Older Age, Male Sex, and Early Start Time Lengthen the Recovery Room Stay Following Total Joint Arthroplasty in an Ambulatory Surgical Center.

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.

The Impact of Parental Presence on Emergence Delirium in Pediatric Patients After General Anesthesia: A Systematic Review and Meta-analysis.

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.

Identifying behaviors that characterize emergence delirium: An observational study.

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.

Respiratory complications during recovery from gastrointestinal endoscopies performed by gastroenterologists under moderate sedation.

BACKGROUND/AIMS: Data on the incidence of adverse respiratory events during recovery from gastrointestinal endoscopy are limited. The aim of this study was to investigate the incidence of these complications. METHODS: In this retrospective cohort study, data were obtained from the electronic records of 657 consecutive patients, who underwent gastroenterological procedures under sedation. RESULTS: Pulse oximetry oxygen saturation (SpO2) <90% for <60 seconds occurred in 82 patients (12.5%) and in 11 patients (1.7%), SpO2 of <90% for >60 seconds occurred in 79 patients (12.0%) and in 11 patients (1.7%), and SpO2 <75% occurred in four patients (0.6%) and in no patients during the procedure and recovery period, respectively. No major complications were noted. The occurrence of desaturation during recovery was correlated with desaturation during the procedure (p<0.001). American Society of Anesthesiologists score (odds ratio [OR], 1.867; 95% confidence interval [CI], 1.008-3.458), ischemic heart disease (OR, 1.815; 95% CI, 0.649-5.080), hypertension (OR, 1.289; 95% CI, 0.472-3.516), and diabetes mellitus (OR, 2.406; 95% CI, 0.950-6.095) increased the occurrence of desaturation during recovery. CONCLUSION: We found no major complications during recovery after balanced propofol-based sedation administered by a gastroenterologist-nurse team. Patients with the identified risk predictors must be monitored carefully.

[Patient handover from anaesthesia to postanaesthesia unit: An analysis of the current situation in three Swiss hospitals]. / Patientenübergabe Anästhesie ­ Aufwachraum.

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.

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.

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.

Avaliação da intensidade e do desconforto da sede de pacientes em pós-operatório imediato* / Evaluación de la intensidad y malestar de la sed en pacientes en el postoperatorio inmediato / Assessment of the intensity and discomfort of the thirst of patients in the immediate postoperative period

Objetivo: avaliar a intensidade e o desconforto provocados pela sede em pacientes em pós-operatório imediato. Método: estudo exploratório-descritivo, desenvolvido com pacientes internados na sala de recuperação pós-anestésica de um hospital público paranaense. Avaliaram-se indivíduos maiores de 18 anos, de ambos os sexos, com cognitivo preservado, internados de junho de 2021 a janeiro de 2022. A intensidade e o desconforto da sede foram mensurados por escalas específicas. Resultados: avaliaram-se 150 pacientes, com média de 43,9 anos. A maioria era do sexo masculino (65,3%), sem comorbidades (68,7%), submetida à raquianestesia (58%) e cirurgia ortopédica (59,3%), com soroterapia em curso (92,7%). O tempo médio de cirurgia foi 1,5 hora e 14,6 horas de jejum; 72,7% da amostra verbalizou sede, sendo que 37,6% queixaram-se de forma espontânea. Conclusão: os participantes de pesquisa apresentaram intensidade (6,6) e desconforto (7,6) moderados de sede no pós-operatório, tornando-se necessário discutir protocolos institucionais de intervenção para diminuir tal evento.

Objective: to evaluate the intensity and discomfort caused by thirst in patients in the immediate postoperative period. Method: exploratory-descriptive study developed with patients hospitalized in the post-anesthetic recovery room of a public hospital in Paraná. Individuals over 18 years of age, of both sexes, with preserved cognitive function, hospitalized from June 2021 to January 2022, were evaluated. Thirst intensity and discomfort were measured by specific scales. Results: 150 patients were evaluated, with a mean of 43.9 years. Most were male (65.3%), without comorbidities (68.7%), underwent spinal anesthesia (58%) and orthopedic surgery (59.3%), with ongoing serotherapy (92.7%). The mean surgery time was 1.5 hours and 14.6 hours of fasting; 72.7% of the sample verbalized thirst, and 37.6% complained spontaneously. Conclusion: the research participants presented moderate intensity (6.6) and discomfort (7.6) of thirst in the postoperative period, making it necessary to discuss institutional intervention protocols to reduce such event.

Objetivo: evaluar la intensidad y el malestar causado por la sed en pacientes en el postoperatorio inmediato. Método: estudio exploratorio-descriptivo, desarrollado con pacientes internados en la sala de recuperación postanestésica de un hospital público de Paraná. Se evaluaron personas mayores de 18 años, de ambos sexos, con habilidades cognitivas conservadas, hospitalizadas entre junio de 2021 y enero de 2022. Se midió la intensidad y el malestar de la sed mediante escalas específicas. Resultados: Se evaluaron 150 pacientes, con una edad media de 43,9 años. La mayoría eran hombres (65,3%), sin comorbilidades (68,7%), con anestesia espinal (58%) y cirugía ortopédica (59,3%), con sueroterapia en curso (92,7%). El tiempo promedio de cirugía fue de 1,5 horas y 14,6 horas de ayuno; El 72,7% de la muestra verbalizó sed, con un 37,6% quejándose espontáneamente. Conclusión: los participantes de la investigación presentaron moderada intensidad (6,6) y malestar (7,6) de la sed en el postoperatorio, siendo necesario discutir protocolos de intervención institucional para la reducción de ese evento.

Development and validation of a predictive model for PACU hypotension in elderly patients undergoing painless gastrointestinal endoscopy / 中华麻醉学杂志

Objective:To develop and validate a predictive model for post-anesthesia care unit (PACU) hypotension in elderly patients undergoing painless gastrointestinal endoscopy.Methods:The medical records of elderly patients of both sexes, aged ≥60 yr, of American Society of Anesthesiologists Physical Status classification Ⅰ-Ⅲ, undergoing painless gastrointestinal endoscopy at the Endoscopy Center of Subei People′s Hospital from March to June 2021, were retrospectively collected. The patients were randomly divided into training and validation sets according to the ratio of 3∶1. In the training set, the characteristic variables associated with PACU hypotension were screened by Lasso regression, and the independent risk factors for PACU hypotension were identified by multivariate logistic regression analysis of the characteristic variables, according to which a nomogram model predicting the risk for PACU hypotension was established.The discrimination, calibration and accuracy of the model were evaluated by calibration curve and receiver operating characteristic(ROC)curve. And the clinical practicability of the model was determined by decision curve analysis and further assessed by external validation.Results:Of the 973 patients ultimately included, 378 patients experienced PACU hypotension, with an incidence of 38.8%. Multivariate logistic regression analysis showed that age, prolonged preoperative water deprivation time, increased percentage of changes in SBP before and after induction, and intraoperative MAP <65 mmHg were independent risk factors for hypotension in the PACU, and intraoperative use of norepinephrine was a protective factor. The nomogram model was then developed based on the results. The area under the ROC curve was 0.710 (95% confidence interval [ CI] 0.672-0.748) in training set and 0.778 (95% CI 0.720-0.837) in validation set. In training and validation sets, the calibration curves were tested by Hosmer-Lemeshow good of fit test, the P values were 0.590 and 0.950, respectively. The decision curve analysis curve showed that the risk threshold of the prediction model in the training and validation sets were between 20% and 82% and between 18% and 92%, respectively, in the external validation. Conclusions:The nomogram model for prediction of PACU hypotension is successfully established based on age, prolonged preoperative water deprivation, percentage of change in SBP before and after induction, intraoperative MAP <65 mmHg and use of norepinephrine in elderly patients undergoing painless gastrointestinal endoscopy, and the model can visually and individually predict the risk of PACU hypotension.

Risk factor for prolonged post-anesthesia care unit stay in elderly patients after painless gastrointestinal endoscopy / 中华麻醉学杂志

Objective:To identify the risk factor for prolonged post-anesthesia care unit (PACU) stay in elderly patients after painless gastrointestinal endoscopy.Methods:The elderly patients received painless gastrointestinal endoscopy from March to June 2021 in our hospital were included in this study. The information such as preoperative interview, patient′s general condition, current and past medical history, intraoperative conditions, and conditions in the PACU was collected. Patients were divided into non-prolonged group (group N) and prolonged group (group D) based on whether PACU stay was prolonged, and the risk factors for prolonged PACU stay were identified by logistic regression analysis.Results:There were 257 patients in group D and 716 cases in group N, and the incidence of prolonged PACU stay was 26.4%. Compared with group N, the proportion of preoperative frailty, smoking, intraoperative hypotension, and ratio of hypotension, somnolence and dizziness in PACU were significantly increased in group D ( P<0.05). The results of logistic regression analysis showed that preoperative frailty, smoking, intraoperative hypotension, and hypotension, somnolence and dizziness in PACU were independent risk factors for prolonged PACU stay( P<0.05). Conclusions:Preoperative frailty, smoking, intraoperative hypotension, and hypotension, somnolence and dizziness are independent risk factors for prolonged PACU stay in elderly patients after painless gastrointestinal endoscopy.

Effects of dexmedetomidine on vital signs during postoperative anesthesia recovery period in gynecological patients undergoing general anesthesia surgery and analysis on risk factors for complications / 中国基层医药

Objective:To investigate the effects of dexmedetomidine on vital signs during recovery from general anesthesia in gynecological patients undergoing general anesthesia surgery and analysis of risk factors for complications.Methods:A total of 80 gynecological patients undergoing general anesthesia surgery who received treatment in Lishui People's Hospital from March 2021 to March 2022 were included in this study. They were randomly divided into an observation group and a control group ( n = 40/group). All patients were subjected to general anesthesia. The observation group was infused with 0.5 μg/kg dexmedetomidine intravenously 15 minutes before induction of anesthesia and then infused with dexmedetomidine at a rate of 0.2 μg/kg per hour until 20-30 minutes before the end of the operation. The control group was identically given 0.9% normal saline. The recovery quality, vital signs before surgery and during recovery from general anesthesia (systolic blood pressure, diastolic blood pressure, heart rate, body temperature), and complications during recovery from general anesthesia were compared between the two groups. These patients were divided into a complication group and a non-complication group according to whether there were complications during recovery from general anesthesia. Univariate and multivariate Logistic regression analyses were performed to analyze the high-risk factors for complications occurring during recovery from general anesthesia in gynecological patients undergoing general anesthesia surgery. Results:The time to awaken, time to recover spontaneous respiration, and time to extubation in the observation group were significantly shorter than those in the control group ( t = 3.74, 2.97, 2.56, all P < 0.05). Systolic blood pressure, diastolic blood pressure, and heart rate measured during recovery from general anesthesia were significantly lower in the observation group compared with the control group ( t = 5.71, 4.53, 4.53, all P < 0.001). Body temperature ( t = 4.40, P < 0.001) and the incidence of complications ( χ2 = 5.69, P < 0.05) were significantly lower in the observation group compared with the control group. These patients were divided into complication ( n = 22) and non-complication ( n = 58) groups according to whether they had complications during recovery from general anesthesia. Univariate and multivariate logistic regression analyses showed that American Association of Anesthesiologists grade II, presence of underlying diseases, abnormal leukocyte count, and no use of dexmedetomidine were the risk factors for postoperative complications in gynecological patients undergoing general anesthesia surgery ( OR = 2.38, 2.86, 2.17, 3.60, all P < 0.05). Conclusion:Dexmedetomidine can improve awakening quality and vital signs and reduce complications during recovery from general anesthesia. American Association of Anesthesiologists grade, underlying disease, abnormal white blood cell count, and no use of dexmedetomidine are the risk factors for complications occurring during recovery from general anesthesia in gynecological patients undergoing general anesthesia surgery.

Instruments to Identify Delirium in Patients Recovering From Anesthesia: A Scoping Review.

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.

The association between unanticipated prolonged post-anaesthesia care unit length of stay and early postoperative deterioration: A retrospective cohort study.

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.

Cost-Effectiveness in Perioperative Care: Application of Markov Modeling to Pathways of Perioperative Care.

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.

Comparison of Perioperative Active or Routine Temperature Management on Postoperative Quality of Recovery in PACU in Patients Undergoing Thoracoscopic Lobectomy: A Randomized Controlled Study.

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.

Implantação dos protocolos PEWS e NEWS na unidade de recuperação anestésica / Implementation of the PEWS and NEWS protocols in the post-anesthesia care unit / Implementación de los protocolos PEWS y NEWS en la unidad de recuperación anestésica

Objetivo: Descrever a construção e a implantação dos protocolos PEWS e NEWS na recuperação anestésica com recurso da automação robó-tica. Método: Relato de experiência sobre a construção e a implantação de protocolos de deterioração clínica na recuperação anestésica em um hospital filantrópico de grande porte localizado no município de São Paulo. O processo de trabalho envolveu a determinação dos protocolos, a construção das regras operacionais para o sistema, o desenvolvimento do sistema eletrônico e a implantação com treinamento da equipe assistencial. Resultados: Foi implantado o processo de deterioração clínica com os protocolos PEWS e NEWS de forma automatizada e sinalizado o acionamento por meio de um iconograma no painel da sala de recuperação pós-anestésica. Conclusão: A implantação dos protocolos foi concluída com sucesso; o uso da automação robótica pode simplificar os fluxos de trabalho e o tempo de coleta de sinais vitais para fornecer uma pontuação do escore. Protocolos de deterioração clínica auxiliam na tomada de decisão das enfermeiras da recuperação anestésica, desde que aplicados em conjunto com o julgamento clínico.

Objective: To describe the development and implementation of the PEWS and NEWS protocols in post-anesthesia recovery using robotic automation. Method: Experience report on the development and implementation of clinical deterioration protocols in post-anesthesia recovery in a large philanthropic hospital located in the city of São Paulo, Brazil. The work involved the determination of protocols, construction of operational rules for the system, development of the electronic system and implementation with training of the assistance team. Results: Prediction of clinical deterio-ration was implemented with the PEWS and NEWS protocols in an automated way, and activation was signaled through an iconogram in the panel of the post-anesthesia care unit. Conclusion: The implementation of the protocols was successfully completed; the use of robotic automation can simplify workflows and reduce the time to collect vital signs to provide a score. Clinical deterioration protocols help nurses' decision-making in anesthesia reco-very, as long as they are applied in conjunction with clinical judgment.

Objetivo: Describir la construcción e implementación de los protocolos PEWS y NEWS en recuperación anestésica utilizando automatiza-ción robótica. Método: Relato de experiencia sobre la construcción e implementación de protocolos de deterioro clínico en la recuperación anestésica en un gran hospital filantrópico de la ciudad de São Paulo. El proceso de trabajo implicó la determinación de protocolos, construcción de reglas de fun-cionamiento del sistema, desarrollo en sistema electrónico e implementación con capacitación del equipo de asistencia. Resultados: Signos de deterioro clínico utilizando los puntajes PEWS y NEWS, lo construimos de forma automatizada e identificamos mediante un signo compuesto por una iconogra-fía en el panel multiprofesional de la unidad, de forma visible para cualquier miembro del equipo. Conclusión: La implementación de los protocolos se completó con éxito, el uso de la automatización robótica puede simplificar los flujos de trabajo y el tiempo de recopilación de signos vitales para pro-porcionar una puntuación. Los protocolos de deterioro clínico auxilian la toma de decisiones del enfermero en la recuperación anestésica, siempre que sean aplicados en conjunto con el juicio clínico.

Monitoring postoperative lung recovery using electrical impedance tomography in post anesthesia care unit: an observational study.

With electrical impedance tomography (EIT) recruitment and de-recruitment phenomena can be quantified and monitored at bedside. The aim was to examine the feasibility of EIT with respect to monitor atelectasis formation and resolution in the post anesthesia care unit (PACU). In this observational study, 107 postoperative patients were investigated regarding the presence and recovery of atelectasis described by the EIT-derived parameters Global Inhomogeneity Index (GI Index), tidal impedance variation (TIV), and the changes in end-expiratory lung impedance (ΔEELI). We examined whether the presence of obesity (ADP group) has an influence on pulmonary recovery compared to normal weight patients (NWP group). During the stay at PACU, measurements were taken every 15 min. GI Index, TIV, and ΔEELI were calculated for each time point. 107 patients were monitored and EIT-data of 16 patients were excluded for various reasons. EIT-data of 91 patients were analyzed off-line. Their length of stay averaged 80 min (25th and 75th quartile 52-112). The ADP group demonstrated a significantly higher GI Index at PACU arrival (p < 0.001). This finding disappeared during their stay at the PACU. Additionally, the ADP group showed a significant increase in ΔEELI between PACU arrival and discharge (p = 0.025). Furthermore, TIV showed a significantly lower value during the first 90 min of PACU stay as compared to the time period thereafter (p = 0.036). Our findings demonstrate that obesity has an influence on intraoperative atelectasis formation and de-recruitment during PACU stay. The application of EIT in spontaneously breathing PACU patients seems meaningful in monitoring pulmonary recovery.

Development of a recovery-room discharge checklist (SAMPE checklist) for safe handover and its comparison with Aldrete and White scoring systems.

BACKGROUND: The postoperative care transition from the postanesthetic recovery room (PACU) to the common ward or even home discharge represents a critical step of the surgical patients' handover. Although some systems have been proposed to measure the ability to discharge after an anesthetic-surgical procedure effectively, there is no consensus defining which variables should necessarily be evaluated by these instruments. The instruments routinely used do not evaluate important domains for discharge and are laborious to fill, which compromises the professionals' adhesion. The objectives are to describe the creation of a new recovery room discharge tool (SAMPE checklist) and determine the degree of agreement of the new tool with two classical scales. METHODS: In a cross-sectional observational study, 997 patients were selected from the general population undergoing a wide range of surgical procedures in a quaternary care hospital. At 90 minutes after leaving the operating room (OR), patients were evaluated and information was collected to fill out the new SAMPE checklist and two other scores (Aldrete and White) to examine the degree of agreement between them. RESULTS: SAMPE checklist has presented a satisfactory agreement with the White score and lower agreement with Aldrete modified score. CONCLUSION: This new instrument, as demonstrated in this study with nearly 1000 patients from different contexts, is easy to apply, has high adhesion potential, and can be considered a new option to formalize the discharge from the recovery room.

Dor na sala de recuperação pós-anestésica: incidência e fatores preditivos / Pain in the post-anesthetic recovery room: incidence and predictive factors

Objetivo: Analisar a incidência da dor e seus fatores preditivos na sala de recuperação anestésica. Método: Trata-se de um estudo em três fases: (1) revisão sistemática de literatura. Esta fase seguiu as recomendações metodológicas do Instituto Joanna Briggs para revisões de etiologia e fatores de risco; (2) estudo observacional, analítico, prospectivo, realizado em dois momentos de avaliação, antes e depois do procedimento cirúrgico. Como local para o estudo, foi escolhido o Centro Cirúrgico de um hospital universitário do estado de Minas Gerais. Para seleção dos pacientes, foi feita uma amostragem não probabilística, por conveniência, dos casos consecutivos os quais realizaram cirurgia eletiva, nos meses de fevereiro a setembro de 2019. O projeto foi aprovado pelo Comitê de Ética em Pesquisa da Universidade Federal de Minas Gerais. A coleta de dados ocorreu em duas fases, primeira durante o período pré-operatório, na sala de recepção do Centro Cirúrgico e a segunda na sala de recuperação pós-anestésica. (3) formulação deum modelo preditivo utilizando como tratamento estatístico Path Analysis. Os ajustes do modelo foram verificados por meio dos índices de ajuste Comparative Fit Indexe Root Mean Square Error of Approximation. Resultados:(1) Na revisão sistemática foram achados 735 estudos e selecionados 10 para a síntese. Os principais fatores de risco achados foram idade, sexo, ansiedade, tabagismo, uso de opioide, classificação do estado clínico, tempo de cirurgia, tipo de cirurgia. Com estes resultados foi construído um questionário para coleta de dados utilizado na segunda fasedo estudo. (2) No estudo observacional, a amostra final foi constituída por 226pacientes,189 (83,6%) foi do sexo feminino e com idade média de 47,58 anos, com desvio padrão de 13,96 anos; 154(68,1%) com classificação do estado clínico pela American Society Anesthesiologists igual a II. A média do tempo de duração da cirurgia foi de 163,9minutos, com desvio padrão de 75,9 minutos. Na sala de recuperação pós-anestésica72 (31,9%) dos pacientes referiram dor, a média da máxima dor sentida foi de 2,2 pontos, com desvio padrão de 3,4 pontos(valor mínimo de 0 e máximo de 10pontos). (3) Na construção do modelo preditivo, foi testado um modelo com as variáveis sociodemográficas, variáveis clínicas e variáveis cirúrgicas. Os resultados não indicaram bom ajuste aos dados para o modelo, incluindo todas as variáveis preditivas. Do mesmo modo, foi testado o modelo final com índices de modificação com resultados que indicaram um ajuste aceitável a os dados. Assim, idade, sexo, tipo de diagnostico, tipo de cirurgia, tempo de cirurgia e analgésico intraoperatório foram variáveis preditoras para dor na sala de recuperação pós-anestésica. Conclusão: A incidência da dor na sala de recuperação pós-anestésica é alta e foram identificados seis preditores para dor na sala de recuperação pós-anestésica. Estes devem ser reconhecidos como fatores potencialmente importantes ao desenvolver protocolos de cuidados clínicos específicos para melhorar os resultados da dor e orientar futuras pesquisas sobre dor pós-operatória.

Objective: To analyze the incidence of pain and its predictive factors in the anesthetic recovery room. Method: This is a three-phase study: (1) systematic literature review. This phase followed the Joanna Briggs Institute methodological recommendations for etiology and risk factor reviews; (2) observational, analytical, prospective study, carried out in two evaluation moments, before and after the surgical procedure. As the place for the study, the Surgical Center of a university hospital in the state of Minas Gerais was chosen. For patient selection, a nonprobabilistic convenience sampling was performed of consecutive cases who underwent elective surgery, from February to September 2019. The project was approved by the Research Ethics Committee of the Federal University of Minas Gerais. Data collection took place in two phases, the first during the preoperative period, in the reception room of the Surgical Center and the second in the postanesthetic recovery room. (3) formulation of a predictive model using Path Analysis as statistical treatment. The model fits were verified using the Comparative Fit Index and Root Mean Square Error of Approximation indices. Results: (1) In the systematic review, 735 studies were found and 10 were selected for synthesis. The main risk factors found were age, sex, anxiety, smoking, use of opioids, classification of clinical status, time of surgery, type of surgery. With these results, a questionnaire was constructed for data collection used in the second stage of the study. (2) In the observational study, the final sample consisted of 226 patients, 189 (83.6%) were female and had a mean age of 47.58 years, with a standard deviation of 13.96 years; 154 (68.1%) with clinical status classification by the American Society Anesthesiologists equal to II. The mean duration of the surgery was 163.9 minutes, with a standard deviation of 75.9 minutes. In the post-anesthetic recovery room, 72 (31.9%) of the patients reported pain, the mean maximum pain felt was 2.2 points, with a standard deviation of 3.4 points (minimum value of 0 and maximum value of 10 points). ). (3) In the construction of the predictive model, a model was tested with sociodemographic variables, clinical variables and surgical variables. The results did not indicate a good fit to the data for the model, including all predictive variables. Likewise, the final model was tested with modification indices with results that indicated an acceptable fit to the data. Thus, age, sex, type of diagnosis, type of surgery, duration of surgery and intraoperative analgesic were predictive variables for pain in the post-anesthesia care unit. Conclusion: The incidence of pain in the post-anesthesia care unit is high and six predictors for pain in the post-anesthesia care room were identified. These should be recognized as potentially important factors when developing specific clinical care protocols to improve pain outcomes and guide future research on postoperative pain.

Escala de avaliação de enfermagem para o paciente na sala de recuperação pós-anestésica: construção e validação / Nursing assessment scale for patients in the post-anesthesia care unit: construction and validation

Introdução: a ocorrência de complicações no paciente em Sala de Recuperação Pós-Anestésica está diretamente relacionada às condições clínicas pré-operatórias, à extensão e tipo de cirurgia, às intercorrências cirúrgicas e anestésicas, bem como à efetividade das medidas terapêuticas aplicadas. Objetivo: construir e validar escala de Avaliação de Enfermagem para o paciente na Sala de Recuperação Pós-Anestésica. Metodologia: trata-se de uma pesquisa metodológica, para construção e validação de uma escala denominada "Avaliação de Enfermagem para o paciente na Sala de Recuperação Pós-Anestésica - AEPRA", desenvolvida em dois campos, o primeiro, um Hospital da Rede Pública Federal de Belo Horizonte, e o segundo, um Hospital da rede Municipal de Sete Lagoas. A escolha dos itens que compuseram a escala foi baseada nos resultados evidenciados em síntese de literatura, a saber: temperatura axilar, frequência cardíaca, respiração, pressão arterial sistólica, saturação periférica de oxigênio, consciência, movimentação, dor, náusea e vômito e ferida operatória, onde cada um dos dez (10) itens tem o escore mínimo de um (1) e o máximo de quatro (4), assim o escore pode variar de 10 a 40 pontos. A validação aparente e de conteúdo foi realizada com dez (10) juízes, por meio dos Índices de Validade de Conteúdo. A análise de confiabilidade foi realizada por meio do Coeficiente de Correlação Intraclasse. Foram avaliados cada item que compôs a escala, bem como globalmente, por dois interobservadores, separadamente e concomitantemente. Para validade de critério concorrente e validação de critério preditiva, realizou-se o cálculo amostral, e a aplicação da escala em 86 pacientes, adultos, com classificação de American Society of Anesthesiologists I, II ou III, submetidos a diversos tipos de procedimentos anestésicos-cirúrgicos. Para validação de critério concorrente, considerou-se como padrão ouro a Escala de Aldrete e Kroulik, e a análise por meio da correlação de Spearman. Para validade de critério preditivo da complicação foi utilizado o método Generalized Equations Estimating. A verificação do melhor ponto de corte do escore total para a alta, foram avaliadas as curvas Receiver Operating Characteristic e a Area Under the Curve. Resultados: a validação aparente e de conteúdo obteve a média global de 89% e a análise de confiabilidade por meio do Coeficiente de Correlação Intraclasse obteve confiabilidade global de 0,91. Quanto a validade de critério, foi realizada a comparação entre a escala proposta e a padrão ouro, sendo que houve correlação significativa (Valor-p <0,001) e positiva, com "r" igual ou maior 0,5, para todos os parâmetros e entre o total de cada uma das escalas; exceto para o parâmetro ventilação/respiração (Valor-p = 0,397). Em relação à validade de critério preditiva, a análise multivariada revelou fortemente a relação dos parâmetros temperatura, pressão arterial sistólica, saturação periférica de oxigênio e mobilidade como ocorrência de complicações. Por meio das curvas Receiver Operating Characteristic e a Area Under the Curve, tem-se nos pontos de corte 39 (AUC = 0,667) e 38 (AUC = 0,594), evidenciando os melhores pontos de corte. Conclusão: A escala de Avaliação de Enfermagem para o paciente na Sala de Recuperação Pós-Anestésica, é um instrumento confiável e válido para avaliação do paciente na Sala de Recuperação Pós-Anestésica.

Introduction: the occurrence of complications in patients in the Post-Anesthetic Recovery Room is directly related to preoperative clinical conditions, the extent and type of surgery, surgical and anesthetic complications, as well as the effectiveness of therapeutic measures applied. Objective: build and validate the Nursing Assessment Scale for patient in Post-Anesthetic Recovery Room. Methodology: this is a methodological research, for the construction and validation of a scale called "Nursing Assessment for patient in Post-Anesthetic Recovery Room - NAPPARR", developed in two fields, first, a Hospital of the Federal Public Network. of Belo Horizonte, and second, a Hospital Municipal of Sete Lagoas. The choice of items that made up the scale was based on the results evidenced in a synthesis of literature, namely: axillary temperature, heart rate, breathing, systolic blood pressure, peripheral oxygen saturation, consciousness, movement, pain, nausea and vomiting and surgical wound, each of ten (10) items has a minimum score of one (1) and a maximum of four (4), so the score can vary from 10 to 40 points. The face and content validation was performed with ten (10) judges, using Content Validity Indexes. Reliability analysis was performed using the Intraclass Correlation Coefficient. Each item that composed the scale was evaluated, as well as globally, by two interobservers, separately and concomitantly. For concurrent criterion validity and predictive criterion validation, the sample size calculation was performed, and the scale was applied to 86 adult patients classified as American Society of Anesthesiologists I, II or III, who underwent different types of anesthetic procedures- surgical. For validation of concurrent criteria, the Aldrete and Kroulik Scale was considered as the gold standard, and the analysis by means of the Spearman correlation. For validity of predictive criteria for complications, the Generalized Equations Estimating method was used. To verify the best cut-off point of the total score for discharge, the Receiver Operating Characteristic and Area Under the Curve curves were evaluated. Results: the apparent validation and the content obtained an overall average of 89% and the reliability analysis using the Intraclass Correlation Coefficient obtained an overall reliability of 0.91. As criterion validity, a comparison was made between the proposed scale and the gold standard, and there was a significant (p-value <0.001) and positive correlation, with "r" equal to or bigger than 0.5, for all parameters and between the total of each of the scales; except for the ventilation/respiration parameter (p-value = 0.397). Regarding the predictive criterion validity, the multivariate analysis strongly revealed the relationship of the parameters temperature, systolic blood pressure, peripheral oxygen saturation and mobility as the occurrence of complications. Through the Receiver Operating Characteristic curves and the Area Under the Curve, the cut-off points 39 (AUC = 0.667) and 38 (AUC = 0.594) are found, showing the best cut-off points. Conclusion: The Nursing Assessment Scale for the patient in the Post-Anesthetic Recovery Room is a reliable and valid instrument for the evaluation of the patient in the Post-Anesthetic Recovery Room.

The Recovery Room: Transition from a Sleepy Postoperative Unit to a Vibrant and Cost-Effective Multipurpose Perioperative Care Unit.

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.