RESUMO
Delayed emergence is defined as failure to regain consciousness 30 to 60 minutes after general anesthesia. Although incidence is low and difficult to accurately estimate, there is a wide differential diagnosis to be considered. Emergency manuals (EMs) are visual cognitive aids that can be used in the operating room to help manage intraoperative complications. They provide immediate access to evidence-based guidelines to optimize management of intraoperative complications. They are being increasingly implemented in the clinical setting and have been shown to improve patient safety. A case of a patient with delayed emergence after undergoing robotic-assisted cholecystectomy is described here. The delayed emergence section of the Stanford Anesthesia Emergency Model was referenced immediately and guided management of the patient. Utilization of an EM resulted in rapid return to baseline mental status. EMs allow health care providers to respond to intraoperative scenarios efficiently and effectively and ultimately improve patient care.
RESUMO
BACKGROUND: Insurance type has been reported to be an independent predictor of overall survival in lung cancer patients. We studied the effect of insurance type on patient outcomes after minimally invasive pulmonary lobectomy for lung cancer. METHODS: We retrospectively analyzed 433 consecutive patients who underwent robotic-assisted pulmonary lobectomy by one surgeon during an 80-month period. Perioperative outcomes and intraoperative and postoperative complications were noted. Disposition at discharge after surgery (favorable, eg, transfer to home with self-care or with home health nursing and/or physical therapy, versus unfavorable, eg, long-term acute care or rehabilitation facility, hospice, or death) and 5-year overall survival (5-years OS) were also recorded. We used Pearson χ2, analysis of variance (ANOVA), and Kruskal-Wallis test to compare variables and Cox regression for survival analysis. RESULTS: There were 107 patients (mean age 57.5 years) with private insurance, 118 (mean age 70.3 years) with public insurance (Medicare or Medicaid), 196 (mean age 71.8 year; P < .001) with combination insurance plans (Medicare plus a privately supplied supplemental), and 12 patients with no insurance (excluded owing to low sample size). There were more current smokers in the public insurance group, more former smokers in the combination insurance group, and more nonsmokers in the private insurance group (P = .03). There were more comorbidities in the public and combination insurance groups versus the private insurance group, including gastroesophageal reflux disease (P = .003), hypertension (P = .01), and hyperlipidemia (P < .001). The groups had no differences in tumor size or pathologic stage. There were higher numbers of intraoperative conversions to open lobectomy in the private and public insurance groups versus the combination insurance group (P = .001). Also, the private and combination insurance groups had more cases of favorable disposition at discharge after surgery compared with the public insurance group (P < .001). Multivariable regression analyses identified private insurance type as an independent predictor of favorable disposition at discharge (public versus private plan; odds ratio, 0.43; 95% confidence interval [CI], 0.22-0.85, P = .02) and 5-year OS (combination versus private plan; hazard ratio, 2.68; 95% CI, 1.26-5.67, P = .01; public versus private plan; HR, 2.84; 95% CI, 1.37-5.89; P = .01). CONCLUSION: Although public or combination insurance type was associated with greater risk of all-cause mortality, and public insurance type was associated with less favorable disposition at discharge after surgery and overall conversion to open lobectomy, insurance type was not associated with increased intraoperative complications, hospital duration of stay, or in-hospital mortality after minimally invasive robotic-assisted pulmonary lobectomy.
