversal agents among patients undergoing selected surgeries based on data from two large hospitals. Specifically, this study sought to test the hypothesis that the application of reversal agents in surgeries using a neuromuscular block would be associated with a decrease in elapsed OR time.

METHODS

This retrospective cohort study used clinical data from two large hospitals. The authors selected seven types of surgical cases involving thoracic, cardiac, vascular, abdominal, peripheral, urological, and neurological systems. Eligible cases were elective surgeries performed under general anesthesia and using one or more NMBAs (including rocuronium, vecuronium, cisatracurium, and/or pancuronium). Multivariate linear regressions were conducted to examine the relationships among neuromuscular blockade, reversal agent use (including neostigmine, pyridostigmine, and edrophonium), and elapsed OR time by controlling for age, gender, and patient comorbidities.

RESULTS

A total of 9670 surgeries were included in this analysis. The mean elapsed OR time across all surgeries was 227 min, and vecuronium was the most commonly used NMBA. Approximately 67% of all surgeries used a reversal agent. After controlling for confounding factors, use of a reversal agent was shown to be associated with the reduction of elapsed OR time in six of seven types of surgery. The magnitude of this effect ranged from 12 to 46 min of OR time saved. The exception was thoracic surgeries, for which use of a reversal agent was shown to be associated with longer OR time (approximately 26 min). Multivariate regression analyses revealed that the type of NMBA used was also a significant predictor of elapsed time for all surgeries (except cardiac).

CONCLUSIONS

This analysis has shown that use of selected neuromuscular blockade reversal agents may lead to more efficient OR resource use.

Value of preoperative clinic visits in identifying issues with potential impact on operating room efficiency

BACKGROUND

Preoperative clinics have been shown to decrease operating room delays and cancellations. One mechanism for this positive economic impact is that medical issues are appropriately identified and necessary information is obtained, so that knowledge of the patients' status is complete before the day of surgery. In this study, the authors describe the identification and management of medical issues in the preoperative clinic.

METHODS

All patients coming to the Preoperative Clinic during a 3-month period from November 1, 2003, through January 31, 2004, at the Brigham and Women's Hospital, Boston, Massachusetts, were studied. Data were collected as to the type of issue, information needed to resolve the issue, time to retrieve the information, cancellation and delay rates, and the effect on management.

RESULTS

A total of 5,083 patients were seen in the preoperative clinic over the three-month period. A total of 647 patients had a total of 680 medical issues requiring further information or management. Of these issues, 565 were thought to require further information regarding known medical problems, and 115 were new medical problems first identified in the clinic. Most of the new problems required that a new test or consultation be done, whereas most of the old problems required retrieval of information existing from outside medical centers. New problems had a far greater probability of delay (10.7%) or cancellation (6.8%) than old problems (0.6% and 1.8%, respectively).

CONCLUSIONS

The preoperative evaluation can identify and resolve a number of medical issues that can impact efficient operating room resource use.

Needles used for spinal anesthesia

Since the discovery of spinal anesthesia in 1885 by J Leonard Corning, spinal needles have been modified to simplify their use and minimize complications. Needle design variables, such as diameter, tip design and orifice location, have been altered to enable rapid flow of cerebral spinal fluid (CSF) and injected medications, yet simultaneously limit dural trauma and loss of CSF. CSF loss can result in a severe postdural puncture headache (PDPH). Blunt pencil-point tip needles have been observed to cause a lower incidence of PDPH than similar sized sharp, cutting tip needles. Smaller diameter needles are also associated with a lower incidence of PDPH. A recent alteration in spinal needles is not to the needle per se, but rather the microcatheters placed through them; currently used in Europe, such catheters are again being evaluated in the USA. Further advancements in spinal needles will most likely involve some of the design elements previously altered, as well as new features not yet recognized as important at this time.

Second Symposium on the Definition and Management of Anaphylaxis: Summary Report—Second National Institute of Allergy and Infectious Disease/Food Allergy and Anaphylaxis Network Symposium

There is no universal agreement on the definition of anaphylaxis or the criteria for diagnosis. In July 2005, the National Institute of Allergy and Infectious Disease and Food Allergy and Anaphylaxis Network convened a second meeting on anaphylaxis, which included representatives from 16 different organizations or government bodies, including representatives from North America, Europe, and Australia, to continue working toward a universally accepted definition of anaphylaxis, establish clinical criteria that would accurately identify cases of anaphylaxis with high precision, further review the evidence on the most appropriate management of anaphylaxis, and outline the research needs in this area.

Second symposium on the definition and management of anaphylaxis: summary report--Second National Institute of Allergy and Infectious Disease/Food Allergy and Anaphylaxis Network symposium

There is no universal agreement on the definition of anaphylaxis or the criteria for diagnosis. In July 2005, the National Institute of Allergy and Infectious Disease and Food Allergy and Anaphylaxis Network convened a second meeting on anaphylaxis, which included representatives from 16 different organizations or government bodies, including representatives from North America, Europe, and Australia, to continue working toward a universally accepted definition of anaphylaxis, establish clinical criteria that would accurately identify cases of anaphylaxis with high precision, further review the evidence on the most appropriate management of anaphylaxis, and outline the research needs in this area.

Effect of amniotic fluid on coagulation and platelet function in pregnancy: an evaluation using thromboelastography

Amniotic fluid embolism is a rare obstetric complication. The exact pathogenesis of this syndrome remains unknown and significant controversy exists whether coagulopathy should always be present. We used thromboelastography to assess the effect of amniotic fluid on coagulation and platelet function in pregnant women. Different volumes of amniotic fluid (10-60 microl) were added to blood (330 microl) from pregnant women and thromboelastography variables determined. There were three important findings. R time, reflecting time to first clot formation, was significantly decreased with the addition of 10 microl amniotic fluid; platelet function, as determined by Reopro-TEG technique, was increased with the addition of 30 microl of amniotic fluid; and there was no evidence of fibrinolysis in any samples studied. In conclusion, our study substantiates the hypothesis that coagulation profile changes are invariable accompaniments of amniotic fluid embolism.