Patient and Operational Factors Do Not Substantively Affect the Annual Departmental Quality of Anesthesiologists' Clinical Supervision and Nurse Anesthetists' Work Habits.

INTRODUCTION: Although safety climate, teamwork, and other non-technical skills in operating rooms probably influence clinical outcomes, direct associations have not been shown, at least partially due to sample size considerations. We report data from a retrospective cohort of anesthesia evaluations that can simplify the design of prospective observational studies in this area. Associations between non-technical skills in anesthesia, specifically anesthesiologists' quality of clinical supervision and nurse anesthetists' work habits, and patient and operational factors were examined. METHODS: Eight fiscal years of evaluations and surgical cases from one hospital were included. Clinical supervision by anesthesiologists was evaluated daily using a nine-item scale. Work habits of nurse anesthetists were evaluated daily using a six-item scale. The dependent variables for both groups of staff were binary, whether all items were given the maximum score or not. Associations were tested with patient and operational variables for the entire day. RESULTS: There were 40,718 evaluations of faculty anesthesiologists by trainees, 53,772 evaluations of nurse anesthetists by anesthesiologists, and 296,449 cases that raters and ratees started together. Cohen's d values were small (≤0.10) for all independent variables, suggesting a lack of any clinically meaningful association between patient and operational factors and evaluations given the maximum scores. For supervision quality, the day's count of orthopedic cases was a significant predictor of scores (P = 0.0011). However, the resulting absolute marginal change in the percentage of supervision scores equal to the maximum was only 0.8% (99% confidence interval: 0.2% to 1.4%), i.e., too small to be of clinical or managerial importance. Neurosurgical cases may have been a significant predictor of work habits (P = 0.0054). However, the resulting marginal change in the percentage of work habits scores equal to the maximum, an increase of 0.8% (99% confidence interval: 0.1% to 1.6%), which was again too small to be important. CONCLUSIONS: When evaluating the effect of assigning anesthesiologists and nurse anesthetists with different clinical performance quality on clinical outcomes, supervision quality and work habits scores may be included as independent variables without concern that their effects are confounded by association with the patient or case characteristics. Clinical supervision and work habits are measures of non-technical skills. Hence, these findings suggest that non-technical performance can be judged by observing the typical small sample size of cases. Then, associations can be tested with administrative data for a far greater number of patients because there is unlikely to be a confounding association between patient and case characteristics and the clinicians' non-technical performance.

Preventing Prolonged Times to Awakening While Mitigating the Risk of Patient Awareness: Gas Man Computer Simulations of Sevoflurane Consumption From Brief, High Fresh Gas Flow Before the End of Surgery.

Prolonged times to tracheal extubation are associated with adverse patient and economic outcomes. We simulated awakening patients from sevoflurane after long-duration surgery at 2% end-tidal concentration, 1.0 minimum alveolar concentration (MAC) in a 40-year-old. Our end-of-surgery target was 0.5 MAC, the Michigan Awareness Control Study's threshold for intraoperative alerts. Consider an anesthetist who uses a 1 liter/minute gas flow until surgery ends. During surgical closure, the inspired sevoflurane concentration is reduced from 2.05% to 0.62% (i.e., MAC-awake). The estimated time to reach 0.5 MAC is 28 minutes. From a previous study, 28 minutes exceeded ≥95% of surgical closure times for all 244 distinct surgical procedures (N=23,343 cases). Alternatively, the anesthetist uses 8 liters/minute gas flow with the vaporizer at MAC-awake for 1.8 minutes, which reduces the end-tidal concentration to 0.5 MAC. The anesthetist then increases the vaporizer to keep end-tidal 0.5 MAC until the surgery ends. An additional simulation shows that, compared with simulated end-tidal agent feedback control, this approach consumed 0.45 mL extra agent. Simulation results are the same for an 80-year-old patient. The extra 0.45 mL has a global warming potential comparable to driving 26 seconds at 40 kilometers (25 miles) per hour, comparable to route modification to avoid potential roadway hazards.

Lack of Validity of Absolute Percentage Errors in Estimated Operating Room Case Durations as a Measure of Operating Room Performance: A Focused Narrative Review.

Commonly reported end points for operating room (OR) and surgical scheduling performance are the percentages of estimated OR times whose absolute values differ from the actual OR times by ≥15%, or by various intervals from ≥5 to ≥60 minutes. We show that these metrics are invalid assessments of OR performance. Specifically, from 19 relevant articles, multiple OR management decisions that would increase OR efficiency or productivity would also increase the absolute percentage error of the estimated case durations. Instead, OR managers should check the mean bias of estimated OR times (ie, systematic underestimation or overestimation), a valid and reliable metric.

Survey of Lactating Anesthesiologists Using Wearable Breast Milk Pumps While Working in Operating Rooms and Other Clinical Settings.

We performed a prospective Internet survey study of anesthesiologists lactating in 2022 or 2023. Approximately half (48%, 75 of 156) lacked convenient dedicated lactation space and approximately half (55%, 86 of 155) used a wearable breast pump. The vast majority using a wearable pump did so in clinical settings, including operating rooms (88%, 76 of 86). When using during cases, approximately half reported that milk production was sufficient to substitute for lactation pumping sessions (52%, 39 of 75). Based on probability distributions of surgical times, future research can evaluate the usefulness of wearable pumps based on the objective of reducing anesthesiologists' durations of lactation sessions to <15 minutes.

Effect of a non-reactive absorbent with or without environmentally oriented electronic feedback on anesthesia provider's fresh gas flow rates: A greening initiative.

STUDY OBJECTIVE: To examine the effects of a non-reactive carbon dioxide absorbent (AMSORB® Plus) versus a traditional carbon dioxide absorbent (Medisorb™) on the FGF used by anesthesia providers and an electronic educational feedback intervention using Carestation™ Insights (GE HealthCare) on provider-specific change in FGF. DESIGN: Prospective, single-center cohort study set in a greening initiative. SETTING: Operating room. PARTICIPANTS: 157 anesthesia providers (i.e., anesthesiology trainees, certified registered nurse anesthetists, and solo anesthesiologists). INTERVENTIONS: Intervention #1 was the introduction of AMSORB® Plus into 8 Aisys CS2, Carestation™ Insights-enabled anesthesia machines (GE HealthCare) at the study site. At the end of week 6, anesthesia providers were educated and given an environmentally oriented electronic feedback strategy for the next 12 weeks of the study (Intervention #2) using Carestation™ Insights data. MEASUREMENTS: The dual primary outcomes were the difference in average daily FGF during maintenance anesthesia between machines assigned to AMSORB® Plus versus Medisorb™ and the provider-specific change in average fresh gas flows after 12 weeks of feedback and education compared to the historical data. MAIN RESULTS: Over the 18-week period, there were 1577 inhaled anesthetics performed in the 8 operating rooms (528 for intervention 1, 1049 for intervention 2). There were 1001 provider days using Aisys CS2 machines and 7452 provider days of historical data from the preceding year. Overall, AMSORB® Plus was not associated with significantly less FGF (mean - 80 ml/min, 97.5% confidence interval - 206 to 46, P = .15). The environmentally oriented electronic feedback intervention was not associated with a significant decrease in provider-specific mean FGF (-112 ml/min, 97.5% confidence interval - 244 to 21, P = .059). CONCLUSIONS: This study showed that introducing a non-reactive absorbent did not significantly alter FGF. Using environmentally oriented electronic feedback relying on data analytics did not result in significantly reduced provider-specific FGF.

A threshold of 100 or more colony-forming units on the anesthesia machine predicts bacterial pathogen detection: a retrospective laboratory-based analysis.

PURPOSE: Preventing the spread of pathogens in the anesthesia work area reduces surgical site infections. Improved cleaning reduces the percentage of anesthesia machine samples with ≥ 100 colony-forming units (CFU) per surface area sampled. Targeting a threshold of < 100 CFU when cleaning anesthesia machines may be associated with a lower prevalence of bacterial pathogens. We hypothesized that anesthesia work area reservoir samples returning < 100 CFU would have a low (< 5%) prevalence of pathogens. METHODS: In this retrospective cohort study of bacterial count data from nine hospitals, obtained between 2017 and 2022, anesthesia attending and assistants' hands, patient skin sites (nares, axilla, and groin), and anesthesia machine (adjustable pressure-limiting valve and agent dials) reservoirs were sampled at case start and at case end. The patient intravenous stopcock set was sampled at case end. The isolation of ≥ 1 CFU of Staphylococcus aureus, methicillin-resistant Staphylococcus aureus, Enterococcus, vancomycin-resistant Enterococcus, gram-negative (i.e., Klebsiella, Acinetobacter, Pseudomonas, and Enterobacter spp.) or coagulase-negative Staphylococcus was compared for reservoir samples returning ≥ 100 CFU vs those returning < 100 CFU. RESULTS: Bacterial pathogens were isolated from 24% (7,601/31,783) of reservoir samples, 93% (98/105) of operating rooms, and 83% (2,170/2,616) of cases. The ratio of total pathogen isolates to total CFU was < 0.0003%. Anesthesia machine reservoirs returned ≥ 100 CFU for 44% (2,262/5,150) of cases. Twenty-three percent of samples returning ≥ 100 CFU were positive for ≥ 1 bacterial pathogen (521/2,262; 99% lower confidence limit, 22%) vs 3% of samples returning < 100 CFU (96/2,888; 99% upper limit, 4%). CONCLUSIONS: Anesthesia machine reservoir samples returning < 100 CFU were associated with negligible pathogen detection. This threshold can be used for assessment of terminal, routine, and between-case cleaning of the anesthesia machine and equipment. Such feedback may be useful because the 44% prevalence of ≥ 100 CFU was comparable to the 46% (25/54) reported earlier from an unrelated hospital.

RéSUMé: OBJECTIF: La prévention de la propagation des agents pathogènes dans la zone de travail de l'anesthésie réduit les infections du site opératoire. L'amélioration du nettoyage réduit le pourcentage d'échantillons de l'appareil d'anesthésie présentant ≥ 100 unités de formation de colonie (UFC) par surface échantillonnée. Le fait de cibler un seuil < 100 UFC lors du nettoyage des appareils d'anesthésie pourrait être associé à une prévalence plus faible d'agents pathogènes bactériens. Nous avons émis l'hypothèse que les échantillons des réservoirs de la zone de travail d'anesthésie < 100 UFC résulteraient en une faible prévalence (< 5 %) d'agents pathogènes. MéTHODE: Dans cette étude de cohorte rétrospective des données de décompte bactérien de neuf hôpitaux, obtenues entre 2017 et 2022, les mains des anesthésiologistes et des assistant·es en anesthésie, les sites cutanés des patient·es (narines, aisselles et aines) et les réservoirs de l'appareil d'anesthésie (soupape de réglage de limitation de pression et cadrans d'agent) ont été échantillonnés au début et à la fin de chaque cas. Les échantillons sur l'ensemble de robinets d'arrêt intraveineux des patient·es ont été prélevés à la fin de chaque cas. L'isolement de ≥ 1 UFC de staphylocoque doré, de staphylocoque doré résistant à la méthicilline, d'entérocoque, d'entérocoque résistant à la vancomycine, de staphylocoque à Gram négatif (c.-à-d. Klebsiella, Acinetobacter, Pseudomonas et Enterobacter spp.) ou à coagulase négative a été comparé pour les échantillons de réservoir retournant ≥ 100 UFC vs ceux qui comportaient < 100 UFC. RéSULTATS: Des bactéries pathogènes ont été isolées dans 24 % (7601/31 783) des échantillons de réservoir, 93 % (98/105) des salles d'opération et 83 % (2170/2616) des cas. Le rapport entre le nombre total d'isolats d'agents pathogènes et le nombre total d'UFC était de < 0,0003 %. Les échantillons pris sur les réservoirs d'appareils d'anesthésie ont retourné ≥ 100 UFC dans 44 % (2262/5150) des cas. Vingt-trois pour cent des échantillons retournés ≥ 100 UFC étaient positifs pour ≥ 1 agent pathogène bactérien (521/2262; limite de confiance inférieure à 99 %, 22 %) vs 3 % des échantillons retournant < 100 UFC (96/2888 ; 99 % de la limite supérieure, 4 %). CONCLUSION: Les échantillons pris sur les réservoirs de l'appareil d'anesthésie comportant < 100 UFC étaient associés à une détection négligeable d'agents pathogènes. Ce seuil peut être utilisé pour l'évaluation du nettoyage final, de routine et entre les cas de l'appareil et de l'équipement d'anesthésie. Une telle rétroaction peut être utile parce que la prévalence de 44 % de ≥ 100 UFC était comparable aux 46 % (25/54) rapportés précédemment dans un autre hôpital.

Modeling daily veterinary anesthetist patient care hours and probabilities of exceeding critical thresholds.

OBJECTIVE: Use a referral dental clinic model to study how to calculate accurate 95% upper confidence limits for probabilities of workloads (total case duration, including turnover time) exceeding allocated times. ANIMALS: Dogs and cats undergoing dental treatments. METHODS: Managerial data (procedure date and duration) collected over 44 consecutive operative workdays were used to calculate the daily anesthetist workload. Workloads were compared with a normal distribution using the Shapiro-Wilk test, serial correlation was examined by runs test, and comparisons among weekdays were made using the Kruskal-Wallis test. The 95% confidence limits for normally distributed workloads exceeding allocated times were estimated with a generalized pivotal quantity. The impact of a number of procedures was assessed with scatterplots, Pearson linear correlation coefficients, and multivariable linear regression. RESULTS: Mean anesthetist's workload was normally distributed (Shapiro-Wilk P = .25), without serial correlation (P = .45), and without significant differences among weekdays (P = .52). Daily workload, mean 9.39 hours and SD 3.06 hours, had 95% upper confidence limit of 4.47% for the probability that exceeding 16 hours (ie, 8 hours per each of 2 tables). There was a strong positive correlation between daily workload and the end of the workday (r = .85), significantly larger than the correlation between the end of the workday and the number of procedures (r = .64, P < .0001). CLINICAL RELEVANCE: There are multiple managerial applications in veterinary anesthesia wherein the problem is to estimate risks of exceeding thresholds of workload, including the costs of hiring a locum, scheduling unplanned add-on cases, planning for late discharge of surgical patients to owners, and coordinating anesthetist breaks.

Survey of anesthesia department chairs about the environmental sustainability initiatives of their programs.

BACKGROUND: Anesthesia departments can reduce their environmental impact. Barriers exist to the promotion of individual anesthesiologists' roles in environmentally sustainable practices. We hypothesized that accountability of departmental leadership is associated with reports of practices that can encourage and sustain environmentally favorable practices. METHODS: Invitations to complete a six-question survey were sent to academic anesthesia department chairs in the United States and Canada. Questions were presented in random sequence. We assessed the association between the sum of the answers to five questions about department- and hospital-related sustainability activities (e.g., more than one "educational session dedicated to environmental sustainability … for anesthesiology residents or other trainees?") and the sixth question ("In the past 12 months, did review of the anesthesia department chair or review of your department include" more than one "item related to promotion of environmental sustainability?"). RESULTS: Of the 138 departments receiving invitation and reminder emails, 63 departments (46%) responded to our requests. The median (interquartile range) was 1 (0,3) sustainability activity for "No" items evaluating the department chair or department (N = 43) versus 4 (2, 4.5) activities for "Yes" evaluation of department chair or department (N = 20) (Wilcoxon-Mann-Whitney test, P = 0.0021; median regression, P = 0.0002). Results were similar for sensitivity analyses (excluding one question about hospital leadership, excluding the four responding Canadian departments, controlling for time to complete the survey, and controlling for the date of completion of the survey). CONCLUSIONS: Anesthesia department chairs and departments with annual performance evaluations that included items related to environmental sustainability reported more activities to promote sustainability. The result suggests that leadership-sponsored initiatives directed toward environmental sustainability are associated with environmental sustainability activities in anesthesia departments.

Bibliometric Analysis of Contributions of Anesthesiology Journals and Anesthesiologists to Operating Room Management Science.

BACKGROUND: Anesthesiology journals appear to have been progressively publishing a smaller percentage of operating room (OR) management studies. Similarly, non-anesthesiologists have increasingly been authors of these publications. Five hypotheses were formulated to evaluate these impressions based on 2 of the authors' curation of an online, comprehensive bibliography of OR management articles and corresponding referenced course materials. METHODS: We studied all 2938 publications having Scopus' SciVal topic T.6319 (OR management) more than 28 years from 1996 through May 2023, including 8608 distinct authors. RESULTS: Half (50%) of the publications were absent from PubMed, and the percentage absent has been increasing progressively (Kendall's τ = 0.71; P < .0001). Fewer than half were published in journals including anesthesiology as the sole classification (20%) or as one of the classifications (27%). The anesthesiology journals have been publishing a progressively decreasing fraction (τ = -0.61; P < .0001). Among the 11 authors each contributing at least 1% of the OR management science publications, 9 were anesthesiologists and the other 2 had anesthesiologists as coauthors on all these publications. Only 3% of authors had at least 10 OR management publications from earlier years. There were 75% of authors with no such earlier publications and 85% with 0 or 1. There was a progressive increase in the number of authors publishing OR management annually and with at most 1 such earlier publication (τ = 0.90; P < .0001). Only 20% of publications had any author with at least 10 earlier OR management publications, 48% had every author with no such earlier publications, and 60% had all authors with 0 or 1. CONCLUSIONS: Although most of the authors with the greatest production of OR management science were anesthesiologists, the percentage of publications in anesthesiology journals has been decreasing progressively. Anesthesiologists cannot rely solely on anesthesiology journals to keep up with the field. For most publications, every author had few or no earlier publications on the topic. Clinicians and managers relying on OR management science will continue to need to apply more information when judging whether published results can reliably be applied to their facilities.

Narrative Review of Prolonged Times to Tracheal Extubation After General Anesthesia With Intubation and Extubation in the Operating Room.

This narrative review summarizes research about prolonged times to tracheal extubation after general anesthesia with both intubation and extubation occurring in the operating room or other anesthetizing location where the anesthetic was performed. The literature search was current through May 2023 and included prolonged extubations defined either as >15 minutes or at least 15 minutes. The studies showed that prolonged times to extubation can be measured accurately, are associated with reintubations and respiratory treatments, are rated poorly by anesthesiologists, are treated with flumazenil and naloxone, are associated with impaired operating room workflow, are associated with longer operating room times, are associated with tardiness of starts of to-follow cases and surgeons, and are associated with longer duration workdays. When observing prolonged extubations among all patients receiving general anesthesia, covariates accounting for most prolonged extubations are characteristics of the surgery, positioning, and anesthesia provider's familiarity with the surgeon. Anesthetic drugs and delivery systems routinely achieve substantial differences in the incidences of prolonged extubations. Occasional claims made that anesthesia drugs have unimportant differences in recovery times, based on medians and means of extubation times, are misleading, because benefits of different anesthetics are achieved principally by reducing the variability in extubation times, specifically by decreasing the incidence of extubation times sufficiently long to have economic impact (ie, the prolonged extubations). Collectively, the results show that when investigators in anesthesia pharmacology quantify the rate of patient recovery from general anesthesia, the incidence of prolonged times to tracheal extubation should be included as a study end point.

Introduction to Bayesian Analyses for Clinical Research.

Bayesian analyses are becoming more popular as a means of analyzing data, yet the Bayesian approach is novel to many members of the broad clinical audience. While Bayesian analyses are foundational to anesthesia pharmacokinetic/pharmacodynamic modeling, they also can be used for analyzing data from clinical trials or observational studies. The traditional null hypothesis significance testing (frequentist) approach uses only the data collected from the current study to make inferences. On the other hand, the Bayesian approach quantifies the external information or expert knowledge and combines the external information with the study data, then makes inference from this combined information. We introduce to the clinical and translational science researcher what it means to do Bayesian statistics, why a researcher would choose to perform their analyses using the Bayesian approach, when it would be advantageous to use a Bayesian instead of a frequentist approach, and how Bayesian analyses and interpretations differ from the more traditional frequentist methods. Throughout this paper, we use various pain- and anesthesia-related examples to highlight the ideas and statistical concepts that should be relatable to other areas of research as well.

Estimation of the contribution to intraoperative pathogen transmission from bacterial contamination of patient nose, patient groin and axilla, anesthesia practitioners' hands, anesthesia machine, and intravenous lumen.

BACKGROUND: Earlier studies showed net cost saving from anesthesia practitioners' use of a bundle of infection prevention products, with feedback on monitored Staphylococcus aureus intraoperative transmission. ESKAPE pathogens also include Enterococcus and gram-negative pathogens: Klebsiella, Acinetobacter, Pseudomonas, and Enterobacter. We evaluated whether bacterial contamination of patient nose, patient groin and axilla, anesthesia practitioners' hands, anesthesia machine, and intravenous lumen all contribute meaningfully to ESKAPE pathogen transmission within anesthesia work areas. METHODS: The retrospective cohort study used bacterial count data from nine hospitals, 43 months, and 448 ESKAPE pathogen transmission events within anesthesia areas of 86 operating rooms. Transmission was measured within and between pairs of successive surgical cases performed in the same operating room on the same day. RESULTS: There were 203 transmission events with S. aureus, 72 with Enterococcus, and 173 with gram negatives. ESKAPE pathogens in the nose contributed to transmission for 50% (99% confidence limit ≥45%) of case pairs, on the groin or axilla for 54% (≥49%), on the hands for 53% (≥47%), on the anesthesia machine for 21% (≥17%), and in the intravenous lumen for 24% (≥20%). ESKAPE pathogens in the nose started a transmission pathway for 27% (≥22%) of case pairs, on the groin or axilla for 24% (≥19%), on the hands for 38% (≥33%), on the anesthesia machine for 11% (≥7.6%), and in the intravenous lumen for 8.0% (≥5.3%). All P ≤ 0.0022 compared with 5%. CONCLUSIONS: To prevent intraoperative ESKAPE pathogen transmission, anesthesia practitioners would need to address all five categories of infection control approaches: nasal antisepsis (e.g., povidone-iodine applied the morning of surgery), skin antisepsis (e.g., chlorhexidine wipes), hand antisepsis with dispensers next to the patient, decontamination of the anesthesia machine before and during anesthetics, and disinfecting caps for needleless connectors, disinfecting port protectors, and disinfecting caps for open female Luer type connectors.

Association between an anesthesia department development program for junior faculty and long-term production of publications: A longitudinal cohort study.

BACKGROUND: An important mission of academic medical departments is to further the scholarship and education of its junior faculty. In 2013, Hindman et al. described the design and initial outcomes of a faculty development program for junior faculty at the University of Iowa Department of Anesthesia. In the current study, we reassessed whether the program increased the production of publications long-term. We included all department faculty, years before joining the department, and years after leaving the department, to control for the effects of simply being current faculty in the department, benefiting from its resources, and having had progressively more experience working. METHODS: The population studied was the faculty for any period between January 2006 and December 2022. The dependent variable was the count of publications in Scopus each year with the faculty member's Scopus identifier, 1996 through 2022. The two-year faculty development program included non-clinical time, two mentors, defined mentorship plan, didactic program, and financial support for clinical and/or laboratory studies. Statistical analyses were with logistic and Poisson random effect models for panel data, with standard errors estimated using jackknife resampling. RESULTS: Among the 128 distinct faculty in the department from 2006 through 2022, the 10% with the most publications per year accounted for 54% of the total annual publications. The two-year program was completed by 41% (53/128). Completion of the faculty development program was associated with a 17% absolute increase in the predicted marginal probability of one or more publications per year, from 25% to 41%. The 95% confidence interval for the 17% absolute increase was 9% to 24% (P < .0001). The predictive marginal effect of completing the program was 1.7 more publications per year per faculty (95% confidence interval 1.1 to 2.4, P < .0001). The estimate was also 1.7 more publications per year while limiting consideration to the 108 faculty who joined the department after 1996 and including as an independent variable the count of publications the year before joining the department. CONCLUSIONS: A faculty development program for junior faculty can reliably increase the production of publications in an anesthesiology department by at least one per year. However, there is considerable heterogeneity in publication production among faculty.

Cross-cultural adaptation and validation of the Iowa Satisfaction with Anesthesia Scale for use in Brazil: a cross-sectional study.

BACKGROUND: The Iowa Satisfaction with Anesthesia Scale (ISAS) was developed to assess the satisfaction of patients undergoing sedation with monitored anesthesia care. This study aimed to cross-culturally adapt the ISAS instrument and evaluate the acceptability, validity, and reliability of the proposed Brazilian version (ISAS-Br). METHODS: The cross-cultural adaptation process involved translation, synthesis, back-translation, expert committee review, pre-testing, and final review of the ISAS-Br. A cross-sectional study was conducted, involving 127 adult individuals undergoing ambulatory surgeries with moderate/deep sedation. The acceptability, reliability, and construct validity of the scale were assessed. RESULTS: The cross-cultural adaptation process did not require significant changes to the final version of the scale. The ISAS-Br demonstrated excellent acceptability, with a completion rate of 99% and an average completion time of 4.6 minutes. Exploratory factor analysis revealed three factors: emotional well-being, physical comfort, and anxiety relief, with respective composite reliability coefficient values of 0.874, 0.580, and 0.428. The test-retest reliability of the ISAS-Br, measured by the intraclass correlation coefficient, was 0.67 (95% confidence interval [95% CI] 0.42 to 0.83), and the Bland-Altman plot showed satisfactory agreement between the measurements. CONCLUSION: The proposed Brazilian version of the ISAS underwent successful cross-cultural adaptation according to international standards. It demonstrated good acceptability and reliability, regarding the assessment of temporal stability. However, the ISAS-Br exhibited low internal consistency for some factors, indicating that this instrument lacks sensitivity to assess the satisfaction of deeply sedated patients. Further studies are necessary to explore the hypotheses raised based on the knowledge of its psychometric properties.

Associations Between Fresh Gas Flow and Duration of Anesthetic on the Maximum Potential Benefit of Anesthetic Gas Capture in Operating Rooms and in Postanesthesia Care Units to Capture Waste Anesthetic Gas.

BACKGROUND: Sevoflurane and desflurane are halogenated hydrocarbons with global warming potential. We examined the maximum potential benefit assuming 100% efficiency of waste gas capture technology used in operating rooms and recovery locations. METHODS: We performed computer simulations of adult patients using the default settings of the Gas Man software program, including the desflurane vaporizer setting of 9% and the sevoflurane vaporizer setting of 3.7%. We performed 21 simulations with desflurane and 21 simulations with sevoflurane, the count of 21 = 1 simulation with 0-hour maintenance + (1, 2, 3, 4, or 5 hours of maintenance) × (0.5, 1, 2, or 4 L per minute fresh gas flow during maintenance). RESULTS: (1) A completely efficient gas capture system could recover a substantive amount of agent even when the case is managed with low flows. All simulations had at least 22 mL agent recovered per case, considerably greater than the 12 mL that we considered the minimum volume of economic and environmental importance. (2) All 42 simulations had at least 73% recovery of the total agent administered, considerably greater than the median 52% recovery measured during an experimental study with one gas capture technology and desflurane. (3) The maximum percentage desflurane (or sevoflurane) that could be captured decreased substantively with progressively longer duration anesthetics for low-flow anesthetics but not for higher-flow anesthetics. However, for all 8 combinations of drug and liters per minute simulated, there was a substantively greater recovery in milliliters of agent for longer duration anesthetics. In other words, if gas capture could be near perfectly efficient, it would have greater utility per case for longer duration anesthetics. (4) Even using a 100% efficient gas capture process, at most 6 mL liquid desflurane or 3 mL sevoflurane per case would be exhaled during the patient's stay in the postanesthesia care unit. Therefore, the volume of agent exhaled during the first 1 hour postoperatively is not a substantial amount from an environmental and economic perspective to warrant consideration of agent capture by having all these patients in the postanesthesia care unit, or equivalent locations, using the specialized anesthetic gas scavenging masks with access to the hospital scavenging system at each bed. CONCLUSIONS: Simulations with Gas Man show a strong rationale based on agent uptake and distribution for using volatile anesthetic agent capture in operating rooms if the technology can be highly efficient at volatile agent recovery.

Forecasting Caseload of Critically Ill Patients Who Are Alert and Without Delirium for at Least Two Consecutive Days for the Assessment of Their Psychological Distress.

INTRODUCTION: One-quarter of alert, non-delirious patients in critical care units report significant psychological distress. Treatment of this distress depends upon identifying these high-risk patients. Our aim was to characterize how many critical care patients remain alert and without delirium for at least two consecutive days and could thus predictably undergo evaluation for distress. METHODS: This retrospective cohort study used data from a large teaching hospital in the United States of America, from October 2014 to March 2022. Patients were included if they were admitted to one of three intensive care units, and for >48 hours all delirium and sedation screenings were negative (Riker sedation-agitation scale four, calm and cooperative, and no delirium based on all Confusion Assessment Method for the Intensive Care Unit scores negative and all Delirium Observation Screening Scale less than three). Means and standard deviations of means for counts and percentages are reported among the most recent six quarters. Means and standard deviations of means for lengths of stay were calculated among all N=30 quarters. The Clopper-Pearson method was used to calculate the lower 99% confidence limit for the percentages of patients who would have had at most one assessment of dignity-related distress before intensive care unit discharge or change in mental status. RESULTS: An average of 3.6 (standard deviation 0.2) new patients met the criteria daily. The percentages of all critical care patients (20%, standard deviation 2%) and hours (18%, standard deviation 2%) meeting criteria decreased slightly over the 7.5 years. Patients spent a mean of 3.8 (standard deviation 0.1) days awake in critical care before their condition or site changed. In the context of assessing distress and potentially treating it before the date of change of condition (e.g., transfer), 66% (6818/10314) of patients would have zero or one assessment, lower 99% confidence limit of 65%. CONCLUSIONS: Approximately one-fifth of critically ill patients are alert and without delirium and thus could be evaluated for distress during their intensive care unit stay, mostly during a single visit. These estimates can be used to guide workforce planning.

Systematic review with meta-analysis of relative risk of prolonged times to tracheal extubation with desflurane versus sevoflurane or isoflurane.

The objective of this systematic review was to estimate the relative risk of prolonged times to tracheal extubation with desflurane versus sevoflurane or isoflurane. Prolonged times are defined as ≥15 min from end of surgery (or anesthetic discontinuation) to extubation in the operating room. They are associated with reintubations, naloxone and flumazenil administration, longer times from procedure end to operating room exit, greater differences between actual and scheduled operating room times, longer times from operating room exit to next case start, longer durations of the workday, and more operating room personnel idle while waiting for extubation. Published randomized clinical trials of humans were included. Generalized pivotal methods were used to estimate the relative risk of prolonged extubation for each study from reported means and standard deviations of extubation times. The relative risks were combined using DerSimonian-Laird random effects meta-analysis with Knapp-Hartung adjustment. From 67 papers, there were 78 two-drug comparisons, including 5167 patients. Studies were of high quality (23/78) or moderate quality (55/78), the latter due to lack of blinding of observers to group assignment and/or patient attrition because patients were extubated after operating room exit. Desflurane resulted in a 65% relative reduction in the incidence of prolonged extubation compared with sevoflurane (95% confidence interval 49% to 76%, P < .0001) and in a 78% relative reduction compared with isoflurane (58% to 89%, P = .0001). There were no significant associations between studies' relative risks and quality, industry funding, or year of publication (all six meta-regressions P ≥ .35). In conclusion, when emergence from general anesthesia with different drugs are compared with sevoflurane or isoflurane, suitable benchmarks quantifying rapidity of emergence are reductions in the incidence of prolonged extubation achieved by desflurane, approximately 65% and 78%, respectively. These estimates give realistic context for interpretation of results of future studies that compare new anesthetic agents to current anesthetics.