Reengineering Intravenous Drug and Fluid Administration Processes in the Operating Room

Step One: Task Analysis of Existing Processes

Deborah B. Fraind, B.S.

*; Jason M. Slagle, M.S.†; Victor A. Tubbesing, B.S.‡; Samuel A. Hughes, Ph.D.†; Matthew B. Weinger, M.D.§

Presented in part at the 74th Annual Congress of the International Anesthesia Research Society, Honolulu, Hawaii, March 13, 2000. Dr. Weinger was a paid consultant of, and held a small equity stake in, FluidSense Corporation (Newburyport, Massachusetts), a manufacturer of intravenous infusion therapy products.

ANESTHESIOLOGY 2002;97:139-147

Background: A reengineering approach to intravenous drug and fluid administration processes could improve anesthesia care. In this initial study, current intravenous administration tasks were examined to identify opportunities for improved design.

Methods: After institutional review board approval was obtained, an observer sat in the operating room and categorized, in real time, anesthesia providers’ activities during 35 cases ( 90 h) into 66 task categories focused on drug/fluid tasks. Both initial room set- up at the beginning of a typical workday and cardiac and noncardiac general anesthesia cases were studied. User errors and inefficiencies were noted. The time required to prepare de novo a syringe containing a mock emergency drug was measured using a standard protocol.

Results: Drug/fluid tasks consumed almost 50 and 75%, respectively, of the set-up time for noncardiac and cardiac cases. In 8 cardiac anesthetics, drug/fluid tasks comprised 27 ± 6% (mean ± SD) of all prebypass clinical activities. During 20 noncardiac cases, drug/fluid tasks comprised 20 ± 8% of induction and 15 ± 7% of maintenance. Drug preparation far outweighed drug administration tasks. Inefficient or error prone tasks were observed during drug/fluid preparation (e.g., supply acquisition, waste disposal, syringe labeling), administration (infusion device failure, leaking stopcock), and organization (workspace organization and navigation, untangling of intravenous lines). Anesthesia providers (n = 21) required 35 ± 5 s to prepare a mock emergency drug.

Conclusions Intravenous drug and fluid administration tasks account for a significant proportion of anesthesia care, especially in complex cases. Current processes are inefficient and may predispose to medical error. There appears to be substantial opportunity to improve quality and cost of care through the reengineering of anesthesia intravenous drug and fluid administration processes. General design requirements are proposed.

* Medical Student, University of California-San Diego. † Senior Research Associate, University of California-San Diego and Veterans Medical Research Foundation. ‡ Research Assistant, Department of Anesthesiology, University of California-San Diego and VA San Diego Healthcare System. § Director, San Diego Center for Patient Safety, Staff Physician, VA San Diego Healthcare System, and Professor of Anesthesiology, University of California-San Diego. Received from the Anesthesiology Ergonomics Research Laboratory, Health Services Research Service, VA San Diego Healthcare System, San Diego, California; the San Diego Center for Patient Safety, La Jolla, California; and the Department of Anesthesiology, University of California-San Diego, La Jolla, California. Submitted for publication August 6, 2001. Accepted for publication February 18, 2002.

Address correspondence to Dr. Weinger: VA Medical Center (125A), 3350 La Jolla Village Drive, San Diego, California 92161-5085. Address electronic mail to: [email protected]. Individual article reprints may be purchased through the Journal Web site, www.anesthesiology.org.

Supported by grants from the Anesthesia Patient Safety Foundation, Pittsburgh, Pennsylvania, the National Patient Safety Foundation, Chicago, Illinois, a Howard Hughes Summer Research Scholarship, La Jolla, California (to Dr. Fraind); grant No. HSR&D IIR 20-0066 from the Department of Veterans Affairs, Washington, DC; and grant Nos. R01-HS11375 and P20-HS11521 from the Agency for Healthcare Research and Quality, Rockville, Maryland.

Impact of Unplanned Extubation and Reintubation after Weaning on Nosocomial Pneumonia Risk in the Intensive Care Unit

A Prospective Multicenter Study

Arnaud de Lassence, M.D.

*; Corinne Alberti, M.D.†; Élie Azoulay, M.D.‡; Eric Le Miere, M.D.§; Christine Cheval, M.D.||; François Vincent, M.D.#; Yves Cohen, M.D.**; Maïté Garrouste-Orgeas, M.D.††; Christophe Adrie, M.D.‡‡; Gilles Troche, M.D.§§; Jean-François Timsit, M.D.||||; for the OUTCOMEREA Study Group##

Background: The authors prospectively evaluated the occurrence and outcomes of unplanned extubations (self-extubation and accidental extubation) and reintubation after weaning, and examined the hypothesis that these events may differ regarding their influence on the risk of nosocomial pneumonia.

Methods: Data were taken from a prospective, 2-yr database including 750 mechanically ventilated patients from six intensive care units. Results: One hundred five patients (14%) experienced at least one episode of these 3 events; 51 self-extubations occurred in 38 patients, 24 accidental extubations in 22 patients, and 56 reintubations after weaning in 45 patients. The incidence density of these 3 events was 16.4 per 1,000 mechanical ventilation days. Reintubation within 48 h was needed consistently after accidental extubation but was unnecessary in 37% of self- extubated patients. Unplanned extubation and reintubation after weaning were associated with longer total mechanical ventilation (17 vs. 6 days; P < 0.0001), intensive care unit stay (22 vs. 9 days; P < 0.0001), and hospital stay (34 vs. 18 days; P < 0.0001) than in control group, but did not influence intensive care unit or hospital mortality. The incidence of nosocomial pneumonia was significantly higher in patients with unplanned extubation or reintubation after weaning (27.6% vs. 13.8%; P = 0.002). In a Cox model adjusting on severity at admission, unplanned extubation and reintubation after weaning increased the risk of nosocomial pneumonia (relative risk, 1.80; 95% confidence interval, 1.15–2.80; P = 0.009). This risk increase was entirely ascribable to accidental extubation (relative risk, 5.3; 95% confidence interval, 2.8–9.9; P < 0.001).

Conclusion: Accidental extubation but not self-extubation or reintubation after weaning increased the risk of nosocomial pneumonia. These 3 events may deserve evaluation as an indicator for quality-of-care studies.

*Staff Physician, §Attending Physician, Medical ICU, Louis Mourier Teaching Hospital. †Staff Physician, Department of Biostatistics, U444-INSERM, Paris 7 University, Paris France. ‡Staff Physician, ICU, Saint Louis Teaching Hospital. ||Staff Physician, Vascular Surgical ICU, ††Staff Physician, Polyvalent ICU, Saint Joseph Teaching Hospital. #Staff Physician, Renal ICU, Tenon Teaching Hospital, Paris, France. **Professor, Medical-surgical ICU, Avicenne Teaching Hospital. ‡‡Staff Physician, Polyvalent ICU, Delafontaine Hospital, Saint Denis, France. §§Staff Physician, Surgical ICU, Antoine Béclère Teaching Hospital. ||||Staff Physician, Medical ICU, Bichat-Claude Bernard Teaching Hospital, Paris, France. ##Individuals participating in the OUTCOMEREA Study Group are listed in the Appendix. Received from the Medical ICU, Avicenne Hospital, Bobigny, France; Surgical ICU, Antoine Béclère Hospital, Clamart, France; Medical and Surgical ICUs, Saint Joseph Hospital, Paris, France; Medical ICU, Louis Mourier Hospital, Colombes, France; and the Medical ICU, Saint-Louis Hospital, Paris, France. Submitted for publication October 22, 2001. Accepted for publication February 27, 2002. OUTCOMEREA® is supported by nonexclusive educational grants from Aventis Pharma France, Paris, France, Wyeth-Lederle, Puteaux-Paris la Défense, France, and Centre National de Recherche Scientifique, Paris, France.

Adress reprint requests to Dr. de Lassence: Service de Réanimation Médicale, Hôpital Louis Mourier, 92701 Colombes Cedex, France. Address electronic mail to: [email protected]. Individual article reprints may be purchased through the Journal Web site, www.anesthesiology.org.

Anaesthesia Type Brings on Temporarily Twitchy Legs Wed Jun 26, 5:30 PM ET

By Hannah Cleaver BERLIN (Reuters Health) - People who have spinal anaesthesia should be warned that they may experience restless legs syndrome afterwards, but that this restlessness will disappear on its own within a few months.

This is the conclusion of a study on possible triggers for the condition, which often robs sufferers of their sleep as severe discomfort in their legs can only be reduced by walking around or at least moving the legs.

Dr. Birgit Hoegl, head of the sleep laboratory at Innsbruck University, Austria, said there also seemed to be a link between low blood iron levels and the onset of the syndrome after a spinal anaesthetic.

In spinal anaesthesia, drugs are injected into the spinal area, resulting in numbness of the body below the injection point.

Presenting her paper at the 12th Meeting of the European Neurological Society here Wednesday, Hoegl said her study looked at 161 patients who had never experienced restless legs syndrome (RLS). Many were pregnant women who received spinal anaesthesia while undergoing C-sections.

Fourteen of the patients developed RLS after anaesthesia. Four had mild RLS, five had a moderate form of the condition, and five had severe RLS. Among an additional 41 patients who already had RLS, four experienced a marked worsening of the condition.

Hoegl told Reuters Health that all those who developed the condition saw it disappear again, generally within about a month, while all were free of it after 3 months.

She said, "We ruled out gender, age, type of anaesthetic and dose as factors, but there does seem to be a correlation between low iron levels and development of RLS. The iron factor seems to be a susceptibility factor.

"The condition is not so bad, nor so long-lasting that one would recommend using a different anaesthetic. But the patient needs to know that it is a possible side-effect of spinal anaesthetic and doctors treating them should also be aware so that if need be, treatment can be offered. It also looks as if preoperative anaemia increases the risk of developing RLS after the operation."

Hoegl and her colleagues, chaired by Werner Poewe, now plan another study to investigate whether RLS appears after other types of anaesthesia.

Anesthestic-related Cardiac Arrest and Its Mortality

A Report Covering 72,959 Anesthetics over 10 Years from a US Teaching Hospital Myrna C. Newland, M.D.

*; Sheila J. Ellis, M.D.†; Carol A. Lydiatt, M.D.‡; K. Reed Peters, M.D.‡; John H. Tinker, M.D.§; Debra J. Romberger, M.D.||; Fred A. Ullrich, B.S.#; James R. Anderson, Ph.D.**

This article is featured in “This Month in Anesthesiology.” Please see this issue of ANESTHESIOLOGY, page 5A.

Presented in part at the annual meeting of the American Society of Anesthesiologists, San Francisco, California, October 14–18, 2000.

Background: A prospective and retrospective case analysis study of all perioperative cardiac arrests occurring during a 10-yr period from 1989 to 1999 was done to determine the incidence, cause, and outcome of cardiac arrests attributable to anesthesia.

Methods: One hundred forty-four cases of cardiac arrest within 24 h of surgery were identified over a 10-yr period from an anesthesia database of 72,959 anesthetics. Case abstracts were reviewed by a Study Commission composed of external and internal members in order to judge which cardiac arrests were anesthesia-attributable and which were anesthesia-contributory. The rates of anesthesia-attributable and anesthesia- contributory cardiac arrest were estimated.

Results: Fifteen cardiac arrests out of a total number of 144 were judged to be related to anesthesia. Five cardiac arrests were anesthesia-attributable, resulting in an anesthesia- attributable cardiac arrest rate of 0.69 per 10,000 anesthetics (95% confidence interval, 0.085–1.29). Ten cardiac arrests were found to be anesthesia-contributory, resulting in an anesthesia-contributory rate of 1.37 per 10,000 anesthetics (95% confidence interval, 0.52–2.22). Causes of the cardiac arrests included medication-related events (40%), complications associated with central venous access (20%), problems in airway management (20%), unknown or possible vagal reaction in (13%), and one perioperative myocardial infarction. The risk of death related to anesthesia-attributable perioperative cardiac arrest was 0.55 per 10,000 anesthetics (95% confidence interval, 0.011–1.09).

Conclusions: Most perioperative cardiac arrests were related to medication administration, airway management, and technical problems of central venous access. Improvements focused on these three areas may result in better outcomes.

* Professor, † Assistant Professor, ‡ Associate Professor, § Professor and Chair, Department of Anesthesiology, || Associate Professor, Internal Medicine and Pulmonology, # Senior Programmer Analyst, ** Professor and Chair, Preventive and Societal Medicine. Received from the Departments of Anesthesiology, Internal Medicine and Pulmonology, and Preventive and Societal Medicine, University of Nebraska Medical Center, Omaha, Nebraska. Submitted for publication February 19, 2001. Accepted for publication February 13, 2002. Support was provided solely from institutional and/or departmental sources.

Address reprint requests to Dr. Newland: Department of Anesthesiology, 984455 Nebraska Medical Center, Omaha, Nebraska 68198-4455. Address electronic mail to: [email protected]. Individual article reprints may be purchased through the Journal Web site, www.anesthesiology.org.

Eliminating Intensive Postoperative Care in Same-day Surgery Patients Using Short-acting Anesthetics

Jeffrey L. Apfelbaum, M.D.

*; Cynthia A. Walawander, M.A.†; Thaddeus H. Grasela, Pharm.D., Ph.D.‡; Phillip Wise, B.S., M.B.A.§; Charles McLeskey, M.D.||; Michael F. Roizen, M.D.#; Bernard V. Wetchler, M.D.**; Kari Korttila, M.D., Ph.D., F.R.C.A.††

For the list of study sites, please see Appendix 2.

This article is featured in “This Month in Anesthesiology.” Please see this issue of ANESTHESIOLOGY, page 5A.

Presented in part at the annual meeting of the American Society of Anesthesiologists, San Diego, California, October 21, 1997.

Background: A multidisciplinary effort was undertaken to determine whether patients could safely bypass the postanesthesia care unit (PACU) after same-day surgery by moving to an earlier time point evaluation of recovery criteria.

Methods: A prospective, outcomes research study with a baseline month, an intervention month, and a follow-up month was designed. Five surgical centers (three community- based hospitals and two freestanding ambulatory surgical centers) were utilized. Two thousand five hundred eight patients were involved in the baseline period, and 2,354 were involved in the follow-up period. Outcome measures included PACU bypass rates and adverse events. Intervention consisted of a multidisciplinary educational program and routine feedback reports.

Results: The overall PACU bypass rate (58%) was significantly different from baseline (15.9%, P < 0.001), for patients to whom a general anesthetic was administered (0.4– 31.8%, P < 0.001), and for those given other anesthetic techniques (monitored anesthesia care, regional or local anesthetics; 29.1–84.2%, P < 0.001). During the follow-up period, the average (SD) recovery duration for patients who bypassed the PACU was significantly shorter compared to that for patients who did not bypass, 84.6 (61.5) versus 175.1 (98.8) min, P < 0.001, with no change in patient outcome. Patients receiving only short-acting anesthetics were 78% more likely (P < 0.002) to bypass the PACU after adjusting for various surgical procedures.

Conclusions: This study represents a substantial change in clinical practice in the perioperative setting. Same-day surgical patients given short-acting anesthetic agents and who are awake, alert, and mobile requiring no parenteral pain medications and with no bleeding or nausea at the end of an operative procedure can safely bypass the PACU.

* Professor and Chair, Department of Anesthesia and Critical Care, University of Chicago Hospitals and Clinics, Chicago, Illinois. † Executive Vice President, ‡ President and CEO, Cognigen Corporation, Williamsville, New York. § Former: Glaxo Wellcome, Incorporated, Research Triangle Park, North Carolina. Current: Vice President, Commercial and Business Development, Ardent Pharmaceuticals, Durham, North Carolina. || Former: Professor and Chair, Department of Anesthesiology, Scott & White Hospital and Clinic, Texas A&M College of Medicine, Temple, Texas. Current: Senior Director, Clinical Development, Hospital Products Division, Abbott Laboratories, Abbott Park, Illinois. # Former: Professor and Chair, Department of Anesthesia and Critical Care, University of Chicago Hospitals and Clinics, Chicago, Illinois. Current: Dean and Vice President of Biomedical Sciences, College of Medicine, State University of New York of Upstate Medical University, Syracuse, New York. ** Clinical Professor, University of Illinois College of Medicine, Chicago, Illinois. †† Professor, Department of Anesthesia and Intensive Care, University of Helsinki, Women’s Hospital, Helsinki, Finland. Submitted for publication July 25, 2001. Accepted for publication January 2, 2002. Supported in part by a grant from Glaxo Wellcome, Incorporated, Research Triangle Park, North Carolina.

Address reprint requests to Dr. Apfelbaum: Department of Anesthesia & Critical Care, The University of Chicago Hospitals and Clinics, 5841 South Maryland Avenue MC4028, Chicago, Illinois 60637. Address electronic mail to: [email protected]. Individual article reprints may be purchased through the Journal Web site, www.anesthesiology.org.

OBSTETRIC ANESTHESIA

Intrathecal Versus Intravenous Fentanyl for Supplementation of Subarachnoid Block During Cesarean Delivery Sahar M. Siddik-Sayyid, MD, FRCA, Marie T. Aouad, MD, Maya I. Jalbout, MD, Mirna I. Zalaket, MD, Carina E. Berzina, MD, and Anis S. Baraka, MD, FRCA

Department of Anesthesiology, American University of Beirut, Medical Center, Beirut, Lebanon

Address correspondence and reprint requests to Anis Baraka, MD, FRCA, Department of Anesthesiology, American University of Beirut, PO Box 11-0236, Beirut, Lebanon. Address e-mail to [email protected].

Forty-eight healthy parturients scheduled for elective cesarean delivery were randomly allocated to receive intrathecally either 12 mg of hyperbaric bupivacaine plus 12.5 µg of fentanyl (n = 23) or bupivacaine alone (n = 25). In the latter group, IV 12.5 µg of fentanyl was administered immediately after spinal anesthesia. We compared the amount of IV fentanyl required for supplementation of the spinal anesthesia during surgery, the intraoperative visual analog scale, the time to the first request for postoperative analgesia, and the incidence of adverse effects. Additional IV fentanyl supplementation amounting to a mean of 32 ± 35 µg was required in the IV Fentanyl group, whereas no supplementation was required in the Intrathecal Fentanyl group (P = 0.009). The time to the first request for postoperative analgesia was significantly longer in the Intrathecal Fentanyl group than in the IV Fentanyl group (159 ± 39 min versus 119 ± 44 min; P = 0.003). The incidence of systolic blood pressure <90 mm Hg and the ephedrine requirements were significantly higher in the IV Fentanyl group as compared with the Intrathecal Fentanyl group (P = 0.01). Also, intraoperative nausea and vomiting occurred less frequently in the Intrathecal Fentanyl group compared with the IV Fentanyl group (8 of 23 vs 17 of 25; P = 0.02).

IMPLICATIONS: Supplementation of spinal bupivacaine anesthesia for cesarean delivery with intrathecal fentanyl provides a better quality of anesthesia and is associated with a decreased incidence of side effects as compared with supplementation with the same dose of IV fentanyl.

REGIONAL ANESTHESIA

New Landmarks for the Anterior Approach to the Sciatic Nerve Block: Imaging and Clinical Study Alain C. Van Elstraete, MD*, Claude Poey, MD , Thierry Lebrun, MD*, and Frédéric Pastureau, MD*

Departments of *Anesthesiology and Radiology, Saint-Paul Medical Center, Fort de France, Martinique, France

Address correspondence and reprint requests to Alain C. Van Elstraete, Département d’Anesthésiologie, Centre Médico-Chirurgical Saint Paul, Clairière, 97200 Fort-de-France, Martinique, France. Address e-mail to [email protected].

In this study, we assessed the reliability of the inguinal crease and femoral artery as anatomic landmarks for the anterior approach to the sciatic nerve and determined the optimal position of the leg during this approach. An imaging study was conducted before the clinical study. The sciatic nerve was located twice in 20 patients undergoing ankle or foot surgery, once with the leg in the neutral position and once with the leg in the externally rotated position. The patient was lying supine. A 22-gauge, 150-mm insulated b-beveled needle connected to a nerve stimulator was inserted 2.5 cm distal to the inguinal crease and 2.5 cm medial to the femoral artery and was directed posteriorly and laterally with a 10°–15° angle relative to the vertical plane. The sciatic nerve was located in all patients at a depth of 10.6 ± 1.8 cm when the leg was in the neutral position and 10.4 ± 1.5 cm when the leg was in the externally rotated position (not significant). In the neutral position and in the externally rotated position, the time needed to identify anatomic landmarks was 28 ± 15 s and 26 ± 14 s, respectively (not significant), and the time needed to locate the sciatic nerve was 79 ± 53 s and 46 ± 25 s (P < 0.006), respectively. We conclude that the inguinal crease and femoral artery are reliable and effective anatomic landmarks for the anterior approach to the sciatic nerve and that the optimal position of the leg is the externally rotated position.

IMPLICATIONS: This new anterior approach to the sciatic nerve using the inguinal crease and femoral artery as landmarks is an easy and reliable technique.

ANESTHETIC PHARMACOLOGY

The Efficacy and Safety of Transdermal Scopolamine for the Prevention of Postoperative Nausea and Vomiting: A Quantitative Systematic Review Peter Kranke, MD*, Astrid M. Morin, MD, DEAA , Norbert Roewer, MD, PhD*, Hinnerk Wulf, MD, PhD , and Leopold H. Eberhart, MD

*Department of Anesthesiology, University of Würzburg; and Department of Anesthesiology, University of Marburg, Germany

Address correspondence and reprint requests to Peter Kranke, MD, Department of Anesthesiology, University of Würzburg, Josef-Schneider-Str. 2, D-97080 Würzburg, Germany. Address e-mail to [email protected].

The role of scopolamine administered via transdermal therapeutic systems in the prevention of postoperative vomiting, nausea, and nausea and vomiting is unclear. We performed a systematic search for full reports of randomized comparisons of transdermal scopolamine with inactive control. Dichotomous data were extracted. In the meta- analysis, relative risks and numbers-needed-to-treat/harm were calculated with 95% confidence intervals (CI). In 23 trials, 979 patients received transdermal scopolamine, and 984 patients received placebo. Sensitivity analyses were performed using restricted data for truncated control event rates (40%–80%) and for large trials. With these data, the relative risks for postoperative vomiting (five reports), nausea (five reports), nausea and vomiting (eight reports), and rescue treatment (three reports) were 0.69 (95% CI, 0.58– 0.82), 0.69 (95% CI, 0.54–0.87), 0.76 (95% CI, 0.66–0.88), and 0.68 (95% CI, 0.54– 0.85), respectively. This means that of 100 patients who receive transdermal scopolamine, approximately 17 will not experience postoperative vomiting who would have done so had they all received a placebo. However, 18 of 100 patients will have visual disturbances, eight will report dry mouth, two will report dizziness, one will be classified as being agitated, and 1–13 patients who are prescribed transdermal scopolamine will not use it correctly. The timing of application does not alter efficacy.

IMPLICATIONS:Of 100 patients who receive transdermal scopolamine, approximately 17 will not vomit in the postoperative period who would have done so had they all received a placebo. However, 18 of 100 patients will have visual disturbances, and eight will report dry mouth. Incorrect use further limits its efficacy.

AMBULATORY ANESTHESIA

Development of an Appropriate List of Surgical Procedures of a Specified Maximum Anesthetic Complexity to Be Performed at a New Ambulatory Surgery Facility Franklin Dexter, MD, PhD*, Alex Macario, MD, MBA , Donald H. Penning, MS, MD , and Patricia Chung, MHA

*Division of Management Consulting and Department of Anesthesia, University of Iowa, Iowa City; Department of Anesthesia, Stanford University, Stanford, California; Department of Anesthesia, Sunnybrook and Women’s Health Sciences Centre; Department of Anaesthesiology, University of Toronto, Ontario, Canada; and Decision Support, Hospital Administration, Sunnybrook and Women’s Health Sciences Centre, Toronto, Ontario, Canada

Address correspondence and reprint requests to Franklin Dexter, Division of Management Consulting, Department of Anesthesia, University of Iowa, Iowa City, IA 52242. Address e-mail to Franklin- [email protected].

A common but difficult task for a hospital when it decides to open a freestanding ambulatory surgery facility is how to decide which surgical procedures should be done at the new facility. This is necessary in order to determine how many operating rooms to plan for the new facility and which ancillary services are needed on-site. In this case study, we describe a novel methodology that we used to develop a comprehensive list of procedures to be done at a new ambulatory facility. The level of anesthetic complexity of a procedure was defined by its number of ASA Relative Value Guide basic units. Broad categories of procedures (e.g., eye surgery) were defined according to the International Classification of Diseases, Ninth Revision, Clinical Modification. We identified 22 categories that are of a type that every procedure in the category has no more than seven basic units. In addition, by analyzing all procedures that the hospital being studied actually performed on an ambulatory basis, we identified six other categories of procedures that were of a type that all procedures eligible for surgery at the new facility had seven or fewer basic units.

IMPLICATIONS: We describe a novel method to develop a comprehensive list of procedures that have a prespecified maximum level of anesthetic complexity to be performed at a new ambulatory surgery facility.

Anesthesiologists and Acute Perioperative Stress: A Cohort Study Zeev N. Kain, MD* , Kar-Mei Chan, MD¶, Jonathan D. Katz, MD*, Arti Nigam, PhD*, Lee Fleisher, MD||, Jackqulin Dolev, MD , and Lynda E. Rosenfeld, MD

Departments of *Anesthesiology, Pediatrics, Child Psychiatry, and Cardiology, Yale University School of Medicine, New Haven, Connecticut; ||Department of Anesthesiology, The Johns Hopkins Institutions, Baltimore, Maryland; and ¶Department of Internal Medicine, Stanford University, Palo Alto, California

Address correspondence and reprint requests to Zeev N. Kain, MD, Department of Anesthesiology, Yale School of Medicine, 333 Cedar St., New Haven, CT 06510. Address e-mail to [email protected].

Previous studies have indicated that many anesthesiologists exhibit symptoms of chronic stress. There is a paucity of data, however, regarding the existence of acute stress signs among anesthesiologists. Anesthesiologists from three practice settings (n = 38) were studied while they were anesthetizing 203 patients. Heart rate (HR) was recorded continuously and arterial blood pressure (BP) was measured hourly and immediately after each induction. Anxiety levels and salivary cortisol levels were also assessed after each induction. Comparison BP and HR data were obtained from the anesthesiologists during a nonclinical day. We found that anesthesiologists’ HR increased during the anesthetic process compared with morning baseline HR (P = 0.008). This HR increase, however, was not clinically significant; the average HR during the anesthetic process ranged from 80 ± 12 to 84 ± 11 bpm. Similarly, although both systolic and diastolic BP after inductions were increased compared with baseline BP (P = 0.001), this increase was not clinically significant. In 9% of the inductions, however, systolic BP exceeded 140 mm Hg, and in 17% of all inductions, diastolic BP exceeded 90 mm Hg. Finally, the average BP of anesthesiologists during a clinical day was not different from the average BP during a nonclinical day (P = 0.9). Self-reported anxiety did not increase significantly after inductions (P = 0.15). An analysis of Holter tapes revealed no rhythm abnormalities and no signs of myocardial ischemia. We conclude that the practice of anesthesiology is associated with minor manifestations of acute physiologic stress during the perioperative process.

IMPLICATIONS: Anesthesiologists experience minor psychologic stress while involved in the anesthetic process.

The Hunsaker Mon-Jet ventilation tube for microlaryngeal surgery: Optimal laryngeal exposure Lisa A. Orloff, MD Nooshin Parhizkar, MD Erica Ortiz, MD

ENT-Ear, Nose & Throat Journal • June 2002

Abstract

Methods of delivering and monitoring anesthesia during microlaryngeal surgery are constantly evolving. In 1994, Hunsaker and colleagues introduced a laser-safe subglottic Mon-Jet ventilation tube, which has the ability to periodically measure end-tidal carbon dioxide levels. We conducted a retrospective review of 84 consecutive patients who had undergone microlaryngeal procedures with the aid of the Hunsaker Mon-Jet tube. Study parameters included the length of anesthetic induction and recovery times, the duration of surgery, the degree of surgical access to the larynx, and the incidence of anesthetic and surgical complications. We found that anesthetic induction and recovery times with the use of the Mon-Jet tube were comparable to those seen with standard endotracheal intubation. We also observed an apparent reduction in surgical time and a consistent subjective improvement in surgical visualization and access. The complication rate was acceptable, airway control was adequate, and use of the Mon-Jet tube was safe in all patients. We conclude that the Mon-Jet tube is a safe and effective subglottic jet ventilation system and that it has distinct advantages over other methods for both the surgeon and the anesthesiologist.

Online ISSN: 1097-0142 Print ISSN: 0008-543X Cancer Volume 95, Issue 1, 2002. Pages: 203-208

Published Online: 28 Jun 2002

Copyright © 2002 American Cancer Society Original Article Rapid titration with intravenous morphine for severe cancer pain and immediate oral conversion Sebastiano Mercadante, M.D. 1 2 * , Patrizia Villari, M.D. 1, Patrizia Ferrera, M.D. 1, Alessandra Casuccio, M.D. 3, Fabio Fulfaro, M.D. 2 1Anesthesia and Intensive Care Unit, Pain Relief and Palliative Care Unit, La Maddalena Cancer Center, Palermo, Italy 2Home Palliative Care Program, SAMOT (Società per l'Assistenza al Malato Oncologico Terminale), Palermo, Italy 3Department of Hygiene and Microbiology, University of Palermo, Palermo, Italy email: Sebastiano Mercadante ([email protected])

* Correspondence to Sebastiano Mercadante, Anesthesia and Intensive Care Unit & Pain Relief and Palliative Care Unit, La Maddalena Cancer Center, V. S. Lorenzo Colli n. 312, 90146, Palermo, Italy

Fax: (011) 39 91 303098

Keywords cancer pain • pain emergencies • opioids • morphine titration • intravenous route • epidemiologic study Abstract

BACKGROUND Cancer pain emergencies presenting with severe excruciating pain require a rapid application of powerful analgesic strategies. The aim of the current study was to evaluate a method of rapid titration with intravenous morphine to achieve relief of cancer pain of severe intensity.

METHODS Forty-nine consecutive patients admitted to a Pain Relief and Palliative Care Unit for severe and prolonged pain were enrolled in the study. Pain was evaluated on a numeric scale of 0-10 (0 indicated no pain and 10 indicated excruciating pain). After the initial assessment (T0), an intravenous line was inserted and boluses of morphine (2 mg every 2 minutes) were given until the initial signs of significant analgesia were detected or severe adverse effects occurred (T1). A continuous reassessment was warranted and the effective total dose administrated intravenously was assumed to last approximately 4 hours and was calculated for 24 hours. The dose immediately was converted to oral morphine (a 1:3 ratio for low doses and a 1:2 ratio for high doses).

RESULTS Data from 45 patients was analyzed. A significant decrease in pain intensity was achieved in a mean of 9.7 minutes (95% confidence interval [95% CI], 7.4-12.1 minutes), using a mean dose of intravenous morphine of 8.5 mg (95% CI, 6.5-10.5 mg). The doses administered rapidly were converted to oral morphine and pain control was mantained until the patient's discharge, which occurred in a mean of 4.6 days (95% CI, 4.1-5.2 days). The incidence of adverse effects was minimal.

CONCLUSIONS The results of the current study demonstrate that cancer pain emergencies can be treated rapidly in the majority of cancer patients with an acceptable level of adverse effects. Intravenous administration of morphine requires initial close supervision and continuity of medical and nursing care. Cancer 2002;95:203-8. © 2002 American Cancer Society. DOI 10.1002/cncr.10636 Received: 19 October 2001; Revised: 4 January 2002; Accepted: 15 January 2002