Hello and welcome back to the Anesthesia Patient Safety Podcast. My name is Alli Bechtel, and I am your host. Thank you for joining us for another show. For this week’s show, we are diving [splash] into the literature for a review of several APSF summaries of recent editorial journal articles focused on anesthesia patient safety from the APSF Newsletter Editorial Board.
Before we dive [splash] into the episode today, we'd like to recognize Medtronic, a major corporate supporter of APSF. Medtronic has generously provided unrestricted support to further our vision that "no one shall be harmed by anesthesia care". Thank you, Medtronic - we wouldn't be able to do all that we do without you!"
To follow along with us today, head over to APSF.org and click on the Patient Safety Resources heading. Fifth one down is In the Literature. There you will find all of our featured articles today and I will include a link in the show notes as well.
Let’s start with the most recent and work our way backwards. Our first featured article today is the APSF summary on the article, “Peripheralization Strategies Applied to Morphinans and Implications for Improved Treatment of Pain which was published in Molecules June 2023 by Schmidhammer and colleagues. Sood and Panday wrote the summary.
The scope of the problem addressed by the article is the challenge for the treatment of chronic pain with opioids which are associated with the development of tolerance and contribute to the opioid epidemic with their central nervous system effects. Thus, it may be beneficial to develop opioids that are unable to penetrate the blood brain barrier with peripheralization by modifying the hydrophilic group at the C6 position. One approach is to add polar groups, such as the zwitterionic moieties, at C-6, which blocks entry into the CNS leading the modified drug to target only the peripheral nervous system. In the article, the authors describe a nano carrier-based strategy with hyperbranched polyglycerols to help deliver morphine to peripheral inflammatory tissues resulting in improved pain relief without CNS effects.
The big takeaways from this article are that designing an opioid medication that stimulates peripheral opioid receptors and is unable to cross the blood brain barrier can help to deliver targeted and potent pain relief without central nervous system effects.
What a great summary and I cannot wait to check out this article. The authors remind us that additional research is needed to evaluate the clinical impact of these peripheral opioid analgesic medications before we throw out our current supply of morphine. Check out the citation in the show notes for more information.
Time to check out our second featured article for the day. This APSF summary was completed by Agarwala on the article, “Anesthesia Risk Alert Program: A Proactive Safety Initiative” by Lee and colleagues published in the Joint Commission Journal on Quality and Patient Safety from June 2023. This article is all about the Anesthesia Risk Alert or ARA program that was implemented as a screening and risk mitigation program at an anesthesia practice with over 6000 clinicians at almost 450 facilities in the United States. The program was developed after evaluating the adverse event data over a 3-year period leading to identification of 5 high-risk clinical scenarios. These include the following:
· Known or suspected difficult airways in patients undergoing general endotracheal anesthesia
· Body mass index or BMI greater than or equal to 45 for patients undergoing general anesthetic
· Patients with pulmonary hypertension
· Patients with an ASA physical status classification of 4 or 5
· Patients at high risk for OR fire.
Then, each of these high-risk clinical scenarios were combined with a recommended risk-mitigation strategy. These include the following:
· For difficult airways, ensuring that a second anesthesia professional is present for induction and emergence
· For patients with high BMI, ensuring that a second anesthesia professional is present for induction and emergence
· Patients with pulmonary hypertension would be discussed with a second clinician
· ASA 4 or 5 patients would also be discussed with a second clinician
· And finally, for the high OR fire risk scenario, making sure to follow the institutional/APSF/ASA risk mitigation strategies.
The authors reports that with education and training, compliance with the protocol and action plan was about 95% over 3 years. Results from the study included decreasing adverse events in patient with high BMI undergoing GA by over 30% and by over 67% for patients with an ASA score of 4 and 5. There was a lack of data infrastructure that limited the ability to determine changes with scenarios for difficult airway and pulmonary hypertension and there was no significant change for the high risk of OR fire scenario. The authors conclude that the study was limited by possible underreporting of adverse events and overreporting of compliance given the nature of self-reporting in the study. However, it appears that having a simple program for intervening in high-risk scenarios may help to decrease adverse events and keep patients safe. I will include the article citation in the show notes. Is the Anesthesia Risk Alert program something that you may be able to implement at your institution?
We are covering a lot from this literature review, so let’s keep swimming.
[Swimming splashes]
What is your anesthetic plan for patients undergoing hip fracture surgery? What is better for these patients, neuraxial or general anesthesia? Let’s check out the next summary. Thank you to Thomas for providing the APSF summary on the article, “Neuraxial versus general anesthesia in elderly patients undergoing hip fracture surgery and the incidence of postoperative delirium: A systemic review and stratified meta-analysis” by Cheung and colleagues published in BMC Anesthesiology in July 2023.
This is a meta-analysis of 10 randomized controlled trials with almost 4,000 patients published between 2000 and 2021 that included studies that looked at at least one of the following outcomes: postoperative delirium incidence, cognitive impairment, mortality, duration of hospital stay, and rehabilitation capacity. The primary objective was to evaluate the impact of neuraxial anesthesia compared to general anesthesia for elderly patients undergoing hip fracture repair surgery on postoperative delirium, cognitive impairment as well as mortality, duration of hospital stay, and functional recovery.
For the methods, two investigators independently screen studies for inclusion and performance data extraction. The Cochrane Collaboration risk-of-bias tool was used and the odds ratio and 95% confidence intervals were calculated to evaluate the pooled data.
Time for the results. There was no statistically significant differences between the neuraxial and general anesthesia groups in the following areas: the incidence of postoperative delirium (and this includes with or without including patients with pre-existing condition of dementia or delirium,) postoperative delirium from postoperative days 2-7, the mini-0mental state examination score, or other neuropsychological testing results. Neuraxial anesthesia was associated with shorter hospital stay especially in patients without pre-existing dementia, but this result was not statistically significant.
The authors conclude that further investigations are needed to better evaluate the differences between neuraxial and general anesthesia and these future studies will need to use a uniform and clear definition of postoperative delirium and evaluate outcomes on delirium prevalence or duration, rehabilitation, and postoperative functionality.
We are really on a roll for our literature review. Do you have a surgeon that you often work with and that you collaborate well with? Perhaps, this strong relationship has led to improved patient safety for the patients being taken care of by your collaborative dyad. Next up, let’s take a look at the APSF summary completed by Jeffrey Huang on the article, “Association Between Familiarity of the Surgeon-Anesthesiologist Dyad and Postoperative Patient Outcomes for Complex Gastrointestinal Cancer Surgery” by Hallet and colleagues published in JAMA Surgery in May 2023. We have talked about the surgeon-anesthesiologist dyad on the podcast before. Effective communication and good collaboration between surgeons and anesthesiologists can go along way to improving patient safety and ensuring positive patient outcomes. Familiarity between team members has been studied outside of medicine and this study looks at the impact of familiarity in the operative room.
This was a retrospective cohort study completed in Ontario, Canada to evaluation the correlation between the familiarity of the surgeon-anesthesiologist pairs, which was measured by the annual numbers of procedures performed by the pair over a four-year period, and the immediate postoperative outcomes following complex gastrointestinal cancer procedures. The primary outcome was major morbidity within 90 days following surgery and the key variable was the annual volume of cases performed by each unique surgeon-anesthesiologist pair.
Now, for some results. There were almost 8,000 index procedures completed by 737 anesthesiologists and 163 surgeons in 17 hospitals. The median annual volume was 27 procedures for surgeons and 6 procedures for anesthesiologists. The median dyad volume was 1 procedure each year with the range from 0-12 procedures per year. There was a linear relationship between the volume of procedures performed by the dyad and the primary outcome of occurrence of major morbidity within 90 days with each additional collaboration between the unique dyad yielding a 5% reduction in the odds of a major morbidity within 90 days. The authors concluded that for adults undergoing this type of surgery, there was a positive correlation between the familiarity of the surgeon-anesthesiologist pair and improved patient outcomes over the first 90 days.
We have time to talk about one for article. Do you know how many steps you have taken today? More importantly for anesthesia patient safety, do you know how many steps your patient has taken? Let’s review the next article, “Utilization of Wearable Pedometer Devices in the Perioperative Period: A Qualitative Systemic Review” by Jin and colleagues published in Anesthesia and Analgesia in March 2023. The APSF summary was completed by Paul Lefebvre.
This article is a system review of studies to evaluate the correlation between data captured on wearable pedometer devices and perioperative outcomes. Over 1400 studies were screened with 18 that met the inclusion criteria. The included studies evaluated data from 30 days prior to surgery all the way to postoperative day #30 with over 1600 patients in the 18 studies with a median age range from 32-76.
The limitations of this article include the heterogeneity across the various studies and lack of randomized clinical trials. The results were that patients with higher step counts during the preop and post-op periods were less likely to have a complications. In addition, patients who were more active immediately following their surgeries were discharged earlier with lower readmission rates. Going forward, more studies are needed to further evaluate the relationship between step count, activity level, and perioperative outcomes. This is an exciting area that needs further study since so many patients who present for surgery are already wearing their own step-counter and can use this to monitor healthy activity levels before and after surgery which may help to decrease postoperative complications.
Whew, what a great literature review! We are staying up to date with the latest in perioperative patient safety.
If you have any questions or comments from today’s show, please email us at podcast@apsf.org. Please keep in mind that the information in this show is provided for informational purposes only and does not constitute medical or legal advice. We hope that you will visit APSF.org for detailed information and check out the show notes for links to all the topics we discussed today.
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Until next time, stay vigilant so that no one shall be harmed by anesthesia care.
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