Ambulatory surgery: room air versus nasal cannula oxygen during transport after general anesthesia.

UNLABELLED: We compared outpatients transported to the postanesthesia care unit (PACU) while breathing room air to 2-4 L/min nasal cannula oxygen (O2) to test the hypothesis that routine supplemental O2 during transport is not required after general anesthesia in an ambulatory surgery center. We also examined whether the arbitrary arrival PACU O2 saturations of > 92% may be used to predict an infrequent incidence of subsequent significant desaturations (< 90%) in the PACU. One-hundred-ninety patients were randomized to receive either room air or 2-4 L/min nasal cannula for transport to PACU after receiving general anesthesia. O2 saturations were recorded before surgery, just before leaving the operating room, and upon arrival in the PACU. The lowest O2 saturation occurring in the PACU was also recorded. The mean arrival PACU O2 saturation was 95.0 in the Room Air group, compared with 97.2 for the Nasal Cannula (NC) group, a statistically significant difference (P < 0.001). In the Room Air group, 20% had arrival O2 saturations < or = 92%, and half of these (10%) had O2 saturations < 90%. In the NC group, 6% had O2 saturations < or = 92%, of which one third (2%) were < 90% on arrival in the PACU. All of these initial desaturations were easily corrected with face-tent O2 administration, deep breathing, or both. Subgroup analysis revealed that patients whose ages were 60 yr or older or those weighing 100 kg or more had lower arrival room air saturations than their younger or slimmer counterparts. In the Room Air group, only three (3.9%) of the patients that arrived in PACU with O2 saturations > 92% had subsequent desaturations < 90%, compared with seven (7.9%) in the NC group. We conclude that most adult patients undergoing ambulatory surgery can be transported safely to the PACU breathing room air after general anesthesia. However, patients whose age was > or = 60 yr or weight was > or = 100 kg, or for whom transient O2 desaturation on transport may be harmful, should be transported while breathing nasal O2 via nasal cannula. IMPLICATIONS: Most adult patients undergoing ambulatory surgery can be transported safely to the PACU breathing room air after general anesthesia. However, patients whose age was > or = 60 yr or weight > or = 100 kg, or for whom transient O2 desaturation on transport may be harmful, should be transported while breathing oxygen via nasal cannula.

Continuous spinal anesthetic technique for endovascular aortic stent graft surgery.

Endovascular aortic stent grafts were first introduced in clinical trials in 1991. Endovascular aortic stent grafts are now being used to repair thoracic and abdominal aneurysms in patients not eligible for open repair because of severe medical coexisting diseases. Previously described anesthetic techniques in the literature for aortic stent graft placement include general anesthesia, epidural anesthesia, combined single-shot spinal and epidural anesthesia, and direct local anesthesia. We report the use of a continuous spinal anesthetic technique as a viable anesthetic option for patients with severe coexisting medical diseases undergoing abdominal aortic stent graft placement.

Iatrogenic superior gluteal mononeuropathy.

Injuries to the superior gluteal nerve (SGN) have been reported as a result of trauma, pyriformis muscle entrapment, injections, and lumbar lordosis and inadequate back stabilization. We report 3 patients who developed isolated SGN injuries, 1 after a partial nephrectomy and 2 following revision of a total hip arthroplasty. SGN should be suspected in anyone developing an abnormal gait after hip or pelvic surgery or after prolonged lateral decubitus positioning.

Fluoroscopy-assisted intubation of a child with an unstable subluxation of C1/C2.

Patients presenting with unstable cervical spine injuries are at risk for additional neurological injury as a consequence of airway manipulation. Techniques of awake intubation may not always be desirable or practical, particularly in the pediatric patient. We describe the use of fluoroscopy during the induction of anesthesia and intubation of a child with an unstable C1/C2 spinal subluxation. Fluoroscopy is readily available and noninvasive. This technique allows for rapid establishment and maintenance of optimal head and neck positioning during induction of general anesthesia and performance of laryngoscopy and tracheal intubation.

The importance of the postoperative anesthetic visit: do repeated visits improve patient satisfaction or physician recognition?

This study evaluates whether repeated postoperative visits by the anesthesiologist improve patient ability to recall the anesthesiologist's name and the patient's perception of and satisfaction with anesthesia services. In a randomized, prospective trial, 144 patients with an anticipated postoperative length of stay of at least three days were enrolled in three groups: Group A patients (n = 48) had one postoperative visit, Group B (n = 48) had two postoperative visits, and Group C (n = 48) had three postoperative visits. All postoperative visits were performed by the attending anesthesiologist on consecutive postoperative days. Patients were contacted two days after their last postoperative visit to complete a study questionnaire. Patients were able to recall the anesthesiologist's name significantly less frequently than the surgeon's name, and there was no difference in name recall among groups. Recall was not affected by patient age, sex, or ASA physical status; the mode of contact (telephone versus personal visit); the anesthesiologist's gender; the presence of preoperative medication; or the identity of the preoperative evaluator. Patients could identify the anesthesiologist's gender approximately 85% of the time, regardless of group, and were more likely to identify female anesthesiologists (P = 0.026, odds ratio 3.3). Patient evaluation of hospital, surgical, and anesthesia care was favorable in all groups and did not vary with group. Increasing the number of postoperative visits does not improve patient name recognition of the anesthesiologist or increase patient satisfaction with or perception of anesthesia services.

Instructional review improves performance of anesthesia apparatus checkout procedures.

Checkout recommendations for anesthesia apparatus are promoted as a means of improving patient safety. We sought to determine residents' performance of institutional checkout procedures and the degree of their improvement after instructional video review. Twenty-nine residents performing a list of pre-use checkout procedures were videotaped (VT1) prior to randomization into a Control or Test group. The Control group had a second videotaping (VT2), whereas the Test group received instructional review of VT1 prior to VT2. Control and Test subjects then had instructional review of all tapes. A blinded investigator scored all tapes without interacting with any subject. Control and Test video scores were compared at VT1 and VT2 using analysis of variance. Differences were sought between the clinical anesthesia (CA) 1-, 2-, and 3-yr residents. Percent "perfect," "partial," or "no" completion of each criterion was calculated to determine performance and improvement. A low-performance rate of 69% (20.6/30) occurred in VT1, significantly improving to 81% (24.2/30) in the Test group after intervention (P < 0.0021) with significant reductions in criteria that were totally missed. Anesthesia apparatus checkout procedures are improved after intensive training sessions, although high rates of completion are not achieved. This performance deficit may have implications for the ability of physicians to detect anesthesia machine faults.