Quantitative Neuromuscular Monitoring Permits Early Diagnosis of Abnormal Butyrylcholinestrase: Two Case Studies Demonstrating Prevention of Awareness from Premature Awakening.

Administration of succinylcholine to patients with a variant in the butyrylcholinesterase (BChE) gene increases the risk of anesthesia emergence prior to recovery from neuromuscular blockade (NMB). Application of quantitative neuromuscular monitoring (NMM) can identify residual NMB. We present two patients with abnormal BChE gene variants. In the first case, quantitative monitoring was applied too late to prevent awareness, but allowed diagnosis and prevented admission to the intensive care unit. In the second case, monitoring was applied prior to NMB, which enabled early diagnosis and prevented premature awakening from anesthesia. These cases illustrate the importance of quantitative NMM, even in short cases and with short-acting depolarizing agents such as succinylcholine. The clinical implications of this report include a more consistent use of NMM to identify and manage patients with undiagnosed abnormal BChE and to prevent premature anesthesia emergence.

Improving Waste Segregation in the Operating Room to Decrease Overhead Cost.

BACKGROUND AND OBJECTIVES: Operating rooms (ORs) disproportionally contribute 20% to 33% of hospital waste nationwide and therefore have a major impact on hospital waste management. Seventy percent of general OR waste is incorrectly eliminated as clinical waste, which compounds unnecessary financial burden and produces negative environmental impact. The primary purpose of this quality improvement (QI) project was to evaluate the effectiveness of waste segregation education for OR anesthesia staff on improving waste segregation compliance in the OR. METHODS: A waste segregation QI project was implemented at a 19-OR hospital. Sharps bins in each OR were monitored for weight in pounds and 6 ORs were monitored for percent compliance both pre- and post-institution of a waste segregation education. In addition, a waste segregation knowledge assessment, waste segregation barriers assessment, and a demographic survey were administered to anesthesia staff. Twenty-two certified registered nurse anesthetists (CRNAs), 13 anesthesiologists, and 4 anesthesia technicians responded to the initial surveys and assessments while 30 of these original 39 participants (77%) responded following the educational intervention. A cost analysis was calculated pre- and post-implementation by multiplying total weight of the sharps bins by the price per pound of sharps. RESULTS: Twenty-three percent of participants reported having formal waste segregation training. Survey responses revealed that the greatest barrier to waste segregation involved bin location (56.4%), followed by lack of time to segregate (25.6%), lack of knowledge of what content goes in the bin (25.6%), and lack of incentive (25.6%). A waste segregation knowledge assessment showed improvement from pre- ( M = 9.18, SD = 1.66) to post-implementation ( M = 9.90, SD = 1.64). Pre-implementation sharps bin compliance was 50.70% while post-implementation bin compliance improved to 58.44%. A 27.64% decrease in sharps disposal cost occurred following implementation, which is estimated to produce a $2964 cost savings per year. CONCLUSIONS: Waste segregation education for anesthesia staff increased their waste management knowledge, improved sharps waste bin compliance, and produced an overall cost savings.