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.

An empirical analysis of American Passenger's willingness to fly in commercial airplanes after vaccination against COVID-19.

Although several studies have explored the effects of the pandemic on aviation, little remains known about whether members of the public are willing to fly again after they have been vaccinated. The current study uses the Health Belief Model (HBM) to fill this missing gap by manipulating the following variables: 1) whether or not the participant is vaccinated; 2) whether or not airlines require that all passengers and crew receive vaccinations; 3) length of flight; 4) destination; and 5) the number of passengers. The data from 678 participants revealed that willingness to fly is much higher if the participants themselves have been vaccinated, if the airlines require all passengers to be vaccinated, if the flight is short, if the destination is domestic, and if the number of passengers is low. These findings did not appear to differ as a function of flying business versus pleasure. We discuss the practical implications of these data as airlines struggle to bring back their customer base.

Sudden cardiac arrest in commercial airports: Incidence, responses, and implications.

Billions of travelers pass through airports around the world every year. Airports are a relatively common location for sudden cardiac arrest when compared with other public venues. An increased incidence of cardiac arrest in airports may be due to the large volume of movement, the stress of travel, or adverse effects related to the physiological environment of airplanes. Having said that, airports are associated with extremely high rates of witnessed arrests, bystander interventions (eg. CPR and AED use), shockable arrest rhythms, and survival to hospital discharge. Large numbers of people, a high density of public-access AEDs, and on-site emergency medical services (EMS) resources are probably the major reasons why cardiac arrest outcomes are so favorable at airports. The success of the chain of survival found at airports may imply that applying similar practices to other public venues will translate to improvements in cardiac arrest survival. Airports might, therefore, be one model of cardiac arrest preparedness that other public areas should emulate.

COVID-19, Personal Protective Equipment, and Human Performance.

Clinicians who care for patients infected with coronavirus disease 2019 (COVID-19) must wear a full suite of personal protective equipment, including an N95 mask or powered air purifying respirator, eye protection, a fluid-impermeable gown, and gloves. This combination of personal protective equipment may cause increased work of breathing, reduced field of vision, muffled speech, difficulty hearing, and heat stress. These effects are not caused by individual weakness; they are normal and expected reactions that any person will have when exposed to an unusual environment. The physiologic and psychologic challenges imposed by personal protective equipment may have multiple causes, but immediate countermeasures and long-term mitigation strategies can help to improve a clinician's ability to provide care. Ultimately, a systematic approach to the design and integration of personal protective equipment is needed to improve the safety of patients and clinicians.

Autopilots in the Operating Room: Safe Use of Automated Medical Technology.

Automated medical technology is becoming an integral part of routine anesthetic practice. Automated technologies can improve patient safety, but may create new workflows with potentially surprising adverse consequences and cognitive errors that must be addressed before these technologies are adopted into clinical practice. Industries such as aviation and nuclear power have developed techniques to mitigate the unintended consequences of automation, including automation bias, skill loss, and system failures. In order to maximize the benefits of automated technology, clinicians should receive training in human-system interaction including topics such as vigilance, management of system failures, and maintaining manual skills. Medical device manufacturers now evaluate usability of equipment using the principles of human performance and should be encouraged to develop comprehensive training materials that describe possible system failures. Additional research in human-system interaction can improve the ways in which automated medical devices communicate with clinicians. These steps will ensure that medical practitioners can effectively use these new devices while being ready to assume manual control when necessary and prepare us for a future that includes automated health care.

Automation failures and patient safety.

PURPOSE OF REVIEW: The goal of automation is to decrease the anesthesiologist's workload and to decrease the possibility of human error. Automated systems introduce problems of its own, however, including loss of situation awareness, leaving the physician out of the loop, and training physicians how to monitor autonomous systems. This review will discuss the growing role of automated systems in healthcare and describe two types of automation failures. RECENT FINDINGS: An automation surprise occurs when an automated system takes an action that is unexpected by the user. Mode confusion occurs when the operator does not understand what an automated system is programmed to do and may prevent the clinician from fully understanding what the device is doing during a critical event. Both types of automation failures can decrease a clinician's trust in the system. They may also prevent a clinician from regaining control of a failed system (e.g., a ventilator that is no longer working) during a critical event. SUMMARY: Clinicians should receive generalized training on how to manage automation and should also be required to demonstrate competency before using medical equipment that employs automation, including electronic health records, infusion pumps, and ventilators.

Helicopter air ambulance services.

PURPOSE OF REVIEW: Helicopter air ambulances are an integral component of modern trauma care, and are able to transport patients to facilities with greater capabilities, extract injured patients from hostile terrain, and speed transport to a trauma center. RECENT FINDINGS: HAA transport does not reduce the total time required to transport a patient, but it does reduce the time that the patient is between healthcare facilities. Factors that have been suggested to improve outcomes for trauma patients include the availability of advanced interventions, skilled personnel, speed, and trauma center access. Despite their potential benefits to the patient, HAA operations carry significant risks. HAA operations are among the most dangerous professions for both pilot and crew with a mortality rate greater than commercial fishing, loggers, and steelworkers. The US Federal Aviation Administration (FAA) has identified that the four most common causes of HAA accidents as inadvertent flight into instrument meteorological conditions, loss of control, controlled flight into terrain, and night conditions. SUMMARY: HAA operations are safe and can improve patient care, but additional research is needed to improve our understanding of HAA operations and their effect on outcomes.

More Than a Tick Box: Medical Checklist Development, Design, and Use.

Despite improving patient safety in some perioperative settings, some checklists are not living up to their potential and complaints of "checklist fatigue" and outright rejection of checklists are growing. Problems reported often concern human factors: poor design, inadequate introduction and training, duplication with other safety checks, poor integration with existing workflow, and cultural barriers. Each medical setting-such as an operating room or a critical care unit-and different clinical needs-such as a shift handover or critical event response-require a different checklist design. One size will not fit all, and checklists must be built around the structure of medical teams and the flow of their work in those settings. Useful guidance can be found in the literature; however, to date, no integrated and comprehensive framework exists to guide development and design of checklists to be effective and harmonious with the flow of medical and perioperative tasks. We propose such a framework organized around the 5 stages of the checklist life cycle: (1) conception, (2) determination of content and design, (3) testing and validation, (4) induction, training, and implementation, and (5) ongoing evaluation, revision, and possible retirement. We also illustrate one way in which the design of checklists can better match user needs in specific perioperative settings (in this case, the operating room during critical events). Medical checklists will only live up to their potential to improve the quality of patient care if their development is improved and their designs are tailored to the specific needs of the users and the environments in which they are used.

Fatigue Risk Management: The Impact of Anesthesiology Residents' Work Schedules on Job Performance and a Review of Potential Countermeasures.

Long duty periods and overnight call shifts impair physicians' performance on measures of vigilance, psychomotor functioning, alertness, and mood. Anesthesiology residents typically work between 64 and 70 hours per week and are often required to work 24 hours or overnight shifts, sometimes taking call every third night. Mitigating the effects of sleep loss, circadian misalignment, and sleep inertia requires an understanding of the relationship among work schedules, fatigue, and job performance. This article reviews the current Accreditation Council for Graduate Medical Education guidelines for resident duty hours, examines how anesthesiologists' work schedules can affect job performance, and discusses the ramifications of overnight and prolonged duty hours on patient safety and resident well-being. We then propose countermeasures that have been implemented to mitigate the effects of fatigue and describe how training programs or practice groups who must work overnight can adapt these strategies for use in a hospital setting. Countermeasures include the use of scheduling interventions, strategic naps, microbreaks, caffeine use during overnight and extended shifts, and the use of bright lights in the clinical setting when possible or personal blue light devices when the room lights must be turned off. Although this review focuses primarily on anesthesiology residents in training, many of the mitigation strategies described here can be used effectively by physicians in practice.

Deep vein thrombosis and venous thromboembolism in trauma.

PURPOSE OF REVIEW: Deep vein thrombosis (DVT) and pulmonary embolus are major causes of hospital-related morbidity and mortality, and are recognized as complications in patients with traumatic injury. Despite the significant morbidity and mortality associated with DVTs, prophylaxis and treatment are still not well understood and remain the subject of research and debate. RECENT FINDINGS: Elements of the patient's history and physical examination, along with thromboelastography, can be used to predict patients who are at greatest risk of DVT and venous thromboembolism (VTE). Novel assays and biomarkers hold promise for more accurate evaluation of coagulation status. Patients with traumatic injury are routinely treated with either mechanical or pharmacological treatments to prevent DVT, and a growing body of evidence suggests that DVT prophylaxis should be initiated as early as possible in a patient's hospital course. SUMMARY: In trauma patients with traumatic injury, early identification and targeted VTE prophylaxis in trauma patients may prevent this life-threatening complication.

Severe Intraoperative Hyperglycemia Is Independently Associated With Postoperative Composite Infection After Craniotomy: An Observational Study.

BACKGROUND: Postoperative infection after craniotomy carries an increased risk of morbidity and mortality. Identification and correction of the risk factors should be prioritized. The association of intraoperative hyperglycemia with postoperative infections in patients undergoing craniotomy is inadequately studied. METHODS: A total of 224 patients were prospectively enrolled in 2 major medical centers to assess whether severe intraoperative hyperglycemia (SIH, blood glucose ≥180 mg/dL) is associated with an increased risk of postoperative infection in patients undergoing craniotomy. Arterial blood samples were drawn and analyzed immediately after anesthetic induction and again before tracheal extubation. The new onset of any type of infection within 7 days after craniotomy was determined. RESULTS: The incidence of new postoperative composite infection was 10% (n = 22) within the first week after craniotomy. Weight, sex, American Society of Anesthesiologists score, preoperative and/or intraoperative steroid use, and diabetes mellitus were not associated with postoperative infection. SIH was independently associated with postoperative infection (odds ratio [95% confidence interval], 4.17 [1.50-11.56], P = .006) after fitting a multiple logistic regression model to adjust for emergency surgery, length of surgery, and age ≥65 years. CONCLUSIONS: SIH is independently associated with postoperative new-onset composite infections in patients undergoing craniotomy. Whether prevention of SIH during craniotomy results in a reduced postoperative risk of infection is unknown and needs to be appraised by further study.

Intraoperative neurophysiologic monitoring: utility and anesthetic implications.

PURPOSE OF REVIEW: Intraoperative neurophysiologic monitoring (IONM) has been rapidly adopted as a standard monitoring technique for a growing number of surgical procedures. This article offers a basic review of IONM and discusses some of its latest applications and anesthetic techniques that optimize monitoring conditions. RECENT FINDINGS: IONM has been demonstrated to alert the surgical team to potential injury and can also be used to detect impending positioning injuries. Upper extremity somatosensory evoked potential monitoring is particularly helpful in preventing ulnar neuropathy that is more common in patients who are positioned prone and with severe arm abduction. Somatosensory evoked potential monitoring has a high specificity for vascular compromise and neurologic ischemia that may occur during neurovascular procedures. Electroencephalography is also helpful in alerting the surgical and anesthesia teams to an impending ischemic event. Although a total intravenous anesthesia technique offers better monitoring conditions, propofol may prolong emergence. SUMMARY: IONM is commonly used in a growing number and variety of surgical procedures, and has been shown to improve outcomes. IONM poses challenges for the anesthesiologist, but tailoring the anesthetic to be compatible with the monitoring techniques in use can help to prevent surgical complications.

Alarm fatigue: impacts on patient safety.

PURPOSE OF REVIEW: Electronic medical devices are an integral part of patient care. As new devices are introduced, the number of alarms to which a healthcare professional may be exposed may be as high as 1000 alarms per shift. The US Food and Drug Administration has reported over 500 alarm-related patient deaths in five years. The Joint Commission, recognizing the clinical significance of alarm fatigue, has made clinical alarm management a National Patient Safety Goal. RECENT FINDINGS: Potential solutions to alarm fatigue include technical, organizational, and educational interventions. Selecting only the right monitors (i.e., avoiding overmonitoring), judicious selection of alarm limits, and multimodal alarms can all reduce the number of nuisance alarms to which a healthcare worker is exposed. SUMMARY: Alarm fatigue can jeopardize safety, but some clinical solutions such as setting appropriate thresholds and avoiding overmonitoring are available.

Red blood cell transfusion in neurosurgical patients.

PURPOSE OF REVIEW: Anemia is common in neurosurgical patients, and is associated with secondary brain injury. Although recent studies in critically ill patients have shifted practice toward more restrictive red blood cell (RBC) transfusion strategies, the evidence for restrictive versus liberal transfusion strategies in neurosurgical patients has been controversial. In this article, we review recent studies that highlight issues in RBC transfusion in neurosurgical patients. RECENT FINDINGS: Recent observational, retrospective studies in patients with traumatic brain injury, subarachnoid hemorrhage, and intracranial hemorrhage have demonstrated that prolonged anemia and RBC transfusions were associated with worsened outcomes. Anemia in patients with ischemic stroke was associated with increased ICU length of stay and longer mechanical ventilation requirements, but mortality and functional outcomes did not improve with RBC transfusion. In elective craniotomy, perioperative anemia was associated with increased hospital length of stay but no difference in 30-day morbidity or mortality. SUMMARY: There is a lack of definitive evidence to guide RBC transfusion practices in neurosurgical patients. Large randomized control trials are needed to better assess when and how aggressively to transfuse RBCs in neurosurgical patients.

Traumatic carotid artery dissection during acrobatic flight associated with -G(z) acceleration.

BACKGROUND: A 38-yr-old man developed the acute onset of expressive aphasia and right hemiparesis during the performance of an advanced aerobatic flight maneuver. CASE REPORT: Magnetic resonance imaging (MRI) demonstrated patchy infarction in the territory of the left middle cerebral artery. Magnetic resonance, angiography (MRA) revealed a dissection of the left internal carotid artery. He had flown an aerobatic routine with multiple abrupt transitions from +8 G(z) to -6 G(z) 4 d prior with no ill effects. He had no risk factors for dissection or stroke. The patient recovered full neurological function within several hours. DISCUSSION: We propose that the arterial dissection occurred during the patient's preceding aerobatic flight, leading to an embolic stroke 4 d later. The most likely mechanism was sustained -G(z) acceleration combined with flexion and rotation of his neck during abrupt transition from +G(z) to -G(z), causing stretching of the internal carotid artery at the point of entry to the skull base and development of an intimal tear.