Emetogenicity-risk procedures in same day surgery center of an academic university hospital in United States: a retrospective cost-audit of postoperative nausea vomiting management.

BACKGROUND: Despite the variable results of published studies, it is imperative for ambulatory surgery centers to self-audit local cost-implications for post-operative nausea and vomiting (PONV) management. OBJECTIVE: Our retrospective cost-audit assessed if there were comparative peri-anesthesia care cost-trends among patients who had undergone Low-Emetogenicity-Risk Procedures (LERP), Moderate-Emetogenicity-Risk Procedures (MERP) and Severe-Emetogenicity-Risk Procedures (SERP). METHODS: This study was a review of Same Day Surgery Center practices in an academic university hospital setting during a three-year period (2010-2012). The patient lists were accessed from CIS and CITRIX App Bar for time audit and OR (operating room) schedule reports. Subsequently, OR pharmacy department ran a search for peri-operative anti-emetics and opioids that were billed for the patients at Same Day Surgery Center for the review period. The primary outcomes were the comparative costs/charges of these medications and comparative durations/ charges for these patients' stay in the post-anesthesia care unit (PACU). Secondary outcomes analyzed in the study included peri-anesthesia durations. RESULTS: A total of 8,657 patient records were analyzed. Almost all analyzed variables revealed statistically significant inter-variable positive correlations. The patients' age was significantly (P < 0.001) different among LERP/MERP/SERP patients (LERP: 48.8 +/- 14.7 years; MERP: 61.8 +/- 14.6 years; SERP: 51.3 +/- 14.5 years). In regards to primary and secondary outcomes, the statistical significant differences among LERP/MERP/SERP patients (after correcting for both patients' age as well as patients' sex) were only achieved for preoperative times (P = 0.002; Power = 0.9), operating room recovery times (P = 0.003; Power = 0.9), PACU stay times (P < 0.001; Power = 1.0), and PACU charges (P < 0.001; Power = 1.0). CONCLUSION: PACU stay times and PACU charges were significantly higher in patients who had undergone SERP as compared to patients who had undergone LERP or MERP at our Same Day Surgery Center.

Ultrasonographic modification of Cormack Lehane classification for pre-anesthetic airway assessment.

BACKGROUND: The major drawback of Cormack Lehane classification for airway assessment is its dependence on invasive direct laryngoscopy and hence it is inapplicable for pre-anesthetic assessment of airway in patients with no prior history of tracheal intubation. STUDY OBJECTIVES: The purpose of the study was to compare and correlate the ultrasound view of the airway and the Cormack Lehane classification of the direct laryngoscopy. METHODS/STUDY PROCEDURES: The present study was conducted on patients scheduled for elective surgery and requiring general anesthesia with direct laryngoscopy and endotracheal intubation. In the pre-operative holding area, the following measurements were obtained with the oblique-transverse ultrasound view of the airway: (a) the distance from the epiglottis to the midpoint of the distance between the vocal folds, (b) the depth of the pre-epiglottic space, and (c) the total time taken by the operator to achieve the final ultrasonic image. The data was then compared with the Cormack Lehane classification during direct laryngoscopy in the operating room. Subsequently based on the correlation data, the ultrasonographic modification of Cormack-Lehane Classification was developed. RESULTS: It was observed that there was a correlation of the distance between the epiglottis and the vocal cords (E-VC) with the Cormack Lehane Grading; correlation was strong negative with regression coefficient of -0.966 (95% CI -1.431 to -0.501; p = 0.0001). Subsequently, the correlation of the pre-epiglottis space (Pre-E) with the Cormack Lehane Grading was strong in positive direction with regression coefficient of0.595 (95% CI 0.261 to 0.929; p = 0.0008). Finally the ratio of Pre-E and E-VC distances with the Cormack Lehane Grading had the strongest positive correlation with regression coefficient of 0.495 (95% CI 0.319 to 0.671; p < 0.0001). Based on these statistical calculations and after rearranging the data, we found that prediction of Cormack Lehane (CL) grades can be adequately (67%-68% sensitivity) made by the ratio of Pre-E and E-VC distances (Pre-E/E-VC) {0 < [Pre-E/E-VC] < 1 approximately CL grade 1; 1 < [Pre-E/E-VC] < 2 approximately CL grade 2; and 2 < [Pre-E/E-VC] < 3 approximately CL grade 3}. The average time taken to complete the ultrasound examination of airway in the preoperative area was 31.7 +/- 12.4 seconds. CONCLUSION: The non-invasive ultrasonographic modification of invasive Cormack Lehane classification for pre-anesthetic airway assessment can supplement the presently available noninvasive modalities of pre-anesthetic airway assessment including the Mallampati Classification.

Ultrasound confirmation of laryngeal mask airway placement correlates with fiberoptic laryngoscope findings.

BACKGROUND: Correct placement of a laryngeal mask airway (LMA) requires confirmation to appreciate the adequacy of laryngeal seal and pulmonary ventilation. OBJECTIVES: The present study was designed to assess the feasibility of ultrasound use for confirmation of correct placement of LMA and its correlation with fiberoptic laryngoscopy as a confirmation tool for LMA position. MATERIALS AND METHODS: 31 ASA I and II patients scheduled for same day surgery under general anesthesia underwent standard general anesthetic technique with AuraOnce or AuraFlex Disposable Laryngeal Mask Airways. The position of the LMA cuff was confirmed by transverse neck ultrasound (USG), and reconfirmed with intra-LMA fiberoptic laryngoscopy (FOL). RESULTS: The ultrasound grade of LMA position strongly correlated positively with the fiberoptic grade of LMA position (r = 0.92; p < 0.0001). This correlation was obtained immediately after LMA placement, as well as just before LMA removal. The Bland-Altman scatter plot showed insignificant differences between the two grading systems with small and good limits of agreement (-0.63 to +0.57). CONCLUSION: Ultrasound examination can replace fiberoptic examination for confirmation of the correct placement of an LMA. Additionally, non-invasive ultrasound examination can further give insight into the cause of airway/ventilation events that may be interfering with the LMA placement and ventilation.