Exploring phenotype-based ventilator parameter optimization to mitigate postoperative pulmonary complications: a retrospective observational cohort study.

Purpose: To identify tidal volume (V) and positive end-expiratory pressure (PEEP) associated with the lowest incidence and severity of postoperative pulmonary complications (PPCs) for each phenotype based on preoperative characteristics.

Methods: The subjects of this retrospective observational cohort study were 34,910 adults who underwent surgery, using general anesthesia with mechanical ventilation. Initially, the least absolute shrinkage and selection operator regression was employed to select relevant preoperative characteristics.

Fast-Tracking Patients in an Academic Hospital to Increase Efficiency and Decrease Discharge Delays: A Process Improvement Plan.

Purpose: The purpose of this quality improvement project was to determine if implementing a Phase II postanesthesia care unit (PACU II) to fast-track patients following surgery in an academic hospital would decrease OR hold times and increase patient flow efficiency.

Design: An observational pre-post design was used to compare PACU bypass rates and recovery times for ambulatory surgery (AS) patients before and after implementation of a patient fast-tracking program.

Methods: A PACU II was instituted and a fast-tracking program using the White Fast-Track Scoring tool was adopted.

Review of the Mechanisms of Ventilator Induced Lung Injury and the Principles of Intraoperative Lung Protective Ventilation.

Intraoperative ventilator induced lung injury is associated with development of postoperative pulmonary complications. Despite advances in modes and methods of mechanical ventilation, postoperative pulmonary complications remain as one of the leading causes of adverse outcomes following surgery and anesthesia. In an attempt to reduce the incidence of postoperative pulmonary complications, the use of an intraoperative ventilatory technique to minimize lung injury has been introduced.

Optimizing Intraoperative Fluid Replacement for Patients Receiving Mannitol During Neurosurgical Procedures: A Quality Improvement Initiative.

Patients undergoing craniotomy are at increased risk of intravascular volume changes due to the use of mannitol. This quality improvement project was conducted to implement a standardized goal-directed fluid therapy (GDFT) protocol using a dynamic physiologic measure in an attempt to maintain euvolemia in patients undergoing craniotomy with mannitol administration. An evidence-based GDFT protocol was integrated into an existing neurosurgical protocol.

Does Ultrasonographic Measurement of Gastric Content Influence Airway Management Decisions?

The presence of gastric content before induction of general anesthesia is the primary modifiable risk factor in the prevention of pulmonary aspiration. The purpose of this project was to determine if ultrasonography could be routinely used to measure gastric content and assign aspiration risk in patients undergoing general anesthesia. Preoperative gastric ultrasonography was performed in a convenience sample of 100 patients.

Evaluating a Quality Improvement Initiative to Increase Anesthesia Providers' Use of and Understanding of Quantitative Neuromuscular Monitors.

Improved understanding of the monitoring and dosing practices of anesthesia providers regarding neuromuscular blockade is necessary. The use of subjective methods such as peripheral nerve stimulation and clinical assessment tests can increase the risk of residual neuromuscular blockade and adverse postoperative outcomes. Quantitative monitoring of neuromuscular blockade is an alternative tool to peripheral nerve stimulation to guide neuromuscular blockade; however, it is rarely used by providers.

Lung-protective ventilation for the surgical patient: international expert panel-based consensus recommendations.

Postoperative pulmonary complications (PPCs) occur frequently and are associated with substantial morbidity and mortality. Evidence suggests that reduction of PPCs can be accomplished by using lung-protective ventilation strategies intraoperatively, but a consensus on perioperative management has not been established. We sought to determine recommendations for lung protection for the surgical patient at an international consensus development conference.

Preparing for Total Power Failure in the Operating Room.

Total electrical power failure in the operating room is an uncommon event, but when it occurs, it poses a major threat to patient safety. Perhaps the most curable threat to patient safety is the lack of provider knowledge regarding what equipment capabilities will be lost and how long devices will function on battery power. The purpose of this project was to determine the internal battery-related capabilities and duration of function of site-specific anesthesia equipment during a total power failure and to develop a power failure protocol.

Use of Near-Infrared Spectroscopy to Measure Tissue Oxygen Saturation During Total Knee Arthroplasty With Use of a Tourniquet.

The primary purpose of this proof-of-concept quality improvement effort was to evaluate the practicality of using near-infrared spectroscopy (NIRS) to measure tissue oxygen saturation (Sto) during total knee arthroplasty (TKA) with use of a tourniquet. NIRS sensors were applied to the biceps femoris (BF) and gastrocnemius (GS) muscles of both lower extremities of patients undergoing TKA procedures. For a convenience sample of 15 patients, measurement of Sto was attempted at baseline, following subarachnoid block administration, and after tourniquet inflation and deflation.

Low-Flow Domiciliary Oxygen as a Mechanism of Ongoing Oxidative Stress.

Background: Oxidative stress occurs when imbalances exist between the production of oxygen free radicals and endogenous antioxidants that neutralize their harmful effects, causing irreversible tissue damage. Oxygen free radicals readily interact with DNA, proteins, and lipids, instigating conformational changes to cellular structures and leading to derangement and dysfunction. Oxidative stress is a key feature in the pathology of COPD.

Nursing Perceptions and Workload Impact of a Standardized Emergence Delirium Assessment Scale in a Postanesthesia Care Unit.

Purpose: Emergence delirium (EDL) is a psychomotor behavioral phenomenon that occurs immediately after emergence from general anesthesia. EDL is nearly 1.5 times more common among military than nonmilitary patients.

Improving infection control practices of nurse anesthetists in the anesthesia workspace.

Background: Anesthesia providers commonly cross-contaminate their workspace and subsequently put patients at risk for a health care-acquired infection. The primary objective of this project was to determine if education and implementation of standardized infection control guidelines that address evidence-based best practices would improve compliance with infection control procedures in the anesthesia workspace.

Methods: Patient care-related hand hygiene of nurse anesthetists was observed in 3 areas of anesthesia practice before and 3 weeks and 3 months after staff education, placement of visual reminders, and the implementation of infection control guidelines.

Enhancing the Quality of the Anesthesia to Postanesthesia Care Unit Patient Transfer Through Use of an Electronic Medical Record-Based Handoff Tool.

Purpose: Anesthesia to postanesthesia care unit (PACU) handoffs are often incomplete, imprecise, and highly variable with respect to information transfer, and therefore can jeopardize patient safety. A standardized anesthesia to PACU electronic medical record (EMR)-based patient handoff checklist was implemented and evaluated for its effect on the information transfer.

Design: An observational preimplementation and postimplementation design was used.

Characterization of bilateral frontal lobe cerebral oxygen saturation in patients with mild traumatic brain injury.

Background: There is clear evidence of the potential for long-term neuro behavioral and cognitive sequelae following a mild traumatic brain injury (mTBI). Although the source of these persistent behavioral and cognitive issues is unclear, several studies have suggested a cerebral vascular disorder is a likely contributor.

Purpose: Measure and compare cerebral blood oxygen saturation values in frontal brain lobes of subjects with and without a history of mTBI.

Retinal oximetry measures systemic hypoxia in central nervous system vessels in chronic obstructive pulmonary disease.

Background: Determination of the blood oxyhemoglobin saturation in the retinal vessels of the eye can be achieved through spectrophotometric retinal oximetry which provides access to the state of oxyhemoglobin saturation in the central nervous system circulation. The purpose of this study was to test the capability of the Oxymap T1 oximeter to detect systemic hypoxemia and the effect of supplemental oxygen on retinal vessel oxyhemoglobin saturation.

Methods: Oxygen saturation of hemoglobin in retinal arterioles and venules was measured in 11 subjects with severe chronic obstructive pulmonary disease (COPD) on long term oxygen therapy.

Point-of-Contact Assessment of Nurse Anesthetists' Knowledge and Perceptions of Management of Anesthesia-Related Critical Incidents.

Most anesthesia providers will experience at least one perioperative critical incident during their career, potentially causing critical incident stress symptoms that may affect their ability to provide patient care. The purpose of this descriptive pilot investigation of Certified Registered Nurse Anesthetists (CRNAs) was to determine if their knowledge of the psychological and physical ramifications of critical incidents, coping strategies to deal with critical incident stress, and satisfaction with departmental handling of critical incidents improved when a formal, institutionally relevant critical incident stress management policy and protocol was developed and implemented. Knowledge of the effects of a critical incident, available coping strategies, and the perceived value of a stress management support protocol were assessed by surveys conducted before and after the implementation of a formal educational program.

Fast-tracking ambulatory surgery patients following anesthesia.

Purpose: The purpose of this process improvement project was to introduce and evaluate the efficacy of fast-tracking ambulatory surgical patients in a community hospital.

Design: An observational pre-post design was used, in which patient data from a reference period (pre-fast-tracking) was compared with patient data collected during an implementation period (post-fast-tracking).

Methods: Anesthesia providers were trained to use a tool to assess patients for eligibility to bypass the postanesthesia care unit (PACU).

A Theoretical Mathematical Model to Estimate Blood Volume in Clinical Practice.

Perioperative intravenous (IV) fluid management is controversial. Fluid therapy is guided by inaccurate algorithms and changes in the patient's vital signs that are nonspecific for changes to the patient's blood volume (BV). Anesthetic agents, patient comorbidities, and surgical techniques interact and further confound clinical assessment of volume status.

The accuracy of a near-infrared spectroscopy cerebral oximetry device and its potential value for estimating jugular venous oxygen saturation.

Background: An intriguing potential clinical use of cerebral oximeter measurements (SctO2) is the ability to noninvasively estimate jugular bulb venous oxygen saturation (SjvO2). Our purpose in this study was to determine the accuracy of the FORE-SIGHT(®) (CAS Medical Systems, Branford, CT), which is calibrated to a weighted average of 70% (SjvO2) and 30% arterial saturation, for Food and Drug Administration pre-market approval 510(k) certification by adapting an industry standard protocol, ISO 9919:2005 (www.ISO.

Chapter 1 posttraumatic stress disorder: a view from the operating theater.

Posttraumatic stress disorder (PTSD) is an anxiety disorder that develops following exposure to a traumatic event. The prevalence and symptom severity of PTSD is greater in military combat Veterans than the civilian population. Although PTSD is a psychiatric disorder, in Veterans, it is associated with several physical comorbidities, chronic pain, substance abuse, and worse self-reported health status which may predispose them to greater perioperative morbidity and mortality.

Effect of elective surgery on subjective health in veterans with chronic posttraumatic stress disorder.

Posttraumatic stress disorder (PTSD) is common, is often chronic, and has been associated with greater risk of postoperative mortality in veterans. The purpose of this study was to determine if elective outpatient surgery had a persistent effect on the physical or mental health of veterans with chronic PTSD. A longitudinal, quasi-experimental study was conducted that followed up 60 veterans with chronic PTSD over 12 weeks.

Reexamining traditional intraoperative fluid administration: evolving views in the age of goal-directed therapy.

Intraoperative volume administration has long been a topic of debate in the field of anesthesia. Only recently, however, has the conversation shifted to a discussion of appropriate intraoperative volume. A thorough review of the literature explores the history of today's widely accepted fluid administration equation and discusses possible explanations and consequences of iatrogenically induced hypervolemia.

Effects of elevated oxygen and carbon dioxide partial pressures on respiratory function and cognitive performance.

Hyperoxia during diving has been suggested to exacerbate hypercapnic narcosis and promote unconsciousness. We tested this hypothesis in male volunteers (12 at rest, 10 at 75 W cycle ergometer exercise) breathing each of four gases in a hyperbaric chamber. Inspired Po2 (PiO2 ) was 0.