Management of anesthetic complications outside the operating room.

PURPOSE OF REVIEW: Nonoperating room anesthesia (NORA) procedures have seen a significant growth over the years along with an increase in the complexity and severity of cases. Providing anesthesia care in these often-unfamiliar locations is risky, and complications are common. This review aims to report the most recent updates regarding managing anesthesia-related complications in patients undergoing procedures in non-operating room locations. RECENT FINDINGS: Surgical innovations, advent of new technology, and the economics of a healthcare environment that strives to improve value by decreasing costs, has expanded the indications for and complexity of NORA cases. In addition, an aging population with increasing comorbidity burden, requirements for deeper levels of sedation have all increased the risk of complications in NORA environments. In such a situation, improvement in monitoring and oxygen delivery techniques, better ergonomics of NORA sites and development of multidisciplinary contingency plans are likely to improve our management of anesthesia-related complications. SUMMARY: Delivery of anesthesia care in out-of-operating room locations is associated with significant challenges. Meticulous planning, close communication with the procedural team, establishing protocols and pathways for help, along with interdisciplinary teamwork can facilitate safe, efficient, and cost-effective procedural care in the NORA suite.

Routine Overnight Vital Signs Are Rarely Associated with Major Clinical Events in Patients Undergoing Radical Cystectomy: A Retrospective Cohort Study.

INTRODUCTION: Evidence has associated patient sleep disruption with adverse clinical outcomes. Overnight vital sign checks are a frequent source of patient sleep disruption. We sought to determine the utility of routine overnight vital sign checks in stable postoperative patients following radical cystectomy for bladder cancer. METHODS: We assembled a database containing all routine vital sign checks from postoperative days 0 through 6 for all patients who underwent radical cystectomy at our institution during a 5-year period (2016-2020). Sets of overnight vital signs were flagged as "abnormal" based on specified criteria and then reviewed by 2 blinded reviewers to determine whether they were associated with significant clinical interventions. RESULTS: A total of 546 patients representing 2,589 patient-nights in the hospital were included. Abnormal vital signs resulting in "moderate" or "major" clinical interventions (corresponding to concern for Clavien-Dindo grade ≥II complications) occurred during 17/2,589 (0.65%) patient-nights. Thus, 152 patient-nights of routine vital sign checks were required to identify a single moderate or major clinical event. Reviewing all overnight-onset complications, we noted that a majority (15/23, 65%) of Clavien-Dindo grade II complications were manifested only by symptoms or laboratory abnormalities without vital sign derangements, whereas all grade ≥III complications had associated vital sign abnormalities. CONCLUSIONS: Routine overnight vital signs were associated with a low frequency of clinically significant events. Reduced intensity of overnight vital sign checks may be a safe addition to enhanced-recovery packages in carefully selected patients.

Enhanced recovery in liver transplantation: A value-based approach to complex surgical care.

BACKGROUND: Value-based healthcare focuses on improving outcomes relative to cost. We aimed to study the impact of an enhanced recovery pathway for liver transplant recipients on providing value. METHODS: In total, 379 liver recipients were identified: pre-enhanced recovery pathway (2017, n = 57) and post-enhanced recovery pathway (2018-2020, n = 322). The enhanced recovery pathway bundle was defined through multidisciplinary efforts and included optimal fluid management, end-of-case extubation, multimodal analgesia, and a standardized care pathway. Pre- and post-enhanced recovery pathway patients were compared with regard to extubation rates, lengths of stay, complications, readmissions, survival, and costs. RESULTS: Pre- and post-enhanced recovery pathway recipient model for end-stage liver disease score and balance of risk scores were similar, although post-enhanced recovery pathway recipients had a higher median donor risk index (1.55 vs 1.39, P = .003). End-of-case extubation rates were 78% post-enhanced recovery pathway (including 91% in 2020) versus 5% pre-enhanced recovery pathway, with post-enhanced recovery pathway patients having decreased median intraoperative transfusion requirements (1,500 vs 3,000 mL, P < .001). Post-enhanced recovery pathway recipients had shorter median intensive care unit (1.6 vs 2.3 days, P = .01) and hospital stays (5.4 vs 8.0 days, P < .001). Incidence of severe (Clavien-Dindo ≥3) complications during the index hospitalization were similar between pre-enhanced recovery pathway versus post-enhanced recovery pathway groups (33% vs 23%, P = .13), as were 30-day readmissions (26% vs 33%, P = .44) and 1-year survival (93.0% vs 94.5%, P = .58). The post-enhanced recovery pathway cohort demonstrated a significant reduction in median direct cost per case ($11,406; P < .001). CONCLUSION: Implementation of an enhanced recovery pathway in liver transplantation is feasible, safe, and effective in delivering value, even in the setting of complex surgical care.