Caring for the caregiver following an adverse event

In this article, we review the potential for adverse impacts on the clinician following a medical error or poor clinical outcome. Second victim syndrome, its symptoms, risk factors, natural history, and possible outcomes are described. We also discuss the important role of organizational leadership and culture and highlight possible programmatic interventions designed to support clinicians following an adverse event.     

The future of pediatric anesthesia

The future of pediatric anesthesia can be thought of in terms of what will happen to the practice of anesthesia, or what will happen to the profession of pediatric anesthesia. The profession will change both under external forces, and by how pediatric anesthetists themselves decide to shape of the profession. The largest external force is likely to be cost. The profession will increasingly be expected to maintain efficiency without compromising quality. Other future issues include credentialing, training and the role of the anesthetists beyond the operating room. It’s harder to predict how the practice of pediatric anesthesia might change. New drugs may change practice, though perhaps it’s more likely that practice will change with better use of existing drugs. New technologies will have an impact in monitoring and in the gathering and dissemination of information. Practice will also change with changes in surgery. Perhaps the biggest changes will come in areas with the greatest unknowns; neonatal anesthesia is an area with many unknowns and thus great potential for change and improvement.     

The development of an opioid sparing anesthesia protocol for pediatric ambulatory tonsillectomy and adenotonsillectomy surgery—A quality improvement project

Pain management following pediatric tonsillectomy and adenotonsillectomy surgery is challenging and traditionally involves perioperative opioids. However, the recent national opioid shortage compelled anesthesiologists at Bellevue Surgery Center to identify an alternative perioperative analgesic regimen that minimizes opioids yet provides effective pain relief. We assembled an interdisciplinary quality improvement team to trial a series of analgesic protocols using the Plan‐Do‐Study‐Act cycle. Initially, we replaced intraoperative morphine and acetaminophen (M/A protocol) with intraoperative dexmedetomidine and preoperative ibuprofen (D/I protocol). However, when results were not favorable, we rapidly transitioned to intraoperative ketorolac and dexmedetomidine (D/K protocol). The following measures were evaluated using statistical process control chart methodology and interpreted using Shewhart's theory of variation: maximum pain score in the postanesthesia care unit, postoperative morphine rescue rate, postanesthesia care unit length of stay, total anesthesia time, postoperative nausea and vomiting rescue rate, and reoperation rate within 30 days of surgery. There were 333 patients in the M/A protocol, 211 patients in the D/I protocol, and 196 patients in the D/K protocol. With the D/I protocol, there were small increases in maximum pain score and postanesthesia care unit length of stay, but no difference in morphine rescue rate or total anesthesia time compared to the M/A protocol. With the D/K protocol, postoperative pain control and postanesthesia care unit length of stay were similar compared to the M/A protocol. Both the D/I and D/K protocols had reduced nausea and vomiting rescue rates. Reoperation rates were similar between groups. In summary, we identified an intraoperative anesthesia protocol for pediatric tonsillectomy and adenotonsillectomy surgery utilizing dexmedetomidine and ketorolac that provides effective analgesia without increasing recovery times or reoperation rates.     

Evaluation of quality of care in neonatal anesthesia using a bundle of intraoperative parameters

Background

Maintenance of physiological homeostasis is key in the safe conduct of pediatric anesthesia. Achieving this goal is especially difficult in neonatal surgery.

Aims

The first aim was to document the absolute number of seven intraoperative parameters monitored during anesthesia in neonates undergoing gastroschisis surgery. The second aims were to determine the frequency of monitoring of each of these intraoperative parameters as well as the proportion of cases in which each parameter was both monitored and maintained within a pre-defined range.

Methods

This retrospective observational analysis includes data from 53 gastroschisis surgeries performed at Caen University Hospital (2009–2020). Seven intraoperative parameters were analyzed. First, we assessed if the intraoperative parameters were monitored or not. Second, when monitored, we assessed if these parameters were maintained within a pre-defined range, based on the current literature and on local agreement.

Results

The median [first–third Q], range (min–max) number of intraoperative parameters monitored during the 53 gastroschisis surgeries was 6 [5–6], range (4–7). There were no missing data for the automatically recorded ones such as arterial blood pressure, heart rate, end-tidal CO_2, and oxygen saturation. Temperature was monitored in 38% of the patients, glycemia in 66%, and natremia in 68% of the cases. Oxygen saturation and heart rate were maintained within the pre-defined range in 96% and 81% of the cases respectively. The blood pressure (28%) and temperature (30%) were instead the least often maintained within the pre-defined range.

Conclusion

Although a median of six out of the seven selected intraoperative parameters were monitored during gastroschisis repair, only two of them (oxygen saturation and heart rate) were maintained within the pre-defined range more than 80% of the time. It might be of interest to extend physiologic age- and procedure-based approach to the development of specific preoperative anesthetic planning.     

Medication safety in pediatric anesthesia: An educational review and a call to action

Children presenting for anesthesia are at high risk for medication error during their care. In this educational review, we address the rates of medication error in pediatric patients undergoing anesthesia, why they are at higher risk than adults, and why reporting chronically underestimates the number of medication errors incurred during the anesthetic care of children. We also introduce the Anesthesia Patient Safety Foundation and Wake Up Safe, two safety organizations that have led the call to decrease medication errors. We discuss various tools to increase medication safety, as championed by Anesthesia Patient Safety Foundation and Wake Up Safe, including human factors research and highlight a few studies that have evaluated and addressed medication safety in the anesthesia environment.     

联合椎管内麻醉时硬膜外注药升高阻滞平面的机制研究

探讨联合椎管内麻醉时硬膜外注药升高阻滞平面的机制。方法：３０例下肢矫形手术患者均采用蛛网膜下隙与硬膜外联合穿刺针行Ｌ２－３穿刺,蛛网膜下隙注入等比重的０．７５％布比卡因１．５ｍｌ后硬膜外置管。患者随机分成三组,每组１０例：硬膜外不给药（Ａ组）,蛛网膜下腔注射药后１５、２０、２５分钟经硬膜外导管给予２％利多卡因各３ｍｌ（Ｂ组）或生理盐水各３ｍｌ（Ｃ组）。结果     

Regional versus general anesthesia in high-risk surgical patients: The need for a clinical trial

Regional anesthesia is often preferred over general anesthesia for patients with cardiovascular disease because of presumed decreased risk of perioperative myocardial ischemia. However, few studies have addressed this issue directly. To determine whether the type of anesthesia is independently associated with myocardial ischemia, records of 134 patients undergoing peripheral vascular grafting under general or regional anesthesia were examined. There were no significant differences preoperatively between groups in ASA class, age, sex, or prevalence of angina, diabetes, or hypertension. Twelve patients developed myocardial ischemia or infarction within 7 days of operation; 11 of these 12 patients had received regional anesthesia (p < 0.015). The association between anesthetic approach and perioperative myocardial ischemia or infarction remained after adjustment for preoperative factors associated with ischemia or with type of anesthesia. General anesthesia does not appear to be associated with increased risk of myocardial ischemia, and stringent recommendations to avoid it in this population may be unfounded. A clinical trial is needed to define more clearly the risks and benefits of different types of anesthesia in high-risk patients.     

Finland's first anaesthesia revealed by newspapers

Background: According to the literature on the history of anaesthesia, Finland's first anaesthesia was given on March 8, 1847 for a ligature of an aneurysm of the subclavian artery. It has, however, not been possible to verify the date with certainty. We therefore wanted to find out whether newspapers might give additional information and how this exceptionally important medical invention had been received by the Finnish newspapers.
Methods: Microfilms of the 10 newspapers which appeared in Finland in 1847 were studied at the Helsinki University library.
Results: The first report which made reference to English newspapers was published on February 10 by "Borgå Tidning". On March 6, "Helsingfors Tidningar" wrote that two anaesthesias had already been given in Helsinki; the first of them for a difficult varicose veins operation and the second for an exarticulation of a shoulder. But there was no information regarding the dates of the operations. Fortunately, both operations had been recorded in the patient diary of the clinic, although without any information about the anaesthesia. According to the diary, Johan August Örn was operated for varicose veins on February 16 and Anders Gustaf Henrikson had his right arm exarticulated on March 3. Both patients recovered. In total, only six pieces of news on anaesthesia were found.
Conclusions: Finland's first anaesthesia was given on February 16, 1847, which is three weeks earlier than had been previously assumed.     

不同麻醉方式对血液流变学的影响

麻醉对外科手术患者术中及术后早期血液流变学产生一定的影响,这可能与围手术期血栓形成等因素有一定的关联.而不同麻醉方式对血液流变学的影响不同,现就此进行综述,为临床麻醉方式的选择提供一定的参考.