Anaesthetists stress is induced by patient ASA grade and may impair non-technical skills during intubation

Articulating Video Stylet Compared to Other Techniques for Endotracheal Intubation in Normal Airways: A Simulation Study in Consultants with No Prior Experience

Simulation for airway management allows for acquaintance with new devices and techniques. Endotracheal intubation (ETI), most commonly performed with direct laryngoscopy (DL) or video laryngoscopy (VLS), can be achieved also with combined laryngo-bronchoscopy intubation (CLBI). Finally, an articulating video stylet (ProVu) has been recently introduced. A single-center observational cross-sectional study was performed in a normal simulated airway scenario comparing DL, VLS-Glidescope, VLS-McGrath, CLBI and ProVu regarding the success rate (SR) and corrected time-to-intubation (cTTI, which accounts for the SR). Up to three attempts/device were allowed (maximum of 60 s each). Forty-two consultants with no experience with ProVu participated (15 ± 9 years after training completion). The DL was significantly faster (cTTI) than all other devices (p = 0.033 vs. VLSs, and p < 0.001 for CLBI and Provu), no differences were seen between the two VLSs (p = 0.775), and the VLSs were faster than CLBI and ProVu. Provu had a faster cTTI than CLBI (p = 0.004). The DL and VLSs showed similar SRs, and all the laryngoscopes had a higher SR than CLBI and ProVu at the first attempt. However, by the third attempt, the SR was not different between the DL/VLSs and ProVu (p = 0.241/p = 0.616); ProVu was superior to CLBI (p = 0.038). In consultants with no prior experience, ProVu shows encouraging results compared to DL/VLSs under simulated normal airway circumstances and further studies are warranted.

Alone Together: Is Strain Experienced Concurrently by Members of Operating Room Teams?: An Event-based Study

Objective

To identify which strain episodes are concurrently reported by several team members; to identify triggers of strain experienced by operating room (OR) team members during the intraoperative phase.

Summary

OR teams are confronted with many sources of strain. However, most studies investigate strain on a general, rather than an event-based level, which does not allow to determine if strain episodes are experienced concurrently by different team members.

Methods

We conducted an event-based, observational study, at an academic medical center in North America and included 113 operations performed in 5 surgical departments (general, vascular, pediatric, gynecology, and trauma/acute care). Strain episodes were assessed with a guided-recall method. Immediately after operations, participants mentally recalled the operation, described the strain episodes experienced and their content.

Results

Based on 731 guided recalls, 461 strain episodes were reported; these refer to 312 unique strain episodes. Overall, 75% of strain episodes were experienced by a single team member only. Among different categories of unique strain episodes, those triggered by task complexity, issues with material, or others' behaviors were typically experienced by 1 team member only. However, acute patient issues (n = 167) and observations of others' strain (n = 12) (respectively, 58.5%; P < 0.001 and 83.3%; P < 0.001) were often experienced by 2 or more team members.

Conclusions and relevance

OR team members are likely to experience strain alone, unless patient safety is at stake. This may jeopardize the building of a shared understanding among OR team members.

Correlation between perioperative parecoxib use and postoperative acute kidney injury in patients undergoing radical mastectomy: a retrospective cohort analysis

Background

Non-steroidal anti-inflammatory drugs (NSAIDs) are among the most widely prescribed drugs worldwide. However, the effect of NSAIDS on postoperative renal function is still unclear. Few studies have assessed the effects of parecoxib on renal function. Our aim is to investigate a correlation between parecoxib and the presence or absence of AKI postoperatively after a breast cancer surgery operation.

Methods

This was a retrospective cohort study that we performed on our hospitalized database. From January 2012 to August 2021, 3542 female patients undergoing radical mastectomy were enrolled, all data including the patients' information and laboratory results were obtained from electronic medical system. The main outcome was the incidence of AKI postoperatively. AKI was defined in accordance with the KDIGO criteria. Study groups were treated with or without parecoxib. Univariable and multivariable logistic regression analyses were performed.

Results

In our study, about 5.76% experienced AKI. The incidence rate of postoperative AKI (3.49%) within 7 days in the parecoxib group was lower than that in the control group (6.00%, P = 0.05). Compared to the control group, the AKI’s incidence was reduced by 49% (OR = 0.46; 95%CI 0.27–0.97) in parecoxib group in multivariable logistic regression analysis. There was a reduction in the incidence of postoperative AKI in other three subgroups: preoperative eGFR < 90 mL/min·1.73/m2 (OR = 0.52; 95%CI 0.27–0.97), blood loss < 1000 ml (OR = 0.48; 95%CI 0.24–0.96) and non-diabetes (OR = 0.51; 95%CI 0.26–0.98).

Conclusions

Parecoxib was associated with incidence of postoperative acute kidney injury.

Mental stress in health care professionals during COVID-19 outbreak

Background

In December 2019, an outbreak of novel corona virus pneumonia occurred in Wuhan City, China, and spread throughout the whole of country in a short period. Figures from China’s National Health Commission show that more than 3300 health care workers have been infected as of early March. In Italy, 20% of responding health care professionals was infected, and some have died. Health care professionals are exposed to different types of stress both physical and psychological in response to this serious infectious public health event.

Research aims

The aim of this study is to measure the degree of mental stress among front line health care workers dealing with COVID-19 patients.

Methods

We conducted the study through online survey questionnaire after obtaining the ethics approval from the Research Ethics Committee of Galway University Hospital in Ireland (Ref: C.A. 2355). All personal information of the medical staff involved in the survey has been kept confidential.

Results

Three hundred nine health care members (209 male and 97 female) have agreed to participate in our survey from different hospitals and different specialties all over the world. Overall PSS Score: mean 19.42 (Standard Deviation ± 5.876, range 1–33). Frontline health care workers working in University Hospitals and tertiary referral centres had lower levels of stress compared to those working in peripheral hospitals (P = 0.007, Kruskal Wallis).

Conclusion

The COVID-19 pandemic is one of the most stressful events that a health care worker may face during his life time. Most of the participants in the survey developed a moderate degree of stress.

The Evolution, Current Value, and Future of the American Society of Anesthesiologists Physical Status Classification System

The American Society of Anesthesiologists (ASA) Physical Status classification system celebrates its 80th anniversary in 2021. Its simplicity represents its greatest strength as well as a limitation in a world of comprehensive multisystem tools. It was developed for statistical purposes and not as a surgical risk predictor. However, since it correlates well with multiple outcomes, it is widely used-appropriately or not-for risk prediction and many other purposes. It is timely to review the history and development of the system. The authors describe the controversies surrounding the ASA Physical Status classification, including the problems of interrater reliability and its limitations as a risk predictor. Last, the authors reflect on the current status and potential future of the ASA Physical Status system.

Situation awareness and the mitigation of risk associated with patient deterioration: A meta-narrative review of theories and models and their relevance to nursing practice

BACKGROUND

Accurate situation awareness has been identified as a critical component of effective deteriorating patient response systems and an essential patient safety skill for nursing practice. However, situation awareness has been defined and theorised from multiple perspectives to explain how individuals, teams and systems maintain awareness in dynamic task environments.

AIM

Our aim was to critically analyse the different approaches taken to the study of situation awareness in healthcare and explore the implications for nursing practice and research as it relates to clinical deterioration in ward contexts.

METHODS

We undertook a meta-narrative review of the healthcare literature to capture how situation awareness has been defined, theorised and studied in healthcare. Following an initial scoping review, we conducted an extensive search of ten electronic databases and included any theoretical, empirical or critical papers with a primary focus on situation awareness in an inpatient hospital setting. Included papers were collaboratively categorised in accordance with their theoretical framing, research tradition and paradigm with a narrative review presented.

RESULTS

A total of 120 papers were included in this review. Three overarching narratives reflecting philosophical, patient safety and solution focussed framings of situation awareness and seven meta-narratives were identified as follows: individual, team and systems perspectives of situation awareness (meta-narratives 1-3), situation awareness and patient safety (meta-narrative 4), communication tools, technologies and education to support situation awareness (meta-narratives 5-7). We identified a concentration of literature from anaesthesia and operating rooms and a body of research largely located within a cognitive engineering tradition and a positivist research paradigm. Endsley's situation awareness model was applied in over 80% of the papers reviewed. A minority of papers drew on alternative situation awareness theories including constructivist, collaborative and distributed perspectives.

CONCLUSIONS

Nurses have a critical role in identifying and escalating the care of deteriorating patients. There is a need to build on prior studies and reflect on the reality of nurse's work and the constraints imposed on situation awareness by the demands of busy inpatient wards. We suggest that this will require an analysis that complements but goes beyond the dominant cognitive engineering tradition to reflect the complex socio-cultural reality of ward-based teams and to explore how situation awareness emerges in increasingly complex, technologically enabled distributed healthcare systems.

[Teamwork and stress in routine interventions: an observational study of multiprofessional OR teams]

Hintergrund

Effektive interprofessionelle Teamarbeit im Operationssaal (OP) und intraoperativer Stress sind von großer Bedeutung für Patientensicherheit und Versorgungsqualität. Dennoch gibt es nur wenige systematische Studien zum Zusammenhang von Teamarbeit im OP und Arbeitsstress.

Ziele der Arbeit

Untersuchung des Zusammenhangs von Teamarbeit und empfundenem Stress bei Routineeingriffen – für das OP-Team als Gesamtheit sowie für die einzelnen Professionen Chirurgie, Anästhesie und Pflege.

Material und Methoden

Durchgeführt wurde eine Mehrmethodenstudie bestehend aus Expertenbeobachtungen mittels eines standardisierten Beobachtungsinstruments (OTAS-D) und systematischer Selbstberichte des gesamten OP-Teams. Erfasst wurden 64 elektive Routineeingriffe unterschiedlicher chirurgischer Fachbereiche. Die statistischen Zusammenhangsanalysen unter Kontrolle prozeduraler Einflussfaktoren wurden mit „Mixed-effects“-Regressionsmodellen berechnet.

Ergebnisse

Die Güte der intraoperativen Teamarbeit lag auf mittlerem Niveau. Der situative Stress während des Eingriffs wurde durch die Befragten eher auf niedrigerem Niveau berichtet, mit signifikanten Unterschieden zwischen den Professionen Chirurgie, Pflege und Anästhesie. Mitglieder des chirurgischen Teams berichteten im Durchschnitt die höchsten Stressniveaus. Ein genereller Zusammenhang zwischen Teamarbeit und Stresserleben konnte nicht beobachtet werden, allerdings für die einzelnen Professionen: Für das chirurgische Team ergaben sich signifikante, positive Zusammenhänge, sowie für die Teamarbeitsdimensionen Zusammenarbeit und Führung. Signifikante negative Zusammenhänge ergaben sich für das Pflegeteam hinsichtlich der Qualität der interdisziplinären Teamarbeit insgesamt sowie für die Teamarbeitsdimension Team-Monitoring.

Diskussion

Die Effekte interprofessioneller Zusammenarbeit im OP auf subjektives Stressempfinden bei Routineeingriffen hängen von Professionszugehörigkeit, Aufgabe und Tätigkeit ab. Weitere Forschungsarbeit ist notwendig, inwiefern gute Teamarbeit bei Routineeingriffen innerhalb und über die Professionen hinweg intraoperativen Stress beeinflusst.

Zusatzmaterial online

Die Online-Version dieses Beitrags (10.1007/s00113-021-00977-w) enthält eine vollständige Liste mit Kurzbeschreibungen der beobachteten Eingriffe. Beitrag und Zusatzmaterial stehen Ihnen auf www.springermedizin.de/link/10.1007/s00113-021-00977-w zur Verfügung.

Laryngoscopic techniques modulate anaesthesiologists' perception of halitosis in patients: A randomised controlled trial

BACKGROUND

Perception of halitosis in patients during intubation is a common and additional stressor for anaesthesiologists and may lead to potential health risks.

OBJECTIVES

We hypothesised that intubation with videolaryngoscopy could help reduce the anaesthesiologists' perception of patients' oral malodor during intubation.

DESIGN

A single-blinded, randomised controlled trial.

SETTING

Single centre general hospital, Guangdong Province, China.

PARTICIPANTS

A total of 440 patients who underwent intubation under general anaesthesia for elective surgery, aged 18 to 60 years old, American Society of Anaesthesiologists class I to III, without upper airway abnormality or airway infection were enrolled.

INTERVENTION

Patients were randomly assigned to receive either UE videolaryngoscopy (UE) or Macintosh's direct laryngoscopy (Macintosh) group. All intubations were performed by one of six very experienced anaesthesiologists.

MAIN OUTCOME MEASURES

The patient's oral odour score was measured prior to induction of anaesthesia. The anaesthesiologists' perception of the patient's oral malodor during intubation was recorded. The shortest distance from patient's mouth to the anaesthesiologist's nose (MN distance), the exertion rating and discomfort were also measured.

RESULTS

The oral malodor score did not differ in the UE and Macintosh groups prior to the induction of anaesthesia. However, the incidence of the anaesthesiologists' perception of halitosis during intubation was significantly lower in the UE group compared with the Macintosh group (P < 0.001). Similarly, the MN distance was significantly greater in the UE group compared with the Macintosh group (P < 0.001). The first-attempt success rate was higher in the UE group compared to the Macintosh group (P < 0.001). However, the exertion scores were considerably higher in the Macintosh group. After intubation, anaesthesiologists experienced more waist and shoulder discomfort with the Macintosh than the UE technique of intubation.

CONCLUSION

Compared with direct laryngoscopy, videolaryngoscopy might reduce the anaesthesiologists' perception of the patients' oral malodor, help improve first-attempt success rate, as well as alleviate the anaesthesiologists' waist and shoulder discomfort.

TRIAL REGISTRATION

Clinicaltrials.gov (ChiCTR-IOR-15007038).

Stress and decision-making in resuscitation: A systematic review

BACKGROUND

During resuscitation decisions are made frequently and based on limited information in a stressful environment.

AIM

This systematic review aimed to identify human factors affecting decision-making in challenging or stressful situations in resuscitation. The secondary aim was to identify methods of improving decision-making performance under stress.

METHODS

The databases PubMed, EMBASE and The Cochrane Library were searched from their commencement to the 13th of April 2019. MeSH terms and key words were combined (Stress* OR "human factor") AND Decision. Articles were included if they involved decision makers in medicine where decisions were made under challenging circumstances, with a comparator group and an outcome measure relating to change in decision-making performance.

RESULTS

22,368 records in total were initially identified, from which 82 full text studies were reviewed and 16 finally included. The included studies ranged from 1995 to 2018 and included a total of 570 participants. The studies were conducted in several different countries and settings, with participants of varying experience and backgrounds. Of the 16 studies, 5 were randomised controlled trials, 3 of which were deemed to have a high risk of bias. The stressors identified were (i) illness severity (ii) socio-evaluative, (iii) noise, (iv) fatigue. The mitigators identified were (i) cognitive aids including checklists, (ii) stress management training and (iii) meditation.

CONCLUSIONS

Human factors contributing to decision-making during resuscitation are identified and can be mitigated by tailored stress training and cognitive aids. Understanding these factors may have implications for clinician education and the development of decision-support tools.

Association of Intraoperative Hypotension with Acute Kidney Injury after Noncardiac Surgery in Patients Younger than 60 Years Old

BACKGROUND/AIMS

Intraoperative hypotension (IOH) may be associated with surgery-related acute kidney injury (AKI). However, the duration of hypotension that triggers AKI is poorly understood. The incidence of AKI with various durations of IOH and mean arterial pressures (MAPs) was investigated.

MATERIALS

A retrospective cohort study of 4,952 patients undergoing noncardiac surgery (2011 to 2016) with MAP monitoring and a length of stay of one or more days was performed. The exclusion criteria were a preoperative estimated glomerular filtration (eGFR) ≤60 mL min-1 1.73 m2-1, a preoperative MAP less than 65 mm Hg, dialysis dependence, urologic surgery, age older than 60 years, and a surgical duration of less than 60 min. The primary exposure was IOH, and the primary outcome was AKI (50% or 0.3 mg dL-1 increase in creatinine) during the first 7 postoperative days. Multivariable logistic regression was used to model the exposure-outcome relationship.

RESULTS

AKI occurred in 186 (3.76%) noncardiac surgery patients. The adjusted odds ratio for surgery-related AKI for a MAP of less than 55 mm Hg was 14.11 (95% confidence interval: 5.02-39.69) for an exposure of more than 20 min. Age was not an interaction factor between AKI and IOH.

CONCLUSION

There was a considerably increased risk of postoperative AKI when intraoperative MAP was less than 55 mm Hg for more than 10 min. Strict blood pressure management is recommended even for patients younger than 60 years old.

Exploring the challenges of task-centred training in obstetric anaesthesia in the operating theatre environment

BACKGROUND

Task-centred learning forms the basis of procedural training in obstetric anaesthesia. We observed that our residents were not building their competence from experiential practice in the operating theatre. We used a broad-based framework to explore the challenges encountered by the residents and clinical supervisors in the learning and teaching of obstetric anaesthesia.

METHODS

The study was conducted at the KK Women's and Children's Hospital, Singapore, from 1 December 2016 to 30 June 2017. A semi-structured interview format was used in the focus group and individual interviews. Information collection continued until data saturation was reached. The interviews were analysed and the challenges were identified. Fourteen residents and five clinical supervisors participated in the focus group and individual interviews respectively.

FINDINGS

The operating theatre constituted a stressful learning and teaching environment for the participants. Five categories of challenges were identified: (1) clinical conditions, (2) concerns about maternal risk and outcomes, (3) reluctance of the residents to vocalise their learning needs, (4) poor feedback, and (5) lack of opportunities for inter-professional practice. These collective challenges reduced the quality of task-centred learning and the effectiveness of supervisor teaching. We described some strategies to overcome these challenges (dedicated trainee lists, obstetric anaesthesia reflective diary, active mentoring system and in-situ simulation).

CONCLUSIONS

Our study described the challenges of obstetric anaesthesia training in the operating theatre environment in an Asian healthcare setting. Research is needed on the influence of supervisors' concern about maternal risks and their teaching behaviours.

The influence of stress responses on surgical performance and outcomes: Literature review and the development of the surgical stress effects (SSE) framework

BACKGROUND

Surgical adverse events persist despite several decades of system-based quality improvement efforts, suggesting the need for alternative strategies. Qualitative studies suggest stress-induced negative intraoperative interpersonal dynamics might contribute to performance errors and undesirable patient outcomes. Understanding the impact of intraoperative stressors may be critical to reducing adverse events and improving outcomes.

DATA SOURCES

We searched MEDLINE, psycINFO, EMBASE, Business Source Premier, and CINAHL databases (1996-2016) to assess the relationship between negative (emotional and behavioral) responses to acute intraoperative stressors and provider performance or patient surgical outcomes.

RESULTS/CONCLUSIONS

Drawing on theory and evidence from reviewed studies, we present the Surgical Stress Effects (SSE) framework. This illustrates how emotional and behavioral responses to stressors can influence individual surgical provider (e.g. surgeon, nurse) performance, team performance, and patient outcomes. It also demonstrates how uncompensated intraoperative threats and errors can lead to adverse events, highlighting evidence gaps for future research efforts.

Simulation fails to replicate stress in trainees performing a technical procedure in the clinical environment

INTRODUCTION

Simulation-based training (SBT) has become an increasingly important method by which doctors learn. Stress has an impact upon learning, performance, technical, and non-technical skills. However, there are currently no studies that compare stress in the clinical and simulated environment. We aimed to compare objective (heart rate variability, HRV) and subjective (state trait anxiety inventory, STAI) measures of stress theatre with a simulated environment.

METHODS

HRV recordings were obtained from eight anesthetic trainees performing an uncomplicated rapid sequence induction at pre-determined procedural steps using a wireless Polar RS800CX monitor © in an emergency theatre setting. This was repeated in the simulated environment. Participants completed an STAI before and after the procedure.

RESULTS

Eight trainees completed the study. The theatre environment caused an increase in objective stress vs baseline (p = .004). There was no significant difference between average objective stress levels across all time points (p = .20) between environments. However, there was a significant interaction between the variables of objective stress and environment (p = .045). There was no significant difference in subjective stress (p = .27) between environments.

DISCUSSION

Simulation was unable to accurately replicate the stress of the technical procedure. This is the first study that compares the stress during SBT with the theatre environment and has implications for the assessment of simulated environments for use in examinations, rating of technical and non-technical skills, and stress management training.