Increased risk of unintentional dural puncture in night-time obstetric epidural anesthesia

Impact of Surgical Timing on Ventriculoperitoneal Shunt Failure Rates: A Population-Based Cohort Study

OBJECTIVE

Hydrocephalus is a common neurosurgical condition treated primarily through ventriculoperitoneal (VP) shunt placement. This study aims to investigate the relationship between the timing of VP shunt surgery (on-call vs. regular hours) and shunt failure rates.

METHODS

In this single-center, population-based observational cohort study, all adult patients who underwent VP shunt surgery were included. The main outcome was reoperation due to shunt failure within 12 months of the index surgery, comparing rates between procedures performed during regular hours and on-call periods. Adjustments for confounders were made using multivariable logistic regression.

RESULTS

Out of 810 cases included, 25% underwent surgery during on-call hours. Shunt failure occurred in 10% of cases, most often due to infection. Patients operated on during on-call hours had a significantly higher rate of shunt failure compared to those operated on during regular hours (17% vs. 7.9%, P < 0.001). However, after adjusting for confounders in a multivariable logistic regression, this relationship was no longer statistically significant (OR: 1.60, P = 0.073).

CONCLUSIONS

The rate of shunt failure was significantly greater in surgeries conducted during on-call hours as opposed to regular hours, but this was not statistically significant after adjusting for confounders. Therefore, the timing of VP shunt surgery may not be an independent risk factor for shunt failure. High-risk scenarios still deserve added caution, and further research is needed to identify factors influencing shunt outcomes and develop strategies to minimize failure rates.

Intrathecal catheter placement after inadvertent dural puncture in the obstetric population: management for labour and operative delivery. Guidelines from the Obstetric Anaesthetists' Association

BACKGROUND

Anaesthetists of all grades who work on a labour ward are likely to be involved in the insertion or management of an intrathecal catheter after inadvertent dural puncture at some point in their careers. Although the use of intrathecal catheters after inadvertent dural puncture in labour has increased in popularity over recent decades, robust evidence on best practice has been lacking.

METHODS

The Obstetric Anaesthetists' Association set up an expert working party to review the literature. A modified Delphi approach was used to produce statements and recommendations on insertion and management of intrathecal catheters for labour and operative delivery following inadvertent dural puncture during attempted labour epidural insertion. Statements and recommendations were graded according to the US Preventive Services Task Force grading methodology.

RESULTS

A total of 296 articles were identified in the initial literature search. Further screening identified 111 full text papers of relevance. A structured narrative review was produced which covered insertion of an intrathecal catheter; initial dosing; maintenance of labour analgesia; topping-up for operative delivery; safety features; complications; and recommended follow-up. The working party agreed on 17 statements and 26 recommendations. These were generally assigned a low or moderate level of certainty. The safety of mother and baby were a key priority in producing these guidelines.

CONCLUSIONS

With careful management, intrathecal catheters can provide excellent labour analgesia and may also be topped-up to provide anaesthesia for caesarean or operative vaginal delivery. The use of intrathecal catheters, however, also carries the risk of significant drug errors which may result in high- or total-spinal anaesthesia, or even cardiorespiratory arrest. It is vital that all labour wards have clear guidelines on the use of these catheters, and that staff are educated as to their potential complications.

Chronic consequences of accidental dural puncture and postdural puncture headache in obstetric anaesthesia - sieving through the evidence

PURPOSE OF REVIEW

Accidental dural puncture (ADP) and postdural puncture headache (PDPH) are relatively common complications of neuraxial anaesthesia and analgesia in obstetrics. Both may result in acute and chronic morbidity. This review intends to discuss the chronic implications of ADP and PDPH and raise awareness of severe and potentially life-threatening conditions associated with them.

RECENT FINDINGS

ADP may be associated with a high rate of PDPH, prolonged hospitalization and increased readmissions. Studies have shown that PDPH may lead to chronic complications such as post-partum depression (PPD), post-traumatic stress disorder (PTSD), chronic headache, backache and reduced breastfeeding rates. There are many case reports indicating that major, severe, life-threatening neurologic complications may follow PDPH in obstetric patients including subdural haematoma and cerebral venous thrombosis.

SUMMARY

Many clinicians still believe that ADP and PDPH are benign and self-limiting conditions whereas there may be serious and devastating consequences of both. It is imperative that all women with ADP and PDPH are appropriately diagnosed and treated.

Factors associated with an inadvertent dural puncture or post-dural puncture headache following labour epidural analgesia: A retrospective cohort study

Inadvertent dural puncture and post-dural puncture headache are complications of labour epidural analgesia and may result in acute and chronic morbidity. Identification of risk factors may enable pre-emptive management and reduce associated morbidity. In this retrospective cohort study, we aimed to identify factors associated with an inadvertent dural puncture or post-dural puncture headache by identifying parturients who received labour epidural analgesia from January 2017 to December 2021. The primary outcome was any witnessed inadvertent dural puncture, inadvertent placement of an intrathecal catheter, clinical diagnosis of post-dural puncture headache, or headache that was assessed to have characteristic post-dural puncture headache features. A wide range of demographic, obstetric, and anaesthetic factors were analysed using univariate and multivariable analyses to identify independent associations with the primary outcome. Data from 26,395 parturients were analysed, of whom 94 (0.36%) had the primary outcome. Within these 94 parturients, 26 (27.7%) had inadvertent dural puncture, 30 (31.9%) had inadvertent intrathecal catheter, and 38 (40.4%) had post-dural puncture headache without documented inadvertent dural puncture or intrathecal catheter insertion. Increased number of procedure attempts (adjusted odds ratio 1.39, 95% confidence interval 1.19 to 1.63), longer procedure duration adjusted odds ratio 1.03, 95% confidence interval 1.01 to 1.05), increased depth of epidural space (adjusted odds ratio 1.10, 95% confidence interval 1.04 to 1.18), greater post-procedure Bromage score (adjusted odds ratio 7.70, 95% confidence interval 4.22 to 14.05), and breakthrough pain (adjusted odds ratio 3.97, 95% confidence interval 2.59 to 6.08) were independently associated with increased odds of the primary outcome, while the use of standard patient-controlled epidural analgesia (PCEA) regimen (adjusted odds ratio 0.50, 95%confidence interval 0.31 to 0.81), increased concentration of ropivacaine (adjusted odds ratio 0.08 per 0.1%, 95% confidence interval 0.02 to 0.46), and greater satisfaction score (adjusted odds ratio 0.96, 95% confidence interval 0.95 to 0.97) were associated with reduced odds. The area under curve of this multivariable model was 0.83. We identified independent association factors suggesting that greater epidural depth and procedure difficulty may increase the odds of inadvertent dural puncture or post-dural puncture headache.

Fatigue among anaesthesiologists in Europe: Findings from a joint EBA/NASC survey

BACKGROUND

Anaesthesiologists deliver an increasing amount of patient care and often work long hours in operating theatres and intensive care units, with frequent on-calls and insufficient rest in between. In the long term, this will negatively influence mental and physical health and well being. As fatigue becomes more prevalent, this has predictable implications for patient safety and clinical effectiveness. 1.

OBJECTIVE

This study aimed to evaluate the prevalence, severity, causes and implications of work-related fatigue amongst specialist anaesthesiologists.

DESIGN

An online survey of specialist anaesthesiologists.

PARTICIPANTS

The survey was sent to anaesthesiologists in 42 European countries by electronic mail.

MAIN OUTCOME MEASURES

Responses from a 36-item online survey assessed work-related fatigue and its impact on anaesthesiologists in European countries.

RESULTS

Work-related fatigue was experienced in 91.6% of the 1508 respondents from 32 European countries. Fatigue was caused by their working patterns, clinical and nonclinical workloads, staffing issues and excessive work hours. Over 70% reported that work-related fatigue negatively impacted on their physical and mental health, emotional well being and safe commuting. Most respondents did not feel supported by their organisation to maintain good health and well being.

CONCLUSION

Work-related fatigue is a significant and widespread problem amongst anaesthesiologists. More education and increased awareness of fatigue and its adverse effects on patient safety, staff well being and physical and mental health are needed. Departments should ensure that their rotas and job plans comply with the European Working Time Directive (EWTD) and introduce a fatigue risk management system to mitigate the effects of fatigue.

Impact of fatigue on anaesthesia providers: a scoping review

BACKGROUND

Recently, fatigue has received more attention as a workplace hazard. This scoping review focuses on fatigue in anaesthesia providers. We explore the prevalence of fatigue in anaesthesia providers, and we examine how fatigue impacts their performance.

METHODS

A literature search was independently conducted from December 2019 through March 2020. The following four databases were consulted: MEDLINE, CINAHL, EMBASE, and PubPsych. Only studies discussing fatigue in anaesthesia providers were eligible.

RESULTS

The initial database search identified a total of 118 studies, of which 30 studies were included in the review. Eight articles concerned the prevalence of fatigue in anaesthesia providers, whereas 22 explored the impact of fatigue on the performance of anaesthesia providers. Up to 60.8% of anaesthesia providers suffered from severe excessive daytime sleepiness, and fatigue was denoted as a common workplace problem in up to 73.1% of anaesthesia providers. Fatigue had a negative influence on medication errors and vigilance, and it decreased the performance of anaesthesia providers during laboratory psychomotor testing. There was a decrease in non-technical skills (notably communication and teamwork) and worsening mood when fatigued.

CONCLUSIONS

Based on this scoping review, fatigue is a prevalent a phenomenon that anaesthesia providers cannot ignore. A combination of deterioration in non-technical skills, increased medication errors, loss of sustained attention, and psychomotor decline can lead to poorer performance and cause patient harm. Concrete strategies to mitigate fatigue should be developed.

Current Status of Clinical Engineer Anesthesia Assistants and Their Effect on Labor Task Shifting in Japan: A Prospective Observational Study in a Single Institute

Introduction:

Anesthesiologists are in short supply across the world, resulting in perpetually long working hours. To reduce the burden on anesthesiologists, tasks that can be performed by non-physicians must be shifted to other medical staff. In hospitals, clinical engineers can work as anesthesia assistants and perform some of the duties of anesthesiologists. This study aimed to evaluate the effect of task shift performed by clinical engineer anesthesia assistants (CEAAs).

Methods:

This was a 1-month prospective observational study that included 33 anesthesiologists (11 fellows and 22 certified anesthesiologists) and 11 CEAAs. The total activity and anesthesia times were extracted from the attendance record as indices of the anesthesiologists' work status. The CEAAs recorded the duration of work performed on behalf of the anesthesiologists as task shift time. The task shift rate was evaluated as follows: task shift time/(task shift time + total activity time) and task shift time/(task shift time) + (total anesthesia time).

Results:

The study period consisted of 19 weekdays. The average daily activity time of the anesthesiologists was 10.1 h, and the average anesthesia time was 8.5 h. The CEAAs performed a total of 546.8 h of task shift. The defined task shift rate was 20.1% when the total activity time was the denominator and 23.1% when the anesthesia time was the denominator.

Conclusions:

CEAAs might be effective in reducing the working hours of anesthesiologists through task shift. Their taking over a portion of the anesthesiologists' duties may allow the anesthesiologists to work more efficiently.

Late Surgical Start Time and the Effect on Rates of Complications in a Neurosurgical Population: A Prospective Longitudinal Analysis

OBJECTIVE

The after-hours effect on postoperative complications has been poorly studied in the neurosurgical literature. A recent retrospective analysis showed that patients with a surgical start time (SST) between 09:01 pm and 07:00 am had a greater risk of complications. This study used a prospective registry to examine the relationship between SST and postoperative complications in a large neurosurgical population.

METHODS

We performed a prospective longitudinal cohort analysis of all consecutive adult patients admitted to our neurosurgery service between October 1, 2018 and May 1, 2019. Complications were prospectively recorded and classified as surgical or medical. Univariate and multivariate logistic regressions were used to analyze these data.

RESULTS

Eighty-five surgical complications (6.6%) and 110 medical complications (8.6%) resulted from 1285 operations on 1145 patients. Later SST was predictive of complications in the emergent population (odds ratio [OR], 2.28; 95% confidence interval [CI], 1.01-5.15; P = 0.048) but not in the elective population. Extubation in the neurosurgical intensive care unit (NICU) versus the operating room strongly predicted medical complications (OR, 6.91; 95% CI, 3.33-14.34; P < 0.0001). Patients with a later SST were significantly more likely to be extubated in the NICU (P < 0.0001).

CONCLUSIONS

Patients undergoing emergent operations with a later SST were significantly more likely to have a postoperative complication. Patients who were extubated in the NICU versus the operating room were significantly more likely to have a medical complication. Patients were more likely to be extubated in the NICU if they had a later SST; therefore, SST may indirectly be associated with an increase in medical complications.

Effects of time of day on radiological interpretation

Accurate interpretation of radiological images involves a complex visual search that relies on several cognitive processes, including selective attention, working memory, and decision-making. Patient outcomes often depend on the accuracy of image interpretations, and yet research has revealed that conclusions vary significantly from one radiologist to another. A myriad of factors has been shown to contribute to the likelihood of interpretative errors and discrepancies, including the radiologist's level of experience and fatigue, and these factors are well reported elsewhere; however, a potentially important factor that has been given little previous consideration is how radiologists' interpretations might be impacted by the time of day at which the reading takes place, a factor that other disciplines have shown to be a determinant of competency. The available literature shows that while the time of day is known to significantly impact some cognitive functions that likely relate to reading competence, including selective visual attention and visual working memory, little is known about the impact of the time of day on radiology interpretation performance. This review explores the evidence regarding the relationship between time of day and performance, with a particular emphasis on radiological activities.

Association between night-time surgery and occurrence of intraoperative adverse events and postoperative pulmonary complications

BACKGROUND

The aim of this post hoc analysis of a large cohort study was to evaluate the association between night-time surgery and the occurrence of intraoperative adverse events (AEs) and postoperative pulmonary complications (PPCs).

METHODS

LAS VEGAS (Local Assessment of Ventilatory Management During General Anesthesia for Surgery) was a prospective international 1-week study that enrolled adult patients undergoing surgical procedures with general anaesthesia and mechanical ventilation in 146 hospitals across 29 countries. Surgeries were defined as occurring during 'daytime' when induction of anaesthesia was between 8:00 AM and 7:59 PM, and as 'night-time' when induction was between 8:00 PM and 7:59 AM.

RESULTS

Of 9861 included patients, 555 (5.6%) underwent surgery during night-time. The proportion of patients who developed intraoperative AEs was higher during night-time surgery in unmatched (43.6% vs 34.1%; P<0.001) and propensity-matched analyses (43.7% vs 36.8%; P=0.029). PPCs also occurred more often in patients who underwent night-time surgery (14% vs 10%; P=0.004) in an unmatched cohort analysis, although not in a propensity-matched analysis (13.8% vs 11.8%; P=0.39). In a multivariable regression model, including patient characteristics and types of surgery and anaesthesia, night-time surgery was independently associated with a higher incidence of intraoperative AEs (odds ratio: 1.44; 95% confidence interval: 1.09-1.90; P=0.01), but not with a higher incidence of PPCs (odds ratio: 1.32; 95% confidence interval: 0.89-1.90; P=0.15).

CONCLUSIONS

Intraoperative adverse events and postoperative pulmonary complications occurred more often in patients undergoing night-time surgery. Imbalances in patients' clinical characteristics, types of surgery, and intraoperative management at night-time partially explained the higher incidence of postoperative pulmonary complications, but not the higher incidence of adverse events.

CLINICAL TRIAL REGISTRATION

NCT01601223.

Operating at night does not increase the risk of intraoperative adverse events

BACKGROUND

We sought to investigate the association between nighttime (NT) operating and the occurrence of intraoperative adverse events (iAEs).

STUDY DESIGN

Our 2007-2012 institutional ACS-NSQIP and administrative databases were screened for iAEs using the ICD-9-CM-based Patient Safety Indicator "accidental puncture or laceration". Procedures were defined as AM (06.00-14.00 h), PM (14.00-22.00 h), or NT (22.00-06.00 h). Univariate and multivariable analyses were performed to investigate the association between PM and NT operating and the occurrence of iAEs.

RESULTS

9136 surgical procedures were included: 7445 AM, 1303 PM, 388 NT. iAEs occurred in 183 procedures. NT patients were younger and less comorbid, but sicker, and with less complex surgeries. There was no correlation between PM or NT operations and iAEs (multivariable analysis [reference: AM operations]: OR = 0.66 [95% CI = 0.40-1.12], P = 0.123; OR = 1.22 [95% CI = 0.51-2.93], P = 0.659, respectively).

CONCLUSION

Operating at night does increase the risk of iAEs.

Day of Surgery and Surgical Start Time Affect Hospital Length of Stay After Total Hip Arthroplasty

BACKGROUND

The United States spends $12 billion each year on ∼332,000 total hip arthroplasty (THA) procedures with the postoperative period accounting for ∼40% of costs. The purpose of this study was to evaluate the effect of surgical scheduling (day of week and start time) on clinical outcomes, hospital length of stay (LOS), and rate of nonhome discharge in THA patients.

METHODS

Analysis of perioperative variables was performed for patients who underwent THA at an urban tertiary care teaching hospital from 2009 to 2014.

RESULTS

A total of 580 THA patients were included for analysis. LOS was higher for the Thursday/Friday cohort compared to Monday/Tuesday (3.7 vs 3.4 days; P = .03). Patients who had a surgical start time after 2 PM had longer LOS compared to patients operated on before 2 PM (3.9 vs 3.5 days; P = .03). After controlling for patient comorbidities and THA surgical approach (direct anterior vs posterior), Thursday/Friday THAs were associated with a 3.27 times risk of extended LOS (>75th percentile LOS) compared to Monday/Tuesday THAs (P < .001). Additionally, case start before 2 PM was protective and associated with a 0.46 times odds of extended LOS (P = .01). LOS reduction opportunity for changing surgical start time to before 2 PM was 0.9 days for high-risk patients (American Society of Anesthesiology class 3/4 and/or liver disease) and 0.2 days for low-risk patients (American Society of Anesthesiology class 1/2).

CONCLUSION

Patients who underwent THA Thursday/Friday or had start times after 2 PM had significantly extended hospital LOS. Preoperative risk modification along with adjustments to surgical scheduling and/or perioperative staffing may reduce LOS and thus hospital expenditures for THA procedures.

Risk Factors for Unintended Dural Puncture in Obstetric Patients: A Retrospective Cohort Study

BACKGROUND

Unintended dural puncture (UDP) is one of the main risks of epidural analgesia, with a reported incidence of approximately 1.5% among the obstetric population. UDP is associated with maternal adverse outcomes, with the most frequent adverse outcome being postdural puncture headache (PDPH). Our retrospective cohort study objective was to identify demographic and obstetric risk factors that increase the risk of unintentional dural puncture as well as describing the obstetric outcome once a dural puncture has occurred.

METHODS

We retrospectively reviewed all cases of UDPs during attempted vaginal delivery between the years 2004 and 2013 in a single Israeli hospital. Each UDP case was matched with the 2 parturients who received epidural analgesia before and 2 parturients after performed by the same anesthesiologist (control group). Demographic, anesthetic, and obstetric variables were compared between the UDP and control groups.

RESULTS

Out of 46,668 epidural procedures, 177 cases of UDPs were documented (0.4%). One hundred seven women (60.5%) developed PDPH, and 38 (35.5%) required an epidural blood patch. In multivariate logistic regression, the degree of cervical dilation in centimeters at the time of epidural insertion was associated with an increased rate of UDP (P < .001). Multiparity was associated with PDPH after UDP (P = .004). Women with UDP had longer length of hospital stay than those without UDP (P < .001).

CONCLUSIONS

UDP, an uncommon complication, is associated with obstetric factors. Nevertheless, it does not seem to be associated with adverse obstetric outcomes except for prolonged duration of hospital stay.

Audit of emergent and urgent surgery for acutely ill pediatric patients: is access timely?

There is a paucity of literature about wait times for urgent/emergent surgeries in Canada. Delays and performance of non-emergent operations overnight increase morbidity and mortality. The study aim was to determine patterns of delays and performance of less-emergent surgery overnight.

METHODS

A retrospective analysis (June 2011-December 2013) of emergent/urgent surgeries was conducted using the ORSOS database (prospective patient and operative data). Surgeries were classified: class 1, 2A, 2B, and 3: target times of 1, 6, 24 and 72h. In hours (IH)=7:45AM-3:30PM, M-F; others were out of hours (OOH) and overnight =2300-0700.

RESULTS

There were 4668 operations: class 1 (5.8%), 2A (29.1%), 2B (42.1%), and 3(23%). For class 1, 2A, 2B, and 3 surgeries, mean in-room times were 2, 4.7, 15.4, and 54h respectively; 59.2% (class 1), 81.9% (class 2A), 81.2% (class 2B) and 74.4%(class 3) were performed in target. OOH occurred for 73.2% (class 1), 71.5%(class 2A), 54.7% (class 2B), and 27.7% (class 3). There were 37 class 2B and 3 surgeries overnight. There was a significant increase surgeries IH: 41.8% to 49.6%.

CONCLUSION

The majority of urgent/emergent surgery occurred OOH and the most unstable patients are least likely to have their operation within target.

LEVEL OF EVIDENCE

4.

Dural tear of unusual cause

Epidural analgesia is highly recommended in cancer anorectal surgery. In addition to the fight against pain it provides some benefit in allowing early rehabilitation of patients. One of the risks of this practice is the dural tear creating a cerebrospinal fluid leak (CSF) in the epidural space (EPD). Clinical features the typical positional headache, a procession of various more or less severe symptoms: nausea, vomiting, dizziness, visual or hearing impairment or radicular pain. We report a dural of unusual cause secondary of the obstruction of tuohy catheter by vertebral cartilage.

Perioperative outcomes of primary renal tumour resections: comparison of in-hours to out-of-hours surgery

PURPOSE

Primary resection is typically performed for children with localised suspected Wilms tumours. Resource limitation may necessitate performing these operations nights and weekends. We hypothesise that outcomes will be worse in patients having nephrectomies out-of-hours (OOH) compared to those in-hours (IH).

METHODS

With IRB ethics approval, primary renal tumour resections performed on oncology patients from 1989-2011 were reviewed retrospectively. IH operations were defined as Monday-Friday 0745-1530 hours. Outcomes included major intraoperative complications, capsule rupture, and blood loss. Data were analysed using Fischer Exact and Mann-Whitney U tests.

RESULTS

There were 64 patients with renal tumours who underwent primary resection. Forty-five procedures were performed IH, and 19 OOH. Groups were similar in age, ASA status, tumour size and grade. In a comparison of major intraoperative complications, capsule rupture, and mean blood loss, differences were 2 vs. 26% (p = 0.007), 27 vs. 42% (p = 0.12), 178 vs. 244 ml (p = 0.15) for IH and OOH respectively. There was one perioperative mortality (OOH).

CONCLUSIONS

Primary renal tumour resections performed OOH were associated with an increase in major complications compared to those performed in standard hours. Avoidance of OOH operating where possible may reduce morbidity for children undergoing primary renal tumour resections.

Surgical time of day does not affect outcome following hip fracture fixation

BACKGROUND

Due to the need for medical optimization and congested operating room schedules, surgical repair is often performed at night. Studies have shown that work done at night increases complications. The primary aim of our study is to compare the rates of complications and 30-day mortality between 2 surgical times of day, daytime group (DTG, 07:00-15:59) and nighttime group (NTG, 16:00-06:59).

METHODS

Retrospective chart review from 2005 through 2010.

SETTING

Level 1 Trauma Center.

PARTICIPANTS

1443 patients with hip fracture, age ≥50 years with isolated injury and surgical treatment of the fracture.

MAIN OUTCOMES AND MEASURES

Thirty-day mortality and complications: myocardial infarction, cardiac event, stroke, central nervous system event, pneumonia, urinary tract infection, postoperative wound infection, and bleeding requiring transfusion of 3 or more red blood cell units.

RESULTS

A total of 859 patients met the inclusion criteria; 668 patients in the DTG and 191 patients in the NTG. The 30-day mortality was 7.8%. The complication rate was 28%. No difference was found in 30-day mortality or complication rate based on the time of day the surgery was performed (P = 1.0 and P = .92, respectively). This remained unchanged when controlling for health status and surgical complexity. Age (odds ratio = 1.03/year), Charlson Comorbidity Index (CCI; odds ratio = 1.21), and American Society of Anesthesiologists (ASA; odds ratio = 1.85) score were predictive of adverse outcomes.

CONCLUSION

Surgical time of day did not affect 30-day mortality or total number of complications. Age, ASA score, and CCI were associated with adverse outcomes.

The fatigued anesthesiologist: A threat to patient safety?

Universally, anesthesiologists are expected to be knowledgeable, astutely responding to clinical challenges while maintaining a prolonged vigilance for administration of safe anesthesia and critical care. A fatigued anesthesiologist is the consequence of cumulative acuity, manifesting as decreased motor and cognitive powers. This results in impaired judgement, late and inadequate responses to clinical changes, poor communication and inadequate record keeping. With rising expectations and increased medico-legal claims, anesthesiologists work round the clock to provide efficient and timely services, but are the "sleep provider" in a sleep debt them self? Is it the right time to promptly address these issues so that we prevent silent perpetuation of problems pertinent to anesthesiologist's health and the profession. The implications of sleep debt on patient safety are profound and preventive strategies are quintessential. Anesthesiology governing bodies must ensure requisite laws to prevent the adverse outcomes of sleep debt before patient care is compromised.

Outcomes of after-hours versus regular working hours primary percutaneous coronary intervention for acute myocardial infarction

Background

Primary percutaneous coronary intervention (PCI) is a proven therapy for acute ST-segment elevation myocardial infarction. However, outcomes associated with primary PCI may differ depending on time of day.

Methods and results

Using the Alberta Provincial Project for Outcomes Assessment in Coronary Heart Disease, a clinical data-collection initiative capturing all cardiac catheterisation patients in Alberta, Canada, the authors described and compared crude and risk-adjusted survival for ST-segment elevation myocardial infarction patients undergoing primary PCI after-hours versus regular working hours. From 1 January 1999 to 31 March 2006, 1664 primary PCI procedures were performed (54.4% after-hours). Mortalities at 30 days were 3.6% for regular hours procedures and 5.0% for after-hours procedures (p=0.16). 1-year mortalities were 6.2% and 7.3% in the regular hours and after-hours groups, respectively (p=0.35). After adjusting for baseline risk factor differences, HRs for after-hours mortality were 1.26 (95% CI 0.78 to 2.02) for survival to 30 days and 1.08 (0.73 to 1.59) for survival to 1 year. A meta-analysis of our after-hours HR point estimate with other published risk estimates for after hours primary PCI outcomes yielded an RR of 1.23 (1.00 to 1.51) for shorter-term outcomes.

Conclusions

After-hours primary PCI was not associated with a statistically significant increase in mortality. However, a meta-analysis of this study with other published after-hours outcome studies yields an RR that leaves some questions about unexplored factors that may influence after-hours primary PCI care.

Minimising the risk of accidental dural puncture with epidural analgesia for labour: a retrospective review of risk factors

BACKGROUND

Accidental dural puncture has a quoted incidence of between 0.19% and 3.6% of obstetric epidurals and is associated with significant morbidity. We set out to determine possible factors associated with an increased risk of accidental dural puncture.

METHODS

We performed a retrospective review of 18385 epidurals, performed over a 15-year period. Factors analysed were: time of day of insertion, loss-of-resistance technique, maternal position, cervical dilatation, grade of anaesthetist and depth to the epidural space.

RESULTS

Using univariate analyses we found no association between the risk of accidental dural puncture and the following variables: time of day of insertion (P=0.71), loss-of-resistance technique (P=0.22), maternal position for insertion (P=0.83), degree of cervical dilatation (P=0.41) and grade of anaesthetist performing the epidural (P=0.34). Conversely, we found that the risk of accidental dural puncture increased with increasing depth to the epidural space. This was confirmed using a logistic regression analysis, from which it was estimated that, for every 1-cm increase in depth, the risk of accidental dural puncture increased by approximately 19% (P=0.019; 95% CI for OR: 1.029-1.38).

CONCLUSION

We conclude that the risk of accidental dural puncture increases with increasing depth to the epidural space. We suggest further study is required to correlate this risk with increasing body mass index.

Out-of-Hours Surgery – a Snapshot in Time

Anaesthesia in Australia is amongst the safest in the world. This record of safety is under threat from increasing pressures to operate at times of poor human performance, particularly late at night. Our institution has a policy mandating the prioritisation of surgery based on clinical need while minimising the risks associated with after-hours surgery. The policy states that “only Category 1 (urgent, needing immediate surgery) and Category 2 cases which cannot wait until the morning should be done between 2230 and 0800”. From 5 March 2007 we performed an eight-week prospective audit of all cases where surgery occurred in this time period. The anaesthetic senior registrar on duty recorded the clinical priority of the case. There were 95 cases commenced between 2230 and 0800 hours during the audit period, of which 28 (30%) were in clear breach of this policy, in some cases delaying urgent surgery. The potential implications of such breaches are significant in the context of worse outcomes for patients undergoing surgery in the after-hours period. When non-urgent cases occupy resources, the capacity of the system to deal with the truly urgent case is significantly impaired.

Adequate ‘in-hours’ resourcing, capacity and appropriate scheduling may be key to maintaining the excellent safety record of anaesthesia. A large study prospectively examining morbidity, error and outcomes of after-hours operating would serve to further elucidate the risk benefit ratio of after-hours operating.

Mitigating on-call symptoms through organizational justice and job control: a cross-sectional study among Finnish anesthesiologists

BACKGROUND

On-call duty has been shown to be associated with health problems among physicians. However, it cannot be abolished, as patient safety has to be assured. Thus, we need to find factors that could mitigate the negative health effects of on-call duty.

METHODS

The cross-sectional questionnaire of the buffering effects of organizational justice, job control, and social support on on-call stress symptoms was sent to all working Finnish anesthesiologists (n=550).

RESULTS

The response rate was 60% (n=328, 53% men). High organizational justice, job control, and social support were associated with a low number of symptoms while on call or the day after in crude analysis and when adjusted for age, gender, and place of work. Only the association between justice and symptoms was robust to additional adjustments for on-call burden and self-rated health. In the interaction analysis among those being on call at the hospital, we found that the higher the levels of job control or organizational justice, the lower the number of symptoms.

CONCLUSIONS

Job control and organizational justice successfully mitigated stress symptoms among those who had on-call hospital duties. It would be worth enhancing decision-making procedures, interpersonal treatment, and job control routines when aiming to prevent on-call stress and related symptoms.

We should work less at night

There is growing amount of evidence that doctors' performance is poorer if they work for over-prolonged duties or at night. These working patterns decrease the standard of care and increase the health care expenses. Furthermore, night workers have serious health risks due to their non-physiological work shifts. Effective ways to reduce the overall consequences of fatigue and night work include minimising the amount of work carried out at nighttime and setting up rules for maximal hours for each work shift.

The increased incidence of anesthetic adverse events in late afternoon surgeries

ANESTHETIC ADVERSE EVENTS have been found to occur more frequently in surgical procedures performed after 4 PM. THE MAJOR FACTORS that contribute to increased anesthetic adverse events include fatigue, circadian rhythm lows or dips, and administrative delays. AN INCREASED SHORTAGE of anesthesia care providers is likely to create longer work hours, thus increasing fatigue, which can lead to more anesthetic adverse events. Awareness of and education about adverse events and solutions are imperative.

Awareness with recall during general anaesthesia: a prospective observational evaluation of 4001 patients

BACKGROUND

We have prospectively evaluated the incidence and characteristics of awareness with recall (AWR) during general anaesthesia in a tertiary care hospital.

METHODS

This study involves a prospective observational investigation of AWR in patients undergoing general anaesthesia. Blinded structured interviews were conducted in the postanaesthesia care unit, on postoperative day 7 and day 30. Definition of AWR was 'when the patient stated or remembered that he or she had been awake at a time when consciousness was not intended'. Patient characteristics, perioperative, and drug-related factors were investigated. Patients were classified as not awake during surgery, AWR, AWR-possible, AWR-not evaluable. The perceived quality of the awareness episode, intraoperative dreaming, and sequelae were investigated. The anaesthetic records were reviewed to search for data that might explain the awareness episode.

RESULTS

The study included 4001 patients. Incidence of AWR was 1.0% (39/3921 patients). If high risk for AWR patients were excluded, the incidence was 0.8%. After the interview on the seventh day, six patients denied having been conscious during anaesthesia; hence, the incidence of AWR in elective surgery was 0.6%. Factors associated with AWR were: anaesthetic technique incidence of 1.1% TIVA-propofol vs 0.59% balanced anaesthesia vs 5.0% O2/N2O-based anaesthesia vs 0.9% other anaesthetic techniques (mainly propofol boluses for short procedures), P=0.008; age (AWR 42.3 yr old vs 50.6 yr old, P=0.041), absence of i.v. benzodiazepine premedication (P=0.001), Caesarean section (C-section) (P=0.019), and surgery performed at night (P=0.013). More than 50% of patients reported intraoperative dreaming in the early interview, mainly pleasant. Avoidable human factors were detected from the anaesthetic records of most patients. Subjective auditory perceptions prevailed, together with trying to move or communicate, and touch or pain perception.

CONCLUSIONS

A relatively high incidence of AWR and dreams during general anaesthesia was found. Techniques without halogenated drugs showed more patients. The use of benzodiazepine premedication was associated with a lower incidence of AWR. Age, C-section with general anaesthesia, and surgery performed at night are risk factors.

Surgical case order does not affect outcomes during robot-assisted radical prostatectomy

Fatigue has been implicated in medical errors. There has not been any report in the surgical literature addressing the impact of case order on patient outcomes. The purpose of this study was to determine whether the order of robot-assisted radical prostatectomy (RARP) has an influence on surgical outcomes. All patients undergoing RARP by a single surgeon (J.V.J.) on days during which there were three consecutive RARP cases were divided into three groups based on case order. They were compared with respect to pre-operative, intra-operative, and post-operative parameters. Complications were classified as surgical (bladder neck contracture, urinary tract infection, post-operative bleeding) or medical (deep venous thrombosis, myocardial infarction, C. difficile colitis) and compared between the groups. A total of 381 patients were evaluated, 127 in each group. The median start time for group 1 was 0732 hours (range 0722-0900 hours), group 2 was 1108 hours (range 1008-1344 hours), and group 3 was 1458 hours (range 1258-1742 hours). Patient age, body mass index, pre-operative PSA, pre-operative Gleason score, and clinical stage were all similar amongst the groups. The total operative time was equivalent, as was the estimated blood loss. Prostate volume and pathologic Gleason score showed no significant changes between groups. Pathologic stage showed a slight trend toward increasing percentages of T3 disease with increasing group number (group 1 = 17%, group 2 = 19%, and group 3 = 24%). Positive margin rates were lowest in group 3 (11.8% for group 1, 12.6% for group 2, and 3.9% for group 3). Complication rates were equivalent at 5-7% overall (2-6% surgical complications, 2-4% medical). Three patients from each group had PSA recurrence. With an experienced surgical team, three RARP procedures may be performed in 1 day without significant variation in surgical outcomes among the cases.

Time of day is associated with postoperative morbidity: an analysis of the national surgical quality improvement program data

OBJECTIVE

To examine the association between surgical start time and morbidity and mortality for nonemergent procedures.

SUMMARY BACKGROUND DATA

Patients require medical services 24 hours a day. Several studies have demonstrated a difference in outcomes over the course of the day for anesthetic adverse events, death in the ICU, and dialysis care. The relationship between operation start time and patient outcomes is yet undefined.

METHODS

We performed a retrospective cohort study of 144,740 nonemergent general and vascular surgical procedures performed within the VA Medical System 2000-2004 and entered into the National Surgical Quality Improvement Program Database. Operation start time was the independent variable of interest. Logistic regression was used to adjust for patient and procedural characteristics and to determine the association between start time and, in 2 independent models, mortality and morbidity.

RESULTS

Unadjusted later start time was significantly associated with higher surgical morbidity and mortality. After adjustment for patient and procedure characteristics, mortality was not significantly associated with start time. However, after appropriate adjustment, operations starting between 4 pm and 6 pm were associated with an elevated risk of morbidity (OR = 1.25, P < or = 0.005) over those starting between 7 am and 4 pm as were operations starting between 6 pm and 11 pm (OR = 1.60, P < or = 0.005).

CONCLUSIONS

When considering a nonemergent procedure, surgeons must bear in mind that cases that start after routine "business" hours within the VA System may face an elevated risk of complications that warrants further evaluation.

Systematic evaluation of errors occurring during the preparation of intravenous medication

INTRODUCTION

Errors in the concentration of intravenous medications are not uncommon. We evaluated steps in the infusion-preparation process to identify factors associated with preventable medication errors.

METHODS

We included 118 health care professionals who would be involved in the preparation of intravenous medication infusions as part of their regular clinical activities. Participants performed 5 infusion-preparation tasks (drug-volume calculation, rounding, volume measurement, dose-volume calculation, mixing) and prepared 4 morphine infusions to specified concentrations. The primary outcome was the occurrence of error (deviation of > 5% for volume measurement and > 10% for other measures). The secondary outcome was the magnitude of error.

RESULTS

Participants performed 1180 drug-volume calculations, 1180 rounding calculations and made 1767 syringe-volume measurements, and they prepared 464 morphine infusions. We detected errors in 58 (4.9%, 95% confidence interval [CI] 3.7% to 6.2%) drug-volume calculations, 30 (2.5%, 95% CI 1.6% to 3.4%) rounding calculations and 29 (1.6%, 95% CI 1.1% to 2.2%) volume measurements. We found 7 errors (1.6%, 95% CI 0.4% to 2.7%) in drug mixing. Of the 464 infusion preparations, 161 (34.7%, 95% CI 30.4% to 39%) contained concentration errors. Calculator use was associated with fewer errors in dose-volume calculations (4% v. 10%, p = 0.001). Four factors were positively associated with the occurrence of a concentration error: fewer infusions prepared in the previous week (p = 0.007), increased number of years of professional experience (p = 0.01), the use of the more concentrated stock solution (p < 0.001) and the preparation of smaller dose volumes (p < 0.001). Larger magnitude errors were associated with fewer hours of sleep in the previous 24 hours (p = 0.02), the use of more concentrated solutions (p < 0.001) and preparation of smaller infusion doses (p < 0.001).

INTERPRETATION

Our data suggest that the reduction of provider fatigue and production of pediatric-strength solutions or industry-prepared infusions may reduce medication errors.

Manual Rotation in Occiput Posterior or Transverse Positions

OBJECTIVE

To identify the risk factors for failure of manual rotation in patients with occiput posterior or transverse positions during labor and to study the cesarean rate according to the success of the rotation.

METHODS

Case-control study comparing failure and success of manual rotation. Cases were all fetuses for whom rotation failed. We used computerized randomization (without matching) to select one control with a successful rotation during the same period for each case with a failed rotation. Maternal, neonatal, and obstetric risk factors for failed rotation were studied with bivariable and multivariable analyses. Mode of delivery was analyzed according to success of the rotation.

RESULTS

During the study period, manual rotations were performed in 796 patients. The procedure failed in 77 (9.7%) women. Attempted rotation before full dilatation tripled the risk of failure in comparison with rotation at full dilatation (adjusted odds ratio 3.4, 95% confidence interval 1.3-8.6), and rotation for failure to progress quadrupled that risk in comparison with prophylactic rotation (adjusted odds ratio 3.3, 95% confidence interval 1.2-8.5). Failure of manual rotation was associated with a higher cesarean delivery rate than was success (58.8% compared with 3.8%, P<.001). All women with unsuccessful manual rotations who delivered vaginally delivered in the occiput posterior position, and all women with successful manual rotation delivering vaginally delivered in the occiput anterior position.

CONCLUSION

Manual rotation may be an effective technique for reducing the cesarean delivery rate in patients with an occiput posterior or transverse position during labor. The success or failure of attempted manual rotation depends upon obstetric conditions, including the indication for rotation and cervical dilatation.

Time of day effects on the incidence of anesthetic adverse events

BACKGROUND

We hypothesized that time of day of surgery would influence the incidence of anesthetic adverse events (AEs).

METHODS

Clinical observations reported in a quality improvement database were categorized into different AEs that reflected (1) error, (2) harm, and (3) other AEs (error or harm could not be determined) and were analyzed for effects related to start hour of care.

RESULTS

As expected, there were differences in the rate of AEs depending on start hour of care. Compared with a reference start hour of 7 am, other AEs were more frequent for cases starting during the 3 pm and 4 pm hours (p < 0.0001). Post hoc inspection of data revealed that the predicted probability increased from a low of 1.0% at 9 am to a high of 4.2% at 4 pm. The two most common event types (pain management and postoperative nausea and vomiting) may be primary determinants of these effects.

CONCLUSIONS

Our results indicate that clinical outcomes may be different for patients anesthetized at the end of the work day compared with the beginning of the day. Although this may result from patient related factors, medical care delivery factors such as case load, fatigue, and care transitions may also be influencing the rate of anesthetic AEs for cases that start in the late afternoon.

The impact of fatigue on patient safety

Modern medicine is founded on a culture of diligent, fatigued physicians. Fatigue is not desirable; however, the task of managing fatigue in health care professionals is complex and an ideal solution has not been described. Solutions need to integrate the immediate need for continued high-quality patient care, education of trainees, and the limited supply of health and human resources. Exploration of alternate scheduling models, broadened scope of practice, and new models of care delivery in demonstration projects or formal studies should be performed before widespread implementation. Appropriate evaluations are essential if well-meaning but larger scale errors in the name of patient safety are to be avoided.

On-call stress among Finnish anaesthetists

We investigated on-call stress and its consequences among anaesthetists. A questionnaire was sent to all working Finnish anaesthetists (n = 550), with a response rate of 60%. Four categories of on-call workload and a sum variable of stress symptoms were formed. The anaesthetists had the greatest on-call workload among Finnish physicians. In our sample, 68% felt stressed during the study. The most important causes of stress were work and combining work with family. The study showed a positive correlation between stress symptoms and on-call workload (p = 0.009). Moderate burnout was present in 18%vs 45% (p = 0.008) and exhaustion in 32% and 68% (p = 0.015), in the lowest vs highest workload category, respectively. The symptoms were significantly associated with stress, gender, perceived sleep deprivation, suicidal tendencies and sick leave. Being frequently on call correlates with severe stress symptoms and these symptoms are associated with sick leave.