Improving Postanesthesia Care Unit (PACU) Delays: A Quality Improvement Project.

PURPOSE: Delays within the postanesthesia care unit (PACU) are a major cause of complications and inefficiency. In this project, we investigated the factors associated with delays in the PACU and implemented policies to mitigate these factors. DESIGN: A quality improvement project. METHODS: Data were collected for 10 months and included 1,134 surgical patients in a tertiary Obstetrics and Gynecology hospital in Kuwait. Several meetings were held with stakeholders to identify and overcome the reasons contributing to delays within the PACU. FINDINGS: Among the top reasons for PACU delay were manpower shortage and lack of bed availability in the surgical wards due to improper admission and discharge policies. Policies were implemented to improve admission policy, hasten patient discharge, and improve patient flow through the operating theater (OT). These policies lead to a significant reduction (25 minutes) in the average time patients spend in the OT, mainly by reducing the stay in the PACU by 19 minutes. CONCLUSIONS: PACU delays were mostly due to reasons outside the OT. Further, follow-up is needed to assess the sustainability of these improvements and identify any new challenges that may arise.

Inferior vena cava assessment in term pregnant women using ultrasound: A comparison of the subcostal and right upper quadrant views.

Point-of-care ultrasound can be used at the bedside to assess the haemodynamic status and fluid responsiveness of a pregnant woman. Previous studies demonstrated that views from the apical and parasternal windows are readily obtainable in labouring women. However, using the subcostal window to assess the inferior vena cava can be challenging because of the gravid uterus. A potential alternative is the right upper quadrant transhepatic window. We sought to compare visualisation of the inferior vena cava via the subcostal and right upper quadrant windows, in full-term pregnant women. This was a prospective pilot study carried out in a tertiary academic obstetric centre. Thirty pregnant non-labouring women at full term were recruited. In each patient, the inferior vena cava was visualised through both the subcostal and the right upper quadrant windows. Time to acquire each image, acquisition success rates and ease of obtaining images were compared for both approaches. Image quality was then reviewed and rated by two independent expert reviewers. There was a significant difference in the time required to obtain each view; subcostal median (interquartile range): 52 (35-59) seconds, right upper quadrant median (interquartile range): 23 (11-55) seconds (P=0.0045). Operator-defined successful image acquisition was 100% for the right upper quadrant window compared to 80% for the subcostal window. Ease of obtaining the view, as rated by the operator, was significantly easier in the right upper quadrant window compared to the subcostal window (P <0.0001). Both reviewers independently rated image adequacy to be significantly greater in the right upper quadrant window (73% and 57%) compared to the subcostal window (40% and 10%) (P=0.0213 and P=0.0005, respectively). Inter-rater agreement ranged between good (Cohen's kappa coefficient 0.64) for right upper quadrant windows to fair (Cohen's kappa coefficient 0.29) for subcostal windows. Inferior vena cava visualisation in term pregnant patients may take less time, be easier and provide better quality images when the right upper quadrant window is used compared to the subcostal window.

Efficacy of surface landmark palpation for identification of the cricoid cartilage in obstetric patients: A prospective observational study.

BACKGROUND AND AIMS: Rapid sequence induction, with the application of cricoid pressure is an accepted practice during induction of general anesthesia in pregnant patients to prevent pulmonary apiration. We found no prior studies assessing the accuracy of locating the cricoid cartilage by professional caregivers, and therefore conducted an observational study to assess the ability of different caregivers - anesthesia consultants, anesthesia residents, respiratory therapists (RTs), and nurses, in the obstetric care unit, to correctly identify the cricoid cartilage of parturients. We hypothesized that anesthesia consultants would be most accurate. MATERIAL AND METHODS: Institutional REB approval was obtained, as was written informed consent from all participants in the study. The subjects were made up of thirty healthy obstetric patients scheduled for elective cesarean delivery. Their cricoid cartilages were assessed by 53 caregivers (assessors). Localization of the cricoid cartilage by assessors was considered accurate if it was within 5 mm of the sonographically identified mark. The difficulty in localization was reported on a VAS scale and the time taken for localization was recorded. RESULTS: Data from 30 subjects and 53 assessors (13 anesthesia consultants, 12 residents, 13 RTs, and 15 nurses) performing a total of 60 evaluations (some assessors evaluated 2 subjects) were analyzed. About 60% of RTs, 53% of anesthesia residents, 40% of anesthesia consultants, and 13% of nurses correctly identified the cricoid cartilage. No differences in caregivers'perception of difficulty were found, but RTs were the quickest at identification (P < 0.001 vs anesthesia consultants; P = 0.002 vs residents; P = 0.071 vs nurses). CONCLUSION: RTs were the most successful and accurate in identifying the cricoid cartilage of parturients among the different groups of professional caregivers.

Ultrasound guided quadratus lumborum block for analgesia after cesarean delivery: case series / Bloqueio do quadrado lombar guiado por ultrassom para analgesia pós cesariana: série de casos

Abstract Introduction: The majority of women having planned cesarean section receive spinal anesthesia for the procedure. Typically, spinal opioids are administered during the same time as a component of multimodal analgesia to provide pain relief in the 16-24 h period postoperatively. The quadratus lumborum block is a regional analgesic technique that blocks T5-L1 nerve branches and has an evolving role in postoperative analgesia for lower abdominal surgeries and may be a potential alternative to spinal opioids. If found effective, it will have the advantage of a reduction in opioid associated adverse effects while providing similar quality of analgesia. Methods: We performed bilateral quadratus lumborum block in 3 women who received a spinal anesthetic for a cesarean delivery and evaluated their post-operative opioid consumption and patient satisfaction. Results: In all 3 patients, there was no additional opioid consumption during the first 24 h after the block. Numeric Rating Scale (NRS) for pain was less than 6 for the first 24 h. Women were all very satisfied with the quality of pain relief. Discussion: Quadratus lumborum block may be a promising anesthetic adjuvant for post-cesarean analgesia. Further randomized controlled trials are needed to compare the efficacy of the quadratus lumborum block with intrathecal opioids.

Resumo Introdução: A maioria das mulheres agendadas para cesariana recebe anestesia raquidiana para o procedimento. Tipicamente, os opioides administrados por via espinhal (VE) são administrados ao mesmo tempo como um componente da analgesia multimodal para proporcionar alívio da dor no período pós-operatório de 16-24 horas. O bloqueio do quadrado lombar (QL) é uma técnica de analgesia regional que bloqueia os ramos nervosos T5- L1 e tem um papel crescente na analgesia pós-operatória de cirurgias abdominais inferiores, pode ser uma potencial opção para os opioides VE. Se for considerado eficaz, esse bloqueio terá a vantagem de uma redução nos efeitos adversos associados aos opioides e proporcionará qualidade semelhante de analgesia. Métodos: O bloqueio bilateral do quadrado lombar foi feito em três mulheres que receberam raquianestesia para parto cesário e o consumo de opioides no pós-operatório e a satisfação das pacientes foram avaliados. Resultados: Em todas as três pacientes, não houve consumo adicional de opioide durante as primeiras 24 horas após o bloqueio. A escala de avaliação numérica (EAN) para dor foi inferior a 6 durante as primeiras 24 horas. Todas as mulheres ficaram muito satisfeitas com a qualidade do alívio da dor. Discussão: O bloqueio do QL pode ser um adjuvante promissor para analgesia pós-cesariana. Estudos randomizados e controlados são necessários para comparar a eficácia do bloqueio do quadrado lombar com opioides administrados por via intratecal.

[Ultrasound guided quadratus lumborum block for analgesia after cesarean delivery: case series]. / Bloqueio do quadrado lombar guiado por ultrassom para analgesia pós cesariana: série de casos.

INTRODUCTION: The majority of women having planned cesarean section receive spinal anesthesia for the procedure. Typically, spinal opioids are administered during the same time as a component of multimodal analgesia to provide pain relief in the 16-24h period postoperatively. The quadratus lumborum block is a regional analgesic technique that blocks T5-L1 nerve branches and has an evolving role in postoperative analgesia for lower abdominal surgeries and may be a potential alternative to spinal opioids. If found effective, it will have the advantage of a reduction in opioid associated adverse effects while providing similar quality of analgesia. METHODS: We performed bilateral quadratus lumborum block in 3 women who received a spinal anesthetic for a cesarean delivery and evaluated their post-operative opioid consumption and patient satisfaction. RESULTS: In all 3 patients, there was no additional opioid consumption during the first 24h after the block. Numeric Rating Scale (NRS) for pain was less than 6 for the first 24h. Women were all very satisfied with the quality of pain relief. DISCUSSION: Quadratus lumborum block may be a promising anesthetic adjuvant for post-cesarean analgesia. Further randomized controlled trials are needed to compare the efficacy of the quadratus lumborum block with intrathecal opioids.