Current Opinion in Anesthesiology最新文献

Purpose of review: We briefly review the concept of psychological safety and discuss the actions that can create it in the anesthesiologist's work environment.

Recent findings: The interest in psychological safety has grown in popularity since the publication of Amy Edmondson's book The Fearless Organization in 2018. While the concept and its benefits are described in the healthcare literature, the specific actions necessary to create it are often not.

Summary: To ensure patient safety, we want members of the teams we lead to be comfortable sharing emerging problems that they see before we become aware of them. As educators, we want trainees to approach us when they do not understand something and openly participate and contribute without the fear of how others will perceive them. These scenarios require an environment of psychological safety - the ability to ask for help, admit mistakes, and be respectfully forthright with unpopular beliefs without the fear of being ostracized or ignored. Methods for creating an environment of psychological safety will be discussed.

Purpose of review: This article explores the unique intersection of the challenges confronting ambulatory anesthesiology education and charts a trajectory forward. The proportion of ambulatory, nonoperating room (NORA), and office-based surgical cases continues to rise; however, the requirements for trainees in these settings have remained static. The rapid evolution of the field combined with a limited workforce also makes continuing education essential, and we discuss the current and future states of ambulatory anesthesia education.

Recent findings: Although numerous resources are available across an array of platforms to foster both trainee education and continuing education for practicing anesthesiologists, there is a paucity of current literature evaluating the impact of new curricula developed specifically for ambulatory, NORA, or office-based anesthesiology (OBA).

Summary: We begin with an appraisal of the current state of ambulatory anesthesiology training and evaluate the gap between current graduate medical education and trends in ambulatory surgery. We then develop a vision for an ideal state of future ambulatory education for residents as well as anesthesiologists in practice and highlight the priorities necessary to reach this vision.

Purpose of review: The role of ambulatory surgery centers in surgical care is evolving, as lower facility fees and improved patient experience increase the popularity of these venues. As care expands in ambulatory surgery center, so does the complexity of cases and patients cared for in these centers, which may pose a risk for patient safety. Anesthesiologists should lead multidisciplinary teams to screen for appropriate patients and procedures.

Recent findings: Patient considerations go beyond physical status and include psychosocial factors. Ensuring patients understand preoperative instructions is crucial to decrease case cancellation rates and facilitate efficiency. Pediatric patients require special considerations including extra attention to preprocedure and postoperative care and instructions, PALS-certified staff, pediatric equipment and medications, as well as heightened awareness of respiratory complications.

Summary: Procedural concerns start with the capabilities of the facility such as equipment, pharmacy, and staffing for each phase of care. However, nuances such as patient throughput in a given day, emergency preparedness, and after-hours staffing will affect both patient safety and staff morale. This article outlines the issues leaders need to consider to ensure patient safety in ambulatory surgery centers.

Purpose of review: To evaluate the current trends, safety, and feasibility of same-day discharge (SDD) in ambulatory cardiac procedures, with a focus on percutaneous coronary interventions (PCI). This review also discusses the impact of technological advancements and explores future directions for expanding the scope of SDD in more complex cardiac procedures.

Recent findings: Recent studies have demonstrated that SDD after PCI is both well tolerated and effective for appropriately selected patients, with outcomes comparable with those of patients who remain hospitalized overnight. Advancements in PCI technology, including improved stent designs, smaller sheath sizes, and the adoption of the transradial approach, have significantly enhanced the feasibility of SDD. Enhanced recovery after surgery (ERAS) pathways, adapted for ambulatory settings, further improve patient safety, particularly as more complex procedures are attempted. However, challenges remain in determining SDD eligibility, particularly in settings with limited emergency care capabilities.

Summary: SDD is a viable and cost-effective option for low-risk patients undergoing PCI and other ambulatory cardiac procedures. The successful implementation of SDD requires careful patient selection, adherence to standardized protocols, and vigilant postprocedural monitoring. Future research should focus on refining patient selection tools, expanding the scope of SDD to include more complex procedures, and enhancing postdischarge monitoring through advanced technologies. Multidisciplinary collaboration and ongoing education are essential to support the well tolerated and effective adoption of SDD in ambulatory cardiac care.

Purpose of review: This review addresses the dental sedation permit requirements for physician anesthesiologists in the United States and the European Union (EU). The regulatory landscape for office-based anesthesia, including dental settings, is often described as the 'Wild West' of patient safety, making it crucial to outline the similarities and differences in dental anesthesia regulations and offer practical guidelines for regulators.

Recent findings: There is virtually no literature that addresses the issue of dental sedation permits for physicians. By summarizing the variation in language and terminology from state to state, this review highlights the inconsistencies and gaps in dental regulations. The review also highlights the limited specific guidance on the permit process for physicians administering dental anesthesia.

Summary: By comparing dental anesthesia regulations and guidelines across all U.S. states and the EU, the review aims to offer practical guidelines for regulators to institute an oversight process that is fair to physician anesthesiologists and does not impede their ability to practice in the dental office setting. This framework for credentialing and permitting physicians in dental office-based anesthesia settings is informed by existing safety recommendations and best practices.

Purpose of review: This review is timely due to the increasing prevalence of obstructive sleep apnea (OSA) among patients undergoing ambulatory surgery, necessitating updated perioperative management strategies to improve outcomes and reduce complications.

Recent findings: Recent studies emphasize the importance of risk stratification using tools like STOP-Bang, highlighting the association between high-risk OSA and increased perioperative complications. Intraoperative management strategies, including the preference for regional anesthesia and careful monitoring of neuromuscular blockade, have been shown to mitigate risks. Postoperative protocols, particularly continuous monitoring, are crucial in preventing opioid-induced respiratory depression.

Summary: Effective management of OSA in ambulatory surgery requires a multidisciplinary approach, encompassing preoperative screening, tailored intraoperative techniques, and vigilant postoperative monitoring. Implementing guidelines and protocols can significantly enhance patient safety and outcomes.

Purpose of review: Medication administration errors represent a significant yet preventable cause of patient harm in the peripartum period. Implementation of best practices contained in this manuscript can significantly reduce medication errors and associated patient harm.

Recent findings: Cases of medication errors involving unintended intrathecal administration of tranexamic acid highlight the need to improve medication safety in peripartum patients and obstetric anesthesia.

Summary: In obstetric anesthesia, medication errors can include wrong medication, dose, route, time, patient, or infusion setting. These errors are often underreported, have the potential to be catastrophic, and most can be prevented. Implementation of various types of best practice cost effective mitigation strategies include recommendations to improve drug labeling, optimize storage, determine correct medication prior to administration, use non-Luer epidural and intravenous connection ports, follow patient monitoring guidelines, use smart pumps and protocols for all infusions, disseminate medication safety educational material, and optimize staffing models. Vigilance in patient care and implementation of improved patient safety measures are urgently needed to decrease harm to mothers and newborns worldwide.

Purpose of review: Surgical site infections (SSI) are one of the most costly complications and hospital organizations are promoting multidisciplinary approaches to address this harm. Anesthesiologists are increasingly recognized as key players influencing surgical outcomes and patient safety, and play a key role in preventing SSIs.

Recent findings: Recent guidelines and strategies to prevent SSI are focused on the areas which anesthesiologists can impact including antimicrobial prophylaxis, proper hand hygiene, decontamination of environmental surfaces and operating room equipment coming in direct contact with patients.

Summary: Timely interventions, including appropriate antibiotics' administration, practicing sterile and aseptic techniques when performing intraoperative procedures and handling medications are impactful steps in the process of improving rates of SSIs. Multidisciplinary participation in local and regional collaborative initiatives to improve adherence to best practices as well as integrated education of all the stakeholders are some of the principles of patient-centered care described in our review.

Purpose of review: Although necessary for treatment of acute pain, opioids are associated with significant harm in the perioperative period and further intervention is necessary perioperatively to mitigate opioid-related harm.

Recent findings: Opioid-naive patients are often first exposed to opioids when undergoing surgery, which can result in significant harm. Despite their benefits in reducing acute postsurgical pain, they are also associated with risks ranging from mild (e.g., pruritis, constipation, nausea) to potentially catastrophic (e.g. opioid-induced ventilatory impairment, respiratory depression, death). Overprescribing of opioids can lead to opioid diversion and drug driving. In this review, we will discuss opioid-related harm and what strategies can be used perioperatively to mitigate this harm. Interventions such as optimizing nonopioid analgesia, implementing Enhanced Recovery after Surgery programs, effective respiratory monitoring, patient education and opioid stewardship programs will be discussed.

Summary: We will review policy and guidelines regarding perioperative opioid management and identify challenges and future directions to mitigate opioid-related harm.