Transport of Critically Ill Patients by the Anesthesia Versus the Intensive Care Unit Service: A Before-After Study of Operating Room Workflows.

BACKGROUND: We implemented a new policy at our institution where the responsibility for intensive care unit (ICU) patient transports to the operating room (OR) was changed from the anesthesia to the ICU service. We hypothesized that this approach would be associated with increased on-time starts and decreased turnover times. METHODS: In the historical model, intubated patients or those on mechanical circulatory assistance (MCA) were transported by the anesthesia service to the OR ("pre-ICU Pickup"). In our new model, these patients are transported by the ICU service to the preoperative holding area (Pre-op) where care is transferred to the anesthesia service ("post-ICU Transfer"). If judged necessary by the ICU or anesthesia attending, the patient was transported by the anesthesia service ("post-ICU Pickup"). We retrospectively reviewed case tracking data for patients undergoing surgery before (January 2014 to May 2015) and after implementation (July 2016 to June 2017) of the new policy. The primary outcome was the proportion of elective, weekday first-case, on-time starts. To adjust for confounders including comorbidities and time trends, we performed a segmented logistic regression analysis assessing the effect of our intervention on the primary outcome. Secondary outcomes were turnover times and compliance with preoperative checklist documentation. RESULTS: We identified 95 first-start and 86 turnover cases in the pre-ICU Pickup, 70 first-start and 88 turnover cases in the post-ICU Transfer, and 6 turnover cases in the post-ICU Pickup group. Ignoring time trends, the crude proportion of on-time starts increased from 32.6% in the pre-ICU Pickup to 77.1% in the post-ICU Transfer group. After segmented logistic regression adjusting for age, sex, American Society of Anesthesiologists (ASA) physical status, Sequential Organ Failure Assessment (SOFA) score, respiratory failure, endotracheal intubation, MCA, congestive heart failure (CHF), valvular heart disease, and cardiogenic and hemorrhagic shock, the post-ICU Transfer group was more likely to have an on-time start at the start of the intervention than the pre-ICU Pickup group at the end of the preintervention period (odds ratio, 11.1; 95% confidence interval [CI], 1.3-125.7; P = .043). After segmented linear regression adjusting for the above confounders, the estimated difference in mean turnover times between the post-ICU Pickup and pre-ICU Transfer group was not significant (-6.9 minutes; 95% CI, -17.09 to 3.27; P = .17). In post-ICU Transfer patients, consent, history and physical examination (H&P), and site marking were verified before leaving the ICU in 92.9%, 93.2%, and 89.2% of the cases, respectively. No adverse events were reported during the study period. CONCLUSIONS: A transition from the anesthesia to the ICU service for transporting ICU patients to the OR did not change turnover times but resulted in more on-time starts and high compliance with preoperative checklist documentation.

Gastrostomy tube placement is safe in advanced amyotrophic lateral sclerosis.

OBJECTIVES: To evaluate the safety and effect on survival of insertion of a gastrostomy tube (G-tube) in patients with amyotrophic lateral sclerosis (ALS) who have upright forced vital capacity (uFVC) ≤ 50% predicted. Current guidelines, which are based on higher rates of post-procedure complications in ALS patients with advanced respiratory dysfunction, have led to a recommendation to perform G-tube insertion before the FVC drops to <50% predicted, even when the patient has no significant dysphagia. METHODS: We assessed 41 ALS patients who received a G-tube, mostly by insertion of a percutaneous endoscopic gastrostomy (PEG) tube by a dedicated team that included a gastroenterologist and one of two anesthesiologists using Monitored Anesthesia Care with deep sedation, and 61 patients who did not receive a G-tube. uFVC was ≤50% predicted in 12 of 41 patients who received a G-tube and in 18 of 61 who did not. RESULTS: The procedure was safe regardless of FVC status, with low rates of post-operative complications in both low and high FVC groups. There was no survival benefit for patients who received a G-tube when compared with those who did not. DISCUSSION: PEG insertion is safe in ALS patients with significant respiratory muscle weakness when performed by a dedicated team, which suggests that the recommendation for G-tube placement should not be based on the patient's respiratory status.

Venous thromboembolism after diaphragm pacing in amyotrophic lateral sclerosis.

INTRODUCTION: Patients with amyotrophic lateral sclerosis (ALS) are prone to venous thromboembolism (VTE) and secondary complications. Because there is an increased incidence of VTE after surgical procedures, placement of a Diaphragm Pacing System (DPS) in ALS patients as treatment for respiratory muscle weakness could potentially increase the incidence of VTE, especially in patients with limited mobility. METHODS: We implanted a DPS in 10 ALS patients who met the criteria for this procedure. They underwent a preoperative evaluation as recommended by the guidelines. RESULTS: We report 2 patients with no symptoms of deep vein thrombosis (DVT) before the surgical procedure who then developed perioperative VTE. CONCLUSIONS: These patients highlight the need to consider preoperative screening for DVT and postoperative thromboprophylaxis in high-risk ALS patients who undergo DPS placement.

Anesthesia information management systems in the ambulatory setting: benefits and challenges.

Adopting an anesthesia information management system (AIMS) is a challenge for anesthesia departments. The transition requires a physician champion and the support of members in every section. This change can be facilitated by visiting similar institutions that are already using AIMS, shadow charting for a sufficient period of time, and understanding that optimization continues after the go-live date. Once implemented, the benefits outweigh the challenges, but understanding where the potential obstacles lie is critical to removing them efficiently and effectively. As different AIMS continue to spread throughout the medical world, so will their benefits.

Blood loss during endoscopic sinus surgery with propofol or sevoflurane: a randomized clinical trial.

IMPORTANCE: Total intravenous anesthesia (TIVA) with propofol has been associated with reduced operative time, decreased perioperative risks, and decreased intraoperative blood loss compared with inhalational anesthesia (IA). During endoscopic sinus surgery (ESS), reduced bleeding from the mucosal surfaces could improve visualization of the anatomy and decrease the risk of serious complications. OBJECTIVE: To compare blood loss during ESS between patients receiving TIVA with propofol and those receiving IA with sevoflurane. DESIGN, SETTING, AND PARTICIPANTS: Prospective, randomized study of 33 patients undergoing ESS in an academic medical center. INTERVENTIONS: Patients received either TIVA or IA. MAIN OUTCOMES AND MEASURES: The primary outcome was rate of blood loss in milliliters per hour. The secondary outcomes included the quality of visibility measured by the surgeon's numeric rating score, ease of anesthesia as measured by the anesthesiologist's numeric rating score, and total blood loss. RESULTS: The mean (SEM) blood loss per hour in the TIVA group was 78.5 (14) mL/h, and in the IA group it was 80.3 (17) mL/h (P = .93). A post hoc subgroup analysis found that in patients with a Lund-Mackay score of 12 or lower, the propofol TIVA group had a lower rate of blood loss compared with the sevoflurane IA group (mean blood loss, approximately 18 mL/h vs approximately 99 mL/h). The anesthesiologist's numeric rating score was significantly higher (indicating greater ease of performance) in the IA group than in the TIVA group. There was no statistically significant difference in the surgical numeric rating score between the 2 groups. CONCLUSIONS AND RELEVANCE: In this comparative study, our results did not show any difference in blood loss and surgical conditions between the TIVA and IA groups. Even further study is not likely to show a difference in blood loss between TIVA and IA during ESS.

The course of myalgia and headache after electroconvulsive therapy.

BACKGROUND: Headache and myalgia seem to be common, though generally mild, complications of electroconvulsive therapy. Relatively little is known regarding the usual severity and time course of these complaints. OBJECTIVE: This study examines the incidence, severity, and time course of myalgia and headache after electroconvulsive therapy. METHODS: Patients rated severity of myalgia and headache immediately before treatment and again after recovery and at 2, 6, 12, and 24 hours posttreatment on a 10-point visual analog scale. Data were analyzed using random-effects linear models. RESULTS: Severity of headache peaked 2 hours after treatment, returning to baseline by 24 hours and was relatively consistent within individuals between treatments. More severe posttreatment headache was reported by patients with a history of incapacitating headache and by those younger than 45 years. Headache was associated with increased duration of seizure. By contrast, myalgia was substantially more pronounced and lasted longer after the first treatment as compared with subsequent treatments. Severity of myalgia was not predicted by degree of fasciculations or motor activity, but was worse in patients younger than 45 years. CONCLUSIONS: Posttreatment headache and myalgia are common but usually mild. Routine pretreatment using non-depolarizing agents is probably unnecessary in most cases but may have a role during the first treatment in a series. By contrast, preventive treatment may be warranted in those with history of severe headache and those who previously have had significant post-ECT headache.