Evaluation of the variability of anesthetic practice in a single institution
Lee, Joshua Donguk
MetadataShow full item record
Anesthetics are provided to millions of patients every year in the United States mostly by anesthesiologists. However, there is a lack of literature or documentation on how anesthetics are administered by various anesthesia providers. In order to have a better understanding on the pattern, we performed retrospective chart review on anesthetic practice for surgical atrial septal defect repair procedures performed in Boston Children's Hospital. Our collected data included: premedication, anesthesia induction methods, anesthesia maintenance methods, choice of vasoactive agents, analgesics, and intravenous accesses, extubation in the operating room, postoperative sedation, and choice of antiemetics and postoperative nausea and vomiting. In addition, the studied patients were divided into two groups based on the institutional initiation of the Fast-track protocol: before and after the implementation of the Fast-track protocol (the Non-fast-track group and the Fast-track group). Some results fell under expectation; for example, in the Non-fast-track group, all patients who were induced intravenously were older than 10 years old, and received propofol for induction, which is the most popular choice of intravenous induction drug. The Fast-track group showed a similar trend; 80% of all intravenously induced patients were 10 years or older and induced with propofol. Also, in both groups, anesthesia was maintained with the combination of IV and volatile anesthetics. An anticipated change in practice pattern was seen in the Fast-track group for the choice of analgesics and postoperative sedation for non-extubated patients; acetaminophen was introduced as an adjunct to other analgesics, and propofol infusion was introduced as a standard drug of postoperative sedation for non-extubated patients, both of which are part of the Fast-track protocol. Interestingly, however, overall intraoperative opioid doses did not show any change. The variation in the choice of intravenous access showed difference before and after the Fast-track implementation; in the Non-fast-track group, extra jugular vein was accessed as the most popular choice, whereas in the Fast-track group, central venous line was the most popular choice. Also, the incidence of postoperative nausea and vomiting was notably lower in patients who were not given anti-emetics after the Fast-track protocol implementation. This calls for a need for a future research on what part of the Fast-track protocol could have resulted this improvement without intraoperative administration of regular anti-emetics. Overall, our results provide future directions for researches on anesthetic practice that may help improve patient safety and efficiency beyond the practice in Boston Children's Hospital.