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Unintentionally retained surgical items (RSIs) are a serious complication representing a surgical "Never" event. The authors previously reported the process and significant improvement over a 3-year multiphased quality improvement RSI reduction effort that included sponge-counting technology. Herein, they report the sustainability of that effort over the decade following the formal quality improvement project conclusion. This retrospective analysis includes descriptive and qualitative data collected during RSI event root cause analysis. Between January 2009 and December 2019, 640 889 operations were performed with 24 RSIs reported. The resulting RSI rate of 1 per 26 704 operations represent a 486% performance improvement compared to the preintervention rate of 1 per 5500 operations. The interval, in days, between RSI events increased to 160 from 26 during the preintervention phase. Cotton sponges were the most retained RSI despite the use of sponge-counting technology. A significant and sustained reduction in RSI is possible after designing a sustainable comprehensive multidisciplinary effort.

Objective:Presently, evidence guiding clinicians on the optimal approach to safely screen patients for coronavirus disease 2019 (COVID-19) to a nonemergent hospital procedure is scarce. In this report, we describe our experience in screening for SARS-CoV-2 prior to semiurgent and urgent hospital procedures.Design:Retrospective case series.Setting:A single tertiary-care medical center.Participants:Our study cohort included patients ≥18 years of age who had semiurgent or urgent hospital procedures or surgeries.Methods:Overall, 625 patients were screened for SARS-CoV-2 using a combination of phone questionnaire (7 days prior to the anticipated procedure), RT-PCR and chest computed tomography (CT) between March 1, 2020, and April 30, 2020.Results:Of the 625 patients, 520 scans (83.2%) were interpreted as normal; 1 (0.16%) had typical features of COVID-19; 18 scans (2.88%) had indeterminate features of COVID-19; and 86 (13.76%) had atypical features of COVID-19. In total, 640 RT-PCRs were performed, with 1 positive result (0.15%) in a patient with a CT scan that yielded an atypical finding. Of the 18 patients with chest CTs categorized as indeterminate, 5 underwent repeat negative RT-PCR nasopharyngeal swab 1 week after their initial swab. Also, 1 patient with a chest CT categorized as typical had a follow-up repeat negative RT-PCR, indicating that the chest CT was likely a false positive. After surgery, none of the patients developed signs or symptoms suspicious of COVID-19 that would indicate the need for a repeated RT-PCR or CT scan.Conclusion:In our experience, chest CT scanning did not prove provide valuable information in detecting asymptomatic cases of SARS-CoV-2 (COVID-19) in our low-prevalence population.

A patient undergoing surgery may receive anesthesia care from several anesthesia providers. The safety of anesthesia care transitions has not been evaluated. Using unconditional and conditional multivariable logistic regression models, we tested whether the number of attending anesthesiologists involved in an operation was associated with postoperative complications.In a cohort of patients undergoing elective colorectal surgical in an academic tertiary care center with a stable anesthesia care team model participating in the American College of Surgeons National Surgical Quality Improvement Program, using unconditional and conditional multivariable logistic regression models, we tested adjusted associations between numbers of attending anesthesiologists and occurrence of death or a major complication (acute renal failure, bleeding that required a transfusion of 4 units or more of red blood cells within 72 hours after surgery, cardiac arrest requiring cardiopulmonary resuscitation, coma of 24 hours or longer, myocardial infarction, unplanned intubation, ventilator use for 48 hours or more, pneumonia, stroke, wound disruption, deep or organ-space surgical-site infection, superficial surgical-site infection, sepsis, septic shock, systemic inflammatory response syndrome).We identified 927 patients who underwent elective colectomy of comparable surgical intensity. In all, 71 (7.7%) patients had major nonfatal complications or death. One anesthesiologist provided care for 530 (57%) patients, 2 anesthesiologists for 287 (31%), and 3 or more for 110 (12%). The number of attending anesthesiologists was associated with increased odds of postoperative complication (unadjusted odds ratio [OR] = 1.52, 95% confidence interval [CI] 1.18-1.96, P = 0.0013; adjusted OR = 1.44, 95% CI 1.09-1.91, P = 0.0106). In sensitivity analyses, occurrence of a complication was significantly associated with the number of in-room providers, defined as anesthesia residents and nurse anesthetists (adjusted OR = 1.39, 95% CI 1.01-1.92, P = 0.0446) and for all anesthesia providers (adjusted OR = 1.58, 95%CI 1.20-2.08, P = 0.0012). Findings persisted across multiple, alternative adjustments, sensitivity analyses, and conditional logistic regression with matching on operative duration.In our study, care by additional attending anesthesiologists and in-room providers was independently associated with an increased odds of postoperative complications. These findings challenge the assumption that anesthesia transitions are care neutral and not contributory to surgical outcomes.

Objective Endoscopic/colonoscopic procedures are either done with gastroenterologist-administered conscious sedation or with anesthesia-administered sedation with propofol. There are potential benefits to anesthesia-administered sedation, but the concern has been the associated increased cost. Methods To perform this study, we used the time-derived activity-based costing (TDABC) technique to accurately assess the true cost of gastrointestinal procedures done with gastroenterologist-administered conscious sedation vs anesthesia-administered sedation in 2 areas of our practice that use predominantly conscious sedation or anesthesia-administered sedation. This type of study has never been reported using such an integrated approach. This study was performed on 2 different days in June 2015. Results The true cost associated with anesthesia-administered sedation in our practice was associated with only 9% to 24% greater cost when the TDABC technique was applied. Conclusion Gastrointestinal procedures with anesthesia-administered sedation are not as costly when all factors are considered. Using novel approaches to cost measurement, such as the TDABC, allows a total cost measurement approach across an episode of care that existing cost measurements in health care are incapable of.

BACKGROUND Patients with polycythemia vera (PV) have historically been considered to be at high risk for perioperative hemorrhagic and thromboembolic complications. However, no recent studies have compared these outcomes between treated PV patients and patients without PV undergoing similar procedures. STUDY DESIGN AND METHODS Patients with PV who underwent surgery with anesthesia from June 1, 2006, to May 31, 2011, were randomly matched (sex, age, type of surgical procedure, surgical year) at a ratio of 1:4 with control patients without PV. Conditional logistic regression analysis adjusting for surgical duration, preoperative hemoglobin, platelet count, and cardiovascular disease was used to assess the association between PV and blood product transfusions, thromboembolism, and other major cardiovascular and pulmonary complications. RESULTS Fifty-six PV patients who underwent 79 surgeries were matched with 312 controls. During hospitalization, 35 (44.3%) and 82 (25.9%) PV and control patients, respectively, were transfused with blood products. PV patients were at increased risk for transfusion intraoperatively (odds ratio [OR], 4.35; 95% confidence interval [CI], 1.79-10.57; p = 0.001) and during hospitalization (OR, 4.35; 95% CI, 1.84-10.31; p

In our large academic supervisory practice, attending anesthesiologists concomitantly care for multiple patients. To manage communications within the procedural environment, we use a proprietary electronic computer-based anesthesiology visual paging system. This system can send an emergency page that instantly alerts the attending anesthesiologist and other available personnel that immediate help is needed. We analyzed the characteristics of intraoperative emergency pages in children and adults.We identified all emergency page activations between January 1, 2005 and July 31, 2010 in our main operating rooms. Electronic medical records were reviewed for rates and characteristics of pages such as primary etiology, performed interventions, and outcomes.During the study period, 258,135 anesthetics were performed (n = 32,103 children, younger than 18 years) and 370 emergency pages (n = 309 adults, n = 61 children) were recorded (1.4 per 1000 cases; 95% confidence interval, 1.3-1.6). Infants had the highest rates (9.4 per 1000; 95% confidence interval, 5.7-14.4) of emergency page activations (P0.001 compared with each other age group). In adults, the most frequent causes were hemodynamic (55%), and in children respiratory and airway (60.7%) events.Emergency pages were rare in patients older than 2 years. Infants were more likely than children 1 to 2 years of age to have emergency page activation, despite both groups being cared for by pediatric fellowship trained anesthesiologists.

To investigate the characteristics of women who have kidney injury during pregnancy.Medical records of all women who gave birth at our institution between January 1, 2005, and December 31, 2010, were retrospectively reviewed electronically. We identified those who incurred a kidney injury [defined by modified Acute Kidney Injury Network (AKIN) criteria: serum creatinine (sCr) increase ≥0.3 mg/dL] during pregnancy or within 30 days postpartum. Identified case records were reviewed in detail.During the study period, 54 women had a kidney injury (0.4 % estimated incidence) with a mean (SD) increase in sCr of 0.46 (0.29) mg/dL; most injuries were AKIN stage 1 with transient increases in sCr. Most of the women (n = 48, 87.3 %) had substantial preexisting or pregnancy-associated comorbid conditions (e.g., kidney disease, hypertension, diabetes), complications (e.g., preeclampsia, HELLP syndrome), or a complicated obstetric course (hemorrhage, infections) that could have contributed to the development of a kidney injury. Two patients had AKIN stage 3 injuries: a previously healthy patient who had a massive hemorrhage during cesarean delivery, and a patient with a renal transplant who had deterioration and eventual postpartum failure of her transplanted kidney.The majority of pregnancy-associated kidney injuries were transient and occurred in women with substantial comorbid conditions or complicated pregnancies.

To study characteristics and outcomes associated with emergency response team (ERT) activation in postsurgical patients discharged to regular wards after anesthesia.We identified all ERT activations that occurred within 48 hours after surgery from June 1, 2008, through December 31, 2009, in patients discharged from the postanesthesia care unit to regular wards. For each ERT case, up to 2 controls matched for age (±10 years), sex, and type of procedure were identified. A chart review was performed to identify factors that may be associated with ERT activation.We identified 181 postoperative ERT calls, 113 (62%) of which occurred within 12 hours of discharge from the postanesthesia care unit, for an incidence of 2 per 1000 anesthetic administrations (0.2%). Multiple logistic regression analysis revealed the following factors to be associated with increased odds for postoperative ERT activation: preoperative central nervous system comorbidity (odds ratio [OR], 2.53; 95% confidence interval [CI], 1.20-5.32; P=.01), preoperative opioid use (OR, 2.00; 95% CI, 1.30-3.10; P=.002), intraoperative use of phenylephrine infusion (OR, 3.05; 95% CI, 1.08-8.66; P=.04), and increased intraoperative fluid administration (per 500-mL increase, OR, 1.06; 95% CI, 1.01-1.12; P=.03). ERT patients had longer hospital stays, higher complication rates, and increased 30-day mortality compared with controls.Preoperative opioid use, history of central neurologic disease, and intraoperative hemodynamic instability are associated with postoperative decompensation requiring ERT intervention. Patients with these clinical characteristics may benefit from discharge to progressive or intensive care units in the early postoperative period.

Operating rooms (ORs) are resource-intense and costly hospital units. Maximizing OR efficiency is essential to maintaining an economically viable institution. OR efficiency projects often focus on a limited number of ORs or cases. Efforts across an entire OR suite have not been reported. Lean and Six Sigma methodologies were developed in the manufacturing industry to increase efficiency by eliminating non-value-added steps. We applied Lean and Six Sigma methodologies across an entire surgical suite to improve efficiency.A multidisciplinary surgical process improvement team constructed a value stream map of the entire surgical process from the decision for surgery to discharge. Each process step was analyzed in 3 domains, ie, personnel, information processed, and time. Multidisciplinary teams addressed 5 work streams to increase value at each step: minimizing volume variation; streamlining the preoperative process; reducing nonoperative time; eliminating redundant information; and promoting employee engagement. Process improvements were implemented sequentially in surgical specialties. Key performance metrics were collected before and after implementation.Across 3 surgical specialties, process redesign resulted in substantial improvements in on-time starts and reduction in number of cases past 5 pm. Substantial gains were achieved in nonoperative time, staff overtime, and ORs saved. These changes resulted in substantial increases in margin/OR/day.Use of Lean and Six Sigma methodologies increased OR efficiency and financial performance across an entire operating suite. Process mapping, leadership support, staff engagement, and sharing performance metrics are keys to enhancing OR efficiency. The performance gains were substantial, sustainable, positive financially, and transferrable to other specialties.

OBJECTIVE To study whether allergy consultation and penicillin allergy skin testing affects the selection of antibacterial prophylaxis perioperatively in surgical patients with history of allergy to penicillin (HOAP). PATIENTS AND METHODS From January 1 through June 30, 2004, we compared 2 different models of practice at our institution. At the Preoperative Evaluation Clinic (POEC), all patients with HOAP are evaluated by an allergist and undergo skin testing for allergy to penicillin. At other (non-POEC) preoperative evaluation settings (OPES), patients with HOAP do not undergo allergy consultation and penicillin skin testing before surgery. Of the 4889 patients screened at the POEC during the study period, 412 consecutive patients with HOAP were included in the study. Of the 416 patients screened at OPES, 69 consecutive patients with HOAP were studied. Logistic regression was used to assess whether allergy consultation was associated with the choice of antibiotic for antibacterial prophylaxis perioperatively, after adjusting for age, sex, and type of surgery. RESULTS Perioperative cephalosporin use was greater among patients screened at POEC vs those screened at OPES (70% vs 39%, P P =.04 adjusted for age, sex, and type of surgery). Vancomycin use was lower for patients screened at POEC vs those screened at OPES (10% vs 28%, P P =.03 adjusted). CONCLUSION For patients with HOAP, evaluation at the POEC was associated with increased use of cephalosporin and decreased use of vancomycin.

John S. Lundy was able to accomplish three major goals during the early years of his stewardship of the section on anesthesia of the Mayo Clinic. In 1925, Lundy established the first anatomy lab at the Mayo Clinic. He believed that the lab would serve as a useful tool for teaching residents as well as research into regional anesthetic techniques. Second, Lundy desired to advance the science of anesthesiology. Lundy developed the concept of balanced anesthesia, pioneered the introduction of barbiturates to the practice of anesthesia, developed anesthesia section services for the use of ventilators, ventilator vests, oxygen tents, and nasal oxygen supplementation. Lastly, in 1935, he established the nation's first blood bank. Lundy and Ralph Tovell had the opportunity to do pioneering work in transfusion medicine, which led to an improvement in the quality of service, and patient safety. These three major accomplishments provided Lundy with abundant scientific material to present to the American Medical Association (AMA) in Chicago. These trips to Chicago allowed him to gain the ear of Olin West, Morris Fishbien, and James E. Pallin. Lundy was able to successfully lobby in 1939 for the creation of a section of anesthesia within the AMA. In 1940, Lundy's dream came true with the recognition of anesthesia as a specialty by the AMA.

Background Previous studies suggest that intraoperative anesthetic care may influence postoperative pain and recovery from surgery. The authors tested the hypothesis that the addition of intrathecal analgesia to general anesthesia would improve long-term functional status and decrease pain in patients undergoing radical retropubic prostatectomy. Methods One hundred patients received either general anesthesia supplemented with intravenous fentanyl or general anesthesia preceded by intrathecal administration of bupivacaine (15 mg), clonidine (75 microg), and morphine (0.2 mg). Patients and providers were masked to treatment assignment. All patients received multimodal pain management postoperatively. Primary outcomes included pain and functional status over the first 12 postoperative weeks. Results Patients receiving intrathecal analgesia required more intravenous fluids and vasopressors intraoperatively. Pain was well controlled throughout the study (mean numerical pain scores < 3 in both groups at all times studied). Intrathecal analgesia decreased pain and supplemental intravenous morphine use over the first postoperative day but increased the frequency of pruritus. Pain and functional status after discharge from the hospital did not differ between groups. Intrathecal analgesia significantly decreased the duration of hospital stay (from 2.8 +/- 2.0 to 2.1 +/- 0.5 days; P < 0.01) as a result of five patients in the control group who stayed in the hospital more than 3 days. Conclusions The benefits of improved immediate analgesia and decreased morphine requirements resulting from intrathecal analgesia must be weighed against factors such as pruritus, increased intraoperative requirement for fluids and vasopressors, and resources needed to implement this modality. Further studies are needed to determine the significance of the decrease in duration of hospital stay.

UNLABELLED For more than a century, Mayo Clinic has used various communication strategies to optimize the efficiency of physicians. Anesthesiology has used colored wooden tabs, colored lights, and, most recently, a distributed video paging system (VPS) that was near the end of its useful life. A computer-based anesthesiology paging system (CAPS) was developed to replace the VPS. The CAPS uses a hands-off paradigm with ubiquitous displays to inform the practice where personnel are needed. The system consists of a dedicated Ethernet network connecting redundant central servers, terminal servers, programmable keypads, and light-emitting diode displays. Commercially available hardware and software tools minimized development and maintenance costs. The CAPS was installed in >200 anesthetizing and support locations. Downtime for the CAPS averaged 0.144 min/day, as compared with 24.2 min/day for the VPS. During installation, neither system was available and the department used beepers for communications. With a beeper, the median response time of an anesthesiologist to a page from a beeper was 2.78 min, and with the CAPS 1.57 min; this difference was statistically significant (P = 0.021, t(67) = 2.36). We conclude that the CAPS is a reliable and efficient paging system that may contribute to the efficiency of the practice. IMPLICATIONS Mayo Clinic installed a computer-based anesthesiology paging system (CAPS) to inform operating suite personnel when assistance is needed in procedure and recovery areas. The CAPS is more reliable than the system it replaced. Anesthesiologists arrive at a patient's bedside faster when they are paged with the CAPS than with a beeper.

PHEOCHROMOCYTOMAS ARE pharmacologically volatile, potentially lethal catecholamine-containing tumors of chromaffin tissue.1 They are usually found in the adrenal medulla, but they may occur wherever chromaffin tissue is located. Chromaffin cells are associated with the celiac, mesenteric, renal, adrenal, hypogastric, testicular, and paravertebral sympathetic nerve plexus. The major sites where pheochromocytomas occur are the adrenal medulla (90%), the paraganglia cells of the sympathetic nervous system, and the organ of Zuckerkandl.2 Approximately 10% of sporadic and 50% of familial adrenal tumors are bilateral, and approximately 10% of pheochromocytomas are multiple in location at the time of presentation.3 Paragangliomas are derived from neural crest cells that migrate in close association with autonomic ganglion cells, and all paragangliomas have the capacity to secrete catecholamines.4,5 Functional paragangliomas that secrete norepinephrine can occur and present similarly to pheochromocytoma. The proportion of catecholamine-secreting paragangliomas is thought to be high for adrenal pheochromocytomas, intermediate for aorticosympathetic and visceroautonomic tumors, and low for paragangliomas of the head and neck, also known as glomus tumors.5 Paragangliomas may present as painless swellings in the neck overlying the carotid bifurcation. These are also called carotid body tumors or chemodectomas.5 Of paragangliomas, 10% are malignant, but they can be locally invasive and can cause cranial nerve palsies.4 The resection of a pheochromocytoma or biochemically active paraganglioma has great potential for intraoperative and postoperative complications owing to release of catecholamines during manipulation of the tumor. Significant hemodynamic and metabolic effects are associated with a sudden decrease in catecholamine levels after removal of a tumor.6 In a series of 138 patients undergoing resection of pheochromocytoma tumors in a variety of anatomic locations between 1926 and 1970, surgical mortality was 2.9%.7 Desmonts et al8 reported a 3.9% mortality rate in their series of 102 patients between 1964 and 1976. A more recent series of 143 patients who underwent pheochromocytoma or paraganglioma resection showed no mortality and the absence of perioperative myocardial infarctions or cerebrovascular accidents.9 Advances in localization techniques, medical management, and anesthetic management have resulted in improved surgical outcomes.10 PRESENTATION

Patients with polycythemia vera (PV) have historically been considered to be at high risk for perioperative hemorrhagic and thromboembolic complications. However, no recent studies have compared these outcomes between treated PV patients and patients without PV undergoing similar procedures.Patients with PV who underwent surgery with anesthesia from June 1, 2006, to May 31, 2011, were randomly matched (sex, age, type of surgical procedure, surgical year) at a ratio of 1:4 with control patients without PV. Conditional logistic regression analysis adjusting for surgical duration, preoperative hemoglobin, platelet count, and cardiovascular disease was used to assess the association between PV and blood product transfusions, thromboembolism, and other major cardiovascular and pulmonary complications.Fifty-six PV patients who underwent 79 surgeries were matched with 312 controls. During hospitalization, 35 (44.3%) and 82 (25.9%) PV and control patients, respectively, were transfused with blood products. PV patients were at increased risk for transfusion intraoperatively (odds ratio [OR], 4.35; 95% confidence interval [CI], 1.79-10.57; p = 0.001) and during hospitalization (OR, 4.35; 95% CI, 1.84-10.31; p 0.001). The likelihood of thromboembolic complications and/or other major complications did not differ between the two study groups (thromboembolic-OR 1.53, 95% CI 0.39-6.02, p = 0.540; other major complications-OR 2.15, 95% CI 0.93-4.96, p = 0.073).Medically managed PV patients had an increased likelihood of receiving blood products perioperatively. Given the low number of observed thromboembolic events, we cannot make definitive conclusions regarding the association between PV and thromboembolism.

Background and Objectives. Preoperative time spent with patients has been abbreviated with the advent of same-day admission requirements and outpatient surgery. This study was conducted to evaluate the effects that materials mailed to the home relating to anesthetic-focused patient education may have on preoperative patient anxiety. Methods. Patients scheduled for a total hip arthroplasty or for a total knee arthroplasty were screened via telephone for inclusion in a prospective, randomized study. Patients were asked about their access to a video cassette recorder/player (VCR) and their limitations regarding hearing or vision. Subjects were randomly assigned to either the intervention group and received two pamphlets and a video describing general and regional anesthesia or to the usual care group. All subjects were mailed a preoperative demographic questionnaire and a State Trait Anxiety Inventory (STAI), as developed by CD Spielberger (1). Questionnaires were completed at least 96 hours prior to admission and again preoperative on the day of surgery. Results. Of 236 patients screened, 26 had no access to a VCR, 6 were hearing or visually impaired, and 4 declined participation. Of 200 subjects randomized, 134 completed both sets of questionnaires and thus form the basis of this report. A statistically significant difference between the subjects who received the video and pamphlets and the usual care subjects was detected with respect to change in STAI-assessed anxiety from baseline to immediately prior to surgery (P = .035). The intervention subjects experienced a smaller mean increase in anxiety. Forty-nine percent of the usual care subjects expressed interest in having additional information. Conclusions. Increase in preoperative anxiety is diminished when additional anesthesia information in printed and video format is made available. Useful information can be provided to patients to view or read prior to surgery.

Advanced liver disease is associated with increased risk for postoperative complications. It is not well known whether the presence of nonalcoholic steatohepatitis (NASH) in morbidly obese patients contributes to the rate of postoperative complications. The main objective was to study the association between NASH and postoperative complications in bariatric patients.A total of 340 contemporary sequential patients who underwent laparoscopic bariatric operations and who had intraoperative liver biopsies were studied. The rates of severe postoperative complications were compared across three patient groups-those with (1) no liver disease or with simple steatosis, (2) mild nonalcoholic NASH [steatosis with necroinflammation and mild fibrosis (stage 0-1)], and (3) advanced NASH [steatosis, necroinflammation, and more advanced fibrosis (stage ≥ 2)].Of 340 patients, 141 (42%) had no NASH, and 151 (44%) and 48 (14%) had mild and advanced NASH, respectively. Superobesity (P = 0.037), diabetes (P 0.001), and cerebrovascular disease (P = 0.013) had highest frequencies in patients with advanced NASH. Hypertension was highly prevalent in cohort (57%) but similarly distributed across three groups. Forty-five patients experienced at least one complication (pulmonary 4, cardiovascular 8, surgical 16, and acute kidney injury 21). The complications rate did not differ significantly across NASH categories. Median hospital stay was 3 days (IQR 2, 3), and it was not associated with NASH severity. There were no 30-day postoperative deaths.Despite the high prevalence of NASH among morbidly obese surgical patients, this condition was not associated with increased risk for postoperative complications. Postoperative acute kidney injury was the most frequent single complications.

Objective: To study a possible association between obstructive sleep apnea (OSA) severity, managed with noninvasive ventilation, and nonalcoholic steatohepatitis (NASH) in bariatric surgical patients. Methods: Medical records of 218 bariatric surgical patients who underwent liver biopsy were reviewed. OSA severity was determined from preoperative polysomnography (apnea-hypopnea index (AHI) ≤ 15 no/mild OSA vs. AHI ≥ 16 moderate/severe OSA). Patients diagnosed with OSA were prescribed noninvasive ventilation. Patients were categorized according to liver histopathology into 3 groups: i) no liver disease or simple steatosis, ii) mild NASH (steatosis with necroinflammation and mild fibrosis (stage 0–1)), and iii) advanced NASH (steatosis with necroinflammation and more advanced fibrosis (stage ≥ 2)). Results: 125 patients (57%) had no/mild OSA, and 93 (43%) had moderate/severe OSA. There was no difference in serum aminotransferases between patients by OSA severity classification. There was a high prevalence of hepatic histopathological abnormalities: 84% patients had steatosis, 57% had necroinflammation, 34% had fibrotic changes, and 14% had advanced NASH. There was no association between severity of NASH and severity of OSA. Conclusions: There is no association between stage of steatohepatitis and OSA severity among morbidly obese patients managed with noninvasive ventilation.

To review the anesthetic management and perioperative outcomes of patients diagnosed with Brugada syndrome (BrS) who were treated at a single centre and to compare those results with a comprehensive review of the existing literature.A retrospective chart review of anesthesia records from patients diagnosed with BrS at the Mayo Clinic was undertaken with the emphasis on administered drugs, ST segment changes, and occurrence of complications, including death, hemodynamic instability, and dysrhythmias. Eight patients were identified who underwent a total of 17 operative procedures from 2000 through 2010. A total of 20 significant ST segment elevations were recorded in four patients, several of which occurred in close temporal relation to anesthetic drug administration. These elevations resolved uneventfully. There were no recorded dysrhythmias, and recovery from anesthesia proceeded uneventfully. A literature review of patients with BrS yielded 52 anesthetics in 43 patients. The only recorded complications included unmasking of a Brugada ECG pattern, one episode of polymorphic ventricular tachycardia, which converted spontaneously to sinus rhythm, and one episode of postoperative ventricular fibrillation in the setting of epidural anesthesia.In this series and in the literature, BrS patients tolerated anesthesia without untoward disease-related complications. Propofol and local anesthetics carry a theoretical risk of arrhythmogenic potential in BrS patients, but clear evidence is lacking. However, awareness of their potential to induce arrhythmias warrants caution, especially with propofol infusions. Factors that might exacerbate ST segment elevations and subsequently lead to dysrhythmias (e.g., hyperthermia, bradycardia, and electrolyte imbalances, such as hyper- and hypokalemia and hypercalcemia) should be avoided or corrected.

We reviewed the results of preoperative screening laboratory tests in asymptomatic healthy patients who underwent elective surgical procedures at our institution in 1988. Substantially abnormal results were found in 160 of 3,782 patients. All such abnormalities involved five tests: aspartate aminotransferase, glucose, potassium, platelet count, and hemoglobin. Thirty of the abnormal test results were predictable on the basis of the history or physical examination. The abnormal test result prompted further assessment in 47 patients. No surgical procedure was delayed, and no association was noted between adverse outcome and any preoperative laboratory abnormality. Because of our findings in this analysis and similar studies on specific tests from other institutions, we no longer require preoperative laboratory screening tests for healthy patients.

Infection is a potentially life-threatening complication of central venous catheterization. Although line-related bacteremias and sepsis are relatively uncommon, the frequent use of central lines in the intensive-care unit makes these infections a common consideration. Semiquantitative culture techniques for analysis of the catheter tip provide evidence for the diagnosis of catheter-related infections. Bacterial growth of more than 15 colony-forming units/plate is typically considered significant. Preventive measures include using sterile insertion techniques, providing meticulous care for the local site, and minimizing the duration of catheter use. The practice of changing lines over a guidewire is controversial. For treatment of most catheter-related infections, the catheter should be removed and antibiotics should be administered if associated systemic infection occurs.

Better perioperative and operative management techniques have contributed to an improvement in the success rate of pancreas transplantation. Because of a shortage of donor organs, the criteria for acceptability of the allograft have been liberalized, and the development of techniques such as combined liver and pancreas procurement has increased allograft availability. Major advances have been made in organ preservation. Currently, pancreas allografts can routinely be stored for 18 to 24 hours. The technique of pancreaticoduodenal transplantation with a duodenocystostomy for the exocrine drainage is widely used. Experience with anesthetic and intensive-care unit management of these patients is accumulating. With the evolution of pancreas transplantation and with the help of the excellent transplant centers in our area, we developed a pancreas transplantation protocol and performed transplantation based on this protocol in 16 recipients at the Mayo Clinic from October 1987 through December 1988.

Background The US Food and Drug Administration issued a black box warning regarding the use of droperidol and the potential for torsade de pointes (TdP). Methods The primary objective of this retrospective study was to determine whether low-dose droperidol administration increased the incidence of TdP in the general surgical population during a 3-yr time period before and after the Food and Drug Administration black box warning. A random sample of 150 surgical patients during each time interval was selected to estimate the droperidol use for each time period. Results During the time period before the black box warning (July 1, 1998 to June 30, 2001), 2,321/139,932 patients (1.66%) had QT prolongation, TdP, or death within 48 h after surgery. We could identify no patients who clearly developed TdP before the black box warning. There was one patient for whom the cause of death could not positively be ruled out as due to TdP. In the time period after the black box warning (July 1, 2002 to June 30, 2005), 2,207 patients (1.46%) had documented QT prolongation, TdP, or death within 48 h after surgery, including only two cases ( Conclusions This indicates that the Food and Drug Administration black box warning for low dose droperidol is excessive and unnecessary.

Amyloidosis is a rare disease process that results in the deposition of insoluble, fibrous amyloid proteins in extracellular spaces and tissues. Amyloid fibrils can be deposited locally or may involve every organ system of the body. Advancements in the treatment for amyloidosis allow longer survival, and patients are being seen in our operating rooms for diagnostic, interventional, and curative purposes. Amyloidosis has numerous implications for anesthesia providers due to the possibility of systemic involvement. This course describes 2 cases of amyloidosis and discusses the types of amyloidosis and their anesthetic implications.

Previous studies suggest that intraoperative anesthetic care may influence postoperative pain and recovery from surgery. The authors tested the hypothesis that the addition of intrathecal analgesia to general anesthesia would improve long-term functional status and decrease pain in patients undergoing radical retropubic prostatectomy.One hundred patients received either general anesthesia supplemented with intravenous fentanyl or general anesthesia preceded by intrathecal administration of bupivacaine (15 mg), clonidine (75 microg), and morphine (0.2 mg). Patients and providers were masked to treatment assignment. All patients received multimodal pain management postoperatively. Primary outcomes included pain and functional status over the first 12 postoperative weeks.Patients receiving intrathecal analgesia required more intravenous fluids and vasopressors intraoperatively. Pain was well controlled throughout the study (mean numerical pain scores3 in both groups at all times studied). Intrathecal analgesia decreased pain and supplemental intravenous morphine use over the first postoperative day but increased the frequency of pruritus. Pain and functional status after discharge from the hospital did not differ between groups. Intrathecal analgesia significantly decreased the duration of hospital stay (from 2.8 +/- 2.0 to 2.1 +/- 0.5 days; P0.01) as a result of five patients in the control group who stayed in the hospital more than 3 days.The benefits of improved immediate analgesia and decreased morphine requirements resulting from intrathecal analgesia must be weighed against factors such as pruritus, increased intraoperative requirement for fluids and vasopressors, and resources needed to implement this modality. Further studies are needed to determine the significance of the decrease in duration of hospital stay.

The types of agents implicated to trigger intraoperative anaphylactic reactions vary among reports, and there are no recent series from the United States. In this retrospective study, we examined perioperative anaphylactic reactions that occurred at a major tertiary referral academic center.To characterize perioperative allergens associated with anaphylactic reactions, we reviewed the Mayo Clinic Division of Allergic Diseases skin test database between 1992 to 2010. The records of all patients who were tested for perioperative and anesthetic medications were reviewed. Charts that included a detailed history obtained by an allergist, skin test results, and tryptase measurements when available were reviewed and categorized.Thirty-eight patients were found to have an anaphylactic reaction during anesthesia, of which 18 were immunoglobulin (Ig)E-mediated anaphylactic reactions (likely causative agent identified by skin test), 6 were non-IgE-mediated anaphylactic reactions (elevated tryptase levels and negative skin test), and 14 were probable non-IgE-mediated anaphylactic reactions (tryptase levels normal or not obtained and negative skin test). Of the IgE-mediated anaphylactic reactions, antibiotics were the most prevalent likely causative agent (50%) whereas neuromuscular blocking drugs were implicated as a likely causative agent in 11% of reactions.Antibiotics were the most common likely causative agent associated with IgE-mediated anaphylactic reactions; however, for 52.6% of reactions, a causative agent could not be determined, suggesting a non-IgE-mediated anaphylactic reaction. The undiagnosed allergic reactions place patients at risk of a subsequent reexposure to the same allergen, or lead to unnecessary avoidance of needed medications.

P ostoperative hoarseness is a complication of endotracheal intubation. Important etiologies may include airway instrumentation with resultant edema, granuloma or nodule formation, hematoma, arytenoid dislocation, and vocal cord paralysis (1). However, the development of unilateral vocal cord paralysis postoperatively may also be caused by abnormal cardiac and/or vascular anatomy induced by specific disease states. Several disease-induced changes in cardiovascular and pulmonary anatomy cause impaired conduction through the left recurrent laryngeal nerve (2–6). We present such a case that occurred postoperatively in a patient with left atrial enlargement secondary to mitral regurgitation and significant pulmonary hypertension whose injury was initially attributed to endotracheal intubation for a surgical procedure.

Transcutaneous pulse oximetry is increasingly being used to supplant arterial blood gas measurement as a means to monitor oxygenation. Previous studies have demonstrated that, despite inadequate ventilation, oxygenation can be maintained during delivery of supplemental oxygen by a process known as diffusion respiration. In this setting, severe hypercapnia and acidosis rapidly develop. This case report demonstrates that pulse oximetry is an unreliable means to monitor adequacy of ventilation. A 75-year-old woman in good health suffered a fracture of the right hip that necessitated arthroplasty. During postoperative recovery, she remained unresponsive while receiving 100% oxygen through an endotracheal tube; mechanical ventilation was not used. Pulse oximetry indicated a blood oxygen saturation of 94 to 96%; however, results of blood gas studies 3 1/2 hours postoperatively revealed profound hypercapnia (arterial carbon dioxide tension, 265 mm Hg) and acidosis (pH, 6.65) but confirmed normal oxygen levels (arterial oxygen tension, 213 mm Hg). Assisted ventilation resulted in normalization of the blood gases and an improved level of consciousness. The patient was then transferred to Mayo Clinic Rochester and had an uneventful recovery.

Objective To estimate the frequency of perioperative morbidities in patients who underwent anesthesia and a surgical procedure with no preoperative laboratory testing. Material and Methods We conducted an electronic database search of medical records of 56,119 patients who underwent surgical or diagnostic procedures and anesthesia at Mayo Clinic Rochester in 1994 and found 5,120 who had no laboratory tests done within 90 days before the procedure. From this group, we randomly selected 1,044 patients (87 from each month) to document the absence of preoperative tests, the presence of preexisting disease (by organ system), the type of anesthetic agent, and the outcomes and tests intraoperatively and postoperatively. Results The 1,044 patients ranged in age from 0 to 95 years (median age, 21). No deaths or major perioperative morbidities occurred (0.0%; exact 95% confidence interval, 0.00 to 0.35 %). Although 10 patients underwent blood typing and screening for antibodies immediately preoperatively, no blood transfusions were necessary. Intraoperatively, 17 laboratory tests and 1 electrocardiogram were obtained, and 3 results were abnormal. Postoperatively, 42 blood tests and 2 electrocardiographic procedures were per- formed. Five of the 42 blood tests showed abnormal results (hemoglobin levels in 3, serum sodium in 1, and arterial blood gases in 1). One electrocardiogram showed normal findings, and the other revealed normal results except for premature ventricular contractions. No laboratory test done intraoperatively or postoperatively was found to change surgical or medical management substantially. One patient who had unanticipated blood loss during an outpatient procedure was admitted to the hospital for observation. Conclusion All 1,044 patients, 97% of whom were relatively healthy, with no recent laboratory testing safely underwent anesthesia and an operation. We conclude that patients who have been assessed by history and physical examination and determined to have no preoperative indication for laboratory tests can safely undergo anesthesia and operation with tests obtained only as indicated intraoperatively and postoperatively. Current anesthetic and medical practices rapidly identify perioperative indications for laboratory evaluation as they arise.

A case of unilateral bronchospasm during pleurodesis in a patient with a history of recurrent pneumothorax and asthma is presented. The etiology of this event is not clear; however, it likely includes reflex parasympathetic bronchoconstriction due to physical stimulation of the pleural surface during pleurodesis. Treatment involved independent lung ventilation, corticosteroids, and aminophylline.