In control or along for the ride? Lessons for anesthesiologists from air traffic control.

PURPOSE OF REVIEW: Anesthesia professionals work in an unpredictable, rapidly changing environment in which they are quickly diagnose and manage uncommon and life-threatening critical events. The perioperative environment has traditionally been viewed as a deterministic system in which outcomes can be predicted, but recent studies suggest that the operating room behaves more like a complex adaptive system, in which events can interact and connect with each other in unpredictable and unplanned ways. RECENT FINDINGS: The increasing complexity of the healthcare environment suggests that the complete elimination of human error is not possible. Complex clinical situations predispose to errors that are the result of high workload, decision making under stress, and poor team coordination. The theory behind complex adaptive systems differs from medicine's traditional approach to safety and highlights the importance of an institutional safety culture that encourages flexibility, adaptability, reporting and learning from errors. Instead of focusing on standardization and strict adherence to procedures, clinicians can improve safety by recognizing that unpredictable changes routinely occur in the work environment and learning how resilience can prevent adverse events. SUMMARY: A better understanding of automation, complexity, and resilience in a changing environment are essential steps toward the safe practice of anesthesia.

Intraoperative hypotension in ambulatory surgery centers.

STUDY OBJECTIVES: To measure the incidence of intraoperative hypotension (IOH) during surgery in ambulatory surgery centers (ASCs) and describe associated characteristics of patients and procedures. DESIGN: Retrospective analysis. SETTING: 20 ASCs. PATIENTS: 16,750 patients having non-emergent, non-cardiac surgery; ASA physical status 2 through 4. INTERVENTIONS: None. MEASUREMENTS: We assessed incidence of IOH using the definition from the Centers for Medicare & Medicaid Services (CMS) Merit-based Incentive Payment System (MIPS)-mean arterial pressure (MAP) < 65 mmHg for at least 15 cumulative minutes-and three secondary definitions: minutes of MAP <65 mmHg, area under MAP of 65 mmHg, and time-weighted average MAP <65 mmHg. MAIN RESULTS: 30.9% of ASC cases had a MAP <65 mmHg for at least 15 min. The incidence of IOH varied significantly, and was higher among younger adults (age 18-39; 36.2%), females (35.2%), and patients with ASA physical status 2 (32.8%). IOH increased with increasing surgery length, even when time-weighted, and was higher among low complexity (30.6%) than moderate complexity (28.8%) procedures, and highest among high complexity procedures (44.1%). CONCLUSIONS: There was substantial occurrence of IOH in ASCs, similar to that described in academic hospital settings in previous literature. We hypothesize that this may reflect clinician preference not to intervene in perceived healthy patients or assumptions about ability to tolerate lower blood pressures on behalf of these patients. Future research will determine whether IOH in ACSs is associated with adverse outcomes to the same extent as described in more complex hospital-based surgeries.

Incidence of intraoperative hypotension during non-cardiac surgery in community anesthesia practice: a retrospective observational analysis.

BACKGROUND: Intraoperative hypotension (IOH) is well-described in the academic setting but not in community practice. IOH is associated with risk of postoperative morbidity and mortality. This is the first report of IOH in the community setting using the IOH measure definition from the Centers for Medicare and Medicaid Services Merit-based Incentive Payment System program. OBJECTIVES: To describe the incidence of IOH in the community setting; assess variation in IOH by patient-, procedure-, and facility-level characteristics; and describe variation in risk-adjusted IOH across clinicians. METHODS: Design Cross-sectional descriptive analysis of retrospective data from anesthesia records in 2020 and 2021. Setting Forty-five facilities affiliated with two large anesthesia providers in the USA. Participants Patients aged 18 years or older having non-emergent, non-cardiac surgery under general, neuraxial, or regional anesthesia. Cases were excluded based on criteria for the IOH measure: baseline mean arterial pressure (MAP) below 65 mmHg prior to anesthesia induction; American Society of Anesthesiologists (ASA) physical status classification of I, V, or VI; monitored anesthesia care only; deliberate induced hypotension; obstetric non-operative procedures; liver or lung transplant; cataract surgery; non-invasive gastrointestinal cases. Main outcomes IOH, using four definitions. Primary definition: binary assessment of whether the case had MAP < 65 mmHg for 15 min or more. Secondary definitions: total number of minutes of MAP < 65 mmHg, total area under MAP of 65 mmHg, time-weighted average MAP < 65 mmHg. RESULTS: Among 127,095 non-emergent, non-cardiac cases in community anesthesia settings, 29% had MAP < 65 mmHg for at least 15 min cumulatively, with an overall mean of 12.4 min < 65 mmHg. IOH was slightly more common in patients who were younger, female, and ASA II (versus III or IV); in procedures that were longer and had higher anesthesia base units; and in ambulatory surgery centers. Incidence of IOH varied widely across individual clinicians in both unadjusted and risk-adjusted analyses. CONCLUSION: Intraoperative hypotension is common in community anesthesia practice, including among patients and settings typically considered "low risk." Variation in incidence across clinicians remains after risk-adjustment, suggesting that IOH is a modifiable risk worth pursuing in quality improvement initiatives.

Five Decades of Trauma Anesthesiology.

We present a brief history of the scientific and educational development of trauma anesthesiology. Key milestones from the past 50 years are noted, as well as the current standing of the subspecialty and prospects for the future.

Scaling up quality in an anesthesia practice.

The resources necessary to improve anesthesia quality and meet reimbursement and regulatory thresholds are scarce, particularly for smaller practices. We examined how small practice integration into a firm with greater resources can facilitate improvements. A mixed-methods analysis was conducted using the data from the US Anesthesia Partners data warehouse, Merit-based Incentive Payment System (MIPS), commercial insurers' surgery length of stay (LOS) databases, anesthesia-specific patient satisfaction surveys, and interviews with practice leadership before and after integration. All integrated practices improved their quality improvement infrastructure and achieved higher MIPS scores, with increased clinician and leadership satisfaction. Patient satisfaction exceeded national benchmarks in all groups, based on 398 392 returned surveys in 2021. Hospital LOS for common operations was shorter, based on a statewide database. This case study demonstrates that partnership with an organization with greater resources can advance anesthesia quality.

2023 American Society of Anesthesiologists Practice Guidelines for Monitoring and Antagonism of Neuromuscular Blockade: A Report by the American Society of Anesthesiologists Task Force on Neuromuscular Blockade.

These practice guidelines provide evidence-based recommendations on the management of neuromuscular monitoring and antagonism of neuromuscular blocking agents during and after general anesthesia. The guidance focuses primarily on the type and site of monitoring and the process of antagonizing neuromuscular blockade to reduce residual neuromuscular blockade.

Expert Advice for the Expert Witness.

The malpractice system in the United States provides civil remedies-payment-for patients injured by non-standard-of-care medical practice. Anesthesiologists are not sued often, but one can still expect to be named in a suit at least once in their career. Although many prefer not to be involved in malpractice cases, there is a critical role for anesthesiologist expert witnesses to educate and inform the court regarding the appropriate standard of anesthesia care, and the contribution, if any, of anesthesia clinicians to specific adverse outcomes. This article describes the basic features of malpractice litigation, offering advice for anesthesiologist expert witnesses.

Pediatric Anesthesia in the Community.

Pediatric anesthesia is a diverse subspecialty practiced at thousands of hospitals and ambulatory surgery centers across the country. Most unusual and high-risk cases are performed in dedicated children's hospitals. However, the majority of cases and practitioners are based in the community. We present a review of demographics in pediatric anesthesia in the United States across 7 years of data from US Anesthesia Partners, a national anesthesia practice, which covers the full range of hospitals and outpatient facilities.

Anesthesia-Related Malpractice Claims in Maryland 1994-2017.

This article presents data on anesthesia cases filed with the Maryland Health Claims Alternative Dispute Office between 1994 and 2017, a publicly available resource that includes all anesthesia-related claims filed in Maryland, regardless of whether they were reported to any national claims repository. Analysis of anesthesia malpractice claims offers critical information that can both decrease legal liability and improve patient outcomes for those receiving anesthesia. A total of 276 claims were filed. Variables under investigation included venue, types of surgery, legal cause of action, trends, and outcomes. Types of anesthesia-related claims included the administration of general anesthesia (59.8%), monitored anesthesia care (14.9%), pain management (10.9%), epidural/spinal anesthesia (9%), nerve blocks (2.9%), and local anesthesia infiltration (2.6%). Most cases (39.5%) involved failure to adequately monitor the patient. Inadequate perioperative care was alleged as the cause of action in 68.8% of cases. Major adverse patient outcomes were death (38.8%), brain damage (21%), and permanent nerve damage (14.9%). Understanding the events that lead to legal action can assist anesthesia providers to focus on ways to improve their practice.

Advocacy for Anesthesiologists.

Advocating for anesthesiology is a professional responsibility. We need to make the public aware of the role we play in assuring their safety and comfort; and we must also ensure that payment models are fair and commensurate with the quality of our work.

Socioeconomic Disparities in Method of Anesthesia for Knee Arthroplasties in the US.

INTRODUCTION: Knee arthroplasty (KA) can be performed using general anesthesia (GA), neuraxial anesthesia (NA) or regional anesthesia (RA). We believe proportion of types of anesthetics have changed but that there is a disparity based on socioeconomic factors. METHODS: Unadjusted rates and adjusted odds ratios for the use of RA or PNB were compared between groupings of patients based on socioeconomic status. RESULTS: General anesthesia is the most common (49.7%) while NA (39.4%) and RA (10.9%) were the second and third. University hospitals and patient home ZIP Code median income had the strongest association with RA as a (adjusted odds ratio (AOR) 26.3, 95% confidence interval (95%CI) 22.1-31.3, p<.01 and AOR 7.58, 95% CI 7.20-7.98, p<.01). CONCLUSION: General anesthesia is the most common but the rate of alternative forms of primary anesthesia type have changed over time. Disparities exist in anesthesia care which are associated with income levels.