Identifying intraoperative events in a simulated laparotomy video: a multinational study of inattentional blindness among anesthesiologists.

PURPOSE: Medical errors may be occasionally explained by inattentional blindness (IB), i.e., failing to notice an event/object that is in plain sight. We aimed to determine whether age/experience, restfulness/fatigue, and previous exposure to simulation education may affect IB in the anesthetic/surgical setting. METHODS: In this multicentre/multinational study, a convenience sample of 280 anesthesiologists watched an attention-demanding video of a simulated trauma patient undergoing laparotomy and (independently/anonymously) recorded the abnormalities they noticed. The video contained four expected/common abnormalities (hypotension, tachycardia, hypoxia, hypothermia) and two prominently displayed unexpected/rare events (patient's head movement, leaky central venous line). We analyzed the participants' ability to notice the expected/unexpected events (primary outcome) and the proportion of expected/unexpected events according to age group and prior exposure to simulation education (secondary outcomes). RESULTS: Anesthesiologists across all ages noticed fewer unexpected/rare events than expected/common ones. Overall, younger anesthesiologists missed fewer common events than older participants did (P = 0.02). There was no consistent association between age and perception of unexpected/rare events (P = 0.28), although the youngest cohort (< 30 yr) outperformed the other age groups. Prior simulation education did not affect the proportion of misses for the unexpected/rare events but was associated with fewer misses for the expected/common events. Self-perceived restfulness did not impact perception of events. CONCLUSION: Anesthesiologists noticed fewer unexpected/rare clinical events than expected/common ones in an attention-demanding video of a simulated trauma patient, in keeping with IB. Prior simulation training was associated with an improved ability to notice anticipated/expected events, but did not reduce IB. Our findings may have implications for understanding medical mishaps, and efforts to improve situational awareness, especially in acute perioperative and critical care settings.

RéSUMé: OBJECTIF: Les erreurs médicales peuvent parfois s'expliquer par la cécité d'inattention, soit le fait de ne pas remarquer un événement/objet qui est à la vue de tous et toutes. Notre objectif était de déterminer si l'âge/l'expérience, le repos/la fatigue et l'exposition antérieure à l'enseignement par simulation pouvaient affecter la cécité d'inattention dans le cadre de l'anesthésie/chirurgie. MéTHODE: Dans cette étude multicentrique/multinationale, un échantillon de convenance de 280 anesthésiologistes ont visionné une vidéo exigeant l'attention portant sur un patient de trauma simulé bénéficiant d'une laparotomie et ont enregistré (de manière indépendante/anonyme) les anomalies qu'ils et elles ont remarquées. La vidéo contenait quatre anomalies attendues/courantes (hypotension, tachycardie, hypoxie, hypothermie) et deux événements inattendus/rares bien en vue (mouvement de la tête du patient, fuite du cathéter veineux central). Nous avons analysé la capacité des participant·es à remarquer les événements attendus/inattendus (critère d'évaluation principal) et la proportion d'événements attendus/inattendus selon le groupe d'âge et l'exposition antérieure à l'enseignement par simulation (critères d'évaluation secondaires). RéSULTATS: Les anesthésiologistes de tous âges ont remarqué moins d'événements inattendus/rares que d'événements attendus/courants. Globalement, les anesthésiologistes plus jeunes ont manqué moins d'événements courants que leurs congénères plus âgé·es (P = 0,02). Il n'y avait pas d'association constante entre l'âge et la perception d'événements inattendus ou rares (P = 0,28), bien que la cohorte la plus jeune (< 30 ans) ait surpassé les autres groupes d'âge. La formation antérieure par simulation n'a pas eu d'incidence sur la proportion d'inobservation des événements inattendus ou rares, mais a été associée à moins de cécité d'inattention envers les événements attendus ou courants. Le repos perçu n'a pas eu d'impact sur la perception des événements. CONCLUSION: Les anesthésiologistes ont remarqué moins d'événements cliniques inattendus/rares que d'événements attendus/courants dans une vidéo exigeant l'attention portant sur la simulation d'un patient traumatisé, ce qui s'inscrit dans la cécité d'inattention. La formation préalable par simulation était associée à une meilleure capacité à remarquer les événements anticipés/attendus, mais ne réduisait pas la cécité d'inattention. Nos résultats peuvent avoir des implications pour la compréhension des accidents médicaux et les efforts visant à améliorer la conscience situationnelle, en particulier dans les contextes de soins périopératoires aigus et de soins intensifs.

Systemic Heparinization After Neuraxial Anesthesia in Vascular Surgery: A Retrospective Analysis.

OBJECTIVES: The American Society of Regional Anesthesia and Pain Medicine's guidelines recommend a 1-hour interval after neuraxial anesthesia (NA) before systemic heparinization to mitigate the risk of spinal hematoma (SH). The study authors aimed to characterize the time interval between NA and systemic heparinization in vascular surgery patients (primary outcome). The secondary outcomes included the historic incidence of SH, and risk estimation of the SH formation based on available data. Heparin dose, length of surgery, difficulty and/or the number of NA attempts, and patient demographics were recorded. DESIGN: A retrospective analysis between April 2012 and April 2022. SETTING: A single (academic) center. PARTICIPANTS: Vascular surgery patients. INTERVENTIONS: Intravenous heparin administration. MEASUREMENTS AND MAIN RESULTS: All (N = 311) vascular patients were reviewed, of whom 127 (5 femoral-femoral bypass, 67 femoral-popliteal bypass, and 55 endovascular aneurysm repairs [EVAR]) received NA and were included in the final analysis. Patients receiving general anesthesia alone (N = 184) were excluded. Neuraxial anesthesia included spinal (N = 119), epidural (N = 4), or combined spinal-epidural (N = 4) blocks. The average time between NA and heparin administration was 42.8 ± 22.1 minutes, with 83.7% of patients receiving heparin within 1 hour of NA. The time between NA and heparin administration was 40.4 ± 22.3, 50.1 ± 23.4, and 31.3 ± 12.5 minutes for femoral-femoral bypass, femoral-popliteal bypass, and EVAR, respectively. Heparin was administered after 1 hour of NA in 20% of femoral-femoral bypass, 27% of femoral-popliteal bypass, and 3.9% of EVAR patients. No SHs were reported during the study period. CONCLUSIONS: The vast majority of vascular surgery patients at the authors' center received heparin within 1 hour of NA. Further studies are required to assess if their findings are consistent in other vascular surgery settings and/or centers.

Perioperative central venous oxygen saturation and its correlation with mortality during cardiac surgery: an observational prospective study / Correlação entre saturação venosa central de oxigênio perioperatória e mortalidade em cirurgia cardíaca: estudo prospectivo observacional

Abstract Background: Cardiac surgery can produce persistent deficit in the ratio of Oxygen Delivery (DO2) to Oxygen Consumption (VO2). Central venous oxygen Saturation (ScvO2) is an accessible and indirect measure of DO2/VO2 ratio. Objective: To monitor perioperative ScvO2 and assess its correlation with mortality during cardiac surgery. Methods: This prospective observational study evaluated 273 patients undergoing cardiac surgery. Blood gas samples were collected to measure ScvO2 at three time points: T0 (after anesthetic induction), T1 (end of surgery), and T2 (24 hours after surgery). The patients were divided into two groups (survivors and nonsurvivors). The following outcomes were analyzed: intrahospital mortality, length of Intensive Care Unit (ICU) and hospital stay (LOS), and variation in ScvO2. Results: Of the 273 patients, 251 (92%) survived and 22 (8%) did not. There was a significant perioperative reduction of ScvO2 in both survivors (T0 = 78% ± 8.1%, T1 = 75.4% ± 7.5%, and T2 = 68.5% ± 9%; p< 0.001) and nonsurvivors (T0 = 74.4% ± 8.7%, T1 = 75.4% ± 7.7%, and T2 = 66.7% ± 13.1%; p < 0.001). At T0, the percentage of patients with ScvO2< 70% was greater in the nonsurvivor group (31.8% vs. 13.1%; p= 0.046) and the multiple logistic regression showed that ScvO2 is an independent risk factor associated with death, OR = 2.94 (95% CI 1.10−7.89) (p= 0.032). The length of ICU and LOS were 3.6 ± 3.1 and 7.4 ± 6.0 days respectively and was not significantly associated with ScvO2. Conclusions: Early intraoperative ScvO2 < 70% indicated a higher risk of death. A perioperative reduction of ScvO2 was observed in patients undergoing cardiac surgery, with high intraoperative and lower postoperative levels.

Resumo Justificativa: A cirurgia cardíaca pode produzir déficit persistente na razão entre oferta de oxigênio (DO2) e consumo de oxigênio (VO2). A Saturação venosa central de Oxigênio (SvcO2) é uma medida acessível e indireta da razão DO2/VO2. Objetivo: Monitorar a SvcO2 perioperatória e avaliar sua correlação com a mortalidade em cirurgia cardíaca. Método: Este estudo observacional prospectivo avaliou 273 pacientes submetidos a cirurgia cardíaca. Coletamos amostras de sangue para medir a SvcO2 em três momentos: T0 (após indução anestésica), T1 (final da cirurgia) e T2 (24 horas após a cirurgia). Os pacientes foram divididos em dois grupos (sobreviventes e não sobreviventes). Os seguintes desfechos foram analisados: mortalidade intra-hospitalar, tempo de permanência na Unidade de Terapia Intensiva (UTI) e de internação hospitalar, e variação na SvcO2. Resultados: Dos 273 pacientes, 251 (92%) sobreviveram e 22 (8%) não. Houve queda significante da SvcO2 perioperatória nos sobreviventes (T0 = 78% ± 8,1%, T1 = 75,4% ± 7,5% e T2 = 68,5% ± 9%; p< 0,001) e nos não sobreviventes (T0 = 74,4% ± 8,7%, T1 = 75,4% ± 7,7% e T2 = 66,7% ± 13,1%; p< 0,001). No T0, a porcentagem de pacientes com SvcO2< 70% foi maior no grupo não sobrevivente (31,8% vs. 13,1%; p = 0,046) e a regressão logística múltipla mostrou que a SvcO2 é um fator de risco independente associado ao óbito, OR = 2,94 (95% IC 1,10 − 7,89) (p = 0,032). O tempo de permanência na UTI e de hospitalização foi de 3,6 ± 3,1 e 7,4 ± 6,0 dias, respectivamente, e não foi significantemente associado à SvcO2. Conclusões: Valores precoces de SvcO2 intraoperatória < 70% indicaram maior risco de óbito em pacientes submetidos à cirurgia cardíaca. Observamos redução perioperatória da SvcO2, com altos níveis no intraoperatório e mais baixos no pós-operatório.

[Perioperative central venous oxygen saturation and its correlation with mortality during cardiac surgery: an observational prospective study]. / Correlação entre saturação venosa central de oxigênio perioperatória e mortalidade em cirurgia cardíaca: estudo prospectivo observacional.

BACKGROUND: Cardiac surgery can produce persistent deficit in the ratio of Oxygen Delivery (DO2) to Oxygen Consumption (VO2). Central venous oxygen Saturation (ScvO2) is an accessible and indirect measure of DO2/VO2 ratio. OBJECTIVE: To monitor perioperative ScvO2 and assess its correlation with mortality during cardiac surgery. METHODS: This prospective observational study evaluated 273 patients undergoing cardiac surgery. Blood gas samples were collected to measure ScvO2 at three time points: T0 (after anesthetic induction), T1 (end of surgery), and T2 (24hours after surgery). The patients were divided into two groups (survivors and nonsurvivors). The following outcomes were analyzed: intrahospital mortality, length of Intensive Care Unit (ICU) and hospital stay (LOS), and variation in ScvO2. RESULTS: Of the 273 patients, 251 (92%) survived and 22 (8%) did not. There was a significant perioperative reduction of ScvO2 in both survivors (T0=78%± 8.1%, T1=75.4%±7.5%, and T2=68.5%±9%; p<0.001) and nonsurvivors (T0=74.4%±8.7%, T1=75.4%±7.7%, and T2=66.7%±13.1%; p <0.001). At T0, the percentage of patients with ScvO2 <70% was greater in the nonsurvivor group (31.8% vs. 13.1%; p=0.046) and the multiple logistic regression showed that ScvO2 is an independent risk factor associated with death, OR=2.94 (95% CI 1.10-7.89) (p=0.032). The length of ICU and LOS were 3.6±3.1 and 7.4±6.0 days respectively and was not significantly associated with ScvO2. CONCLUSIONS: Early intraoperative ScvO2 <70% indicated a higher risk of death. A perioperative reduction of ScvO2 was observed in patients undergoing cardiac surgery, with high intraoperative and lower postoperative levels.

Laryngeal Mask Airway Versus Other Airway Devices for Anesthesia in Children With an Upper Respiratory Tract Infection: A Systematic Review and Meta-analysis of Respiratory Complications.

There is an association between upper respiratory tract infection (URTI) and an increased incidence of perioperative respiratory adverse events (PRAEs), which is a major risk for morbidity during pediatric anesthesia. The aim of the present study was to compare the risk of PRAEs among different airway devices during anesthesia in children with a URTI. A systematic review according to the Cochrane Handbook and Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines was conducted. Only randomized clinical trials evaluating anesthesia in children with a URTI and who were submitted to any of the airway devices were included. From 1030 studies identified, 5 randomized clinical trials were included in the final analysis. There were no statistical differences between laryngeal mask airway (LMA®) and endotracheal tube (ETT) regarding breath holding or apnea (risk ratio [RR], 0.82; 95% confidence interval [CI], 0.41-1.65), laryngospasm (RR, 0.74; 95% CI, 0.18-2.95), and arterial oxygen desaturation (RR, 0.44; 95% CI, 0.16-1.17). The quality of evidence was low for the first outcome and very low for the 2 other outcomes, respectively. The LMA use produced a significant reduction of cough (RR, 0.75; 95% CI, 0.58-0.96, low quality of evidence) compared with ETT. The ideal airway management in children with a URTI remains obscure given that there are few data of perioperative respiratory complications during anesthesia. This systematic review demonstrates that LMA use during anesthesia in children with URTI did not result in decrease of the most feared PRAEs. However, LMA was better than ETT in reducing cough. Further research is needed to define the risks more clearly because cough and laryngospasm have similar triggers, and both bronchospasm and laryngospasm trigger cough.