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Santos LCP, Perkins N, Keates H, Goodwin W. Anaesthetic practices and attitudes to patient safety in a sample of Australian veterinary practices. Vet Anaesth Analg 2024; 51:438-448. [PMID: 39138050 DOI: 10.1016/j.vaa.2024.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Revised: 06/07/2024] [Accepted: 06/10/2024] [Indexed: 08/15/2024]
Abstract
OBJECTIVE To survey anaesthetic practices and attitudes towards veterinary patient safety in Australia. STUDY DESIGN This was a cross-sectional sample population from Australian veterinary practices, including first opinion small animal, mixed animal and referral small animal practices. The survey included practices' anaesthetic management, monitoring equipment and topics regarding patient safety. RESULTS Responses were obtained from 310/1700 (18%) veterinary practices, with 208 respondents from small animal practices (67%), 71 mixed animal practices (23%) and 31 referral small animal centres (10%). Overall, 61% of respondents reported always having a dedicated staff member monitoring the anaesthetic, who was most commonly a certified veterinary nurse (89%). In 22% of the practices, some of the staff monitoring an anaesthetic did not have any qualification. Completion of anaesthetic plans for each animal prior to an anaesthetic was reported by 24.5% of respondents and labelling of syringes was completed in 80% of practices. Pulse oximetry (98%) and temperature (88%) were the most common clinical variables monitored. The use of capnography (46%) or an electrocardiogram (48%) was also reported by the respondents. Emergency drugs, airway and ventilation equipment are available in 96%, 88% and 59% of practices, respectively. A defibrillator was available in 11% of practices with only 54% respondents being confident in using it. Of the respondents 60% were aware of anaesthesia safety interventions and clinical guidelines regarding patient safety during anaesthesia. CONCLUSIONS AND CLINICAL RELEVANCE Despite practices showing a relative improvement over the years in the standard of anaesthesia care, most of them are still not meeting international guidelines. Areas where changes could lead to improved safety practices could include: a trained person dedicated to monitor anaesthesia, pain scoring evaluation in patients recovering from anaesthesia, an increased use of standardised handover checklists, record keeping and an increase in open discussion of adverse events by the veterinary team.
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Affiliation(s)
- Luiz C P Santos
- School Of Biodiversity, One Health & Veterinary Medicine, The University of Glasgow, Garscube Campus, Glasgow, UK; School of Veterinary Sciences, The University of Queensland, Gatton, QLD, Australia.
| | - Nigel Perkins
- School of Veterinary Sciences, The University of Queensland, Gatton, QLD, Australia
| | - Helen Keates
- School of Veterinary Sciences, The University of Queensland, Gatton, QLD, Australia
| | - Wendy Goodwin
- School of Veterinary Sciences, The University of Queensland, Gatton, QLD, Australia
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Khanna AK, Banga A, Rigdon J, White BN, Cuvillier C, Ferraz J, Olsen F, Hackett L, Bansal V, Kaw R. Role of continuous pulse oximetry and capnography monitoring in the prevention of postoperative respiratory failure, postoperative opioid-induced respiratory depression and adverse outcomes on hospital wards: A systematic review and meta-analysis. J Clin Anesth 2024; 94:111374. [PMID: 38184918 DOI: 10.1016/j.jclinane.2024.111374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 12/23/2023] [Accepted: 01/02/2024] [Indexed: 01/09/2024]
Abstract
OBJECTIVE The current standards of postoperative respiratory monitoring on medical-surgical floors involve spot-pulse oximetry checks every 4-8 h, which can miss the opportunity to detect prolonged hypoxia and acute hypercapnia. Continuous respiratory monitoring can recognize acute respiratory depression episodes; however, the existing evidence is limited. We sought to review the current evidence on the effectiveness of continuous pulse oximetry (CPOX) with and without capnography versus routine monitoring and their effectiveness for detecting postoperative respiratory failure, opioid-induced respiratory depression, and preventing downstream adverse events. METHODS We performed a systematic literature search on Ovid Medline, Embase, and Cochrane Library databases for articles published between 1990 and April 2023. The study protocol was registered in Prospero (ID: 439467), and PRISMA guidelines were followed. The NIH quality assessment tool was used to assess the quality of the studies. Pooled analysis was conducted using the software R version 4.1.1 and the package meta. The stability of the results was assessed using sensitivity analysis. DESIGN Systematic Review and Meta-Analysis. SETTING Postoperative recovery area. PATIENTS 56,538 patients, ASA class II to IV, non-invasive respiratory monitoring, and post-operative respiratory depression. INTERVENTIONS Continuous pulse oximetry with or without capnography versus routine monitoring. MEASUREMENTS Respiratory rate, oxygen saturation, adverse events, and rescue events. RESULTS 23 studies (17 examined CPOX without capnography and 5 examined CPOX with capnography) were included in this systematic review. CPOX was better at recognizing desaturation (SpO2 < 90%) OR: 11.94 (95% CI: 6.85, 20.82; p < 0.01) compared to standard monitoring. No significant differences were reported for ICU transfer, reintubation, and non-invasive ventilation between the two groups. CONCLUSIONS Oxygen desaturation was the only outcome better detected with CPOX in postoperative patients in hospital wards. These comparisons were limited by the small number of studies that could be pooled for each outcome and the heterogeneity between the studies.
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Affiliation(s)
- Ashish K Khanna
- Department of Anesthesiology, Section on Critical Care Medicine, Wake Forest University School of Medicine, Winston-Salem, NC, USA; Perioperative Outcomes and Informatics Collaborative (POIC), Winston-Salem, NC, USA; Outcomes Research Consortium, Cleveland, OH, USA
| | - Akshat Banga
- Department of Internal Medicine, Sawai Man Singh Medical College, Jaipur, Rajasthan, India
| | - Joseph Rigdon
- Department of Biostatistics and Data Science, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Brian N White
- Department of Biostatistics and Data Science, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | | | - Joao Ferraz
- Department of Hospital Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Fredrik Olsen
- Department of Anesthesiology and Intensive Care Medicine, Institute of Clinical Sciences, University of Gothenburg, Sweden
| | - Loren Hackett
- Floyd D. Loop Alumni Library, Cleveland Clinic, Cleveland, Ohio, USA
| | - Vikas Bansal
- Division of Nephrology and Critical Care Medicine, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Roop Kaw
- Outcomes Research Consortium, Cleveland, OH, USA; Department of Hospital Medicine, Cleveland Clinic, Cleveland, OH, USA.
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Blike GT, McGrath SP, Ochs Kinney MA, Gali B. Pro-Con Debate: Universal Versus Selective Continuous Monitoring of Postoperative Patients. Anesth Analg 2024; 138:955-966. [PMID: 38621283 DOI: 10.1213/ane.0000000000006840] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/17/2024]
Abstract
In this Pro-Con commentary article, we discuss use of continuous physiologic monitoring for clinical deterioration, specifically respiratory depression in the postoperative population. The Pro position advocates for 24/7 continuous surveillance monitoring of all patients starting in the postanesthesia care unit until discharge from the hospital. The strongest arguments for universal monitoring relate to inadequate assessment and algorithms for patient risk. We argue that the need for hospitalization in and of itself is a sufficient predictor of an individual's risk for unexpected respiratory deterioration. In addition, general care units carry the added risk that even the most severe respiratory events will not be recognized in a timely fashion, largely due to higher patient to nurse staffing ratios and limited intermittent vital signs assessments (e.g., every 4 hours). Continuous monitoring configured properly using a "surveillance model" can adequately detect patients' respiratory deterioration while minimizing alarm fatigue and the costs of the surveillance systems. The Con position advocates for a mixed approach of time-limited continuous pulse oximetry monitoring for all patients receiving opioids, with additional remote pulse oximetry monitoring for patients identified as having a high risk of respiratory depression. Alarm fatigue, clinical resource limitations, and cost are the strongest arguments for selective monitoring, which is a more targeted approach. The proponents of the con position acknowledge that postoperative respiratory monitoring is certainly indicated for all patients, but not all patients need the same level of monitoring. The analysis and discussion of each point of view describes who, when, where, and how continuous monitoring should be implemented. Consideration of various system-level factors are addressed, including clinical resource availability, alarm design, system costs, patient and staff acceptance, risk-assessment algorithms, and respiratory event detection. Literature is reviewed, findings are described, and recommendations for design of monitoring systems and implementation of monitoring are described for the pro and con positions.
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Affiliation(s)
- George T Blike
- From the Departments of Anesthesiology
- Community and Family Medicine, Geisel School of Medicine, Hanover, New Hampshire
- The Dartmouth Institute, Dartmouth College, Hanover, New Hampshire
- Surveillance Analytics Core, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Susan P McGrath
- From the Departments of Anesthesiology
- Surveillance Analytics Core, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Michelle A Ochs Kinney
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
| | - Bhargavi Gali
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
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Bello C, Luedi MM. Postoperative intrahospital monitoring: Transforming the danger zone. J Clin Anesth 2024; 92:111183. [PMID: 37328311 DOI: 10.1016/j.jclinane.2023.111183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 06/07/2023] [Accepted: 06/08/2023] [Indexed: 06/18/2023]
Affiliation(s)
- Corina Bello
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Markus M Luedi
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
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Auckley D, Singh M. Protocolizing perioperative OSA screening and management: moving in the right direction. J Clin Sleep Med 2022; 18:1895-1896. [PMID: 35702018 PMCID: PMC9340586 DOI: 10.5664/jcsm.10154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Dennis Auckley
- Professor of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, MetroHealth Medical Center, Case Western Reserve University, Cleveland, OH
| | - Mandeep Singh
- Department of Anesthesia, Women's College Hospital, and Toronto Western Hospital, University Health Network; University of Toronto, Toronto, ON, Canada
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Singh NP, Makkar JK, Kuberan A, Guffey R, Uppal V. Efficacy of regional anesthesia techniques for postoperative analgesia in patients undergoing major oncologic breast surgeries: a systematic review and network meta-analysis of randomized controlled trials. Can J Anaesth 2022; 69:527-549. [PMID: 35102494 DOI: 10.1007/s12630-021-02183-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 11/08/2021] [Accepted: 11/10/2021] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND The optimal regional technique to control pain after breast cancer surgery remains unclear. We sought to synthesize available data from randomized controlled trials comparing pain-related outcomes following various regional techniques for major oncologic breast surgery. METHODS In a systematic review and network meta-analysis, we searched trials in PubMed, Embase Scopus, Medline, Cochrane Central and Google Scholar, from inception to 31 July 2020, for commonly used regional techniques. The primary outcome was the 24-hr resting pain score measured on a numerical rating score of 0-10. We used surface under the cumulative ranking curve (SUCRA) to establish the probability of an intervention ranking highest. The analysis was performed using the Bayesian random effects model, and effect sizes are reported as 95% credible interval (Crl). We conducted cluster-rank analysis by combining 24-hr pain ranking with 24-hr opioid use or incidence of postoperative nausea and vomiting. RESULTS Seventy-nine randomized controlled trials containing 11 different interventions in 5,686 patients were included. The SUCRA values of the interventions for 24-hr resting pain score were continuous paravertebral block (0.83), serratus anterior plane block (0.76), continuous wound infusion (0.76), single-level paravertebral block (0.68), erector spinae plane block (0.59), modified pectoral block (0.49), intercostal block (0.45), multilevel paravertebral block (0.41), wound infiltration (0.33), no intervention (0.12), and placebo (0.08). When compared with placebo, the continuous paravertebral block (mean difference, 1.26; 95% Crl, 0.43 to 2.12) and serratus anterior plane block (mean difference, 1.12; 95% Crl, 0.32 to 1.9) had the highest estimated probability of decreasing 24-hr resting pain scores. Cluster ranking analysis combining 24-hr resting pain scores and opioid use showed that most regional analgesia techniques were more effective than no intervention or placebo. Nevertheless, wound infiltration and continuous wound infusion may be the least effective active interventions for reducing postoperative nausea and vomiting. CONCLUSION Continuous paravertebral block and serratus anterior plane block had a high probability of reducing pain at 24 hr after major oncologic breast surgery. The certainty of evidence was moderate to very low. Future studies should compare different regional anesthesia techniques, including surgeon-administered techniques such as wound infiltration or catheters. Trials comparing active intervention with placebo are unlikely to change clinical practice. STUDY REGISTRATION PROSPERO (CRD42020198244); registered 19 October 2020.
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Affiliation(s)
- Narinder Pal Singh
- Department of Anaesthesia, MMIMSR, MM (DU), Mullana-Ambala, Ambala, India
| | - Jeetinder Kaur Makkar
- Department of Anaesthesia and Intensive Care, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Aswini Kuberan
- Department of Anaesthesiology and Critical Care, Jawaharlal Institute of Postgraduate Medical Education & Research, Puducherry, India
| | - Ryan Guffey
- Department of Anesthesia, Washington University in St. Louis, St. Louis, MO, USA
| | - Vishal Uppal
- Department of Anesthesia, Perioperative Medicine and Pain Management, Dalhousie University, Nova Scotia Health Authority and Izaak Walton Killam Health Centre, Halifax, NS, Canada.
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Michard F, Thiele RH, Saugel B, Joosten A, Flick M, Khanna AK. Wireless wearables for postoperative surveillance on surgical wards: a survey of 1158 anaesthesiologists in Western Europe and the USA. BJA OPEN 2022; 1:100002. [PMID: 37588692 PMCID: PMC10430871 DOI: 10.1016/j.bjao.2022.100002] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Accepted: 01/12/2022] [Indexed: 08/18/2023]
Abstract
Background Several continuous monitoring solutions, including wireless wearable sensors, are available or being developed to improve patient surveillance on surgical wards. We designed a survey to understand the current perception and expectations of anaesthesiologists who, as perioperative physicians, are increasingly involved in postoperative care. Methods The survey was shared in 40 university hospitals from Western Europe and the USA. Results From 5744 anaesthesiologists who received the survey link, there were 1158 valid questionnaires available for analysis. Current postoperative surveillance was mainly based on intermittent spot-checks of vital signs every 4-6 h in the USA (72%) and every 8-12 h in Europe (53%). A majority of respondents (91%) considered that continuous monitoring of vital signs should be available on surgical wards and that wireless sensors are preferable to tethered systems (86%). Most respondents indicated that oxygen saturation (93%), heart rate (80%), and blood pressure (71%) should be continuously monitored with wrist devices (71%) or skin adhesive patches (54%). They believed it may help detect clinical deterioration earlier (90%), decrease rescue interventions (59%), and decrease hospital mortality (54%). Opinions diverged regarding the impact on nurse workload (increase 46%, decrease 39%), and most respondents considered that the biggest implementation challenges are economic (79%) and connectivity issues (64%). Conclusion Continuous monitoring of vital signs with wireless sensors is wanted by most anaesthesiologists from university hospitals in Western Europe and in the USA. They believe it may improve patient safety and outcome, but may also be challenging to implement because of cost and connectivity issues.
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Affiliation(s)
| | - Robert H. Thiele
- Department of Anesthesiology, University of Virginia, Charlottesville, VA, USA
| | - Bernd Saugel
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg–Eppendorf, Hamburg, Germany
- Outcomes Research Consortium, Cleveland, OH, USA
| | - Alexandre Joosten
- Department of Anesthesiology, University Paris Saclay, Paul Brousse Hospital, Villejuif, France
| | - Moritz Flick
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg–Eppendorf, Hamburg, Germany
| | - Ashish K. Khanna
- Outcomes Research Consortium, Cleveland, OH, USA
- Department of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, NC, USA
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