Lean Strategies in the Operating Room.

Lean strategies can be readily applied to health care in general and operating rooms specifically. The emphasis is on the patient as the customer, respect and engagement of all providers, and leadership from management. The strategy of lean is to use continuous improvement to eliminate waste from the care process, leaving only value-added activities. This iterative process progressively adds the steps of identifying the 7 common forms of waste (transportation, inventory, motion, waiting, overproduction, overprocessing, and defects), 5S (sort, simplify, sweep, standardize, sustain), visual controls, just-in-time processing, level-loaded work, and built-in quality to achieve the highest quality of patient care.

Case reports: response to a partial power failure in the operating room.

Failure of the power supply to the operating suites is a rare event. When it happens, it is critical that the care team responds in a way that optimizes patient safety. In the event we describe in this case report, only the emergency (red) power outlets failed. The anesthesia care team and other staff in the 8 affected rooms with anesthetized patients generally responded appropriately. The optimal response to these events is not necessarily intuitive. It is important to have advanced planning both within the immediate work area and beyond the operating room all the way into the hospital infrastructure.

Dichloroacetate stabilizes the intraoperative acid-base balance during liver transplantation.

Lactic acidosis occurs during orthotopic liver transplantation (OLT), especially during the anhepatic and early postreperfusion phases. Dichloroacetate (DCA) inhibits pyruvate dehydrogenase kinase-1, indirectly activating mitochondrial pyruvate dehydrogenase. This, in turn, markedly reduces systemic lactate production and, to a lesser extent, increases hepatic lactate uptake. The result is moderation of lactic acidosis in many clinical conditions. This study evaluated the efficacy of DCA in controlling lactic acidosis during OLT and improving perioperative outcome from OLT. After informed consent, 250 patients for OLT received either intraoperative DCA or placebo. DCA (40 mg/kg intravenously) or placebo was administered after anesthesia induction and repeated 4 hours later. Intraoperative measures were arterial blood gases, lactate, and Na+ and utilization of blood products, CaCl2, and NaHCO3. Outcome measures were time to tracheal extubation, intensive care unit length of stay, hospital length of stay, requirement for postoperative plasma transfusion, retransplantation, and perioperative mortality. DCA reduced the arterial lactic acid concentration by an average of 44% (1.8 mmol L(-1), P < 0.001), stabilized the acid-base balance, and reduced NaHCO(3) administration by 80% (P < 0.001). Postoperatively, DCA-treated patients required 50% less postoperative plasma transfusion (2 versus 4 units, respectively, P = 0.016), but the incidence of transfusion was similar in both groups (62% versus 60%, P = 0.381). DCA did not alter time to extubation, intensive care unit length of stay, or hospital length of stay. In conclusion, DCA attenuated lactic acidosis during OLT, stabilizing the intraoperative acid-base balance and decreasing NaHCO3 use. DCA decreased postoperative plasma transfusion requirement but otherwise had no measurable effect on perioperative outcome parameters.