A critical appraisal of perioperative sleep apnoea management after nasal surgery: A review of up-to-date literature supplemented by findings of a retrospective observational study.

OBJECTIVE: To review the current recommendations on postoperative precautions for obstructive sleep apnoea patients undergoing elective nasal surgery. DESIGN: Retrospective cohort study. SETTING: Department of Otorhinolaryngology and Anesthesiology/Intensive Care, University Teaching Hospital, Rotterdam, the Netherlands. PARTICIPANTS: The medical charts of 61 patients with sleep apnoea who were admitted to the post-anaesthesia care unit between 2016 and 2020, following nasal surgery were reviewed. MAIN OUTCOME MEASURES: Number of respiratory events during post-anaesthesia care unit admission that required medical intervention. RESULTS: In all 61 patients, continuous positive airway pressure could not be used. In 13 patients (8%), decreased oxygen saturation levels were registered during the first postoperative night, and in five of these patients, supplemental oxygen was needed. No other respiratory incidents of medical interventions were registered. CONCLUSIONS: The number of clinically relevant respiratory events of obstructive sleep apnoea patients with bilateral nasal packing following nasal surgery is low. We suggest that the safety of less expensive and less scarce alternatives of postoperative observation should be explored.

Introduction of a Post-Anaesthesia Care Unit in a Teaching Hospital Is Associated with a Reduced Length of Hospital Stay in Noncardiac Surgery: A Single-Centre Interrupted Time Series Analysis.

BACKGROUND: A post-anaesthesia care unit (PACU) may improve postoperative care compared with intermediate care units (IMCU) due to its dedication to operative care and an individualized duration of postoperative stay. The effects of transition from IMCU to PACU for postoperative care following intermediate to high-risk noncardiac surgery on length of hospital stay, intensive care unit (ICU) utilization, and postoperative complications were investigated. METHODS: This single-centre interrupted time series analysis included patients undergoing eleven different noncardiac surgical procedures associated with frequent postoperative admissions to an IMCU or PACU between January 2018 and March 2019 (IMCU episode) and between October 2019 and December 2020 (PACU episode). Primary outcome was hospital length of stay, secondary outcomes included postoperative complications and ICU admissions. RESULTS: In total, 3300 patients were included. The hospital length of stay was lower following PACU admission compared to IMCU admission (IMCU 7.2 days [4.2-12.0] vs. PACU 6.0 days [3.6-9.1]; p < 0.001). Segmented regression analysis demonstrated that the introduction of the PACU was associated with a decrease in hospital length of stay (GMR 0.77 [95% CI 0.66-0.91]; p = 0.002). No differences between episodes were detected in the number of postoperative complications or postoperative ICU admissions. CONCLUSIONS: The introduction of a PACU for postoperative care of patients undergoing intermediate to high-risk noncardiac surgery was associated with a reduction in the length of stay at the hospital, without increasing postoperative complications.

Non-Invasive Ventilation Reduces Postoperative Respiratory Failure in Patients Undergoing Bariatric Surgery: A Retrospective Analysis.

Background and Objectives: Postoperative non-invasive ventilation (NIV) has been proposed as an attractive strategy to reduce morbidity in obese subjects undergoing general anaesthesia. The increased body mass index (BMI) correlates with loss of perioperative functional residual capacity, expiratory reserve volume, and total lung capacity. The aim of the current study is to evaluate the efficacy of NIV in a post-anaesthesia care unit (PACU) in reducing post-extubation acute respiratory failure (ARF) after biliointestinal bypass (BIBP) in obese patients. Materials and Methods: A retrospective analysis was conducted from January 2019 to December 2020 to compare acute respiratory failure within the first 72 postoperative hours and oximetry values of obese patients who underwent BIBP after postoperative NIV adoption or conventional Venturi mask. Results: In total, 50 patients who received NIV postoperative protocol and 57 patients who received conventional Venturi mask ventilation were included in the study. After 120 min in PACU pH, pCO2, pO2, and SpO2 were better in the NIV group vs. control group (p < 0.001). Seventy-two hours postoperatively, one patient (2%) in the NIV group vs. seven patients (12.2%) in the control group developed acute respiratory failure. Therefore, conventional Venturi mask ventilation resulted in being significantly associated (p < 0.05) with postoperative ARF with an RR of 0.51 (IC 0.27-0.96). Conclusions: After bariatric surgery, short-term NIV during PACU observation promotes a more rapid recovery of postoperative lung function and oxygenation in obese patients, reducing the necessity for critical care in the days following surgery. Therefore, as day-case surgery becomes more advocated even for morbid obesity, it might be considered a necessary procedure.

Identification of Risk Factors Contributing to Prolonged Stay in the Post-anaesthesia Care Unit at a Tertiary Care Hospital in Abu Dhabi, United Arab Emirates.

INTRODUCTION: Post-anesthesia care units (PACU) were developed to reduce postoperative morbidity and mortality and the ideal duration of postoperative stay has been proposed as two hours; however, the incidence and risk factors for prolonged stay are variable. The objective of this study was to assess the incidence of prolonged length of stay in the post-anesthesia care unit at Sheikh Khalifa Medical City (SKMC), Abu Dhabi, United Arab Emirates, and identify the risk factors contributing to it. METHODS AND MATERIALS: This is a retrospective observational study of patients who stayed in the PACU for more than two hours. A total of 2387 patients, both male and female, who underwent surgical procedures between May 2022 to August 2022 at SKMC and were admitted to the PACU after surgery were included in the study and their data were analyzed. RESULTS: Of the 2387 patients who underwent surgical procedures, 43 (1.8%) had prolonged stays in the PACU. Of these, 20 (47%) were adult cases and 23 (53%) were pediatric cases. The main reasons for the delay in discharge from PACU in our study were the non-availability of ward beds (25.5%), followed by pain management (18.6%). CONCLUSIONS: We recommend improving the communication between different specialties, restructuring staffing, implementing changes in perioperative management, and changing operating room scheduling to prevent avoidable reasons contributing to a prolonged stay in the PACU.

Construction of nursing care quality evaluation indicators for post-anaesthesia care unit in China.

AIMS AND OBJECTIVES: To establish a set of scientific and practical nursing care quality evaluation indicators for PACU in China. BACKGROUND: No unified nursing care quality evaluation indicators for post-anaesthesia care unit (PACU) were found in China. DESIGN: An international literature review, domestic cross-sectional survey and two-round e-Delphi study. METHODS: The international literature review and domestic cross-sectional survey were conducted to identify the potential nursing care quality evaluation indicators for PACU. A total of 38 and 32 indicators were extracted from 24 articles and the cross-sectional survey respectively. Two rounds of e-Delphi study were conducted to collect opinions from a panel of 20 independent experts and establish the final version of the nursing care quality evaluation indicators for PACU. A GRRAS checklist was used to guide the reporting of this study. RESULTS: Of 20 experts, 19 completed the first round of e-Delphi study and 18 completed the second round, with a response rate of 95% and 90% respectively. The experts' authority coefficient in the two rounds of e-Delphi study was 0.91 and 0.90 respectively. The Kendall W value of the two rounds ranged between 0.108 and 0.385 (p < .01). Four structure indicators, 12 process indicators and seven outcome indicators were included in the nursing care quality evaluation indicators for PACU. CONCLUSIONS: With the methods of literature review, cross-sectional survey and e-Delphi study, we established a set of scientific and practical nursing care quality evaluation indicators for PACU, to improve the nursing care quality, reduce incidence of complications and ensure patient safety. RELEVANT TO CLINICAL PRACTICE: The findings from this study enable nurses and managers in PACU settings to evaluate clinical nursing care quality using a robust framework.

Nurse competence in the post-anaesthesia care unit in Sweden: a qualitative study of the nurse's perspective.

BACKGROUND: To enable safe and successful recovery for surgery patients, nurses working in post-anaesthesia care units need competence in postoperative care. No consensus defines what this specific competence includes, and it has not been studied from the perspective of nurses working in post-anaesthesia care units. The aim of this study is twofold: 1) To explore and describe nurses' perception of the competence needed to work in post-anaesthesia care units. 2) To explore and describe nurses' perception of what characterizes an expert nurse in post-anaesthesia care units. METHODS: This qualitative inductive study uses individual interviews. Sixteen nurses were recruited from two post-anaesthesia care units located in different parts of Sweden. Inclusion criteria were nurses employed in the post-anaesthesia care units for ≥1 years. Semi-structured individual interviews were conducted; data were analysed using thematic analysis. RESULTS: The interview analysis identified six subthemes and three themes. The themes being adaptable in an ever-changing environment and creating safe care represent the overarching meaning of competence required when working as a nurse in a Swedish post-anaesthesia care unit. Nurses must possess various technical and nontechnical skills, which are core competences that are described in the sub-themes. The theme seeing the bigger picture describes the nurse's perception of an expert nurse in the post-anaesthesia care unit. CONCLUSIONS: Nurse competence in post-anaesthesia care units entails specific knowledge, acknowledging the patient, and working proactively at a fast pace with the patient and team to provide safe, high-quality care. An expert nurse in post-anaesthesia care units can see the bigger picture, helping share knowledge and develop post-anaesthesia care. The expert competence to see a bigger picture can be used in supervising novices and creating a knowledge base for postgraduate education in order to promote safe, high-quality post-anaesthesia care.

Preoperative education improves the preparedness for extubation at emergence from general anaesthesia!

BACKGROUND: Preoperative patient education is an essential responsibility of any healthcare provider, especially an anaesthetist, and is beneficial for perioperative outcome. A smooth emergence and extubation is a clinical skill that needs to be mastered by an anaesthetist. The aim of this study was to analyse whether a detailed preoperative patient education improves the quality of and preparedness for extubation at emergence from general anaesthesia. METHODS: One hundred patients were randomly assigned to two groups. The study group received a detailed preoperative patient education and counselling about the mode of anaesthesia, extubation process and their expected response at extubation while the control group received the routine counselling. The Extubation Quality Scale at emergence and the recovery profile in the post anaesthesia care unit were assessed for both groups. RESULTS: The primary outcome was a better quality of extubation in the patients who received a detailed preoperative patient education. The Extubation Quality Scale was found to be better for patients in the study group (p < 0.001). The endotracheal tube tolerance at a minimum alveolar concentration of ≤0.2 and response to verbal commands at extubation were better for the study group (p < 0.05) besides an earlier discharge from post anaesthesia care unit (p < 0.005). CONCLUSION: Preoperative patient education improves the patients' preparedness for and quality of extubation and recovery from general anaesthesia.

Effects of capnometry monitoring during recovery in the post-anaesthesia care unit: a randomized controlled trial in adults (CAPNOSSPI).

PURPOSE: Continuous capnography should be used on patients admitted to post-anaesthesia care units (PACUs) with endotracheal tubes, but this monitoring is not always performed. Optimized ventilation in the PACU could be part of the global standards of practice to maintain the benefits of perioperative ventilation. The main objective was to study the rate of patients with alveolar hypoventilation before tracheal extubation or Laryngeal Mask Airway (LMA) removal upon the measurement of continuous capnography. METHODS: In this prospective, parallel-group, randomized controlled study, we enrolled adult patients admitted to the PACU after general anaesthesia with an endotracheal tube or LMA in place. Patients were randomly assigned to two groups: in the Capno + group, nurses managed the patients with access to the capnometer and end-tidal carbon dioxide pressure (PETCO2) measurements; in the Capno- group, nurses monitored the patients without seeing PETCO2 measurements. The primary outcome was the percentage of patients with PETCO2 measurements above 45 mm Hg during the minute before extubation. Secondary endpoints included the delay in recovering spontaneous breathing, rate of hypoxemia, delay before extubation, and length of stay in the PACU. RESULTS: Forty-eight patients were randomized into the two groups. The percentage of patients with PETCO2 > 45 mm Hg the minute before extubation was significantly decreased in the Capno + group (83.3% versus 54,1% in the Capno- and Capno + groups respectively, p = 0.029). There were no significant differences concerning secondary endpoints. CONCLUSIONS: The use of PETCO2 monitoring improves patient safety by decreasing the incidence of CO2 retention during recovery from general anaesthesia. This study suggests that this monitoring should be integrated in the PACU. The risk of hypoxemia can also be prevented through the early recognition of apnoea. CLINICAL TRIAL REGISTRY: clinicaltrial.gov. identifier: NCT03370081.

Levels of education and technical skills in registered nurses working in post-anaesthesia care units in Sweden.

BACKGROUND: Specialized nursing care should be provided by nurses working in post-anaesthesia care units to ensure safe and successful recovery after surgery and anaesthesia. However, there is no consensus regarding the competence and education needed by nurses working in post-anaesthesia care units. AIM: The aim of this study is to describe and compare levels of education and technical skills in registered nurses working in post-anaesthesia care units in Sweden, as well as the education that post-anaesthesia care unit nurse managers' desire for registered nurses working in post-anaesthesia care units. METHODS: This descriptive cross-sectional study was conducted in Sweden between September and December of 2019. A web-based survey was developed that included questions about the levels of education and technical skills possessed by registered nurses working in Swedish post-anaesthesia care units and desired by nurse managers for these nurses. The survey was evaluated for content validity by four experts. The survey was distributed to the nurse manager of each studied post-anaesthesia care unit. All nurse managers received written information and were informed that submitting the survey was considered as consenting to participate in the study. RESULTS: Most surveyed nurses held a postgraduate diploma in specialist nursing. Registered nurses performed many tasks autonomously; however, there was a significant difference between specialist nurses and registered nurses, with specialist nurses being more autonomous than registered nurses. Most of the nurse managers (n = 31/45) wanted the registered nurses in their units to have education in postoperative care. The relatively low overall response rate of 58% is a study limitation. CONCLUSIONS: Registered nurses working in post-anaesthesia care units in Sweden must have various technical skills. Some of these skills are only performed by specialist nurses, indicating that postoperative care is an advanced level of nursing care.

National quality improvement indicators project: an initial descriptive study.

BACKGROUND: Anaesthesia Quality Improvement New Zealand developed a set of five quality improvement indicators pertaining to postoperative nausea and vomiting, pain, respiratory distress, hypothermia and a prolonged post-anaesthesia care unit stay. This study sought to assess the proportion of eligible institutions that were able to measure and provide data on these indicators, produce an initial national estimate of these, and a measure of variability in the quality improvement indicators across hospitals in New Zealand. METHODS: All public hospitals that provide a representative to Anaesthesia Quality Improvement New Zealand were eligible for inclusion. Participating institutions were required to provide the number and proportion of patients with each of the five quality improvement indicators over a continuous 2-week period between 1 June 2019 and 25 October 2019. The overall percentage of patients and the median percentage with each outcome were calculated. RESULTS: A total of 79.2% of eligible hospitals participated. The median incidence of the indicators ranged from 1.67% for respiratory distress to 6.31% for prolonged post-anaesthesia care unit stay. The indicator with the largest interquartile range was hypothermia and the smallest was respiratory distress (13.48 and 2.29, respectively). A large variation was seen for prolonged post-anaesthesia care unit stay, hypothermia, pain and postoperative nausea and vomiting. CONCLUSION: The majority of eligible institutions were able to measure and provide data on the quality improvement indicators. There was a low rate of respiratory distress with low variability. A large amount of variability was observed in the other indicators. Future studies are needed to explore the nature of this variability.