Behavioral Interactions in the Perioperative Environment: A New Conceptual Framework and the Development of the Perioperative Child-Adult Medical Procedure Interaction Scale.
Caldwell-Andrews, Alison A. Ph.D.; Blount, Ronald L. Ph.D.; Mayes, Linda C. M.D.; Kain, Zeev N. M.D., M.B.A.
Anesthesiology. 103(6):1130-1135, December 2005.

Background: The authors suggest that research in the area of parental presence during induction of anesthesia should shift to emphasize what parents actually do during induction, rather than focusing simply on their presence. As a first step, the authors aimed to develop a behavioral coding system that would measure child and adult interactions in the perioperative environment.
Methods: The authors enrolled 45 parents and children (aged 2-12 yr) undergoing elective surgery and general anesthesia. A multidisciplinary team examined videotapes and transcriptions of interactions between children, parents, and medical personnel in the holding room and operating room. The team used an existing scale, the Child-Adult Medical Procedure Interaction Scale, as the prototype for the development of a new perioperative behavioral coding system. The research team conducted extensive revisions to the original scale and added multiple codes to the original scale, including nonverbal codes. Interrater reliability was assessed using weighted [kappa] statistics. Construct validity was also examined.
Results: The final Perioperative Child-Adult Medical Procedure Interaction Scale contains 40 codes in four domains. Analyses showed excellent reliability overall for verbal and nonverbal codes. Kappa values averaged 0.87 for verbal codes characterizing adult vocalizations, 0.92 for verbal codes characterizing child vocalizations, and 0.88 for nonverbal codes. Construct validity was demonstrated by finding the hypothesized associations between certain scale codes and children's anxiety (P = 0.0001).
Conclusion: Showing excellent reliability, the Perioperative Child-Adult Medical Procedure Interaction Scale is an appropriate tool for assessing child-adult behavioral interaction during the perioperative period. When sequential analyses are conducted and target behaviors are identified, empirically based parent preparation programs can be developed.

Respiratory Reflex Responses of the Larynx Differ between Sevoflurane and Propofol in Pediatric Patients.
Oberer, Christine M.D.; von Ungern-Sternberg, Britta S. M.D.; Frei, Franz J. M.D.  Erb, Thomas O. M.D., M.H.S.
Anesthesiology. 103(6):1142-1148, December 2005.

Background: The effects of anesthetics on airway protective reflexes have not been extensively characterized in children. The aim of this study was to compare the laryngeal reflex responses in children anesthetized with either sevoflurane or propofol under two levels of hypnosis using the Bispectral Index score (BIS). The authors hypothesized that the incidence of apnea with laryngospasm evoked by laryngeal stimulation would not differ between sevoflurane and propofol when used in equipotent doses and that laryngeal responsiveness would be diminished with increased levels of hypnosis.
Methods: Seventy children, aged 2-6 yr, scheduled to undergo elective surgery were randomly allocated to undergo propofol or sevoflurane anesthesia while breathing spontaneously through a laryngeal mask airway. Anesthesia was titrated to achieve the assigned level of hypnosis (BIS 40 +/- 5 or BIS 60 +/- 5) in random order. Laryngeal and respiratory responses were elicited by spraying distilled water on the laryngeal mucosa, and a blinded reviewer assessed evoked responses.
Results: Apnea with laryngospasm occurred more often during anesthesia with sevoflurane compared with propofol independent of the level of hypnosis: episodes lasting longer than 5 s, 34% versus 19% at BIS 40 and 34% versus 16% at BIS 60; episodes lasting longer than 10 s, 26% versus 10% at BIS 40 and 26% versus 6% at BIS 60 (group differences P < 0.04 and P < 0.01, respectively). In contrast, cough and expiration reflex occurred significantly more frequently in children anesthetized with propofol.
Conclusion: Laryngeal and respiratory reflex responses in children aged 2-6 yr were different between sevoflurane and propofol independent of the levels of hypnosis examined in this study.

Frontal Slab Composite Magnetic Resonance Neurography of the Brachial Plexus: Implications for Infraclavicular Block Approaches.
Raphael, David T. M.D., Ph.D.; McIntee, Diane M.S.; Tsuruda, Jay S. M.D.; Colletti, Patrick M.D.; Tatevossian, Ray M.D.
Anesthesiology. 103(6):1218-1224, December 2005.

Background: Magnetic resonance neurography (MRN) is an imaging method by which nerves can be selectively highlighted. Using commercial software, the authors explored a variety of approaches to develop a three-dimensional volume-rendered MRN image of the entire brachial plexus and used it to evaluate the accuracy of infraclavicular block approaches.
Methods: With institutional review board approval, MRN of the brachial plexus was performed in 10 volunteer subjects. MRN imaging was performed on a GE 1.5-tesla magnetic resonance scanner (General Electric Healthcare Technologies, Waukesha, WI) using a phased array torso coil. Coronal STIR and T1 oblique sagittal sequences of the brachial plexus were obtained. Multiple software programs were explored for enhanced display and manipulation of the composite magnetic resonance images. The authors developed a frontal slab composite approach that allows single-frame reconstruction of a three-dimensional volume-rendered image of the entire brachial plexus. Automatic segmentation was supplemented by manual segmentation in nearly all cases. For each of three infraclavicular approaches (posteriorly directed needle below midclavicle, infracoracoid, or caudomedial to coracoid), the targeting error was measured as the distance from the MRN plexus midpoint to the approach-targeted site.
Results: Composite frontal slabs (coronal views), which are single-frame three-dimensional volume renderings from image-enhanced two-dimensional frontal view projections of the underlying coronal slices, were created. The targeting errors (mean +/- SD) for the approaches-midclavicle, infracoracoid, caudomedial to coracoid-were 0.43 +/- 0.67, 0.99 +/- 1.22, and 0.65 +/- 1.14 cm, respectively.
Conclusion: Image-processed three-dimensional volume-rendered MNR scans, which allow visualization of the entire brachial plexus within a single composite image, have educational value in illustrating the complexity and individual variation of the plexus. Suggestions for improved guidance during infraclavicular block procedures are presented.

Comparison of Morphine, Ketorolac, and Their Combination for Postoperative Pain: Results from a Large, Randomized, Double-blind Trial.
Cepeda, Maria Soledad M.D., Ph.D.; Carr, Daniel B. M.D.; Miranda, Nelcy R.N. ; Diaz, Adriana M.D.; Silva, Claudia M.D.; Morales, Olga M.D.
Anesthesiology. 103(6):1225-1232, December 2005.

Background: Meta-analyses report similar numbers needed to treat for nonsteroidal antiinflammatory drugs (NSAIDs) and opioids. Differences in baseline pain intensity among the studies from which these numbers needed to treat were derived may have confounded the results. NSAIDs have an opioid-sparing effect, but the importance of this effect is unclear. Therefore, the authors sought to compare the proportions of subjects who obtain pain relief with ketorolac versus morphine after surgery and to determine whether the opioid-sparing effect of an NSAID reduces the magnitude of opioid side effects.
Methods: The study was a double-blind, randomized controlled trial. The authors randomly assigned 1,003 adult patients to receive 30 mg ketorolac or 0.1 mg/kg morphine intravenously. They calculated the proportion of subjects who achieved at least 50% reduction in pain intensity 30 min after analgesic administration. Further, so long as pain intensity 30 min after analgesic administration was 5 or more out of 10, patients received 2.5 mg morphine every 10 min until pain intensity was 4 or less out of 10. The authors assessed the presence of opioid-related side effects.
Results: Five hundred patients received morphine and 503 received ketorolac. Fifty percent of patients in the morphine group achieved pain relief, compared with 31% in the ketorolac group (difference, 19%; 95% confidence interval, 13-25%). The ketorolac-morphine group required less morphine (difference, 6.5 mg; 95% confidence interval, -5.8 to -7.2) and had a lower incidence of side effects (difference, 11%; 95% confidence interval, 5-16%) than the morphine group.
Conclusions: Opioids are more efficacious analgesics than NSAIDs, although historic data for these two drugs yield similar numbers needed to treat. Adding NSAIDs to the opioid treatment reduces morphine requirements and opioid-related side effects in the early postoperative period.

A New Inguinal Approach for the Obturator Nerve Block: Anatomical and Randomized Clinical Studies.
Choquet, Olivier M.D.; Capdevila, Xavier M.D., Ph.D.; Bennourine, Khaled M.D.; Feugeas, Jean-Louis M.D.; Bringuier-Branchereau, Sophie M.Sc.; Manelli, Jean-Claude M.D.
Anesthesiology. 103(6):1238-1245, December 2005.

Background: Obturator nerve block is highly recommended for knee surgery in addition to a femoral nerve block. The main disadvantage of the classic approach at the pubic tubercle is low patient acceptance due to pain and discomfort. The authors hypothesized that the use of a new inguinal obturator nerve block technique would reduce pain and discomfort in patients.
Methods: The inguinal approach was simulated in five fresh cadavers. Injection of latex was performed in two cadavers. The location of the needle and the extent of latex solution were analyzed. Fifty patients scheduled to undergo arthroscopic knee surgery were randomly assigned to receive obturator nerve block using either the inguinal (n = 25) or the pubic tubercle approach (n = 25).
Results: In all cadavers, the needle was close to the obturator nerve branches, which were surrounded by the latex solution. In the clinical study, visual analog scale pain scores and discomfort of block placement were significantly lower in the inguinal group compared with the pubic tubercle group (P < 0.01). In the inguinal group, there was a significant decrease in block performance time (P < 0.05) and in bolus of propofol and fentanyl used for the procedure (P < 0.01). Twenty minutes after application of the block, adductor strength decrease, occurrence, and location of cutaneous distribution of the obturator nerve were not significantly different between the groups. The incidence of minor complications was significantly increased in the pubic tubercle group (P < 0.05). No major complications were observed.
Conclusions: The new inguinal approach decreases patient discomfort and pain of block placement as well as the time and sedation and analgesics required for a similar quality of sensory and motor block compared with the pubic tubercle approach.

ACTA ANAESTHESIOLOGICA SCANDINAVICA - VOLVER ARRIBA

Acta Anaesthesiologica Scandinavica
Volume 50 Page 19 - January 2006
doi:10.1111/j.1399-6576.2005.00882.x

Volume 50 Issue 1

http://www.blackwell-synergy.com/doi/full/10.1111/j.1399-6576.2005.00882.x

Postoperative outcome among elderly patients after general anesthesia
Y. Kojima and M. Narita

Background: Preoperative decision-making for elderly patients requires a long-term perspective. The aim of this study was to identify preoperative risk factors for decreased 1- to 5-year survival rates and to compare the survival rates of stratified risk groups with those of the sex- and age-matched general population.
Methods: Subjects were 406 patients, aged 80 years or older, who underwent surgery with general anesthesia. Higher age, male sex, dependency in daily living, low serum albumin level, malignancy, abdominal surgery, emergency surgery and high ASA class were analyzed for survival using univariate and multivariate analysis with Cox's proportional hazard model. One- to 5-year survival rates were estimated using life table analysis for patients divided by risk factors. The survival data were also compared with the cumulative survival rates of the sex- and age-matched general population.
Results: Multivariate analysis identified three factors that were significantly associated with decreased survival rates: male sex, dependency in daily living and abdominal surgery. Long-term survival among patients older than 90 years was comparable to those of the general population. Although improved in recent years, overall survival rates were much lower than expected due to poor outcome among patients dependent in daily living and those who underwent abdominal surgery.
Conclusions: In patients 80 years or older who underwent surgery with general anesthesia, independent risk factors for decreased survival are male sex, dependency in daily living and abdominal surgery. Only patients independent in daily living who underwent non-abdominal surgery had survival rates comparable to those of the general population.

Acta Anaesthesiologica Scandinavica
Volume 50 Page 26  - January 2006
doi:10.1111/j.1399-6576.2005.00866.x

Volume 50 Issue 1

 http://www.blackwell-synergy.com/doi/full/10.1111/j.1399-6576.2005.00866.x

Supplemental 80% oxygen does not attenuate post-operative nausea and vomiting after breast surgery
S. Purhonen, M. Niskanen, M. Wüstefeld, E. Hirvonen and M. Hynynen

Background: Although supplemental oxygen has been shown to be as effective as ondansetron in the prevention of post-operative nausea and vomiting (PONV) in one study in abdominal surgery patients, the antiemetic efficacy of supplemental oxygen is controversial on the basis of studies with other patients. We compared the efficacy of 80% and 30% oxygen in decreasing PONV in breast surgery. Ondansetron was used as an active control.
Methods: Ninety patients were given a standardized sevoflurane anesthetic. They were randomly assigned to three groups: 30% oxygen in nitrogen and saline 2 ml intravenously (i.v.) at the end of surgery (group 30); 80% oxygen in nitrogen and saline 2 ml (group 80); and 30% oxygen in nitrogen and ondansetron 4 mg (group O). Oxygen was administered during surgery and up to 2 h after surgery.
Results: The incidence of total response (no retching or vomiting, no nausea) during the first 24 post-operative hours was not different between group 80 (17%) and group 30 (11%) but was higher in group O (43%) than in group 30 (P < 0.05). Compared with group O, patients in group 80 experienced more vomiting during the study period 0–24 h (66% vs. 32%; P < 0.05) and more nausea during the period 6–24 h (72% vs. 39%; P < 0.05). There was no difference between the groups in their risk for PONV, pain scores, opioid consumption, or patient satisfaction.
Conclusions: In this study, supplemental 80% oxygen administration failed to decrease PONV in breast surgery.

Acta Anaesthesiologica Scandinavica
Volume 50 Page 112  - January 2006
doi:10.1111/j.1399-6576.2006.00874.x

Volume 50 Issue 1

http://www.blackwell-synergy.com/doi/full/10.1111/j.1399-6576.2006.00874.x 

Transarterial block as an addition to a conventional catheter technique improves the axillary block
T. Kjelstrup

Background: We have had favourable experience with a triple injection technique, combining an axillary catheter technique with a transarterial axillary block. This method has been used successfully for routine surgery and re-implantation of fingers, hand or forearm. We hypothesized that with this technique, block onset time and effectiveness are better than with a conventional catheter technique, and designed a study comparing this new technique with a conventional single injection through a catheter.
Methods: Fifty-one adult patients were included in a prospective study. In all patients, a short axillary plexus catheter was positioned close to the median nerve. All patients had an injection through the catheter, while 26 of the patients had an additional injection behind, and in front of, the axillary artery. Sensory and motor block were tested continuously every minute for 29 min. Block success was recorded as onset time to analgesia, anaesthesia and complete motor block in the first 29 min. At 30 and 50 min, an analgesia block score was recorded.
Results: The transarterial injection plus catheter method was more effective, with a higher success rate and faster onset, than the catheter method. Readiness for surgery with analgesia in the median, radial and ulnar nerves was achieved in the catheter group in 13 patients (52%) at a mean time of 20.8 min, and in the combined group in 21 patients (81%) at a mean time of 13.3 min (P < 0.05, P < 0.05). At 50 min the situation was 17 (68%) and 24 (92%), respectively (P < 0.05).
Conclusion: The combined triple injection is faster and more effective than the catheter method alone.

BRITISH JOURNAL OF ANAESTHESIA - TOP

Fluid absorption in endoscopic surgery (REVIEW)
R. G. Hahn
British Journal of Anaesthesia 2006 96(1):8-20

Fluid absorption is an unpredictable complication of endoscopic surgery. Absorption of small amounts of fluid (1–2 litre) occurs in 5–10% of patients undergoing transurethral prostatic resection and results in an easily overlooked mild transurethral resection (TUR) syndrome. Large-scale fluid absorption is rare but leads to symptoms severe enough to require intensive care. Pathophysiological mechanisms consist of pharmacological effects of the irrigant solutes, the volume effect of the irrigant water, dilutional hyponatraemia and brain oedema. Other less widely known factors include absolute losses of sodium by urinary excretion and morphological changes in the heart muscle, both of which promote a hypokinetic circulation. Studies in animals, volunteers and patients show that irrigation with glycine solution should be avoided. Preventive measures, such as low-pressure irrigation, might reduce the extent of fluid absorption but does not eliminate this complication. Monitoring the extent of absorption during surgery allows control of the fluid balance in the individual patient, but such monitoring is not used widely. However, the anaesthetist must be aware of the symptoms and be able to diagnose this complication. Treatment should be based on administration of hypertonic saline rather than on diuretics. New techniques, such as bipolar resectoscopes and vaporizing instead of resecting tissue, result in a continuous change of the prerequisites for fluid absorption and its consequences.

CANADIAN JOURNAL OF ANESTHESIA - TOP

Cognitive function is minimally impaired after ambulatory surgery
Barnaby Ward, FRCA, Charles Imarengiaye, DA, Javad Peirovy, MD and Frances Chung, FRCPC
Canadian Journal of Anesthesia 52:1017-1021 (2005)
 
Purpose: To evaluate the magnitude of subjective cognitive failure in the three days following general anesthesia (GA) for ambulatory surgery.
Methods: After Research Ethics Board approval, 258 patients undergoing general anesthesia (GA) and 250 patients scheduled for local anesthesia (LA) were recruited from our ambulatory surgical unit. Following the method of Tzabar, Asbury and Millar, patients were asked to complete the cognitive failures questionnaire (CFQ) before their procedure (with respect to the previous three days) and on the third postoperative day (with respect to their recovery period).
Results: General anesthesia and LA groups were similar in demographic make-up, except that the LA group contained more patients of American Society of Anesthesiologists physical status I (64.5% vs 52.7%, P < 0.05) and had significantly shorter procedure duration (25 vs 51 min, P < 0.01) than the GA group. Median preoperative CFQ scores (interquartile range) were 26 (18) for the LA group and 26 (18) for the GA group. Postoperative CFQ scores were 25 (20) for the LA group and 28 (22) for the GA group. There was no significant difference in preoperative CFQ score between groups (Mann-Whitney U). When preoperative and postoperative CFQ scores were compared, the small increase seen in the GA group was statistically significant (P < 0.05, Wilcoxon).
Conclusion: A statistically significant impairment of cognitive function in the three days following GA, but not LA was found. However, the magnitude of this impairment was small, and is of doubtful clinical significance. Modern ambulatory anesthesia may cause less delayed cognitive impairment than was previously thought.

Frequency and implications of ambulatory surgery without a patient escort
Frances Chung, FRCPC, Ngozi Imasogie, FRCA, Joyce Ho, Xiangqun Ning, MD, Atul Prabhu, FRCA and Bruna Curti, RN
Canadian Journal of Anesthesia 52:1022-1026 (2005)

Purpose: A study was undertaken to identify the characteristics and outcomes of ambulatory surgical patients without an escort.
Clinical features: During a 38-month period, the incidence of patients without an escort at one tertiary care institution was 0.2% (60/28,391). Five patients had their surgery cancelled. The other 55 patients had their surgery performed. Two groups of patients without an escort were identified: patients who were known not to have an escort preoperatively, and patients with "no show" escort. The number of patients with no show escort is much higher than the number of patients who were known not to have an escort preoperatively. The outcome of the no escort patients was compared with the matched control group of patients with an escort. There were no differences in the rates of unanticipated admission, emergency visits or read-mission into the hospital within 30 days comparing the group of patients with and without an escort.
Conclusions: The absence of an escort in ambulatory surgical patients occurs in 0.2% of surgeries, and varies according to the type of service. The number of patients with no show escort is higher than the number of patients with known no escort preoperatively.

Bilateral hearing loss following a retrobulbar block
Ronald B. George, MD and Jason Hackett, RRT
Canadian Journal of Anesthesia 52:1054-1057 (2005)

Purpose: Regional anesthesia is the most commonly used oph-thalmological anesthetic technique in Canada and the United States. Brainstem anesthesia is not an uncommon complication of retrobulbar blocks. Anesthesiologists are a prominent ele-ment in the ophthalmology suite, in part due to the complica-tions possible with regional anesthesia. This is the first reported case of complete bilateral hearing loss following a retrobulbar block.
Clinical features: A 46-yr-old male with type 1 diabetes mel-litus presenting for ophthalmological surgery had a retrobulbar block performed by the ophthalmologist. Local anesthetic was injected through a 25 G, 1.5 inch needle, entering the orbit infe-riorly on the temporal third of the lower lid. Shortly after the block was completed the patient experienced sudden hearing loss. On examination the hearing loss appeared to be complete and bilateral. The patient was alert and oriented; the remainder of the cranial nerve exam was normal. The patient’s hearing loss gradually improved and three hours after the block his hearing had subjectively returned to normal.
Conclusion: Brainstem anesthesia is not a rare complication of regional anesthesia for ophthalmological surgery. Symptoms include confusion, mental agitation, dizziness, blurred vision or blindness, ophthalmoplegia, deafness, tinnitus, dysphagia, dys-arthria, respiratory depression to apnea, and/or limb paralysis. A connection between the subdural and subarachnoid spaces and the optic sheath exists. The effect on the central nervous system depends upon the amount of local anesthetic injected and the area to which it spreads.

Preoperative screening for sickle cell disease in children: clinical implications
Mark W. Crawford, MBBS FRCPC, Seth Galton, MBBS FRCA and Mohamed Abdelhaleem, MD FRCPC PhD
Canadian Journal of Anesthesia 52:1058-1063 (2005)
 
Purpose: Preoperative screening of at-risk patients for sickle cell disease (SCD) is recommended as a method to decrease perioperative morbidity. However, the effectiveness of pre-operative screening in accomplishing this goal has never been demonstrated. We undertook a retrospective study to determine the prevalence of positive test results among those screened preoperatively at our institution and to determine whether amendments to present screening guidelines can be recommended.
Methods: The hematology laboratory database of a university teaching hospital was searched to identify all patients who underwent preoperative screening for SCD from October 1999 to October 2003. The medical records of those patients testing positive were reviewed.
Results: Of 1,906 children screened preoperatively, 79 (4.1%) were diagnosed as having sickle cell trait and three (0.16%) as having some form of SCD: one had homozygous hemoglobin S and two had sickle-hemoglobin C disease. Two of the three had a family history for SCD and none had a preoperative hemoglobin concentration < 10 g·dL–1. No patient developed perioperative sickle-related complications.
Conclusion: Preoperative screening of 1,906 children identified only one asymptomatic child with undiagnosed SCD and a negative family history, suggesting that routine preoperative screening for SCD is rarely of significant clinical value in our population. Had preoperative screening not been performed, no child requiring preoperative transfusion would have been missed, representing a long-run probability of at least 99.84% that no at-risk child would require transfusion. We recommend that preoperative screening for SCD be undertaken selectively, giving consideration to the risks and benefits of screening to the individual patient.

Remifentanil decreases sevoflurane requirements in children
Damian J. Castanelli, MBBS Fanza, William M. Splinter, MD FRCPC and Natalie A. Clavel, BSc
Canadian Journal of Anesthesia 52:1064-1070 (2005)

Purpose: To establish the effect of increasing concentrations of remifentanil on sevoflurane requirements in children.
Methods: Fifty-eight healthy patients, ASA status I–II aged two to 12 yr, undergoing abdominal wall hernia or hydrocele repairs were serially assigned to one of four test groups to receive remifentanil 0.03 µg·kg^-1·min^-1, 0.06 µg·kg^-1·min^-1, 0.12 µg·kg^-1·min^-1, or 0.25 µg·kg^-1·min^-1 iv. Patients received a bolus of remifentanil 1 µg·kg^-1 iv before the infusion began. End-tidal sevoflurane concentration was adjusted according to a Dixon up-and-down approach. Ten minutes after starting the remifentanil infusion, the surgical incision was made. The patient was observed for one minute from the time of incision by a solitary blinded rater for either flexion or withdrawal of one or more extremities in response to skin incision.
Results: The mean minimum alveolar concentration of sevoflurane was 2.39 ± 0.58 with 0.03 µg·kg^-1·min^-1 remifentanil, 1.91 ± 0.36 with 0.06 µg·kg^-1·min^-1 remifentanil, and 0.92 ± 0.11 with 0.12 µg·kg^-1·min^-1 remifentanil. Remifentanil 0.25 µg·kg^-1·min^-1 lead to the sevoflurane being decreased to a level associated with spontaneous patient awakening.
The effective dose (ED50) values of sevoflurane were 2.44 [95% confidence interval (CI) 2.16–2.72], 2.00 (95% CI 1.78–2.22), and 1.18 (95% CI 0.99–1.36) for remifentanil infusion rates of 0.03 µg·kg^-1·min^-1, 0.06 µg·kg^-1·min^-1, and 0.12 µg·kg^-1·min^-1 respectively.
Conclusion: The administration of remifentanil produced a dose-dependent decrease in the minimum alveolar concentration of sevoflurane necessary for inhibition of movement reaction in response to surgical incision. The use of remifentanil may allow for flexible analgesic control and rapid recovery in children anesthetized with sevoflurane.


PUB MED - TOP

Increasing Operating Room Efficiency Through Parallel Processing
David M. Friedman, MD, Suzanne M. Sokal, MSPH, Yuchiao Chang, PhD, and David L. Berger, MD
Ann Surg 2006;243: 10–14

Objective: Because of rising costs and shrinking reimbursements, hospitals must continually find ways to improve efficiency and productivity. This study attempts to increase caseloads in ambulatory surgery operating rooms while maintaining patient satisfaction and safety.
Summary Background Data: In most hospitals, patients move through their operative day in a linear fashion, starting at registration and finishing in the recovery room. Given this pattern, only 1 patient may occupy the efforts of the operating room team at a time. By processing patients in a parallel fashion, operating room efficiency and patient throughput are increased while costs remain stable.
Methods: Patients undergoing hernia repairs under local anesthesia with intravenous sedation were divided into a control group and an experimental group. Patients in the control group received their local anesthesia in the operating room at the start of the surgery. The experimental group patients received their local anesthesia in the induction room by the surgeon while the operating room was being cleaned and set up.
Results: While operative time for the control group and the experimental group were nearly identical, the turnover time and the induction time were significantly shorter for the experimental group. The cumulative reduction in time during the operative day was sufficient to allow the addition of new operative cases.
Conclusions: This study demonstrates a system of increasing operating room efficiency by changing patient flow rather than simply working to streamline existing steps. This increase in efficiency is not associated with the expansion of hospital budgets or a decrease in patient safety or satisfaction.

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