The preoperative evaluation form: assessment of quality from one hundred thirty-eight institutions and recommendations for a high-quality form.

STUDY OBJECTIVE: To develop a rating system to evaluate the preoperative evaluation form in three categories: informational content, ease of use, and ease of reading; to analyze forms contributed by the Association of Anesthesia Clinical Directors; to offer an example of a more optimal form; and interest practitioners in evaluating the quality of their evaluation forms. SETTING: University medical center. DESIGN/MEASUREMENTS: The informational content of the forms was graded by a rating system developed to give a score based on the importance of the data to anesthesia management and legal documentation. Based on the amount of informational content, the forms were grouped into categories ranging from severely deficient to excellent. The ease of use and ease of reading were determined by specific criteria. MAIN RESULTS: 138 forms were analyzed. The mean +/- SD information score was 265 +/- 41, with a range of 140 to 333 (maximum score possible = 363). Fifteen percent of the forms were considered severely deficient to substandard whereas 52% were deemed very good to excellent. A large proportion of forms omitted at least one essential information item. Twelve percent and 6% were labeled poor with regard to ease of use and ease of reading, respectively. Academic centers performed significantly better in the content and ease of use of their forms compared to those from private centers. CONCLUSIONS: A good preoperative evaluation form is an important tool in the anesthetic management of a patient and plays a significant role in the medical legal arena. We found that a surprisingly high percentage of forms are missing important information. A form that contains all of the information and also meets our ease of use and reading standards was developed and offered as an example.

Operating room start times and turnover times in a university hospital.

STUDY OBJECTIVE: To measure the start time for the first case of the day and the turnover times for subsequent cases in the operating rooms (ORs) at an academic hospital. DESIGN: Prospective study. SETTING: ORs at a university medical center. PATIENTS: All patients undergoing an operative procedure that started between 7 A.M. and 5 P.M. weekdays for the period January 1, 1989, through June 30, 1989. INTERVENTIONS: For each patient, the following times were recorded: OR ready, patient enters OR, anesthesia induction complete, surgery start, surgery end, patient leaves OR. MEASUREMENTS AND MAIN RESULTS: Patients were brought into the OR just before the scheduled start time. Surgical incision was made 21 to 49 minutes after the patient was brought into the OR. Room turnover time (time from patient in to patient out) was almost uniformly 36 minutes. Patient turnover time (time from end of surgery in one patient to end of induction of next patient) was generally 1 hour. Turnover times were shorter for those ORs in which primarily monitored anesthesia care was provided and longer in ORs in which patients routinely required invasive monitoring. CONCLUSIONS: The scheduled start time for the first case of the day was generally the time the patient was brought into the OR. Because of the variable amount of time required for anesthesia induction and surgical preparation and draping, incision occurred 21 to 49 minutes later. The time between cases when no surgery was occurring was significantly longer than room turnover time because of the need to wake up one patient and induce the following patient. Because of a lack of standardized definitions, there is probably a strong perceptual difference among anesthesiologists, OR nurses, and surgeons when viewing start and turnover times. At our own teaching institution, shortening turnover times would increase the amount of elective OR time available, but the impact would not be significant because the number of procedures done per OR each day is low.

Risk factors for mortality after failed coronary angioplasty: an anesthesia perspective.

Monitored anesthesia care (MAC) for percutaneous transluminal coronary angioplasty (PTCA), and anesthesia for emergent coronary artery bypass graft (CABG) surgery due to failed PTCA, have added relatively new challenges to the cardiac anesthesiologist in community practice. This study attempted to define easily identifiable preangioplasty and periangioplasty risk factors for mortality after failed PTCA. A total of 1,380 angioplasties performed in a single community hospital were retrospectively reviewed; 120 (8.7%) were attempted PTCAs requiring subsequent CABG during the same hospital stay. The 120 failures included 10 surgical mortalities (8.3%); multivariate analysis revealed several significant differences between the mortality and survivor groups. Mortality tended to be higher in insulin-dependent diabetics (P = 0.003), females (P = 0.005), and patients 70 years or over (P = 0.043). Previous CABG, decreased left ventricular ejection fraction, and number of vessels with significant disease did not differ between the groups. Patients who died required more vasopressor agents (P = 0.011) during PTCA and experienced cardiac arrests (P = 0.011) at significantly higher rates than survivors. Left system (left anterior descending or circumflex coronary artery) angioplasty, inability to pass the angioplasty guidewire, and antiarrhythmic drug use did not differ between groups. Data concerning endotracheal intubation in the catheterization laboratory and time from laboratory exit to initiation of cardiopulmonary bypass, while bivariately significant, were too sparse for multivariate analysis. The authors believe that several risk factors for postangioplasty surgical mortality are easily determined without access to diagnostic angiographic studies.(ABSTRACT TRUNCATED AT 250 WORDS)

Evaluation of outpatient experience with vitreoretinal surgery.

The experience of 55 consecutive individuals undergoing outpatient vitreoretinal surgery was evaluated. Objective variables, including preoperative and intraoperative information, subjective postoperative pain, and discomfort were measured with a previously validated 100 mm visual analogue scale. Patients also ranked the overall experience. Average pain and discomfort scores in the recovery room were 21.8 and 22.6 and overnight were 26.7 and 30.4 (scale 0 to 100), respectively. Eighty eight per cent of subjects were satisfied with the experience. Elevated pain and discomfort scores were statistically correlated with scleral buckling, prolonged surgical or recovery room time, requirement for parenteral pain medications, and high intraocular pressure on the first postoperative visit. None of the patients needed further hospital treatment. This study suggests that vitreoretinal surgery in an appropriately selected population does not require routine inpatient care.

Effects of central bolus injections of potassium chloride on arterial potassium concentration in patients undergoing cardiopulmonary bypass.

The effects of central venous bolus injections of potassium chloride (KCl) on arterial potassium concentration were studied in patients undergoing cardiopulmonary bypass. Ten subjects were studied, and each received a rapid bolus injection of KCl, 33 microEq/kg, both before and after cardiopulmonary bypass. Injections were delivered through the proximal infusion port of a 7.5F pulmonary artery catheter, which was situated in either the superior vena cava or the right atrium. Monitored variables included the electrocardiogram, mean arterial, central venous, and pulmonary artery pressures, end-tidal carbon dioxide and inspired oxygen concentrations, and temperature. Blood was sampled continuously at either the radial artery alone or both the radial artery and aortic root at 2 mL/4.3 s. The difference in magnitude between the maximal potassium concentration achieved and the prebolus baseline potassium concentration (delta K) was correlated with cardiac output, stroke volume, and prebolus baseline potassium concentration (baseline [K+]), using simple linear regression analysis. Although significant hyperkalemia (eg, 7 to 9 mEq/L) developed in both the aortic root and radial artery, this was of no electrocardiographic or hemodynamic consequence, presumably because of the transient nature of the hyperkalemic response, following bolus injection of KCl. There was no significant correlation between delta K and cardiac output or stroke volume; however, delta K did correlate significantly with the Baseline [K+] in a direct linear relationship. It is concluded that central bolus injections of KCl through the proximal infusion port of the pulmonary artery catheter at 33 microEq/kg are safe. This technique should be used cautiously in patients with extremely low cardiac outputs or where intracardiac shunting of blood may exist, as these situations could potentially result in greater hyperkalemic responses than those observed in the current study.

A comparison of the effects of central v peripheral bolus injections of potassium chloride on aortic root potassium concentrations in swine.

Clinically relevant doses of potassium chloride (equivalent to 2 mEq/60 kg of body weight) were administered as rapid intravenous (IV) boluses to healthy halothane-anesthetized pigs. Potassium was given either peripherally through a standard IV ear catheter or centrally through the central venous port of a pulmonary artery catheter. Multiple injections were made in each pig, and cardiac output was varied by changing end-tidal halothane concentration. The aortic root potassium concentration was measured every three to six seconds for 90 seconds following potassium administration in each pig. Monitored variables included end-tidal halothane, end-tidal carbon dioxide, pulmonary artery pressure, mean arterial blood pressure, cardiac output, electrocardiogram, and temperature. Following both peripheral and central administration of potassium chloride, aortic root potassium increased significantly. However, the time required to achieve the peak aortic root potassium concentration was significantly less after central administration. In addition, the change in aortic root potassium concentration was greater following central administration compared with peripheral. The change in aortic root potassium concentration correlated inversely with cardiac output only after central, but not peripheral injection. Despite marked transient hyperkalemia in all animals, no electrocardiographic evidence of hyperkalemia could be demonstrated. It is concluded that small bolus doses of potassium chloride (2 mEq/60 kg) can be given safely either peripherally or centrally in normal, hemodynamically stable swine.

Multipatient anesthetic mass spectrometry: rapid analysis of data stored in long catheters.

A centrally located mass spectrometer sequentially samples airway gases from ten anesthetized patients through 30 m long, 1.07 mm, ID, nylon catheters and three way solenoid valves. End-tidal and inspired concentrations of O2, N2, CO2, N2O, and halothane, enflurane, or isoflurane are displayed on a computer terminal screen in each OR with trend plots. While a gas sample from one room is being analyzed, all other catheters are slowly sampled in order to continuously store 20-s concentration profiles ready for analysis. The stored gas sample is analyzed at twice the rate it was sampled. The computer switches catheters after one breath has been validated from two comparable end-tidal PCO2 values. Large flow changes produced by switching from one catheter to the next require regulation of the pump pressure in the mass spectrometer. This method reduces the time required to sample each room to 6.96 s (4-10 rooms). Catheter transit slows the response to a step increase in concentration by about 0.13 s (from 10 per cent-90 per cent) and prolongs the transit time through the catheter for a volatile anesthetic by about 0.04 s more than N2. The monitoring facility is used in each room for an average of 5.5 h/day. Two years of experience suggest that it can facilitate detection of faulty technique and equipment, reduce cost of anesthetic agents by encouraging use of closed systems, increase patient safety, aid research and teaching, and diminish exposure of OR personnel to anesthetics. Inherent problems have resulted in an inoperative time of less than 2 per cent.