BACKGROUND:The authors used a nursing task inventory system to assess nursing resources for patients with and without adverse postoperative events in the postanesthesia care unit (PACU).METHODS:Over 3 months, 2,031 patients were observed, and each task/activity related to direct patient care was recorded and assigned points according to the Project Research in Nursing (PRN) workload system. PRN values for each patient were merged with data from an anesthesia database containing demographics, anesthesia technique, and postoperative adverse events. Mean and median PRN points were determined by age, sex, duration of procedure, and mode of anesthesia for patients with and without adverse events in the PACU. Three theoretical models were developed to determine the effect of differing rates of adverse events on the requirements for nurses in the PACU.RESULTS:The median workload (PRN points) per patient was 31.0 (25th-75th percentile, 25-46). Median workload was 26 points for patients with no postoperative events and 155 for > or = six adverse events. Workload varied by type of postoperative event (e.g., unanticipated admission to the intensive care unit, median workload = 95; critical respiratory event = 54; and nausea/vomiting = 33). Monitored anesthesia care or general anesthesia with spontaneous ventilation used less resources compared with general anesthesia with mechanical ventilation. Modeling various scenarios (controlling for types of patients) showed that adverse events increased the number of nursing personnel required in the PACU.CONCLUSIONS:Nursing care documentation based on requirements for individual patients demonstrates that the rate of postoperative adverse events affects the amount of nursing resources needed in the PACU.

Since postoperative pain is associated with morbidity and increased hospital resources, reducing pain should improve patient care. Enhanced education and individualized feedback were introduced at the study hospital to promote anesthesiologists' use of patient-controlled analgesia, nonsteroidal antiinflammatory drugs, epidural morphine, and nerve blocks. After 6-mo baseline, anesthesiologists at the study hospital attended educational seminars and received literature about pain management. Personalized feedback forms were then distributed to each anesthesiologist showing the management and rates of pain for their patients. Practice was as usual at a control hospital. Pain in the postanesthesia care unit (PACU) and for 6-h post-PACU discharge was assessed using PACU records and interviews for 3413 patients at the study hospital and 1753 at the control hospital. From the baseline to the feedback period, the absolute increase in the proportion of patients receiving at least one promoted strategy was greater at the study hospital than at the control hospital (44.9% vs 22.8% P < 0.0001). Mean pain scores with activity decreased at both hospitals; study hospital 7.6 (7.3-7.8, 99% confidence interval) to 6.2 (5.9-6.5); control hospital 7.3 (6.9-7.6) to 6.1 (5.7-6.4). Education and feedback increased the use of pain management strategies at the study hospital. The modest change in patient outcome was unlikely related to directed interventions.

BACKGROUND:Because the ultimate purpose of new medical knowledge is to achieve improved health outcomes, physicians need to possess and use this knowledge in their practice. The authors introduced enhanced education and individualized feedback to reduce postoperative nausea and vomiting (PONV). The primary objective was to increase anesthesiologists' use of preventive measures to reduce PONV, and the secondary objective was to determine whether patient outcomes were improved. METHODS:After obtaining hospital ethics committee approval, the effect of education and feedback on anesthesiologist performance and the rate of PONV in major surgery elective inpatients during a 2-yr period was assessed. After baseline data collection (6 months), anesthesiologists at the study hospital received enhanced education (8 months) and individualized feedback (10 months). Parallel data collection was performed at a control hospital at which practice was continued as usual. The education promoted preventive measures (antiemetic premedication, nasogastric tubes, droperidol, metoclopramide). Individualized feedback provided the number of patients receiving promoted measures and the rate of PONV. The mean percentage of anesthesiologists' patients receiving at least one promoted measure and the rate of PONV were compared with baseline levels. RESULTS:At the study hospital, there was a significant increase in the mean percentage of the anesthesiologists' female patients receiving a preventive measure as well as a significant increase in the use of droperidol > or = 1 mg (P < 0.05) for all patients. The use of other promoted measures was unaffected. Absolute rates of PONV were unaffected at the study hospital until the post-feedback period (decrease of 8.8% between baseline and post-feedback (P = 0.015)). CONCLUSION:It was demonstrated that enhanced education and individualized feedback can change anesthesiologists' practice patterns. The actual benefit to patients from use of preventive measures was limited when used in the everyday clinical situation. Therefore, only modest decreases in PONV were achieved, despite the use of preventive measures.

BACKGROUND:The purpose of this study was to determine the relationship of four postanesthesia care unit (PACU) cardiovascular events to long-term outcomes (unplanned critical care admission or mortality) and to evaluate the contribution of anesthetic management compared with other perioperative factors in predicting these events. METHODS:For patients admitted to the PACU after receiving general anesthesia (n = 18,380), the risk of long-term outcomes was examined for patients in the PACU with hypertension, tachycardia, bradycardia, or hypotension. Using logistic regression (P < 0.05), risk factors (grouped as patients, surgical, anesthetic, operating room observations, and other PACU observations) for each cardiovascular event were determined. For each factor grouping, the relative contributions to each cardiovascular event were compared using maximum likelihood chi-square analysis. RESULTS:Patients in the PACU with hypertension or tachycardia had more unplanned critical care admissions (2.6% and 4.0% vs. 0.2% for patients with no events) and greater mortality (1.9% and 2.3% vs. 0.3% and 0.4%) (P < 0.01). For PACU hypertension (rate 2.0%), age, smoking, renal disease, female gender, and angina were significant risk factors. For PACU tachycardia (0.9%), intraoperative tachycardia and dysrhythmia were the major contributors. Patient factors also increased the risk of bradycardia (2.5%); namely age, ASA physical status 1 or 2, and preoperative beta blocker therapy. For hypotension (2.2%), duration of surgery > 2 h, completion after 6 PM, and gynecologic intraabdominal procedures were significant risk factors. Compared to patient, surgical, intraoperative, or PACU observations, anesthetic factors studied (premedication, induction agent, ventilation, use of opioids) provided only a small contribution in predicting these events. CONCLUSIONS:Hypertension and tachycardia in the PACU, although infrequent, are associated with increased risk of unplanned critical care admission and mortality. Patient, surgical, intraoperative, or PACU observations contribute more to cardiovascular events in the PACU than do differences in anesthetic management identified in this study.

BACKGROUND:Previous studies have noted a high incidence of adverse outcomes in the postanesthesia care unit (PACU), but few have examined associated factors and patient outcomes. To determine the frequency of acute, unanticipated respiratory problems and to examine the associated patient, surgical, and anesthetic factors, we prospectively collected preoperative, intraoperative, and postoperative data on 24,157 consecutive PACU patients who received a general anesthetic during a 33-month period. METHODS:A PACU critical respiratory event (CRE), was defined as any unanticipated hypoxemia (hemoglobin oxygen saturation < 90%), hypoventilation (respiratory rate < 8 breaths/min or arterial carbon dioxide tension > 50 mmHg) or upper-airway obstruction (stridor or laryngospasm) requiring an active and specific intervention (ventilation, tracheal intubation, opioid or muscle relaxant antagonism, insertion of oral/nasal airway or airway manipulation). These problems were documented by PACU nurses whereas data on case-mix, surgical factors, and intraoperative management were retrieved from the anesthetic record. Significant patient, surgical, and anesthetic factors were identified by logistic regression analysis. Other morbidity experienced by patients with a CRE was also noted. RESULTS:For patients given general anesthesia the risk of a CRE was 1.3% (hypoxemia 0.9%, hypoventilation 0.2%, airway obstruction 0.2%). Preoperative factors that increase risk were age > 60 yr, male gender, diabetes, and obesity (P < 0.05). Patients who underwent operative procedures on an emergency basis and whose operation was longer than 4 h were also at increased risk, but those undergoing perineal procedures were at lower risk (P < 0.05). Anesthetic risk factors (P < 0.05) included opioid premedication (relative odds 1.8), sedatives preoperatively (2.0), fentanyl > 2.0 micrograms.kg-1.h-1 as the sole opioid (1.9), fentanyl used in combination with morphine (1.6) and atracurium > or = 0.25 mg.kg-1.h-1 (2.2). Patients in whom anesthesia was induced with thiopental (relative odds 2.5), compared with those who received propofol for induction, were also at increased risk of a CRE. Patients with a CRE stayed longer in PACU, had higher rates of unanticipated admissions to the intensive care unit and were more likely to have PACU cardiac problems (P < 0.01). CONCLUSIONS:A CRE is relatively rare. Multiple patient and surgical factors and specific aspects of anesthetic management are associated with the occurrence of a CRE in the PACU.

It is assumed in many gas exchange equations that dead space (VD) is a constant fraction of tidal volume (VT) during anesthesia despite variations in respiratory pattern. We tested this assumption by measuring VD/VT ratios, using samples of mixed expired gas and arterial blood in 20 healthy anesthetized children (aged 1 to 17 years), divided into three groups. Group 1 was intubated; ventilation was controlled; total minute ventilation was held constant; and frequency (f) varied from 10 to 30/minute. Group 2 was intubated; breathing was spontaneous; and pattern was altered from fast and shallow to slow and deep. Group 3 was given mask anesthesia; breathing was spontaneous; and VD/VT was measured at fast frequency only. The inter-relationships of dead space to tidal volume varied with the type of ventilation. In group 1 VD increased in direct proportion to VT (mean slope 0.25 ± 0.05; p < 0.001). In group 2, VD was smaller and remained constant despite alterations in tidal volume (mean slope 0.09 ± 0.09; p > 0.05). Although VD/VT at the fast frequency was similar in the two groups, i.e., 0.35 in group 1 (f = 30) and 0.36 in group 2 (f = 35.6), differences became evident at slower frequencies. For a 50% reduction in frequency, VD/VT decreased only 15% during controlled ventilation, but 41% during spontaneous respiration. During mask anesthesia (group 3) VD/VT at a mean frequency at 29.4 was 0.55. For group 2 VD per kilogram was related to age by the equation VD/kg = 1.72–0.06 (age in years) ml at the fast frequency of 35.6 (n = 7; r = 0.73). The equation at a slower frequency of 23.2 was not significantly different. During mechanical ventilation the dead space volume was always larger than during spontaneous breathing and in addition was rate dependent. At f = 30, VD/kg = 2.78–0.10 (age in years) ml (n = 7, r = 0.80); at f = 10, VD/kg = 6.74–0.25 (age in years) ml (n = 7; r = 0.83). These measurements demonstrate that in children with spontaneous respiration, increases in tidal volume are distributed to perfused lung regions with a net decrease in VD/VT ratio. In contrast, with controlled ventilation wasted ventilation increases as VT is increased with no net change in VD/VT ratio.