Narr, Bradly J.

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.

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.

BACKGROUNDPatients 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 METHODSPatients 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.RESULTSFifty‐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).CONCLUSIONSMedically 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 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 (<0.1%) of TdP. The incidence of droperidol exposure was approximately 12% (exact 95% confidence interval, 7.3-18.3%) before the black box warning and 0% after placement of the black box warning on droperidol. Therefore, we estimate that approximately 16,791 patients (95% confidence interval, 10,173-25,607) were exposed to droperidol, none of whom experienced documented TdP. Conclusions This indicates that the Food and Drug Administration black box warning for low dose droperidol is excessive and unnecessary.

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.