Safety of Non-Operating Room Anesthesia: A Closed Claims Update

An update on the mechanisms and risk factors for anesthesia-related cardiac arrest in children: a narrative review

The relation between surgery and anesthesia safety in children and a country's Human Development Index (HDI) value has been described previously. The aim of this narrative review was to provide an update on the mechanisms and risk factors of Anesthesia-Related Cardiac Arrest (ARCA) in pediatric surgical patients in countries with different HDI values and over time (pre-2001 vs. 2001‒2024). Electronic databases were searched up to March 2024 for studies reporting ARCA events in children. HDI values range from 0 to 1 (very-high-HDI countries: ≥ 0.800, high-HDI countries: 0.700‒0.799, medium-HDI countries: 0.550‒0.699, and low-HDI countries: < 0.550). Independent of time, the proportion of children who suffered perioperative Cardiac Arrest (CA) attributed to anesthesia-related causes was higher in very-high-HDI countries (50%) than in countries with HDI values less than 0.8 (15‒36%), but ARCA rates were higher in countries with HDI values less than 0.8 than in very-high-HDI countries. Regardless of the HDI value, medication-related factors were the most common mechanism causing ARCA before 2001, while cardiovascular-related factors, mainly hypovolemia, and respiratory-related factors, including difficulty maintaining patent airways and adequate ventilation, were the major mechanisms in the present century. Independent of HDI value and time, a higher number of ARCA events occurred in children with heart disease and/or a history of cardiac surgery, those aged younger than one year, those with ASA physical status III‒V, and those who underwent emergency surgery. Many ARCA events were determined to be preventable. The implementation of specialized pediatric anesthesiology and training programs is crucial for anesthesia safety in children.

Patient selection for nonoperating room anesthesia

PURPOSE OF REVIEW

Given the rapid growth of nonoperating room anesthesia (NORA) in recent years, it is essential to review its unique challenges as well as strategies for patient selection and care optimization.

RECENT FINDINGS

Recent investigations have uncovered an increasing prevalence of older and higher ASA physical status patients in NORA settings. Although closed claim data regarding patient injury demonstrate a lower proportion of NORA cases resulting in a claim than traditional operating room cases, NORA cases have an increased risk of claim for death. Challenges within NORA include site-specific differences, limitations in ergonomic design, and increased stress among anesthesia providers. Several authors have thus proposed strategies focusing on standardizing processes, site-specific protocols, and ergonomic improvements to mitigate risks.

SUMMARY

Considering the unique challenges of NORA settings, meticulous patient selection, risk stratification, and preoperative optimization are crucial. Embracing data-driven strategies and leveraging technological innovations (such as artificial intelligence) is imperative to refine quality control methods in targeted areas. Collaborative efforts led by anesthesia providers will ensure personalized, well tolerated, and improved patient outcomes across all phases of NORA care.

Artificial intelligence and nonoperating room anesthesia

PURPOSE OF REVIEW

The integration of artificial intelligence (AI) in nonoperating room anesthesia (NORA) represents a timely and significant advancement. As the demand for NORA services expands, the application of AI is poised to improve patient selection, perioperative care, and anesthesia delivery. This review examines AI's growing impact on NORA and how it can optimize our clinical practice in the near future.

RECENT FINDINGS

AI has already improved various aspects of anesthesia, including preoperative assessment, intraoperative management, and postoperative care. Studies highlight AI's role in patient risk stratification, real-time decision support, and predictive modeling for patient outcomes. Notably, AI applications can be used to target patients at risk of complications, alert clinicians to the upcoming occurrence of an intraoperative adverse event such as hypotension or hypoxemia, or predict their tolerance of anesthesia after the procedure. Despite these advances, challenges persist, including ethical considerations, algorithmic bias, data security, and the need for transparent decision-making processes within AI systems.

SUMMARY

The findings underscore the substantial benefits of AI in NORA, which include improved safety, efficiency, and personalized care. AI's predictive capabilities in assessing hypoxemia risk and other perioperative events, have demonstrated potential to exceed human prognostic accuracy. The implications of these findings advocate for a careful yet progressive adoption of AI in clinical practice, encouraging the development of robust ethical guidelines, continual professional training, and comprehensive data management strategies. Furthermore, AI's role in anesthesia underscores the need for multidisciplinary research to address the limitations and fully leverage AI's capabilities for patient-centered anesthesia care.

Anaesthesia clinicians' perception of safety, workload, anxiety, and stress in a remote hybrid suite compared with the operating room

BACKGROUND

Anaesthesia care outside of the standard operating room (OR) can be challenging. This prospective matched case-pair study describes the difference in anaesthesia clinicians' perception of safety, workload, anxiety, and stress in two settings by comparing similar neurosurgical procedures performed in either the OR or a remote hybrid room with intraoperative MRI (MRI-OR).

METHODS

A visual numeric scale for safety perception and validated instruments for workload, anxiety, and stress were administered to enrolled anaesthesia clinicians after induction of anaesthesia and at the end of eligible cases. The difference in outcomes reported by the same clinician for unique pairs of similar operations performed in both settings (OR vs MRI-OR) was compared using the Student t-test with the general bootstrap algorithm to address the presence of clusters.

RESULTS

Over 15 months, 37 clinicians provided data for 53 case pairs. Working in the remote MRI-OR vs OR was associated with lower perceived safety (7.3 [2.0] vs 8.8 [0.9]; P<0.001), higher scores in the workload subdomains effort and frustration (41.6 [24.1] vs 31.3 [21.6]; P=0.006 and 32.4 [22.9] vs 20.7 [17.2]; P=0.002, respectively), and higher anxiety (33.6 [10.1] vs 28.4 [9.2]; P=0.003) at the end of the case. Stress was rated higher in the MRI-OR after induction of anaesthesia (26.5 [15.5] vs 20.9 [13.4]; P=0.006). Effect sizes (Cohen's D) were moderate to good.

CONCLUSIONS

Anaesthesia clinicians reported lower perceived safety and higher workload, anxiety, and stress in a remote MRI-OR compared with a standard OR. Improving non-standard work settings should benefit clinician well-being and patient safety.

CLINICAL TRIAL REGISTRATION

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Increasing rates of general anesthesia use in lumpectomy procedures: A 15-year trends analysis

BACKGROUND

Anesthesia methods in oncologic breast surgery have evolved with less invasive practices. The aims of this study were primarily to examine trends in anesthesia type used during lumpectomy.

METHODS

We analyzed lumpectomy procedures from 2005 to 2019 using the NSQIP database. Upon defining the nadir in general anesthesia (GA) and peak in monitored anesthesia care (MAC) use as 2007, we compared patient characteristics and complications in the 2007 versus 2019 GA and MAC cohorts. Multivariable logistic regression was used to examine associations with receipt of GA.

RESULTS

Of 253 545 lumpectomy patients, 191 773 (75.6%) received GA and 61 772 (24.4%) received MAC. From 2005 to 2019, GA rates increased from 66.7% to 82.5%, while MAC rates decreased from 33.3% to 17.5%. More GA patients were obese and American Society of Anesthesiologists class 3. Over time, age and body mass index (BMI) increased in both GA and MAC cohorts. Odds of receiving GA increased over time, and predictors included concurrent axillary lymph node dissection (p < 0.0001) or sentinel lymph node biopsy (p < 0.0001).

CONCLUSIONS

We demonstrate increasing use of GA over time for lumpectomy, which may be related to aging lumpectomy patient population with higher BMIs. We also find a strong association between use of GA and concurrent lymph node procedures.

Gas Pressure From the Endoscope: An Unexplored Contributor to Morbidity and Mortality?

Background It has been shown that the incidence of venous air embolism and venous carbon dioxide (CO₂) embolism is high during endoscopic retrograde cholangiopancreatography (ERCP). We examined insufflating gas flow and maximum pressure produced by three types of commonly used endoscopes because we could not readily locate technical data for endoscope gas flow and maximum emitted pressure in the manufacturer's manuals. Methods We tested the Olympus GIF-Q180 used for esophagogastroduodenoscopy, the CF-Q180 used for colonoscopy, and the TJF-Q180 used for ERCP (Olympus America Inc., Center Valley, Pennsylvania). Under three different clinical gas insufflation scenarios, we measured in vitro maximum gas pressure transduced from a closed space created at the endoscope tip in a worst-case scenario analysis. Results We showed that it is readily possible to generate a pressure (>5-30 times normal central venous pressure) in the air space at the tip of all three endoscopes when insufflation is activated and the gas egress is limited. Conclusions These findings shed additional light on in vivo occurrences of gas embolism during gastrointestinal endoscopy. We postulate that in addition to using exclusively CO₂ as the insufflating gas, the risk of gas embolism can be further diminished by regulating insufflating gas pressure at the tip of endoscopes.

Systems safety in nonoperating room anesthesia locations

PURPOSE OF REVIEW

Nonoperating room anesthesia (NORA) care is an area of rapid growth over the last decade. However, literature describing safety systems in NORA is limited. This review evaluates historical safety models described by Donabedian and Reason, assesses the NORA environment and safety concerns that may contribute to adverse events, and provides potential solutions via a human-centered systems safety design.

RECENT FINDINGS

Systems Engineering Initiative for Patient Safety (SEIPS) 3.0 provides a framework for quality and patient safety improvement. Although the previous SEIPS 2.0 model has been used to evaluate NORA environments with focus on the case volume, high productivity pressure, and significant physical constraints common to NORA sites, literature describing SEIPS 3.0 in relation to NORA care is sparse. Given the rate of malpractice claims for death in NORA settings, solutions that address the multifactorial nature of adverse events are needed.

SUMMARY

The SEIPS 3.0 model may be applied to NORA care. Changes should focus on staffing ratios, staff/patient education, checklist utilization, burnout prevention, scheduling efficiency, anesthesia workstation standardization, communication improvements, room layout, medication and supply availability and storage, and the global managerial approach. Team members must demonstrate flexibility and a willingness to adapt to successfully implement change.

Sedation-analgesia techniques for nonoperating room anesthesia: an update

PURPOSE OF REVIEW

There has been a substantial increase in nonoperating room anesthesia procedures over the years along with an increase in the complexity and severity of cases. These procedures pose unique challenges for anesthesia providers requiring meticulous planning and attention to detail. Advancements in the delivery of sedation and analgesia in this setting will help anesthesia providers navigate these challenges and improve patient safety and outcomes.

RECENT FINDINGS

There has been a renewed interest in the development of newer sedative and analgesic drugs and delivery systems that can safely provide anesthesia care in challenging situations and circumstances.

SUMMARY

Delivery of anesthesia care in nonoperating room locations is associated with significant challenges. The advent of sedative and analgesic drugs that can be safely used in situations where monitoring capabilities are limited in conjunction with delivery systems, that can incorporate unique patient characteristics and ensure the safe delivery of these drugs, has the potential to improve patient safety and outcomes. Further research is needed in these areas to develop newer drugs and delivery systems.

Prevention of pulmonary complications in sedated patients undergoing interventional procedures in the nonoperating room anesthesia setting

PURPOSE OF REVIEW

Nonoperating room anesthesia (NORA) procedures have expanded in number, variety, and complexity. NORA involves all age groups, including frail older adults and patients often considered too sick to tolerate traditional surgical interventions. Postoperative pulmonary complications are a significant source of adverse events in the perioperative setting. We present a review focused on preventing pulmonary complications in the interventional NORA setting.

RECENT FINDINGS

NORA locations should function as independent, autonomous ambulatory units. We discuss a strategic plan involving a thorough preoperative evaluation of patients, including recognizing high-risk patients and their anesthetic management. Finally, we offer guidance on the challenges of conducting sedation and anesthesia in patients with coronavirus disease 2019 (COVID-19) or a history of COVID-19.

SUMMARY

The demands on the interventional NORA anesthesia team are increasing. Strategic planning, checklists, consistent staffing assignments, and scheduled safety drills are valuable tools to improve patient safety. In addition, through quality improvement initiatives and reporting, NORA anesthetists can achieve reductions in periprocedural pulmonary complications.

Frameworks for value-based care in the nonoperating room setting

PURPOSE OF REVIEW

Nonoperating room anesthesia (NORA) presents a unique opportunity for the application of value-based care (VBC) principles to procedures performed in the office-based and nonoperating room inpatient settings. The purpose of this article is to review how value is defined in NORA and enabling principles by which anesthesiologists can maximize value in NORA.

RECENT FINDINGS

In order to drive value, NORA providers can target improvements in clinical outcomes where NORA lags behind operating room-based anesthesia (death, over-sedation, nerve injury), implement protocols focusing on intermediate outcomes/quality (postoperative nausea and vomiting, pain control, hypothermia, delirium), incorporate patient-reported outcomes (PROs) to assess the trajectory of a patient's perioperative care, and reduce costs (direct and indirect) through operational and supply-based efficiencies. Establishing a culture of patient and provider safety first, appropriate patient selection with targeted, perioperative optimization of comorbidities, and efficient deployment of staff, space, and resources are critical enablers for success.

SUMMARY

Value in NORA can be defined as clinical outcomes, quality, patient-reported outcomes, and efficiency divided by the direct and indirect costs for achieving those outcomes. We present a novel framework adapting current VBC practices in operating room anesthesia to the NORA environment.

Pro-Con Debate: Monitored Anesthesia Care Versus General Endotracheal Anesthesia for Endoscopic Retrograde Cholangiopancreatography

Over the past several decades, anesthesia has experienced a significant growth in nonoperating room anesthesia. Gastrointestinal suites represent the largest volume location for off-site anesthesia procedures, which include complex endoscopy procedures like endoscopic retrograde cholangiopancreatography (ERCP). These challenging patients and procedures necessitate a shared airway and are typically performed in the prone or semiprone position on a dedicated procedural table. In this Pro-Con commentary article, the Pro side supports the use of monitored anesthesia care (MAC), citing fewer hemodynamic perturbations, decreased side effects from inhalational agents, faster cognitive recovery, and quicker procedural times leading to improved center efficiency (ie, quicker time to discharge). Meanwhile, the Con side favors general endotracheal anesthesia (GEA) to reduce the infrequent, but well-recognized, critical events due to impaired oxygenation and/or ventilation known to occur during MAC in this setting. They also argue that procedural interruptions are more frequent during MAC as anesthesia professionals need to rescue patients from apnea with various airway maneuvers. Thus, the risk of hypoxemic episodes is minimized using GEA for ERCP. Unfortunately, neither position is supported by large randomized controlled trials. The consensus opinion of the authors is that anesthesia for ERCP should be provided by a qualified anesthesia professional who weighs the risks and benefits of each technique for a given patient and clinical circumstance. This Pro-Con article highlights the many challenges anesthesia professionals face during ERCPs and encourages thoughtful, individualized anesthetic plans over knee-jerk decisions. Both sides agree that an anesthetic technique administered by a qualified anesthesia professional is favored over an endoscopist-directed sedation approach.

Efficacy of high flow nasal oxygenation against hypoxemia in sedated patients receiving gastrointestinal endoscopic procedures: A systematic review and meta-analysis

STUDY OBJECTIVE

To evaluate the impact of high flow nasal oxygenation (HFNO) on the risk of hypoxemia during gastrointestinal endoscopic procedures (GEPs) under sedation.

DESIGN

Meta-analysis of randomized controlled trials.

SETTING

Gastrointestinal endoscopy.

INTERVENTION

HFNO.

PATIENTS

Adults patients undergoing GEPs under sedation.

MEASUREMENTS

The primary outcome was risk of hypoxemia, while the secondary outcomes included risks of severe hypoxemia, hypercapnia, need for jaw thrust or other airway interventions, and procedural interruption as well as procedure time, minimum SpO₂, and level of carbon dioxide (CO₂). Analyses based on age, gender, flow rate, risk status of patients were performed to investigate subgroup effects.

RESULTS

Medline, Google scholar, Cochrane Library, and EMBASE databases were searched from inception to July 2021. Seven randomized controlled trials (RCTs) involving 2998 patients published from 2019 to 2021 were included. All GEPs were performed under propofol sedation. Pooled results revealed significantly lower risks of hypoxemia [relative risk (RR) = 0.31, 95% CI:0.13-0.75; 2998 patients], severe hypoxemia (RR = 0.38, 95% CI:0.2-0.74; 2766 patients), other airway interventions (RR = 0.34, 95% CI:0.22-0.52; 2736 patients), procedural interruption (RR = 0.12, 95% CI:0.02-0.64, 451 patients) and a lower CO₂ level [standard mean difference (MD) = -0.21, 95% CI: -0.4 to -0.03; 458 patients] in HFNO group compared to control group. Subgroup analysis focusing on risk of hypoxemia showed no significant subgroup effects, indicating consistent benefits of HFNO in different clinical settings. There were no difference in minimum SpO₂ (p = 0.06; 262 patients), risk of hypercapnia (p = 0.09; 393 patients), need for jaw thrust (p = 0.28; 2256 patients), and procedure time (p = 0.41, 1004 patients) between the two groups.

CONCLUSION

Our results demonstrated the efficacy of high flow nasal oxygenation for reducing the risk of hypoxemia in patients receiving elective gastrointestinal endoscopic procedures under sedation. Further studies are warranted to verify its cost-effectiveness in the gastrointestinal endoscopy setting.

Patient safety education in anesthesia: current state and future directions

PURPOSE OF REVIEW

Although patient safety is a core component of education in anesthesiology, approaches to implementation of education programs are less well defined. The goal of this review is to describe the current state of education in anesthesia patient safety and the ideal patient safety curriculum.

RECENT FINDINGS

Anesthesiology has been a pioneer in patient safety for decades, with efforts amongst national organizations, such as the American Society of Anesthesiologists and the Anesthesia Patient Safety Foundation to disseminate key standards and guidelines in patient safety. However, few, if any strategies for implementation of a patient safety curriculum in anesthesiology exist.

SUMMARY

Patient safety education is crucial to the field of anesthesiology, particularly with the advancement of surgical and anesthesia technologies and increasing complexity of patients and procedures. The ideal patient safety curriculum in anesthesiology consists of simulation, adverse event investigation and analysis, and participation in process improvement. Efforts in education must adapt with changing technology, shifts in the way anesthesia care is delivered, and threats to physician wellness. Future efforts in education should harness emerging platforms, such as social media, podcasts, and wikis.

Morbidity, mortality, and systems safety in non-operating room anaesthesia: a narrative review

Non-operating room anaesthesia (NORA) describes anaesthesia delivered outside a traditional operating room (OR) setting. Non-operating room anaesthesia cases have increased significantly in the last 20 yr and are projected to account for half of all anaesthetics delivered in the next decade. In contrast to most other medication administration contexts, NORA is performed in high-volume fast-paced environments not optimised for anaesthesia care. These predisposing factors combined with increasing case volume, less provider experience, and higher-acuity patients increase the potential for preventable adverse events. Our narrative review examines morbidity and mortality in NORA settings compared with the OR and the systems factors impacting safety in NORA. A review of the literature from January 1, 1994 to March 5, 2021 was conducted using PubMed, CINAHL, Scopus, and ProQuest. After completing abstract screening and full-text review, 30 articles were selected for inclusion. These articles suggested higher rates of morbidity and mortality in NORA cases compared with OR cases. This included a higher proportion of death claims and complications attributable to inadequate oxygenation, and a higher likelihood that adverse events are preventable. Despite relatively few attempts to quantify safety concerns, it was possible to find a range of systems safety concerns repeated across multiple studies, including insufficient lighting, noise, cramped workspace, and restricted access to patients. Old and unfamiliar equipment, lack of team familiarity, and limited preoperative evaluation are also commonly noted challenges. Applying a systems view of safety, it is possible to suggest a range of methods to improve NORA safety and performance.

Patient monitoring in the nonoperating room anesthesia (NORA) setting: current advances in technology

PURPOSE OF REVIEW

Nonoperating room anesthesia (NORA) procedures continue to increase in type and complexity as procedural medicine makes technical advances. Patients presenting for NORA procedures are also older and sicker than ever. Commensurate with the requirements of procedural medicine, anesthetic monitoring must meet the American Society of Anesthesiologists standards for basic monitoring.

RECENT FINDINGS

There have been improvements in the required monitors that are used for intraoperative patient care. Some of these changes have been with new technologies and others have occurred with software refinements. In addition, specialized monitoring devises have also been introduced into NORA locations (depth of hypnosis, respiratory monitoring, point-of care ultrasound). These additions to the monitoring tools available to the anesthesiologist working in the NORA-environment push the boundaries of procedures which may be accomplished in this setting.

SUMMARY

NORA procedures constitute a growing percentage of total administered anesthetics. There is no difference in the monitoring standard between that of an anesthetic administered in an operating room and a NORA location. Anesthesiologists in the NORA setting must have the same compendium of monitors available as do their colleagues working in the operating suite.

Preoperative optimization of patients undergoing interventional procedures: infrastructure, logistics, and evidence-based medicine

PURPOSE OF REVIEW

Patients presenting for non-operating room procedures are often 'too sick' for surgery and require specific anesthesia care in remote areas with logistical and scheduling challenges.

RECENT FINDINGS

Increased complexity and scope of minimally invasive procedures have expanded this practice. In addition, the concept of therapeutic options other than conventional surgery is gaining traction.

SUMMARY

Our review of recent literature confirms the complexity and supports the safety of providing care in non-operating room anesthesia locations. Standard preanesthesia assessments and principles apply to these areas.

An update on pediatric sedation techniques in nonoperating room locations

PURPOSE OF REVIEW

To review advancements in care for pediatric patients in nonoperating room settings.

RECENT FINDINGS

Advances in patient monitoring technology, utilization of Child Life specialists, and alternative staffing models are helping anesthesia providers meet the rising demand for coverage of pediatric nonoperating room anesthesia (NORA) cases. The Wake Up Safe and Pediatric Sedation Research Consortium registries are exploring outcome measures regarding the safety of pediatric anesthesia in off-site locations and have reported an increased risk for severe respiratory and cardiac adverse events when compared to OR anesthesia sites. Additionally, malpractice claims for NORA have a higher proportion of claims for death than claims in operating rooms.

SUMMARY

Pediatric NORA requires thorough preparation, flexibility, and vigilance to provide safe anesthesia care to children in remote locations. Emerging techniques to reduce anesthetic exposure, improve monitoring, and alternative staffing models are expanding the boundaries of pediatric NORA to provide a safer, more satisfying experience for diagnostic and interventional procedures.

National trends in nonoperating room anesthesia: procedures, facilities, and patient characteristics

PURPOSE OF REVIEW

Nonoperating room anesthesia (NORA) continues to increase in popularity and scope. This article reviews current and new trends in NORA, trends in anesthesia management in nonoperating room settings, and the evolving debates surrounding these trends.

RECENT FINDINGS

National data suggests that NORA cases will continue to rise relative to operating room (OR) anesthesia and there will continue to be a shift towards performing more interventional procedures outside of the OR. These trends have important implications for the safety of interventional procedures as they become increasingly more complex and patients continue to be older and more frail. In order for anesthesia providers and proceduralists to be prepared for this future, rigorous standards must be set for safe anesthetic care outside of the OR.Although the overall association between NORA and patient morbidity and mortality remains unclear, focused studies point toward trends specific to each non-OR procedure type. Given increasing patient and procedure complexity, anesthesiology teams may see a larger role in the interventional suite. However, the ideal setting and placement of anesthesia staff for interventional procedures remain controversial. Also, the impact of COVID-19 on the growth and utilization of non-OR anesthesia remains unclear, and it remains to be seen how the pandemic will influence the delivery of NORA procedures in postpandemic settings.

SUMMARY

NORA is a rapidly growing field of anesthesia. Continuing discussions of complication rates and mortality in different subspecialty areas will determine the need for anesthesia care and quality improvement efforts in each setting. As new noninvasive procedures are developed, new data will continue to shape debates surrounding anesthesia care outside of the operating room.

Frameworks for trainee education in the nonoperating room setting

PURPOSE OF REVIEW

As the volume and types of procedures requiring anesthesiologist involvement in the nonoperating room anesthesia (NORA) setting continue to grow, it is important to create a formal curriculum and clearly define educational goals.

RECENT FINDINGS

A NORA rotation should be accompanied by a dedicated curriculum that should include topics such as education objectives, information about different interventional procedures, anesthesia techniques and equipment, and safety principles. NORA environment may be unfamiliar to anesthesia residents. The trainees must also learn the principles of efficiency, rapid recovery from anesthesia, and timely room turnover. Resident education in NORA should be an essential component of their training. The goals and objectives of the NORA educational experience should include not only developing the clinical knowledge necessary to implement the specific type of anesthetic desired for each procedure, but also the practical knowledge of care coordination needed to safely and efficiently work in the NORA setting.

SUMMARY

As educators, we must foster and grow a resident's resilience by continually challenging them with new clinical scenarios and giving them appropriate autonomy to take risks and move outside of their comfort zone. Residents should understand that exposure to such unique and demanding environment can be transformative.

Medication safety in nonoperating room anesthesiology

PURPOSE OF REVIEW

Medication errors remain a prominent source of medical harm in spite of over 20 years of effort in establishing standardized protocols and procedures, implementing assistive electronic technologies to identify medications and prevent administration errors and in establishing a just culture with regard to reporting events and near misses.

RECENT FINDINGS

Some of these interventions are even more necessary in the nonstandard environment of a non-operating room anesthesiology (NORA) procedure suite, where the anesthesiologist is often far removed from colleagues, in a dark room, lacking the standard medications commonly found in their operating room. Medication availability in NORA sites may be limited because of lack of standardization or distance from the operating room pharmacy. Proper preparation of medication may be impaired by poor lighting and cramped conditions. Medication administration might be hampered by a lack of infusion pumps or pumps without the proper medication library needed by the anesthesiologist.

SUMMARY

Specific attention must be paid to enhancement of medication safety in NORA sites to overcome additional challenges inherent in the provision of anesthesia care remote from the standard operating room setting.

Effect of high-flow vs. low-flow nasal plus mouthguard oxygen therapy on hypoxaemia during sedation: a multicentre randomised controlled trial

Whether high-flow vs. low-flow nasal oxygen reduces hypoxaemia for sedation during endoscopic retrograde cholangiopancreatography is currently unknown. In this multicentre trial, 132 patients ASA physical status 3 or higher, BMI > 30 kg.m^-2 or with known or suspected obstructive sleep apnoea were randomly allocated to high-flow nasal oxygen up to 60 l.min^-1 at 100% F_I O₂ or low-flow nasal oxygen at 4 l.min^-1 . The low-flow nasal oxygen group also received oxygen at 4 l.min^-1 through an oxygenating mouthguard, totalling 8 l.min^-1 . Primary outcome was hypoxaemia, defined as S_p O₂ < 90% regardless of duration. Hypoxaemia occurred in 7.7% (5/65) of patients with high-flow and 9.1% (6/66) with low-flow nasal oxygen (percentage point difference -1.4%, 95%CI -10.9 to 8.0; p = 0.77). Between the groups, there were no significant differences in frequency of hypoxaemic episodes; lowest S_p O₂ ; peak transcutaneous carbon dioxide; hypercarbia (transcutaneous carbon dioxide > 2.66 kPa from baseline); requirement of chin lift/jaw thrust; nasopharyngeal airway insertion; bag-mask ventilation; or tracheal intubation. Following adjustment for duration of the procedure, the primary outcome remained non-significant. In high-risk patients undergoing endoscopic retrograde cholangiopancreatography, oxygen therapy with high-flow nasal oxygen did not reduce the rate of hypoxaemia, hypercarbia or the need for airway interventions, compared with combined oral and nasal low-flow oxygen.

Implementation of contextualized, emergency management cognitive aids in a periodontics clinic

BACKGROUND

Emergencies in outpatient clinics are rare. However, potentially catastrophic events can be challenging to manage due to a variety of factors, including limited equipment and staff. The purpose of this quality improvement project was to improve the staff knowledge and familiarity with critical performance elements for emergencies encountered in the setting of a periodontics clinic.

METHODS

Emergency cognitive aids tailored to the clinic's resources were created for anaphylaxis, airway obstruction, and sublingual hemorrhage. The project pre-post-test repeated measures design evaluated the effectiveness of cognitive aids using a combination of hands-on simulation, written knowledge assessments, and self-efficacy surveys. Training sessions and simulations were provided to the clinic's existing care teams made up of a periodontist and two dental assistants with an anesthetist who was present for simulations involving sedation. Due to the small sample size (N = 14) and non-normal distribution, all metrics were evaluated using non-parametric statistics.

RESULTS

Significant improvements were found in knowledge assessment (-2.310, P = 0.021) and self-efficacy (-2.486, P = 0.013) scores when retention after a training session before and after the introduction of cognitive aid was compared. The mean simulation scores and times improved steadily or reached maximum scores during the project progression.

CONCLUSION

Training sessions before and after cognitive aid introduction were effective in improving knowledge, self-efficacy, and simulation performance. Future projects should focus on validating the process for creating contextualized cognitive aids and evaluating the effectiveness of these cognitive aids in larger samples.

Anesthetic considerations in patients with implantable devices and chronic pain surgery

The use of advanced invasive techniques for the control of chronic pain in patients with multiple comorbidities is becoming increasingly common. Neuromodulation offers a new management alternative involving the infusion of one or more drugs into the epidural or intrathecal space through a fully implantable infusion pump. It also involves spinal stimulation, a minimally invasive technique in which electrodes are positioned in the epidural space and connected to a pulse generator that is implanted subcutaneously and generates pulses designed to suppress the noxious stimulus. This article will describe the anesthetic considerations in cases of implantable drug delivery systems, and spinal and peripheral nerve stimulation devices. Additionally, patients with electrical or drug neuromodulation devices may present to anesthetic practice for surgical indications unrelated to their chronic pain pathology. Hence the importance of being familiar with the basic components of these devices, how they work, what drugs they use and the potential associated complications in the perioperative context, in order to ensure proper management and patient safety.

Safety of the LMA®Gastro™ for Endoscopic Retrograde Cholangiopancreatography

BACKGROUND

Endoscopic retrograde cholangiopancreatography (ERCP) patients typically receive either tubeless anesthesia or general endotracheal anesthesia (GETA). Patients receiving propofol-based total intravenous anesthesia (TIVA) are at higher risk of sedation-related adverse events (SRAEs) than patients receiving GETA, primarily due to the need for additional airway maneuvers. The increasing use of non-operating room (OR) anesthesia and the perception of a higher incidence of adverse outcomes in non-OR areas has led to the development of devices to improve safety while maintaining efficiency. The purpose of this study was to evaluate if the LMA Gastro™ could be used as a safe alternative to tubeless anesthesia for successfully completing ERCPs.

METHODS

Eligible subjects were identified within the patient population at MD Anderson Cancer Center. Inclusion criteria consisted of adult patients (≥18 years old) scheduled for elective ERCP with TIVA. This was a prospective observational study in which the following data were collected: number of attempts and time to successful supraglottic airway (SGA) placement, vital signs, peripheral oxygen saturation (SpO2), median end-tidal CO2, practitioner satisfaction, and any complications.

RESULTS

A total of 30 patients were included in this study. The overall rate of successful SGA placement within 3 attempts was 96.7% (95% confidence interval [CI], 82.8-99.9) or 29/30. The rate of successful ERCP with SGA placement within 3 attempts was 93.3% (95% CI, 77.9-99.2) or 28/30. Both the gastroenterologist and anesthesiologist reported satisfaction with the device in 90% of the cases (in 66.7% of the cases both anesthesiologist and gastroenterologist scored the device a 7/7 for satisfaction). Patients maintained an SpO2 of 95%-100% from induction to discharge, with the exception of 1 patient who had an SpO2 of 93%. The median end-tidal CO2 during the procedure for all patients was 35 mm Hg. Observed aspiration did not occur in any patient. Symptoms of hoarseness (13.3%), mouth soreness (6.7%), sore throat (6.6%), and minor bleeding/cuts/redness/change in taste to the tongue (3.3%) were determined through patient questioning before postanesthesia care unit (PACU) discharge.

CONCLUSIONS

Our study suggests that the LMA Gastro might be a safe alternative for ERCP procedures. There was a high level of practitioner satisfaction. Only minor complications, such as hoarseness, mouth or throat soreness, or minor trauma to the tongue were experienced by patients. Similar incidences of complications may occur with GETA and tubeless anesthesia. The procedure was well tolerated by all patients; all patients maintained adequate oxygenation and required only minimal blood pressure support.

Use of Virtual Reality to Reduce Anxiety and Pain of Adults Undergoing Outpatient Procedures

(1) Background: Research has demonstrated that virtual reality (VR) has reduced pain and anxiety for patients undergoing health procedures. The aim of this quality improvement project was to implement and evaluate immersive VR as a non-pharmacological intervention to reduce pain and anxiety in those adults undergoing outpatient procedures under monitored anesthesia care. (2) Methods: This quality improvement project incorporated the Plan-Do-Study-Act (PDSA) model and employed a pre/post-implementation evaluation. Seven patients used VR during outpatient surgeries. Pain and anxiety scores were evaluated. (3) Results: Patients using VR exhibited lower pain and anxiety scores post-procedure compared to pre-procedure. Both patients and providers indicated high satisfaction with the VR experience. (4) Conclusions: This quality improvement project demonstrated the successful translation of research into practice. VR is a novel intervention that can reduce both pain and anxiety to improve the patient’s perioperative experience.

Nonoperating room anaesthesia: safety, monitoring, cognitive aids and severe acute respiratory syndrome coronavirus 2

PURPOSE OF REVIEW

With an ageing population, mounting pressure on the healthcare dollar, significant advances in medical technology, and now in the context of coronavirus disease 2019, the traditional paradigm in which operative procedures are undertaken is changing. Increasingly, procedures are performed in more distant, isolated and less familiar locations, challenging anaesthesiologists and requiring well developed situational awareness. This review looks at implications for the practitioner and patient safety, outlining considerations and steps involved in translation of systems and processes well established in the operating room to more unfamiliar environments.

RECENT FINDINGS

Despite limited nonoperating room anaesthesia outcome data, analysis of malpractice claims, anaesthesia-related medical disputes and clinical outcome registries have suggested higher morbidity and mortality. Complications were often associated with suboptimal monitoring, nonadherence to recommended guidelines and sedationist or nonanaesthesiologist caregivers. More recently, clear monitoring guidelines, global patient safety initiatives and widespread implementation of cognitive aids may have contributed to nonoperating room anaesthesia (NORA) outcomes approaching that of traditional operating rooms.

SUMMARY

As NORA caseloads increase, understanding structural and anaesthetic requirements is essential to patient safety. The severe acute respiratory syndrome coronavirus 2 pandemic has provided an opportunity for anaesthesiologists to implement lessons learned from previous analyses, share expertise as patient safety leaders and provide valuable input into protecting patients and caregivers.

Nonoperating room anesthesia in different parts of the world

PURPOSE OF REVIEW

Advances in early diagnosis and treatment of diseases using minimally invasive procedures has led to an increase in the number of cases in locations outside the operating room. This surge created the need for anesthesia services to expand to these areas to provide well tolerated and favorable procedural conditions. The present review describes nonoperating room anesthesia patterns in different parts of the world.

RECENT FINDINGS

Nonoperating room anesthesia has grown exponentially over the last years. Patients scheduled in these areas are sicker and older compared to the operating room patients. Anesthesiologist-directed care has proven to be well tolerated, with less serious complications and improvement in patients and proceduralist satisfaction.

SUMMARY

There are marked variations in how anesthesia services are delivered in out of operating room locations in different parts of the world. Although there are some data available from the United States, expansion of minimally invasive procedures across continents will likely lead to the emergence of various models of delivering anesthetic care.

Pediatric Anesthesia Outside the Operating Room: Safety and Systems

Anesthesia care performed outside the operating room is a growing area of pediatric anesthesia practice. The anesthesiology team expects to care for children in diverse locations, which include diagnostic and interventional radiology, gastroenterology and pulmonary endoscopy suites, radiation oncology sites, and the cardiac catheterization laboratory. To provide safe, high-quality care the anesthesiologist working in these environments must understand the unique environmental, logistical, and perioperative considerations and risks involved with each remote location. This 2-part review provides an overview of safety and system considerations in pediatric nonoperating room anesthesia before describing in more detail considerations for particular remote anesthetizing locations.

Nonoperating room anesthesia for children

PURPOSE OF REVIEW

Nonoperating room anesthesia (NORA) cases performed in pediatric patients have increased over the past decade. It is imperative for the anesthesia provider to be familiar with the nuances of this environment and the myriad of cases to ensure delivery of safe and efficient care.

RECENT FINDINGS

Though case volume has increased, sedative agents have largely remained unchanged. NORA sites must meet the same operating room standards and expectations of anesthesia established by the American Society of Anesthesiologists. Despite the increasing NORA volume and efforts to instill a similar culture of safety as the operating room complex, NORA cases present challenges with limited resources and access to the patient, highlighting the need for resident and fellow training to include NORA experiences.

SUMMARY

Experience working in the NORA environment helps provide, maintain, and improve the cognitive fitness and resilience that an anesthesiologist needs to tackle the complexities from the variety of NORA cases and locations. Patient factors aside, procedural considerations can affect the anesthetic plan, so understanding the nuances of the procedure helps the anesthesia provider provide safe and efficient care.

Practice horizons in pediatric nonoperating room anesthesia

PURPOSE OF REVIEW

Anesthesia outside the operating room is rapidly expanding for adult and pediatric patients. Anesthesia clinicians practicing in this area need a good understanding of the challenges of the NORA environment and the anesthetic risks and perioperative implications of practice so that they can deliver safe care to their patients.

RECENT FINDINGS

Recent reports from large patient databases have afforded anesthesiologists a greater understanding of the risk of NORA when compared to anesthesia in the operating room. Descriptions of advances in team training with the use of simulation have allowed the development of organized procedural teams. With an emphasis on clear communication, an understanding of individual roles, and a patient-centered focus, these teams can reliably develop emergency response procedures, so that critical moments are not delayed in an environment remote from usual assistance.

SUMMARY

With appropriate attention to organizational concerns (i.e. team environment, safety protocols) and unrelenting focus on patient safety, anesthesiologists can assist in safely providing the benefit of cutting-edge technical advancements to pediatric patients in these challenging environments.

Ultrasound-guided serratus anterior plane block combined with parasternal block in subcutaneous implantable cardioverter defibrillator implantation: Results of a pilot study

BACKGROUND

The standard approach to subcutaneous defibrillator (S-ICD) implantation often requires general anesthesia or anesthesiologist-delivered deep sedation. Ultrasound-guided serratus anterior plane block (SAPB) combined with parasternal block (PSB) has been proposed in order to provide anesthesia/analgesia and to reduce the need for sedation during S-ICD implantation. In this pilot study, we compared the double-block approach (SAPB + PSB) with the single-block approach (SAPB only) and with the standard approach involving local anesthesia and sedation.

METHODS

We prospectively enrolled 22 patients undergoing S-ICD implantation: in 10, the single-block approach was adopted; in 12, the double-block approach. As a control group, we retrospectively enrolled 14 consecutive patients who had undergone S-ICD implantation under standard local anesthesia and sedation in the previous 6 months. Intra- and postprocedural data, including patient-reported pain intensity, were collected and compared in the three study groups.

RESULTS

The double-block approach was associated with a shorter procedure duration than the single-block and standard approaches (63.3 ± 7.9 vs 70.1 ± 6.8 vs 76.9 ± 7.8 min; P < .05) and with a lower dose of local an aesthetic for infiltration (18.9 ± 1.7 vs 27.5 ± 4.6 vs 44.6 ± 4.0 cc; P < .001). Both the double- and single-block approaches were associated with lower pain intensity at the device pocket and the lateral tunneling site (P < .05). The double-block approach proved superior to the other two approaches in controlling intraoperative pain at the parasternal tunneling site (P < .05).

CONCLUSIONS

In our study, SAPB combined with PSB was superior to SAPB alone and to the standard approach in controlling intraoperative pain during S-ICD implantation. In addition, this approach resulted in shorter procedure durations.

Safety in office-based anesthesia: an updated review of the literature from 2016 to 2019

PURPOSE OF REVIEW

Office-based anesthesia (OBA) is rapidly growing across the world. Availability of less invasive interventions has facilitated the opportunity of offering new procedures in office-based settings to patient populations that would not have been considered in the past. This article provides a practical approach to discuss and analyze newest literature supporting different practices in the field of OBA. In addition, an update of the most recent guidelines and practice management directives is included.

RECENT FINDINGS

Selected procedures may be performed in the office-based scenario with exceedingly low complication rates, when the right patient population is selected, and adequate safety protocols are followed. Current regulations are focused on reducing surgical risk through the implementation of patient safety protocols and practice standardization. Strategies include cognitive aids for emergencies, safety checklists, facility accreditation standards among other.

SUMMARY

New evidence exists supporting procedures in the office-based scenario in areas such as plastic and cosmetic surgery, dental and oral surgery, ophthalmology, endovascular procedures and otolaryngology. Different systematic approaches have been developed (guidelines and position statements) to promote standardization of safe practices through emergency protocols, safety checklists, medication management and surgical risk reduction. New regulations and accreditation measures have been developed to homogenize practice and promote high safety standards.

Safety in the nonoperating room anesthesia suite is not an accident: lessons from the National Transportation Safety Board

PURPOSE OF REVIEW

To review the findings of National Transportation Safety Board-related aviation near misses and catastrophes and apply these principles to the nonoperating room anesthesia (NORA) suite.

RECENT FINDINGS

NORA is a specialty that has seen tremendous growth. In 2019, NORA contributes to a larger proportion of anesthesia practice than ever before. With this growth, the NORA anesthesiologist and team are challenged to provide safe, high-quality care for more patients, often with complex comorbidities, and are forced to utilize deeper levels of sedation and anesthesia than ever before. These added pressures create new avenues for human error and adverse outcomes.

SUMMARY

Safety in modern anesthesia practice often draws comparison to the aviation industry. From distinct preoperational checklists, defined courses of action, safety monitoring and the process of guiding individuals through a journey, there are many similarities between the practice of anesthesia and flying an airplane. Consistent human performance is paramount to creating safe outcomes. Although human errors are inevitable in any complex process, the goal for both the pilot and physician is to ensure the safety of their passengers and patients, respectively. As the aviation industry has had proven success at managing human error with a dramatic improvement in safety, a deeper look at several key examples will allow for comparisons of how to implement these strategies to improve NORA safety.

A closed claims analysis of vocal cord injuries related to endotracheal intubation between 2004 and 2015

STUDY OBJECTIVE

To provide a contemporary medicolegal analysis of claims brought against anesthesiologists for injuries related to endotracheal intubation.

DESIGN

A retrospective study of closed claims data from the Controlled Risk Insurance Company (CRICO) Comparative Benchmarking System (CBS) database between 2004 and 2015.

SETTING

Closed claims that occurred in any surgical specialty in which the patient was undergoing general anesthesia and anesthesiology was named as the primary responsible service.

PATIENTS

Twenty claims were identified for analysis in 7 surgical specialties. Patient ages ranged from 45 to 76. Data regarding patient comorbidities and case history were obtained when available.

INTERVENTIONS

None.

MEASUREMENTS

Data collected includes patient demographics such as age, outcome severity, alleged complication, plaintiff allegations, contributing factors to the injury, the surgical specialty in which the injury occurred, and the ultimate result of the claim (dismissed/denied/settled).

MAIN RESULTS

Out of 20 claims, settlement payments were made in 10% of claims with a mean payment amount of $7669. Mean patient age was 55.6 years. Within severity of injuries, 65% of claims were classified as "Permanent Minor." The most common contributing factor in claims was "Technical Knowledge/Performance" and the most common plaintiff allegation was "Trauma from endotracheal tube placement." Bilateral vocal cord paralysis, unilateral (left-sided) vocal cord paralysis, and laryngeal nerve injury were the top alleged complications. The surgical specialty in which claims most often resulted was orthopedic surgery.

CONCLUSIONS

Injuries related to endotracheal intubation remain an ongoing challenge to anesthesiologists. Their etiology is often multifactorial and was found in this study to stem most commonly from technical errors and patient co-morbidities. A detailed discussion of risks with patients during the consent process, careful documentation of such discussion, and prompt referral to specialists when needed are critical. Understanding the patterns related to injuries during intubation is essential in order to develop strategies for improved patient safety and outcomes.