Patient flow in the Post Anesthesia Care Unit: an observational study.

PURPOSE: Anesthesiologists are constantly striving for improvement in health care delivery. We assessed the patient flow in the Post Anesthesia Care Unit (PACU) to determine if patients are being transported out of the PACU when ready. METHODS: A University student recorded the flow of 336 patients who recovered in our Post Anesthesia Care Unit. The corresponding nursing and orderly complements were recorded. If a delay arose between the time the patient was deemed fit for discharge by the PACU nurse and the time the patient was transported from the PACU, the student determined the duration and cause(s) of the delay. RESULTS: The number of patients, nurses, and orderlies increased from three to twelve, three to seven, and one to two respectively throughout the elective working day. Seventy-six per cent of patients studied were delayed in transport from the PACU, with 26% of patients waiting 30 min. The average delay in discharge for patients increased during the day from 0 to 65 +/- 54 min from the time of fit for discharge, as determined by the PACU nurse, until transport. Five causes were identified as contributing to the delay: orderly too busy (41%), awaiting Anesthesia assessment (36%), Post Anesthesia Care Unit nurse too busy (15%), receiving floor not ready (6%), and patient awaiting radiographic interpretation (2%). CONCLUSION: Our study has shown that system errors unnecessarily prolongs the stay of patients in the PACU.

The performance of spinal anesthesia is marginally more difficult in the elderly.

BACKGROUND AND OBJECTIVES: We sought to determine if spinal anesthesia is more difficult to perform in the elderly. METHODS: All spinal anesthetics administered over 18 months by 18 anesthesiologists were eligible. We excluded anesthetics for hip fractures and cesarean deliveries. We recorded time to completion, number of spinal needles used, and number of approaches. The patients were prospectively divided into three age categories: patients <50 years of age (group 1); 50-70 years of age (group 2); and >70 years of age (group 3). Descriptive statistics and chi-square test were performed. RESULTS: Nine hundred and ninety-nine anesthetics were analyzed. There were 368, 336, and 295 entries in groups 1, 2, and 3, respectively. Although the mean +/- SD (in min) times to accomplish the spinal technique were not significantly different (4.3 +/- 4.1, 4.4 +/- 3.2, and 4.6 +/- 3.4 for groups 1, 2, and 3), there was a statistically greater frequency of more than one spinal needle used and more than one approach needed in the elderly. CONCLUSIONS: We conclude that patient age is a minor independent predictor of increased technical difficulty with spinal anesthesia.

Anesthesiologists and the time interval between cases in cardiac surgery.

STUDY OBJECTIVE: To determine whether an association exists between individual anesthesiologists and nonpatient care time in the operating room (OR). DESIGN: Retrospective chart review. SETTING: Cardiac surgery operating theatre in a University Hospital. PATIENTS: 312 elective coronary artery bypass procedures over 2 years. MEASUREMENTS AND MAIN RESULTS: The time interval between cases, as defined by the time between the first patient out and the second patient in, was compared. Six anesthesiologists, labelled 1 to 6, were involved in the 156 data points analyzed. The mean (+/- SD) time interval between cases, in minutes, for anesthesiologists 1 to 6 were, respectively: 24 +/- 9, 25 +/- 8, 27 +/- 8, 29 +/- 5, 30 +/- 4, 31 +/- 7. The difference among the anesthesiologists' mean time interval between cases was significant (p < 0.01). The mean time interval between cases was significantly different between anesthesiologists 1 and 6 (p < 0.01) and between anesthesiologists 2 and 6 (p < 0.05). CONCLUSION: The impact of a shorter time interval between cases on OR efficiency remains unknown. Further education and investigation of this issue are warranted.

Airway closure and intraoperative hypoxaemia: twenty-five years later.

PURPOSE: The literature describing the pulmonary mechanisms of increased PA-PaO2 during general anaesthesia was examined to define the role of airway closure and sub-radiological atelectasis. SOURCE: A Medline search was designed to include articles dealing with the stated purpose, which is thus selective rather than a meta-analysis. The MeSH consisted of the following words: Anesthesia: general/inhalational; Pulmonary gas exchange; Ventilation:perfusion ratio; Lung Physiology; Lung Volume measurements; Closing Volume/Capacity; Functional Residual Capacity; Atelectasis; Diaphragm. Also, Dr H. Rothen and Prof. G. Hedenstierna supplied raw data. PRINCIPAL FINDINGS: Changes in shape and dimensions of the thorax and abdomen immediately after induction of anaesthesia result in marked alterations in the efficiency of oxygenation. Three pathways can be described: increased effects of airway closure, increased low ventilation: perfusion in dependent lung zones, and frank atelectasis. The magnitude of the alterations is determined by the patients' age and body habitus. Some of the changes may carry-over into the postoperative period. The data suggest that increasing tidal volume during anaesthesia will reduce the effects of airway closure and that vital capacity breaths will re-expand atelectatic areas. CONCLUSION: Airway closure and atelectasis contribute equally to the increased ventilation: perfusion mismatching that occurs during general anaesthesia.

A comparison of simple identification tests to distinguish cerebrospinal fluid from local anaesthetic solution.

Local anaesthetic solution is sometimes used to enlarge the epidural space in preparation for the insertion of an indwelling epidural catheter and during subsequent checking a small volume of fluid may be aspirated. Twelve anaesthetists were asked to distinguish 0.1 ml plain bupivacaine 0.25% from 0.1 ml simulated cerebrospinal fluid (CSF) solution. The distinction was based on differences in the physicochemical properties of the two test solutions, namely, temperature, presence of glucose, pH, and turbidity when mixed with thiopentone. Temperature difference resulted in correct identification of the two solutions in 75% of cases, the presence of glucose in 92%, pH in 83%, and turbidity in 25% of cases. No single test resulted in correct identification by all the anaesthetists. We suggest that more than one physicochemical test is required to identify correctly the nature of the small volume of liquid which may be aspirated from an epidural catheter.