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. We are diving into the February 2024 APSF Newsletter today. That’s right, all new articles and episodes with exclusive content from many of the authors.
Before we dive into the episode today, we'd like to recognize Edwards Lifesciences, a major corporate supporter of APSF. Edwards Lifesciences has generously provided unrestricted support to further our vision that "no one shall be harmed by anesthesia care". Thank you, Edwards Lifesciences - we wouldn't be able to do all that we do without you!"
Today, we are discussing a Q&A article from the February 2024 APSF Newsletter. It is “Post-Alcohol Consumption Cognitive Performance” by Todd Nelson and Michael Fitzsimons. To follow along with us, head over to APSF.org and click on the Newsletter heading. First one down is the current newsletter and then scroll down until you get to our featured article today. I will include a link in the show notes as well. Before we get into the article, we are going to hear from one of the authors. I will let him introduce himself now.
[Nelson] “Hi, my name is Todd Nelson. I'm an anesthesiologist practicing in Colorado Springs, Colorado. I attended residency at Dartmouth Hitchcock Medical Center. I've been practicing in Colorado for almost two decades. Other clinical interests include reviewing existing chest CT scans to identify coronary artery calcifications, which are frequently not documented by radiologists or noticed by cardiologists.”
[Bechtel] To kick off the show today, I asked Nelson why he wrote this article. Let’s take a listen to what he had to say.
[Nelson] “The main reason I became more interested in this topic of alcohol consumption and cognitive performance is because my oldest son wants to become a pilot and is working towards obtaining his pilot's license. During residency and throughout my career, I've heard dozens of talks and read countless articles on the parallels between aviation safety precautions and anesthesia safety standards.
However, it was not until recently when talking to a patient who was a pilot that I was made aware of the specific FAA recommendations on alcohol abstinence before flying.”
[Bechtel] And with that let’s get into the question to the editor raised by Nelson and stay tuned for the response from Fitzsimons. First up, Nelson provides some background information from the Federal Aviation Administration including the recommendations regarding alcohol consumption for pilots including the following:
1. As a minimum, adhere to all the guidelines of 14 CFR Part 91.17:
· 8 hours from “bottle to throttle”
· Do not fly while under the influence of alcohol
· Do not fly while using any drug that may adversely affect safety
2. A more conservative approach is to wait 24 hours from the last use of alcohol before flying. This is especially true if intoxication occurred or if you plan to fly Instrument Flight Rules. Cold showers, drinking black coffee, or breathing 100% oxygen cannot speed up the elimination of alcohol from the body.
3. Consider the effects of a hangover. Eight hours from “bottle to throttle” does not mean you are in the best physical condition to fly or that your blood alcohol concentration is below the legal limits.
There are additional FAA guidelines regarding removing from duties any employee performing a safety-sensitive function with a breath alcohol concentration above 0.04 on a required alcohol test or who uses alcohol in violation of the FAA guidelines. Temporary removal from performing safety-sensitive functions occurs if breath alcohol concentration is between 0.02-0.039 on a required alcohol test. In the United States, a standard drink has about 14-15 grams of alcohol which can be found in a 12-ounce beer, a 5-ounce glass of wine, or 1.5ounce shot of 80-proof liquor. A man weighing 180 pounds who consumes two standard drinks would have a blood alcohol level of about 0.04.
While there are many similarities between anesthesia and aviation, at this time, the American Society of Anesthesiologists Guidelines for Occupational Health and Wellness does not have recommendations related to alcohol intake, patient safety, and anesthesia professional performance. This is a patient safety concern since after consuming alcohol, there may be significant effects on psychomotor speed, short-term memory, long-term memory, and sustained attention during the next day at work. Anesthesia professionals need to be at the top of their cognitive processing game especially when attention is divided and there are competing mental demands. Alcohol consumption increases the risk for sleep apnea as well as decreasing sleep quality which can impact cognitive function on the short term and long term.
Nelson leaves us with the following call to action and question:
“Given the detrimental after-effects of alcohol consumption on cognitive performance, anesthesia professionals should seek societal recommendations that address an alcohol abstinence window before engaging in anesthetic care of patients (i.e., time from “glass to mask”). Should on-the-job random alcohol breath tests for anesthesia professionals involved in safety-sensitive patient care functions be implemented in routine practice?”
Thank you so much to Nelson for highlighting this important anesthesia patient safety concern. I also asked Nelson what he hopes to see going forward. Here is what he had to say.
[Nelson] “What do you hope to see going forward? To quote Dr. Fitzsimmons, Anesthesia professional societies should take the recommendations of Nelson and others as a challenge to develop guidelines for the performance of anesthesia after the use of recreational substances, such as beginning with alcohol, but ultimately including other recreational substances. End of quote. Well-run, forward-thinking anesthesia groups committed to patient safety will follow the wise counsel of Dr. Fitzsimmons and draft guidelines for alcohol abstinence and the appropriate time from glass to mask. Alcohol consumption has well documented adverse effects on athletic performance. Examples include impaired muscle recovery, reduced coordination, decreased endurance and impaired decision making. The Indian Wells Tennis Tournament is underway in the desert of California. It would be difficult to find a top competitor who is not abstaining from alcohol during the tournament. Likewise, high performing anesthesiologists can remain at the peak of their game by avoiding the residual negative consequences of alcohol consumption on job performance.”
Thank you to Nelson for contributing these clips to the show today. And now, it’s time to discuss the response from Fitzsimons.
The response opens with some important background information. Alcohol abuse or dependence occurs in 12.9% of male physicians and 21.4% of female physicians. Anesthesia professionals are not at increased risk for developing alcohol abuse or dependence, but they are not immune from it either. The work demands for anesthesia professionals includes pattern recognition, rapid situational assessment, prompt physical response, and judgement based on experience and memory. Fitzsimmons asserts that it is incomprehensible that any health care provider can argue that it is acceptable to provide anesthesia care while under the acute effects of alcohol or while legally intoxicated. The question remains what time frame is needed between consumption of alcoholic beverages and performance in a safety-sensitive area. It may be reasonable to start with the Federal Aviation Administration guidelines to help keep patient safe. Let’s go through the history of these guidelines now. The 8-hour bottle to throttle rule was first suggested in 1966 and formalized in 1970. It may have been an arbitrary time frame from the very beginning. There are some weaknesses with this policy including:
Subject to individual compliance
Not based on amount of alcohol consumed
Does not take into account if other recreational substances were used
Does not address impact of sleep duration
Assumes recognition of personal impairment
With this rule in place, it is likely that pilots will regulate alcohol consumption so that they are not affected at the 8-hour mark, but it is difficult to consistently assess impairment.
Let’s review the levels of alcohol use defined by the National Institute on Alcohol Abuse and Alcoholism keeping in mind that less alcohol consumption is better for long-term health.
Drinking in moderation involves no more than two drinks a day for men and one drink daily for women.
Binge drinking involves 5 or more drinks by a man or two or more drinks by a woman in two hours.
Heavy drinkers participate in binge drinking more than 5 days a month.
These categories do not define the safe time frame after consumption though.
While moderate drinkers may be able to estimate their blood alcohol concentration accurately, heavy drinkers and alcoholic are not able to do this successfully. In addition, according to the 1990 study by Ross and Ross, pilots overestimate the amount of alcohol necessary to reach a certain blood alcohol concentration and underestimate the time required for alcohol elimination.
Another important limitation of the FAA guidelines is the established levels of BAC at 0.04 in a blood or breath alcohol specimen. This rule was established in the 1980s after years of resistance due to the belief that only a small number of aviation accidents were related to alcohol use. The FAA level is lower than the 0.08 level set by states for operation of motor vehicles. Keep in mind that some states set even lower levels for commercial vehicle operators or minors. The FAA level of 0.04 is lower than the defined legal intoxication limit for motor vehicle operation to perhaps add an extra level of safety. There is a logistical problem since commercial pilots must comply with random, reasonable suspicion, post-accident, return to duty, and follow-up drug testing, they do not need to undergo routine testing prior to all flights. There are reports of pilots with obvious impairment who needed to be removed from duty, but less obvious impairment may go undetected. In addition, even when there is obvious impairment, this must be reported by an observer before testing will be done.
The dependence on reporting by a colleague is a weakness in this rule. Almost one-third of physicians would not report an impaired medical colleague, and this may be similar for pilots as well. There are anesthesia departments that perform drug testing, but it is not known how they test for acute alcohol impairment.
Since this policy uses breath alcohol testing, certification as a Breath Alcohol Technician or Screening Test Technician is required to maintain standards to the level of the Department of Transportation. As a result, breath alcohol testing may be limited, or blood alcohol testing will need to be used instead.
Another weakness of the FAA guidelines is the assumption that if 8 hours has passed since alcohol consumption and the BAC is less than 0.04, then performance automatically returns to a baselines level from before any alcohol intake. The guidelines state that there may be effects of a hangover, but this is only subjective and requires individual discretion. The definition of a hangover includes the combination of negative mental and physical symptoms that may last until the next day after heavy alcohol consumption even as the blood alcohol concentration approaches 0. Hangover symptoms include fatigue, nausea, headache, weakness, and sound sensitivity. There are different scales to estimate the effects from a hangover such as the Hangover Symptoms Scale, the Acute Hangover Scale, and the Alcohol Hangover Severity Scale, but these scales may underestimate the severity of symptoms and degree of persistent impairment. Mild to moderate hangover symptoms are likely to be present after alcohol consumption to intoxication and symptoms may be present even after consumption of much lower levels of alcohol consumption. There are studies that have evaluated driving ability the day after alcohol consumption when the blood alcohol concentration is near 0. For example, the study by Alford and colleagues compared simulated driving performance before alcohol consumption and the day after when the blood alcohol concentration was 0% in half the participants and between 0.01-0.08 in the others. The degree of impairment on response times, excursions from lane, and time off road was similar in participants from the residual alcohol and the zero-alcohol group with symptoms of hangover. Plus, the participants were not aware of their level of impairment. Another study by Scholey and colleagues looked at the relationship between hangover and cognitive performance after a night of heavy alcohol consumption with an average number of drinks at 13.5. Cognitive function and working memory were impaired during the hangover period. Memory and psychomotor performance were impaired at 9am following a night of normal drinking in the study by McKinney and Coyle. During the testing, the participants had alcohol levels at or near 0. The impact of alcohol on performance may be difficult to determine due to additional factors including amount, frequency of consumption, timing in relation to assessment, gender, metabolism, binge drinking compared to social drinking, and concurrence of dependence or abuse. Sleep disturbances associated with alcohol consumption may also negatively impact cognitive performance the next day as well.
What we know is that alcohol levels below legal intoxication and hangover symptoms have a negative impact on performance. There are no formal guidelines for anesthesia professionals at this time. It is not as simple as adopting the GAA guidelines since there are weaknesses that must be addressed: the arbitrary ‘glass to mask’ time, the subjective nature of hangover, reliance on self-policing for testing, and logistic limitations of alcohol testing. There is a call to action for anesthesia professional societies to develop guidelines for the performance of anesthesia after using alcohol and then expanding to include other recreational substances. These guidelines must address the following:
· Time from glass to mask
· Substance screening tests pre-placement, under conditions of reasonable suspicion for impairment, and after a significant critical event when impairment is likely
Education is needed for anesthesia professionals and trainees about the impact of these substances on performance with clear steps for how to report colleagues suspected of impairment and how to obtain confidential personal care for individuals with substance use disorders. Anesthesia professionals may not be able to provide safe anesthesia care following alcohol consumption and with persistent hangover symptoms. Going forward, we need to develop a clear policy and robust, objective systems related to the use of alcohol and other recreational substances and the performance of safe anesthesia care.
Thank you so much to Nelson for contributing audio clips to the show today and asking this important question. These are important considerations so that anesthesia professionals only pick up the mask when there are no residual effects from the glass on their performance.
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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