Will reducing anesthesia turn over time add a case?

Dr. Cartier

Decreases in Anesthesia-Controlled Time Cannot Permit One Additional Surgical Operation to Be Reliably Scheduled During the Workday.

Franklin Dexter, M.D., Ph.D.; Stacy Coffin, M.D.; and John H. Tinker, M.D.;Anesthesia & Analgesia, Vol. 81, pp. 1263-1268, 1995

            This study was designed in order to analyze how anesthesia controlled time (ACT) can be more effectively managed in order more efficiently treat patients, and thus optimizing the number of cases performed in a given work day.  ACT was defined as the time the patient arrived in the OR until the patient left the OR, minus the surgical case time.  709 consecutive cases were statistically analyzed, and the results showed that ACT would have to be decreased by over 100% in order to permit increasing the total number of cases by one case in a given workday.  This is a very interesting study.  It seems to indicate that at this particular facility the ACT was already fairly efficient if such a drastic improvement would be necessary in order to increase the case load by one, suggesting that perhaps other factors, such as surgical time, or check-in/nursing factors may need to be analyzed to more effectively operate more cases in one day.

Bis monitoring and recovery in Ambulatory Anesthesia

Dr. Cartier

Anesthesiology:

October 1997 - Volume 87 - Issue 4 - p 842–848

Song, Dajun MD, et al

“Titration of Volatile Anesthetics Using Bispectral Index Facilitates Recovery after Ambulatory Anesthesia”

This prospective, randomized study was designed to evaluate the usefulness of bispectral index (BIS) in the wake-up period of anesthesia.  Several groups were assigned to receive various forms of maintenance anesthesia, including Desflurane, Sevoflurane, nitrous oxide, and fentanyl, and some combinations thereof.  The control groups were blinded to the BIS number, while others attempted to titrate their anesthetics to approximately 60.  In the end, those anesthesia providers who used the BIS to titrate their anesthetics had higher BIS numbers, used less volatile anesthetics, and had quicker verbal responsiveness times.

Can you bypass PACU for Outpatient Knee Surgery?

Cameron Cartier, DO

Article Review

PACU Bypass after Outpatient Knee Surgery Is Associated with Fewer Unplanned Hospital Admissions but More Phase II Nursing Interventions

Anesthesiology:

October 2002 - Volume 97 - Issue 4 - pp 981-988

This prospective study was designed to compare post-operative complications of patients who bypassed PACU with those who went to PACU following outpatient knee surgery.  The patients receiving the outpatient knee surgery were evaluated based upon a new criteria to separate whether or not the patients would bypass the PACU.   Eighty-seven percent of the patients bypassed the PACU.  These patients required more nursing interventions in the step-down unit, but required less hospitalizations secondary to anesthetic complications.  This article shows that hospital based criteria may be considered in specific patient populations in order to help decrease the amount of recovery time needed for patients to help save the hospital time, money, and staff.

Does Decompressive Craneictomy Really Work? Dr. Cartier

Cameron Cartier, DO

Article Review

“Decompressive Craniectomy in Diffuse Traumatic Brain Injury”

NEJOM March 2011

            Decompressive craniectomy is a common neurosurgical operation used to help relieve increased intracranial pressure in the presence of diffuse traumatic brain injury in order to prevent further deleterious effects caused by secondary injury.  Despite the high volume of cases, there are not many studies investigating how beneficial it is to the long term outcome of the patient when compared to more conservative, medical management.  This prospective, multi-centered study assigned 155 patients over the course of eight years to groups who either received bifrontotemporoparietal decompressive craniectomy or a standard, medical management, including increased sedation, diuretics, and optimization of carbon dioxide levels.  This study showed that patients who underwent decompressive craniectomy versus medical management had less time with increased intracranial pressures and shorter stays in the ICU requiring mechanical ventilation.  However, these patients were shown to have worse long term outcomes when measured by the Extended Glascow Coma Scale.  These results, as admitted in the Discussion portion of the study, were contrary to the original hypothesis of the authors and prompts further studies investigating the overall impact on relatively common surgical approaches such as this. 

Propofol/Desflurane/Isoflurane in Morbid Obese Patients, Dr. Cartier

Cameron Cartier, DO

Article Review

Postoperative Recovery After Desflurane, Propofol, or Isoflurane Anesthesia Among Morbidly Obese Patients: A Prospective, Randomized Study

A & A September 2000 vol. 91 no. 3 714-719

Background:  Morbidly obese patients can present with several complications after surgery, one of which is delayed emergence times.

Results/Discussion: Patients were randomly selected to receive Desflurane, Propofol, or Isoflurane for maintenance of anesthesia during laparoscopic gastroplasties.  Patients who received Desflurane recovered more quickly and consistently, demonstrated higher oxygen saturation levels and were more mobile quicker than those patients who received Propofol or Isoflurane.  The article concludes with the recommendation that morbidly obese patients should receive Desflurane for anesthetic maintenance in order to improve postoperative status of the patient.

Case Study: Amniotic Fluid Embolism, Dr. Cartier

Cameron Cartier, DO

Case Scenario: Amniotic Fluid Embolism

Bruno Riou, MD, Ph D

Anesthesiology, January 2012 issue

          Amniotic fluid embolism is a rare condition found in the time period immediately prior, during and shortly after deliver which can have catastrophic consequences. This condition is very difficult to diagnose in the early stages and we do not currently have a precise pathophysiology cause to this condition, although it is thought to be partly immune mediated or anaphylactic in nature.  The diagnosis remains a diagnosis of exclusion, but should be considered in any peripartum patient that presents with any combination of acute hemodynamic collapse, respiratory distress/hypoxia, DIC and/or mental status change without any other medical explanation.

          Some early signs and symptoms include: acute dyspnea and/or cyanosis, sudden tachycardia, hypotension, acute agitation/ALOC, seizure, coagulopathy, sudden desaturation, loss of EtCO2, ST changes and fetal distress.

          The managemnt of this condition relies on early suspicion and early aggressive hemodynamic support. The main therapies include oxygenation, circulatory support and correction of coagulopathy. Immediate Cesarian section improves neonatal neurological recovery and overall maternal outcome.

Epidural vs General for aortic surgery, Dr. Cartier

Cameron Cartier, DO

Journal of Cardiothoracic Anesthesia, Feb 2004

“Combined epidural and general anesthesia”

            Are epidurals associated with better patient outcome for infrarenal abdominal aortic surgery?  This particular study was a randomized, prospective study to test that hypothesis.  This study was carried out at New York Medical College, and randomly selected patients undergoing infrarenal abdominal aortic surgery into two groups: the first group received a combination of an epidural with “light” general anesthesia, and the second group received general anesthesia alone.  Great care was taken to monitor the hemodynamic status intra-operatively in both groups, as well as monitoring closely how patients did post-operatively.  After the cross-clamping of the aorta, the cardiac index and pulmonary capillary wedge pressures did not change significantly in the group that received the epidural, whereas the patients who received general anesthesia alone had a significant drop in cardiac index as well as an increase in pulmonary capillary wedge pressure.  Post-operatively, the patients who received the epidural demonstrated less incidence of ventilatory dependent respiratory failure, less vasodilatory requirements, and shorter stays in the ICU.  Based on these findings, this article recommends the use of combined epidural/general anesthesia for patients undergoing this particular surgery.  Possible limitations of this study are that this study was only performed in one hospital, which leads to a relatively small patient population