Anahat Dhillon

Neuromuscular blocking agent administration for emergent tracheal intubation is associated with decreased prevalence of procedure-related complications.

Background:Emergent intubation is associated with a high rate of complications. Neuromuscular blocking agents are routinely used in the operating room and emergency department to facilitate intubation. However, use of neuromuscular blocking agents during emergent airway management outside of the operating room and emergency department is controversial. We hypothesized that the use of neuromuscular blocking agents is associated with a decreased prevalence of hypoxemia and reduced rate of procedure-related complications. Methods:Five hundred sixty-six patients undergoing emergent intubations in two tertiary care centers, Massachusetts General Hospital, Boston, MA, and the University of California Los Angeles, Ronald Reagan Medical Center, Los Angeles, CA, were enrolled in a prospective, observational study. The 112 patients intubated during cardiopulmonary resuscitation were excluded, leaving 454 patients for analysis. All intubations were supervised by attendings trained in Critical Care Medicine. We measured intubating conditions, oxygen saturation during and 5 mins following intubation. We assessed the prevalence of procedure-related complications defined as esophageal intubation, traumatic intubation, aspiration, dental injury, and endobronchial intubation. Results:The use of neuromuscular blocking agents was associated with a lower prevalence of hypoxemia (10.1% vs. 17.4%, p = .022) and a lower prevalence of procedure-related complications (3.1% vs. 8.3%, p = .012). This association persisted in a multivariate analysis, which controlled for airway grade, sedation, and institution. Use of neuromuscular blocking agents was associated with significantly improved intubating conditions (laryngeal view, p = .014; number of intubation attempts, p = .049). After controlling for the number of intubation attempts and laryngoscopic view, muscle relaxant use is an independent predictor of complications associated with emergency intubation (p = .037), and there is a trend towards improvement of oxygenation (p = .07). Conclusion:The use of neuromuscular blocking agents, when used by intensivists with a high level of training and experience, is associated with a decrease in procedure-related complications.

Revised cardiac risk index (RCRI) is a useful tool for evaluation of perioperative cardiac morbidity in kidney transplant recipients

Background We evaluated a published Revised Cardiac Risk Index (RCRI) to determine if this preoperative cardiovascular risk stratification tool would be useful in the kidney transplant recipient population. Methods We identified all kidney transplants from 2005 to 2009 (n=1652) at our institution. We performed a detailed retrospective chart review of (a) all recipients who underwent preoperative coronary angiography (n=169) and (b) an age-matched and transplantation year–matched group who did not undergo coronary angiography (n=156). Charts were reviewed for the presence of specific preoperative cardiovascular risk factors and perioperative cardiovascular complications (as defined by RCRI plus elevation of troponin) from time of surgery to hospital discharge. The total number of risk factors for each patient was compared with the occurrence of postoperative cardiac complications to identify a possible association. Results The number of risk factors was highly predictive of cardiovascular complications (receiver operating characteristic area, 0.77; P<0.0001). History of coronary artery disease was most strongly associated (odds ratio, 20.59; confidence interval, 4.73–89.53; P=0.0001) and history of congestive heart failure was also significantly associated with cardiac complications (odds ratio, 2.95; confidence interval, 1.01–8.59; P=0.0475). Conclusion The RCRI is a useful tool for cardiac risk stratification in kidney transplantation and could be used to develop protocols for intraoperative and postoperative care to minimize complications.

Catastrophic Events in the Perioperative Setting: A Survey of U.S. Anesthesiologists

Catastrophic events in the perioperative period can adversely impact the wellbeing of the healthcare workers involved. These second victims may experience symptoms including depression, isolation and loss of confidence related to the event. A limited amount of published research suggests those who receive formal support (e.g. departmental debriefing) may have an improved recovery experience. This cross-sectional study was conducted to assess the proportion of U.S. anesthesiologists who have experienced catastrophic perioperative events and bring into focus the association between event details, respondent characteristics and utilization of formal support with recovery time. Additionally, we aimed to ascertain the current state of post-event formal support and opinions for ideal event handling across the anesthesiology practice. A seventeen-question survey was distributed to 5,000 attending anesthesiologist members of the American Society of Anesthesiologists (ASA). 289 responses were received. 85% report having experienced a catastrophic event; greater than 80% of those involved a death. 42% took a few days or less to recover yet 24% took a year or more. 31% had department debriefing and 25% had multidisciplinary debriefing. No association between gender, practice setting, years of experience and recovery time was detected. Comments revealed highly individualized recovery experiences and heterogeneity in processes for post-event debrief. Regarding current, institutional practice: 56% report there is no departmental debriefing team and 16% do not know if such a team exists. 49% feel debriefing should be mandatory. Comments reflect a variety of opinions regarding ideal support. Resources that address the complexities of the recovery experience should be thoughtfully developed and made available to those who may benefit from them.

Preoperative risk stratification of critically ill patients

STUDY OBJECTIVE Risk assessment historically emphasized cardiac morbidity and mortality in elective, outpatient, non-cardiac surgery. However, critically ill patients increasingly present for therapeutic interventions. Our study investigated the relationship of American Society of Anesthesiologists (ASA) class, revised cardiac risk index (RCRI), and sequential organ failure assessment (SOFA) score with survival to discharge in critically ill patients with respiratory failure. DESIGN Retrospective cohort analysis over a 21-month period. SETTING Five adult intensive care units (ICUs) at a single tertiary medical center. PATIENTS Three hundred fifty ICU patients in respiratory failure, who underwent 501 procedures with general anesthesia. MEASUREMENTS Demographic, clinical, and surgical variables were collected from the pre-anesthesia evaluation forms and preoperative ICU charts. The primary outcome was survival to discharge. MAIN RESULTS Ninety-six patients (27%) did not survive to discharge. There were significant differences between survivors and non-survivors for ASA (3.7 vs. 3.9, p=0.001), RCRI (1.6 vs. 2.0, p=0.003), and SOFA score (8.1 vs. 11.2, p<0.001). Based on the area under the receiver operating characteristic curve for these relationships, there was only modest discrimination between the groups, ranging from the most useful SOFA (0.68) to less useful RCRI (0.60) and ASA (0.59). CONCLUSIONS This single center retrospective study quantified a high perioperative risk for critically ill patients with advanced airways: one in four did not survive to discharge. Preoperative ASA score, RCRI, and SOFA score only partially delineated survivors and non-survivors. Given the existing limitations, future research may identify assessment tools more relevant to discriminating survival outcomes for critically ill patients in the perioperative environment.

The Perioperative Surgical Home for the Geriatric Population

The perioperative surgical home while in its infancy in many ways is a concept trialed under different names for decades with the goals being to improve patient outcomes and satisfaction while decreasing costs. This can be achieved by decreasing variability, utilizing multidisciplinary teams, coordinating care across the continuum, and engaging the patient in the process. Geriatric patients serve as the prime population to benefit from these concepts given their increased risk and cost due to their comorbidities, increased concentration on quality of life, and the magnitude of impact of a “simple procedure.” With only increasing operative and nonoperative procedures being performed in these patients, development of rigorous programs utilizing concepts of the PSH will improve care into the future.

High intraoperative endotracheal tube cuff pressure incidence and clinical impact

To the Editor, Endotracheal intubation constitutes a routine function of anesthetic practice in the operating room, sealing the airway to prevent leaks and aspiration of pharyngeal contents into the trachea. However, the rate of laryngotracheal injury following intubation has been suggested to be 11%. It is theorized that the vast majority of post-intubation sequelae are related to persistently elevated cuff pressures. Although considerable attention is paid to the state of cuff pressure management for intubated patients admitted to intensive care units, almost no attention is given to the status of intraoperative cuff pressure management. To evaluate the potential for quality improvement, we aimed to identify the overall incidence of high intraoperative cuff pressure within a high-volume surgical academic center. Our University Office of the Human Protection Program policy regarding quality assurance indicated that Institutional Review Board approval was not required. To measure the cuff pressure, we utilized an NS 60-PBS 60 cmH2O Vacuum/Pressure Gauge (Instrumentation Industries, Inc., Bethel Park, PA, USA) connected via a three-way stopcock to the endotracheal tube pilot balloon. Specifically, the steps followed for cuff pressure measurements were: 1. Wash hands and put on gloves. 2. Ensure the stopcock ‘‘off’’ sign is in the direction of the valve that will attach to the pilot balloon circuit. 3. With a gloved finger, cover the remaining open valve. 4. Push the syringe inward until the pressure on the manometer reads approximately 25 cmH2O. 5. Attach the stopcock valve to the pilot balloon. 6. Turn the ‘‘off’’ sign 90 to face the valve occluded by the gloved finger. 7. After momentary pressure adjustment, read and record the pressure level from the gauge face. 8. Immediately turn the ‘‘off’’ sign 90 back in the direction of the pilot balloon. 9. Detach the stopcock.

Decision-making errors in anesthesiology

Cognitive error is a term used to define a faulty thought process, as opposed to a gap in knowledge or a deficiency in technical skills. Faulty thought processes and preferences are important factors in medical decision-making mistakes. Although many authors have used traditional human factor paradigms to classify errors, the application of decisionmaking psychology in the specialty of anesthesiology is advancement in the understanding of error cause, prevention, and recovery. Decisionmaking psychology seeks to explain the human factor components that occur, despite skill, knowledge, and good intentions. Latent conditions have been defined by Reason as gaps that are present in a system and ultimately allow an adverse event to take place. Therefore, latent conditions should represent the primary targets of any safety management system. We believe that cognitive errors are caused by deeply ingrained and subconscious thought processes and should therefore be viewed as latent conditions that can be targeted and minimized. Many catalogs of biases and cognitive errors have appeared in the popular press; they sometimes vary in their precise definitions and are often perceived to be overlapping or redundant. It seems unlikely that strict terminology will be agreed upon, but this is less important than a general understanding of thought process pitfalls. This chapter explores principles of cognitive behavior and specific cognitive errors that are likely to be responsible for anesthesiologists’ mistakes.

Sepsis: a review of therapeutics and considerations for anesthesiologists.

Sepsis and septic shock remain a major cause of morbidity and mortality. The complexity of the disease pathophysiology has resulted in a rich area of research on etiology and therapeutics. Anesthesiologists will often encounter the syndrome in their routine practice. This review summarizes some of the basic concepts of therapeutics and some novel therapeutics that are pertinent to anesthesia.