Persisting high rates of omissions during anesthesia induction are decreased by utilization of a pre- & post-induction checklist.

INTRODUCTION: Although Checklists (CL) for routine anesthesia cases have demonstrated their values in various studies, they have found little traction so far. While several reports have shown the benefit of CL preventing omissions prior to anesthesia induction, no investigation yet has scrutinized omissions during the post-induction phase immediately after intubation. This study evaluated the rate of omissions prior to and following the induction of non-emergent general anesthesia, as well as the impact of checklists on omission prevention. METHODS: We performed a monocentric, prospective, observational study during induction of general anesthesia cases. We evaluated the omission rate made for the pre- as well as the immediate post-induction phase and determined the impact of pre-and post-induction CL on the rate of omission corrections. The CL used were introduced two years prior to the study. The observed providers were limited to those familiar with the institutional CL. Usage of CL was not mandated. RESULTS: 237 general anesthesia inductions were included in the observation. At least one omission in 32% of all cases in the pre-induction setup was found and in 40% within the immediate post-induction phases. CL significantly reduced omission rates (relative risk = 0.64, 95% CI = 0.45-0.92, p = 0.01). CONCLUSION: Omission rates during the pre- and post-induction phases of routine general anesthesia procedures remain high. Pre- and post-induction CL have the potential to increase patient safety and should be considered for routine anesthesia with appropriate training provided.

Anaesthesia-specific checklists: A systematic review of impact.

Checklists are recognised as powerful tools to prevent avoidable errors in high-reliability organisations. In healthcare, the perioperative area has been a leading field in the development of a wide range of checklists. However, clinical literature on this subject is still sparse and heterogeneous, producing results that are sometimes conflicting. This systematic review assesses the current literature on perioperative routine and crisis checklists. Literature searches did not use a date limit and included articles up to March 2019. The methodological heterogeneity precluded combining data from the individual studies into a quantitative meta-analysis. Data are presented by means of a qualitative comparison with the reference groups based on a content analysis approach. Of the 874 identified articles, 25 were included in this review. Most identified studies (23, 92%) have shown that the use of checklists in anaesthesia can decrease human error, improve patient safety and teamwork, and increase quality of care. Beyond the WHO surgical time-out, anaesthesia-specific checklists have been shown to be useful for provider handoffs, emergencies, and routine anaesthesia procedures. However, literature on anaesthesia-specific checklists is still limited and very heterogeneous. More large-scale studies are necessary to identify an ideal anaesthesia checklist and its most appropriate implementation method.

Checklists and Other Cognitive Aids For Emergency And Routine Anesthesia Care-A Survey on the Perception of Anesthesia Providers From a Large Academic US Institution.

BACKGROUND: The use of printed or electronic checklists and other cognitive aids has gained increasing interest from anesthesia providers and professional societies. While these aids are not currently considered standard of care, the perceptions of the clinician might have an impact on their adoption. OBJECTIVES: We conducted a comprehensive survey to study the current opinions of anesthesia provider on the use of checklists and other cognitive aids. PATIENTS AND METHODS: A questionnaire was developed by a departmental checklist focus group, which aimed to identify the perception of health care checklists in general as well as specific checklists for routine and crisis situations in anesthesia. Furthermore participants were asked regarding their perception of performing routine anesthesia and managing crisis situations without any cognitive aids. Using a web-based system, the survey was administered to all anesthesia providers at a single large United States academic medical center (University of California San Francisco). Demographic information included professional status (faculty, anesthesia resident, or nurse anesthetists [certified registered nurse anesthetists; CRNA]) and years of clinical experience. RESULTS: 69% of 312 providers responded. 98% of the survey takers consider the procedural time-out (the widely used pre-incision operating room checklist) as important or very important. We found that many anesthesia providers acknowledged limitations in their ability to perform clinical tasks without any lapses, and a majority would use checklists and other cognitive aids if available. Their acceptances are especially high for crisis situations (87 - 97%, depending on years of experience) and routine care that providers do not perform often (76 - 91%). Printed or electronic aids for patient-care transition and shift hand-offs were also valued (61% and 58%). To prepare for and perform routine anesthesia care, 40% of providers claimed interest in using checklists, however, the interest differed significantly with clinical experience: While both the least and most experienced providers valued aids for routine anesthesia (54% and 50%), only 29% of providers with 2 - 10 years of anesthesia experience claimed interest in using them. Distraction from patient care and decreased efficiency were concerns expressed for the use of routine checklist (27% and 31%, respectively). The main factors found to support the successful implementation of checklists into clinical care are ease of use and thoughtful integration into the anesthesia workflow. CONCLUSIONS: Providers at our large academic institution generally embrace the concept of checklists and other cognitive aids. This was true for all providers for checklists for procedural time outs, anesthesia crisis situations and those for routine procedures that providers rarely perform. Only very experienced and very junior providers appreciated the use of checklists for routine care. There remains a discrepancy between these claims and provider's perception on their clinical competency based on memory alone.

Regional anesthesia and anticoagulation.

PURPOSE OF REVIEW: Patients receiving perioperative anticoagulation are a challenge for anesthesiologists when regional anesthesia would be a beneficial component of the anesthetic plan. Newly approved antithrombotic drugs maintain the need for updated review articles and recommendations. RECENT FINDINGS: Due to the very low incidence of bleeding complications, guidelines are solely based on retrospective analyses of case reports and pharmacological considerations. Hence, they should not be taken as evidence-based 'cook books'. Recommendations of well established anticoagulants like heparin and non-steroidal antiinflammatory drugs may have a solid basis. However, the lack of data on new antithrombotic drugs including GII/GIIIA antagonists, factor X and thrombin-inhibitors requires a more conservative approach when regional anesthesia is considered. Current literature emphasizes postoperative monitoring; clear recommendations of its performance, however, are missing. SUMMARY: Decisions to perform regional anesthesia in patients under anticoagulation should always be made on an individual risk-benefit assessment. A vigilant preoperative evaluation of the patient's medication and physical findings are as important as awareness of postoperative plans for anticoagulation.

Muscle relaxants.

Studies on the toxic effects of muscle relaxants are difficult to design because of the need for mechanical ventilation and, consequently, concomitant administration of anaesthetic drugs which may influence the results. The following overview shows that muscle relaxants are weak toxic agents with regard to their teratogenicity, carcinogenicity and cytotoxic effects (including tissue- and organ-damaging effects). Moreover, this chapter presents other side-effects of muscle relaxants under the broad heading of toxicity: the succinylcholine-triggered cytotoxic effects on skeletal muscle cells with different aetiology, for example, or persistent muscle weakness after long-term administration of non-depolarizing muscle relaxants. Receptor stimulation in the central nervous system may cause acute excitement and seizures. Muscle relaxants and their metabolites may interact with muscarinic and nicotinic receptors in other organs and the ganglionic system, for example in the cardiovascular system. Direct stimulation of mast cells, with consequent release of histamine, after administration of muscle relaxants may clinically impose as toxic reactions.