Current Opinion in Anesthesiology最新文献

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: 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.

Purpose of review: There have been significant advancements in depth of anesthesia (DoA) technology. The Anesthesia Patient Safety Foundation recently published recommendations to use a DoA monitor in specific patient populations receiving general anesthesia. However, the universal use of DoA monitoring is not yet accepted. This review explores the current state of DoA monitors and their potential impact on patient safety.

Recent findings: We reviewed the current evidence for using a DoA monitor and its potential role in preventing awareness and preserving brain health by decreasing the incidence of postoperative delirium and postoperative cognitive dysfunction or decline (POCD). We also explored the evidence for use of DoA monitors in improving postoperative clinical indicators such as organ dysfunction, mortality and length of stay. We discuss the use of DoA monitoring in the pediatric population, as well as highlight the current limitations of DoA monitoring and the path forward.

Summary: There is evidence that DoA monitoring may decrease the incidence of awareness, postoperative delirium, POCD and improve several postoperative outcomes. In children, DoA monitoring may decrease the incidence of awareness and emergence delirium, but long-term effects are unknown. While there are key limitations to DoA monitoring technology, we argue that DoA monitoring shows great promise in improving patient safety in most, if not all anesthetic populations.

Purpose of review: This review explores the timely and relevant applications of machine learning in ambulatory anesthesia, focusing on its potential to optimize operational efficiency, personalize risk assessment, and enhance patient care.

Recent findings: Machine learning models have demonstrated the ability to accurately forecast case durations, Post-Anesthesia Care Unit (PACU) lengths of stay, and risk of hospital transfers based on preoperative patient and procedural factors. These models can inform case scheduling, resource allocation, and preoperative evaluation. Additionally, machine learning can standardize assessments, predict outcomes, improve handoff communication, and enrich patient education.

Summary: Machine learning has the potential to revolutionize ambulatory anesthesia practice by optimizing efficiency, personalizing care, and improving quality and safety. However, limitations such as algorithmic opacity, data biases, reproducibility issues, and adoption barriers must be addressed through transparent, participatory design principles and ongoing validation to ensure responsible innovation and incremental adoption.

Purpose of review: Patient safety in anesthesiology has advanced significantly over the past several decades. The current process of improving care is often based on studying adverse events (AEs) and near misses. However, there is a wealth of information not captured by focusing solely on these events, potentially resulting in missed opportunities for care improvements.

Recent findings: We review terms such as AEs and nonroutine events (NREs), and introduce the concept of unanticipated events (UEs), defined as events that deviate from intended care that may/may not have been caused by error, may/may not be preventable, and may/may not have caused injury to a patient. UEs incorporate AEs in addition to many other anesthetic events not routinely tracked, allowing for trend analysis over time and the identification of additional opportunities for quality improvement. We review both automated and self-reporting tools that currently exist to capture this often-neglected wealth of data. Finally, we discuss the responsibility of quality/safety leaders for data monitoring.

Summary: Consistent reporting and monitoring for trends related to UEs could allow departments to identify risks and mitigate harm before it occurs. We review various proposed methods to expand data collection, and recommend anesthesia practices pursue UE tracking through department-specific reporting interfaces.