Vol. 71, N. 2 | Mar-Apr 2021 | ISSN 0104-0014
Brazilian Journal of ANESTHESIOLOGY Revista Brasileira de Anestesiologia BJAN Brazilian Journal of Anesthesiology Why do patients get dissatisfied? Brazilian Journal of Anesthesiology
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Editor-in-Chief Jean Jacques Rouby – Pierreand Marie Curie University, Paris, France Maria José Carvalho Carmona – Faculdade de Medicina da Universidade de São Paulo, Jean Louis Teboul – Paris-Sud University, Paris, France SP, Brazil Jean Louis Vincent – Université Libre De Bruxelles, Brussels, Belgium João Batista Santos Garcia – Universidade Federal do Maranhão, São Luís, MA, Brazil João Manoel da Silva Júnior – Hospital do Servidor Público, SP, Brazil Co-Editor João Paulo Jordão Pontes – Universidade Federal de Uberlândia, MG, Brazil André Prato Schmidt – Hospital das Clínicas da Universidade Federal do Rio Grande do Judymara Lauzi Gozzani – Universidade Federal de São Paulo, SP, Brazil Sul, RS, Brazil Kurt Ruetzler – Cleveland Clinic, Cleveland, OH, USA Laszlo Vutskits – Geneva University Hospitals, Geneve, GE, Switzerland Leandro Gobbo Braz – Faculdade de Medicina de Botucatu da Universidade Estadual Associate Editors Paulista, São Paulo, SP, Brazil Ana Maria Menezes Caetano – Universidade Federal de Pernambuco, Recife, PE, Brazil Luciano Gattinoni – University of Göttingen, Göttingen, Germany Cláudia Marquez Simões – Hospital Sírio Libanês, São Paulo, SP, Brazil Leopoldo Muniz da Silva – Faculdade de Medicina de Botucatu da Universidade Estadual Florentino F. Mendes – Universidade Federal de Ciências da Saúde de Porto Alegre, RS, Brazil Paulista, SP, Brazil Gabriel Magalhães Nunes Guimarães – Universidade de Brasília, DF, Brazil Ligia Andrade da S. Telles Mathias – Irmandade da Santa Casa de Misericórdia de São Guilherme A.M. Barros – Faculdade de Medicina de Botucatu da Universidade Estadual Paulo, SP, Brazil Paulista, SP, Brazil Luiz Antônio Diego – Universidade Federal Fluminense, Rio de Janeiro, RJ, Brazil Leonardo Henrique Cunha Ferraro – Universidade Federal de São Paulo, SP, Brazil Luiz Fernando dos Reis Falcão – Universidade Federal de São Paulo, SP, Brazil Liana Maria Torres de Araújo Azi – Universidade Federal da Bahia, Salvador, BA, Brazil Luiz Marciano Cangiani – Hospital da Fundação Centro Médico Campinas, Campinas, SP, Brazil Luciana Paula Cadore Stefani – Universidade Federal do Rio Grande do Sul, RS, Brazil Marcelo Gama de Abreu – University Hospital Carl Gustav Carus, Dresden, SN, Germany Luis Vicente Garcia – Faculdade de Medicina da Universidade de São Paulo, Ribeirão Preto, Marcelo Luis Abramides Torres – Faculdade de Medicina da Universidade de São Paulo, SP, Brazil SP, Brazil Luiz Marcelo Sá Malbouisson – Hospital das Clínicas da Faculdade de Medicina da Márcio Matsumoto – Hospital Sírio Libanês, São Paulo, SP, Brazil Universidade de São Paulo, SP, Brazil Marcos Antônio Costa de Albuquerque – Universidade Federal de Sergipe, SE, Brazil Marcello Fonseca Salgado-Filho – Universidade Federal Fluminense, Rio de Janeiro, RJ, Brazil Marcos Francisco Vidal Melo – Harvard University, Boston, MA, USA Norma Sueli Pinheiro Módolo – Faculdade de Medicina de Botucatu da Universidade Maria Ângela Tardelli – Universidade Federal de São Paulo, SP, Brazil Estadual Paulista, São Paulo, SP, Brazil Mariana Fontes Lima Neville – Universidade Federal de São Paulo, SP, Brazil Paulo do Nascimento Junior – Faculdade de Medicina de Botucatu da Universidade Mário José da Conceição – Fundação Universidade Regional de Blumenau, SC, Brazil Estadual Paulista, São Paulo, SP, Brazil Massimiliano Sorbello – AOU Policlinico Vittorio Emanuele, Catania, Italy Rodrigo Leal Alves – Hospital São Rafael, Salvador, BA, Brazil Matheus Fachini Vane – Hospital das Clínicas da Faculdade de Medicina da Universidade Vanessa Henriques Carvalho – Universidade Estadual de Campinas, SP, Brazil de São Paulo, SP, Brazil Vinicius Caldeira Quintão – Hospital das Clínicas da Faculdade de Medicina da Universidade Mônica Maria Siaulys – Hospital e Maternidade Santa Joana, São Paulo, SP, Brazil de São Paulo, SP, Brazil Nádia Maria da Conceição Duarte – Universidade Federal de Pernambuco, Recife, PE, Brazil Neuber Martins Fonseca – Faculdade de Medicina da Universidade Federal de Uberlândia, MG, Brazil Editorial Committee Nicola Disma – Istituto Giannina Gaslini, Génova, Italy Adrian Alvarez – Hospital Italiano de Buenos Aires, BA, Argentina Oscar César Pires – Universidade de Taubaté, SP, Brazil Adrian Gelb – University of California, San Francisco, CA, USA Paolo Pelosi – Universita Degli Studi Di Genova, Genoa, LI, Italy Alexandra Rezende Assad – Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ, Brazil Paulo Alípio – Universidade Federal Fluminense, RJ, Brazil Angela Maria de Sousa – Hospital das Clínicas da Faculdade de Medicina Pedro Amorim – Centro Hospitalar e Universitário do Porto, Portugal Antônio Carlos Aguiar Brandão – Universidade do Vale do Sapucaí, Pouso Alegre, MG, Brazil Pedro Francisco Brandão – Universidade Federal do Espírito Santo, ES, Brazil Augusto Key Takaschima – Serviços Integrados de Anestesiologia, Florianópolis, SC, Brazil Pedro Paulo Tanaka – Stanford University School of Medicine, California, USA Bernd W. Böttiger – University Hospital of Cologne, Klinikum Köln, Germany Philip Peng – University of Toronto, Toronto, Ontario, Canada Bobbie Jean Sweitzer – Northwestern Medicine, Chicago, USA Priscilla Ferreira Neto – Instituto da Criança HCFMUSP, SP, Brazil Carlos Galhardo Júnior – Instituto de Cardiologia, MS/RJ, Brazil Raffael Pereira Cezar Zamper – London Health Science Center, London, UK Carlos Manuel Correia Rodrigues de Almeida – Hospital CUF Viseu, Viseu, Portugal Rajinder K. Mirakhur – Royal Hospital, Belfast, Northern Ireland, United Kingdom Carolina Baeta Neves D. Ferreira – Hospital Moriah, São Paulo, SP, Brazil Ricardo Antônio Guimarães Barbosa – Hospital das Clínicas da Faculdade de Medicina da Cátia Sousa Govêia – Universidade de Brasília, DF, Brazil Universidade de São Paulo, SP, Brazil Célio Gomes de Amorim – Universidade Federal de Uberlândia, MG, Brazil Ricardo Vieira Carlos – Hospital das Clínicas da Faculdade de Medicina da Universidade de Clarita Bandeira Margarido – Sunnybrook Health Sciences Care, Toronto, Ontário, Canada São Paulo, SP, Brazil Claudia Regina Fernandes – Universidade Federal do Ceará, CE, Brazil Rodrigo Lima – Queens University, Toronto, Ontário, Canadá Clyde Matava – The Hospital for Sick Children, Toronto, Ontário, Canada Rogean Rodrigues Nunes – Hospital São Lucas, Fortaleza, CE, Brazil David Ferez – Universidade Federal de São Paulo, SP, Brazil Ronald Miller – University of California, San Francisco, CA, USA Deborah Culley – Harvard University, Boston, USA Sara Lúcia Ferreira Cavalcante – Hospital Geral do Inamps de Fortaleza, CE, Brazil Domingos Cicarelli – Hospital das Clínicas da Faculdade de Medicina da USP, SP, Brazil Thaís Cançado – Serviço de Anestesologia de Campo Grande, MS, Brazil Durval Campos Kraychette – Universidade Federal da Bahia, BA, Brazil Waynice Paula-Garcia – Universidade de São Paulo, Brazil Edmundo Pereira de Souza Neto – Centre Hospitalier de Montauban, Tarn-et-Garonne, France Wolnei Caumo – Universidade do Rio Grande do Sul, Porto Alegre, RS, Brazil Eduardo Giroud Joaquim – Universidade Federal de São Paulo, SP, Brazil Eliane Cristina de Souza Soares – Universidade Federal de Minas Gerais, MG, Brazil Emery Brown – Massachusetts Institute of Technology, Cambridge, Massachusetts USA Previous Editors-in-Chief Eric Benedet Lineburger – Hospital São José, Criciúma, SC, Brazil Oscar Vasconcellos Ribeiro (1951-1957) Erick Freitas Curi – Hospital Santa Rita, Vitória, ES, Brazil Zairo Eira Garcia Vieira (1958-1964) Fabiana A. Penachi Bosco Ferreira – Universidade Federal de Goiás, GO, Brazil Bento Mário Villamil Gonçalves (1965-1979) Fábio Papa – University of Toronto, Toronto, Ontario, Canada Masami Katayama (1980-1988) Fátima Carneiro Fernandes – Universidade Federal do Rio de Janeiro, RJ, Brazil Antônio Leite Oliva Filho (1989-1994) Federico Bilotta – Sapienza Università Di Roma, Rome, Italy Luiz Marciano Cangiani (1995-2003) Felipe Chiodini – Faculdade de Medicina da Universidade de São Paulo, SP, Brazil Judymara Lauzi Gozzani (2004-2009) Fernando Abelha – Hospital de São João, Porto, Portugal Mario José da Conceição (2010-2015) Frederic Michard – MiCo, Consulting and Research, Denens, Switzerland Gastão Duval Neto – Universidade Federal de Pelotas, RS, Brazil Maria Ângela Tardelli (2016-2018) Giovanni Landoni – Vita-Salute San Raffaele University, Milan, Italy Gildásio de Oliveira Júnior – Alpert Medical School - Brown University, Providence, USA Editorial Office Giovanni Landoni – Vita-Salute San Raffaele University, Milano, Italy Managing Editor – Mel Ribeiro Hazem Adel Ashmawi – Universidade de São Paulo, SP, Brazil Communications and Marketing Coordinator – Felipe Eduardo Ramos Barbosa Ismar Lima Cavalcanti – Hospital Geral de Nova Iguaçu, RJ, Brazil Editorial Assistant – Pedro Saldanha Librarian – Teresa Libório Translator – Emily Catapano
The Revista Brasileira de Anestesiologia/Brazilian Journal of Anesthesiology (BJAN) is the official journal of Sociedade Brasileira de Anestesiologia (SBA). The BJAN only accepts original articles for publication that can be submitted in English or Portuguese, and are published in English. Before submitting a manuscript, authors must read carefully the Instructions to Authors. It can be found at:
Edited by | Editada por Sociedade Brasileira de Anestesiologia (SBA) Rua Prof. Alfredo Gomes, 36, Rio de Janeiro/RJ, Brazil – CEP 22251-080 Telefone: +55 21 3528-1050 E-mail: [email protected] www.sbahq.org Published by | Publicada por Elsevier Editora Ltda. Telefone RJ: +55 21 3970-9300 Telefone SP: +55 11 5105-8555 www.elsevier.com ISSN: 0104-0014 © 2021 Sociedade Brasileira de Anestesiologia. Published by Elsevier Editora Ltda. All rights reserved. Coming soon: ISSN 0104-0014 • Volume 71 • Number 2 • March-April, 2021
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Editorial 97 The anesthesiologist and the dissatisfi ed patient Florentino Fernandes Mendes Infographic 100 Who is dissatisfi ed with anesthesia? Claudia Marquez Simões 101 Seven questions in COVID-19 airway management: 5W2H Miguel Ángel Fernández Vaquero, Laura Reviriego-Agudo, María Gómez-Rojo, Pedro Charco-Mora Clinical Research 103 Anesthesia-related care dissatisfaction: a cohort historical study to reveal related risks Chie Okuda, Satoki Inoue, Masahiko Kawaguchi 110 Analysis of publication speed of anesthesiology journals: a cross-sectional study Chitta Ranjan Mohanty, Snigdha Bellapukonda, Manisha Mund, Bikram Kishore Behera, Soumya Swaroop Sahoo 116 A survey of acute pain service in Canadian teaching hospitals Qutaiba A. Tawfi c, Alexander Freytag, Kevin Armstrong 123 Urgent/emergency surgery during COVID-19 state of emergency in Portugal: a retrospective and observational study Andreia Filipa Sá, Sofi a Fonseca Lourenço, Rafael da Silva Teixeira, Filinto Barros, António Costa, Paulo Lemos 129 Comparison of three sitting positions for combined spinal - epidural anesthesia: a multicenter randomized controlled trial Mehmet Özgür Özhan, Ceyda Özhan Çaparlar, Mehmet Anıl Süzer, Mehmet Burak Eskin, Bülent Atik 137 Patient safety in an endoscopy unit: an observational retrospective analysis of reported incidents Cora Salles Maruri Correa, Airton Bagatini, Cassiana Gil Prates, Guilherme Becker Sander Systematic Review 142 Wristbands use to identify adult patients with diffi cult airway: a scoping review Eduardo Lema-Florez, Juan Manuel Gomez-Menendez, Fredy Ariza, Andrea Marin-Prado Narrative Review 148 Historical development of the anesthetic machine: from Morton to the integration of the mechanical ventilator Pablo Romero-Ávila, Carlos Márquez-Espinós, Juan R. Cabrera Afonso
ii Brazilian Journal of Anesthesiology Vol. 71, N. 2, Mar–Apr, 2021 162 Competency-based anesthesiology teaching: comparison of programs in Brazil, Canada and the United States Rafael Vinagre, Pedro Tanaka, Maria Angela Tardelli Case Reports 171 Anesthetic management of a patient with face hemangioma: case report Meryem Onay, Sema Şanal Baş, İrem Özdöl, Birgül Yelken 175 Permanent hemidiaphragmatic paresis after interscalene brachial plexus block: a case report Nina Cugnin, Benjamin Le Gaillard, Edmundo Pereira de Souza Neto 178 Anesthesia management of pediatric dentistry patients with cardiofaciocutaneous syndrome: a case report Gian Luigi Gonnella, Pietro Paolo Giuri, Bruno Antonio Zanfi ni, Matteo Biancone, Luciano Frassanito, Cristina Olivieri, Gaetano Draisci 181 Anesthetic management of scoliosis operation in a pediatric patient with Frank-ter Haar syndrome: a case report Irem Basaran, Ezgi Gozubuyuk, Nur Canbolat, Ipek S. Edipoglu, Mehmet I. Buget Short Communication 184 A Brazilian national preparedness survey of anesthesiologists during the coronavirus pandemic Vinícius Caldeira Quintão, Claudia Marquez Simões, Gibran Elias Harcha Munoz, Paul Barach, Maria José Carvalho Carmona, on behalf of the Brazilian Network for Research on Complications in Anesthesia, (BRANCA) Letters to the Editor 188 Introduction of a reasonable manner for injection studies using cadavers Hyang-Do Ham, Yeon-Dong Kim, Hyung-Sun Won 190 Burnout during the COVID-19 pandemic: time to ponder Manbir Kaur, Priyanka Sethi, Neeraj Gupta, Pradeep Bhatia 191 Basic training in cardiovascular anesthesia: wouldn’t it be the time for a unifi ed program in Brazil? Caetano Nigro Neto, Eric Benedet Lineburger, Vinicius Tadeu dos Santos Nascimento, Marcello Fonseca Salgado-Filho 192 Mobile camera as an aid to minimize drug errors Bharat Paliwal, Manoj Kamal, Pradeep Bhatia, Sadik Mohammed 193 Expanding the horizon of costoclavicular block – shouldering new responsibility! Kartik Sonawane, Tuhin Mistry 195 Macintosh laryngoscope: time for retirement? Dante Ranieri Junior, Paulo do Nascimento Junior 196 ERA(S) protocols in the pandemic era: need of the hour Chashamjot Bawa, Rashi Sarna, Mehak Dureja, Rajeev Chauhan 197 Immunonutrition in perioperative care of COVID-19 patients: an old weapon for a new disease? Cristian Deana 198 Linezolid a potential treatment for COVID-19 coinfections Vahid Damanpak Moghadam, Zohre Momenimovahed, Maryam Ghorbani, Javad Khodadadi 198 GAWA during COVID-19 pandemic: a setback? Sofi a Almeida Carvalho, Inês Fernandes Ferraz, Filipa Pires Duarte, Miguel Ghira 200 Transesophageal echocardiography probe cover: implementation of a cross-contamination containment strategy during the COVID-19 pandemic John S. Bozek, Heather K. Hayanga, Partho Sengupta, Mir Ali Abbas Khan, Matthew B. Ellison 201 COVID-19 pandemic mental health risks among anesthesiologists: it is not only burnout Alessandro Vittori, Giuliano Marchetti, Roberto Pedone, Elisa Francia, Ilaria Mascilini, Franco Marinangeli, Sergio Giuseppe Picardo
Brazilian Journal of Anesthesiology iii Vol. 71, N. 2, Mar–Apr, 2021 Brazilian Journal of Anesthesiology 2021;71(2) 97---99
EDITORIAL The anesthesiologist and the dissatisfied patient
Satisfaction is a sensitive measurement of a well-functioning The records had incomplete information on each case, and service, and applicable to anesthesia. Dealing with dissatis- consequently, many other non-registered variables may have faction is a difficult task, but we must thank patients who, affected patient satisfaction. Even if the exact reasons for with their comments, somehow, contribute to improving our the factors that contributed to dissatisfaction are unknown, activity. After all, any complaint is a feedback. And in a com- the study suggests that there is room for improving our petitive world, there is great value in always offering the specialty.4 best experiences.1 In our daily practice, we rarely find dissatisfied Not perfection, but solving the problem when somet- patients without active surveillance for extracting data on hing goes wrong is what is expected. In fact, in an satisfaction. Although there is a growing number of publi- observational study, 35% of patients reported discomfort cations addressing the issue, most of it is retrospective, and complications related to postoperative side effects, uses non-validated inhouse questionnaires or data stored such as thirst, pain, and drowsiness. However, only 5% of in databases, or face to face postoperative interviews patients reported dissatisfaction with any aspect related with the investigator.5 This caveat must be highlighted, to care provided by an anesthetist.2 This could indicate given that retrospective studies and interviews can con- that patient dissatisfaction is not directly associated with tain confounding factors and biases in answers, because complications.3 patients tend to show more satisfaction when seeking In this issue of BJAN, Okuda et al assessed dissa- healthcare.6 tisfaction with anesthetic care of patients submitted to Many factors contribute to patient satisfaction, inclu- general anesthesia in a Japanese hospital.4 They perfor- ding accessibility and convenience of services, which depend med a retrospective study investigating the dissatisfaction on institutional structures, interpersonal relations, compe- rate for anesthesia and its contributing factors by using a tence of healthcare professionals, patient expectations and questionnaire that included anesthesia-associated adverse preferences, emotional status, severity of disease, previous events and a simplified patient satisfaction scale. Of the experience with anesthesia, professionalism, cleanliness 9,429 patients analyzed, 549 assessed the anesthetic care and quality of hospital facilities, waiting time, medical as unsatisfactory (5.82%). The multivariate analysis identi- costs, and how easy it is to put in a complaint.7,8 fied the presence of a preoperative coexisting condition (OR, Determining surrogate results for anesthesia care- 1.29; 95%CI, 1.05---1.59),combination of regional anesthesia associated patient satisfaction is challenging, and not always (OR, 1.44; 95%CI, 1.10---1.88),self-reported awareness (OR, appropriate. For example, could more empathy in posto- 1.99; 95%CI, 1.29---3.06),postoperative nausea and vomiting perative care influence patient satisfaction more than the (PONV) (OR, 1.54; 95%CI, 1.25---1.90), occurrence of night- reduction in symptoms related to anesthesia complications.3 mares (OR, 1.96; 95%CI, 1.52---2.53), and number of days A study observed that the time spent in communicating required for the postanesthetic visit to be performed by with doctors, carefulness during clinical investigation, and the anesthetist (OR, 1.01; 95%CI, 1.00---1.02)as independent the knowledge of physicians when providing an explanation factors associated with dissatisfaction of the anesthesia ser- on diseases were associated with outpatient satisfaction.9 vice. Moreover, especially for elderly outpatients, a physician- Even if the study was well conducted, it must be read patient relationship of trust, and assertive communication within its limitations, and the major one is the retrospec- would be among the major factors associated with general tive design with data extracted from anesthesia records. satisfaction.10,11 https://doi.org/10.1016/j.bjane.2021.02.028 © 2021 Sociedade Brasileira de Anestesiologia. Published by Elsevier Editora Ltda. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). EDITORIAL
4
By looking at the results of Okuda et al., it seems A Japanese study found 3.9% of dissatisfaction with anest-
reasonable to accept that PONV could be associated with hesia. Dissatisfaction rates were higher among women than
dissatisfaction, given the observation that patients classify among men, and for spinal in comparison to general anest-
12
nausea and vomiting as an undesirable surgical result. hesia, and mainly for patients between 20 and 39 years of
17
Patients with memory of tracheal extubation have shown age.
more dissatisfaction with the anesthesia received. This also A Greek study showed that general patient satisfac-
seems logical, and that the variable should deserve atten- tion with the anesthesia service was high, in the range of
13 18
tion in future studies. The satisfaction of patients has 96.3---98.6%.
grown significantly with the introduction of one postope- A study performed in Brazil with patients submitted to
14
rative visit versus none. In a fast-tracking society, delay in orthopedic surgery showed that male gender, nausea, vomi-
time to post-procedure visits could be a reason for dissatis- ting, pain during hospital stay in the ward, and deeper levels
faction. of sedation were possible predictive factors of lower scores
19
But how can we explain the high rates of self-reported for quality of recovery.
intraoperative awareness and postoperative nightmares To summarize, there is inconsistency regarding patient
based on a questionnaire? The results of this study provide satisfaction studies, which can be explained by differences
important information on the understanding of the levels of in institutional structures, interpersonal relations, compe-
patient dissatisfaction, but well-designed prospective stu- tence of healthcare professionals, culture, education and
dies are needed to define the incidence of intraoperative economic status of different countries, patient expecta-
awareness and nightmares, and the impact on patient well- tions, and preferences and dissimilarities in tools used to
being and satisfaction. collect data.
When we analyze studies published, we can better
understand how challenging surveying surgical patient
Conflicts of interest
satisfaction is. A systematic review studied the level of satis-
faction of outpatient surgery patients and its influencing
The author declares no conflicts of interest.
factors at tertiary Chinese hospitals. The domains studied
more frequently included patient demographics, professio-
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INFOGRAPHIC Who is dissatisfied with anesthesia? Claudia Marquez Simões Hospital Sírio-Libanês,s Servic¸o Médicos de Anestesia, São Paulo, SP, Brazil Available online 10 March 2021
DOI of original article: https://doi.org/10.1016/j.bjane.2021.02.006 ଝ Article reference: C. Okuda, S Inoue, M. Kawaguchi. Anesthesia- related care dissatisfaction: a cohort historical study to reveal related risks. Braz J Anesthesiol. 2021;71;103---109. E-mail: [email protected] https://doi.org/10.1016/j.bjane.2021.03.001 © 2021 Sociedade Brasileira de Anestesiologia. Published by Elsevier Editora Ltda. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). Brazilian Journal of Anesthesiology 2021;71(2) 101---102
INFOGRAPHIC Seven questions in COVID-19 airway management: 5W2H Miguel Ángel Fernández Vaquero a, Laura Reviriego-Agudob, María Gómez-Rojo c, Pedro Charco-Mora d,∗ a Clínica Universidad de Navarra, Departamento de Anestesiología y Cuidados Intensivos, Madrid, Spain. Learning, Teaching and Investigation Difficult Airway Group (FIDIVA) b Hospital Clínico Universitario de Valencia, Servicio de Anestesiología y Reanimación, Valencia, Spain. Learning, Teaching and Investigation Difficult Airway Group (FIDIVA) c Hospital Universitario Ramón y Cajal, Servicio de Anestesiología y Reanimación, Madrid, Spain d Hospital Universitario y Politécnico La Fe, Servicio de Anestesiología y Reanimación, Valencia, Spain. Learning, Teaching and Investigation Difficult Airway Group (FIDIVA)
Available online 19 February 2021
∗ Corresponding author. E-mail: [email protected] (P. Charco-Mora). https://doi.org/10.1016/j.bjane.2020.12.025 © 2021 Sociedade Brasileira de Anestesiologia. Published by Elsevier Editora Ltda. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). M.Á. Vaquero, L. Reviriego-Agudo, M. Gómez-Rojo et al.
In December 2019 a new virus, a novel type of coro- For COVID-19 airway management, we proposed to ask 7 navirus, was reported in Wuhan, Hubei province, China, basic questions in airway management (see Figure), 5W2H, causing Severe Acute Respiratory Failure. This SARS-CoV-2 trying to solve this problem. Why (1), When (2), Who (3), virus was described by the World Health Organization as Where (4), What (5), How (1) and How much (2). COVID-19 for referring to the pathology it caused.1 In August 2020, this virus is a global pandemic that Conflicts of interest affects more than 100 countries worldwide, and Spanish healthcare workers were among the most involved and The authors declare no conflicts of interest. infected worldwide. The numbers in our country are over- whelming: as a November 2020, over 440,000 confirmed cases, over 29,000 casualties, and over 55,000 infected References healthcare professionals. Healthcare staff is more than 20% of the total of the country, being in other countries 1. Orser BA. Recommendations for Endotracheal Intubation of like Italy 10%, and in China or USA approximately 3-4%, COVID-19 Patients. Anesth Analg. 2020;130:1. according to the European Center for Disease Control and 2. Alhazzani W, Møller MH, Arabi YM, et al. Surviving Sepsis Cam- paign: guidelines on the management of critically ill adults Prevention.2 with Coronavirus Disease 2019 (COVID-19). Intensive Care Med. Airway maneuvers have proven to be one of the phases 2020;46:854---87. of greatest contagion exposure for healthcare personnel 3. Martín Delgado MC, Aviles-Jurado FX, Álvarez Escudero J. Doc- (intubation, aspiration of secretions, extubation and tra- umento de consenso de la Sociedad Espanola˜ de Medicina cheostomy). Therefore, we believe it is fundamental to Intensiva, Crítica y Unidades Coronarias (SEMICYUC), la Sociedad standardize the care given to these patients in order to Espanola˜ de Otorrinolaringología y Cirugía de Cabeza y Cuello y reduce mortality and to reduce the number of infected la Sociedad Espanola˜ de Anestesiología y Reanimación (SEDAR) healthcare workers.3 sobre l. Med Intensiva. 2020.
102 Brazilian Journal of Anesthesiology 2021;71(2) 103---109
CLINICAL RESEARCH Anesthesia-related care dissatisfaction: a cohort historical study to reveal related risks
Chie Okuda, Satoki Inoue ∗, Masahiko Kawaguchi
Nara Medical University, Division of Intensive Care, Department of Anesthesiology, Nara, Japan
Received 3 March 2020; accepted 18 October 2020 Available online 3 February 2021
KEYWORDS Abstract Anesthesia Background: Most previous reports have used questionnaires to investigate patient satisfaction department, regarding anesthesia-related care. We retrospectively investigated the dissatisfaction rate for Hospital; anesthesia and the contributing factors for it using a questionnaire including anesthesia-related Patient satisfaction; adverse events and a simplified patient satisfaction scale. Administrative Methods: This is a retrospective review of an institutional registry containing 21,606 anesthesia claims, Healthcare cases. We conducted multivariate logistic analysis in 9,429 patients using the incidence of dis- satisfaction as a dependent variable and other covariates, including items of anesthesia registry and a postoperative questionnaire, as independent variables to investigate factors significantly associated with the risk of dissatisfaction with anesthesia. Results: In the study population, 549 patients rated the anesthesia service as dissatisfactory. Multivariate analysis identified the preoperative presence of coexisting disease [odds ratio (OR), 1.29; 95% confidence interval (CI), 1.05---1.59], combination of regional anesthesia (OR, 1.44; 95% CI, 1.10---1.88),self-reported awareness (OR, 1.99; 95% CI, 1.29---3.06),postoperative nau- sea and vomiting (PONV) (OR, 1.54; 95% CI, 1.25---1.90), occurrence of nightmares (OR, 1.96; 95% CI, 1.52---2.53), and the number of days taken to visit a postoperative anesthesia consul- tation clinic (OR, 1.01; 95% CI, 1.00---1.02)to be independently associated with dissatisfaction with anesthesia service. Conclusions: Patients with coexisting disease, undergoing a combination of regional anesthe- sia, with self-reported awareness, experiencing PONV, suffering from nightmares, and who took longer to visit a postoperative anesthesia consultation clinic tended to rate our anesthesia ser- vice as dissatisfactory. Although the exact reasons for the factors contributing to dissatisfaction are unknown, this study suggests that there is room to improve our service. © 2021 Sociedade Brasileira de Anestesiologia. Published by Elsevier Edi- tora Ltda. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
∗ Corresponding author. E-mail: [email protected] (S. Inoue). https://doi.org/10.1016/j.bjane.2021.02.006 © 2021 Sociedade Brasileira de Anestesiologia. Published by Elsevier Editora Ltda. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). C. Okuda, S. Inoue and M. Kawaguchi
Introduction index monitoring was used; however, this decision was based on the preference of the attendant. Tracheal intubation According to a recent large observational study, 35% of was performed using a Macintosh-type laryngoscope by res- the patients reported severe discomfort related to post- idents under the guidance of the registered (consultant) operative side effects, such as thirst, surgical pain, and anesthetist or by the registered anesthetist. Anesthesia was maintained with sevoflurane (1.5---2%) in a 40% oxy- drowsiness. However, only 5% of the patients reported dis- -1 -1 satisfaction with any aspect of anesthesia-related care.1 gen and air mixture or with propofol (6---10 mg.kg .h ); -1 -1 This may indicate that anesthesia-related complications nitrous oxide was not used. Fentanyl ( 1 --- 2 g.kg .h ) or -1 -1 are not directly associated with patient dissatisfaction remifentanil (0.1---0.2 g.kg .min ) was used for analgesia. Rocuronium (0.2---0.3mg.kg-1.h-1) was used for neuromuscu- or satisfaction regarding anesthesia management. Patient -1 satisfaction is a sensitive measure of a well-functioning lar blockade, and sugammadex ( 2 --- 4 mg.kg ), since August -1 -1 health service system, which is applicable to the anesthesia 2010, or neostigmine (40 g.kg ) plus atropine (20 g.kg ), service.2 However,it is difficult, and not always appropriate, until July 2010, was used for the reversal of neuromuscular to determine surrogate outcomes for patient satisfaction blockade after the evaluation of the neuromuscular block- with anesthesia-related care.2 For example, the amount ade status using a nerve stimulator. In case of management of empathic postoperative care may well have had more by residents, anesthesia management was supervised by influence on patient satisfaction than a reduction in symp- consultant anesthetists, and residents could consult super- toms from anesthesia-related complications.2 Indeed, it has visors at any time. Tracheal extubation was performed been reported that patients usually rate the medical care immediately after patients regained consciousness. Tracheal they receive highly,3 and it has also been suggested that extubations were also performed by residents under the a focus on patient satisfaction may blunt caregiver sensi- guidance of the consultant anesthetist or by the consul- tivity to the need for further improvement.4 Actually, in tant anesthetist. Unless the patient’s trachea was extubated our practice, we seldom encounter patient dissatisfaction in the operating room, patients were transferred to the without attempting to elicit dissatisfaction from patients. intensive care units and managed under mechanical ventila- Paradoxically, it is reasonable to think that there should be tion until tracheal extubation was performed. Occasionally, a proper reasoning that cannot be ignored in expressing their postoperative analgesia was provided with intravenous fen- dissatisfaction. tanyl or epidural ropivacaine combined with fentanyl using Most previous reports have used questionnaires to investi- a patient-controlled analgesia device. After the completion gate patient satisfaction regarding anesthesia-related care. of anesthesia, the attendant in charge filled out the form However, in this situation, we do not think that dis- for the institutional registry of anesthesia, which included satisfaction is the reciprocal of ‘‘satisfaction’’ because the following information: the attendant’s name, name of questionnaires usually include a choice of ‘‘even,’’ regard- the person who performed the intubation, patient’s demo- ing satisfaction or dissatisfaction. Therefore, we need to graphic variables, information on the final diagnosis and surgical procedures (later categorized into three classes thoroughly investigate the rate of dissatisfaction with the 5 anesthesia service. In this study, we retrospectively inves- based on the modified surgical risk stratification), back- tigated the dissatisfaction rate for anesthesia-related care, ground illnesses (hypertension, diabetes mellitus, coronary as well as the factors contributing to dissatisfaction, using artery disease, history of heart failure, and lung disease), a questionnaire including anesthesia-related adverse events duration of anesthesia and surgery, American Society of and a simplified patient satisfaction scale. Anesthesiologists (ASA) physical status, urgency of surgery (emergency or elective), anesthesia technique (inhala- tional or intravenous with or without regional analgesia), Methods intraoperative patient positioning, final airway assessment, requirement of transfusion, implementation of postopera- Approval for the review of patient clinical charts, for access tive analgesia, requirement of postoperative intensive care, to data of the institutional registry of anesthesia, and for and adverse intraoperative events, including cardiac events, reporting of the results was obtained from the Institutional hypotension, arrhythmia, and hypoxia. The attendant in Review Board. The requirement for written informed con- charge of the case also followed up the patient and recorded sent was waived by the Institutional Review Board (No. 1428 any complications, including any unpleasant experience approved on Dec-19-2016 and revised on Aug-23-2019). with anesthesia, over several postoperative days. In addi- tion, as a general institutional rule, the patients visited the Perioperative patient treatment postoperative anesthesia consultation clinic by hospital dis- charge and completed a questionnaire using a self-report No standardization was conducted for the methods of form; the questionnaire included items on tooth injury, post- induction and maintenance of anesthesia. However, the operative nausea and vomiting, sore throat, hoarseness, methods of anesthesia did not differ significantly as this occurrence of nightmares, recall of extubation, and intra- study was performed in only one hospital. No premedica- operative awareness. Patients were also requested to rate tion was used, and general anesthesia was usually induced our perioperative care using a simplified patient satisfaction with intravenous propofol (1---2.5 mg.kg-1) plus either fen- scale (very satisfactory, satisfactory, even, and dissatisfac- tanyl ( 1 --- 2 g.kg-1) or remifentanil (0.2---0.3 g.kg-1.min-1). tory). We also recorded how many days had passed since the Moreover, neuromuscular blockade was achieved with operative day when the patient visited the postoperative rocuronium (0.6---0.9 mg.kg-1). In most cases, bispectral anesthesia consultation clinic.
104 Brazilian Journal of Anesthesiology 2021;71(2) 103---109
using Pearson or Spearman coefficient matrix correlation, respectively. Discrimination of the final model for dissatis- faction was assessed using the likelihood-ratio test. The area under the receiver operating characteristic (ROC) curve was calculated to assess the performance of the model. Calibra- tion of the model was tested using the Hosmer---Lemeshow statistic. The statistical model was then tested on the vali- dation dataset. In short, calculation of predicted risk using the validation cohort data with logistic regression coef- ficients from the derivation dataset was performed. The ROC curve was calculated to assess the performance of the model. Analyses were computed using the MedCalc sta- tistical package (version 18.11.6, MedCalc Software bvba, Ostend, Belgium). p < 0.05 was considered statistically sig- nificant.
Results
We analyzed data from 9,429 patients, of whom 549, rep- resenting 5.82% of the overall population, were found to Figure 1 Flow diagram for patient inclusion and exclusion. rate our service as dissatisfactory. Patient data and periop- erative characteristics were compared between patients in Data handling both categories (Table 1). Univariate analysis revealed that older age, presence of coexisting disease, postoperative ICU admission, use of inhalational anesthetics, combina- Data were collected between January 2009 and December tion of regional anesthesia, difficult airway, self-reported 2013, during which period there were 21,606 anesthesia intraoperative awareness, memory of extubation, dental cases. The exclusion criteria for the current study (and the injury, PONV, hoarseness, sore throat, postoperative pain, reasons for consequent reductions in eligible patients) were occurrence of nightmares, and longer time taken to visit as follows: (1) cases without general anesthesia (n = 2,588), the postoperative anesthesia consultation clinic were can- (2) cases missing a history of visiting the anesthesia consul- didates associated with dissatisfaction with our anesthesia tation clinic or those who were unable to answer the service for the next multivariate analysis. No collinearity questionnaire due to disturbance of cognitive dysfunction was observed between any of the variables. (n = 2,004), (3) cases < 15 years old (n = 1,543), and (4) Multivariate analysis in the derivation cohort (n = 7544) cases missing anesthesia registry data sets or answers on revealed that preoperative presence of coexisting disease the postoperative questionnaire (n = 6,042) (Figure 1). (OR, 1.29; 95% CI, 1.05---1.59), combination of regional anesthesia (OR, 1.44; 95% CI, 1.10---1.88), self-reported Statistical analysis awareness (OR, 1.99; 95% CI, 1.29---3.06), PONV (OR, 1.54; 95% CI, 1.25---1.90), occurrence of nightmares (OR, 1.96; Continuous variables are presented as mean ± standard 95% CI, 1.52---2.53), and days taken to visit the consulta- deviation if normally distributed or median and interquartile tion clinic (OR, 1.01; 95% CI, 1.00---1.02)were independently range if nonparametric. Categorical variables are presented associated with dissatisfaction with our anesthesia service as the number of patients. In the study cohort (9,429 (Table 2). Discrimination of the final models, assessed by patients), univariate analysis was used to identify factors the likelihood-ratio test, was significant for these varia- associated with dissatisfaction. Four fifths (n = 7,544) of the bles (p < 0.001). Hosmer---Lemeshow analysis suggested study participants were randomly assigned into the model an acceptable calibration (p = 0.900). The explanatory derivation cohort and reserved one-fifth (n = 1,885) for inter- model based on these variables had an area under the nal validation. We conducted multivariate logistic analysis receiver operating characteristic curve of 0.628 (95% CI, in the derivation cohort using the incidence of dissatisfac- 0.617---0.639) (Figure 2A). Figure 2B shows the calculated tion as a dependent variable and other covariates, including ROC curve using the validation cohort data with logistic items of anesthesia registry and the postoperative question- regression coefficients from the derivation dataset. The area naire, as independent variables in order to investigate the under the curve (AUC) was 0.621 (95% CI, 0.599---0.643), factors that were significantly associated with the risk of which was thus very similar to the AUC from the derivation dissatisfaction with the anesthesia service. Candidate fac- cohort. tors with a significant univariate association (p < 0.2) with A post hoc power calculation was conducted for this dissatisfaction were used to perform multivariable logistic forced-entry multivariable logistic regression model using regression analysis by forced-entry methods. All candidate 15 variables. We followed standard methods to estimate variables were entered in the initial model and presented the sample size for multivariable logistic regression, with at as adjusted odds ratios (ORs) with 95% confidence intervals least ten outcomes required for each included independent (CI). Interactions between variables were systematically variable.6 With an incidence of dissatisfaction of 549/9,429 searched, and collinearity was considered for r or rho > 0.8 (5.82%) in this population, we required 2,577 patients to
105 C. Okuda, S. Inoue and M. Kawaguchi
Table 1 Results of univariate analyses.
Dissatisfaction (n = 549) No dissatisfaction (n = 8,880) p-value Age (years) 57.5 (17.8) 58.8 (17.2) 0.093a Sex (M/F) 246/303 4170/4710 0.333 Hight (cm) 159.4 (9.2) 160.0 (9.2) 0.438 Weight (kg) 58.1 (12.9) 58.6 (12.5) 0.450 ASA physical status (1-5) 2 (1-2) 2 (1-2) 0.326 Coexisting disease (Y/N) 336/213 4948/3932 0.013a Duration of anesthesia (min) 251 (149) 255 (152) 0.473 Duration of surgery (min) 187 (137) 192 (140) 0.433 Surgical intensity (1-3) 2 (2-2) 2 (2-2) 0.931 Emergency (Y/N) 82/467 1230/7650 0.484 ICU admission (Y/N) 116/433 1625/7255 0.1a Inhalational anesthesia (Y/N) 413/136 6943/1937 0.111a Postoperative analgesia (Y/N) 166/383 2887/5993 0.28 Combination of regional anesthesia (Y/N) 127/422 1738/7142 0.047a Surgical posture (Supine) (Y/N) 442/107 7035/1845 0.515 Resident management (Y/N) 308/241 5083/3797 0.625 Difficult airway (Y/N) 25/524 298/8582 0.145a Transfusion (Y/N) 73/476 1190/7690 1 Intraoperative adverse event (Y/N) 3/546 28/8852 0.424 Self-reported awareness (Y/N) 34/515 277/8603 < 0.0001a Memory of extubation (Y/N) 55/494 650/8230 0.024a Dental injury (Y/N) 8/541 80/8800 0.172a PONV (Y/N) 180/369 2091/6789 < 0.0001a Hoarseness (Y/N) 253/296 3476/5404 0.0013a Sore throat (Y/N) 253/296 3534/5346 0.004a Postoperative pain (Y/N) 399/150 6056/2824 0.029a Nightmare (Y/N) 112/437 901/7979 < 0.0001a Time taken for postoperative anesthesia 9.2 (8.5) 8.3 (7.1) 0.007a consultation clinic (day)
ASA, American Society of Anesthesiologists; ICU, intensive care unit; PONV, postoperative nausea and vomiting. Variables are expressed as number of patients, Mean (SD) or Median (IQR). a Variables marked with an asterisk were entered into the logistic regression model.
Table 2 Results of multivariate analysis in the derivation cohort (n = 7,544).
Variables Odds ratio 95% CI p-value Age (years) 0.99 0.99-1.001 0.334 Coexisting disease 1.29 1.05-1.59 0.014 ICU admission 1.00 0.74-1.35 0.975 Inhalational anesthesia 0.86 0.68-1.08 0.197 Combination of regional anesthesia 1.44 1.10-1.88 0.007 Difficult airway 1.45 0.84-2.49 0.180 Self-reported awareness 1.98 1.29-3.06 0.002 Memory of extubation 0.98 0.69-1.39 0.896 Dental injury 1.54 0.72-3.32 0.265 PONV 1.54 1.25-1.90 0.0001 Hoarseness 1.15 0.93-1.42 0.186 Sore throat 1.12 0.91-1.38 0.299 Postoperative pain 1.19 0.95-1.49 0.124 Nightmare 1.96 1.52-2.53 < 0.0001 Time taken for postoperative anesthesia 1.01 1.00-1.02 0.026 consultation clinic(day)
ICU, intensive care unit; PONV, postoperative nausea and vomiting.
106 Brazilian Journal of Anesthesiology 2021;71(2) 103---109
Figure 2 Receiver-operating characteristic (ROC) curves. A, the ROC curve of the 7,544 patients of the derivation data set; B, the ROC curve of the 1,885 patients of the validation data set. perform accurate multivariable logistic regression with ten A nightmare is an unpleasant dream that can cause a variables, which demonstrates that our sample size was suf- strong emotional response, typically fear but also despair, ficient to build the model. anxiety, and great sadness, from the mind. The dream may contain situations of discomfort, or psychological or physi- cal terror. Sufferers often awaken in a state of distress and may be unable to return to sleep for an extended period.13 Discussion A nightmare is a type of sleep disorder13; thus, it is rea- sonable to suppose that nightmares can affect a patient’s This study demonstrated that cases with coexisting dis- quality of life during his/her hospital stay, which can also ease, undergoing a combination of regional anesthesia, with cause dissatisfaction with our anesthesia service. The actual self-reported awareness, experiencing PONV, suffering from question regarding nightmares at the postoperative anes- nightmares, and who took longer to visit the postoperative thesia consultation clinic was ‘‘Have you had a terrifying or anesthesia consultation clinic were all prone to rating our deeply upsetting dream postoperatively?’’. Regarding this anesthesia service as dissatisfactory. Interestingly, it seems question, the time and place were not considered, and the that patients did not really mind who (residents or anes- nightmare incidence was determined by referring to the thetists) provided the anesthesia. patient’s report. Regarding PONV, it has been previously reported that We found that preoperative coexisting disease was asso- patients continue to rank nausea/vomiting as their most ciated with dissatisfaction with our anesthesia service. undesirable surgical outcome.7 Therefore, it is easy to It has been previously suggested that patients frequently understand that the presence of PONV was one of the leading complained of receiving inconsistent information, had dif- causes of dissatisfaction with our anesthesia service. ficulty in obtaining information, and also had an untimely The preface of the Fifth National Audit Project (NAP 5) communication of information.14 The presence of coexist- report states that intraoperative awareness is an intraop- ing disease can make informed consent more severe, which erative complication greatly feared by patients and is a may increase the opportunities to encounter such situa- concern raised frequently during preoperative visits.8 Thus, tions. It has been also suggested that the leading causes it is also easy to understand that self-reported awareness of patient complaints were unprofessional conduct, poor caused dissatisfaction with our anesthesia service. In this provider---patient communication, patient treatment and connection, the incident rate of awareness in our population care, and having to wait for care.15 The presence of coex- was 3.4%, which is up to 30-fold higher than the previ- isting disease should increase the frequency of preoperative ous reports.9 We included all self-reported intraoperative extra medical examinations, which may also increase the awareness cases based on questionnaires, but without any opportunities to encounter such situations. specific validation in our analysis. Therefore, it is highly It has been reported that patients who preferred gen- probable that the majority of our awareness cases were eral anesthesia over regional anesthesia, or those who were not true intraoperative awareness cases, which means that scheduled to undergo regional anesthesia, expressed more such patients might have mis-imagined their experience fear of suffering back pain and of needle puncture.16,17 The of anesthesia as a result of dreaming either intraopera- results also suggested that patients are unaware of the real tively or postoperatively.10,11 We previously investigated the risks and benefits of regional anesthesia. In addition, as factors associated with self-reported awareness.12 In this mentioned above, patients frequently complain of having investigation, we found that higher ASA physical status and received inconsistent information.14 Their actual percep- emergency case were positively, and application of postop- tion of regional anesthesia might have been different from erative analgesia was negatively associated with incidence their expectation, even though they endured fear of needle of self-reported awareness.12 puncture.
107 C. Okuda, S. Inoue and M. Kawaguchi
Interestingly, the longer time taken to visit the post- riencing PONV, suffering from nightmares, and who took operative anesthesia clinic, the higher was the proportion longer to visit the postoperative anesthesia consultation of patients who rated our anesthesia service as dissatisfac- clinic tended to rate our anesthesia service as dissat- tory was. It has been reported that the level of satisfaction isfactory. Although the exact reasons for these factors with the continuity of personal care from the anesthetist contributing to patient dissatisfaction remain unknown, this was significantly increased by the introduction of a sin- study suggests that there is room to improve our service. gle postoperative visit by the anesthetist compared with What is known no visit, although the overall satisfaction with anesthesia ‘‘Dissatisfaction’’ is not the reciprocal of ‘‘satisfaction’’. was unchanged.18 It has also been reported that one of the Considerable rates of the patients reported severe dis- predictors for anesthesia satisfaction was having received comfort related to postoperative side effects; however, more than two anesthesiologist visits after surgery.19 This few patients reported dissatisfaction with any aspect of topic may still be a matter of debate,20 no contact with anesthesia-related care. patients for a longer period may mean poor provider---patient What is new communication, which is one of main causes for patient We investigated the rate of dissatisfaction with the dissatisfaction.15 In our hospital, the attendant in charge anesthesia service. Coexisting disease, regional anesthesia, of the case visited and followed up the patient postoper- self-reported awareness, PONV,nightmares, and longer peri- atively, but not officially, which means it was not clinical ods until visiting a postoperative anesthesia consultation routine task. Thus, it may be important for anesthesiolo- clinic may dissatisfy patients undergoing general anesthesia. gists to officially visit patients at postsurgical wards in cases where it is difficult to ensure an early consultation clinic Conflicts of interest visit. The current study has several limitations that merit dis- cussion. First, this study was retrospective in nature; thus, The authors declare no conflict of interest. unmeasured variables could still confound the results. We used data from the institutional registry of anesthesia, References which includes minimal essential information about each case, but does not include precise details. Therefore, we 1. Walker Emk, Bell M, Cook Tm, et al. Central SNAP-1 Organ- did not obtain several variables which might have affected isation; National Study Groups. Patient reported outcome of patient dissatisfaction. For example, it was reported that adult perioperative anaesthesia in the United Kingdom: a cross- anxiety and discomfort due to thirst and drowsiness were sectional observational study. Br J Anaesth. 2016;117:758---66. most frequently cited as the worst aspect of the periop- 2. Heidegger T, Saal D, Nübling M. Patient satisfaction with anaes- erative experience.1 However, our study did not include thesia - Part 1: satisfaction as part of outcome - and what these items. Second, this study relied on patient self-reports satisfies patients. Anaesthesia. 2013;68:1165---72. to determine symptoms, which were based on memory. It 3. Ware JE, Hays RD. Methods for measuring patient satisfaction has been reported that prospective methods using ques- with specific medical encounters. Med Care. 1988;26:393---402. 4. Goldwag R, Berg A, Yuval D, et al. Predictors of patient dissat- tionnaires detect substantially more unpleasant events than 20 isfaction with emergency care. Isr Med Assoc J. 2002;4:603---6. approaches based on spontaneous patient reports, which 5. Eagle KA, Berger PB, Calkins H, et al. American College of may explain the relatively higher incidences of postopera- Cardiology/American Heart Association Task Force on Practice tive anesthesia-related complications in our population. It Guidelines (Committee to Update the 1996 Guidelines on Peri- cannot be denied that these recalls of anesthesia-related operative Cardiovascular Evaluation for Noncardiac Surgery). complications could have affected the patients’ rating of ACC/AHA guideline update for perioperative cardiovascular our service. Third, a considerable number of patients were evaluation for noncardiac surgery-executive summary a report excluded from the study. However, the excluded patients of the American College of Cardiology/American Heart Associ- might not have affected the results because the exclusion ation Task Force on Practice Guidelines (Committee to Update was performed according to the objective criteria, and the the 1996 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery). Circulation. 2002;105:1257---67. missing data were at least missing at random. Forth, there 6. Peduzzi P, Concato J, Kemper E, et al. A simulation study of the should have been some deviations from our institutional number of events per variable in logistic regression analysis. J anesthesia protocol because the methods of anesthesia were Clin Epidemiol. 1996;49:1373---9. basically left to the preference of the anesthesia attendant. 7. Macario A, Weinger M, Carney S, et al. Which clinical anesthesia However, our hospital is a teaching hospital. Therefore, it is outcomes are important to avoid? The perspective of patients. reasonable to think that the deviation from the standard Anesth Analg. 1999;89:652---8. protocol was not so large even though there had been some 8. Van Besou J-P, Harrop-Griffith W, O’Sullivan EP. Chapter 1 Fore- deviations. Lastly, our study represents an audit of clinical word. In: Pandit JJ, Cook TM, editors. NAP5 5th National Audit practice at an individual institution, and our findings might Project of The Royal College of Anaesthetists and the Associ- not be generalizable to the practice of anesthesiology as a ation of Anaesthetists of Great Britain and Ireland. Accidental Awareness during General Anaesthesia in the United Kingdom whole. and Ireland. London: The Royal College of Anaesthetists; 2014. p. 9---10. 9. Pandit JJ, Andrade J, Bogod DG, et al. Royal College of Anaes- Conclusions thetists and the Association of Anaesthetists of Great Britain and Ireland. The 5th National Audit Project (NAP5) on acci- Patients with coexisting disease, undergoing a combination dental awareness during general anaesthesia: summary of main of regional anesthesia, with self-reported awareness, expe- findings and risk factors. Anaesthesia. 2014;69:1089---101.
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10. Leslie K, Skrzypek H, Paech MJ, et al. Dreaming during anes- 15. Montini T, Noble AA, Stelfox HT. Content analysis of patient thesia and anesthetic depth in elective surgery patients: a complaints. Int J Qual Health Care. 2008;20:412---20. prospective cohort study. Anesthesiology. 2007;106:33---42. 16. Lavado JS,Gonc¸ alves D, Gonc¸alves L, et al. General or 11. Leslie K, Sleigh J, Paech MJ, et al. Dreaming and elec- regional? Exploring patients’ anaesthetic preferences and per- troencephalographic changes during anesthesia maintained ception of regional anaesthesia. Rev Esp Anestesiol Reanim. with propofol or desflurane. Anesthesiology. 2009;111: 2019;66:199---205. 547---55. 17. Bheemanna NK, Channaiah SRD, Gowda PKV, et al. Fears and 12. Takechi A, Inoue S, Kawaguchi M. Anaesthesia management by Perceptions Associated with Regional Anesthesia: A Study from residents does not alter the incidence of self-reported anaes- a Tertiary Care Hospital in South India. Anesth Essays Res. thesia awareness: A teaching hospital-based propensity score 2017;11:483---8. analysis. Anaesth Crit Care Pain Med. 2019;38:63---8. 18. Saal D, Heidegger T, Nuebling M, et al. Does a postoperative 13. Reynolds CFIII, O’Hara RM, Morin CM, et al. Nightmare Disorder. visit increase patient satisfaction with anaesthesia care? Br J In: The DSM-5 Task Force. Diagnostic and Statistical Manual of Anaesth. 2011;107:703---9. Mental Disorders. 5th ed. Virginia: American Psychiatric Associ- 19. Capuzzo M, Gilli G, Paparella L, et al. Factors predic- ation; 2013. p. 404---7. tive of patient satisfaction with anesthesia. Anesth Analg. 14. Mattarozzi K, Sfrisi F, Caniglia F, et al. What patients’ complaints 2007;105:435---42. and praise tell the health practitioner: implications for health 20. Mashour GA, Avidan MS. Intraoperative awareness: contro- care quality. A qualitative research study. Int J Qual Health versies and non-controversies. Br J Anaesth. 2015;115 Suppl Care. 2017;29:83---9. 1:20---6.
109 Brazilian Journal of Anesthesiology 2021;71(2) 110---115
CLINICAL RESEARCH Analysis of publication speed of anesthesiology journals: a cross-sectional study
Chitta Ranjan Mohanty a, Snigdha Bellapukonda b,∗, Manisha Mund b, Bikram Kishore Behera b, Soumya Swaroop Sahoo c
a All India Institute of Medical Sciences, Department of Trauma and Emergency, Bhubaneswar, India b All India Institute of Medical Sciences, Department of Anaesthesiology and Critical Care, Bhubaneswar, India c All India Institute of Medical Sciences, Department of Community and Family Medicine, Bathinda, India
Received 9 April 2020; accepted 8 December 2020 Available online 19 February 2021
KEYWORDS Abstract Anesthesiology; Background: Publication speed is one of the critical factors affecting authors’ preference to a Bibliometric analysis; journal for manuscript submission. The publication time of submitted manuscripts varies across Peer review; journals and specialty. Journal Impact Factor Objectives: Several bibliometric studies in various fields of medicine, except in anesthesiology, have addressed the issue of publication speed and factors that influence the publication speed. We aimed to identify factors affecting the publication speed of indexed anesthesiology journals. Method: Overall, 25 anesthesiology journals indexed in MEDLINE database were retrospectively analyzed for the time required during different stages of publication process. A total of 12 orig- inal articles published in the year 2018 were randomly selected from each journal based on the number of issues. Time periods from submission to acceptance and from submission to publi- cation were noted, and their association with impact factor (IF), advanced online publication (AOP), and article processing charges (APCs) were evaluated. Results: The median time from submission to acceptance and from submission to publication for the selected journals were 120 (IQR [83-167]) days and 186 (IQR [126-246]) days, respectively. Publication speed was not found to have any correlation with IF and APC. However, journals with AOP required significantly lesser time for publication than those without AOP 138.5 and 240 days, respectively, (p = 0.011). Moreover, the IF of journals with AOP was significantly higher than that of journals without AOP (p = 0.002). Conclusion: The study provides an overview of total time required for peer review, acceptance, and publication in indexed anesthesiology journals. Researchers should focus on journals with AOP for expediting the publication process and avoiding publication delays. © 2021 Published by Elsevier Editora Ltda. on behalf of Sociedade Brasileira de Anestesiologia. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/ licenses/by-nc-nd/4.0/).
∗ Corresponding author. E-mail: [email protected] (S. Bellapukonda). https://doi.org/10.1016/j.bjane.2021.02.025 © 2021 Published by Elsevier Editora Ltda. on behalf of Sociedade Brasileira de Anestesiologia. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). Brazilian Journal of Anesthesiology 2021;71(2) 110---115
Introduction 6 issues per year. Furthermore, the journals were catego- rized based on IF into four groups: less than 1, between 1 To select a journal for the submission of a scientific arti- and 2, between 2 and 3, and more than 3 to compare the cle for publication, authors consider several factors such publication speed. as acceptance rate, impact factor (IF), review and publica- tion speed, along with the reach and readership of journals. Statistical analysis The publication speed is often correlated to the publica- 1 tion efficiency, and publication time varies across journals Statistical analysis was performed using R version 3.6.1, a 2,3 and specialty. Availability of the online manuscript sub- software for statistical computing and graphics (The R foun- mission system and electronic-only form of various journals dation, Vienna, Austria). Categorical variables are expressed 2,3 has decreased the time from submission to publication. In as frequency or percentages. The data were analyzed for addition to editorial policy and procedures, the number of normality by using the Shapiro---Wilks test. Numerical varia- submitted articles also affects the publication speed. bles are expressed as median ± interquartile range (IQR). Several bibliometric studies in various disciplines have The Mann---WhitneyU test and Kruskal---Wallis test were per- addressed the issue of publication speed and factors affect- formed to compare two and more than two independent 4 --- 6 ing the publication speed. To the best of our knowledge, groups, respectively. Pearson’s correlation was used to ana- none of these studies have been conducted in the field of lyze the correlation between numerical variables. A p-value anesthesiology. This study aimed to retrospectively analyze of < 0.05 was considered statistically significant (Supplemen- the publication speed of indexed anesthesiology journals tary File 1). and the factors affecting the publication speed. Results Methods Figure 1 represents the flow diagram of the included and This cross-sectional study was conducted for anesthesiology excluded journals and factors analyzed in the study. Over- journals published in 2018, and the study period was from all, 25 journals were included for the final analysis, and July 2019 to September 2019. Time taken for the accep- 289 original articles were evaluated for dates of submission, tance and publication of original articles by the journals acceptance, and online/print publication. Of the total, 7 were considered as primary outcome measures. Anesthesi- (28%) journals were found to provide information on APC. ology journals indexed in the MEDLINE database 2018 and Information obtained from journal websites indicated the publishing original articles in the field of anesthesiology availability of publication statistics for 7 journals (28%), were included in the study. The exclusion criteria for journal which provided information on publication speed. Table S1 selection were as follows: published content related exclu- presents the information on peer review and submission to sively to ‘‘pain’’ or ‘‘critical care’’, journals publishing only publication time along with bibliometric parameters of the review articles and case reports, and journals with unavail- included journals. The medians (IQR) of SA and SP (in days) ability of data regarding the date of submission, acceptance, of all the journals were 120 (83---167) and 186 (126---246) and online publication/print publication. Based on these days, respectively. Table 1 presents the results of compari- exclusion criteria, we shortlisted 25 journals for analysis. son of SA and SP between journals with and without AOP and A set of 12 articles published in 2018 were randomly between journals with and without APC. The comparison of selected from each journal. The selection of articles was SA and SP between journals with respect to the number of based on the number of issues published in 2018. For exam- issues is shown in Table 2. Figure 2 (A---D)represents the box ple, 1 article was selected from each issue from a journal plot depicting the comparative publication timings with fac- with 12 issues per year, 2 articles from a journal with 6 issues tors such as APC, IF,number of issues published per year, and per year, and 3 articles from a journal with 4 issues per AOP. year. For a journal publishing less than 12 original articles No correlation was found between SA and IF (r = 0.153, per year, all the articles were included in the study. The p = 0.464) and between SP and IF (r = -0.0878; p = 0.676). selection of 12 articles from each journal was performed The median SP of journals having IF less than 1, between using computer-generated random number technique to 1 and 2, between 2 and 3, and more than 3 was 202, 152, avoid selection bias. The dates of submission, receiving the 138, and 245 days, respectively (p = 0.76). Figure 3 shows revised version, acceptance, and publication (online) were the scatter plot depicting the relation of SP and SA with obtained from the selected articles and recorded in the data IF. Figure 4 shows the boxplot depicting a comparison of IF extraction sheet. In case the option for online publication between journals with or without AOP. The IF of journals was not available, the date for print publication was con- with AOP was significant higher IF than those without AOP sidered. Data on IF, advanced online publication (AOP), and (median 0.22 vs. 1.619; p = 0.002). article processing charges (APCs) were obtained from the journal website. The acceptance time or peer review time has been defined as the interval between the date of sub- Discussion mission to the date of acceptance (SA). The publication time has been defined as the interval between the date of submis- Bibliographic parameters of journals are pivotal not only for sion and the date of online publication (SP). All the included the beginners but also for the established authors in their journals, based on their publication frequency, were cate- respective fields. In our study, the time from submission gorized into four groups: less than 4, 4, 6, and more than to publication was found to be less for journals with AOP.
111 C.R. Mohanty, S. Bellapukonda, M. Mund et al.
Assessed for eligibility
Anaesthesiology Journals selected from Enrollment MEDLINE database
(n = 120)
Journals Excluded (n = 95)
♦ Not meeting inclusion criter ia (n = 27)
♦ Journals without availability of data
(date of received, date of acceptance and date of publica on) (n = 68)
Journals included for analysis (n=25)
Journals with < 4 Journals with 4 issues Journals with 6 issues Journals with > 6 issues per year per year per year issues per year (n = 6) (n = 5) (n = 8) (n = 6)
Analysis
Time of acceptance Advance Article No of issues onli ne Impact factor Time of publication processing per year Time publication charge
Figure 1 Flow diagram of the included and excluded journals.
Table 1 Comparison of SA and SP between journals with and without AOP and journals with and without APC is shown.
Time period Article with Article without p-value Article with APCd Article p-value AOP AOPc m m without APC median time edian time edian time median time period (days) period (days) period (days) period (days) SAa 107.5 142.75 0.441 111.75 121 0.832 SPb 138.5 240 0.011 193.5 157 0.544
a Submission to acceptance time. b Submission to publication time. c Advanced online publication time. d Article processing charges.
The publication time was not affected by the number of Asaad et al. conducted an observational study to ana- issues per year or the IF of the journal. Moreover, contrary lyze the time required from submission to acceptance and to the common notion, the publication time was not less for to online and print publications in six plastic surgery jour- journals with APCs. nals during 2018. They concluded that the median time
112 Brazilian Journal of Anesthesiology 2021;71(2) 110---115
Table 2 Comparison of SA and SP of journals having less than four issues per year, four issues per year, six issues per year and more than six issues per year is shown.
Time period < Four Four Six > Six p-value issues/year m issues/year issues/year issues/year edian time median time median time median time period (days) period (days) period (days) period (days) SAa 107.5 142.5 120 140.5 0.731 SPb 139 224 196 130 0.337
a Submission to acceptance time. b Submission to publication time.
Figure 2 A, Box plot depicting the submission to publication time (SP) in days (median ± IQR) of journals with article processing charges (APC-1) and without APC (0). B, Box plot depicting SP in days (median ± IQR) of journals with impact factor (IF) [IF-0 (IF < 1), IF-1 (IF between 1---2),IF-2 (IF between 2---3),IF-3 [IF > 3]) (APC-1). C, Box plot depicting SP in days (median ± IQR) of journals with number of issues per year (Issues 0: < 2 issues/year, Issues 1: 2 issues/year, Issues 2: 4 issues/year, Issues 3: > 4 issues/year). D, Box plot depicting SP in days (median ± IQR) of journals with APC-1 and without APC (0). from submission to in-print publication, from submission et al. reported that the peer review process increases the to acceptance, and from acceptance to publication was publication time.8 In this study, the median peer review 10.3 months (IQR 8---12.6), 4.6 months (IQR 3---6.8), and 5.4 time was 120 days. In a study conducted by Chen et al., months (4.2---6.3), respectively.5 Stamm et al. conducted a which included 51 ophthalmic journals, the median peer retrospective analysis in head and face medicine for one review time was 133 days and the time from submis- year and concluded that mean peer review time is 37.8 sion to publication was 233 days.2 Shah et al. conducted days and the mean time from submission to acceptance an observational study on biomedical Indian journals and is 95.9 days. The total time from submission to publi- reported that the median peer review time is 143.5 cation was found to be 99.3 days in the study.7 Wyness days.3
113 C.R. Mohanty, S. Bellapukonda, M. Mund et al.
Figure 3 A, Scatter plot depicting the correlation between IF and submission to acceptance time (SA); B, Scatter plot depicting the correlation between IF and SP.
Figure 4 Box plot depicting the effect of IF on advanced online publication (AOP).
The option of AOP is increasingly being provided by var- tronic publication decreases the time from acceptance to ious journals worldwide to allow rapid access of research publication.9 material to readers. Thus, the prospect of AOP facilitates APC is levied to help journals cover the publication- the dissipation of research work and hence evidence-based associated costs and those incurred by editorial and peer healthcare. In this study, AOP significantly influenced the review systems. It is a debatable topic regarding the dis- total time from submission to publication. However, the semination of research work. In our study, the SP time was time from submission to acceptance, which is a surro- not shown to be affected by APC (p = 0.54). Hence, we con- gate indicator of the review process, was not found to firm that the publication speed remains unaffected by APC be influenced by AOP. Shah et al. conducted a study (Fig. 2). on the Indian biomedical journals cited in the Jour- The IF was considered an important surrogate indicator nal Citation Report of 2013 and reported that AOP is for the performance of journals; however, its fallacies were an excellent option to improve the publication speed of proven later.10,11 It is influenced by various factors related journals.3 Additionally, Bagla et al. mentioned that elec- to author and journal metrics. We compared the effect of IF
114 Brazilian Journal of Anesthesiology 2021;71(2) 110---115 on the time from submission to publication. With increase for rapid publication, which will help in individual progress in IF, SP time was found to decrease. However, the jour- and research appraisal. nals with the highest IF ultimately had the longest SP time. Timely dissemination of research findings plays an essen- This may indicate the high standard of scrutiny of journals tial role in evidence generation. Hence, there should be a with high IFs and the workload owing to the submission of concerted effort between publishers and authors to identify a large number of manuscripts. Kalcioglu et al. conducted the bottlenecks and reduce avoidable delays in the publi- a study on otorhinolaryngology journals from 1999 to 2013 cation process. Provision of services such as AOP will be of and reported similar results in relation to IF. An increase substantial help because they expedite the overall publica- in the number of issues along with the option of AOP may tion process. decrease this time. Chen et al. conducted a similar study on ophthalmology journals and concluded that IF does not Conflicts of interest affect the publication speed and that the availability of AOP significantly increases the publication speed.2 Shah et al., The authors declare no conflicts of interest. in their study on biomedical journals, concluded that IF does not affect the publication speed.3 These results are consistent with that of the present study. In this study, Appendix A. Supplementary data the journals with AOP were found to have a significan- tly higher IF than those without AOP (p = 0.002). These Supplementary material related to this article can be found, findings are consistent with those reported by Chen et al. in the online version, at doi:https://doi.org/10.1016/ (p = 0.015).2 j.bjane.2021.02.025. We analyzed the effect of the number of issues of a jour- nal per year on SP time. The SP time of the journals, except References for those with 2 issues per year (139 days), was found to decrease with increase in the number of issues per year; 1. Solomon DJ, Björk BC. Publication fees in open access publish- however, the association was not statistically significant (p ing: Sources of funding and factors influencing choice of journal. = 0.33). The result suggests that the number of issues per J Am Soc Inf Sci Techno. 2012;63:98---107. year may not help in increasing the publication speed. Con- 2. Chen H, Chen CH, Jhanji V. Publication times, impact factors, versely, Kalcioglu et al. stated that the publication time and advance online publication in ophthalmology journals. Oph- might be decreased by increasing the number of issues, par- thalmology. 2013;120:1697---701. ticularly in high IF journals.6 3. Shah A, Sherighar SG, Bhat A. Publication speed and advanced Our study has certain limitations. The subject area was online publication: Are biomedical Indian journals slow? Per- spect Clin Res. 2016;7:40. limited exclusively to anesthesiology, and journals related 4. Gordon D, Cooper-Arnold K, Lauer M. Publication speed, to critical care and pain medicine were excluded. Only orig- reporting metrics, and citation impact of cardiovascular trials inal articles were considered to maintain uniformity; these supported by the National Heart, Lung, and Blood Institute. J articles mostly have a universal format (IMRaD) and are strin- Am Heart Assoc. 2015;4:e002292. gently peer reviewed. However, the publication speed of 5. Asaad M, Rajesh A, Banuelos J, et al. Time from submis- other article types was not assessed. Additionally, journals sion to publication in plastic surgery journals: The story of indexed in databases other than MEDLINE were not included. accepted manuscripts. J Plast Reconstr Aesthet Surg. 2020;73: Therefore, the study results may not completely represent 383---90. information regarding publication metrics in anesthesiology 6. Kalcioglu MT, Ileri Y, Karaca S, et al. Research on the submis- journals. The acceptance rate of journals was not analyzed. sion, acceptance and publication times of articles submitted to international otorhinolaryngology journals. Acta Informatica In case of some journals (for example, the British Journal of Medica. 2015;23:379. Anesthesia), there were some issues with complete online 7. Stamm T, Meyer U, Wiesmann HP,et al. A retrospective analysis data accessibility. Despite these limitations, this study is a of submissions, acceptance rate, open peer review opera- novel attempt to provide a realistic view to the publication tions, and prepublication bias of the multidisciplinary open speed in indexed anesthesiology journals. Additionally, the access journal Head & Face Medicine. Head and face medicine. effect of APC on publication time was determined in this 2007;13(1):27. study, which has not been reported yet. 8. Wyness T, Mc Ghee, Patel DV, et al. Manuscript rejection Through the analysis of various factors that contribute to in ophthalmology and visual science journals:identifying and the publication speed in anesthesiology journals, we advo- avoiding the common pitfalls. Clin Experiment Ophthalmol. cate that the option of AOP is a great asset to increase 2009;37:864---7. 9. Bagla J, Mishra D, et al. Time-lag from submission to print- the publication speed. Of the journals included in the ing in Indian biomedical journals. Indian Pediatr. Indian Pediatr. study, 15 (60%) had the option of AOP. This provision may 2011;48:67---8. be imbibed by other journals to improve the publication 10. Doja A, Eady K, Horsley T. The h-index in medical education: process. The implementation would definitely require addi- an analysis of medical education journal editorial boards. BMC tional resources and adaptation by the production team. As medical education. 2014;14:251. indicated in the study, the publication speed is not affected 11. Dickersin K, Olson CM, Rennie D. Association between time by APC. Thus, the belief that paid journals publish faster interval to publication and statistical significance. JAMA. may be misleading. The IF or number of issues of a journal 2002;287:2829---31. per year may not help in assessing the publication speed. The beginners may choose a journal with the option of AOP
115 Brazilian Journal of Anesthesiology 2021;71(2) 116---122
CLINICAL RESEARCH A survey of acute pain service in Canadian teaching hospitals
Qutaiba A. Tawfic a,∗, Alexander Freytag b, Kevin Armstrong c
a Western University, London Health Science Centre, University Hospital, Department of Anesthesia and Perioperative Medicine, London, Canada b Western University, London Health Science Centre, University Hospital, London, Canada c Western University, London Health Science Centre, University Hospital, Department of Anesthesia and Perioperative Medicine, Complex Pain Management Program, London, Canada
Received 20 October 2019; accepted 7 June 2020 Available online 3 February 2021
KEYWORDS Abstract Surveys and Background: The first national survey to ascertain the prevalence, structure, and functioning questionnaires; of the APS in Canadian university affiliated hospitals was conducted in 1991. This is a follow-up Acute pain survey to assess the current status of the APS in Canada. Methods: We requested completion of a 26-question survey from lead personnel of the APS teams or Anesthesia departments of Canadian teaching hospitals. Results: Among the 32 centers that were contacted, 21 (65.6%) responded. Of these respon- dents, 18 (85.7%) indicated that they have a structured APS (72.22% adults, 5.56% pediatrics, 22.22% mixed). Among the 18 centers with an APS, 16 of the services are led by an anesthesi- ologist. Eight centers (44.44%) have a regional anesthesia group, of which five (27.75%) have a regional anesthesia group that is distinct from the APS team. Nine centers (50%) offer ambula- tory nerve catheter analgesia after discharge home. Fifteen centers (83.33%) use standardized order sets, and 13 centers (72.22%) use an electronic record for APS. More than 50% of the centers use intravenous lidocaine and ketamine as a part of their multimodal analgesia. Conclusion: Most Canadian teaching hospitals do have a functioning APS. This survey has the potential to generate research questions about the availability of standardized and advanced acute pain management in Canada’s teaching hospitals. © 2021 Sociedade Brasileira de Anestesiologia. Published by Elsevier Edi- tora Ltda. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
∗ Corresponding author. E-mail: [email protected] (Q.A. Tawfic). https://doi.org/10.1016/j.bjane.2021.02.002 © 2021 Sociedade Brasileira de Anestesiologia. Published by Elsevier Editora Ltda. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). Brazilian Journal of Anesthesiology 2021;71(2) 116---122
Introduction tributed to the lead postoperative pain management health care providers at these centers via email, and was accom- The Acute Pain Service (APS) was first suggested through panied by an explanation of the purpose of our study. The an editorial published in 1976.1 By 1985, the first APS was questionnaire included 24 questions with closed answers and established by a group of anesthesiologists at the Univer- 2 open ended questions. The questionnaire was designed in sity of Washington.2 Ready and colleagues describe their a way not to identify the responders or their institutions. In ¨ rationale, goals, and experience for developing the first Q1 Does your hospital have an acute pain service (APS)?’’, if structured APS team.2 A group of anesthesiologists from the the response was no, the survey ended because the rest of University Hospital of Kiel in Germany published, in 1994, the questionnaire depends on the presence of APS. their APS experience which dated back to 1985.3 After that, many medical organizations started to recognize the impor- tance of establishing a well-designed APS to address the Results issue of acute postoperative pain.4 The establishment of an APS helped to expand the usage of some specialized pain APS demographics and structure management techniques, such as patient-controlled anal- gesia (PCA), nerve block catheters and epidural infusions of Among the 32 centers that were contacted, 21 centers local anesthetic and different opioids in surgical wards.4,5 (65.6%) responded. Out of the 21 respondents (Figure 1), However, the structures and practices of an APS is quite var- 18 centers (85.7%) stated that they have a formal APS ied between, and within the same organizations. Also, not (72.22% adults, 5.56% pediatrics and 22.22% mixed). Acute all medical organizations or hospitals around the world have pain management was provided by a wide range of personnel a well-structured APS.6 In Canada, a survey completed in (Figure 2). At the responding centers, staff anesthesiologists 1991-1992 revealed that half of university-affiliated teach- (88.89%) were most like to participate in pain management, ing hospitals had an established APS and two thirds of those together with anesthesia residents (55.56%), registered hospitals without an APS were planning to establish this nurses (55.56%), nurse practitioners (38.89%), pharmacists service.7 After 25 years, our research team decided to con- (11.11%), advanced practice nurse (11.11%), clinical fellows duct a follow-up survey to assess the academic and clinical (22.22%), and anesthesia technicians (5.55%). Regarding developments of the APS at major Canadian teaching hospi- after-hours (on-call), for postoperative pain management a tals. number of providers are involved. Most centers (72.22%) rely on the on-call (non-APS) anesthesiologist. Other providers Methods include an APS- assigned anesthesiologist (33.33%), a reg- istered nurse (11.11%), a surgeon (5.55%), and/or clinical fellows (33.33%). The volume of patients being cared for by A 26-question survey was provided to the lead personnel the APS per week was <100 in 61.11% and ≥100 in 38.885% of the APS teams or Anesthesia Departments at selected of the centers. Canadian teaching hospitals. This survey was designed to collect information describing the structure and function of acute pain management at these hospitals. The question- naire was designed by two Anesthesiologists and members Pain protocols and standardized orders of the APS team at London Health Science Centre --- Western University and the content was peer-reviewed for validity Fifteen centers (83.33%) utilize standardized order sets by a domain specialist. The survey was designed by expert for postoperative pain management and thirteen centers personnel using Qualtrics software. The survey was avail- (72.22%) use an electronic record for APS orders and doc- able in English only. Our institution’s Research Ethics Board umentation of follow-up. Fourteen centers (77.77%) have provided approval, and a list of targeted Canadian teaching updated postoperative pain management protocols. Fif- hospitals was compiled. We excluded community hospitals teen centers (83.33%) utilize standardized order sets for with affiliation to universities, and hospitals offering no or postoperative pain management. These standardized orders limited inpatient surgical care. A copy of the survey was dis- include printed hardcopy protocols (60%), electronic pro- tocols on hospital website (66.67%), pharmacologic pain interventions (73.33%), and non-pharmacologic pain inter- ventions (20%).
Postoperative pain assessment
The measure of successful pain management by APS teams is as follows: a change in pain scores (83.33%), changes in functional ability (61.11%), developing less side effects from treatment (55.56%), patients’ satisfaction (50%), shortened patients’ length of stay (38.89%), less frequent returning to emergency department because of pain or medication Figure 1 The presence of APS in main Canadian teaching hos- side effect after discharge (16.67%) and success of regional pitals. anesthesia (11.11%).
117 Q.A. Tawfic, A. Freytag and K. Armstrong
Figure 2 Acute pain management providers in teaching hospitals.
Figure 3 The relation between acute pain service and regional anesthesia teams in teaching hospitals.
Regional anesthesia and ambulatory analgesia labelled). Ketamine is added to IV-PCA opioids in two cen- ters (11.11%). Intravenous lidocaine infusion for analgesia Fifteen centers (83.33%) have an established regional anes- is used in ten centers (55.55%). Continuous cardiovascular thesia team. In ten centers (55.56%), regional anesthesia and monitoring is required in 30% of these centers (3/10). APS work as one team. In five centers (27.75%), the regional anesthesia team is distinct from the APS team (Figure 3). Nine centers (50%) offer ambulatory nerve catheter anal- Pain management modalities and patient follow-up gesia after discharge home. Ten centers (55.55) follow up with their patients after discharge from the hospital when All 18 centers which have an APS offer intravenous patient- they receive a regional block. The after-discharge follow- controlled analgesia (IV-PCA) and epidural analgesia. IV-PCA up is performed by the regional anesthesia team (33.33%), is followed by the APS team (94.44%), in conjunction with the anesthesiologist who started the block (33.33%), the APS other providers who are not part of the APS team, a regis- team (16.67%) or a registered nurse (16.67%). tered nurse and/or a clinical nurse specialist (38.88%), and a surgeon (16.67%). Regarding epidural catheter manage- ment, follow-up is performed by the APS team (94.44%) Lidocaine and ketamine or the anesthesiologist who started the epidural (5.56%). Other non-APS members also provide follow-up: a registered Ketamine is used for postoperative pain management in nurse and/or a clinical nurse specialist (33.33%), or a sur- 61.11% of the centers. Ten centers (55.55%) run intravenous geon 11.11 %. Dedicated regional anesthesia teams are not ketamine. Five centers (27.77%) use oral ketamine (off routinely involved in epidural follow-up.
118 Brazilian Journal of Anesthesiology 2021;71(2) 116---122
Provider satisfaction
Regarding the participants’ satisfaction about the acute pain management provided by their center(s) the result were as follows: very satisfied (33.33%), satisfied (27.77%), some- what satisfied (16.66%), dissatisfied (5.55%), very dissatisfied (11.11%), and no response (5.55%) (Figure 5).
Suggestions to improve APS
A request was made of the lead personnel of the APS teams for suggestions to improve the APS in their center and other academic centers (Table 1). Most of the suggestions focused on the need for more resources/support to improve the APS and patients care.
Figure 4 The presence of acute pain service fellowship in teaching hospitals. Discussion
Since the 1991 survey (published in 1993) no further follow- up surveys to our knowledge have been completed to assess Continuous peripheral nerve catheter analgesia for inpa- the status of the APS in Canada.7 Like the initial survey, tients is offered in 94.44% of the 18 centers which offer we also focus on Canadian teaching centers, however, we regional anesthesia. Follow-up is performed by the APS team restricted our inquiry to major teaching hospitals rather (88.88%) and/or the anesthesiologist who started the nerve than all the university-affiliated hospitals. The reason for catheter (16,67%), the regional anesthesia team (11.11%), a this decision is that not all university-affiliated hospitals will registered nurse and/or a clinical nurse specialist who are have the same resources to develop a well-structured com- not part of APS team (33.33%), or a surgeon (11.11%). prehensive acute pain management program or to establish academic/educational programs such as clinical fellowships. In the intervening years since the survey by Zimmermann Additional training in Acute Pain Management et al., we are able to say that a well-structured, protocol driven APS is more common in Canadian teaching hospitals Five centers (27.75%) have a structured APS fellowship today. Also, there is progress towards the establishment of (Figure 4) and 11 centers (61.11%) have a structured regional new educational programs (Acute Pain Fellowship). Many anesthesia fellowship. questions address the important relation between the APS
Figure 5 Acute pain service providers’ satisfaction.
119 Q.A. Tawfic, A. Freytag and K. Armstrong
Table 1 Suggestions by providers to improve acute pain expected that for those with an APS there is significant service. variations in the structure and function between teaching hospitals. Other points of interest include that only 27.75% Understanding common issues and solutions across the of Canadian teaching centers offer APS fellowship programs, country (e.g. performing regular surveys/meetings). 22.22% of the centers do not have updated postoperative More support to deal with the challenge of patients with pain protocols in place, 16.66% of the centers do not utilize acute-on-chronic pain and/or addiction. an electronic record for APS documentation and follow-up Improve human resources and more financial support to and surgeons appear to play a limited role in APS. improve the infrastructure of the service. It is desirable that teaching hospitals advance the sub- Implement more regional anesthesia techniques, lidocaine specialty by developing a comprehensive and advanced and ketamine to pain service. acute postoperative pain management system. Such sys- Collect data about feedback regarding effectiveness of tems would also be expected to function in a similar interventions/care for patients under APS. fashion to other subspecialty programs at teaching hospi- Implement APS educational/fellowship programs. tals. This would include the opportunity for post-graduate E-Learning management platforms/modules on pain. training, research in the area of acute pain management, APS -management electronic database. the development of evidence-driven protocols, auditing of the effectiveness of existing or new protocols; investigat- ing the safety and effectiveness of new pain medications; and regional anesthesia in these centers, as the presence and studying the cost---effectiveness of postoperative pain 4,8 of a regional anesthesia service is one of requirements to management. It is also important to have an updated pain develop an advanced APS. management protocol or guideline as indicated by the Amer- 9 Zimmermann et al. reported that 53% of hospitals had an ican Society of Anesthesiologists. established APS and another 35% were planning to organize Applying these protocols or guidelines is necessary to one (Total 88%). In our survey, 85.7% of the hospitals stated ensure a safe and efficient pain service. However, proto- that they have a structured APS. In this regard, progress cols and guidelines only define the basics of acute pain appears to have been made. management, and APS team members need to use their Of interest is the finding that from self-reporting there own clinical experience to decide about the details of 8,9 are teaching hospitals without a formalized APS. It may be pain management. This may indicate the importance of
Figure 6 Flow chart showing the development of the survey and the data collection process. APS, acute pain service.
120 Brazilian Journal of Anesthesiology 2021;71(2) 116---122 specialized APS training for both physicians and nurses.8 that the availability of the APS has increased over the last Unfortunately, the results of this survey suggest that some of 25 years. Our results provide an impetus for the pain mana- the teaching hospitals in Canada are still facing a problem gement community to design research projects which delve in developing and updating their APS protocols and guide- into how and why the structure and function of an APS varies lines. Also, it suggests that these are limited opportunities among those Canadian teaching hospitals, why there are lim- for training programs (Acute Pain Fellowships). ited opportunities for acute pain training in Canada, where This survey also discovered the absence of consistency improved infrastructure and support of APS is needed, and among the teaching hospitals in regard to patient’s assess- analysis of the cost benefit of APS. Regular follow-up surveys ment. The majority of the primary teaching hospitals in will allow continued re-assessment of an important patient Canada focus on the changes in pain scores, while only care service. 50-60% of the hospitals focus on the assessment of func- tional ability, patients’ satisfaction or the development of Conflict of interest adverse events to pain medications. The most commonly used measure of success in the survey is a measured change The authors declare no conflicts of interest. in pain scores (83.33 %), followed by changes in func- tional ability (61.11%), reduced side effects from treatment (55.56%), patients’ satisfaction (50%), shortened patients’ Acknowledgement length of stay (38.89%), less frequent return to the emer- gency department because of pain or medication side effect Authors would like to thank Ms. Lee-Anne (MSc.), the after discharge (16.67%), and the success of regional anes- Research Coordinator for the Department of Anesthesia and thesia (11.11%). Perioperative Medicine at Western University, for her assis- There have been multiple follow-up APS surveys done in tance with editing the manuscript and compiling the contact Europe and the United States to understand the progress information for the for the participants in the survey. 6,10---12 and the limitations of the APS. There is no consistency Also, authors would like to thank Ms. Brie McConnell regarding the questions used, and/or the type of hospitals (MLIS), the Medical Librarian for Department of Anesthe- involved in these surveys. This lack of consistency makes sia and Perioperative Medicine at Western University for her it difficult to compare the findings between surveys and assistance for designing the questionnaire for the survey. between countries. What is apparent is that the availabil- ity of an APS has increased over the last decade. However, the clinical and academic quality of the APS is still widely References variable between health centers. Patients surveys from the United States and Europe 1. Editorial: Postoperative pain. Anaesth. Intensive Care. showed that around 55% of surgical patients have experi- 1976;4:95. enced poorly controlled pain after surgery despite advances 2. Ready LB, Oden R, Chadwick HS, et al. Development of an anesthesiology-based postoperative pain management service. in modalities for pain management.13---16 Unfavorable low Anesthesiology. 1988;68:100---6. patients’ satisfaction indicated that the structure, organi- 3. Maier C, Kibbel K, Mercker S, et al. Postoperative pain therapy zation, academic activities, and quality of APS should be at general nursing stations: an analysis of eight years’ experi- 8,12,16 revisited and improved. ence at an anesthesiological acute pain service. Anaesthesist. Based on our survey results about participant satisfac- 1994;43:385---97. tion and suggestions (Figure 6 and Table 1), there is a need 4. Upp J, Kent M, Tighe PJ. The evolution and practice of acute for more support, and improved resources if there are to pain medicine. Pain Med. 2013;14:124---44. be improvements in acute pain management. Similarly, it 5. Miaskowski C, Crews J, Ready LB, et al. Anesthesia-based pain is expected that the availability of educational materials, services improve the quality of postoperative pain manage- research activity and training opportunities will improve the ment. Pain. 1999;80:23---9. 6. Montes A, Aguilar JL, Benito MC, et al. Acute Pain Group of the quality of acute pain management. Spanish Pain Society (SED). Management of postoperative pain in Spain: a nationwide survey of practice. Acta Anaesthesiol Limitations Scand. 2017;61:480---91. 7. Zimmermann DL, Stewart J. Postoperative pain management One limitation of this study is related to typical use question- and acute pain service activity in Canada. Can J Anaesth. naires in survey with a self-selection of the questionnaire. 1993;40:568---75. Sampling bias also cannot be excluded due to the self- 8. Tawfic QA, Faris AS. Acute pain service: past, present and selection of hospitals willing to reply. Our response rate is future. Pain Manag. 2015;5:47---58. reasonable for surveys; however, the small sample of hospi- 9. American Society of Anesthesiologists Task Force on Acute Pain tals included in this survey can be one of the limitations. In Management. Practice guidelines for acute pain management in this type of survey, we cannot exclude a bias due to the pos- the perioperative setting: an updated report by the American Society of Anesthesiologists Task Force on Acute Pain Manage- sibility of overestimation of quality of care and education of ment. Anesthesiology. 2012;116:248---73. responses. 10. Van Boekel RL, Steegers MA, Verbeek-van Noord I, et al. Acute pain services and postsurgical pain management in the Nether- Conclusion lands: a survey. Pain Pract. 2015;15:447---54. 11. Nasir D, Howard JE, Joshi GP, et al. A survey of acute pain ser- This is a follow-up survey of the current state of the APS at vice structure and function in United States hospitals. Pain Res primary teaching hospitals in Canada. The survey indicated Treat. 2011;2011:934932.
121 Q.A. Tawfic, A. Freytag and K. Armstrong
12. Erlenwein J, Koschwitz R, Pauli-Magnus D, et al. A follow-up 15. Gerbershagen HJ, Aduckathil S, van Wijck AJ, et al. Pain on Acute Pain Services in Germany compared to international intensity on the first day after surgery: a prospective cohort survey data. Eur J Pain. 2016;20:874---83. study comparing 179 surgical procedures. Anesthesiology. 13. Sommer M, de Rijke JM, van Kleef M, et al. The prevalence of 2013;118:934---44. postoperative pain in a sample of 1490 surgical inpatients. Eur 16. Tawfic Q, Kumar K, Pirani Z, et al. Prevention of chronic post- J Anaesthesiol. 2008;25:267---74. surgical pain: the importance of early identification of risk 14. Gan Tj, Habib As, Miller Te, et al. Incidence, patient satisfac- factors. J Anesth. 2017;31:424---31. tion, and perceptions of post-surgical pain: results from a US national survey. Curr Med Res Opin. 2014;30:149---60.
122 Brazilian Journal of Anesthesiology 2021;71(2) 123---128
CLINICAL RESEARCH Urgent/emergency surgery during COVID-19 state of emergency in Portugal: a retrospective and observational study
Andreia Filipa Sá a,∗,1, Sofia Fonseca Lourenc¸o a,1, Rafael da Silva Teixeira b, Filinto Barros a, António Costa a, Paulo Lemos a
a Centro Hospitalar Universitário do Porto, Servic¸o de Anestesiologia, Porto, Portugal b Universidade de Coimbra, Faculdade de Medicina, Instituto de Biofísica, Coimbra, Portugal
Received 29 July 2020; accepted 2 January 2021 Available online 19 February 2021
KEYWORDS Abstract COVID-19; Background: SARS-CoV-2 virus changed society’s behaviour. Population was advised to reduce COVID-19 diagnostic unnecessary heath care use to accommodate urgent cases and daily increase of COVID-19 testing; patients. Health care facilities faced huge challenges, having to readjust their response to Surgical procedures, preserve good quality of care. In Portugal, a significant reduction in the number of admissions operative; to the Emergency Department (ED) was reported all over the country, however the impact on Emergency service, the dynamics of undeferrable surgery remains to be reported. This study compares the volume hospital and characteristics of urgent/emergency surgery during the 2020 COVID-19 pandemic with the homologous period in 2019, chronologically illustrating the national evolution of new COVID-19 cases and the social and hospital containment response. Methods: A retrospective observational study was conducted in a tertiary hospital center located in the most affected region by COVID-19 in Portugal. Medical records of patients who underwent urgent/emergency surgery between March 1st and May 2nd of both 2020 and 2019 were examined and the volume of surgeries were compared. Also, daily national updates from Portuguese Directorate-General for Health were analysed. Results: During the COVID-19 pandemic approximately 30% less patients underwent urgent/emergency surgery (99%CI = 0.18---0.61, p < 0.001). Waiting time for surgery showed no difference between both years (p = 0.068), but patients who did surgery during the 2020 pandemic had higher mortality rates than the ones who did it in 2019 (11.4% in 2020 and 5.9% in 2019, p = 0.001). Reduction in surgery volume was correlated with the increasing number of infected cases nationally.
∗ Corresponding author. E-mail: [email protected] (A.F. Sá). 1 Both Sofia Lourenc¸o and Andreia Filipa Sá are first authors of this article. https://doi.org/10.1016/j.bjane.2021.01.003 © 2021 Sociedade Brasileira de Anestesiologia. Published by Elsevier Editora Ltda. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). A.F. Sá, S.F. Lourenc, ¸o R.S. Teixeira et al.
Conclusion: This study demonstrates decreasing numbers of urgent/emergency procedures dur- ing the COVID-19 pandemic that may be justified by the national growth number of infected cases. Preoperative mass screening strategy was implemented without compromising the effi- ciency of surgical service, but patients’ mortality was higher. The importance of visiting the ED during COVID-19 pandemic for serious cases that cannot be managed in other settings should be highlighted. © 2021 Sociedade Brasileira de Anestesiologia. Published by Elsevier Editora Ltda. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/ licenses/by-nc-nd/4.0/).
Introduction affected by the virus nationally. The country has universal health coverage provided by National Health Service. The SARS-CoV-2 virus is now widely acknowledged and has This study aims to compare the volume, characteris- become one of the most debated and studied subjects world- tics, and mortality of urgent/emergency surgery in COVID-19 wide. It emerged in China in December 2019 and quickly state of emergency with the homologous period of 2019. spread to the rest of the world, including Europe.1,2 The first case in Portugal was announced on March 2, 2020 with Materials and methods increasing number of cases being reported everyday.3 On March 18, 2020, Portugal declared the state of emer- After institutional approval, the authors conducted a ret- gency --- the first of which there was memory in the country.4 rospective observational study in Hospital Geral de Santo As of that day, services considered non-essential ceased and António. It is integrated in Centro Hospitalar Universitário do widespread quarantine was imposed. National public health Porto (CHUP), a tertiary hospital and trauma center located advised to reduce unnecessary heath care use in order to in the Northern region of Portugal that covers a large geo- accommodate urgent cases and daily increase of COVID- graphical area and a population of more than 3 million 19 patients. Scheduled surgery was reduced to what was inhabitants.11 strictly necessary (namely oncological or otherwise prior- Electronic medical records of patients referred to ity surgery). Urgent/emergency surgery and traumatology, urgent/emergency surgery between March 1st and May 2nd however, kept being referred, and required immediate and of both 2020 and 2019 were examined. Urgent/emergency coordinated intervention. surgery procedures were defined as interventions required Across Europe several health care systems faced unprece- to deal with an acute threat to life, organ, limb, or tissue dented pressure, which threatened to undermine its caused by trauma, acute disease process, acute exacer- effectiveness and sustainability. Reports from Spain, Scot- bation of a chronic disease process, or complication of a land, and Italy described a dramatic reduction in the number surgical or other interventional procedure. The selected of emergency or acute care surgeries during the peak of the time interval matches the day before the first diagnosed COVID-19 emergency.5 --- 7 In Portugal, a significant reduction case in our country and the end of emergency state imposed in the number of admissions to the Emergency Department by the national government. Patients’ demographic data, (ED) was reported all over the country,8---10 however, the surgical specialties, waiting time for surgery (since the impact on the dynamics of undeferrable surgery remains to request for surgery until patient surgery), knowledge of be reported. COVID-19 screening test results and 30-day mortality were The authors report from a tertiary university hospital collected. ASA (American Society of Anesthesiologists) phys- in Porto, the second largest city in Portugal and the most ical status classification system was examined as it offers
Table 1 Demographic data of patients submitted to urgent/emergency surgery in the homologous period (2019 vs. 2020). E denotes Emergency.
All patients 2019 2020 p-value (n = 1100) (n = 643) (n = 457) Age, median [IQR], years 65 [0 to 1] 63 [0 to 1] 67 [0 to 1] 0.017 Sex, n (%) 0.968 Male 629 (57.2) 368 (57.2) 261 (57.1) Female 471 (42.8) 275 (42.8) 196 (42.9) ASA-PS, n (%) 0.085 ASA I E 64 (5.8) 41 (6.4) 23 (5.0) ASA II E 306 (27.8) 190 (29.5) 116 (25.4) ASA III E 501 (45.5) 271 (42.1) 230 (50.3) ASA IV E 201 (18.3) 126 (19.6) 75 (16.4) ASA V E 28 (2.5) 15 (2.3) 13 (2.8)
124 Brazilian Journal of Anesthesiology 2021;71(2) 123---128
Figure 1 Distribution of urgent/emergency surgery over time in homologous periods (2019 vs. 2020).
clinicians a simple categorization of a patient’s physio- When analyzing 30-day-mortality, patients who under- logical status that can be helpful in predicting operative went urgent/emergency surgery during 2020 COVID-19 risk.13 National pandemic evolution and implemented gov- pandemic had higher mortality rates than the ones who did ernment public health measures were updated daily at the it during 2019 (11.4% in 2020 and 5.9% in 2019, p = 0.001). Portuguese Directorate-General for Health website.14 Since the state of emergency was declared in Portu- All patient identification details were anonymized previ- gal, the reduction in volume of urgent/emergency surgery ously to the data analysis to secure personal information. observed in our hospital accompanied the increase of newly Descriptive analysis, Mann-Whitney U and Chi-square tests diagnosed cases (Fig. 2). Actually, we estimate a correla- were performed using software IBM® SPSS® Statistics v.26 tion between these two variables (Fig. 3) --- cross-correlation (National Opinion Research Center, USA). Statistical sig- coefficient of 0.573. The strongest estimated correlation nificance was attributed to p-values less than 0.005. The between the number of COVID-19 cases and the reduced sur- difference of urgent/emergency surgeries between 2019 and gical volume occurred at lag-2 days. This time-series analysis 2020 and its cumulative sum over time was calculated. allowed for detection of a lagged relationship that proba- To analyze the potential correlation between the growing bly indicates a cause-and-effect link --- the impact of new number of COVID-19 cases and the cumulative reduction of COVID-19 cases in surgical volume was seen with a lag of urgent/emergency surgery, cross-correlation with autocor- two days. relation removed by simple pre-whitening was performed using the function ‘‘cross-correlations’’ of the package Discussion ‘‘analyze’’ in software SPSS. The effect of pre-whitening was to reduce unassociated autocorrelation and/or trends within time series prior to computation of their cross- Urgent/emergency surgery represents a therapeutic inter- correlation function. An auto-regressive model was fit to the vention to manage acute conditions that imply clinical two variables since both displayed first order autocorrela- deterioration or potential threat to life that should be tive relationship using the function ‘‘auto-correlations’’ of engaged in a short time. In view of this definition, it would the package ‘‘analyze’’ in software SPSS. The pre-whitened be expected that urgent/emergency surgery could remain variables consisted of the residuals of this fitted model. unchanged in the present year. However, as described in several European reports, this study suggests that the COVID-19 pandemic caused a major reduction in demand of urgent/emergency procedures.5 --- 7 Results In fact, this investigation proposes that the observed reduc- tion didn’t seem to be random or static and was correlated Table 1 describes the characteristics of patients who under- with the national growth of COVID-19 cases. This allows the went urgent/emergency surgery during the studied period. authors to propose that the augmentation of national cases No significant difference between patients’ sex (p = 0.968), and the recurrent alarm of mass media may have seed the ASA classification (p = 0.085) or age (p = 0.017) was observed fear of contamination, reducing the visits to the ED and, during the two periods. During the pandemic, approximately consequently, the demand for urgent/emergency surgery. 30% less patients (99%CI = 0.18---0.61, p < 0.001) were admit- Considering Figure 2, the increasing number of new cases ted to urgent/emergency surgery (623 in 2019 and 457 in forced a profound change in the National Health System. 2020, Figure 1). Waiting time for surgery showed no differ- Tw o dates stood out as cornerstones of change. The first was ence between both years (Table 2, p = 0.068). March 18, when the declaration of the state of emergency
125 A.F. Sá, S.F. Lourenc, ¸o R.S. Teixeira et al.
Figure 2 Shows the number of new infected cases reported nationally, the containment measures that were imposed by the government and the reorganization of our hospital over time. Also, on a daily scale, the number of urgent/emergency procedures and the application of screening tests in the period under study is presented. by the government marked the beginning of quarantine screening strategy that gave priority to patients in need measures. The second referred to the acknowledgment of of urgent/emergency surgery. At that time there were no mitigation phase, when preoperative screening test avail- available rapid tests in our hospital (made in 60 minutes), ability was guaranteed, and the COVID-19 operating theatre so patients had to wait about 4 hours to have an available (OT) was established. From March 27 all patients undergo- screening test result. On the other hand, the significant ing urgent surgery were tested and allocated to COVID-19 reduction in the surgical volume may have contributed to or non-COVID-19 areas, except for 16 patients who required the greater efficiency of surgical services. emergency surgical care. All 16 patients were allocated to Analyzing the population in both periods, the patient COVID-19 OT until knowledge of the test result. demographics, ASA classifications, and characteristics of Screening recommendations led to changes in admis- procedures were similar. However, during the pandemic sion for urgent/emergency surgery and the need to ensure period mortality was higher, reaching almost double from appropriate waiting times for surgery was a concern for sur- previous year.12 This finding supports data introduced by a gical services. However, this study shows that there was Portuguese study presenting evidence of excess mortality no significant difference in the waiting time for surgery. during the COVID-19 lockdown, 3.5 to 5-fold higher than This result can be understood based on an institutional what can be explained by the official national COVID-19
126 Brazilian Journal of Anesthesiology 2021;71(2) 123---128
Table 2 Distribution of urgent/emergency surgical specialties and waiting time for surgery in the homologous period (2019 vs. 2020).
All patients (n = 1100) 2019 (n = 643) 2020 (n = 457) p-value Waiting time until surgery, n (%) 0.068 Less than 1 day (< 24 hours) 957 (87.0) 541 (84.1) 416 (91.0) More than 1 day 143 (13.0) 102 (15.9) 41 (9.0) Distribution of surgeries per surgical area, n (%) 0.030 Orthopedic surgery 299 (27.2) 187 (29.1) 112 (24.5) General surgery 281 (25.5) 177 (27.5) 104 (22.8) Vascular surgery 269 (24.5) 133 (20.7) 136 (29.8) Neurosurgery 119 (10.8) 72 (11.2) 47 (10.3) Urology 79 (7.2) 46 (7.2) 33 (7.2) Gastroenterology 15 (1.4) 7 (1.1) 8 (1.8) Ophthalmology 15 (1.4) 10 (1.6) 5 (1.1) Maxillofacial surgery 1.2 (1.1) 5 (0.8) 7 (1.5) Ear, Nose, and Throat surgery 9 (0.8) 4 (0.6) 5 (1.1) Plastic surgery 2 (0.2) 2 (0.3) 0 (0.0)
Figure 3 Curves of cumulative number of COVID-19 national cases and cumulative reduction in surgical volume between years (2019 vs. 2020).
deaths. Additionally, as reported by other European coun- should provide guidance to help patients to choose the best tries, a greater severity of pathologies or delayed use of place to receive care and to ensure that those with serious ED could be pointed out as plausible explanations for the illnesses and injuries continue going to ED, without fear of increase in mortality.5 --- 7 inefficiency or contamination. Otherwise, delayed diagnosis The authors recognize that the study has several limi- can imply potential life-threatening outcomes. tations, namely, those inherent to its retrospective nature. Additionally, as waiting time for urgent/emergency surgery Conclusion may determine its outcome, it would have been more accu- rate to present it in hours instead of days. As it is a This study suggests that the COVID-19 pandemic caused recent and still ongoing situation, a relatively short period a reduction in urgent/emergency procedures that can was analyzed and may not be representative. Considering be correlated with the national growth of COVID-19 the size of the population sample and the fact that is a cases. Preoperative mass screening test strategy for single-centered study, the findings may not describe national urgent/emergency patients was implemented without com- reality, although, as mentioned above, CHUP covers a wide promising the efficiency of surgical services. Despite the geographical area that cannot be ignored. similar characteristics of population and procedures, a As a second wave of COVID-19 pandemic spreads through higher mortality was observed during the pandemic. Europe, it is extremely important to highlight learning points from the past. Even maintaining adequate testing strate- gies and similar waiting times for surgery, the mortality Conflicts of interest rates increased. In view of this findings, health care systems The authors declare no conflicts of interest.
127 A.F. Sá, S.F. Lourenc, ¸o R.S. Teixeira et al.
Appendix A. Supplementary data 7. D’Urbano F, Fabbri N, Radica MK, Rossin E, Carcoforo P. Emer- gency surgery in COVID-19 outbreak: Has anything changed? Single center experience. World J Clin Cases. 2020;8:3691---6. Supplementary material related to this article can be found, 8. Santana R, Rocha J, Sousa J, et al. https://www.ensp.unl. in the online version, at doi:https://doi.org/10.1016/ pt/wp-content/uploads/2017/06/tendencia-de-resposta- j.bjane.2021.01.003. dos-servicos-de-urg-emerg-covid-19.pdf, 2020. 9. Campos A. Procura das urgências caiu 45%. Onde estão References os enfartes e os AVC, perguntam os investigadores | Covid-19 | PÚBLICO. https://www.publico.pt/2020/04/ 03/sociedade/noticia/procura-urgencias-caiu-45-onde-estao- 1. Zhu N, Zhang D, Wang W, et al. A novel coronavirus from patients enfartes-avc-perguntam-investigadores-1910910. Published 3 with pneumonia in China, 2019. N Engl J Med. 2020;382:727---33. April 2020. Accessed May 9, 2020. 2. ECDC. Risk assessment: Outbreak of acute respiratory syn- 10. Pereira JC. Servic¸o de Urgência Hospitalar:lic¸ ões da pandemia drome associated with a novel coronavirus, China: first local covid-19 | Opinião | PÚBLICO. https://www.publico.pt/2020/ transmission in the EU/EEA − third update. https://www.ecdc. 04/30/opiniao/opiniao/servico-urgencia-hospitalar-licoes- europa.eu/en/publications-data/risk-assessment-outbreak- pandemia-covid19-1914446. Published 30 April 2020. Accessed acute-respiratory-syndrome-associated-novel-1. Published May 9, 2020. 2020. Accessed May 9, 2020. 11. RELATÓRIO & CONTAS 2018 : Centro Hospitalar Univer- 3. DGS. RELATÓRIO DE SITUAC¸ÃO-1.; 2020. https://covid19. sitário do Porto. https://www.chporto.pt/pdf/princ min-saude.pt/ponto-de-situacao-atual-em-portugal/. bom gov/chp RC 2018Final.pdf. Published 2018. Accessed Accessed May 9, 2020. May 10, 2020. 4. Decreto do Presidente da República 14-A/2020, 2020-03-18 - 12. Nogueirai PJ, De Araújo Nobre M, Nicola PJ, et al. Excess mortal- DRE. Diário da República n.o 55/2020, 3o Suplemento, Série ity estimation during the COVID-19 pandemic: Preliminary data I. https://dre.pt/web/guest/home/-/dre/130399862/details/ from Portugal. Acta Med Port. 2020;33:376---83. maximized. Published 18 March 2020. Accessed May 9, 2020. 13. https://www.asahq.org/standards-and-guidelines/asa- 5. Cano-Valderrama O, Morales X, Ferrigni CJ, et al. Acute Care physical-status-classification-system. Accessed May 9, 2020. Surgery during the COVID-19 pandemic in Spain: Changes in 14. https://covid19.min-saude.pt/relatorio-de-situacao/. volume, causes and complications. A multicentre retrospective Accessed May 9, 2020. cohort study. Int J Surg. 2020;80:157---61. 6. Dick L, Green J, Brown J, et al. Changes in Emergency General Surgery During Covid-19 in Scotland: A Prospective Cohort Study. World J Surg. 2020;44:3590---4.
128 Brazilian Journal of Anesthesiology 2021;71(2) 129---136
CLINICAL RESEARCH Comparison of three sitting positions for combined spinal - epidural anesthesia: a multicenter randomized controlled trialଝ
Mehmet Özgür Özhan a, Ceyda Özhan C¸aparlar b, Mehmet Anıl Süzer a, Mehmet Burak Eskin c, Bülent Atik d,∗
a Private C¸ankaya Hospital, Department of Anesthesiology and Reanimation, Ankara, Turkey b University of Medical Sciences Yildirim Beyazit Training and Research Hospital, Department of Anesthesiology and Reanimation, Ankara, Turkey c University of Medical Sciences Gulhane Training and Research Hospital, Department of Anesthesiology and Reanimation, Ankara, Turkey d Balikesir University Medical Faculty Health Practice and Research Hospital, Department of Anesthesiology and Reanimation, Balikesir, Turkey
Received 4 August 2019; accepted 8 August 2020 Available online 28 December 2020
KEYWORDS Abstract Traditional sitting Background and objectives: The aim of this prospective, multi-centered and multi-arm parallel position; randomized trial was to test the hypothesis that modified sitting positions including hamstring Hamstring stretch stretch position (HSP) and squatting position (SP) would reduce needle - bone contact events position; and increase the success rate of combined spinal - epidural anesthesia (CSEA) compared to Squatting position; traditional sitting position (TSP) in patients undergoing total knee or hip arthroplasty. Combined spinal Patients and methods: Three hundred and sixty American Society of Anesthesiologists (ASA) I- epidural anesthesia; III patients, aged between 45-85 years were randomly allocated to one of three groups using Arthroplasty computer-generated simple randomization: group TSP (n = 120), group HSP (n = 120), and group SP (n = 120). Primary outcome measures were the number of needle-bone contact and success rates. Secondary outcome measure was the ease of interspinous space identification. Results: Seven patients in group SP and four of HSP could not tolerate their position and were excluded. Number of needle-bone contact, success rates, and grade of interspinous space iden- tification were similar between groups (p = 1.000). Independent of positioning, the success rates were higher in patients whose interspinous space was graded as easy compared to difficult or
ଝ The study was carried out in operating theaters of Private C¸ankaya Hospital, Ankara, Turkey; University of Medical Sciences Gülhane Training and Research Hospital, Ankara, Turkey; University of Medical Sciences Yildirim Beyazit Training and Research Hospital, Ankara, Turkey; and Balikesir University Medical Faculty Health Practice and Research Hospital, Balikesir, Turkey. ∗ Corresponding author. E-mail: bulent [email protected] (B. Atik). https://doi.org/10.1016/j.bjane.2020.12.012 © 2020 Published by Elsevier Editora Ltda. on behalf of Sociedade Brasileira de Anestesiologia. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). M.Ö. Özhan, C.Ö.C¸ aparlar, M.A. Süzer et al.
impossible (p < 0.001). Success rates reduced, interspinous space identification became more challenging, and number of needle --- bone contact increased as patient’s body mass index (BMI) increased (p < 0.001). Conclusion SP and HSP may be used as alternatives to the TSP. BMI and ease of interspinous space identification may be considered important determinants for CSEA success. © 2020 Published by Elsevier Editora Ltda. on behalf of Sociedade Brasileira de Anestesiologia. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/ licenses/by-nc-nd/4.0/).
Introduction compared to traditional sitting position in patients undergo- ing total knee or hip arthroplasty. The positioning of a patient is one of the major factors contributing to the success of a neuraxial block; other fac- Methods tors include the ease of identifying anatomical landmarks including the midline and interspinous space, and the anes- thesiologist’s level of experience.1 The quality of positioning This was a prospective, multi-centered and multi-arm par- was defined as good or poor according to the ability to allel randomized clinical trial. The trial was approved by flex the spine adequately. Poor positioning leads to mul- the hospital’s ethics committee (04.16. 2018-49/08). A tiple attempts for the intervention due to needle --- bone written informed consent was obtained from all subjects contact (NBC), which may result in back pain, hematoma, participating in the trial. The trial was registered at Clinical- and paresthesia.2 The conditions may cause dissatisfaction Trials.gov (http://clinicaltrials.gov), (NCT03541798, date of and cause the patient to refuse the procedure.3,4 A flexed registration: May 1, 2019) prior to patient enrollment. This back and reduced lumbar lordosis are considered to be nec- manuscript adheres to the Consolidated Standards of Report- 10---12 essary for optimal positioning in either the sitting or lateral ing Trials (CONSORT) statement. The trial ended after decubitus positions. These maneuvers widen the inter- the pre-planned number of patients concluded the intended spinous space and push the thecal sac into a more superficial follow-up period. Patients were randomly assigned to one of position.3,4 three parallel groups, initially in 1:1:1 ratio to receive CSEA The traditional sitting position (TSP) is the most com- in three different sitting positions. It was decided that the mon position for spinal or epidural anesthesia where the patients were dropped out after trial commencement who patient sits on the operating table, with both feet placed on could not tolerate their position or developed sudden dete- a stool, and both hips and knees maximally flexed (Fig. 1). rioration in vital parameters during the intervention which Four decades ago, a new sitting position was introduced to required emergency treatment. reduce lumbar lordosis for ‘‘easier’’ spinal puncture; this The inclusion criteria were as follows: American Society position involved maximum extension of the knees, adduc- of Anesthesiologists (ASA) physical status class I-III patients, tion of the hips, and forward bending.5 Based on this idea, aged between 40 and 85 years, scheduled for elective uni- modified sitting positions have been introduced for spinal or lateral total hip or knee arthroplasty under combined spinal epidural anesthesia. In these positions, the patients are sat ---epidural anesthesia were enrolled in the study. up on the operating table, but the legs remain on the table, The exclusion criteria were patient refusal, history of which is different from the TSP. In the hamstring stretch previous lumbar surgery, neurological disease, obvious lum- position (HSP), the knees are maximally extended (Fig. 2), bar scoliosis, the inability to flex the knees, coagulation whereas in the squatting position (SP), both the hips and disorders, and trauma surgery. knees are maximally flexed (Fig. 3).6 --- 8 Similar success rates The trial was conducted in the orthopedic operating the- have been reported in studies comparing TSP with modi- atres of two academic training and research hospitals and fied sitting positions for epidural or spinal anesthesia.6 --- 8 of a tertiary hospital. Five staff anesthesiologists with more However, to the best of our knowledge, this issue has not than ten years of experience in regional anesthesia partici- been previously investigated for combined spinal --- epidural pated in the study who performed more than 500 combined anesthesia (CSEA) with the aim for reducing needle --- bone spinal --- epidural anesthesia procedures in traditional sit- contact events and for increasing the success rate of the ting position and hamstring stretch position. Patients were intervention. CSEA is frequently used in orthopedic lower invited on the day before the surgery. Saline or Ringer’s lac- -1 -1 limb surgery because it provides motor and sensory blocks tate solution (1-3 mL.kg .h , up to 1 L) was intravenously by the spinal anesthesia component, while indwelling an (IV) administered for hydration during the fasting period, epidural catheter enables the modification of the block and which lasted six hours for light meals and two hours for clear postoperative analgesia.9 fluids. Tw o milligrams of IV midazolam was administered as The aim of this study was to test the hypothesis that mod- the premedication before the patients were transferred to ified sitting positions including hamstring stretch position the operating room. After arriving in the operating room, the and squatting position would reduce needle --- bone contact patients were monitored with noninvasive blood pressure, and increase the success rate of the needle - through --- nee- pulse oximetry, and electrocardiogram equipment. Patient dle technique combined spinal --- epidural anesthesia (CSEA) characteristics including sex, age, weight, height, and body
130 Brazilian Journal of Anesthesiology 2021;71(2) 129---136
Figure 1 Traditional sitting position. The picture shows the positions of the patient, the nurse anesthetist, and the anesthesiol- ogist.
Figure 2 Hamstring stretch position. The picture shows the positions of the patient, the nurse anesthetist, and the anesthesiol- ogist.
Figure 3 Squatting position. The picture shows the positions of the patient, the nurse anesthetist, and the anesthesiologist. mass index (BMI) were recorded. Patients were randomly in maximum extension, hips in adduction, and trunk leaning assigned to one of three parallel groups in 1:1:1 ratio to forward (Fig. 2). In group SP, the patients were seated on receive CSEA in three different sitting positions: the tra- the operation table with their hip and knee joints flexed. ditional sitting group (Group TSP, n = 120), the hamstring The patients hugged their knees, and both the buttocks and stretch group (Group HSP, n = 120), and the squatting group plantar surfaces of the feet were supported by the operat- (Group SP, n = 120). Patients in group TSP were placed in a ing table (Fig. 3). A nurse anesthetist helped support the sitting position with their legs on a stool at the edge of the patients from the ventral side for TSP and from the lat- operation table, their knees flexed to 90◦, and their hips eral side for HSP and SP; the nurse held their posture by adducted (Fig. 1). Patients in group HSP were seated with holding their shoulders. All patients were asked to bend for- their lower extremities placed on the operation table, knees ward and flex their back as much as they could tolerate.
131 M.Ö. Özhan, C.Ö.C¸ aparlar, M.A. Süzer et al.
The patient’s back was facing the anesthesiologist perform- If spinal anesthesia was failed, general anesthesia was ing the procedure and the anesthesiologist sat on a stool induced. behind the patient at a level where he/she could easily The primary outcome measures were the number of observe the patients’ back (Figs. 1 --- 3 ). After the patients needle-bone contact (NBC) events and success rate of CSEA. were positioned, the anesthesiologist graded the ease of The secondary outcome measure was the grade of inter- the identifying the interspinous space using palpation of spinous space identification. The correlation between the the adjacent lumbar spinous processes on a 3-point scale: grade of interspinous space identification and success rate easy = both adjacent spinous processes are palpable, diffi- was also investigated. The grade of interspinous space iden- cult = one of the adjacent spinous processes is palpable, and tification, number of NBC events, and success rates were impossible = both adjacent spinous processes are impalpa- compared between different BMI classes to find out whether ble. Tw o interspinous spaces (the first and second) were a relationship exist between BMI and determinants of the selected from the L2-L3, L3-L4, and L4-L5 intervertebral intervention. Success of the intervention was modeled using levels to undergo CSEA. univariate and multivariate logistic regression models with After sterile preparation and dressing, the skin and sub- respect to sitting positions, body mass index classes, and cutaneous tissue were infiltrated with a local anesthetic ease of intervertebral space identification. In previous stud- (3 mL of 2% lidocaine). CSEA was performed at the first inter- ies, the success rate of needle insertion without NBC has spinous space with a midline approach using a CSEA set (B. been reported to be 50% in traditional sitting position, 60% Braun Melsungen AG, Germany) that contains an 18 gauge in the hamstring stretch position and, 70% in the squatting (G) Tuohy epidural needle, a 27 G Whitacre spinal needle, position.4,6 A power analysis revealed that a minimum sam- and an epidural catheter. ple size of 110 patients per group was needed to achieve The Tuohy needle was introduced in the midline at a power of 0.8 (80%) with a confidence level of 95%.13 It the interspinous space and directed slightly cephalad. The was aimed to enroll 360 patients (120 in each arm) to allow epidural space was located with the loss of resistance to withdrawal or loss to follow- up rate of 10%. the saline technique. Then, the spinal needle was advanced Randomization was performed with computer-generated through the epidural needle until it penetrated the dura simple random sequence to assign patients to one of three mater with the distal aperture facing the cephalad (nee- study arms. Allocation concealment was achieved by means dle -through- needle technique). Following this, 3-3.5 mL of of sealed, opaque and continuously numbered envelopes, 0.5% hyperbaric bupivacaine (15-17.5 mg) was administered which were matched with patients according to their order after obtaining of free flow of cerebrospinal fluid through of inclusion in the study. The study coordinator (MÖÖ) was the spinal needle. The spinal needle was withdrawn, and responsible for the generation of the random sequence an epidural catheter was inserted 4 cm into the epidural and for its concealment in opaque, numbered envelopes. A space and secured. The case was termed ‘‘Success at First research assistant enrolled the participants and allocated Try’’. When a bone contact occurred, the Tuohy needle was each patient to the next sealed envelope containing the withdrawn to subcutaneous tissue. It was redirected cepha- information on the randomized group. The envelopes were lad, horizontal or caudad. A maximum of three redirections opened by the anesthesiologist before the intervention who were allowed. If the epidural space was located, spinal anes- performed CSEA. thesia and epidural catheter placement were performed The following parameters were recorded and compared as described. The case was termed ‘‘Success after Needle between the study groups: demographic characteristics, Redirection’’. However, the epidural needle was withdrawn grade of intervertebral space identification, number of after three failed redirections. A new puncture site was needle --- bone contact events, number of successful and not allowed at the same level. The case was then termed failed cases of combined spinal - epidural anesthesia, and ‘‘Failed CSEA at the First Intervertebral Space’’. complications. At this stage, a second attempt was carried out at the second interspinous space with the same approach that was used for the first attempt. If the attempt was successful Statistical analysis without needle bone contact, the case was termed ‘‘Success at the Second Intervertebral Space’’. If the second attempt The data were analyzed using IBM SPSS Statistics version 21 also failed, the case was recorded as a ‘‘Failed CSEA for the (IBM SPSS Inc, Chicago, IL) pocket program. The descriptive Position’’ case and the study was stopped. At this stage, statistics calculated for the continuous variables were the the patients were directed to the following options: a) a mean, and standard deviation (mean ± SD), and those for the spinal anesthesia was attempted using a 27 G spinal needle categorical variables were the frequency distribution and (B.Braun Melsungen AG, Germany). If the spinal anesthesia percentage (n, %). Pearson’s chi-square (2) test was used was successful, the case was termed ‘‘Failed CSEA, Suc- to assess the differences in distributions of the categorical cessful Spinal Anesthesia’’. If spinal anesthesia was failed variables between groups. The normality of the data was too, general anesthesia was induced. b) In the case of suc- assessed with the Kolmogorov - Smirnov test. Differences cessful location of epidural space with Tuohy needle but in the non-normally distributed variables between groups of failure of spinal anesthesia using needle --- through --- were assessed with Kruskal - Wallis variance analysis.14 needle technique, the epidural catheter was inserted into The variables which will be included in multivariate logis- epidural space and a spinal puncture was attempted using tic regression model were described by univariate logistic a 27 G spinal needle at an inferior level. If spinal anes- regression analysis using Wald statistics.15 The variables thesia was successful, the case was termed as ‘‘Successful with Wald p values < 0.25 were included in the multivari- CSEA with Separate Level --- Separate Needle Technique’’. ate model. The p value of the sitting positions was > 0.25,
132 Brazilian Journal of Anesthesiology 2021;71(2) 129---136 so the sitting positions were not included in the multivari- was found that the rate of ‘‘easy’’ interspinous space iden- ate model. p < 0.05 was considered statistically significant tification significantly decreased as the body mass index for all tests. increased (100% > 97.3% > 51% > 15.0%; p < 0.001). The grade of interspinous space identification was impossible in 26.1% of obese patients versus 0% in non-obese patients. On the Results other hand, the first try success rate (NBC = 0) was the high- est in patients with a normal body mass index but the lowest A total of 360 patients were included in the study. There in obese patients (p < 0.001). However, the logistic regres- were 201 (55.8%) female and 159 (44.2%) male patients. sion analysis revealed that the sitting positions and body ± The mean age was 68.29 7.40 years. Seven patients (5.8%) mass index were insignificant factors in the success of the in group SP and 4 patients in group HSP (3.3%) could not CSEA. In contrast, the ease of interpinous space identifica- tolerate their position during the intervention due to dis- tion was a significant factor (p < 0.001) (Table 3). comfort and pain at the knee or hip. These eleven patients A total of 24 (6.87%) complications were observed and were excluded from the study and general anesthesia was treated throughout the study period. Eight adverse events induced. The procedure was well - tolerated by all the occurred in each group (p = 1.000). For the TSP, HSP, and patients in group TSP. The data from remaining 349 patients SP groups, the adverse events were back pain (3, 2, and 2 were available for the intention-to-treat analysis. Fig. 4 cases, respectively), hypotension (4, 5, and 4 cases, respec- shows the flow diagram of participants through each stage tively), bradycardia (1, 0, and 1 case, respectively), and of the study. Patient recruitment happened between May 2, unintentional dural puncture (0, 1, and 1 case, respectively); 2019 and December 23, 2019 and patients were followed-up (p = 1.000). for 3-5 days after surgery. The trial ended after the pre- planned number of patients who concluded the intended follow-up. The demographic data were comparable across the three study groups (Table 1). Discussion Primary outcome measures The results of the study demonstrated that the success rate The overall success rate of CSEA was 93.3% in the remain- of CSEA and the number of needle - bone contact events ing 349 patients. When the success rates were compared were not different between the traditional sitting position between study groups, it was found that the success rate and modified positions, including the hamstring stretch and was the highest in group TSP and the lowest in group SP, squatting positions. The ease of the interspinous space iden- but this difference was not statistically significant (93.3% tification was also similar across the positions. Based on the vs. 92.2% vs. 92.0%; p = 1.000), (Table 2). data in the present study, it can be stated that hamstring The success rates ‘‘at First Try’’ (NBC = 0), after¨ Nee- stretch and squatting position can be used as alterna- dle Redirection’’ (NBC = 1 or 2), and ‘‘at the Second Level’’ tive positions to the traditional sitting position in patients (NBC = 3-5) were also similar between the three groups undergoing knee or hip arthroplasty under combined spinal- (p = 1.00, Table 2). Needle --- through - needle technique epidural anesthesia. This statement is consistent with the CSEA failed in 26 patients (7.45%). The rate of ‘‘Failed CSEA results of few studies comparing modified sitting positions for the Position’’ (NBC = 6) was statistically similar between with the traditional sitting position for epidural or spinal 6 --- 8 the TSP, HSP, and SP groups (6.7% vs. 7.8% vs. 8%, respec- anesthesia. In an earlier study, the number of needle --- tively; p = 1.00). Spinal anesthesia was successful in three bone contact events and failure rates were found to be sim- patients of group TSP, in two patients of group HSP, and in ilar between the HSP and TSP positions and it was stated three patients of group SP. The remaining eighteen patients that the HSP increased lumbar flexion but also created ten- received general anesthesia. sion in the supraspinous ligament which led to interspinous depression.5 In another study, the traditional sitting position was com- Secondary outcome measures pared with the squatting position in patients undergoing lower abdominal or extremity surgery under spinal anesthe- Interspinous space identification was identified easy in sia. The number of needle-bone contact events was lower 59.0%, difficult in 33.0%, and impossible in 8.0% of all in the squatting group although the ease of interspinous patients. The grades of interspinous space identification space identification and success rates were similar. It was were not statistically different among the three groups concluded that this difference favoring the squatting posi- (p = 0.990). There was a correlation between the grade of tion may be due to the induced tension in the supraspinous interspinous space identification and success rates of the ligament.7 In another study, there was not a significant dif- intervention (p < 0.001). The success rate at first try was ference in the number of needle --- bone contact events, significantly higher in patients whose interspinous space grades of interspinous space identification or success rates was considered easy to identify than in patients whose among patients who were positioned in the TSP, HSP and SP interspinous space was considered difficult or impossible for spinal anesthesia.8 However, the overall success rates in to identify (73.3% > 16.5% > 0.0%; respectively, p < 0.001). those studies ranged between 98.3% and 99.0%, which was The rate of failed CSEA also increased as the identifica- higher than that in our study (92.0%-93.3%). This discrepancy tion of interspinous space became more challenging (easy may be explained by the differences between our study and (1.0%) < difficult (10.4%) < impossible (42.9); p < 0.001). It other studies in the literature:
133 M.Ö. Özhan, C.Ö.C¸ aparlar, M.A. Süzer et al.
Figure 4 Diagram showing the flow of participants through each stage of the trial.
Table 1 Patient baseline characteristics and features of surgical procedures performed according to treatment group.
Baseline characteristics Group TSP (n = 120) Group HSP (n = 116) Group SP p (n = 113)
Age (years)a 68.3 (7.5) 67.9 (7.3) 68.4 (7.5) 0.815 Gender (n) Female/Male 68 / 52 63 / 53 64 / 49 0.917 Body Mass Underweight 9 (7.5%) 11 (9.5%) 10 (8.8%) 1.000 Index Classb Normal 39 (32.5%) 37 (31.9%) 36 (31.9%) (kg.m-2) Overweight 35 (29.2%) 33 (28.4%) 32 (28.3%) Obesity class I 22 (18.3%) 20 (17.2%) 21 (18.6%) Obesity class II 11 (9.2%) 12 (10.3%) 10 (8.8%) Obesity class III 4 (3.3%) 3 (2.6%) 4 (3.5%) ASA status (n) I / II / III 51 / 56 / 13 49 / 55 / 12 50 / 50 / 13 0.992 Arthroplasty (n) Hip / Knee 79 / 41 79 / 37 68 / 45 0.434
TSP,traditional sitting position; HSP,hamstring stretch position; SP,squatting position; ASA, American Society of Anesthesiologists physical status classification. p < 0.05 was considered as statistically significant. a Data presented as mean (standard deviation). b Data presented as absolute number (%). a) The patients in this current study groups were older was between 35 and 39.9 kg m-2 in 33 (9.2%) patients (68.29 ± 7.40 years) than those included in other stud- and was higher than 40 kg m-2 in 11 (3.1%) patients in ies (between 40.4 ± 0.8 years and 48.8 ± .8.6 years.6 --- 8 the current study. When the success rates and number It is well known that degenerative spine conditions are of needle-bone contact events were compared between common in older patients and cause a gradual loss of different body mass index classes, it was found that the a normal spine structure and function over time. Gen- success rate was lower and the number of needle-bone eral symptoms include spinal deformity, limited motion contact events was higher in patients with higher body and chronic pain with movement, which may make the mass index. Additionally, interspinous space identifica- neuraxial procedure more difficult to perform. tion was also considered difficult in overweight patients b) Obese patients were included in our study. In other stud- and impossible in obese patients which increased the ies, patients with a body mass index higher than 32, 35 failure rate. It was reported that patient’s age greater and 40 kg m-2 were excluded.6 --- 8 The body mass index than 65 years and BMI > 30 kg m-2 are associated with
134 Brazilian Journal of Anesthesiology 2021;71(2) 129---136
Table 2 Comparison of study groups regarding number of needle bone contact, success of the intervention and ease of intervertebral space identification.
Variable Group TSP (n = 120) Group HSP (n = 116) Group SP (n = 113) p
Needle Bone 0 59 (49.2%) 56 (48.3%) 55 (48.7%) 0.997 Contacta 1 26 (21.7%) 25 (21.6%) 25 (22.1%) 2 2 (1.7%) 1 (0.9%) 1 (0.9%) 3 21 (17.5%) 19 (16.4%) 19 (16.8%) 4 4 (3.3%) 5 (4.3%) 4 (3.5%) 5 0 (0.0%) 1 (0.9%) 0 (0.0%) 6 8 (6.6%) 9 (7.8%) 9 (8.0%) Successa at First Try 59 (49.2%) 56(48.3%) 55 (48.6%) After Needle Redirection 28 (23.3%) 26 (22.4%) 26 (23.0%) 1.000 at Second Intervertebral Space 25 (20.8%) 25 (21.5%) 23 (20.4%) Overall 112 (93.3%) 107 (92.2%) 104 (92.0%) Failed CSEA 8 (6.7%) 9 (7.8%) 9 (8.0%) Ease of Inter- Easy (n = 206) 69 (57.5 %) 70 (60.3%) 67 (59.3 %) 0.995 Vertebral Space Difficult (n = 115) 41 (34.2 %) 37 (31.9%) 37 (32.7 %) Identificationa Impossible (n = 28) 10 (8.3%) 9 (7.8%) 9 (8.0%)
TSP,traditional sitting position; HSP,hamstring stretch position; SP,squatting position; NBC, needle bone contact; CSEA, combined spinal epidural anesthesia. p < 0.05 was considered as statistically significant. a Data presented as absolute number (%).
Table 3 Relationship of body mass index and ease of interspinous space identification to the success rate of the intervention, multivariate logistic regression model.
Variables Regression coefficient Standard error Wald’s 2 valuea 95% CI of OR p
OR Lower Upper Body Mass Index Normal weight Reference --- 0.40 ------0.940 Under weight -17.196 -16.913 0.00 0.000 0.000 --- 0.998 Overweight -18.451 -16.411 0.00 0.000 0.000 --- 0.998 Obese -19.605 -16.192 0.00 0.000 0.000 --- 0.998 Ease of Intervertebral Space Identification Easy Reference --- 15.640 ------< 0.001 Difficult -2.475 -2.740 6.165 0.065 0.007 0.562 0.013 Impossible -4.337 -4.23 14.866 0.009 0.001 0.098 < 0.001
CI, confidence interval, OR, odds ratio. p < 0.05 was considered statistically significant. a The variables with a Wald’s 2 value > 0.25 were included in the multivariate model.
poor positioning which result in having difficulty in ade- similar issues in separate level - separate needle CSEA quately flexing the lumbar spine.1 The findings in the technique and spinal or epidural anesthesia, the needle current study are consistent with those in reports that - through - needle combined spinal - epidural anesthesia revealed that a higher body mass index is associated technique has specific mechanisms as the failure to pen- with the difficulty in performing the neuraxial interven- etrate dura mater due to the inadequate advancement tion due to an increased lumbar epidural depth and poor of a short spinal needle that is too short, failure to sta- visibility of the landmarks used for interspinous space bilize the fine spinal needle, and deviation of from the identification.5,7,8,16,17 However, it should be noted that midline during local anesthetic administration.9 BMI was not found as a significant factor in the success rate of the intervention according to logistic regression It was observed that four patients in group HSP and analysis. another seven patients in group SP could not tolerate c) A combined spinal --- epidural anesthesia technique was their position due to pain during the procedure whereas used in our study. Although failures might be caused by no patient in group TSP. The pain might be unbearable
135 M.Ö. Özhan, C.Ö.C¸ aparlar, M.A. Süzer et al. with maximum extension or flexion of the knees in patients References with degenerated joints, as the positions stretch the mus- cles. It has been reported that muscle impairments and 1. de Filho GR, Gomes HP, da Fonseca MH, et al. Predictors of suc- pain in patients with osteoarthritis are not only limited cessful neuraxial block: a prospective study. Eur J Anaesthesiol. to the quadriceps but also involve the hamstring and hip 2002;19:447---51. muscles.18,19 2. Ruˇzman T, Gulam D, Drenjanˇcevi´c IH, et al. Factors asso- This study has several limitations: a) the block performers ciated with difficult neuraxial blockade. Local Reg Anesth. could not be blinded to the positioning b) they did not have 2014;7:47---52. sufficient experience to perform CSEA in the squatting posi- 3. Rhee Wj, Chung Cj, Lim Yh, et al. Factors in patient dis- tion, and c) the grading of interspinous space identification satisfaction and refusal regarding spinal anesthesia. Korean J Anesthesiol. 2010;59:260---4. was subjective. 4. Gurunathan U, Kunju SM, Hay KE, et al. Usefulness of a visual Ultrasonography has gained popularity in recent years aid in achieving optimal positioning for spinal anesthesia: a ran- as a useful tool for clinical examinations when per- domized trial. BMC Anesthesiol. 2018;18:11. forming central neuraxial blocks. It provides objec- 5. Tashayod ME, Tamadon S. Spinal block in sitting position without tive information including the depth of the epidural moving the legs. Middle East J Anaesthesiol. 1980;5:529---33. space, and the location of the midline and interspinous 6. Fisher KS, Arnholt AT, Douglas ME, et al. A randomized trial spaces.20,21 of the traditional sitting position versus the hamstring stretch It is concluded that both the squatting and hamstring position for labor epidural needle placement. Anesth Analg. stretch positions may be used as alternative positions to the 2009;109:532---4. traditional sitting position for combined spinal --- epidural 7. Soltani Mohammadi S, Hassani M, Marashi SM. Comparing the squatting position and traditional sitting position for ease of anesthesia in patients undergoing hip or knee arthroplasty spinal needle placement: a randomized clinical trial. Anesth because of the similar success rates, number of needle --- Pain Med. 2014;4:e13969. bone contact events, and grades of interspinous space iden- 8. Soltani Mohammadi S, Piri M, Khajehnasiri A. Comparing three tification. However, it should be noted that patients with different modified sitting positions for ease of spinal needle degenerated knee or hip joints may have intolerance to insertion in patients undergoing spinal anesthesia. Anesth Pain modified sitting positions due to pain. The body mass index Med. 2017;7:e55932. and the grade of intervertebral space identification may be 9. Cook TM. Combined spinal---epidural techniques. Anaesthesia. important determinants of combined spinal --- epidural anes- 2000;55:42---64. thesia success. Additional studies using radiologic imaging or 10. Antes G. The new CONSORT statement. BMJ. 2010;340:c1432. ultrasound are required to identify more objective measure- 11. Moher D, Hopewell S, Schulz KF, et al. CONSORT 2010 explana- tion and elaboration: updated guidelines for reporting parallel ments that predict difficulty of performing combined spinal group randomised trials. BMJ. 2010;340:c869. --- epidural anesthesia. 12. Juszczak E, Altman DG, Hopewell S, Schulz K. Reporting of Multi-Arm Parallel-Group Randomized Trials: Extension of the Registration CONSORT 2010 Statement. JAMA. 2019;321:1610---20. 13. Cohen J. Statistical power analysis for the behavioral sciences. 2nd ed. Hillsdale, NJ: Lawrence Erlbaum; 1988. p. 16. The trial was registered prior to patient enrollment at 14. Altman DG. Practical Statistics for Medical Research. Chapman ClinicalTrials.gov (http://clinicaltrials.gov), (NCT03541798, & Hall/CRC; 1991. principal investigator: Ceyda Ozhan Caparlar, date of regis- 15. Alexopoulos EC. Introduction to multivariate regression analy- tration: May 1, 2019). sis. Hippokratia. 2010;14:23---8. 16. Clinckscales CP, Greenfield ML, Vanarese M, et al. An observa- Conflict of interest tional study of the relationship between lumbar epidural space depth and body mass index in Michigan parturients. Int J Obstet Anesth. 2007;16:323---7. The authors declare no conflicts of interest. 17. Brummett CM, Williams BS, Hurley RW, et al. A Prospective, observational study of the relationship between body mass Author’s contributions index and depth of the epidural space during lumbar trans- foraminal epidural steroid injection. Regional Anesthesia & Pain Medicine. 2009;34:100---5. MÖÖ conducted the study, collected the data and con- 18. Dirac¸ oglu D, Baskent A, Yagci I, et al. Isokinetic strength mea- tributed the writing of the manuscript. CÖC¸ and MBE surements in early knee osteoarthritis. Acta Reumatol Port. analyzed the study results and contributed the revision 2009;34:72---7. of manuscript. MAS and BA assisted in analysis data and 19. Alnahdi AH, Zeni JA, Snyder-Mackler L. Muscle impair- contributed the writing of the manuscript. MÖÖ designed, ments in patients with knee osteoarthritis. Sports Health. directed the study and reviewed the study results. 2012;4:284---92. 20. Perlas A, Chaparro LE, Chin KJ. Lumbar Neuraxial Ultrasound for Spinal and Epidural Anesthesia: A Systematic Review and Acknowledgements Meta-Analysis. Reg Anesth Pain Med. 2016;41:251---60. 21. S¸ ahin T, Balaban O. Lumbar Ultrasonography for Obstetric The authors thanks to Volkan Türkmen for his professional Neuraxial Blocks: Sonoanatomy and Literature Review. Turk J expertise in biostatistics. Anaesthesiol Reanim. 2018;46:257---67.
136 Brazilian Journal of Anesthesiology 2021;71(2) 137---141
CLINICAL RESEARCH Patient safety in an endoscopy unit: an observational retrospective analysis of reported incidents
Cora Salles Maruri Correa a, Airton Bagatini a,∗, Cassiana Gil Prates b, Guilherme Becker Sander c a Hospital Ernesto Dornelles, Centro de Ensino e Treinamento do Sane (CET-SANE), Porto Alegre, RS, Brazil b Hospital Ernesto Dornelles, Servic¸o de Epidemiologia e Gerenciamento de Riscos, Porto Alegre, RS, Brazil c Hospital Ernesto Dornelles, Unidade de Endoscopia Gastrointestinal, Porto Alegre, RS, Brazil
Received 29 January 2020; accepted 12 December 2020 Available online 19 February 2021
KEYWORDS Abstract Medical errors; Introduction: Patient safety is a serious public health with serious implications on morbid- Risk management; ity, mortality, and quality of life of patients, in addition to negatively affecting the public Gastrointestinal image of healthcare institutions and professionals. It requires further investigation, especially endoscopy; in specialties lacking published data, such as endoscopy. Patient safety Objective: To analyze patient safety incidents reported in a gastrointestinal endoscopy unit of a tertiary hospital in southern Brazil. Methods: This retrospective, cross-sectional study quantitatively described patient safety inci- dents related to endoscopic procedures. The sample consisted of reports of incidents that occurred from 2015 to 2017. The data were descriptively analysed, and the study was approved by the relevant research ethics committee. Results: Overall, 42,863 endoscopic procedures were performed and 167 reports were submit- ted in the period, accounting for a prevalence of incidents of 0.38%. Most incidents did not result in unnecessary harm to patients (76.6%). The most prevalent incidents were those related to patient identification, followed by those related to pathology exams, exam reports, gastroin- testinal perforations, skin lesions, falls and medication errors. The rate of adverse events (harm to patient) in patients undergoing any endoscopic procedure was 0.06%. Conclusions: The incidence of unnecessary harm (adverse event) associated with any endo- scopic procedure was relatively low in this study. However, the identification of reported incidents is crucial for evaluating and improving the quality of care provided to patients. © 2021 Sociedade Brasileira de Anestesiologia. Published by Elsevier Editora Ltda. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by- nc-nd/4.0/).
∗ Corresponding author. E-mail: [email protected] (A. Bagatini). https://doi.org/10.1016/j.bjane.2021.02.023 © 2021 Sociedade Brasileira de Anestesiologia. Published by Elsevier Editora Ltda. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). C.S. Correa, A. Bagatini, C.G. Prates et al.
Introduction In this context, the aim of this study was to analyse reports associated with patient safety in an in-hospital gas- Patient safety is a serious public health issue that has trointestinal endoscopy unit. been the focus of a number of investigations worldwide. Healthcare-associated harm has serious implications on mor- Material and methods bidity, mortality, and quality of life of patients, in addition to negatively affecting the public image of healthcare insti- The study was approved by the Research Ethics Com- tutions and professionals.1 mittee of Hospital Ernesto Dornelles (approval number A milestone on the global patient safety movement was 83037718.5.0000.5304). The study was conducted in accor- the publication of ‘‘To err is human: building a safer health dance with the ethical standards as laid down in the 1964 system’’, an Institute of Medicine report2 that estimated the Declaration of Helsinki and its later amendments. For this number of deaths each year in United States (US) hospitals type of study, formal consent is not required. due to medical errors (between 44,000 and 98,000) and the This retrospective, cross-sectional study quantitatively total cost for the US government (between $17 billion and described patient safety reports related to endoscopic pro- $29 billion). Subsequent evidence suggests that the figures cedures performed at the Endoscopy Unit of Hospital Ernesto are even higher (between 210,000 and 400,000 deaths),3 and Dornelles, southern Brazil. This general hospital provides medical errors are described as the third leading cause of high-complexity services and has 320 beds for inpatients, death in the US.4 including 40 in the intensive care unit (ICU). Created in Important advances seeking to minimize the impact of 2014, the Endoscopy Unit has four examination rooms and errors and ensure safety to patients, practitioners, hospi- performs, on average, 1,200 procedures per month. Upper tals, and society have been observed in the past decade, gastrointestinal endoscopy, colonoscopy, nasoenteric tube especially with initiatives such as the World Alliance for placement, gastrostomy, and haemostasis of gastrointestinal Patient Safety, launched by the World Health Organization bleeding are offered. (WHO).5 In Brazil, the National Patient Safety Program sets The study included all reports related to patient safety out mandatory actions to be taken by healthcare facilities, that the Endoscopy Unit staff (nurses, practical nurses, and such as the creation of patient safety committees, imple- physicians) sent to the Epidemiology and Risk Management mentation of patient safety protocols, and management of Unit (which is responsible for patient safety policy) from patient safety incidents.6 January 1, 2015 to December 31, 2017. Standardized forms The WHO describes a patient safety incident as any event were used to ensure the anonymity of the reporting person. or circumstance that could have resulted, or did result, Incidents were classified according to the WHO Taxon- in unnecessary harm to a patient. An adverse event, in omy for Patient Safety5 as follows: reportable circumstance, turn, is defined as an incident that causes actual harm to which is an event with significant potential for harm; near a patient.5 miss, which is an incident that did not reach the patient; no There has been an important growth in the use of upper harm incident, which is an event that reached the patient and lower gastrointestinal endoscopy in recent years. This and caused no harm; and adverse event, which is an incident minimally invasive method allows performing diagnostic and that resulted in harm to the patient. therapeutic approaches through direct visualization, biopsy, Based on the degree of harm, adverse events were clas- polyp removal, mucosal resection, and haemostasis of gas- sified as follows: mild, when symptoms are mild, harm is trointestinal bleeding.7,8 Currently, upper gastrointestinal minimal, and no or minimal intervention is required; moder- endoscopy has also been used in the treatment of obesity ate, when the patient is symptomatic, requiring intervention with minimally invasive procedures such as endoscopic intra- (e.g., additional surgical procedure) and increased length of gastric balloon placement and, more recently, endoscopic stay, causing permanent or prolonged harm; severe, when sleeve gastroplasty.9 The increasing demand for healthcare the patient is symptomatic, requiring life support or major professionals and services that perform upper gastrointesti- surgical/medical intervention, shortening life expectancy nal endoscopy requires a greater focus on the availability of or causing permanent or prolonged harm; death, when the this procedure and its quality and safety indicators. Although event resulted in death or precipitated this outcome.5 teams involved in this type of procedure have gained prac- When a report did not describe an incident (event or tical experience, there are still few studies providing data circumstance that could have resulted, or did result, in on endoscopy-related incidents. unnecessary harm to a patient),5 it was classified as fol- The scope of endoscopy safety studies ranges from the lows: healthcare-related event (when an unexpected event assistance level, including patient admission, data checking, occurred in a medical procedure, which could not have and reason for treatment, to the procedural level, including been predicted or informed to the patient); nonconformity, trained teams, required equipment, proper environment to when some inconsistency occurred in healthcare delivery, perform the procedure, adequate monitoring, and health- such as inadequately scheduled procedure, which included care professional best prepared for administering sedation wrong date, unnecessary patient isolation, and patient with during the procedure.10---14 A report from the United King- latex allergy scheduled to a service that does not offer this dom (UK) government defines the following as eminently option; and others, when cases did not fit into the previously preventable incidents: failure to monitor and respond to described categories, such as a suspended procedure due to oxygen saturation, patient misidentification, wrong endo- inadequate clinical status or a cancellation requested by the scopic procedure, and misplaced nasogastric tubes.15 patient.
138 Brazilian Journal of Anesthesiology 2021;71(2) 137---141
Table 1 Demographic variables and characteristics of 167 tencies in scheduled procedures (wrong date, patient with reports of incidents and other events associated with patient latex allergy scheduled to a service that does not offer this safety. option, and unnecessary patient isolation), a procedure that did not meet the standards because there was no anaes- Variables n % thesiologist in the room, and a patient with gastrostomy Procedure tube who was fed through the cuff. Reports classified as Upper gastrointestinal endoscopy (UGIE) 50 29.9 ‘‘others’’ did not fit into the categories described above. Colonoscopy 42 25.1 In eight cases, patients did not undergo the procedure. Five UGIE + colonoscopy 26 15.6 procedures were suspended because patients’ clinical status Gastrostomy 15 9.0 was inadequate, one procedure was suspended because the Nasoenteric tube placement 12 7.2 patient had not fasted, and two procedures were cancelled Hemostasis of gastrointestinal bleeding 9 5.4 by the patients. Others 13 7.8 Most cases (105) did not require any additional inter- Urgent procedure (yes) 7 4.2 vention. However, 37.1% were managed with some type of Inpatient (yes) 66 39.5 evaluation or intervention, which increased the length of Classification stay for 30.5% of patients. When an incident or healthcare- Incidents 111 66.5 related event required intervention, medical evaluation was Reportable circumstance 2 1.2 the most frequent approach (55), followed by need of ICU Near miss 38 22.8 or emergency admission (38), diagnostic tests (36), med- No harm incident 45 26.9 ications (18), suspended procedure (16), calling a rapid Adverse event 26 15.6 response team (10), intubation (13), surgical procedure (6), Health care-related event 42 25.1 mask ventilation (5), and need of repeating an exam (2). Nonconformity 6 3.6 Others 8 4.8 Time of occurrence Discussion Before procedure 67 40.1 During procedure 41 24.6 In the study period, there were 167 reports of incidents that After procedure 59 35.3 occurred in the Endoscopy Unit. Of the events reported, 111 (66.5%) were considered incidents as described in the WHO taxonomy. Thus, the rate of incidents was 0.25% The data were descriptively analysed through simple (111/42,863), and 23.4% of patients suffered some degree (n) and relative (%) frequency for categorical variables of harm. The rate of adverse events in patients undergoing and through mean and standard deviation or median and any endoscopic procedure was 0.06% (26/42,863). interquartile range for quantitative variables. In Latin America, an estimated 10.5% of inpatients are affected by some type of adverse event during hospital stay, while the rate of preventable events is 58.9%.16 In Brazil, Results the estimated incidence of patients undergoing adverse events is 7.6%, and 66.7% of those events are considered Overall, 42,863 procedures were performed and 167 reports preventable.17 In the present study, the overall rate of were submitted (0.38%) in the study period. In 2015, there reports of incidents and adverse events was 0.38%. No equiv- were 12,816 procedures and 33 reports (0.26%); in 2016, alent studies were found to compare specific data from 14,592 procedures and 59 reports (0.40%); and in 2017, different gastrointestinal endoscopy units. 15,455 procedures and 75 reports (0.48%). Demographic Regarding safety in gastrointestinal endoscopic proce- variables and characteristics of the 167 reports are shown dures, which is the focus of this paper, all patients must be in Table 1. thoroughly evaluated, including before, during, and after Of all events reported, 111 (66.5%) were considered inci- any procedure. Having access to patient medical history dents as described in the WHO taxonomy; thus, the rate is essential because previous health conditions may affect of incidents was 0.25% (111/42,863). Most incidents did not tolerance to the procedure, e.g., history of obstructive result in unnecessary harm to patients (76.6%). However, in sleep apnea may indicate impaired ventilatory function with 26 cases, some degree of harm was identified: mild, 57.7%; sedation.18 Women of childbearing age should be asked moderate, 11.5%; severe, 23.1%; and death, 7.7%. The rate about a possible pregnancy, especially in case of elective of adverse events in patients undergoing any endoscopic procedures that may be delayed, as sedative drugs may procedure was 0.06% (26/42,863). Regarding only the 111 not be safe for pregnant patients. All medications and reported incidents, those related to patient misidentifica- dosages used by patients should be recorded.18 Informed tion were most frequent (35%), followed by those related to consent should always be obtained prior to the procedure, pathology exams (13.5%), exam reports (12.6%), gastroin- with guidance on risks, benefits, and how sedation will be testinal perforations (6.3%), skin lesions (4.5%), falls (2.7%), administered.14,18 and medication errors (2.7%). The Brazilian National Health Surveillance Agency passed Healthcare-related events accounted for 25.1% of all the Resolution of the Collegiate Board of Directors number reports. They included desaturation (4.8%), bradycardia 6, as of March 1, 2013, providing that an endoscopic proce- (1.8%), cardiac arrest (1.2%), aspiration (1.8%), and others dure with deep sedation or non-topical anaesthesia requires (38.9%). The reported nonconformities consisted of inconsis- a legally qualified professional to administer anaesthetics. In
139 C.S. Correa, A. Bagatini, C.G. Prates et al. addition, the patient should be monitored during the entire unit, endoscopic procedures have anesthesiologists to mon- procedure until he/she is well enough to be transferred to itor the patient and administer sedation. the recovery room.19 With regard to endoscopy-associated complications, a Incidents might occur at different moments, such as US study that analysed 12,407 colonoscopies performed by arrival, admission, procedure, or even recovery from seda- eight gastroenterologists reported that perforation occurred tion. However, studies show that approximately half of in only two patients (0.016%).23 In our study, 23,088 colono- significant adverse events occurring in gastrointestinal endo- scopies were performed and seven perforations occurred, scopic procedures is associated with sedation.10 In our study, accounting for 0.03%. 40.1% of all reports consisted of events that occurred before The risks identified for cardiopulmonary complications procedures, while 24.6% occurred during and 35.3% after can be divided into: patient-specific: 1) ischemic heart dis- procedures. When considering only the 26 adverse events ease; 2) moderate-to-severe lung disease; 3) inpatients; reported in our evaluation, 73% occurred during, 23% after, 4) oxygen saturation < 95%; 5) age > 70 years; 6) Amer- and 3.84% before procedures. In our study, however, 50% ican Society of Anesthesiologists (ASA) class III and IV; of adverse events occurring during and after procedures or procedure-specific: 1) urgent procedures; 2) sedation were due to gastrointestinal perforation and gastrointesti- method; 3) use of adjuvant sedative agents; 4) use of nal laceration/bleeding without perforation, 19.2% due to supplemental oxygen, which may conceal hypoventilation skin lesions, and 11.5% due to falls. when only pulse oximetry is assessed.11 In our study, there Among the major concerns in healthcare services, patient was no specific analysis for cardiopulmonary complications misidentification is known as a key problem in ensuring alone, as we included other incidents and adverse events. patient safety. In 2003, the Joint Commission had already In addition, there was no statistically significant association placed improving patient identification as the first of its six between age and other variables such as patients with higher International Patient Safety Goals.20 Then, in 2007, the US incidence of complications, in- or outpatients, and number organization published a report with solutions for patient of comorbidities reported. Conversely, patients undergo- safety, focusing on proper identification. This report had the ing urgent procedures had lower incidence of complications alarming evidence that adverse events due to medication when compared with those undergoing elective procedures errors, transfusion errors, testing errors, and wrong person (p = 0.05). procedures most frequently derive from failure to correctly Our analysis was based on reports that the Endoscopy Unit identify patients.21 In our study, 39 reports were associ- staff voluntarily sent to the Epidemiology and Risk Manage- ated with patient misidentification, accounting for 23.4% of ment Unit. We know that voluntary reporting alone is not all reports (n = 167), and 82% of these patients had already optimal for the identification of incidents, but it must be been admitted. Misidentification included patients without encouraged by the staff coordination team. identification wristband or with illegible identification wrist- Notification through computerized systems, although still band. No adverse events due to those errors were reported. incipient in many institutions, has been developed as a A Brazilian study conducted at a São Paulo state teaching strategy for improving incident management.24 A study con- hospital prepared an instrument that asked patients if they ducted at Hospital das Clínicas of Ribeirão Preto School of knew an identification wristband existed, if they had used Medicine observed an increase in the number of reports with it in the present admission, and if it had been removed and the implementation of computerized reporting when com- why.22 The results showed that only 4.1% of patients were pared to handwritten reporting. This may be explained by given an identification wristband at the time of admission. the fact that the electronic method is free of punishment; The situation is even more serious when considering that however, it still struggles with underreporting.25 As our unit 20.8% of patients who were transferred from other hospi- still lacks a computerized reporting system, all reports are tals to the study hospital had their wristband removed after handwritten, mostly by nurses and practical nurses. Thus, admission. Additionally, 22% of patients had never used iden- we know that our data may be incomplete because of under- tification wristbands, demonstrating that the importance of reporting. this device remains poorly understood, as well as the need The use of checklists is gaining ground in the debate of ensuring that all patients and their beds are properly over prevention of errors. A 2013 study reported an expe- identified during the entire admission.22 rience of introduction of a checklist into a gastrointestinal In many places, the increased number of procedures endoscopy unit, outlining lessons regarding team engage- requiring sedation, such as gastrointestinal endoscopies, ment and training, best method of implementation, and has not been proportional to the availability of trained errors that were identified and could be corrected. As the professionals to administer drugs for such purpose.12 This article reinforces, preventing all possible errors during a fact, along with an apparent ease of administration of procedure is unfeasible; however, a checklist can establish sedative techniques, has led to the appearance of non- those amenable to identification and correction and can pro- anaesthesiologists in charge of inducing sedation.12,13 All the vide guidance such as avoiding that the patient enters the guidelines reviewed by Wehrmann and Triantafyllou13 estab- examination room without identification wristband, altering lished that the endoscopist is not able to single-handedly incorrect information about the patient, identifying aller- administer propofol sedation and monitor the patient; thus, gies reported, checking informed consent, and preventing another professional is required to perform those tasks, errors in the description of histopathological samples and namely an anesthesiologist, a gastroenterologist trained other exam reports.26 Our unit has already implemented a in propofol administration, or a nurse trained in propo- periodically updated checklist system that aims to reduce fol administration. However, the use of propofol is still the occurrence of errors as much as possible. Our check- restricted to anesthesiologists in some countries.13 In our list is used at four different moments: at endoscopy unit
140 Brazilian Journal of Anesthesiology 2021;71(2) 137---141 admission, in the examination room before and after the 7. Ono H. Early gastric cancer: diagnosis, pathology, treatment procedure, and finally in the recovery room. techniques and treatment outcomes. Eur J Gastroenterol Hep- The information obtained in this study allowed us to atol. 2006;18:863---6. analyse the reports of incidents that occurred in the study 8. Loperfido S, Baldo V, Piovesana E, et al. Changing trends in period, with specific data on our Endoscopy Unit. To our acute upper-GI bleeding: a population-based study. Gastrointest Endosc. 2009;70:212---24. knowledge, there are no similar studies addressing patient 9. Abu Dayyeh BK, Acosta A, Camilleri M, et al. Endoscopic safety at an endoscopy unit, which makes our work original. sleeve gastroplasty alters gastric physiology and induces loss of The limitations of this study include its retrospective body weight in obese individuals. Clin Gastroenterol Hepatol. design, which prevents the acquisition of further data. 2017;15:37---43. In addition, because the reports had to be submitted by 10. Aisenberg J. Endoscopic sedation: equipment and personnel. healthcare professionals, a team member was responsible Gastrointest Endosc Clin N Am. 2008;18:641---9. for notifying the Epidemiology and Risk Management Unit, 11. Cohen Lb. Patient monitoring during gastrointestinal which may have led to underreporting. endoscopy: why, when, and how? Gastrointest Endosc Clin N Am. 2008;18:651---63. 12. Van der Linden P. Sedation in gastrointestinal endoscopy: an Conclusions anesthesiologist’s perspective. Digestion. 2010;82:102---5. 13. Wehrmann T, Triantafyllou K. Propofol sedation in gastrointesti- The study showed the incidents that occurred in the nal endoscopy: a gastroenterologist’s perspective. Digestion. endoscopy unit in a hospital in southern Brazil, emphasizing 2010;82:106---9. the magnitude and characteristics of patient safety prob- 14. Feld AD. Endoscopic sedation: medicolegal considerations. Gas- lems, especially with regard to underreporting. The data trointest Endosc Clin N Am. 2008;18:783---8. obtained can provide the basis for the development of mon- 15. Department of Health. The ‘‘never events’’ list for 2012/13. London, UK: Patient Safety and Investigations; 2012. itoring and care strategies in other health institutions with 16. Ministerio de Sanidad y Política Social de Espana.˜ Prevalencia regard to endoscopic procedures, creating learning oppor- de efectos adversos en hospitales de latinoamérica. Madrid, ES: tunities and the potential for culture change and, with this, Estudio IBEAS; 2010. developing safer healthcare. 17. Mendes W, Martins M, Rozenfeld S, et al. The assessment of In the healthcare setting, providing care in line with the adverse events in hospitals in Brazil. Int J Qual Health Care. principles of quality management and free of unnecessary 2009;21:279---84. harm to patients, professionals, institutions and society is 18. Mitty RD, Wild DM. The pre- and postprocedure assessment imperative. In view of the current rise of endoscopic pro- of patients undergoing sedation for gastrointestinal endoscopy. cedures for diagnosis and treatment, as well as the lack of Gastrointest Endosc Clin N Am. 2008;18:627---40. national studies addressing patient safety in this specialty, 19. Ministério da Saúde. Agência Nacional de Vigilância Sanitária. Resoluc¸ão RCD no 6, de 10 de Marc¸o de 2013. Dispõe sobre os analysing patient safety incidents related to such proce- requisitos de boas práticas de funcionamento para os servics ¸o dures is required to broaden and strengthen the discussion, de endoscopia com via de acesso ao organismo por orifícios ensuring the continuous improvement of care processes and exclusivamente naturais. Brasília, DF: Diário Oficial da União; patient safety. 2013. 20. Joint Commission. National patient safety goals. Oakbrook Ter- Conflicts of interest race, IL: Joint Commission; 2006. 21. World Health Organization (WHO), Joint Commission Inter- national (JCI), WHO Collaborating Centre for Patient Safety The authors declare no conflicts of interest. Solutions. Patient safety solutions. Geneva, Switzerland: WHO; 2007. References 22. Miasso AI, Cassiani SHB. Erros na administrac¸ão de medicamen- tos:o divulgac¸ã de conhecimentos e identificac¸ão do paciente como aspectos relevantes. Rev Esc Enferm USP. 2000;34: 1. National Patient Safety Foundation (NPSF). RCA2: improving 16---25. root cause analyses and actions to prevent harm. Boston, MA: 23. Rathgaber SW, Wick TM. Colonoscopy completion and compli- National Patient Safety Foundation; 2015. cation rates in a community gastroenterology practice. 2. Committee on Quality of Health Care in America.Kohn LT, Cor- Gastrointest Endosc. 2006;64:556---62. rigan JM, Donaldson MS, editors. To ERR is human: building a 24. Gong Y, Kang H, Wu X, et al. Enhancing patient safety event safer health system. Washington, DC: National Academies Press; reporting: a systematic review of system design features. Appl 2000. Clin Inform. 2017;8:893---909. 3. James JT. A new, evidence-based estimate of patient harms 25. Capucho HC, Arnas ER, Cassiani SHB. Seguranc¸a do paciente: associated with hospital care. J Patient Saf. 2013;9:122---8. comparac¸ão entrenotificac¸ ões voluntárias manuscritas e 4. Makary MA, Daniel M. Medical error---- the third leading cause of informatizadas sobre incidentes em saúde. Rev Gaúcha Enferm. death in the US. BMJ. 2016;353:i2139. 2013;34:164---72. 5. World Health Organization (WHO). The conceptual framework 26. Matharoo M, Thomas-Gibson S, Haycock A, et al. Implementa- for the international classification for patient safety. Geneva, tion of an endoscopy safety checklist. Frontline Gastroenterol. Switzerland: WHO; 2009. 2014;5:260---5. 6. Ministério da Saúde. Portaria no 529, de 1o de Abril de 2013. Institui o Programa Nacional de Seguranc¸a do Paciente (PNSP). Brasília, DF: Diário Oficial da União; 2013.
141 Brazilian Journal of Anesthesiology 2021;71(2) 142---147
SYSTEMATIC REVIEW Wristbands use to identify adult patients with difficult airway: a scoping review
Eduardo Lema-Florez a,b,∗, Juan Manuel Gomez-Menendez a,b, Fredy Ariza a,c, Andrea Marin-Prado a
a Universidad del Valle, Department of Anaesthesiology, Cali, Colombia b Centro Médico Imbanaco, Department of Anaesthesiology, Cali, Colombia c Universidad ICESI, Fundacion Valle del Lili, Department of Anesthesiology, Cali, Colombia
Received 26 December 2019; accepted 24 December 2020 Available online 19 February 2021
KEYWORDS Abstract Airway management; Background: Difficult airway is a clinical situation in which a trained anesthesiologist expe- Hospital risk report; riences trouble with facemask ventilation and/or laryngoscopy and/or intubation. Poor Patient care identification of at-risk patients has been identified as one of the causes of difficult airway planning; management. Patient identification Objectives: We aimed to review the literature regarding the use of wristbands to identify adult systems; patients with known or predicted difficult airway in hospitals. Risk assessments Methods: We searched Web of Science (WoS), Scopus, MEDLINE and OVID following the stages described by the PRISMA Extension for Scoping Reviews (PRISMA-ScR). We used a combination of MeSH terms and non-controlled vocabulary regarding the use of difficult airway wristbands in adults. Three researchers independently reviewed the full texts and selected the papers to be included based on the inclusion criteria. Results: Our search generated 334 articles after removing duplicates. After reviewing full text articles, only seven studies were included. Here we found that most were from the United States, in which the authors report the use of in-patients’ wristbands in adults. According to the authors, the use of wristbands is being implemented as a measure of improved quality and safety of in-patients with difficult airway either known or suspected. Conclusions: The identification with wristbands of a difficult airway at an appropriate time is an identification strategy can have a low cost but a high impact on morbidity. It is pertinent to develop a methodology such as the use of wristbands, that allows a good classification and identification of patients with difficult airway in hospitals from Latin America. © 2021 Sociedade Brasileira de Anestesiologia. Published by Elsevier Editora Ltda. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by- nc-nd/4.0/).
∗ Corresponding author. E-mail: [email protected] (E. Lema-Florez). https://doi.org/10.1016/j.bjane.2021.02.022 © 2021 Sociedade Brasileira de Anestesiologia. Published by Elsevier Editora Ltda. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). Brazilian Journal of Anesthesiology 2021;71(2) 142---147
Introduction ( ( TITLE-ABS-KEY ( airway¨ control¨) OR TITLE-ABS-KEY ( airway¨ management¨) OR TITLE-ABS-KEY ( difficult¨ airway¨) One of the leading causes of anesthesia-related injury is OR TITLE-ABS-KEY ( airway¨ ¨))) the failure to intubate the trachea and secure the airway.1 AND The American Society of Anesthesiologists (ASA) published in ( ( TITLE-ABS-KEY ( wristband ) OR TITLE-ABS-KEY ( 1993 an initial practice guideline for difficult airway mana- bracelet ) OR TITLE-ABS-KEY ( bracelet¨ identification¨) OR gement to prevent the adverse outcomes associated, such TITLE-ABS-KEY ( bracelet¨ medical information¨) OR TITLE- as brain damage, myocardial injury, and death.2,3 The term ABS-KEY ( bracelet¨ hospital¨) OR TITLE-ABS-KEY ( alert¨ ‘‘difficult airway’’ is used for a clinical situation in which a bracelet¨))) trained anesthesiologist experiences trouble with facemask Only for the OVID search we also included in the equation ventilation and/or laryngoscopy and/or intubation.4 --- 6 Diffi- the term ‘‘Patient identification system’’. All searches were cult intubation has been reported with an incidence of 0.5% made without language or time restrictions until July 2020. up to 10% in patients undergoing general anesthesia depend- To control publication bias, we also conducted a generic and ing of used parameters.7 As this fact varies across studies, academic Internet search and a metasearch. A search strat- there are no standardized definitions for difficult airway in egy defined for ‘‘gray literature’’ was included to gather the emergency department setting, where the incidence of information from the source Google Scholar, with the non- the difficult airway has been described as wide as 2% to 27%.8 controlled terms ‘‘wristbands’’, ‘‘bracelets’’, and ‘‘difficult Risk factors related to difficult airway scenario include airway’’. poor identification of at-risk patients, poor or incom- plete planning, inadequate provision of skilled staff and Data charting process and data extraction equipment,9 delayed recognition of events,10 and failed res- 11 cue due to failure in interpreting the capnography. As We included studies describing in-hospital factors associ- difficult airway is, unfortunately, an ever-present hazard ated with unexpected difficult airway events and possible in anesthetic practice, some recommendations have been strategies to assertive identification of these subjects. Three suggested to better management of this issue, including individuals (EL, FA, GMG) independently examined the titles the establishment of a structured difficult airway/intubation and abstracts identified in the search. Articles considered as registry linked to a highly visible coded patient wristband for 12 relevant were selected and downloaded for full-text review. in-hospital identification of such patients. Three researchers (EL, FA, GMG) independently reviewed The use of visible wristbands for subjects with different the full texts and selected the papers to be included in risk conditions have been proven important and a safe way the scoping review based on the inclusion criteria. With the for identification by all the medical staff that works at a hos- 12---15 studies finally selected, the same researchers extracted the pital and have contact with them. This alert tool could data. Disagreements were resolved by consensus. be vital for a patient with difficult airway and should be employed widely by the hospitals. In this context, the pur- pose of this study is to review the literature regarding the Synthesis of results use of wristbands to identify adult patients with known or predicted difficult airway in hospitals. The variables of abstraction included: author, year of the study, country, journal, study design, and wristband appli- cability. A data extraction table was built in Microsoft Excel Methodology to organize the results.
Protocol and registration Results
This scoping review was based on the stages described by A systematic search of scientific evidence in Web of Sci- the PRISMA Extension for Scoping Reviews (PRISMA-ScR).16 ence (WoS), Scopus, MEDLINE, OVID, and Google scholar The protocol was registered at the Open Science Framework yielded 334 results after duplicates were removed. Of these, database.17 the abstracts and titles were screened, and 301 citations excluded. Thirty articles were retrieved and reviewed in Eligibility criteria full-text, and after applying the inclusion/exclusion crite- ria, 23 articles were further excluded. The resulting seven Original studies that implemented the use of in-hospital studies were used for the qualitative analyses (Fig. 1). Main wristbands for the identification of adult patients with dif- characteristics and information of the selected papers are ficult airway were eligible for this scoping review. summarized in Table 1. The studies found ranged from 1992 to 2017, and most of them were from hospitals in the United States. Most studies were retrospective reviews, and only Information sources and search one case report. The use of wristbands is being implemented in hospitals as a measure of improve quality and safety of The structured searching for relevant papers at Web of Sci- patients with difficult airway. According to the studies, these ence (WoS), Scopus, MEDLINE, and OVID used a combination wristbands should be of a bright color such as green or blue of MeSH terms and non-controlled vocabulary that we con- to enhance visibility, and patients must keep it throughout sidered crucial to our objective, in the equation: the hospitalization.
143 E. Lema-Florez, J.M. Gomez-Menendez, F. Ariza et al. esponse Team (DART) should their airway have a difficult airway hadattached a next green to alert their band patientband. identification This alert band stayedthroughout with the the hospitalization. patient Each patient identified as havingairway a is difficult given a blueimmediately wristband activate to the Difficult Airway R (DAID) bracelet arose from aimprovement safety-focused become compromised. Patients identified as having aairway/intubation difficult were entered into an ongoing ‘‘Anesthesia-Medical Alert’’ investigation that involved immediate application of a temporary patientand wristband enrollment in an in-househigh registry. visibility The of the wristbandinformation and alerted its health care providersthe to special requirements of thethe patients duration for of their hospitalization. implemented since 2011 as aimprovement quality intervention Wristband applicability UK anaesthetic departments responded that used warning bracelets issued whilstpatient the is in the hospitaldocumentation as and a communication method of of airway problems. After the documentation of ain difficult a airway patient, identification deviceswristbands such and as alert stickers inamong the others notes, are being used. review The creation of a difficult airway identification etrospective review Since 1996, in-patients who were known to etrospective etrospective etrospective review Difficult airway wristband alerts were descriptive analysis R Case report R Study type R Cross-sectional study According to the questionnaires, only 4% of the Survey and retrospective analysis R Anesthesia & Analgesia Journal of Clinical Anesthesia Anesthesia & Analgesia Journal The Joint Commission Journal on Quality and Patient Safety Anaesthesia Anaesthesia and Intensive Care Journal of Intensive Care Medicine United States United States United States Country United States United Kingdom New Zealand United States Characteristics and main information of articles included in this review. et al. 2009 Berkow Mark et al. 1992 Mark et al. 2015 Table 1 Author/Year Atkins et al. 2017 Barron et al. 2003 Baker et al. 2013 Darby et al. 2016
144
Brazilian Journal of Anesthesiology 2021;71(2) 142---147
Records identi fied through database
no searching i
tacifitnedI (n = 43)
Scopus: 9
MEDLINE: 5 Addition al records identified WoS: 5 through other sources OVID: 24 (n = 367)
Records after duplicates removed (n = 334) cree ning S
Records screened Records excluded (n = 334) (n = 301)
Full -text articles excluded
Full -text arti cles assessed because they did not met
li gibility for eli gibility
E the inclusion criteria
(n = 30) (n = 23) Studies incl uded in systematic review
ud ed (n = 7) Incl
Figure 1 PRISMA Flow diagram.
Discussion problems before attempting the intubation.7,8 Even after using multiple clinical screening tests, a significant inci- With this study we aimed to review the literature regard- dence of unanticipated difficult laryngoscopy (1%---8%) has 18 ing the use of wristbands to identify adult patients with been observed. The identification for individuals with pre- known or predicted difficult airway in hospitals. Here we vious high C-L grades or difficult/impossible access to airway found seven original studies, most from the United States, in by visual reminders would be of relevance to healthcare per- which the authors report the use of in-patients’ wristbands sonal and multidisciplinary teams in order to remind the in adults. According to the authors, the use of wristbands seriousness of this condition and force them to consider a is being implemented as a measure of improved quality and structured plan if troubles are present. There are different safety of in-patients with difficult airway either known or tests that can be combined to achieve a better airway mana- suspected. gement in the patient. The Mallampati classification is one of the most used and is based on the structures identified when seated patients have maximal mouth opening and tongue 3 Identification of patient with difficult airway protrusion. Computed tomography and magnetic resonance imaging are also helpful to measure the internal diameter of the trachea and to identify disease processes such as In emergency settings, identification of anticipated diffi- trauma, infection, and neoplasm.3,19 Ultrasound and plain cult airway is a crucial step to achieve first-pass success radiographs are used too, the latter can be useful to demon- and avoid encountering a ‘‘cannot intubate, cannot venti- strate tracheal compression or deviation and to indicate the late’’ situation. The level of difficult intubation depends need for more investigation and imaging.3,19,20 on the degree of glottic view with laryngoscopy. Cormack Difficult airway in a patient is most likely to be evident and Lehane (C-L) classification system is the most widely in an operating room, nonetheless, subsequent events might used scale to categorize the degree of visualization of lar- occur in different places and involve physician or nonphysi- ynx by direct laryngoscopy. The C-L grades 3 and 4 are cian providers. Hence, anesthesiologist or any healthcare highly correlated with difficult or failed intubations. How- provider should make every effort to identify patients with ever, as identification of the C-L grade needs to insert the difficult airway both in and out of the operating room, and laryngoscopy, clinicians should estimate the probability of
145 E. Lema-Florez, J.M. Gomez-Menendez, F. Ariza et al. effectively communicate this information widely, making it authors explained the use of a blue wristband in patients accessible, using universal and easy-to-understand terms to with known difficult airway as a measure included in their advise other health professionals, family members, or the Difficult Airway Response Team (DART) program developed patients themselves about the condition.21 in 2005. Recently, a new proposal has arose regarding the iden- tification of patients with difficult airway called ‘‘The DAS The use of wristbands in hospitals Airway Alert Card and Difficult Airway Database Project’’. This project aims to address this issue by providing a simple When difficult airway has been recognized, medical staff and easy reporting system that promise not only to make it should document specific details for which templates for this easy to report but also ensures availability of this informa- purpose have been previously published.22 Measures such tion full-time. This is a remarkable effort to unify the health as wristbands and patient identification emblems/bracelets issues of patients, specifically regarding the difficult airway, and alert cards, such as that provided by the New Zealand in a national database. However, this project is only for the Society of Anaesthetists in a tertiary referral hospital, have United Kingdom. been employed according to Baker et al.23 Difficult airway information must be shared openly so that future potential Limitations problems are avoided.22 One of the best ways to share this information is to develop an international alert system that allows health care providers to have instant access to the The main limitation of our study was the few number of conditions of a patient, even if the patient have to be trans- original articles found in the search, we believe this might ferred to a health care institute in another city or country.23 be due to the lack of documentation of wristband use in Hoffmeister and De Moura15 did a quantitative study to patients with difficult airway rather than a reflection of low check the presence of identification wristbands and iden- use of this strategy. tifiers used in a hospital from Brazil. They found that out of 385 patients, 95.8% of the patients used the wristbands, Conclusions while the remaining did not use them because they did not think it was important. The identifiers used on the The identification of a difficult airway with wristbands at an wristbands were mainly the full name and the registra- appropriate time is a strategy can have low cost but high tion number. The authors found that some patients used impact on morbidity. Here we found that the use of wrist- anti-allergic micropore covering the internal section of the bands is being implemented as a measure to improve quality wristbands to avoid an allergic reaction to the material. and safety of in-patients with difficult airway either known On the other hand, according to the Health ministry in or suspected in developed countries. However, we did not Colombia, the use of wristbands is essential for the correct find studies from Latin-American countries, which lead us to identification of the patients and its absence is classified as believe that it is pertinent to develop a methodology such as 24 an active failure that can lead to major adverse events. the use of wristbands, that allows a good classification and Their recommendation when the bands are depleted is to identification of patients with difficult airway in hospitals use any other method to identify the patients such as cards from Latin America. with the patient’s information. Nevertheless, a unified clas- Moreover, it would be a good improvement in quality the sification system should be developed nationwide, not only establishment of a coding color for the wristbands within in Colombia but also in other Latin-American countries that hospitals nationwide, as well as improving the quality of the lack of a proper in-hospital identification system for their material used for the wristbands, making sure that the ink difficult airway patients, which is evident given the absence used for inscriptions on the wristbands do not wash off eas- of publications regarding this matter. ily. It would also be important to consider that some patients 25 In the retrospective review of Atkins et al. at the Hospi- may be allergic to the material of the wristbands, and they tal of the University of Pennsylvania, the authors report the should be made with anti-allergic materials. In addition, we implementation of a Difficult Airway ID system since 2006, believe that it may be important to consider the develop- in which the medical staff place a wristband on the patient ment of an application or database of universal consultation, with documented difficult airway or anticipated difficult air- with its identification number of patients with difficult air- way while they are in the hospital. This system, according way. to the authors, is along the lines of a model described by Berkow et al.26 Regarding the use of wristbands, Berkow et al.,26 report that since 1996, in-patients with known dif- Conflicts of interest ficult airway wore throughout their hospitalization time, a green alert band attached to their identification band. The authors declare no conflicts of interest. Moreover, Darby et al.,27 developed at the University of Pittsburgh Medical Center Presbyterian Hospital, a Difficult References Airway Management Team since 2005, which involved since 2011 the use of difficult airway wristband alerts as a qual- 1. Niforopoulou P, Pantazopoulos I, Demestiha T, et al. Video- 12 ity improvement intervention. Mark et al. in 1992 and Mark laryngoscopes in the adult airway management: a topical review 28 et al. in 2015 report the application of a temporary patient of the literature. Acta Anaesthesiol Scand. 2010;54:1050---61. wristband with high visibility at the Johns Hopkins Hospi- 2. Apfelbaum JL, Hagberg CA, Caplan RA, et al. Practice guide- tal in Baltimore, Maryland. In their study from 2015, the lines for management of the difficult airwayan updated report
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by the American Society of Anesthesiologists task force on 17. Lema-Flórez E, Gómez-Menendez J, Ariza F, et al [cited 2020 management of the difficult airway. J Am Soc Anesthesiol. Aug 8]. Available from: https://osf.io/ynmvf/, 2020. 2013;118:251---70. 18. Shiga T, Wajima Z, Inoue T, et al. Predicting difficult intu- 3. Gajree S, O’Hare KJ. Identification of the difficult airway. bation in apparently normal patients: a meta-analysis of Anaesth Intensive Care Med. 2017;18:447---50. bedside screening test performance. Anesthesiology. 2005;103: 4. Oriol-López S, Hernández-Mendoza M, Elena Hernández-Bernal 429---37. C, et al. Assessment, prediction and occurrence of difficult intu- 19. Crawley SM, Dalton AJ. Predicting the difficult airway. BJA Educ. bation. Rev Mex Anestesiol Anestesiol. 2009;32:41---9. 2014;15:253---7. 5. Sakrikar G, Shah P. Correlation of anticipated difficult airway 20. Jain K, Gupta N, Yadav M, et al. Radiological evaluation of with concurrent intubation: a prospective observational study. airway - What an anaesthesiologist needs to know! Indian J Airway. 2019;2:22---7. Anaesth. 2019;63:257---64. 6. Wilkes M, Beattie C, Gardner C, et al. Difficult airway commu- 21. Feinleib J, Foley L, Mark L. What We All Should Know About Our nication between anaesthetists and general practitioners. Scott Patient’s Airway. Difficult Airway Communications, Database Med J. 2013;58:2---6. Registries, and Reporting Systems Registries. Anesthesiol Clin. 7. Xu Z, Ma W, Hester DL, et al. Anticipated and unantici- 2015;33:397---413. pated difficult airway management. Curr Opin Anaesthesiol. 22. Barron FA, Ball DR, Jefferson P, et al. ‘‘Airway Alerts’’. How 2018;31:96---103. UK anaesthetists organise, document and communicate difficult 8. Goto T, Goto Y, Hagiwara Y, et al. Advancing emergency air- airway management. Anaesthesia. 2003;58:73---7. way management practice and research. Acute Med Surg. 23. Baker PA, Moore CL, Hopley L, et al. How do anaesthetists in 2019;6:336---51. New Zealand disseminate critical airway information? Anaesth 9. Leeuwenburg TJ. Access to difficult airway equipment and Intensive Care. 2013;41:334---41. training for rural GP-anaesthetists in Australia: results of a 2012 24. Ministerio de Salud de Colombia. Asegurar la correcta survey. Rural Remote Health. 2012;12:2127. identificación del paciente en los procesos asistenciales 10. Gormley G, Mannion S. Airway Management in Ambulatory Anes- [Internet]. Available from: https://www.minsalud.gov.co/ thesia. Curr Anesthesiol Rep. 2014;4:342---51. sites/rid/Lists/BibliotecaDigital/RIDE/DE/CA/asegurar- 11. Cook TM, MacDougall-Davis SR. Complications and failure of identificacion-paciente-procesos-asistenciales.pdf. airway management. Br J Anaesth. 2012;109:i68---85. 25. Atkins JH, Rassekh CH, Chalian AA, et al. An Airway Rapid 12. Mark LJ, Beattie C, Ferrell CL, et al. The difficult airway: mech- Response System : Implementation and. Jt Comm J Qual Patient anisms for effective dissemination of critical information. J Clin Saf. 2017;43:653---60. Anesth. 1992;4:247---51. 26. Berkow LC, Greenberg RS, Kan KH, et al. Need for emergency 13. Smith AF, Casey K, Wilson J, et al. Wristbands as aids to reduce surgical airway reduced by a comprehensive difficult airway misidentification: an ethnographically guided task analysis. J program. Anesth Analg. 2009;109:1860---9. Int Soc Qual Heal Care. 2011;23:590---9. 27. Darby JM, Halenda G, Chou C, et al. Emergency Surgical Airways 14. Sevdalis N, Norris B, Ranger C, et al. Designing evidence- Following Activation of a Difficult Airway Management Team in based patient safety interventions: the case of the UK’s Hospitalized Critically Ill Patients: A Case Series. J Intensive National Health Service hospital wristbands. J Eval Clin Pract. Care Med. 2018;33:517---26. 2009;15:316---22. 28. Mark LJ, Herzer KR, Cover R, et al. Difficult airway response 15. Hoffmeister LV, De Moura GMSS. Use of identification wristbands team: a novel quality improvement program for managing among patients receiving inpatient treatment in a teaching hos- hospital-wide airway emergencies. Anesth Analg. 2015;121:127. pital. Rev Lat Am Enfermagem. 2015;23:36---43. 16. Tricco AC, Lillie E, Zarin W, et al. PRISMA Extension for Scoping Reviews (PRISMA-ScR): Checklist and Explanation. Ann Intern Med. 2018;169:467---73.
147 Brazilian Journal of Anesthesiology 2021;71(2) 148---161
NARRATIVE REVIEW Historical development of the anesthetic machine: from Morton to the integration of the mechanical ventilator
Pablo Romero-Ávila a,∗, Carlos Márquez-Espinós b, Juan R. Cabrera Afonso b,c
a Hospital Costa del Sol, Department of Anesthesiology and Resuscitation, Marbella, Spain b Hospital La Línea, La Linea de la Concepción, Department of Anesthesiology and Resuscitation, Cádiz, Spain c University of Cádiz, School of Medicine, Department of the History of Science, Cádiz, Spain
Received 16 July 2019; accepted 22 November 2020 Available online 10 February 2021
KEYWORDS Abstract The first anesthetic machines appeared following their public demonstration by Anesthetic machine; Morton in 1846. These initial devices were simple inhalers based on the evaporation of the Mechanical anesthetic agent. Their main problem was the loss of effectiveness with cooling. More complex ventilator; inhalers were subsequently developed, in which the main difference was the possibility to pro- Vaporizers; vide more than one agent. Moreover, the concentration of the inhaled anesthetic was regulated Safety monitoring; for greater efficiency. At the beginning of the twentieth century, gas machines emerged, allow- Modern history ing the application of an anesthetic flow independent of the patient’s inspiratory effort. These medicine machines incorporated technological advances such as flow meters, carbon dioxide absorption systems and fine adjustment vaporizers. In this period, in the field of thoracic surgery, intra- operative artificial ventilation began to be employed, which helped overcome the problem of pneumothorax associated with open pleura by applying positive pressure. From the 1930s, the gas machines were fitted with a ventilator, and by the 1950s this had become a basic compo- nent of the anesthesia system. Later still, in the 1980s, alarm and monitoring systems were incorporated, giving rise to the current generation of workstations. © 2021 Sociedade Brasileira de Anestesiologia. Published by Elsevier Editora Ltda. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/ by-nc-nd/4.0/).
Introduction
The anesthetic machine is one of the most important tools ∗ Corresponding author. used by anesthesiologists, and understanding its characteris- E-mails: [email protected], [email protected] (P. Romero-Ávila). tics and functions is an essential part of anesthetic practice. https://doi.org/10.1016/j.bjane.2021.02.017 © 2021 Sociedade Brasileira de Anestesiologia. Published by Elsevier Editora Ltda. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). Brazilian Journal of Anesthesiology 2021;71(2) 148---161
Figure 2 Replica of Snow’s ether inhaler. Image courtesy of Figure 1 Replica of Morton’s inhaler, used in his first public the Geoffrey Kaye Anesthesia History Museum, Melbourne, Aus- demonstration (October 1846). Courtesy of the Association of tralia. Registration number 4575. Reproduced with permission. Anaesthetists Heritage Center. Reference LDBOC: 1.1.3. Repro- duced with permission.
Moreover, this technology is subject to continuous change in devices such as Squire’s ether inhaler, Robinson’s ether and innovation, and so professionals must remain up to date inhaler, and the Hooper ether inhaler, in England; the Char- in their field.1 rière device, in France; and the Dieffenbach inhaler, in 9 Generically, the term anesthetic machine, apparatus or Germany. equipment is taken to mean the set of elements intended These devices shared certain common characteristics: to provide medicinal gases and anesthetics to a patient dur- they consisted of a glass ether container with an entrance ing an anesthetic act, whether in spontaneous or controlled orifice and an exit orifice, which was attached to an interme- ventilation. diate element, a hose or a tube, the other end of which was Anesthetic machines have evolved from simple inhalers connected to the patient’s respiratory tract. A sponge was to today’s work stations, resulting from the integration of introduced into the container to increase the evaporation 4 the anesthesia device itself with monitoring, alarm, and pro- surface, according to the basic principle of vaporisation. tection systems.2 The anesthesia device consists of several The technique was significantly advanced with Snow’s components, including gas delivery and evacuation systems, ether inhaler (1847). John Snow quickly realized that the vaporizers, electronic flow meters, and a ventilator.3 administration of ether with these original apparatuses was The purpose of this article is to examine how the main unsatisfactory. He believed it necessary to administer the components of the anesthetic machine have evolved, and ether via large gauge tubes, providing sufficient exposure of to describe their gradual integration into a single device, the application area. Moreover, it was essential to maintain from its rudimentary beginnings until the introduction of the the temperature, and thus the gaseous state of the ether by mechanical ventilator. heating the vaporization chamber. Therefore, he designed his own inhaler (Fig. 2) based on these ideas and including a vaporization chamber inside a tin or copper-plated box, The first anesthetic devices: simple inhalers which served as a hot water bath to prevent the ether from (1846-1876) cooling when the appliance was in use.10 In November 1847, James Young Simpson introduced Morton’s ether inhaler (Fig. 1), which was introduced on chloroform into clinical anesthetic practice. For its adminis- October 16, 1846 at the Massachusetts General Hospital tration, he recommended pouring some liquid onto a hollow (Boston, USA), is considered the first real anesthesia device. sponge, pocket handkerchief, piece of linen or paper, and Although ether had previously been used for anesthetic placing this over the patient’s mouth and nostrils.11 This purposes, it was administered by applying a folded towel, recommendation was very well received by surgeons, who soaked with ether, to the patient’s nose.4,5 were thus freed from the use of cumbersome and some- Morton’s ether inhaler consisted of a small crystal ball times ineffective ether devices, the production of which containing a sponge and fitted with two necks. The ether began to decline. For the next 20 years, anesthesia, whether was deposited through one of the necks, and a wooden spout by chloroform or ether, was commonly administered by the was attached to the other, regulating the passage of gas, and application of a soaked compress, at first, and later via wire connected at the far end to the patient’s mouth.6 Morton cones and masks. In every case, these methods were open rapidly modified and improved this prototype, and at the or semi-open.12 public demonstration held the following day, on October 17, In 1862, Joseph Thomas Clover invented a chloroform he had already incorporated valves in the exit nozzle, as anesthesia device which enabled the accurate measurement noted by Henry Jacob Bigelow in his letter to the Boston and administration of mixtures of chloroform and air (Fig. 3), Medical and Surgical Journal.7,8 helping avoid the overdoses (sometimes fatal) that had com- News of the success of Morton’s public demonstration monly occurred before with this anesthetic.13 Other devices arrived in Europe in just two months, leading to a boom in for chloroform were also developed, such as the Sansom the manufacture of anesthesia devices, from late 1846 until inhaler14 in 1865 and the Junker apparatus in 1867 (Fig. 4), mid-1847. These first designs were based on the description which had a hand-operated bellows with which to propel the of Morton’s inhaler made in Bigelow’s letter, and resulted mixture of gases towards the patient.15
149 P. Romero-Ávila, C. Márquez-Espinós and J.R. Cabrera Afonso
Figure 5 Clover’s nitrous oxide/ether apparatus (1876). Man- Figure 3 Clover’s Chloroform Apparatus (1862). Free access ufacturer’s catalogue, p. 325. Public Domain. Credit: Wellcome image. Credit: Wellcome Collection. CC BY. Collection. CC BY.
Figure 6 Clover’s portable regulating ether inhaler (1877). Figure 4 Junker-type inhaler for anesthesia, London, England Image courtesy of the Geoffrey Kaye Anesthesia History (1867). Public Domain. Credit: Science Museum, London. CC BY. Museum, Melbourne, Australia. Registration number 1792.
However, accidents with chloroform were still another connection to the india-rubber bag containing the commonplace,16,17 leading physicians to consider other anesthetic gases, and which in turn was connected to the anesthetics and to demand more precise anesthesia facepiece. The ether vaporizer could be used alone, or in devices. conjunction with nitrous oxide by activating a tap at the base of the storage cylinder. At the top of the interme- diate element, a control key allowed the nitrous oxide to Complex inhalers (1876-1908) pass through the ether chamber or bridged it to be sup- plied directly to the patient. Thus, the anesthesia could be The development of complex inhalers occurred as a conse- induced with nitrous oxide and later maintained with the quence of two clinical needs: to adjust the concentration of ether vaporizer, a method that was less disagreeable for the the anesthetic agent inspired, and to administer more than patient.22 one inhalation agent.18 In 1877, to adjust the concentration of the anesthetic Nitrous oxide had been known for its hilarious and anal- agent inspired, Clover produced a portable ether regulator gesic properties since the late eighteenth century. The inhaler. This apparatus consisted of a small spherical metal drawback was that its collection and administration required chamber, partially filled with ether, which was traversed by bulky and highly complex equipment, hampering portability two concentric tubes, on the ends of which were fitted a and basically limiting its use to dental surgeries, where it rubber bag and a mask, respectively (Fig. 6). By rotating the was used as a gas analgesic.19 However, in 1870 both George sphere around the central tube, two apertures in the base Barth and Coxeter & Son, working in Great Britain, managed were gradually opened and the air breathed by the patient to compress the gas and store it in liquid form in steel cylin- passed over the ether. A small reservoir of water attached ders, and in 1873, the Johnston & Brother company did the to the sphere was intended to attenuate the cooling of the same in New York.20,21 This innovation greatly facilitated the ether as it evaporated.23 This device was the first to properly use of nitrous oxide in surgical medicine. regulate the amount of air inhaled, and became very popular In a further development, Clover manufactured a nitrous in the United Kingdom, where it was in use by RAF medical oxide/ether apparatus in 1876, which was the first attempt services until the Second World War.24 to sequence the administration of these anesthetic gases. The incorporation of oxygen into the gas mixture was not The apparatus consisted of an ether vaporizer, a steel cylin- considered necessary until the beginning of the twentieth der containing liquid nitrous oxide, a gas stopcock attached century, although in 1868, Edmund Andrews, a surgeon at to it, an india-rubber bag and a facepiece (Fig. 5). The Northwestern University, suggested adding oxygen to the vaporizer and the nitrous oxide cylinder were each con- nitrous oxide. This recommendation was followed by Paul nected to an intermediate element, which was attached by Bert and by Clover. Thus, in 1879, Bert combined 15% oxygen
150 Brazilian Journal of Anesthesiology 2021;71(2) 148---161
Figure 8 Hewitt’s modification of Clover’s portable ether inhaler (ca. 1901). Public Domain. Credit: Science Museum, Lon- don. CC BY.
Figure 7 Hewitt apparatus for the administration of nitrous oxide and oxygen. Public Domain. Credit: Wellcome Collection. CC BY. with 85% nitrous oxide to produce anesthesia in a hyperbaric pressure chamber, although this solution remain impractical until 1885 because the technology available was insufficient to store pure oxygen in high-pressure cylinders.21 Among the first devices to combine nitrous oxide with oxygen, an interesting example is the apparatus described by Hewitt in 1893 (Fig. 7), which was composed of two nitrous oxide cylinders, an oxygen cylinder, a structure to Figure 9 Harcourt Chloroform inhaler.Dudley W. Buxton (Lon- support and combine the cylinders, a double india-rubber don: John J. Griffin, 1904). Public Domain. Credit Wellcome tube (internal and external), a double india-rubber bag, Collection. CC BY. a stopcock and a face mask.25,26 A notable aspect of this device was the incorporation of a stopcock to regulate the tank did not rotate on the central pillar, but remained fixed; administration of the two gases. This control had positions instead, the central tube, which was divided into two parts, to administer air, nitrous oxide, or an oxygen-nitrous oxide could be rotated inside the tank, a procedure that made it mixture, in variable proportions.27 possible to add ether to the tank without having to remove The introduction of pressure-reducing valves greatly the inhaler from the patient’s face.30 improved the performance of the anesthetic machines, Another groundbreaking anesthetic machine, which allowing the operator to reduce high pressures within the appeared in Germany at the beginning of the twentieth cen- cylinder, by varying degrees, to a constant, low outlet pres- tury, was Roth-Dräger’s oxygen and chloroform apparatus, sure, even when the pressure inside the cylinder had fallen that, despite its name, facilitated the joint administration of from 130 to 10 atmospheres.28 ether and chloroform. The first model of this device was pre- At the beginning of the twentieth century, the inhaled sented by the surgeon Otto Roth in Berlin at the 31st Annual anesthetics in standard clinical practice were ether, chloro- German Congress of Surgeons in 1902. This machine was form and nitrous oxide, while ethyl chloride and ethylene, one of the first to have a continuous supply of oxygen and introduced during the second half of the nineteenth cen- allowed the controlled, reliable administration of a mixture tury, were less popular.29 For this reason, the new anesthesia of oxygen and anesthetic gases, propelled by mechanical devices in continual development were based on the prop- means.31,32 erties of these three inhalation anesthetics. In 1901 Hewitt In the United Kingdom, important advances in the deliv- introduced his ether inhaler, which was a modification of ery of chloroform were obtained with the devices proposed Clover’s earlier device (Fig. 8). The main change was to by Hartcourt and by Waller in 1903, and with the Levy inhaler increase the diameter of the central breathing tube, which in 1904. In 1901, the British Medical Association appointed reduced the discomfort of the first respiratory efforts, while a committee to investigate the mortality of chloroform and the patient was still conscious, and reduced the risk of rales, chose the chemist Vernon Harcourt to pilot this project. Har- cyanosis and respiratory distress, which still affected anes- court built an apparatus (Fig. 9), described in 1903 in the thetized patients quite frequently. With this new device the British Medical Journal, designed to deliver no more than
151 P. Romero-Ávila, C. Márquez-Espinós and J.R. Cabrera Afonso
Figure 10 Ombrédanne’s apparatus. Image courtesy of the Museum of the History of Medicine and Science Institute López Pinero,˜ Universitat de València-CSIC, Spain. Reproduced with permission.
2% chloroform in air, and with the capacity to compensate for a decrease in the concentration of the solution caused by changes in temperature.33 Another pioneer,August Waller also considered that chloroform accidents were more likely to be caused by an overdose than to the idiosyncrasy initially attributed to the drug, and focused on laboratory studies to determine dangerous, fatal and minimum effective doses of the anesthetic. On the basis of his findings, he manufactured an anesthesia device that regulated the proportion of chlo- roform vapor supplied on a balance integrated within the device, which he termed the Waller Chloroform Balance.34 In 1904, in a further refinement to regulate the concen- tration of chloroform in the gas mixture, A.G. Levy developed an inhaler that allowed the operator to produce a maximum concentration of 3.5% of chloroform in inspired air. Levy’s main contribution was to introduce a compensator preventing the interference of respiratory effort with the concentration of chloroform, as the respiratory pump acted as the driving force for the device. Before any deep breaths Figure 11 Neu´s apparatus. Reprinted from Best Practice & were taken, the compensator was activated manually to Research Clinical Anaesthesiology, Vol 15 (3). M. Goerig, J. reduce the concentration of chloroform, thus avoiding an Schulte am Esch, History of nitrous oxide --- with special refe- overdose.35 rence to its early use in Germany, 331---338. Copyright (2001) Finally, to end this section on complex inhalers, we with permission from Elsevier. must discuss the Ombredanne device of 1908 (Fig. 10),36 another modification of Clover’s inhaler. Louis Ombredanne, a Parisian surgeon, considered chloroform a very dangerous porated various components originally designed for other agent, and so he worked mainly with ether. However, he applications, but which greatly improved the performance was critical of the apparatuses available for this purpose; and safety of the anesthetic machine. In Germany, in 1906, although he was convinced that the efficiency of the ether Franz Kuhn designed a closed circuit anesthetic machine was determined by the inhalation of its vapors in an enclosed with two canisters of soda lime to absorb carbon dioxide space, he favored the intermittent admission of fresh air and valves to direct the flow of the gas. This machine, man- in order to avoid the supply of mixtures of hypoxic gases. ufactured by the Dräger company, became known as the Accordingly, he designed a new device that was fitted with Kuhn-Dräger anesthetic machine and allowed positive pres- a control to regulate the amount of ether vapor inspired, sure ventilation to be applied. However, the development of the fraction of exhaled air that the patient again inhaled, this machine was limited by fears about possible interaction and the amount of new air that was added following each between the chloroform and the soda lime.37 inspiration In 1908, Karl Küppers invented and patented the gas flow rotameter, which allowed physicians to regulate gases more Gas machines (1906-1930s) precisely. In 1910, Maximiliam Neu designed an apparatus to supply nitrous oxide and oxygen, fitted with a rotameter to Technological progress also led to the development of gas measure the flow of each gas (Fig. 11). However, the high machines for use with nitrous oxide. These devices incor- cost of this anesthetic machine limited its development.38
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Figure 13 Gwathmey-Woolsey nitrous oxide-oxygen appara- Figure 12 McKesson’s apparatus, connected to cylinders of tus with cylinders attached. O, regulating valve for oxygen; oxygen and nitrous oxide, which were used when the small gas O2, oxygen tank; N2O, nitrous-oxide tank. Observe bubble bot- tanks of the apparatus were exhausted. Public domain image. tle. Original image from Gwathmey JT. Anesthesia. New York: Courtesy of HathiTrust. Available at: https://babel.hathitrust. Appleton; 1914. org/cgi/ptid=hvd.32044103003448&view=1up&seq=483. in combination through a stopcock. In addition, it regulated In the United States, Elmer McKesson introduced a new the proportion of anesthetic gases inhaled and was fitted concept for the provision of gas flow on demand during anes- with a lamp to heat the gases.42---44 thesia and in 1910 he presented an intermittent flow device Shortly afterwards, in 1915, in St. Louis (USA), D.E. Jack- for the administration of anesthetic gases (Fig. 12). This was son built an anesthetic machine which incorporated a closed the first anesthetic machine to have an automatic cutoff reg- circuit to reuse the exhaled gas and thereby reduce the ulated by the patient’s breathing. With this device, the air costs of anesthesia. Moreover, it incorporated a carbon diox- current flowed only while the patient inhaled, and stopped ide absorber, consisting of a solution of sodium hydrate when the patient exhaled, which produced important sav- and calcium hydrate through which the exhaled gases were ings in anesthetic and medicinal gases. The machine was passed. The machine could operate with nitrous oxide, ethyl able to administer nitrous oxide, oxygen and ether, either chloride, ether, chloroform or ethyl bromide, among other alone or in combination.39 anesthetic gases, in addition to oxygen, and also included a In Boston, two years later, in 1912, Cotton and Boothby small electric motor that acted as an air pump.45 developed an anesthetic machine that provided an uninter- The growing acceptance of gas machines and continual rupted flow of anesthetic gases and oxygen. In addition, a developments in materials facilitating airway control led to new method to visually measure the gas flow was incorpo- the appearance of anesthesia based on endotracheal insuf- rated. This method, termed the ‘‘bubble bottle’’, consisted flation. In England, in 1916, Shipway manufactured a device of passing each gas separately through the water in a glass enabling the insufflation of ‘‘warm anesthetic vapors’’ and mixing chamber (and so they were also known as wet or highlighted the advantages of this form of administration in water flow meters). The bubble rate of gases through the an article published in The Lancet.46 water was used to estimate the flow and proportion of each A year later, in 1917, Boyle developed his anesthetic gas.40,41 The Cotton & Boothby apparatus was subsequently machine from Gwathmey’s basic model and presented it used as a prototype for the manufacture of other anes- in London, at the Royal Society of Medicine, in 1918. The thetic machines, such as the one presented by Crile and original design was composed of a wooden structure in the Teter at the 27th International Congress of Medicine, held form of a box, which acted as a frame, with two trans- in London in 1912. That meeting was attended by James Tay- verse bars from which hung the cylinders of compressed loe Gwathmey, the first president of the American Society gas (two of oxygen and two of nitrous oxide), an ether of Anesthesiologists, and Dr. H. Edmund G. Boyle, among vaporizer and a water flow meter (the bubble bottle from others, who later manufactured other anesthesia devices the Cotton & Boothby apparatus). In addition, the machine modifying and refining Cotton & Boothby’s initial model.42 had a manometer to measure the pressure in the cylinders, Gwathmey presented his anesthetic machine in Min- sensitive pressure-reducing valves and an alcohol lamp (to neapolis in 1912 (Fig. 13). This device, which incorporated prevent the nitrous oxide from freezing and thus obstructing Cotton & Boothby’s water flow meters and was manufac- the cylinder). Boyle’s anesthesia device, originally manufac- tured by the Foregger company from 1914, allowed oxygen, tured by Coxeter & Sons, and subsequently acquired by the nitrous oxide and ether to be administered, either singly or British Oxygen Company, is considered the standard design
153 P. Romero-Ávila, C. Márquez-Espinós and J.R. Cabrera Afonso
Figure 14 Boyle´s Machine. Left: First model, with wooden frame, 1917. Right: 1958 model, with metal structure. Gas cylinders and pressure regulators are fixed to the frame of the table. In the upper part is the block of rotamers and vaporisers. Reproduced from Watt OM. The evolution of the Boyle apparatus, 1917---67. Anaesthesia 1968, with permission of Wiley & Sons.
Table 1 Evolution of the Boyle apparatus. manufacture the machine, and it became the standard anes- thesia device of the Royal Army Medical Corps during the 1920 Addition of a chloroform vaporiser final stages of the First World War. However, Marshall did 1921---1924 Incorporation of the Waters carbon dioxide not publish his invention, and Boyle, who had attended the absorption system presentation of Marshall’s machine, made some slight mod- 1926 Introduction of bypass controls to regulate ifications, and presented it as his own device.49 the quantity of ether/chloroform In 1921, following the path suggested by Shipway, Mag- 1927 Addition of a carbon dioxide flow meter ill introduced his first device for the tracheal insufflation of 1930 Inclusion of a plunger device in the ether in hot air,a portable design that was very well received vaporiser by anesthetists, who habitually worked on an itinerant 1931---1933 Substitution of water flow meters by dry basis. These initial designs received successive modifications flow meters between 1923 and 1932, enabling the joint administration of 1937 Replacement of dry flow meters with nitrous oxide and oxygen, and the incorporation of gas flow flowmeters meters.50,51 1941 Incorporation of the Coxeter-Mushin¨ Mark In 1924, Ralph Waters introduced the use of granules for I¨circle absorber unit in Boyle’s EMS model. the absorption of carbon dioxide.52 Based on the closed cir- 1952 Incorporation of non-interchangeable plugs cuit proposed by Jackson in 1915, Brian C. Sword designed in the gas connections. an anesthetic machine in 1930, which incorporated the first 1958 Incorporation of the Bodok seal in gas closed-circle circuit with carbon dioxide absorption through connections.46,47 the Waters granules, which were composed of 50% cal- cium oxide and 50% sodium hydroxide. These granules were packed into cannisters and also acted as a dehydrating agent for the physical composition of anesthesia stations today, for exhaled gases.53 although it has undergone numerous modifications since its first appearance (Fig. 14), as technological advances have been made47,48 (Table 1). Modern vaporizers (1937-1952) A contemporary of the first version of Boyle’s appara- tus was the anesthetic machine proposed by the English In the development of vaporizers, two moments in the twen- barge commander Geoffrey Marshall, who in 1917 presented tieth century are especially significant. During Macintosh’s the Coxeter company with his own design for a sequential first trip to Spain, in 1937, the deplorable state of anesthe- machine (inspired by Gwathmey’s device) supplying nitrous sia observed led him to design a portable ether inhaler that oxide, oxygen and ether. The Coxeter company decided to could be used in unfavourable circumstances. After contact-
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Figure 16 Foregger Copper Kettle. Image courtesy of the Figure 15 Oxford Vaporiser. Image courtesy of the Geoffrey Harry Daly Museum (Australian Society of Anaesthetists). Kaye Anesthesia History Museum, Melbourne, Australia. Regis- tration number 4724. Reproduced with permission. by the Copper Kettle, and their development has continued to the present day. ing Epstein, a physicist from Berlin, and other specialists in chemistry and physiology, he designed what became known as the Oxford vaporizer (Fig. 15). This device maintained Integration of the ventilator (1930s-1960s) the ether at a constant, high temperature, thus providing a continuous, high concentration of ether vapor, enabling the According to Wilkinson, mechanical ventilators were intro- operator to supply a given, predetermined concentration of duced into anesthetic practice in the early 1950s and quickly anesthetic gas, according to a scale marked on the machine. became standard components of anesthetic machines, The Oxford vaporizer had three concentric chambers. The within equipment such as the Blease Pulmoflator, the innermost one was filled with 400 cc of hot water. The mid- Engström apparatus, the Cape machine and the Barnet dle one was hermetically closed and contained 1300 g of machine.59 hydrated calcium chloride crystals. Finally, the outermost This evolution was marked by various significant devel- one was filled with ether. This arrangement maintained the opments. Intraoperative artificial ventilation was first ether at a constant temperature, and so the vapor pressure introduced in thoracic surgery, an area of medicine that within the chamber also remained constant. In addition, the presents a singular problem: when the pleural space is vaporizer was fitted with a connection enabling the admin- opened, this provokes a pneumothorax, the magnitude of istration of oxygen.54,55 which is largely related to the size of the thoracotomy. For Another major advance was achieved in 1952, when many years, pneumothorax was the major problem facing Lucien Morris introduced a new vaporizer for the administra- thoracic surgeons, since this condition could lead to the tion of liquid anesthetic agents. Until then, the vaporizers collapse of the exposed lung, paradoxical breathing and available had been made of glass, and diverted part of the hemodynamic problems.60 gas flow onto the liquid to be vaporised, in order to regulate Tw o contrasting approaches were taken to this problem. the final concentration. However, this method only provided On the one hand, since 1828, when Leroy discovered that a coarse degree of adjustment. Morris replaced the glass positive pressure ventilation produced barotraumatism and container bottle, which tended to cool the anesthetic agent, pneumothorax,61 there had been great skepticism within the with a copper container that retained the heat much bet- scientific community about this type of ventilation. In conse- ter. In addition, he made changes to the circuit design and quence, the field of mechanical ventilation was dominated in the vaporisation area to obtain known, constant volumes by negative pressure ventilation systems, which all operated of saturated vapor, thus achieving a precise vaporisation of in a similar fashion: the patient’s body was placed inside a the anesthetic gases to be inhaled.56 more or less airtight chamber, with the head protruding. The Morris vaporizer became known as the ‘‘Copper Ket- A negative pressure was then applied within this chamber, tle’’, and was first manufactured by the Foregger company causing the thorax to expand. When the atmospheric pres- in the United States (Fig. 16). Copies of the design subse- sure was subsequently restored, exhalation took place.62 quently appeared in the United Kingdom, Japan, and South In 1904, in line with this view, Ferdinand Sauerbruch, a America, with certain modifications, and it became the German surgeon, built a negative pressure chamber, within vaporizer of choice for the administration of halothane.57 which thoracic cavity surgery could be performed without After the appearance of halogenated inhalational anes- provoking the collapse of the lung. After achieving good thetics in 1956, further designs of vaporizers were results with this device, Sauerbruch travelled through the developed, including the Fluotec (Cyprane Ltd.) and the USA and several European countries to promote his differ- Vapor (Drägerwerk),58 most of which were clearly influenced ential pressure chamber.63
155 P. Romero-Ávila, C. Márquez-Espinós and J.R. Cabrera Afonso
Figure 17 The Matas-Smythe modified Fell-ODwyer´ apparatus for artificial ventilation. Original image from reference.70
However, other pioneers in this field took a very different approach. In 1896, two French surgeons, Tuffier and Hal- lion, proposed a means of overcoming this problem via the insufflation of air through the larynx or trachea to achieve distension of the lung, after successful experiments in this respect with dogs under positive pressure ventilation and laryngotracheal intubation.64 The promising results obtained with these animal experiments encouraged Tuffier and Hal- lion to use artificial intraoperative ventilation with human Figure 18 Brat & Schmieden’s apparatus (1908). Reproduced patients,65 a feat enabled by their mastery of respiratory from reference60, with permission of Wiley & Sons. physiology and the effective regulation of inhalatory anes- thesia during artificial ventilation.66 ratus (1908) (Fig. 18), the Tiegel apparatuses (1908 and A year later, Milton’s ‘‘Mediastinal Surgery’’ was pub- 1909) and the Lotsch positive pressure apparatus (1910)60 lished in The Lancet. In this paper, the author referred to (Fig. 19 and 20). the thoracic cavity as ‘‘terra incognita’’ for the surgeon, and New York doctors Nathan W. Green and Henry H. Janeway highlighted the need for ventilation with positive pressure were working along the same lines, and in 1910, they pub- when operating in this area.67 lished a paper reporting their experiences with mechanical The potential benefits of artificial ventilation in thoracic ventilation during thoracic surgery on animals. In particular, surgery were also apparent to Rudolph Matas, a New Orleans a dog that had been treated with curare and then under- surgeon of Spanish origin. Matas was convinced that, through went thoracic surgery was kept alive for four hours with the use of artificial respiration, intrathoracic surgery could the intermittent application of positive pressure ventilation. be successfully performed.68,69 Accordingly, Matas collab- These authors also observed that the conditions for tho- orated in 1902 with John Smythe in the design of a new racic surgery were more favorable when it was performed device based on the Fell-O’Dwyer apparatus (Fig. 17), con- under artificial ventilation.71 In this area, too, Janeway sisting of a graduated cylinder for the precise administration and Green described an apparatus for the application of of the desired volume of air (up to 1500 mL), a mercury mechanical ventilation. This was an adaptation of Brauer’s manometer to measure intrapulmonary pressure and a mod- invention for the application of positive pressure to the air- ified Fell-O’Dwyer cannula fitted with a port to facilitate way during thoracic surgery. The greater sophistication of the administration of oxygen or chloroform during artificial this machine, and the synchronization provided, enabled respiration.70 patients to receive ventilation independently of their own As observed above, the Kuhn-Dräger anesthetic machine, breathing.72 which provided positive pressure ventilation by means of In 1916, Giertz demonstrated, through animal experi- a bellows, was manufactured in Germany in 1906. How- mentation, that artificial ventilation by rhythmic insuffla- ever, worries about the possible interaction of the soda lime tion was preferable to assisted respiration with constant with chloroform, together with the hostility towards positive differential pressure as proposed by Sauerbruch. From these pressure ventilation displayed by Sauerbruch, an influential observations, the Swedish surgeon Frenckner developed the figure of the time, limited its development.31 ‘‘Spiropulsator’’ (Fig. 21), a mechanical ventilator that Despite the widespread objection to the use of positive administered the mixture of anesthetics during artificial pressure ventilation outside the operating room, design- ventilation. In 1933, Frenckner, working with two Swedes, ers sought to overcome the problem of pneumothorax the engineer Anderson and the surgeon Crafoord, designed in thoracic surgery by creating devices that integrated an anesthesia device that provided intermittent positive a manual ventilator for the application of positive pres- ventilation. This new machine, known as the ‘‘Frenckner- sure, associated with anesthetic vaporizers or nitrous oxide Crafoord-Anderson’’ apparatus, was a combination of the bottles. Such devices included the Brat & Schmieden appa- Spiropulsator and an anesthesia device manufactured by the
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Figure 19 Tiegel’s apparatuses. Left: 1908 version. Right:1909 version. Reproduced from reference60, with permission of Wiley & Sons.
Figure 21 Frenckner Spiropulsator. Image courtesy of the Anesthesia Museum of the Besancn ¸o Hospital, France. Repro- duced with permission.
Figure 20 The Lotsch positive pressure apparatus (1910). Reproduced from reference60, with permission of Wiley & Sons. Trier Moerch, a Danish doctor who was a member of the resistance during the German occupation in World War II, received permission to study anesthesiology at the Karolin- ska Institute, Stockholm, in 1943. During his stay in Sweden, AGA company, and was used by Crafoord in the anesthe- he learned to use the Spiropulsator and once back in his sia of several hundred patients undergoing major thoracic country, he designed and produced a respirator, despite surgery.73 The Frenckner-Crafoord-Anderson device can be the shortage of materials available due to the wartime considered the first hybrid anesthesia apparatus in which an blockade.75 Moerch combined his respirator with McKesson- electric ventilator was an integral component. Nargraf’s anesthetic machine to produce a new hybrid device Despite the good results obtained with positive pressure (Fig. 22), consisting of an electrically operated piston pump, intraoperative ventilation, in 1937 Sauerbruch still consid- which was inserted into a closed circuit and replaced the ered this technique dangerous and unnecessary.74 ventilation bag.73
157 P. Romero-Ávila, C. Márquez-Espinós and J.R. Cabrera Afonso
Figure 22 McKesson´s machine with Trier Moerch’s Respira- tor. Figure from Moerch ET. Controlled Respiration by Means of Special Automatic Machines as Used in Sweden and Denmark. Figure 24 Dräger Romulus (1952). Image courtesy of Dräger- Anaesthesia 1948, with permission of Wiley and Sons. werk AG & Co. KGaA, Lubeck. All rights reserved. Reproduced with permission.
Figure 23 Blease Pulmoflator. Reprinted from British Jour- Figure 25 Ohio DM 5000 anesthesia machine. Public nal of Anaesthesia, Vol 26 (2). Mushin WW, Rendell-Baker L. Domain. Available at: https://www.flickr.com/photos/ Modern Automatic Respirators, 131---47, Copyright (1954), with gehealthcare/5101978942/in/album-72157625084928691/. permission from Elsevier.
sion included rotameters for gases, including cyclopropane, In 1945, in Liverpool (UK), John H. Blease designed an together with gas cylinders, apparatus for blood pressure intermittent positive pressure ventilator. After the war, in measurement, an aspirator, bronchoscope accessories and 1947, an improved version, the Pulmoflator, was produced an instrument tray.76,77 (Fig. 23). This was the first positive pressure ventilator to be In parallel with the development of positive pressure made in Britain, and successive improvements and sophis- ventilators, the widespread adoption of intermittent posi- tications were patented. In 1953, Blease incorporated the tive pressure ventilation in surgical anesthetic practice was Pulmoflator P. 1 within an anesthetic machine, terming the favoured during the late 1940s and early 1950s by two device ‘‘The combined Pulmoflator’’, P.2. This new ver- important events: the introduction of curare into clinical
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Figure 26 Panel A, Time line for simple inhalers; Panel B, Time line for complex inhalers; Panel C, Time line for gas machines; Panel D, Time line for ‘‘integration of the ventilator’’.
anesthetic practice,78 and the triumph of positive pressure model of 1952 (Fig. 24), was one of the anesthetic machines ventilation over negative pressure ventilation in 1952, dur- in which the Pulmomat was incorporated. Later, in 1959, the ing the Copenhagen poliomyelitis epidemic.79 Spiromat 5000 anesthetic machine was designed as a com- These events boosted the acceptance of the ventilator in bination of the Spiromat 4900 long-term ventilator and the anesthetic machines. Thus, during the 1950s, in addition to Romulus anesthetic machine.80 the ventilator-equipped anesthesia apparatus described by From the 1960s, Ohio Medical Products began incorporat- Wilkinson, the Dräger company produced the ‘‘Dräger Pul- ing ventilators into their anesthesia equipment, in the 4000 momat’’ in 1952. This was a new type of ventilator designed series and in the DM 5000 model81 (Fig. 25). Since then, the as an additional unit to be connected to any Dräger anes- ventilator has become an essential component of anesthetic thetic machine with a circle system. The Dräger Romulus machines.
159 P. Romero-Ávila, C. Márquez-Espinós and J.R. Cabrera Afonso
Conclusions 7. Bigelow HJ. Insensibility during surgical operations produced by inhalation. Boston Med Surg J. 1846;35:309---17. 8. Haridas RP, Bause GS. Correspondence by Charles T. Jackson In just over a century, devices for the administration of containing the earliest known illustrations of a Morton ether anesthetic gases have evolved from simple inhalers to inhaler. Anesth Analg. 2013;117:1236---40. sophisticated anesthetic machines, spurred by the ever- 9. Duncum BM. The Development of Inhalation Anaesthesia. Lon- greater precision achieved in the mixtures inhaled. Other don: Oxford University Press; 1947. p. 131---4. relevant factors in this progress were financial considera- 10. Snow J. On the Inhalation of Vapors of Ether in Surgical tions and concerns for patient safety. Initially, anesthetists Operations. Containing a Description of the Various Stages of played a leading role in the design and manufacture of new Etherization and a Statement of the Results of Nearly Eighty devices, but they were later supplanted by large compa- Operations in Which Ether Has Been Employed at St. George’s nies and became mere users of the technology. Moreover, and University College hospitals. London: John Churchill; 1847. the historical development of inhalational anesthetic agents p. 1---15. 11. Simpson JY. On a new anaesthetic agent, more efficient than influenced the evolution of the anesthetic machine, since sulphuric ether. The Lancet. 1847;50:549---50. many devices were designed according to the physical and 12. Franco Grande A, Álvarez Escudero J, Cortés Laíno˜ J. El Aparato chemical properties of specific agents. Finally, the inte- de Anestesia en Espana.˜ Aspectos Tecnológicos y Evolución gration of the ventilator into the anesthetic machine was Durante los Primeros 100 anos˜ de la Moderna Anestesia. In: a crucial development, fundamentally changing the anes- Franco Grande A, Álvarez Escudero J, Cortés Laíno˜ J, editors. thetists’ functions involved. Mechanical ventilation freed Historia de la Anestesia en Espana˜ 1847 --- 1940. Madrid: Arán; the operator’s hands, enabling other intraoperative tasks to 2005. p. 287---307. be undertaken, an advance in which the needs and condi- 13. Rushman GB, Davies NJH, Atkinson RS. A Short History of Anaes- tions of thoracic surgery were of decisive importance. thesia. The First 150 Years. Oxford: Butterworth Heinemann; Figure 26 (panels A to D) shows the timelines for sim- 1996. p. 28. 14. Sansom AE. Chloroform: Its Action and Administration. London: ple inhalators, complex inhalators, gas machine, and the Churchill; 1865. integration of the ventilator in the anesthesia machine. In 15. Junker FE. Description of a new apparatus for administering these, we can see a summary of the major advances in the narcotic vapours. Med Tim Gaz. 1867;2:590. development of these devices. 16. Clover JT. Chloroform accidents. Br Med J. 1871;8:33. 17. Lister J. Chlorofor Accidents. Br Med J. 1871;2:117---9. 18. Nunez˜ CM. The evolution of anesthesia machine. Bull Anesth Conflicts of interest Hist. 1996;15:12---5. 19. Franco Grande A, Álvarez Escudero J, Cortés Laíno˜ J. Historia de The authors declare no conflicts of interest. la Anestesia por el Óxido Nitroso. In: Franco Grande A, Álvarez Escudero J, Cortés Laíno˜ J, editors. Historia de la Anestesia en Espana˜ 1847 --- 1940. Madrid: Arán; 2005. p. 275---81. Acknowledgement 20. Smith WDA. A history of nitrous oxide and oxygen anaesthesia. Part X: the early manufacture, storage and purity of nitrous The authors thank the research team at the Costa del Sol oxide. BJA. 1967;39:351---81. Hospital for their support. We also express our thanks to 21. Dorsch JA, Dorsch SE. Anaesthesia Machines and Breathing Sys- the Association of Anesthetists’ Heritage Centre, the Geof- tems: An Evolutionary Success Story. In: EI Eger-II, Saidman LJ, frey Kaye Museum of Anesthetic History, the López Pinero˜ Westhorpe RN, editors. The Wondrous Story of Anaesthesia. New York: Springer; 2014. p. 703---14. Museum of the History of Medicine and Science, the Anes- 22. Clover JT. On an apparatus for administering nitrous oxide gas thesia Museum of then Besanc¸o Hospital, the Harry Daly and ether, singly or combined. Br Med J. 1876;2:74---5. Museum, the Wellcome Collection, Drägerwerk AG & Co, 23. Clover JT. Portable regulating ether inhaler. Br Med J. Elsevier and Wiley & Sons, for permission to reproduce the 1877;1:69---70. figures used. 24. Atkinson RS, Boulton TB. Clover’s portable regulating ether inhaler (1877). A notable one hundredth anniversary. Anaesthe- sia. 1977;32:1033---6. References 25. Hewitt FW. Anaesthetic and their administration. London: Robinson; 1893. 1. Venticinque SG, Andrews JJ. Anestesia Inhalatoria. Sistemas de 26. Hewitt FW. The Administration of Nitrous Oxide and Oxygen for Administración. In: Miller RD, Cohen NH, Eriksson LI, et al., Dental Operations. London: Ash & Son; 1897. editors. Miller. Anestesia. 8th ed. Barcelona: Elsevier; 2016. p. 27. Hewitt FW. Further observations on the Use of Oxygen with 752---820. Nitrous Oxide. J Brit Dent Assn. 1893;15:380---7. 2. Soro M, Belda FJ, Llórens J, et al. Estructura de los Equipos de 28. Epstein HG, Hunter AR. Anaesthetic apparatus. A Pictorial Anestesia. In: Belda FJ, Llórens J, editors. Ventilación Mecánica Review of the Development of the Modern Anaesthetic Machine. en Anestesia y Cuidados Críticos. Madrid: Arán; 2009. p. 313---49. BJA. 1968;40:636---47. 3. Patil VP, Shetmahajan MG, Divatia JV. The modern integrated 29. Whalen FX, Bacon DR, Smith HM. Inhaled anesthetics: an histori- anaesthesia workstation. Indian J Anaesth. 2013;57:446---54. cal overview. Best Pract Res Clin Anaesthesiol. 2005;19:323---30. 4. Thompson PW, Wilkinson DJ. Development of anaesthetic 30. Edwards G. Frederic William Hewitt (1857-1916). Ann R. Coll machines. BJA. 1985;57:640---8. Surg Engl. 1951;8:233---45. 5. Anaya-Prado R, Schadegg-Pena˜ D. Crawford Williamson Long: 31. The Roth-Drager oxygen and chloroform apparatus. Br Med J. The True Pioneer of Surgical Anesthesia. J Invest Surg. 1907;1:1067---8. 2015;28:181---7. 32. Goerig M. The Development of Anaesthesiology in German- 6. King AC. History and development of anaesthetic apparatus. Speaking Countries. In: EI Eger-II, Saidman LJ, Westhorpe RN, BMJ. 1946;2:536---9.
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editors. The Wondrous Story of Anaesthesia. New York: Springer; 57. Srinivasa NR. Copper Kettle Revisited. Anesthesiology. 2014. p. 371---90. 2006;104:881---4. 33. Davison MH, Essex L, Pask EA. Older methods of the vaporisation 58. Hill DW. Halothane concentrations obtained with a Dräger of liquid anaesthetics. Anaesthesia. 1963;18:302---10. ‘‘Vapor’’ vaporizer. BJA. 1963;35:285---9. 34. Thomas KB. The development of Anaesthetic Apparatus. A His- 59. Wilkinson DJ. Evolution of the Anesthesia Machine. Curr Anaesth tory based on the Charles King Collection of the Association of Crit Care. 1991;2:51---6. anaesthetists of Great Britain and Ireland. Oxford: Blackwell 60. Mushin WW, Rendell-Baker L. The principles of Thoracic Scientific Publications; 1975. Anaesthesia. Past and Present. Oxord: Blackwell Scientific Pub- 35. Zuck D. The development of the anaesthetic vaporizer. The lications; 1953. contribution of A.G. Levy. Anaesthesia. 1988;43:773---5. 61. Chopin C. Lhistoire´ de la ventilation mécanique: des machines 36. Ombrédanne L. Un Appareil pour l’anesthésie par l’éther. Gaz et des hommes. Réanimation. 2007;16:4---12. des Hopitaux. 1908;81:S1095. 62. Yano R, Gonzalo JA, Fernández M. Historia de la ventilación 37. Thierbach A. Franz Kuhn, his contribution to anaesthesia and mecánica. In: González A, Gonzalo JA, Del Blanco A, editors. emergency medicine. Resuscitation. 2001;48:193---7. Manual de ventilación mecánica en medicina intensiva, aneste- 38. Goerig M, Schulte am Esch J. History of nitrous oxide---- with spe- sia y urgencias. Oviedo: Imprenta Gofer; 2005. p. 1---9. cial reference to its early use in Germany. Best Pract Res Clin 63. Cherian SM, Nicks R, Lord RS. Ernest Ferdinand Sauerbruch: Anaesthesiol. 2001;15:313---38. Rise and fall of the piooner of thoracic surgery. World J Surg. 39. McKesson EI. Nitrous oxyde-oxygen Anaesthesia. With a descrip- 2001;25:1012---20. tion of a new apparatus. Surg Gynecol Obstet. 1911;13:456---62. 64. Tuffier T, Hallion L. Respiration artificielle par insufflations pul- 40. Cotton FJ, Boothby WM. Intratracheal Insufflation Anaesthesia: monaire dans certaines operations intrathoraciques. Gaz Hebd Considered from its Physiological and Clinical Aspects. Ann Surg. Med Chir. 1896;43:1131. 1913;57:43---63. 65. Tuffier T, Hallion L. Operations intrathoraciques avec respiration 41. Bause GS. The Cotton-Boothby apparatus. Anesthesiology. artificielle par insufflation. C R Soc BioI. 1896;48:951---4. 2009;111:708. 66. Tuffier T, Hallion L. Sur la régulation de la pression intra- 42. Cope DK. James Tayloe Gwathmey: Seeds of a Developing Spe- broncrique et de la narcose dans la respiration artificielle par cialty. Anesth Analg. 1993;76:642---7. insufflation. C R Soc BioI. 1896;48:1086---8. 43. New inventions. The Gwathmey gas oxygen apparatus. The 67. Milton H. Mediastinal Surgery. Lancet. 1897;1:872---5. Lancet. 1916;188:607. 68. Hutson LR Jr, Vachon CA. Dr. Rudolph Matas: innovator and pio- 44. Ball CM. The Foregger Midget. A Machine that Traveled. Anes- neer in anesthesiology. Anesthesiology. 2005;103:885---9. thesiology. 2013;119:1023---30. 69. Matas R. Intralaryngeal insufflation. JAMA. 1900:1468---73. 45. Jackson DE. A New Method for the Production of General Anes- 70. Matas R. Artificial respiration by direct intralaryngeal intubation thesia and Anesthesia With a Description of the Apparatus Used. with a modified O’Dwyer tube and a new graduated air-pump, Anesth Analg. 1971;50:181---9. in its applications to medical and surgical practice. Am Med. 46. Shipway FE. The advantages of warm anaesthetic vapours, 1902:1---2. and an apparatus for their administration. The Lancet. 71. Green NW, Janeway HH. Artificial respiration and intrathoracic 1916;187:70---4. oesophageal surgery. Ann Surg. 1910;52:58---66. 47. Gurudatt C. The basic anaesthesia machine. Indian J Anaesth. 72. Somerson JS, Sicilia MR. Historical perspectives on the 2013;57:438---45. development and use of mechanical ventilation. AANA J. 48. Watt OM. The evolution of the Boyle apparatus, 1917-67. Anaes- 1992;60:83---94. thesia. 1968;23:103---18. 73. Moerch ET. Controlled Respiration by Means of Special Auto- 49. Metcalfe NH. Sir Geoffrey Marshall (1887---1982): respiratory matic Machines as Used in Sweden and Denmark. Anaesthesia. physician, catalyst for anaesthesia development, doctor to both 1948;3:4---11. Prime Minster and King, and World War I Barge Commander. J 74. Brodsky JB, Lemmens HJ. The history of anesthesia for thoracic Med Biogr. 2011;19:10---4. surgery. Minerva Anestesiol. 2007;73:513---24. 50. Waters RM, Rovenstine EA, Guedel AE. Endotracheal 75. Rosenberg H, Axelrod JK. Ernst Trier Mørch: Inventor, Anesthesia and Its Historical Development. Anesth Analg. Medical Pioneer, Heroic Freedom Fighter. Anesth Analg. 1933;12:196---203. 2000;90:218---21. 51. McLachlan G. Sir Ivan Magill KCVO, DSc, MB, BCh, BAO, FRCS, 76. McKenzie AG. The inventions of John Blease. BJA. FFARCS (Hon), FFARCSI (Hon), DA, (1888-1986). Ulster Med J. 2000;85:928---35. 2008;77:146---52. 77. Mushin WW, Rendell-Baker L. Modern Automatic Respirators. 52. Waters RM. Clinical scope and utility of carbon dioxide filtration BJA. 1954;26:131---47. anesthesia. Anesth Analg. 1924;3:20---2. 78. Bennet AE. The History of the Introduction of Curare Into 53. Sword BC. The Closed Circle Method of Administration of Gas Medicine. Anesth Analg. 1968;47:484---92. Anesthesia. Anesth Analg. 1930;9:198---202. 79. Slutsky AS. History of Mechanical Ventilation. From Vesalius to 54. Unzueta-Merino MZ. Influencia de la escuela de Oxford en el Ventilator -induced Lung injury. Am J Respir Crit Care Med. desarrollo de la Anestesiología moderna en Espana:˜ La huella 2015;191:1106---15. de Robert Macintosh. PhD thesis, Universidad Autónoma de 80. Haupt J. The History of Anesthesia at Dräger. Hamburg: Lübeck: Barcelona; 1999. Dräger Druck; 2014. 55. Epstein HG, Macintosh R. An anaesthetic inhaler with automatic 81. Scheiber P. Anaesthesia Equipment. Performance, Classification thermo-compensation. Anaesthesia. 1956;11:83---8. and Safety. Berlin: Springer-Verlag; 1972. 56. Morris LE. A new vaporizer for liquid anesthetic agents. Anes- thesiology. 1952;13:587---93.
161 Brazilian Journal of Anesthesiology 2021;71(2) 162---170
NARRATIVE REVIEW Competency-based anesthesiology teaching: comparison of programs in Brazil, Canada and the United States
Rafael Vinagre a,b,∗, Pedro Tanaka a, Maria Angela Tardelli c
a Stanford University, School of Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Stanford, California, USA b Lincoln Medical and Health Care Center, Department of Internal Medicine, Bronx, New York, USA c Universidade Federal de São Paulo (UNIFESP), Escola Paulista de Medicina, Departamento de Cirurgia, Disciplina de Anestesiologia, Dor e Medicina Intensiva, São Paulo, SP, Brazil
Received 6 September 2020; accepted 24 December 2020 Available online 3 March 2021
KEYWORDS Abstract In 2017, the Brazilian Society of Anesthesiology (SBA) and the National Medical Resi- Competency-based dency Committee (CNRM) presented a joint competence matrix to train and evaluate physicians curriculum; specializing in Anesthesiology, which was enforced in 2019. The competency-based curriculum Anesthesiology; aims to train residents in relation to certain results, in that residents are considered capable Medical residency; when they are able to act in an appropriate and effective manner within certain standards of Medical education; performance. Canada and the United States (US) also use competency-based curriculum to train Entrustable their professionals. In Canada, the format is the basis for using an evaluation method known as Professional Activities Entrustable Professional Activities (EPA), in which the mentor assesses residents’ capacity to (EPA); perform certain tasks, classified in 5 levels. The US, in turn, uses Milestones as evaluation, in Milestones which competencies and sub-competencies are assessed according to residents’ progress dur- ing training. The present article aims to describe and compare the different competency-based curriculum and the evaluation methods used in the three countries, and proposes a reflection on future paths for medical education in Anesthesiology in Brazil. © 2021 Sociedade Brasileira de Anestesiologia. Published by Elsevier Editora Ltda. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/ 4.0/).
∗ Corresponding author. E-mail: [email protected] (R. Vinagre). https://doi.org/10.1016/j.bjane.2020.12.026 © 2021 Sociedade Brasileira de Anestesiologia. Published by Elsevier Editora Ltda. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). Brazilian Journal of Anesthesiology 2021;71(2) 162---170
Introduction Systems-Based Practice, Interpersonal and Communication Skills, and Medical Knowledge.7 Unlike other teaching meth- In 2017, the Brazilian Society of Anesthesiology (SBA) and ods, the competency-based curriculum aims toward the the National Medical Residency Committee (CNRM) chose to development and assessment of physicians undergoing spe- unify the competence matrix used to build the curriculum cialization in regard to certain results, adding concepts from and evaluate physicians specializing in Anesthesiology. The other methods of teaching, such as the Miller pyramid to aim was standardize teaching in Anesthesiology and develop assess progression of the apprentice, and style of education 8 evaluations throughout the country. The new competence for each level of the Dreyfus model. matrix was enforced in 2019.1 Objective Competencies The present study aims to present and compare three distinct competency-based curriculum and assess them in The characterization of the skills of physicians training as terms of training in Anesthesiology specialization in three specialists to consider them competent depends on the eval- different countries, Brazil, Canada, and the United States, uator’s judgement. As suggested by Mulder, professionals and proposes a reflection on the future paths for teaching are competent when they act in a responsible and effec- Anesthesiology in Brazil. tive way according to certain standards of performance.2 However, unlike the assessment of a physician trainee’s performance, which is observable and measurable, compe- Competence-matrixes of residency programs tency assessment cannot be specified accurately. This is so because it involves characteristics inherent to each individ- Brazil ual, such as their capacity and skills, making an accurate description difficult.3 Given those characteristics are not Specialization in Anesthesiology in Brazil has evolved, and in accessible to evaluators, they will infer in order to assess the past year began to be used as a joint competency matrix physicians training as specialists. Therefore, assessment between the Brazilian Society of Anesthesiology and the describes physicians’ performance during specialization, National Medical Residency Committee. Such measure aims and not their competence. Performance is, therefore, the to train and build skills of physicians in Anesthesiology spe- behavior observed and assessed as competent. cialization with the objective of acquiring the competencies Competency-based Medical Education emphasizes pro- required to perform appropriate anesthesia for diagnostic, gram assessment in two distinct functions --- assessment of surgical, and therapeutical procedures.1 The competency development (formative) and decision making (summative). matrix is divided by year, and each year of specialization Assessment performed in a low-risk workplace aims to pro- describes the competencies required. There are a total of vide significant feedback to the apprentice in order to orient 10 specific objectives and 49 competencies divided among learning, while decisions on high-risk competencies should the 3-years of specialization. Assessment of competencies be performed based on aggregated assessment data, col- varies among services, and there is no single national for- lected throughout time and on several points in time through mat on how each specialty trainee should be assessed, or a individual assessments.4 timetable to be followed to assure that everyone reaches a Countries such as Canada and the United States (US) also certain level until the end of a specialization program. use a competency-based curriculum similar to the Brazilian In the first year of specialization (R1), the physician matrix of competency for evaluating and assuring the qual- should improve knowledge in theory and practices in ity of education of specialty training. In Brazil, the matrix medicine, and be capable of relating them to Anesthesi- presented by SBA and CNRM guides the evaluation of physi- ology. Toward that end, the R1 should present skills for cian trainees’ learning throughout the years, in that they lower complexity procedures with supervision on elective acquire appropriate objectives and competences in each patients submitted to minor and medium size surgeries. year of specialization. Examples of competences to be reached at the end of the In Canada, competencies are the basis for another eval- first year are: (1) gather accurate and essential informa- uation method, called Entrustable Professional Activities tion on patients and their complaints, along with complete, (EPA). EPA emerged as an evaluation tool to assess perfor- general, and specific physical examination during pre- mance at the workplace. Besides Canada, other countries, anesthesia assessment; (2) set up and interpret basic such as The Netherlands, Australia, and New Zealand also monitoring, and do whatever is required to maintain clinical have a consolidated system based on EPA for some special- stability of patients; (3) assess and perform tracheal intuba- ties, such as Gynecology and Obstetrics, and Psychiatry.5 tion and extubation; and (4) assess and perform neuraxial The Netherlands also have taken the first step toward this anesthesia.1 more contemporary format of competency-based curriculum In the second year of specialization (R2), more responsi- in Anesthesiology.6 bility is granted to physicians undergoing specialization, and The US uses a competency- and sub-competency- based they are in charge of pre-anesthetic evaluation and anes- curriculum as a means of a standardized evaluation called thesia plan for medium size and major surgeries, and for milestones. The system offers a framework to assess the anesthesia for higher complex procedures, with the help development of specialty trainees regarding essential physi- of other tools or not, such as ultrasonography. Knowledge cian competencies. The competencies are Patient Care, on managing acute pain and patients in intensive care, Professionalism, Practice Based Learning and Improvement, whether in the ICU or post-anesthesia recovery room, is
163 R. Vinagre, P. Tanaka and M.A. Tardelli also explored. Examples of competencies to be reached in trust. Physicians must understand the roles of other health this stage of learning are: (1) difficult airway assessment professionals, the responsibility and need to learn from oth- and domain of the control algorithm; (2) assessment and ers who partake in patient care. Physicians take over the role performance of anesthesia blockades and ultrasound-guided of leaders in the health care system, whether at the local, vascular access; and (3) analysis, diagnosis and treatment of regional, national or global level. They join other health intraoperative and postoperative anesthesia complications professionals to contribute to and guarantee a high-quality in the post-anesthesia recovery room.1 health system, and are responsible for providing excellence During the third and last year of specialization (R3), in services to patients through their clinical teaching activi- physicians should have a comprehensive view of the patient, ties and administrative responsibilities. A physician’s work is including, but not restricted to, preoperative evaluation not only treating conditions diagnosed, but also includes dis- of patients to be submitted to any kind of surgical proce- ease prevention, health promotion, protection of and equity dure, intraoperative management of anesthesia for major in health, which characterizes the Health Defensor compe- surgeries (e.g., heart surgeries, transplantations, vascu- tency. Equity in health should be viewed as a way to promote lar radiology, among others), and intensive postoperative integral health without discriminating the population in view management when required. R3 are expected to present of color, race, gender, sexual orientation, ethnicity, religion, professionalism and commitment to their training, including social class, economic status or schooling, for example. The theory, practice and scientific learning, and should deliver, Scholar competency remits to lifelong commitment to excel- in a specified timeframe, a course conclusion paper. Exam- lence through continuous learning, conveying knowledge to ples of competencies to be the reached by R3 in order to others, assessing evidence and contributing to research. successfully conclude specialization are: (1) making deci- The seventh competence is Professionalism, which reflects sions under adverse conditions, showing emotional control what society expects of physicians, promotion of public and equilibrium, using leadership to minimize any possi- well-being, integrity, altruism, humbleness and respect to ble complications, and being aware of their limitations; diversity, the basis of the implicit contract established (2) communicating effectively with physicians, other health between society and the professional, the physician. professionals, and health-related services, especially with The seven competencies described in CanMEDS also surgeons, during surgery, as to changes in physiological include key-competencies, enabling competencies and key- parameters capable of interfering unfavorably in the imme- concepts, so as to divide and explain in more detail what diate result of anesthesia or surgery; (3) deciding, during is expected of physicians undergoing specialization. The anesthesia, the need to use scientifically acceptable techni- Medical Expert competency has five key-competences, for cal variants, in order to overcome unexpected difficulties.1 example, ‘‘Practice medicine within the scope defined for each one’s practice and experience’’. Each key-competence has enabling competencies to qualify each key-competence. Canada Enabling competencies related to the previous example include ‘‘demonstrate commitment to high quality care In Canada, the competencies described in the Canadian of patients’’, ‘‘apply clinical knowledge and of relevant Medical Education Directives for Specialists (CanMEDS), biological sciences to the discipline’’ and ‘‘acknowledge developed by the Royal College of Physicians and Surgeons and respond to the complexity, uncertainty and ambiguity of Canada, initially in 1996 and reviewed most recently in inherent to medical practice’’, among others. Key-concepts 2015, is the foundation for using Entrustable Professional are comprised of enabling competencies, which may fit Activities (EPA). EPAs were introduced by Ten Cate in 2005 into more than one key-concept. Enabling competencies as a new model for evaluation in the workplace, aimed at mentioned above would be respectively related to the fol- helping supervisors to determine if required competences lowing key-concepts: ‘‘compassion’’ and ‘‘duty to care were reached by a physician undergoing specialization.9 for’’; ‘‘application of clinical knowledge and from biomed- CanMEDS is a matrix that identifies and describes skills ical sciences’’, ‘‘clinical reasoning’’ and ‘‘working with that physicians training as specialists should acquire to a healthcare team’’; and ‘‘clinical decision making’’ and effectively respond to patient needs. It includes seven ‘‘complexity, uncertainty and ambiguity in clinical decision competencies: Medical Expert, Communicator, Collaborator, making’’ (Table 1). Leader, Health Advocate, Scholar and Professional. Evaluation, however, is not only based on the compe- Medical Expert is described as the core competence, the tencies described above. They are the foundation for the intersection point among all competences, representing the evaluation system known as Entrustable Professional Activ- central role of the physician. Competencies approach physi- ities (EPA). Each EPA comprises several competencies, and cians’ knowledge, such as clinical skills and professional the same competencyy can be present in more than one EPA values aimed at providing high quality patient-centered (Table 2). EPA can be defined as a professional practice activ- care. Toward that end, patient status, best practices and sci- ity that can be totally entrusted to a physician undergoing entific evidence are taken into account. The Communicator specialization as soon as the required skilled to execute such competency represents physician-patient/family relations, activity without supervision is demonstrated.11 In Canada, which must be well established to facilitate attainment of EPAs are divided in Transition to Discipline, Foundations of and sharing information effectively for patient care, always Discipline, Core of Discipline and Transition to Practice.12 aimed at a patient-centered approach. Collaborator repre- The first EPA group, Transition to Discipline represents sents work in a multidisciplinary team, reminding physicians the transition of a medical undergraduate student to the of their duty to work along with other health professionals, beginning of specialization in Anesthesiology, and represents family members and the community, based on respect and simpler and less complex activities. Examples of this group
164 Brazilian Journal of Anesthesiology 2021;71(2) 162---170
Table 1 Competence and its subclassifications. Example of how competences, key-competencies, enabling competencies and key-concepts are described. Each key-competency is listed and associated with key-concepts to which they apply.
Competency: specialist physician
Key-competency Enabling competencies Keyconcepts Practice medicine within the scope (1) Demonstrate commitment to high Apply clinical knowledge and from defined by practice and experience quality care to patients; biomedical sciences: 2 (2) Apply clinical knowledge and from Compassion: 1 biomedical sciences relevant to the discipline; Complexity, uncertainty and ambiguity in (3) Acknowledge and respond to clinical decision making: 3 complexity, uncertainty and ambiguity Duty to care: 1 inherent to medical practice. Clinical reasoning: 2 Work with healthcare team: 2 Clinical decision making: 3
Table 2 Constitution of EPAs. Example of EPA matrix using episode of exacerbation during chronic pain; (3) establish competencies. Note that a certain Competency can be and manage difficult venous access and invasive monitoring present in more than one EPA, and that EPA encompasses for pediatric patients over 1 year of age. several and different numbers of competences. The last EPA group that trainee physicians in Anesthe- siology should attain is called Transition to Practice. This EPA 1 EPA 2 EPA 3 EPA 4 EPA 5 group proposes to assure that physicians in their last year Competency1 ᭹ ᭹ ᭹ ᭹ of specialization are ready to practice anesthesia manage- Competency2 ᭹ ᭹ ᭹ ment in the largest variety of complex patients and surgical Competency3 ᭹ ᭹ ᭹ procedures, so as to be apt to work without supervision. Competency4 ᭹ ᭹ ᭹ Examples of activities of this group are: (1) management of Competency5 ᭹ ᭹ ᭹ ᭹ all aspects of care of patients admitted, referred for opin- Competency6 ᭹ ᭹ ᭹ ion by the Anesthesiology service; (2) management of all Competency7 ᭹ ᭹ ᭹ aspects of care of the obstetric patient, including obstet- ric ward management-related organizational aspects; (3) Adapted from Holmboe, E., Durning, S. and Hawkins, R., Practi- development of a learning and personal career plan. cal Guide To The Evaluation Of Clinical Competence, 2018).10 Considering what has been exposed, we may conclude that EPA do not directly evaluate the competencies to be reached, but the ‘‘doing’’ skills of a physician specializing. of EPA are: (1) perform preoperative evaluation of patients The key question for evaluation of EPA is: ‘‘Can we trust this ASA I or II to be submitted to low complexity elective surgical physician undergoing specialization to perform this activ- procedures; (2) preparation of the Operating Room for low ity?’’ Additionally, to evaluate the capacity of a physician complexity elective surgical procedures for patients ASA I training as a specialist to perform the activity in a trust- or II; (3) perform postoperative transfer of adult ASA I or II worthy way, 5 levels of supervision and trust reliability are patients after low complexity elective surgical procedures, considered.13---15 They are: including postoperative prescriptions. The second EPA group, Foundations of Discipline, encom- passes basic-fundamental activities of Anesthesiology, more 1 Physicians undergoing specialization may be present and complex than the previous one, but still with restriction as observe, but are not able to execute the EPA. In the ini- to complexity. Examples of EPA to be attained in this group tial stages, physician trainees are expected to be present are: (1) identify patients with potential difficult airway and and observe what they will do in the following stage of prepare initial management options; (2) anticipate, prevent learning. Gradually, they will be trusted to perform some and conduct adequately expected or common intraoperative parts of the activity. events and physiological changes during low and medium 2 Allowed to perform the activity with direct and proactive risk surgical procedures; (3) manage pediatric patients with supervision of the mentor, who should be present in the common postoperative complications at the post anesthesia operating room. During this stage, physician trainees can recovery room or ward. perform the activity fully and independently. The mentor, After accomplishing these activities, physician trainees who is present in the room can interfere or take over the should then attain the EPA related to the Core of Disci- activity at any time believed required. pline, the group that concentrates the higher number of 3 Allowed to perform activity with indirect and reactive activities, therefore considered the core of teaching Anes- supervision, in which the supervisor should be ready to thesiology. Examples of activities classified in this group be promptly available to enter the operating room. In this are: (1) use ultrasound to help diagnostics and to manage stage, physician trainees are fully independent to perform hemodynamically unstable or critical patients; (2) provide activity, without a supervisor present in the room, albeit multimodal management to patients with acute pain or available within minutes.
165 R. Vinagre, P. Tanaka and M.A. Tardelli
4 Allowed to act without qualified supervision in the prox- beyond the objectives defined for the residency has to be imities; with at-distance supervision, basically performing demonstrated, with advanced goals and skills, which may without supervision. In this stage, physician trainees can describe the performance of someone already practicing perform activity fully without nearby supervision. Physi- Anesthesiology for some years. For example, participating cian trainees report to supervisor on the same day or in the organization of tests to attain the title of Anesthe- following day. siology or provide ideal pre-anesthesia consulting to other 5 Allowed to supervise physician trainees in years junior Anesthesiologists. In addition to these levels, there is a field to them performing an EPA. This level is assured for last to check ‘‘did not reach level 1’’. For each level, there is the year physicians undergoing specialization, when they can option of checking an option at the level and one between supervise other, less experienced, trainees. levels. The option to check the level represents that the physician undergoing specialization is at the level checked, and the option between levels represents that the physician The United States (US) undergoing specialization shows milestones of the previous level and some of the levels above (Table 3). Currently, evaluation of the performance of physicians Each milestone should be checked according to each sub- undergoing specialization or fellowships in Anesthesiology competency and competency. There are six competencies. in the US is done using evaluation of sub-competencies They are Patient Care, Medical Knowledge, Systems-based and competencies, known as The Anesthesiology Milestone Practice, Practiced-based Learning and Improvement, Pro- Project, established in December 2013. Milestones are a fessionalism and Interpersonal and Communication Skills. framework to evaluate physician trainees’ performance in Each one of the competencies has sub competencies spec- the main competence and sub-competence elements that ifying characteristics. For example: (1) Interpersonal and they should have in a specialty or subspecialty. Every six Communication Skills --- communication with patients and months, all medical residency programs in Anesthesiology family; (2) Interpersonal and Communication Skills --- lead- should submit to the regulating agency, the Accreditation ership time and skills; (3) Professionalism --- provide and Council for Graduate Medical Education (ACGME), the qual- receive feedback; (4) Professionalism --- responsibility with ity of physician teaching in the US, the results indicating in patients, family and society; (5) Practiced-based Learning which milestone each one of its physician trainees are at, to and Improvement ---self-learning; (6) Patient Care --- periop- assess progress. Beside ACGME, the American Board of Anes- erative pain management. thesiology (ABA) also requires that programs send evaluation Milestone evaluation is performed at different levels. of clinical competencies of all physicians in specialization During each rotation, there is an assessment for specialty and fellows in Anesthesiology electronically, annually in Jan- training physicians, such as in Neuroanesthesia, Anesthesia uary and July. In order to complete such evaluations, global for Obstetrics, or Anesthesia for Pediatrics. Each rotation marks should be selected, classified as ‘‘satisfactory’’, when is responsible for the evaluation method, and there can a physician training as specialist/fellow constantly meets be more than one evaluator, generally someone who has expectations, or ‘‘unsatisfactory’’, when below expecta- worked with the physician trainee, or the rotation coordi- tions. If a physician training as specialist/fellow does not nator. These assessments are then submitted to the clinical pass a test on basic concepts twice or more, this is also con- competency committee, that is responsible for the final sidered unsatisfactory. These competencies are considered evaluation of the physician trainee each semester, taking the initial step toward Anesthesiology certification.16 into account the assessment made in each rotation, and Milestones are organized from levels 1 to 5 and, by narra- each committee member’s own experience with a certain tive of each sub competence, represent an assessment tool physician trainee. Then, the evaluation is submitted to the of the development of a physician undergoing specializa- ACGME to analyze each one’s progress. tion during training in Anesthesiology. Level 1 represents the internship year, before beginning training in Anesthesiology, when the physician trainee should present the milestones Discussion: similarities and singularities expected of someone who has finished the first year after graduating Medical school. Level 2 is appropriate to those The three countries have competency-based curriculum that who present milestones expected of a physician trainee guide the training and consequent evaluation of physicians during Anesthesiology training, but that still has not been undergoing specialization. However, they are used in sig- exposed in a significant manner to Anesthesiology subspe- nificantly different ways. In the North American countries, cialties. At level 3, physician trainees present the milestones there are competency-based evaluation formats, in which a expected of someone after having significant contact and concept is assigned to the physician trainee in a standardized experience in anesthesiology subspecialties. Level 4 sub- manner for all medical residency programs in both countries. stantially shows the milestones expected for specialization Medical residency in Anesthesiology in Brazil lasts 3 years; in Anesthesiology, and that one is ready for the transition in Canada, 5 years; in the US it lasts 4 years, with the first to independent practice as an Anesthesiologist. Level 4 is year as internship. the graduation target --- end of R3 --- however, according In the US, submission every semester of the evaluation of to ACGME, the decision if a physician trainee is ready to physician trainees by the clinical competency committee, conclude residency belongs to the residency coordinator, comprised by the Anesthesiologists of the programs, assures and reaching level 4 is not required to conclude specializa- that the programs assess trainees systematically. Due to tion. Level 5 is reserved only to some exceptional physicians ACGME requirements, physician trainees are assured evalu- undergoing specialization. At this level, having advanced ation according to the nationally proposed guidelines. Such
166 Brazilian Journal of Anesthesiology 2021;71(2) 162---170
Table 3 Example of table containing Competency, sub-Competency and milestone to be completed by medical residency programs in Anesthesiology.
Patient care: management of perioperative pain
Did not reach Competency: (Sub competency level 1 Level 1 Level 2 Level 3 Level 4 Level 5 Knowledge of an Knowledge of a Knowledge of a Appropriate Objective individual prior to physician physician knowledge for knowledge and first year of undergoing undergoing independent objectives beyond Anesthesiology specialization with specialization with practice of those defined by (Milestone) little exposure to significant contact Anesthesiology residency; Anesthesiology with (Milestone) presenting subspecialties Anesthesiology performance (Milestone) subspecialties similar to (Milestone) Anesthesiologist with some years of experience (Milestone)
Adapted from The Anesthesiology Milestones Project, 2015.7 format allows monitoring progression and addressing defi- mat of Canada and the US can facilitate the analysis and ciencies of each physician trainee more easily and promptly, judgement of assessment as to competencies attained, mak- and in a customized way. However, the pressure for doc- ing them less vague or subjective, generating a better guide uments to be filled out may mean extra red tape to the for evaluation. However, excess of subclassifications can be program. This may lead to Anesthesiologists being shifted more confusing to understand by the evaluating reader, and and having extra work in order to be part of the evalu- may require a lot of time for understanding or classifying and ation committee, making the program cope with possible assessing physician trainees, leading to possibly abandoning costs and overtime or the need to have a larger Anesthesiol- or undervaluing filling out the evaluation. This can result in a ogy staff. In Canada, on the other hand, despite the unified less specific and detailed evaluation done with less care, and evaluation format, programs do not need to submit the per- with impact on the way each one gets feedback to improve formance of their specialty training physicians to a central learning. agency. The Brazilian Society of Anesthesiology requires that Currently in Brazil, competencies are the basis for certain rotations be performed by physicians undergoing each program to guide its teaching and individual per- specialization during their training period. According to the formance evaluation. Despite medical residency programs 2020 SBA Regulation of the Training and Teaching Centers being required to be accredited by the Ministry of Educa- (Centros de Ensino e Treinamento --- CET)17:I --- Pre- and tion (MEC), by the Brazilian Society of Anesthesiology (SBA) postoperative: minimum of 10% of annual time load, for and have the endorsement of the Brazilian Medical Associ- pre-anesthesia evaluation (preoperative evaluation office ation (AMB), there is no standardized evaluation system for and pre-anesthesia visit), post-anesthesia visit, treatment of practice in the workplace that controls the technical quality postoperative pain and acute and chronic pain syndromes; II of future Anesthesiologists. The National Medical Residency --- Intensive Care Unit and anesthesia for urgency and emer- Committee (CNRM) demands quarterly evaluations of physi- gency: minimum of 15% of annual time load; III --- Operating cians undergoing specialization, including knowledge of Room, diagnostic and therapeutic services: minimum of 45% theory of the curriculum matrixes and behavior and profes- of annual time load; IV --- Obstetric Center: minimum of sionalism, which each program is in charge of implementing. 10% of annual time load; V --- Optional rotations: cardiology, In Canada and in the US, evaluation of behavior and profes- pneumology, neurology, clinical laboratory, physiology labo- sionalism are also explained by evaluation criteria in EPA and ratory, pharmacology laboratory, experimental surgery and Milestones, respectively. The evaluation of theory learning hemotherapy, or other, at the discretion of the Institution. is standardized by the Brazilian Society of Anesthesiology In Canada, the Royal College of Physicians and Surgeons of (SBA), by means of an annual national test for physicians Canada determines a minimum of requirements for physi- undergoing specialization. The evaluation is similar to the cian training during the 5 years of specialization. Programs In-Training Examination (ITE) of the US, and also is carried should include a minimum of 12 months of anesthesia in out by most of the Anesthesiology residency programs in adult patients; 3-months of pediatric anesthesia; 2 months Canada. of anesthesia for obstetrics; 1 month of chronic pain mana- In both North American countries, competencies are gement; 6 months of internal medicine; and 3 months in classified in major groups and in turn classified in sub compe- intensive care unit, not exceeding 6 months.18 A similar tencies. In Brazil, competencies are listed in a general way, control is required by ACGME in the US, in that there is mini- and described according to what physician trainees should mum amount of rotations required by ACGME that physician attain each year. The classification and subclassification for- trainees should complete.19 The program should provide
167 R. Vinagre, P. Tanaka and M.A. Tardelli
Table 4 Comparison of main characterístics of each country for evaluating physician training in Anesthesiology.
Brazil US Canada Competency-based curriculum Yes Yes Yes Milestone-based evaluation No Yes No EPA-based evaluation No No Yes Central agency for submission of No Yes No performance of physicians undergoing specialization Common competence evaluation system No Yes Yes in the workplace for the country Years of training in anesthesiology 3 4a 5 Limit of working hours per week19 60 h/week; 6-h 80 h/week, Maximum 24 hours per rest after night average of 4 duty shift and not more duty; 1 day off weeks; 1 day than seven duty days in per week off per week; 28 days. Variable among 10-h rest provinces. In Alberta, between duty duty can last up to shifts 26 hours, while in Quebec, they are limited to 16 hours. Rotations required by programs Yes Yes Yes Number of cases required Yes b Yes c No
a 4-years, with the first year of internship. b According to the2020 Regulation of the Centros de Ensino e Treinamento (CET) of the Brazilian Society of Anesthesiology (SBA): Provide minimum of 440 anesthesia acts and 900 annual hours of practical training in anesthesia for each medical specialist, comprising, mandatory anesthesia procedures for General Surgery, Obstetrics, children 0 to 12 years and urgency and emergency, and also, for at least the following surgical specialties: Proctology, Peripheral Vascular Surgery, Orthopedics and Trauma, Gynecology, ENT, Ophthalmology, Urology, Diagnostic Tests, Cardiothoracic Surgery and Neurosurgery. c Minimum number of procedures and cases required by ACGME: https://www.acgme.org/Portals/0/PFAssets/ProgramRequirements/040 Anesthesiology 2019 TCC.pdf?ver=2019-03-21-161242-837.
during the internship year experience with pain manage- a variability of 2 to 3 times in the number of cases each one ment; at least 1-month, but not more than 2, in intensive did.20 care unit and emergency medicine. During the 3 years of Table 4 summarizes and explains the evaluation meth- Clinical Anesthesiology, physician trainees should complete ods used, in addition to comparing other aspects, with time at least: 2 weeks in preoperative medicine; 2 weeks in load, years of training in the specialty, number of cases postanesthesia recovery; 4 months in intensive care unit each physician trainee should do throughout training, and (including the month(s) during the pre-anesthesiology year mandatory rotations during residency. --- internship); 2 months in anesthesia for pediatric surgery, obstetrics anesthesia, neuroanesthesia and anesthesia for cardiothoracic surgery; 3 months in pain medicine; 2 weeks Possible paths to be taken and conclusions in anesthetic care for diagnostic or therapeutic procedures outside the surgical suite. All specialty training physicians The competency-based curriculum approaches the responsi- should obtain a certificate in Advanced Cardiovascular Life bility of training programs in Anesthesiology to train capable Support (ACLS) at least once during training, and should take specialists, able to practice independently. Such competen- part in at least one clinical experience drill a year. cies are structured according to the needs of society and Given the competency-based curriculum is based on clin- patients. ical training, registration of cases done by physicians during There are currently, several medical residency programs specialization can reflect each one’s competence. There are in the US, not only in Anesthesiology, studying and trying currently in the US minimum requirements of number of to implement EPA as the evaluation method of physicians cases to be done in each subspecialty. In Brazil and Canada undergoing specialization, such as Pathology, Radiology and there is no regulation as to the number of cases required. In Pediatriacs.8,21,22 Breckwoldt J et al. describe EPA as the Brazil, physicians during specialization are required to do at progress of the competency-based curriculum concept in least 440 acts and 900 annual hours of practical training, but medical education, presenting a more holistic vision of without specification of the number of cases in each subspe- physicians being trained.23 One core evaluation point in EPA cialty. Although the US requires a minimum number of cases is professionalism of physician trainees in regard to patient, for each physician during specialization, a study has shown family, society and work colleagues, beyond practical skills that within the same residency program in the US where for procedures. This part can be considered difficult to eval- everyone attained the number of required cases, there was uate, and its teaching and evaluation is the role of more
168 Brazilian Journal of Anesthesiology 2021;71(2) 162---170 experienced mentor physicians. Several studies have shown Conflicts of interest the versatility of EPA and application in providing feedback and evaluation to the apprentice and development of the The authors declare no conflicts of interest. curriculum. One way of evaluating the development in the work- place of a physician undergoing specialization is through References EPA. This form of evaluation generates valuable feedback for development, which should be provided adequately by 1. Melo RL, Azevedo RA. SBA e CNRM unificam programa para MEs. mentor physicians. Ideally, they should be trained to provide Anest Rev. 2018;68:35---7. constructive feedback and point out their purpose without 2. Mulder M. Conceptions of Professional Competence. In: Bil- damaging the physician trainee-mentor relationship. Simul- let S, Harteis C, Gruber H, editors. International Handbook taneously, there should be a change in feedback culture, of Research in Professional and Practice-based Learning. Dor- that should stop being seen, both by the physician trainee drecht: Springer; 2014. p. 107---37. and the mentor, as something negative, but as a trigger for 3. Hager P. The competence affair, or why vocational education learning. and training urgently needs a new understanding of learning. J Vocat Educ Train. 2004;56:409---33. Feedback, therefore, can be defined as a catalyzer 24 4. Martin L, Sibbald M, Brandt Vegas D, Russell D, Govaerts M. The that transforms evaluation into learning, in which infor- impact of entrustment assessments on feedback and learning: mation is given to improve the performance of physician Trainee perspectives. Med Educ. 2020;54:328---36. trainees according to observation in comparison to expected 5. Englander R, Carraccio C. From theory to practice: making standards.25 The development of an electronic portfolio entrustable professional activities come to life in the context (e-portfolio) in a website format or mobile app can help of milestones. Acad Med. 2014;89:1321---3. specialty training physicians and the program to monitor 6. Wisman-Zwarter N, van der Schaaf M, Ten Cate O, Jonker G, van feedback and progression throughout the years. Fast and Klei WA, Hoff RG. Transforming the learning outcomes of anaes- easy access would be useful, in addition to the assessment thesiology training into entrustable professional activities: a of procedures or specific activities. Delphi study. Eur J Anaesthesiol. 2016;33:559---67. 7. The anesthesiology milestone project. J Grad Med Educ. Good-quality feedback has several benefits for the 2014;6:15---28. apprentice, such as improvement in interpersonal rela- 8. McCloskey CB, Domen RE, Conran RM, et al. Entrustable pro- tions, growth in self-confidence, motivation, competency fessional activities for pathology: recommendations from the 26 and team work, improving the quality of patient care. College of American Pathologists Graduate Medical Education Although mentors tend to think that physician trainees Committee. Acad Pathol. 2017;4:2374289517714283. do not want to get feedback, the study by Wolpaw, J 9. ten Cate O. Entrustability of professional activities and et al. showed that they do want to get more feedback competency-based training. Med Educ. 2005;39:1176---7. than they are getting, and that possible retaliation to the 10. Holmboe ES, Ten Cate O, Durning SJ, Hawkins RE. Assessment staff responsible for negative feedback is not likely to Challenges in the Era of Outcomes-Based Education. In: Holm- happen.27 boe ES, Durning SJ, Hawkins RE, editors. Practical Guide th toe Evaluation of Clinical Competence. Philadelphia: Elsevier; 2018. A model characterized by an approach in which rou- p. 24---78. tine information on the competencies of apprentices is 11. Ten Cate O, Chen HC, Hoff RG, Peters H, Bok H, van der Schaaf collected and their progress is continuously analyzed is M. Curriculum development for the workplace using Entrustable called Programmatic Assessment. When required, it is Professional Activities (EPAs): AMEE Guide No. 99. Med Teach. complemented by additional assessments to collect infor- 2015;37:983---1002. mation purposefully, aimed at informing the maximum to 12. Anesthesiology Specialty Committee. EPA Guide: Anesthesi- students and mentors, and to allow for high-risk deci- ology. Ottawa: Royal College of Physicians and Surgeons of sions at the end of the training stage.28 In this model, Canada; 2017. each approach provides constructive feedback to physician 13. ten Cate O, Scheele F. Competency-based postgraduate train- trainees. ing: can we bridge the gap between theory and clinical practice? Acad Med. 2007;82:542---7. Regarding EPA, the longitudinal analysis of evaluation 14. Ten Cate O. Nuts and bolts of entrustable professional activities. leads to a line of development, and, therefore, makes J Grad Med Educ. 2013;5:157---8. it possible to analyze in which activities and moments 15. Ten Cate O, Hart D, Ankel F, et al. Entrustment decision making physicians undergoing specialization showed gains during in clinical training. Acad Med. 2016;91:191---8. learning. In turn, progression related to Milestones has only 16. The American Board of Anesthesiology. Gauging Performance, been described recently in Internal Medicine, showing that, https://theaba.org/training%20info.html. Acesso em 12 de in general, more advanced physician trainees have higher Dezembro de 2020. marks than those during initial training.29 17. Sociedade Brasileira de Anestesiologia. https://www.sbahq. A standard evaluation in the learning workplace in Anes- org/resources/pdf/arquivos/estatuto/sba/2020/REGULA- thesiology throughout the country may help assure the MENTO-DOS-CET.pdf, 2020. 18. Royal College of Physicians and Surgeons of Canada. desired quality in the training of future Anesthesiologists https://www.med.mun.ca/getattachment/65f8411c-aeb4- in Brazil. The requirement of sending evaluations to a cen- 474d-9923-5a2946900960/Specialty-Training-Requirements-in tral committee, like SBA, can make evaluation of physicians -Anesthesiol-(1).aspx, 2006,. Acesso em 15 de Agosto de 2020. undergoing specialization more effective, also facilitating 19. Accreditation Council for Graduate Medical Education (ACGME). the analysis of progress by trainees themselves and by their https://www.acgme.org/Portals/0/PFAssets/ProgramRequire programs. ments/040 Anesthesiology 2019 TCC.pdf?ver=2019-03-21- 161242-837, 2019.
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20. Yamamoto S, Tanaka P, Madsen MV, Macario A. Analysis of resi- 25. van de Ridder JM, Stokking KM, McGaghie WC, ten Cate OT.What dent case logs in an anesthesiology residency program. A A Case is feedback in clinical education? Med Educ. 2008;42:189---97. Rep. 2016;6:257---62. 26. Duffy K. Providing constructive feedback to students during 21. Wagner JP, Lewis CE, Tillou A, et al. Use of entrustable mentoring. Nurs Stand. 2013;27:50---6,quiz 8. professional activities in the assessment of surgical resident 27. Wolpaw J, Saddawi-Konefka D, Dwivedi P, Toy S. Faculty competency. JAMA Surg. 2018;153:335---43. underestimate resident desire for constructive feedback and 22. Schumacher DJ, Schwartz A, Zenel JA Jr, et al. Nar- overestimate retaliation. J Educ Perioper Med. 2019;21:E634. rative performance level assignments at initial entrust- 28. Schuwirth L, van der Vleuten C, Durning SJ. What programmatic ment and graduation: integrating epas and milestones to assessment in medical education can learn from healthcare. improve learner assessment. Acad Med. 2020, http://dx. Perspect Med Educ. 2017;6:211---5. doi.org/10.1097/ACM.0000000000003300. 29. Hauer KE, Vandergrift J, Lipner RS, Holmboe ES, Hood S, McDon- 23. Breckwoldt J, Beckers SK, Breuer G, Marty A. Entrustable pro- ald FS. National internal medicine milestone ratings: validity fessional activities : Promising concept in postgraduate medical evidence from longitudinal three-year follow-up. Acad Med. education. Anaesthesist. 2018;67:452---7. 2018;93:1189---204. 24. Konopasek L, Norcini J, Krupat E. Focusing on the formative: building an assessment system aimed at student growth and development. Acad Med. 2016;91:1492---7.
170 Brazilian Journal of Anesthesiology 2021;71(2) 171---174
CASE REPORTS Anesthetic management of a patient with face hemangioma: case report
Meryem Onay ∗, SemaS¸ anal Bas¸, ˙Irem Özdöl, Birgül Yelken
Eskisehir Osmangazi University, Faculty of Medicine, Department of Anesthesiology and Reanimation, Eskisehir, Turkey
Received 8 October 2019; accepted 29 November 2020 Available online 11 February 2021
KEYWORDS Abstract Anesthetic agents and/or surgical positions, the total volume of hemangioma may Hemangioma; increase under general anesthesia; thus, airway management of patients with a hemangioma Difficult airway may be very difficult. Our patient in this case report has a periorbital and oropharyngeal management; hemangioma that reaches down to the esophagus. We observed that the size and volume of Beta-blockers; the hemangioma increased significantly during elective nephrectomy surgery. After adequate Anesthesia therapy with steroids and beta-blockers, the size of the hemangioma decreased during the post- operative care unit monitoring period. We report this case to show the importance of airway management of hemangiomas with the potential for life-threatening complications. © 2021 Sociedade Brasileira de Anestesiologia. Published by Elsevier Editora Ltda. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by- nc-nd/4.0/).
Introduction Size, volume, location, aggressive nature, and increased growth may lead to life-threatening complications. Possible Infantile hemangiomas are benign neoplasms that are com- complications may be predicted depending on the location 2 posed of a normal or abnormal proliferation of vascular site. Here, we present our experience with a patient with a structures. Seventy percent of hemangiomas are con- periorbital and oropharyngeal hemangioma during elective genital. Most of them regress spontaneously.1 Treatment nephrectomy under general anesthesia. involves steroids, beta-blockers, interferon-a, vincristine, cyclophosphamide, pulse dry laser, and surgery.1 Recurrence Case report risk is high, which is independent of treatment. Ten percent of infantile hemangiomas may lead to tissue destruction. The patient was a 40-year-old male with a weight of 73 kg, a height of 178 cm, and American Society of Anes- thesiologists (ASA) II. His complaint was effort dyspnea; ∗ Corresponding author. however, his ECG was normal sinus rhythm, and echocar- E-mails: [email protected], [email protected] diography revealed an ejection fraction (EF) of 60%, which (M. Onay). is completely normal. Cardiovascular and respiratory sys- https://doi.org/10.1016/j.bjane.2021.02.019 © 2021 Sociedade Brasileira de Anestesiologia. Published by Elsevier Editora Ltda. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). M. Onay, S.S¸. Bas¸, ˙I. Özdöl et al.
Figure 1 Preoperative, intraoperative and postoperative pictures of a patient with facial hemangioma. After general anesthesia was applied, the size of the hemangioma was increased and color change with the intraoperative lateral decubitus position observed. After medical and conservative treatment, the hemangioma partially regressed and the patient was extubated. He completely recovered by the 24th hour. A, Preoperative 24 hours; B, Intraoperative growing hemangioma; C, Postoperative 24 hours, regressed hemangioma. tem examination were normal. Ten years ago, he had an cure. The patient told us that he had been asymptomatic elective inguinal hernia operation under spinal anesthesia since birth. Written and oral informed consent were taken without any complications. He had a history of frequent uri- and signed. Possible complications were explained in detail: nary tract infections. A simple nephrectomy was planned bleeding, aspiration, difficult intubation, and tracheotomy. because of a unilateral atrophic kidney. The Mallampati An oropharyngeal hemangioma may involve difficult airway score was 2. His neck movements and mouth opening were management tools (airway gum-elastic bougie, tracheotomy normal. There was a periorbital and oropharyngeal heman- set, supraglottic airway device, and video laryngoscopy) and gioma on the left of his face. He mentioned that the necessary equipment. On the operation table, routine non- hemangioma reached the esophagus (Figure 1A). In the pre- invasive monitoring (blood pressure, heart rate, saturation, operative period, it was evaluated by the Ear Nose Throat 3-lead ECG) was performed. With a face mask, 3 minutes of (ENT) with a flexible nasopharyngolaryngoscope. There was preoxygenation was performed with 100% oxygen. Anesthe- a purple-colored lesion suggesting hemangioma on the hard sia induction involved intravenous (IV) lidocaine (1 mg.kg-1) palate. Vocal cords are mobile and there is no edema. and propofol (3 mg.kg-1). Adequate mask ventilation was His medical history revealed that all lesions were already performed. Then, rocuronium 0.6 mg.kg-1 IV was adminis- present at birth. The size of those lesions depended on the tered for muscle relaxation. We did not want to traumatize ‘‘upright’’ position of the patient, which means that when the hemangioma during endotracheal intubation, which is the patient is upright standing or sitting, the size and vol- why we used the C-MAC Storz video laryngoscope to see ume of the hemangioma are small. When the patient lies and record the visual content between the upper palate down (horizontally), the size and volume of the hemangioma and lip. Using a spiral endotracheal tube (ID 8.0 mm), intu- increase. When he stands up again, it regresses, and the bation was performed very carefully. If there was a failed size and volume decrease spontaneously. No specific treat- intubation, the next step would be tracheotomy. Because ment was recommended. There is no medical or surgical supraglottic airway device were not dropped due to intraoral
172 Brazilian Journal of Anesthesiology 2021;71(2) 171---174 lesions and risk of bleeding, invasive right radial artery blood adverse effects, such as bronchoconstriction, hypotension, pressure monitoring was performed. The right lateral flank hypoglycemia, and early depletion of cardiac performance, position was set on the operation table for the surgeons to which are some of the main complications, especially under operate. Anesthesia maintenance involved sevoflurane 2---3% 6 months of age. Therefore, close monitoring protocols (MAC 1---1.3) and 50% oxygen + 50% air with IV remifentanil are recommended. Nonselective beta-blockers have ther- infusion 0.1-0.3 mcg.kg-1. minute-1. The hemangioma color apeutic effects on hemangiomas; for example, palpation changed, and the volume increased gradually (Figure 1B) causes hemangiomas to soften, vasoconstriction leads to after induction and lateral flank positioning. some color changes, the expression of VEGF and bFGF genes The tube rope (string) position was checked to ensure may decrease, the RAF mitogen gene may activate the pro- that it did not interfere with circulation. An intraopera- tein kinase pathway, and capillary endothelial cells may tive ENT consultation was made. The heart rate was 72 trigger apoptosis.4 We observed that the rapidly growing beats/minute, the blood pressure was 90/64 mmHg, and hemangioma during the operation was rapidly resolved by the peripheral oxygen saturation was 98%. The ENT rec- using steroids and beta-blockers in our case. ommended metoprolol 2 mg IV, methylprednisolone 80 mg Studies have been conducted with other beta-blockers IV, and ranitidine 50 mg IV. We also administered these similar to propranolol, such as nadolol and timolol. However, medications. The hemodynamics were stable throughout it should be noted that other beta-blockers also have some the intraoperative period. For extubation, all preparations adverse side effects; appropriate doses should be titrated to were made, including invasive interventions. At the end obtain optimal benefit. Beta-blockers have been shown to of surgery, the patient was again in the supine position. be alternatives to steroids in terms of hemangioma shrink- The hemangioma partially regressed in the supine posi- age and color change.1 Nonselective beta-blockers have tion and the upper airway was evaluated as safe with been shown to be effective in the treatment of infantile a flexible nasopharyngolaryngoscope. Vocal cords are no hemangiomas located in the orbital region. Both propra- edema and hemangioma in the left upper lip. Sugam- nolol and metoprolol were combined with steroids to treat madex (2 mg.kg-1) was administered. We waited until the infantile hemangiomas located in the orbital region. This patient spontaneously breathed on his own. When protective study suggested beta-blockers as the first-line treatment for upper respiratory reflexes returned, we extubated him. No hemangiomas in children.5 complications occurred. The size and volume of the heman- Chen et al. revealed that hemangioma tissue has sig- gioma decreased in the postoperative period. The color also nificantly more HIF-1a (hypoxia-inducible factor-1a) than returned to normal. During postanesthetic care unit (PACU) normal tissues. The level of HIF-1a (hypoxia-inducible monitoring, we waited to be sure that the airway was fully factor-1a) decreased significantly after propranolol treat- safe and secure. When the patient was completely awake ment depending on the time and dose. Propranolol inhibits and stable, we transferred him to his bed in a urology ward apoptosis (which is activated by HIF-1a, hypoxia-inducible room (Figure 1C). The postoperative period was stable and factor-1a). Propranolol also inhibits the cellular prolifer- without complications, and the hemangioma regressed. He ation, migration, and tubal formation of hemangiomas, was discharged from the hospital on the fifth postoperative which is why propranolol may be considered in the future day. to be the first-line treatment choice.2 Although steroids were shown to be the first choice of medical treatment for infantile hemangiomas, it was recently shown that steroids Discussion may also lead to unwanted complications such as men- tal retardation, infections, and pain by way of actions on A hemangioma is a malformation of normal and/or abnor- the proliferative phase of the hemangioma.1 In the case mal vascular structures that regresses spontaneously. The of hemangiomas that are located in the airway region (on pathogenesis is not yet fully understood. Gene mutations, the inside wall of the respiratory tract), the treatment deletions, hormonal factors, and microtraumas may be protocol depends on the patient age, lesion localization, causative or predisposing factors that lead to hemangioma and hemodynamic parameters.3 In our case, we preferred during the infancy/newborn period of human life.1 Gen- metoprolol combined with steroids for our treatment pro- erally, hemangiomas are located in the head and neck.3 tocol; nevertheless, we believe that surgical position and In adulthood, hemangiomas do not respond to medical vasodilatation (due to anesthetics) are two main factors treatment and tend to bleed upon surgical interventions. that worsen hemangioma volume and the risk of airway Treatment indications are as follows: functional symptoms, compromise. airway obstruction, swallowing difficulty, and bleeding attack.1 Here, we aimed to emphasize the importance of successful airway management with appropriate treatment Conclusion of the rapidly growing hemangioma in a patient who under- went simple nephrectomy. In surgery, oropharyngeal hemangiomas may compromise First, in 2008, Leaute-Lebeze et al started steroids for airway security and even cause life-threatening the treatment of hemangioma; however,their patient devel- complications because of the vasodilatation effects of oped obstructive cardiomyopathy. Then, steroid treatment anesthetics and surgical positions on the hemangioma. was gradually decreased and stopped; it was noticed by Adult patients may also require steroids and beta-blockers chance that the hemangioma coincidentally became smaller. for treatment to decrease hemangioma volume and relieve Instead of steroids, the use of the nonselective beta-blocker symptoms. In this patient, we had concerns about airway propranolol is advised. However, propranolol also has some security because the hemangioma was very large and was
173 M. Onay, S.S¸. Bas¸, ˙I. Özdöl et al. even larger with anesthetics and in the surgical position. We 2. Chen Y, Bai N, Bi J, et al. Propranolol inhibits the proliferation, emphasize here all the elective preparations, anesthetic migration and tube formation of hemangioma cells through HIF- needs, effective doses of treatment drugs, side effects, 1␣ dependent mechanisms. Braz J Med Biol Res. 2017;50:e6138. surgical positions, and possible life-threatening outcomes. 3. Kumar P, Kaushal D, Garg PK, et al. Subglottic hemangioma masquerading as croup and treated successfully with oral pro- pranolol. Lung India. 2019;36:233. Conflicts of interest 4. Léauté-Labrèze C, de la Roque Dumas E, Hubiche T, et al. Propra- nolol for severe hemangiomas of infancy.(Letter to the editor). The authors declare no conflicts of interest. N Engl J Med. 2008;358:2649---51. 5. Porubanova M, Sharashidze A, Hornova J, et al. -blockers in the treatment of periocular infantile capillary haemangioma. Neo- References plasma. 2015;62:974---9.
1. Xu S-Q, Jia R-B, Zhang W, et al. Beta-blockers versus corticos- teroids in the treatment of infantile hemangioma: an evidence- based systematic review. World J Pediatr. 2013;9:221---9.
174 Brazilian Journal of Anesthesiology 2021;71(2) 175---177
CASE REPORTS Permanent hemidiaphragmatic paresis after interscalene brachial plexus block: a case report
Nina Cugnin, Benjamin Le Gaillard, Edmundo Pereira de Souza Neto ∗
Centre Hospitalier de Montauban, Département d’Anesthésia, France
Received 24 September 2019; accepted 5 December 2020 Available online 3 February 2021
KEYWORDS Abstract Interscalene brachial plexus block has been widely used in shoulder surgery. We Regional anesthetic report one case of long-term phrenic palsy following ultrasound-guided interscalene brachial techniques; plexus block and we will discuss the possible etiology and mechanism of this disability. For Interscalene block; painful shoulder surgery, ultrasound-guided interscalene brachial plexus block remains topical. Neurologic symptoms Alternative blocks, such as suprascapular and axillary blocks, may be reserved for patients with pre-existing respiratory pathology. © 2021 Sociedade Brasileira de Anestesiologia. Published by Elsevier Editora Ltda. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/ licenses/by-nc-nd/4.0/).
Introduction ultrasound allows better visualization of structures, recent literature suggests that the incidence of this potential 2 --- 4 Interscalene Brachial Plexus Block (IBPB) has been widely severe complication is higher than previously indicated. used in shoulder surgery allowing better intraoperative and We report one case of long-term phrenic palsy following postoperative pain management and a reduction in hospital IBPB after ultrasound guidance and we discuss the possible stay.1 etiology and mechanism of this disability. Although it is usually considered a safe block, the risk of complications like hemidiaphragmatic paresis as a result of Report ipsilateral phrenic nerve block has been reported.2 --- 4 This type of paresis is often transient and is resolved over A 64-year-old male (72 kg, 170 cm) was scheduled for an the duration of the local anesthetic’s action, but it results exeresis of sebaceous cyst of the left shoulder. Vital signs in a decrease in forced vital capacity of 20---25%.2,3 Although (blood pressure, temperature, and oxygen saturation) were normal. His medical history included hypertension, hypercholes- ∗ Corresponding author. terolemia, left hypertrophic cardiomyopathy with normal E-mail: [email protected] ventricular function, and a sleep apnea syndrome requiring (E.P. Souza Neto). temporary apparatus between 2002 and 2007 before weight https://doi.org/10.1016/j.bjane.2021.02.009 © 2021 Sociedade Brasileira de Anestesiologia. Published by Elsevier Editora Ltda. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). N. Cugnin, B. Le Gaillard and E.P. Souza Neto
Figure 1 Chest X-ray (A) and thoracoabdominal computed tomography (B) with an important rise in the right diaphragmatic dome evoking a diaphragmatic paresis. loss and epigastralgia. He never had general anesthesia desaturation and the distance travelled was 450 meters, or and had one surgery of hemorrhoids with spinal anesthesia. 67% of the theoretical distance. His routine drug therapy consisted of lercanidipine 10 mg Thoracoabdominal computed tomography confirms that once daily, fenofibrate 160 mg once daily, and esomepra- the right diaphragmatic dome is raised with atelectasis of zole 20 mg. No additional paraclinical examination was the pulmonary parenchyma related to the dome lift without requested. We decided to allow the surgery with only an any specific appearance anomaly (Figure 1B). IBPB. Cervical-thoracic Magnetic Resonance Imaging (MRI) After the intravenous route was secured in the contralat- found no root compression nor right phrenic nerve nor right eral forearm, routine monitors (ECG, noninvasive blood brachial plexus abnormality. pressure, pulse oximetry) were applied. The skin was pre- Unfortunately, one year after the surgery the respiratory pared in typical sterile fashion. The IBPB was performed functional exploration was discreetly improved, and he has using a S-Nerve ultrasound system (SonoSite®, Bothell, WA, to benefit from nocturnal ventilatory support. USA) with a 1 3 --- 6 MHz 38-mm high-frequency linear array transducer (HFL38×; SonoSite®). The transducer was cov- ered with a sterile adhesive bandage (Microtek®, Ecolab®, Discussion Zutphen, The Netherlands). IBPB was performed with a 4 cm 24G needle (SonoTap®, The incidence of transient diaphragm paresis following a Pajunk®, GA, USA) in the posteriocaudal medial direction, successful IBPB is almost 100% but a permanent diaphragm under ultrasound visualization without nerve stimulation. paralysis is rare, with an incidence of 0.048% to 0.1%.2,3 For Fifteen millilitres of mepivacaine 1.5% was injected lateral our institution, it is our first case described. from the plexus at the level of C6 and perineural spread The mechanism for prolonged hemidiaphragmatic pare- around all nerve roots with local anesthetic was confirmed sis is unclear. Some factors that may lead to prolonged with ultrasound. After 20 minutes, a sensory blockade was diaphragmatic paresis include infections, metabolic prob- observed without adverse effects. lems, alcoholism, vitamin deficiencies, exposure to toxins, The surgery time took totally 30 minutes and it was and trauma or pressure on the nerve.2,3 done without any problem. The patient remained in the In our patient medical history, there were no vitamin defi- postanesthesia care unit for 20 minutes. The patient ciencies, alcoholism, metabolic problems, or the existence returned to ambulatory care and he was discharged from of a preexisting subclinical polyneuropathy. Other potential the hospital 6 hours after the end of the surgery without causes could be evoked, like nerve damage due to direct problem. needle trauma, intraneural injection, or an inflammatory Twenty-four hours after discharged he reported a short scarring that could be responsible for a nerve entrapment.2,3 breath and dyspnea. Given the asymptomatic character Regarding the risks of surgical trauma, the installation had of the exertional dyspnea, multiple blood exams and a been properly verified, patient was awake, and there is a coronary angiography were performed. They were normal. low risk for direct surgical trauma. However, the chest X-ray demonstrated phrenic nerve paral- Causes described for inflict nerve injury, as transection, ysis, with a very important rise in the right diaphragmatic piercing, stretching, and compression (by needle or anes- dome evoking a diaphragmatic paresis (Figure 1A). Res- thetic product) seem unlikely, especially since we used the piratory functional exploration found a severe restrictive sonographic method. In this case, we used a technique of syndrome with a vital capacity at 1.86 L that is 46% of normal lateral to medial puncture because we know it is best to vital, a Tiffeneau coefficient at 75%, and a total lung capac- avoid damage to the phrenic nerve. Indeed, a puncture lat- ity of 3.9 L that is 59% of normal. Ambient air saturation at eral to medial presents risk of damage to the long thoracic rest was 96%, at the walking test of 6 minutes there was no and dorsal scapular nerve while a puncture medial to lateral
176 Brazilian Journal of Anesthesiology 2021;71(2) 175---177 presents an increased risk for vascular and phrenic nerve lasting side effects, especially in respiratory function.1,3---5 lesions.2,3 However, the sonographic technique does not pre- Although the IBPB has advantages over general anesthesia vent paralysis because prolonged phrenic nerve palsy has (particularly with volatile agents), which includes better been reported after ultrasound guided IBPB.2 --- 5 The combi- perioperative analgesia, decreased incidence of postoper- nation of the ultrasound and nerve stimulation technique ative nausea and vomiting, and faster postanesthesia care may seem interesting to detect if the needle was close to unit discharge times in ambulatory surgery, its indication can the nerve. In our case no nerve damage or compression was be discussed according to the surgery.1,12 found in cervical-thoracic MRI. In conclusion, the benefits of IBPB with regard to post- The volume administered may be responsible for high operative analgesia should be weighed against the risks incidences of diaphragmatic paresis. A volume of 5 to 10 mL of potential devastating complications.1 --- 3 The combined can prevent the risk of paresis and toxicity associated low-volume, ultrasound guided and alternative blocks, such with local anesthetic.3 --- 5 Nevertheless, a recent study shows as suprascapular and axillary blocks, may reduce rate of that low volumes can lead to diaphragmatic paresis in one hemidiaphragmatic paresis while providing good analgesia third of cases in obese patients.4,5 In addition, risk fac- when compared with IBPB. tors for neuropathy are identified such as diabetes, cervical brachial pathology, history of surgery or cervical trauma, or Conflicts of interest obesity.3 --- 5 Our patient had none of these risk factors, but the volume injected was probably too important (15 mL). The authors declare no conflicts of interest. A high risk of toxicity for neural structures after inter- scalene brachial plexus block has been demonstrated in prospective studies that identified brachial plexus damage References (i.e., sensory dysfunction a week or more after intersca- lene brachial plexus block that is not attributable to other 1. Beecroft CL, Coventry DM. Anaesthesia for shoulder surgery. causes) in 4.4---14%of block subjects.6 --- 8 Permanent sensory CEACCP. 2008;8:193---8. dysfunction is much more rare because of neuronal regrowth 2. El-Boghdadly K, Chin KJ, Chan VWS. Phrenic nerve palsy and the plentiful redundancy and plasticity of peripheral and and regional anesthesia for shoulder surgery: anatomi- cal, physiologic, and clinical considerations. Anesthesiology. central sensory systems.6 --- 8 2017;27:173---91. Recovery is thought to be quite good and often takes 6 3. Buise MP, Bouwman RA, van der Gaag A, et al. Phrenic nerve 9 to 12 months with the normalization of vital capacity. In a palsy following interscalene brachial plexus block; a long-lasting retrospective study in 23 consecutive patients with uni- or serious complication. Acta Anaesthesiol Belg. 2015;66:91---4. bilateral diaphragm paralysis, Gayan-Ramirez et al. (2008) 4. Riazi S, Carmichael N, Awad I, et al. Effect of local anaes- demonstrated that functional recovery occurred in 43% of thetic volume (20 vs. 5 mL) on the efficacy and respiratory the patients after 12 months and in 52% after 24 months.10 consequences of ultrasound-guided interscalene brachial plexus Type and etiology of paralysis did not influence recovery. block. Br J Anaesth. 2008;101:549---56. Compound motor action potential of the diaphragm, anthro- 5. Marty P, Ferre F, Basset B, et al. Diaphragmatic paralysis in pometric characteristics, and baseline pulmonary function obese patients in arthroscopic shoulder surgery: consequences and causes. J Anesth. 2018;32:333---40. did not predict functional respiratory recovery. Moreover, 6. Borgeat A, Ekatodramis G, Kalberer F, Benz C. Acute and it did not result in a greater percentage functional respi- nonacute complications associated with interscalene block 10 ratory recovery. Relapse after an initial improvement was and shoulder surgery: a prospective study. Anesthesiology. 10 observed in 26% of the patients. Most patients with asymp- 2001;95:875---80. tomatic unilateral diaphragmatic paralysis do not require 7. Borgeat A, Dullenkopf A, Ekatodramis G, Nagy L. Evaluation of treatment. Surgical options are considered if the underly- the lateral modified approach for continuous interscalene block ing cause is treated and the patient still has symptoms, after shoulder surgery. Anesthesiology. 2003;99:436---42. or if the patient has bilateral diaphragmatic paralysis.10,11 8. Candido KD, Sukhani R, Doty R Jr, et al. Neurologic seque- There are various treatment options including plication and lae after interscalene brachial plexus block for shoulder/upper phrenic nerve stimulation. Plication of the affected site arm surgery: The association of patient, anesthetic, and surgi- cal factors to the incidence and clinical course. Anesth Analg. is a very useful treatment method that allows weaning 10,11 2005;100:1489---95. from mechanical ventilation. Plication is preferably per- 9. Xu WD, Gu YD, Lu JB, et al. Pulmonary function after formed in unilateral diaphragmatic paralysis in non-morbidly complete unilateral phrenic nerve transection. J Neurosurg. 10,11 obese patients. Phrenic nerve stimulation is performed 2005;103:464---7. in intact phrenic nerve without evidence of myopathy. 10. Gayan-Ramirez G, Gosselin N, Troosters T, Bruyninckx F, Gos- This procedure can be performed in patients with bilateral selink R, Decramer M. Functional recovery of diaphragm paral- diaphragmatic paralysis with cervical spine injuries.10,11 ysis: a long-term follow-up study. Respir Med. 2008;102:690---8. After one year, our patient unfortunately did not regain 11. Ricoy J, Rodríguez-Núnez˜ N, Álvarez-Dobano˜ JM, et al. normal function and was dyspneic at efforts. He only feels an Diaphragmatic dysfunction. Pulmonology. 2019;25:223---35. improvement in his adaptation to effort after starting kine- 12. Gonano C, Kettner SC, Ernstbrunner M, et al. Comparison of economic aspects of Interscalene Brachial plexus blockade and sitherapy. Surgical diaphragmatic plication will be proposed general anaesthesia for arthroscopic shoulder surgery. Br J if the symptoms persist. Anaesth. 2009;103:428---33. As this case shows, and despite its importance in painful shoulder surgery, IBPB can have rare but serious long-
177 Brazilian Journal of Anesthesiology 2021;71(2) 178---180
CASE REPORTS Anesthesia management of pediatric dentistry patients with cardiofaciocutaneous syndrome: a case report
Gian Luigi Gonnella ∗, Pietro Paolo Giuri, Bruno Antonio Zanfini, Matteo Biancone, Luciano Frassanito, Cristina Olivieri, Gaetano Draisci
Policlinico Universitario Agostino Gemelli, ‘‘A. Gemelli’’ University Polyclinic Foundation, Catholic University of the Sacred Heart, Department of Anesthesiology and Intensive Care Medicine, Rome, Italy
Received 12 February 2020; accepted 18 October 2020 Available online 6 February 2021
KEYWORDS Abstract Cardiofaciocutaneous syndrome is a rare syndrome characterized by particular cran- Cardiofaciocutaneous iofacial features, cardiac abnormalities, and multiple organ diseases. Patients present with syndrome; pulmonary stenosis, hypertrophic cardiomyopathy, short neck, micrognathia, laryngomalacia, Airway management; and tracheomalacia. These conditions may strongly influence patient perioperative outcomes. Congenital heart We describe a 15-year-old child with cardiofaciocutaneous syndrome presenting for a dentistry defects procedure. She had an uneventful perioperative and postoperative course except for difficult airway management. © 2021 Sociedade Brasileira de Anestesiologia. Published by Elsevier Editora Ltda. This is an open access article under the CC BY-NC-ND license (http://creativecommons. org/licenses/by-nc-nd/4.0/).
Introduction tic valve), and rhythm disturbances. These defects may be identified at birth or later in life.1,2 Craniofacial inspection Cardiofaciocutaneous (CFC) syndrome is a rare condition reveals high forehead, macrocephaly, bitemporal narrowing, characterized by an autosomal dominant inheritance pat- hypoplasia of the supraorbital ridges, ocular hypertelorism, tern and several congenital abnormalities involving multiple down slanting palpebral fissures, epicanthal folds, pto- organ systems.1 The cardiac defects include pulmonary sis, short wide nose, and anteverted nares, posteriorly stenosis, atrial and ventricular septal defects, Hypertrophic rotated low-set ears. Airway presents high-arched palate, Cardiomyopathy (HOCM), heart valve anomalies (mitral relative micrognathia, laryngomalacia, tracheomalacia, and valve dysplasia, tricuspid valve dysplasia, and bicuspid aor- hypersalivation. Osteo-muscular malformations (kyphosis, scoliosis, hypotonia), gastroesophageal reflux, growth hor- mone deficit, developmental delay, and seizure disease may be displayed.1 Currently, more than 100 individuals with ∗ Corresponding author. CFC syndrome are reported in the literature, and 200 to E-mail: [email protected] 1 (G.L. Gonnella). 300 individuals are estimated worldwide. To the best of https://doi.org/10.1016/j.bjane.2020.10.013 © 2021 Sociedade Brasileira de Anestesiologia. Published by Elsevier Editora Ltda. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). Brazilian Journal of Anesthesiology 2021;71(2) 178---180 our knowledge, this is the first report describing anesthesia Then, 10 mg of esomeprazole for gastric protection, 2 mg management in dentistry procedures in a patient with CFC. of dexamethasone and 2 mg of ondansetron for post- Consent was obtained from the patient’s parent to publish operative nausea and vomiting prevention, and 200 mg this case report. Institutional review board approval was not of acetaminophen for postoperative pain were adminis- necessary. tered. The surgery, consisting of seven dental extractions, lasted 56 minutes. The patient was hemodynamically sta- ble throughout the case. Once the surgical procedure was Case completed, anesthesia emergence operations were carried out, and postextubation stridor complicated this stage. This A 15-year-old female child presented for elective den- complication was promptly solved through the administra- tal treatment of high-level caries. Because of her heart tion of high flow oxygen and nebulized epinephrine 500 mcg defect and dysmorphic facial features two years after in 5 mL of normal saline while gently applying CPAP. The birth, a genetic workup revealed a MEK1 gene mutation patient was discharged in the postanesthesia care unit once diagnostic for CFC syndrome. Her medical history was sig- she was fully awake and her vital parameters were stable. nificant for seizure disorder, global development delay, She was observed for 4 hours in the postanesthesia care unit gastroesophageal reflux, megacolon, and severe scoliosis. and for 5 hours in the outpatient hospital ward, and then 2D color Doppler echocardiography documented asymmetric discharged to return home. hypertrophic cardiomyopathy of the left ventricle (inter- ventricular septum diastolic thickness of 11 mm and 15 mm in the subaortic portion), no obstruction of the Left Ven- Discussion tricular Outflow Tract (LVOT wave maximum velocity (VLVOT) =167 cm.s-1), mitral valve dysplasia with moderate mitral CFC syndrome is part of a family of syndromes, includ- insufficiency, and ejection fraction of 62%. ing Noonan and Costello syndromes, which have phenotypic On the day of surgery, her physical examination revealed similarities. Noonan syndrome presents similar craniofacial an alert female with body mass index of 19. The patient traits, congenital heart defects (pulmonary valve steno- had macrocephaly with narrowing at the temples, short sis, HOCM), and fewer neurological conditions than CFC.1 and wide nose, hypertelorism, and low-set ears. Full air- Costello patients share similar facial traits with patients way examination was not possible because the patient with Noonan and CFC. HOCM and rhythm disturbances are was uncooperative; nevertheless, we observed macroglos- displayed in Costello syndrome.1,3 These syndromes have sia, short neck and short thyromental distance, which are analogous phenotypic presentations, thus clinical diagno- predictors of possible difficult intubation. Moreover, she sis based only on clinical features is difficult. Genetic tests presented severe scoliosis with a moderate restrictive res- are needed to differentiate between the syndromes. Noonan piratory deficit. patients have PTPN11, KRAS, SHOC2, and NRAS1 mutations. She presented generalized hypotonia that was greater Patients with an HRASmutation have a diagnosis of Costello in her lower extremities. Her seizure disorder was man- syndrome.1 CFC syndrome is characterized by mutations in aged with levetiracetam 250 mg twice daily, perampanel genes BRAF, KRAS, MEK1 (MAP2K1), or MEK2 (MAP2K2) that 4 mg, and carbamazepine 400 mg twice daily. After mon- are part of a RAS-extracellular signal-regulated kinase path- itoring, the patient’s vital parameters were as follows: way that has roles in cell differentiation, proliferation, and arterial blood pressure 110/54 mmHg, heart rate 92 bpm, apoptosis.1,3 respiratory rate 21 min, temperature 36.3◦C, oxyhemoglobin The multisystem involvement of CFC syndrome may saturation 95% while breathing room air, and bispectral present significant challenges during the perioperative index 96. Anesthesia was induced with nitrous oxide and period. The dysregulation of the RAS/Mitogen Acti- oxygen (7:3 ratio) and 8% sevoflurane. After insertion of vated Protein Kinase (MAPK) signaling pathway contributes an intravenous (IV) catheter, 20 mg of propofol, 20 mcg to the craniofacial dysmorphia of normal craniofacial of fentanyl, and 20 mg of rocuronium were administered. development.4 Anesthesiologists should be aware that Subsequently, mild airway obstruction occurred, which was several phenotypic craniofacial, dental, and palatal abnor- easily remedied by an oropharyngeal airway and positive malities can complicate airway management. Our patient pressure. The first direct laryngoscopy with a number 3 presented macrocephaly, micrognathia, reduced thyromen- Macintosh laryngoscope revealed difficult glottis visualiza- tal distance, and a short neck. These features posed tion (Cormack-Lehane score 3). Tw o more attempts using concerns regarding difficult airway management and led us Glidescope were needed to secure the patient airway. After to plan a stepwise approach according to the Difficult Air- optimizing head and neck extension, videolaryngoscopy with way Society 2015. Predicted difficult airway management a number 3 angulated blade associated with BURP (Backward was confirmed during direct laryngoscopy, and endotracheal Upward Rightward Pressure) enhanced glottis visualiza- intubation was secured using an angulated blade videolaryn- tion (Cormack-Lehane score 2), allowing intubation with a goscope already available in the operating room associated 4.5 mm cuffed endotracheal tube armored with a preformed with laryngeal manipulation (BURP). Anesthesia providers stylet, without using glottis directed topical spray of lido- should be aware that although visualization of the airway is caine. General anesthesia was maintained with sevoflurane superior using angulated videolaryngoscopy, an appropriate (1.5---2.5%) according to a bispectral index value between airway view will not necessarily provide easy tube insertion. 40 and 60. Amoxicillin-clavulanic acid (1 g) was given Children with predicted difficult airway management are a before incision. An additional 20 mg of methylprednisolone high-risk group, and multiple tracheal intubation attempts was administered after prolonged airway manipulation. are an important risk factor for respiratory complications.
179 G.L. Gonnella, P. P. Giuri, B.A. Zanfini et al.
Thus, every tracheal intubation should be treated as a riences because these patients have difficulties cooperating critical intervention. This case study has a major limita- with medical staff. tion. To reduce the number of intubation attempts, the use Most patients have concomitant severe feeding prob- of Glidescope should have been considered as a first-line lems manifesting as oral aversion, gastroesophageal reflux, option. Furthermore, fiberoptic intubation deserves special gastrointestinal dysmotility, intestinal malrotation, and consideration. It is the gold standard for tracheal intuba- constipation.1 They frequently need a feeding tube and fun- tion in adults with predicted difficult airways. However, this doplication. Given the varying severity of reflux affecting method is more difficult with the narrow airway of an unco- these patients, anesthesiologists must be aware of the pos- operative pediatric patient. sibility of aspiration. Gastric reflux was not present in our Individuals with CFC syndrome may have unrecognized patient, but considering the aspiration risk, she was fasted laryngo-tracheomalacia that can make them prone to respi- before induction of anesthesia. ratory complications. In addition to this potential risk factor, There are very few studies describing anesthesia mana- our patient underwent prolonged airway instrumentation, gement in CFC syndrome. In this report, the anesthesiologist and despite the administration of methylprednisolone and was faced with cardiac, breathing and airway management accurate suction of blood and secretions, she underwent difficulties, which are the most challenging. To protect postextubation stridor, which ended after prompt admin- patients with CFC, it is mandatory to consider their neu- istration of nebulized epinephrine and CPAP. The genetic rological status and gastrointestinal disease as these may mutation in this syndrome inhibits myoblast differentia- also heavily influence perioperative outcome. tion, leading to fewer myosin heavy chains and ultimately abnormal muscle fiber size and variability.5 Respiratory Conflicts of interest muscle weakness may render these patients sensitive to the sedative and respiratory depressant effects of opioids The authors declare no conflicts of interest. during the postoperative period. For this reason, we admin- istered a low dose of fentanyl encouraging local dental anesthesia performed by the surgeon. Seventy-five per- References cent of patients with CFC will have one or more cardiac abnormalities.2 The most common cardiac defects are pul- 1. Rauen KA. Cardiofaciocutaneous syndrome. In: Pagon RA, Adam monary valve stenosis (45%) and HOCM (40%), which may MP, Ardinger HH, Bird TD, Dolan C, Fong CT, Smith RJH, Stephens ® progress with age.1,2 Our patient presented HOCM and K, Amemiya A, editors. GeneReviews [Internet]. Seattle, WA: University of Washington, Seattle; 2007. p. 1993---2020. Jan 18 mitral valve dysplasia with moderate mitral insufficiency. [Updated 2012 Sep 6]. Because HOCM epinephrine addition to local anesthetic was 2. Armour CM, Allanson JE. Further delineation of cardiofaciocuta- avoided, nebulized epinephrine was underdosed to avoid neous syndrome: clinical features of 38 individuals with proven the risk of left ventricular outflow tract obstruction. Mitral mutations. J Med Genet. 2008;45:249---54. valve defects make antibiotic prophylaxis for endocardi- 3. Katcher K, Bothwell M, Tobias JD. Anaesthetic implications of tis mandatory. Accordingly, a pediatric cardiac evaluation, Costello syndrome. Paediatr Anaesth. 2003;13:257---62. including echocardiogram and electrocardiogram, is recom- 4. Goodwin AF, Oberoi S, Landan M, et al. Craniofacial and dental mended during the preanesthetic assessment. Almost 50% development in cardiofaciocutaneous syndrome: the importance of CFC patients will have seizures, and all have signifi- of Ras signaling homeostasis. Clin Genet. 2013;83:539---44. cant developmental delay.2 Our patient had developmental 5. Tidyman WE, Han SL, Rauen KA. Skeletal muscle pathology in Costello and cardiofaciocutaneous syndromes: developmental delay and seizure disorder that was well controlled by consequences of germline Ras/MAPK activation on myogenesis. antiepileptic therapy. Thereafter, anesthesiologists should Am J Med Genet C Semin in Med Genet. 2011;157C:104---14. be prepared for potentially challenging perioperative expe-
180 Brazilian Journal of Anesthesiology 2021;71(2) 181---183
CASE REPORTS Anesthetic management of scoliosis operation in a pediatric patient with Frank-ter Haar syndrome: a case report
Irem Basaran, Ezgi Gozubuyuk, Nur Canbolat ∗, Ipek S. Edipoglu, Mehmet I. Buget
Istanbul Medical Faculty Hospital, Department of Anesthesiology, Istanbul, Turkey
Received 10 March 2020; accepted 29 November 2020 Available online 10 February 2021
KEYWORDS Abstract Frank-ter Haar syndrome is a rare disorder characterized by multiple skeletal, car- Frank-ter Haar diovascular abnormalities, and facial features. Some of these characteristic facial features syndrome; are important for anesthesiologists to predict the difficult airway. We present the anesthe- Airway management; sia management of an 8-year-old boy with Frank-ter Haar syndrome who underwent posterior General anesthesia; spinal instrumentation operation for scoliosis. In these patients, it is vital to anticipate possible Scoliosis difficult intubation before surgery and make all necessary preparations. © 2021 Sociedade Brasileira de Anestesiologia. Published by Elsevier Editora Ltda. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by- nc-nd/4.0/).
Introduction small chin). Very few cases have been reported worldwide.1 Some of these characteristic features are important for Frank-ter Haar syndrome (FTHS) is a rare autosomal- anesthesiologists to predict the possible difficulties during recessive disease and characterized by skeletal, cardiovas- induction of anesthesia and intubation. As far as we know, cular, and ocular abnormalities. Mutations in the SH3PXD2B there are few reports about anesthetic management of a gene on chromosome 5q35.1 are the most common underly- patient with FTHS. ing genetic defect in FTHS.1 The syndrome is characterized by multiple skeletal abnormalities, developmental delay, Case report and characteristic facial features (unusually large cornea, flattened back of the head, wide fontanels, prominent fore- An 8-year-old boy, weighing 21 kg, was admitted to the hos- head, widely spaced eyes, prominent eyes, full cheeks, and pital with scoliosis. After written informed parental consent was obtained, posterior spinal instrumentation was planned for the patient. He was born by cesarean-section delivery at ∗ Corresponding author. term. The patient had the diagnosis of FTHS. Atrial septal E-mail: [email protected] (N. Canbolat). defect, ventricular septal defect, and patent ductus arte- https://doi.org/10.1016/j.bjane.2020.11.005 © 2021 Sociedade Brasileira de Anestesiologia. Published by Elsevier Editora Ltda. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). I. Basaran, E. Gozubuyuk, N. Canbolat et al. riosus had been detected in the neonatal period. He had 15 mL.kg-1. The urine output was 230 mL. To prevent airway cleft lip, cleft palate, and pes equinovarus. He had surgery edema, the child received 20 mg of methylprednisolone. for closure of the ventricular septal defect and cleft lip and The duration of the operation was 6 hours. Intravenous palate. There were no past medical reports available. He paracetamol of 15 mg.kg-1, tramadol of 1 mg.kg-1, and mor- was diagnosed with heart failure. He was under pediatric phine of 0.1 mg.kg-1 were administered before the end of cardiology follow-up and on tablet enalapril 5 mg once a day. the surgery. The patient was sent to the intensive care He had a history of frequent respiratory tract infections, unit in intubated state for mechanical ventilator support. and his last infection was 15 days before with cough and Within 5 days of admission to the intensive care unit, he purulent sputum which was treated by 7 days of antibiotic was extubated without any complications. Morphine-based medication. intravenous patient-controlled analgesia was used to main- The patient’s general physical examination revealed tain postoperative analgesia. Self-reported pain intensity typical facial dysmorphism, gingival hypertrophy, pectus was assessed by using the Numerical Rating Scale 0---10.The carinatum, and thoracolumbar kyphoscoliosis. Abnormal postoperative period was uneventful with no changes wor- blood gas analyses and decreased lung volumes in pulmonary thy of note. He was transferred to the service of orthopedics function tests were detected because of the restrictive lung and traumatology clinic. The patient was discharged home capacity. Examination of the cardiovascular system revealed on the tenth postoperative day. a pan systolic murmur on the apex. Echocardiogram showed a dilated left atrium, severe mitral valve regurgitation, and mild aortic valve regurgitation. The pediatric cardi- Discussion ology unit suggested prophylaxis for infective endocarditis with ampicillin 50 mg.kg-1 and gentamicin 2 mg.kg-1. Rou- FTHS is a congenital syndrome affecting mainly the skele- tine preoperative laboratory tests were normal. The child tal system and has ocular and facial features. It was had retrognathia and micrognathia and a mild restriction in described by Frank and Ter Haar in 1973.2 The most common his neck movements. He had a grade 3 Mallampati score. abnormalities associated with this syndrome are brachy- According to these findings, arrangements were made for dactyly, hypertelorism, wide nasal bridge, wide mouth, the patient with a difficult airway such as laryngeal mask and depressed nasal bridge. Skeletal system anomalies like airways (LMAs), a Storz DCI (Karl Storz, Tuttlingen, Ger- abnormality of the metacarpal bones, kyphosis, scolio- many) C-MAC video laryngoscope, fiberoptic bronchoscope, sis, osteolysis, and beaking of vertebral bodies have been and variable sizes of endotracheal tubes. described. The most common ocular finding is macrocornea In the operation room, standard monitoring was installed, with or without glaucoma.1 Cardiac problems like mitral including SpO2, noninvasive blood pressure, and an elec- valve prolapse or other congenital heart defects may be trocardiogram. Subsequently, anesthesia induction was present. Maxillodental anomalies such as mandibular prog- performed with 8% sevoflurane carried by 6 L.min-1 oxygen nathy, gingival overgrowth, or premature loss of teeth may flow. The mask ventilation was successful, and anesthesia be observed.3 was induced with fentanyl 1 mcg.kg-1 and rocuronium 0.6 Even though the patient had multiple congenital heart mg.kg-1 intravenously. At first, a C-MAC videolaryngoscope defects, which were atrial septal defect, ventricular sep- was used to intubate the patient, but there was no view tal defect, and patent ductus arteriosus, his upper airway of the epiglottis or vocal cords. The Cormack-Lehane grade anatomy causing difficult endotracheal intubation was one was 4. Then, a Fastrach LMA (size 3) was placed, and it pro- of the most challenging features for us as anesthesiolo- vided adequate ventilation. The child had a low body mass gists. Moreover, due to severe kyphoscoliosis, the patient index, but his upper airway was suitable for the Fastrach LMA had restrictive lung disease which made the postoperative (size 3). As the patient would be operated in the prone posi- intensive care unit follow-up obligatory. tion, a secure airway with tracheal intubation was needed. In this case, predicting the difficult intubation at the The endotracheal tube (size 5.0) was inserted through the preoperative examination was crucial. The first step was Fastrach LMA. The first attempt failed with esophageal to prepare a wide range of equipment for intubation. intubation. Afterwards, the patient was ventilated through According to the 2015 Difficult Airway Society Guideline, the LMA after oxygenation. This time, endotracheal intu- if tracheal intubation fails by laryngoscopy, the second bation was attempted with a smaller-sized 4.5 cuffed step is placement of supraglottic airway devices. There endotracheal tube. Confirmation of endotracheal intuba- are four options that may be applied after placement of tion was made with a capnograph and auscultation. The a supraglottic airway device: (i) waking the patient up, (ii) anesthesia was maintained with oxygen/air and infusions intubating the trachea via the supraglottic airway devices, of remifentanil and propofol. The left femoral artery was (iii) proceeding without intubating the trachea, or (iv) cannulated, and the right femoral vein was catheterized. tracheostomy/cricothyroidotomy.4 In the presented case, The patient was turned prone for posterior spinal instrumen- when we could not obtain an image with the C-MAC video tation. Somatosensory-evoked potentials and motor-evoked laryngoscope, in accordance with the Difficult Airway Soci- potentials were monitored during the operation. A load- ety Guideline, we switched to the second step and placed a ing dose of 10 mg.kg-1 followed by a continuous infusion of Fastrach LMA to the patient. The patient was then intubated 1 mg.kg-1.h-1 tranexamic acid was given to the child until by placing an endotracheal tube through the LMA. In another skin closure. Throughout the surgery, an Hb threshold of 8 case reported by Tommasino et al. (2018), difficult intuba- g.dL-1 was aimed to be kept with blood-gas monitoring. The tion was encountered in a child with the same syndrome.3 In patient was transfused with pediatric erythrocyte suspen- the paper they presented, the child was a 5-year-old male sions of 25 mL.kg-1 (∼525 mL) and fresh frozen plasmas of who underwent dental restoration under general anesthesia.
182 Brazilian Journal of Anesthesiology 2021;71(2) 181---183
He had micrognathia, arched palate, and kyphosis. When he For patients undergoing scoliosis surgery, bleeding is also was 4 years old, difficult intubation was reported. In view of an important problem. Additionally, children with FTHS are this, they prepared for a potentially difficult intubation. In challenging for anesthesiologists also due to potential car- our case, the patient was an 8-year-old male who underwent diac problems and restrictive lung diseases. We think that posterior spinal instrumentation operation for scoliosis. His the relevant medical specialists should be consulted before neck movements were limited, while he also had retrog- the surgery, and their recommendations about the patient nathia and micrognathia. The cardiac examination findings should be taken into consideration. of both children were similar. In both cases, after induction with sevoflurane, the patients could be ventilated with a Conflicts of interest mask. Following this step, Cormack-Lehane grade 4 views were obtained in both of them by videolaryngoscopy. After The authors declare no conflicts of interest. that, they preferred to intubate the patient with a fiberoptic bronchoscope, whereas we intubated the patient by placing the LMA then delivering the tube through the LMA Fastrach.3 References As widely known, major scoliosis surgeries generally cause significant blood loss. There are no definitive guide- 1. Zrhidri A, Jaouad IC, Lyahyai J, et al. Identification of two novel lines for patients who significantly bleed perioperatively. SH3PXD2B gene mutations in Frank-Ter Haar syndrome by exome The American Society of Anesthesiologists guidelines offered sequencing: Case report and review of the literature. Gene. 2017;628:190---3. restrictive 7.0 g.dL-1 blood management protocols for 2. Frank Y, Ziprkowski M, Romano A, et al. Megalocornea associ- adults, but they excluded infants, neonates and children ated with multiple skeletal anomalies: a new genetic syndrome? 5 under 35-kg. The child was a 21-kg boy and there are J Genet Hum. 1973;21:67---72. no definitive suggestions for transfusion thresholds for this 3. Tommasino C, Albicini M. Anaesthesia and orphan diseases: diffi- patient group. We preferred a little higher hemoglobin cult tracheal intubation in a child with Frank-ter Haar syndrome. threshold of 8.0 g.dL-1 because we were faced with active Eur J Anaesthesiol. 2018;35:542---4. bleeding due to the operation, and we were managing with a 4. DAS guidelines for management of unanticipated difficult little-known syndrome in a patient with cardiac anomalies. intubation; 2015 https://das.uk.com/guidelines/das intubation There are few articles about the anesthetic management guidelines of children with FTHS, but he was one of the more chal- 5. American Society of Anesthesiologists Task Force on Perioper- ative Blood Management. Practice guidelines for perioperative lenging ones because we managed a major scoliosis surgery blood management: an updated report by the American Society and a little-known syndrome at the same time. In these of Anesthesiologists Task Force on Perioperative Blood Manage- patients, it is vital to anticipate possible difficult intuba- ment. Anesthesiology. 2015;122:241---75. tion before surgery and make all necessary preparations.
183 Brazilian Journal of Anesthesiology 2021;71(2) 184---187
SHORT COMMUNICATION A Brazilian national preparedness survey of anesthesiologists during the coronavirus pandemic
Vinícius Caldeira Quintão a,b,∗, Claudia Marquez Simões a,c, Gibran Elias Harcha Munoz a, Paul Barach d,e,f, Maria José Carvalho Carmona a, on behalf of the Brazilian Network for Research on Complications in Anesthesia, (BRANCA)†
a Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas (HCFMUSP), Disciplina de Anestesiologia, São Paulo, SP, Brazil b Hospital Municipal Infantil Menino Jesus,s Servic¸o Médicos de Anestesia, São Paulo, SP, Brazil c Hospital Sírio-Libanês,s Servic¸o Médicos de Anestesia, São Paulo, SP, Brazil d Wayne State University, School of Medicine, Children’s Hospital, Detroit, United States e Jefferson College of Population Health, Philadelphia, United States f University of Queensland, Queensland, Australia
Received 8 December 2020; accepted 2 February 2021 Available online 19 February 2021
The coronavirus disease 2019 (COVID-19) pandemic has With the spread of the disease, in April 2020, the United forced healthcare systems to examine the judicious allo- States of America was the epicenter of the pandemic, and cation of scarce medical resources to the highest priority access to PPE remained a significant concern. Several loca- patients. Healthcare professionals, especially anesthesiol- tions reported a shortage of PPE. Despite the American ogists, are at risk of infection during airway management. Society of Anesthesiologists recommending the use of N95 Personal Protective Equipment (PPE) has become a critical masks and complete vestments, the US and Brazil went item to prevent the contamination of the anesthesiologists, through a PPE shortage crisis. With the emergence of sec- with numerous papers reporting on the uneven use, PPE ond waves around the world, PPE shortage remains a major reuse guidance and availability.1 --- 3 Despite explicit occupa- concern. tional protection recommendations, many anesthesiologists There is limited data describing the full extent of avail- have been infected, and some have died. ability of PPE and the actual changes implemented in Brazil and their approaches to improve pandemic pre- paredness. A report from the Brazilian Medical Association (AMB) stated that the most missing PPE was the N95 masks, accounting for around 87% of the 2,000 complaints.4 ∗ Corresponding author. This survey aims to describe the current: (1) prepared- E-mail: [email protected] (V.C. Quintão). † ness efforts of anesthesiologists in Brazil, (2) changes The list of members of the Brazilian Network for Research on in policies/procedures/guidelines, and (3) to assess the Complications in Anesthesia (BRANCA) is available in the Appendix. https://doi.org/10.1016/j.bjane.2021.02.027 © 2021 Sociedade Brasileira de Anestesiologia. Published by Elsevier Editora Ltda. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). Brazilian Journal of Anesthesiology 2021;71(2) 184---187 perceptions of occupational safety by Brazilian anesthesi- The majority (48.7%) reported the creation of dedicated ologists. teams to assist COVID-19 patients. A third of respondents We conducted a cross-sectional national survey of anes- (35.8%) reported changing in medical functions and 15.9% thesiologists across Brazilian hospitals. This study was reported changing in the work shift length. Telemedicine or conducted according to the Strengthening the Reporting remote assistance was reported by 21.7% of respondents as of Observational Studies in Epidemiology (STROBE) and the a change of work pattern during the pandemic. Checklist for Reporting Results of Internet E-surveys (CHER- Regarding PPE, 11.5% of the respondents reported no RIES) guidelines. This survey was reviewed and approved access to PPE. More than a half (54.8%) reported PPE scarcity by the local institutional review board (IRB) at Hospital das and 16.6% reported unavailability to reuse or other reported Clínicas, Faculdade de Medicina, Universidade de São Paulo situations, for instance, lack of HEPA filters, and malfunc- (Research approval number: 4.074.87). tioning PPE. Also, some respondents stated that the PPE The questionnaire was developed and reviewed by physi- was unavailable at the beginning of the pandemic, but cians and researchers with expertise in anesthesiology, the availability improved over time. With the lack of PPE, critical care, and survey development. A pilot study was 16% of anesthesiologists were forced to use makeshift PPE performed with twenty anesthesiologists to test for length equipment. The most common were 3D printed face shields and comprehensibility, content, and ease of completion. The (12.5%) and homemade surgical masks (6.3%). Table 1 sum- survey was pretested to improve the face validity (whether marizes the use of different PPE in clinical scenarios. or not the survey measures what it is supposed to measure) Considering airway management, the most frequent inno- and content validity (the degree to which the survey is rep- vative measure taken during this period was to reduce the resentative of the topic). A link and a QR code were created number of people in the room during intubation (74.6%), to send the survey through the Brazilian Society of Anes- followed by the use of video laryngoscope (44.2%), use of thesiology (SBA) and São Paulo Society of Anesthesiology checklists (36%), introducing new communication methods (SAESP) mailings and social networks. Tw o email reminders between the staff (16.4%), and introducing digital technol- were sent by the study coordinator. Data were automatically ogy and telemedicine (15.1%). stored and protected in REDCap®. Statistical analysis of only Some respondents emphasized that their hospitals do completed questionnaires was performed using STATA ® 15.1. not have the measures to enhance safety (37.6%), but oth- Data are presented as frequencies. ers answered their hospitals had checklists (42.7%), buddy The survey was conducted from June 29 to July 31, 2020 systems (26.4%), spotters (19.2%), and a higher number of and included 34 items in multiple parts addressing seven healthcare professionals (11.9%). themes: 1) demographics, 2) patient flow during the pan- In regard to donning and doffing PPE competencies, most demic, 3) changes to the staffing models related to the hospitals did not formally evaluate (70.5%), but in 20.7% pandemic, 4) use of PPE, 5) changes in clinical practice competencies were formally assessed in clinical situations, and innovations, 6) current modalities of training, and 7) 1% through a written test, 11.5% with simulation, 3.7% COVID-19 testing. with structured feedback, and 5.7% evaluated with recorded We received 511 complete responses out of 945 (54%), of videos of the areas. which 10.4% were anesthesiology residents (n = 53). Regard- The primary concern when assisting a COVID-19 patient is ing the gender of the respondents, 55% were male, 44.8% the lack of PPE (41.9%), followed by the frequent changes in female, and 0.2% other. Almost 40% of the respondents had clinical recommendations and protocols (37%), lack of PPE more than 20 years of professional experience in anesthe- training (34.1%), absence of clinical recommendations and siology, and 86.7% practiced clinical anesthesia in private protocols (29%), patient overcrowding (28.4%), lack of staff hospitals (43.4%). Most respondents work in hospitals with (21.3%), and lack of nurses (20%). less than 100 beds (26.2%), followed by hospitals with more We asked if hospitals conducted training sessions of than 400 beds (25.8%). PPE use and 72.2% answered they had, 14.5% responded Sixty-one percent reported working in a dedicated they didn’t, and 13.3% didn’t know. This differs from the COVID-19 unit. More than 55% reported caring for patients Associac¸ão Paulista de Medicina survey made with all medi- in the OR, 22.7% in the ICU, 20.7% during airway or rapid cal specialists, in which only 15.5% of the total were response teams, 5% are caring for COVID-19 patients on a trained.5 The training sessions were lecture based and ses- ward, 4.7% in the emergency room, and 4.9% in other areas, sions were applied (51.1%) using videos (42.5%), small group such as diagnostic exams or during critical patient trans- training (40.3%), and other categories such as photos, What- portation within or between hospitals. Most parts of the sApp groups, and posters with instructions (2.2%). hospitals seemed to have the operational capability pre- A very controversial topic reported was regarding testing served when the survey was answered (69.3%). Yet, nearly for COVID-19. Most institutions are testing only symp- a quarter of the respondents reported that their hospitals tomatic patients (39.1%). In some other situations testing is were opening additional COVID-19 units. being performed, such as for preoperative elective patients Elective surgeries were not reduced in only 4.3% of the (27.6%), high-risk patients (24.9%), high-risk health pro- hospitals. At most hospitals (33.3%), there was a reduction fessionals (19.8%). In only 25.6% of the respondents all of 50% of the volume of elective procedures. In 29.4% of healthcare professionals were tested, and 10% reported that the hospitals, elective procedures were reduced by 80%. no staff testing was done. In 19.8% of the hospitals only emergency surgeries were COVID-19 has placed extraordinary and sustained allowed, including in non-COVID-19 dedicated institutions. resource demands on anesthesia and critical care services. The specialized COVID-19 hospitals reported only conducting This survey provides a first snapshot of the current prepared- emergency procedures. ness efforts among a set of Brazilian hospitals during the
185 V.C. Quintão, C.M. Simões, G.E. Munoz et al.
Table 1 Preparedness efforts of Anesthesiologists for COVID-19.
Type of PPE For general care % Airway intubation % For non-COVID-19 % (n = 511) (n = 511) (n = 511) Surgical mask 80% 73.8% 85.3% Mask N95 / PFF2 93.2% 96.5% 75.9% Respirator with air purifier 8.4% 10.8% 5.9% TNT apron 55.8% 50.1% 50.3% Waterproof apron 67.7% 76.1% 46.6% Waterproof coveralls/jumpsuit 11.5% 15.7% 5.7% Waterproof shoe protection 15.7% 21.1% 11.2% Cap 93.9% 89.8% 86.1% Balaclava (head and neck protection) 8.4% 9.8% 5.1% Single gloves 79.3% 70.3% 83.8% Double gloves 42.9% 57.9% 36% Protective goggles 84.7% 87.9% 78.9% Face shield 92.2% 94.9% 75.7% Waterproof shoes (booties) 5.5% 8.2% 4.3%
first months of the pandemic. The majority of surveyed hos- Appendix. Authors. List of members of the pitals implemented dramatic changes to their workflow and Brazilian Network for Research on adapted their staffing models, with nearly a quarter creating Complications in Anesthesia (BRANCA) dedicated COVID-19 care units. This survey has several limitations. While 511 anesthe- siologists and residents responded, this represents only a Alexandre Slullitel (Hospital das Clínicas, Faculdade de sample of all Brazilian anesthesiologists and hospitals, which Medicina, Universidade de São Paulo, São Paulo, SP, Brazil. may impact the generalizability of our findings. Additionally, ORCID: 0000-0003-3770-4290); Wallace Andrino da Silva the survey responses are inherently prone to bias and may (Hospital Universitário Onofre Lopes, Universidade Fed- not always accurately reflect the actual practice of clinical eral do Rio Grande do Norte, Natal, RN, Brazil. ORCID: performance, rather than policies and intent. 0000-0002-7049-0979); André Prato Schmidt (Servic¸o de We conclude, in this first national survey, that the cur- Anestesia e Medicina Perioperatória, Hospital de Clínicas de rent preparedness efforts among Anesthesiologists in Brazil Porto Alegre, Universidade Federal do Rio Grande do Sul, during the first wave of the COVID-19 pandemic have been Porto Alegre, RS, Brazil. ORCID: 0000-0001-5425-2180); Car- highly variable and at least 11.5% of the respondents had no los Galhardo Júnior (Hospital São Lucas Copacabana, Rio access to PPE, representing a major threat to providers. de Janeiro, RJ, Brazil. Instituto Nacional de Cardiologia, COVID-19 should serve as a warning to prompt a radical Rio de Janeiro, RJ, Brazil. ORCID: 0000-0001-8358-183X); rethink of the way Anesthesiologists practice infection con- Célio Gomes de Amorim (Universidade Federal de Uberlân- trol. Anesthesiologists have implemented several strategies dia, Uberlândia, MG, Brazil. ORCID: 0000-0003-0833-7372); including modifications to staffing and workflows, changes Cláudia Regina Fernandes (Universidade Federal do Ceará, in their acute resuscitation and airway management, treat- Fortaleza, CE, Brazil); Erick Freitas Curi (Universidade ment protocols, limiting personnel’s exposure to contagion, Federal do Espírito Santo, Vitória, ES, Brazil. ORCID: while using simulation as a training modality to support pro- 0000-0003-1790-5685); Luiz Guilherme Villares da Costa tocol changes in response to COVID-19. We need to use this (Departamento de Anestesiologia, Hospital Israelita Albert once in a century crisis as an opportunity to implement Einstein, São Paulo, SP, Brazil. ORCID: 0000-0001-5044- better individual and organizational occupational learn- 9998); Fabiana Aparecida Penachi Bosco Ferreira (Faculdade ing. We must make the scientific process more transparent de Medicina, Universidade Federal de Goiás, Goiânia, GO, and inclusive by making scientific knowledge, methods, Brazil. ORCID: 0000-0002-4629-0467); Luiz Fernando dos Reis data, and evidence freely available and accessible for Falcão (Disciplina de Anestesiologia, Dor e Medicina Inten- everyone. siva da Universidade Federal de São Paulo, Escola Paulista de Medicina, São Paulo, SP, Brazil. ORCID: 0000-0002- 8527-3125); Ismar Lima Cavalcanti (Universidade Federal Conflict of interest Fluminense, Rio de Janeiro, RJ, Brazil. ORCID: 0000-0002- 0412-2609); Laís Helena Navarro e Lima (Departamento The authors declare no conflicts of interest. de Anestesiologia da Faculdade de Medicina de Botucatu --- UNESP, Botucatu, SP, Brazil. Department of Anesthe- Acknowledgment siology and Perioperative Medicine. Queen’s University, Kingston, Ontario, Canada. ORCID: 0000-0001-9596-7289); We acknowledge the Scientific Department of the Brazil- Lucas Wynne Cabral (Servic¸o de Anestesiologia, Hospital São ian Society of Anesthesiology (SBA) to support the survey’s Lucas Rede D’Or, Aracaju, SE, Brazil. ORCID: 0000-0002- divulgation to the associate Brazilian anesthesiologists. 6201-9650); Lucas Siqueira de Lucena (Departamento de
186 Brazilian Journal of Anesthesiology 2021;71(2) 184---187
Anestesiologia, Hospital Universitário Walter Cantídio, For- Fernandes (Hospital das Clínicas, Faculdade de Medicina, taleza, CE, Brazil. ORCID: 0000-0001-6530-6420); Luciana Universidade de São Paulo, São Paulo, SP,Brazil. Department Cadore Stefani (Hospital de Clínicas de Porto Alegre, Uni- of Anesthesia and Pain Management, Mount Sinai Hospital, versidade Federal do Rio Grande do Sul, Porto Alegre, RS, Toronto, Ontario, Canada. ORCID: 0000-0001-9298-6118); Brazil. ORCID: 0000-0002-3038-3108); Luciana Chaves de Clovis Tadeu Bevilacqua Filho (Servic¸o de Anestesia e Medic- Morais (Departamento de Anestesiologia, Instituto Dr. José ina Perioperatória, Hospital de Clínicas de Porto Alegre, Frota, Fortaleza, CE, Brazil. ORCID: 0000-0003-4734-6546); Universidade Federal do Rio Grande do Sul, Porto Alegre, Marcello Fonseca Salgado-Filho (Universidade Federal Flu- RS, Brazil. ORCID: 0000-0002-1375-7489). minense, Rio de Janeiro, RJ, Brazil. Instituto do Corac¸ão, Hospital das Clínicas, Faculdade de Medicina, Universidade References de São Paulo, São Paulo, SP, Brazil. ORCID: 0000-0001-8285- 0356); Maria Angela Tardelli (Disciplina de Anestesiologia, 1. The Lancet. COVID-19: protecting health-care workers. Lancet. Dor e Medicina Intensiva da Universidade Federal de São 2020;395:922. Paulo, Escola Paulista de Medicina, São Paulo, SP, Brazil. 2. Lockhart SL, Duggan LV, Wax RS, et al. Personal protective equip- ORCID: 0000-0001-8596-2791); Matheus Fachini Vane (Hos- ment (PPE) for both anesthesiologists and other airway managers: pital das Clínicas, Faculdade de Medicina, Universidade principles and practice during the COVID-19 pandemic. Can J de São Paulo, São Paulo, SP, Brazil. Faculdade de Ciên- Anaesth. 2020;67:1005---15. cias Médicas de São José dos Campos --- HUMANITAS, São 3. World Health Organization. Rational use of personal pro- José dos Campos, SP, Brazil. ORCID: 0000-0003-3062-1484); tective equipment for coronavirus disease (COVID-19) and Roseny dos Reis Rodrigues (Hospital das Clínicas, Faculdade considerations during severe shortages; 2020. Available from de Medicina, Universidade de São Paulo, São Paulo, SP, https://apps.who.int/iris/handle/10665/331695 (accessed 05th July 2020). Brazil. ORCID: 0000-0002-3796-5952); Saulo Fernandes de 4.o Associac¸ã Médica Brasileira. FALTAM EPIs EM TODO O PAÍS; 2020. Mattos Dourado (Departamento de Anestesiologia, Instituto Available from https://amb.org.br/epi/ (accessed 12th April Dr. José Frota, Fortaleza, CE, Brazil. ORCID: 0000-0002- 2020). 6817-3990); Suely Pereira Zeferino (Instituto do Corac¸ão, 5. Associaco ¸ã Paulista de Medicina. Os medicos´ e a pandemia Hospital das Clínicas, Faculdade de Medicina, Universidade do novo coronav´irus (COVID-19); 2020. Available from de São Paulo, São Paulo, SP, Brazil. ORCID: 0000-0002-9315- http://associacaopaulistamedicina.org.br/files/2020/pesquisa- 1398); Tais Felix Szeles (Hospital das Clínicas, Faculdade apm-medicos-covid-19-abr2020.pdf (accessed 05th July 2020). de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil. ORCID: 0000-0002-6904-4816); Hermann dos Santos
187 Brazilian Journal of Anesthesiology 2021;71(2) 188---203
LETTER TO THE EDITOR
Introduction of a reasonable Gelatin is a derived protein obtained from collagen, a nat- ural protein, characterized by dissolving above a certain manner for injection studies temperature (37 ◦C) and re-coagulating when cooled. The using cadavers shape of gelatin can be maintained after its spread, which is the reason why gelatin is suitable for estimating the dis- Dear Editor, tribution and volume of the injected solution. However, the detailed description about formulating the solution using There has been a growing interest in the actual spreadability gelatin or the process of injecting is lacking in the previous of the injected drugs through novel and diverse modalities, studies. Thus, we would like to introduce the actual pro- such as the erector spinae plane block, quadratus lumborum cesses of manufacturing and injecting the solution used in block, and serratus plane block, etc. used for pain relief. our laboratory, which are as follows. For evaluation of the actual spread of the injectant, imag- Preparation: ing techniques such as X-ray, computed tomography, and Gelatin (available regardless of any brand) / Tap water / magnetic resonance imaging with contrast agents have been Blue colored ink (any brand) / 80-mm × 20G echogenic Tuohy utilized traditionally. needle (any brand) / Syringe (adequate volume for study) / Recently, the ultrasound has been recognized as more Beaker / Water bath / Hot plate with temperature control reliable than other devices for precisely guiding the needle / Hot towel / Ice bag / Ultrasound device (any brand). tip to the targeted structure for injection or nerve blockade. Processes of manufacturing the solution (Figure 1) and Thus, it has been applied to a number of cadaveric stud- confirming the status: ies for estimating the spreadability of the injection using solutions blended with dyes. In these studies, the stab- 1) Blend the gelatin with the tap water in 1:1 volume ratio bing feeling associated with the needle, injection speed, in a small beaker. and absorption of drugs, etc. may show variable results in 2) Fill a water bath and place it a hot plate. different conditions between cadavers and living patients. 3) Place the beaker having the mixture and thermometer in In addition, the viscosity of the injected solution may also the water bath. affect their final results. Therefore, the results are different 4) Check the complete dissolution of the mixture with from the actual clinical practice. temperature held constant between 40 ◦C and 45 ◦C (boil- In the previous cadaveric studies, diverse solutions have ing gelatin mixture can destroy tissue structures during been utilized for the injection: a solution mixed with injection). 0.9% normal saline, methylene blue, and gadopentetate 5) Blend the melted mixture with moderate amount of blue 1 dimeglumine, a mixture with distilled water, latex, and colored ink (Figure 2A) and place a drop or two on ice for 2 green colored dye, a mixture with 0.5% methylene blue, checking its coagulability and the depth of shade. 3 latex, and black colored ink, and a mixture with 0.5% 6) Apply a hot towel to the target area of cadaver before 4 methylcellulose and India ink. However, these solutions the US-guided injection for 5 minutes, for preventing have some limitations, such as leakage and stickiness asso- unexpected coagulation of gelatin. ciated with the dissection, and some of these materials are 7) Inject the gelatin solution slowly using Tuohy needle, likely to be expensive. For overcoming these limitations, monitoring the US image to determine whether the solu- 5 some previous studies recommended gelatin as an option. tion is working as expected (Figure 2B).
Figure 1 A diagram for showing processes of manufacturing the gelatin solution. Brazilian Journal of Anesthesiology 2021;71(2) 188---203
Figure 2 Pictures for showing each step for real practice using gelatin. (A) Applying heat to the gelatin mixture, (B) US-guided injection of gelatin solution by pain physician, (C) Freezing with ice on injected area, (D) Fine dissection and confirmation by the anatomy expert.
8) Wait for 1 --- 2 min after injection and apply the prepared block: A cadaveric and clinical evaluation. Reg Anesth Pain Med. ice bag to the target area of cadaver for the complete 2018;43:745---51. coagulation of gelatin (Figure 2C). 5. Pepper AM, North TW, Sunderland AM, Davis J. Intraoperative 9) Confirm the volume and area of spread of the injectant adductor canal block for augmentation of periarticular injec- through fine dissection by the anatomy expert (Figure tion in total knee arthroplasty: a cadaveric study. J Arthroplasty. 2016;31:2072---6. 2D). Hyang-Do Ham a,b, Yeon-Dong Kim a,b,∗, In conclusion, we anticipate that this protocol would Hyung-Sun Won b,c,∗ encourage pain physicians to develop a new injection tech- nique and to reveal the associated anatomical relationship. a Wonkwang University, School of Medicine, Wonkwang University Hospital, Department of Anesthesiology and Conflicts of interest Pain Medicine, Iksan, Korea b Wonkwang University, School of Medicine, Jesaeng-Euise The authors declare no conflicts of interest. Clinical Anatomy Center, Iksan, Korea c Wonkwang University, School of Medicine, Department of References Anatomy, Iksan, Korea 1. Adhikary SD, Bernard S, Lopez H, Chin KJ. Erector spinae plane ∗ Corresponding author. block versus retrolaminar block: A magnetic resonance imaging and anatomical study. Reg Anesth Pain Med. 2018;43:756---62. E-mails: [email protected] (Y.Kim), [email protected] 2. Yang HM, Choi YJ, Kwon HJ, O J, Cho TH, Kim SH. Comparison (H. Won). of injectate spread and nerve involvement between retrolam- Received 15 September 2020; accepted 26 October 2020 inar and erector spinae plane blocks in the thoracic region: a cadaveric study. Anaesthesia. 2018;73:1244---50. https://doi.org/10.1016/j.bjane.2020.10.016 3. Mayes J, Davison E, Panahi P, et al. An anatomical evaluation of 0104-0014/ © 2021 Sociedade Brasileira de Anestesiologia. the serratus anterior plane block. Anaesthesia. 2016;71:1064---9. Published by Elsevier Editora Ltda. This is an open access article 4. Elsharkawy H, Maniker R, Bolash R, Kalasbail P, Drake RL, under the CC BY-NC-ND license Elkassabany N. Rhomboid intercostal and subserratus plane (http://creativecommons.org/licenses/by-nc-nd/4.0/).
189
LETTER TO THE EDITOR
2. Strengthening Relationships: Maintaining and strength-
Burnout during the COVID-19
ening our important relationships (including parents,
pandemic: time to ponder
spouse, friends) help us by rejuvenating our mental health.
Dear Editor,
3. Targeting Goals: Setting and targeting personal goals is a
critical step for work---life balance. These include listen-
Burnout Syndrome (BOS) is a work-related constellation of
ing to music, watching movies, or activities of personal
symptoms (including emotional, physical, and mental) that
interest. Fulfilling our goals provide motivation for our
usually occurs in individuals without any prior history of psy-
1 daily lives.
chological or psychiatric disorders. The term ‘‘burnout’’
4. Ensuring organizational support: The workforce must be
was coined in the 1970s by the American psychologist Her-
strengthened along with flexible and shorter duty hours.
bert Freudenberger to describe the consequences of severe
2 Provision of adequate duty offs, post-duty rewards,
stress and high ideals in ‘‘helping’’ professions. In this let-
catering to the physical and emotional needs of the
ter, we are stressing on factors leading to burnout among
health care physicians.
Health Care Professionals (HCP) especially during this pan-
demic with its preventive measures.
Pandemics costs us a lot in every aspect of life, be it Conflicts of interest
physical, social, mental, or emotional. The same is the case
seen with a recent hit COVID-19 caused by Severe Acute Res-
The authors declare no conflicts of interest.
3
piratory Syndrome Coronavirus 2 (SARS-CoV-2). COVID-19
contributes to burnout among the primary workforce --- ‘‘the
References
corona warriors’’ by disturbing working schedules, changes
in practice, prolonged duty hours in ICU wearing Personal
Protective Equipment (PPE), lack of adequate sleep and 1. Queen D, Harding K. Societal pandemic burnout: a COVID legacy.
rest, and inability to deliver effective care to patients. It Int Wound J. 2020;17:873---4.
has also presented HCP with unique emotional challenges 2. InformedHealth.org [Internet]. Depression: what is burnout?
4
Cologne, Germany: Institute for Quality and Efficiency in Health
due to high mortality rate in COVID-19 ICUs.
Care (IQWiG); 2006 [updated 18.07.20].
There is an emerging crisis of human resources in this
3. Zhang J, Zhou L, Yang Y, et al. Therapeutic and triage strategies
pandemic and HCP needs to work for extended hours to
for 2019 novel coronavirus disease in fever clinics. Lancet Respir
manage patients. Level of morbidity and mortality in these
Med. 2020;8:e11---2.
ICUs leads to depression in HCP’s, making them constantly
4. Ruparelia J, Gosal JS, Garg M, et al. Challenges to neurosur-
worrying about risking self and family members.
gical residency training during COVID-19 pandemic: an Indian
Most frontline corona warriors are staying separately in
perspective. World Neurosurg. 2020. S1878-8750:31149-9 [pub-
accommodation provided by the hospital during duty days or lished online ahead of print, 28.05.20].
a quarantine period following potential exposure. They are 5. Sasangohar F, Jones SL, Masud FN, et al. Provider burnout and
separated from their loved ones. This also leads to loneliness fatigue during the COVID-19 pandemic: lessons learned from a
high-volume intensive care unit. Anesth Analg. 2020;131:106---11.
and depression.
Some of the presenting symptoms to identify burnout
∗
Manbir Kaur , Priyanka Sethi, Neeraj Gupta,
includes irritability, interpersonal conflicts, social with-
Pradeep Bhatia
drawal, difficulty in concentrating, disturbed sleep, along
with impaired immune system. This again predisposes them
5 India Institute of Medical Sciences (AIIMS), Department of
for infection. There is a strong relationship between
Anesthesia and Critical Care, Department of Neonatology,
compassion fatigue, burnout, and moral distress.
Jodhpur, Rajasthan, India
The initial step in preventing and managing the burnout
∗
is its recognition. We suggest following interventions at the
Corresponding author.
individual and organizational level to prevent this syndrome.
E-mail: [email protected] (M. Kaur).
Received 1 October 2020; accepted 31 October 2020
1. Scheduling the stress relieving activities: Structure our
lives to provide adequate balance between work and https://doi.org/10.1016/j.bjane.2020.10.017
life. We should calendar important events including vaca- 0104-0014/ © 2021 Sociedade Brasileira de Anestesiologia.
tions, exercise, personal interest for hobbies, which are Published by Elsevier Editora Ltda. This is an open access article
under the CC BY-NC-ND license
very important for healthy work---life balance in this pan- (http://creativecommons.org/licenses/by-nc-nd/4.0/). demic era.
190 Brazilian Journal of Anesthesiology 2021;71(2) 188---203
Basic training in cardiovascular in cardiovascular anesthesia procedures. The program has undergone several reformulations throughout the years, and anesthesia: wouldn’t it be the in 2018, after a judicious assessment by EACTA, it was time for a unified program in certified as the first and only center for basic training in Brazil? cardiovascular and thoracic anesthesia outside the Euro- pean continent, and whose Hospital Base is the Instituto Dear Editor, Dante Pazzanese de Cardiologia. This brought key results to the program, such as exchange with other centers of In the past years, significant advances have been attained excellence abroad, in addition to participation in major mul- in the treatment of patients with severe cardiovascular dis- ticenter studies. We can also include the complementation eases in different areas of cardiology, such as cardiovascular program specialized in Surgical Intensive Care and Anesthe- surgery and interventionist procedures in the cath-lab. siology of Universidade de São Paulo (USP) --- São Paulo and, The current medical residency programs in anesthesiol- recently, the specialization course in Cardiovascular Anes- ogy in Brazil (Ministry of Education and Culture --- M E C and/or thesia of the Instituto Nacional de Cardiologia (INC) --- Rio Brazilian Society of Anesthesiology --- SBA) are founded on de Janeiro. However, the programs offered are frequently general training of residents for a period of three years in not uniform and do not drive toward the same basic training different medical specialties in which anesthetists work. The of anesthetists who seek improvement. current model does not provide enough time, and often does In 2007, the estimated number of cardiac surgeries not allow in-depth teaching and practice in certain increas- performed in Brazil in the unified health system (SUS) ingly more specific and complex areas, which are essential alone was approximately 350 heart surgeries/1,000,000 to perioperative decision-making, such as cardiovascular inhabitants/year (including defibrillator and pacemaker anesthesia. Thus, many recently trained anesthesiologists implants).4 A growing number of these procedures may lead eventually are additionally trained by more experienced to an estimated 350,000 in 2021, beside the increase in the anesthetists who have already been working with heart number of complex procedures, such as percutaneous aortic surgery for years, or they seek improvement in one of few valve implants. To date, over 2,500 patients are estimated to hospitals to be able to practice more safely. have been submitted to this kind of procedure in our coun- It is currently very common to observe anesthetists try and this number may reach up to 12,000 a year.5 It is who work almost exclusively with cardiovascular surgery, important to underscore that not only major centers but explaining the increasing demand for pursuing improvement also several inner cities have the potential to perform such to fit job market requirements. surgeries; therefore, the need to build skills in anesthetists The American Society of Cardiovascular Anesthesiologists in the area is increasingly more evident and growing. (SCA) has implemented for many years a fellowship program Another point is the growing interest in learning and for anesthetists to complement learning and expand the using perioperative transesophageal echocardiography as an number of professionals with skills to work in the cardiovas- additional monitoring method by anesthetists. It is very cular area. The members believe that excellence in clinical important we contemplate this topic for teaching on how to care, education, and research in Cardiothoracic Anesthesia use TEE by the anesthetist also be uniform, and in compli- is better attained through ‘‘standard training’’ in the sub- ance with the Brazilian Society of Cardiology. EACTA, for specialty. Adult Cardiothoracic Anesthesia (ACTA) has been example, requires that fellows trained at their credentialed a medical subspecialty since 2006 in the United States, training centers include a course with theory and practice and training program requirements are mostly controlled by in TEE in the basic program, that allows trainees to acquire the Accreditation Council for Graduate Medical Education the required knowledge to pass certification tests.2 (ACGME).1 Based on this scenario, we believe that more comprehen- The European Association of Cardiovascular and Thoracic sive and longer skill-building of anesthetists that will work Anesthesiology (EACTA) has been concerned for some time in cardiovascular surgery is increasingly more necessary. The with the quality of training of its trainees. EACTA recently basic program in cardiovascular anesthesia with standard- published a new model of a basic curriculum for cardiovascu- ized teaching, already employed in other countries, is an lar and thoracic anesthesia, aimed at more uniform teaching alternative that can be appropriate for Brazil according to and skill development of professionals.2 our needs. Moreover, advances in intraoperative monitoring, such as Transesophageal Echocardiography (TEE) has led many anes- thetists to pursue learning on how to use TEE appropriately. Financial support The objective of a recent publication was to standard- This study was supported entirely by department funds. ize the management of intraoperative echocardiography for anesthesiologists according to the SBA and the Department of Cardiovascular Imaging (DIC) of the Brazilian Society of Conflicts of interest Cardiology.3 There are currently few specific programs offering train- The authors declare no conflicts of interest. ing in cardiovascular anesthesia in Brazil. Among them, the program of the Centro de Estudos da Clínica de Aneste- Acknowledgments sia São Paulo has been a forerunner training course in cardiovascular anesthesia in which recently graduated anes- The authors thank all the other individuals who helped and thetists accompany professionals with long time experience provided contributions to the study.
191 LETTER TO THE EDITOR
References Caetano Nigro Neto a,∗, Eric Benedet Lineburger b, Vinicius Tadeu dos Santos Nascimento a, Marcello Fonseca c,d 1. Capdeville M, Hargrave J, Patel PA, et al. Contemporary Salgado-Filho
challenges for fellowship training in adult cardiothoracic anes- a thesiology: perspectives from program directors around the Instituto Dante Pazzanese de Cardiologia, São Paulo, SP, United States. J Cardiothorac Vasc Anesth. 2020;34:2047---59. Brazil b 2. Erdoes G, Vuylsteke A, Schreiber JU, et al. European Associ- Hospital São Jose, Criciúma, SC, Brazil ation of Cardiothoracic Anesthesiology (EACTA) Cardiothoracic c Universidade Federal Fluminense, Niterói, RJ, Brazil and Vascular Anesthesia Fellowship Curriculum: First Edition. J d Santa Casa de Misericórdia, Juiz de Fora, MG, Brazil Cardiothorac Vasc Anesth. 2020;34:1132---41. ∗ 3. Salgado-Filho MF, Morhy SS, Vasconcelos HD, et al. Con- Corresponding author. senso sobre Ecocardiografia Transesofagica´ Perioperatoria´ da E-mail: [email protected] (C. Nigro Neto). Sociedade Brasileira de Anestesiologia e do Departamento de Received 12 October 2020; accepted 14 November 2020 Imagem Cardiovascular da Sociedade Brasileira de Cardiologia. Rev Bras Anestesiol. 2018;68:1---32. https://doi.org/10.1016/j.bjane.2020.11.003 4. Gomes WJ, J Mendonc¸a JT, Domingo, Braile D. Resultados em 0104-0014/ © 2021 Published by Elsevier Editora Ltda. on behalf of cirurgia cardiovascular oportunidade para rediscutir o atendi- Sociedade Brasileira de Anestesiologia. This is an open access mento médico e cardiológico no sistema público de saúde do país. article under the CC BY-NC-ND license (http://creativecommons. Rev Bras Cir Cardiovasc. 2007;22:III---VI. org/licenses/by-nc-nd/4.0/). 5. Lopes MAC, Nascimento BR, Oliveira GMM. Tratamento da Estenose Aórtica do Idoso no Brasil: Até quando podemos esperar? Arq Bras Cardiol. 2020;114:313---8.
Mobile camera as an aid to avoid the errors in drug administration, it is strongly recom- mended that the label on any drug or ampoule or syringe minimize drug errors should be carefully read and checked with a second per- son before a drug is drawn up or injected. Similar packaging Dear Editor, and presentation of drugs should also be avoided wherever possible.3 Human errors are the most common cause of drug errors.1 Standard specifications exist for labels for small-volume The National Coordinating Council for Medication Error (100 mL or less) parenteral drug containers. The stan- Reporting and Prevention defines medication error is any dard provides recommendations for the color, size, design, preventable event that may cause or lead to inappropri- general properties and typographical characteristics of the ate medication use or patient harm while the medication labels. It also states that the font size should be as large is in the control of the health care professional, patient, as possible to aid readers. A size of 9 points, as measured or consumer.2 Product labeling is one of the several fac- in ‘Times New Roman’, not narrowed, with a space between tors that may contribute to such events. A drug label carries lines of at least 3 mm, is the minimum for the packet leaflet. information about its composition, recommended mode, and User testing, meant to test the readability of a specimen route of administration, manufacturing and expiry date. To
Figure 1 A, Image of ampoule taken while keeping at convenient distance; B, Zoomed mobile image of the same ampoule; C, Ampoule’s label as visible through a magnifying glass.
192 Brazilian Journal of Anesthesiology 2021;71(2) 188---203 with a group of selected test subjects, is also advocated. and Mr. Satyanarayan Tripathi for digital art The American Society of Anesthesiologists has also amended work. its statement on creating labels of pharmaceuticals for use in anesthesiology. But we could not find similar literature References on ampoules. Several ampoules carry information which is difficult to read by naked eye (Figure 1A). This becomes 1. Kothari D, Gupta S, Sharma C, Kothari S. Medication error in especially important for ampoules that are looking similar anaesthesia and critical care: A cause for concern. Indian J 4 as they carry potential of drug being administered wrongly. Anaesth. 2010;54:187---92. One solution to the problem is to use a magnifying glass to 2. The National Coordinating Council for Medication Error Report- read it but this would necessitate carrying one during prac- ing and Prevention. NCC MERP: The First Ten Years ‘Defining the tice. Mobile phones are now routinely carried by everyone. Problem and Developing Solutions’; 2005. p. 4. Hence an easy and feasible alternate is to have a photograph 3. Glavin RJ. Drug errors: consequences, mechanisms, and avoid- of the ampoule with the mobile camera and zoom to read ance. Br J Anaesth. 2010;105:76---82. it (Figure 1B). The photo could easily be shared with others 4. Paliwal B, Purohit A, Sethi P. Apnoea during Spinal Anesthesia: A to have it cross-checked by several persons simultaneously, Medication Error. Karnataka Anaesth J. 2016;2:37---8. and any discrepancy in judgment can be resolved. It will Bharat Paliwal ∗, Manoj Kamal , Pradeep Bhatia , also provide complete details at single glance unlike sev- Sadik Mohammed eral adjustments required with the magnifying lens (Figure 1C). The image quality will undoubtedly depend on the pix- All India Institute of Medical Sciences, Department of els of camera but it will definitely be an aid to naked eye Anesthesiology and Critical Care, Jodhpur, India examination. ∗ Corresponding author. Conflicts of interest E-mail: [email protected] (B. Paliwal). The authors declare no conflicts of interest. Received 2 October 2020; accepted 29 November 2020 https://doi.org/10.1016/j.bjane.2020.11.009 Acknowledgement 0104-0014/ © 2021 Sociedade Brasileira de Anestesiologia. Authors acknowledge Dr. Anamika Purohit for Published by Elsevier Editora Ltda. This is an open access article under the CC BY-NC-ND license technical assistance in preparing the manuscript (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Expanding the horizon of suprascapular nerve, while sparing the phrenic nerve. The reported incidence of PNP in clinical settings following the costoclavicular block --- CCB is low but variable. Ipsilateral PNP was observed in 0% or shouldering new responsibility! 5% with 20 ml and 8.9% with 35 ml of LA following ultrasound- guided CCB in various clinical settings.1,2,4 Bilateral use of Dear Editor, CCB with 15 ml of LA for each side was also reported without any clinical or sonographic evidence of PNP.1 We have been Ultrasound-guided costoclavicular block (CCB) is a variant using CCB in our daily practice since its first description in of infraclavicular brachial plexus block. The advantages of the literature and observed a relatively very low incidence local anesthetic (LA) deposition at costoclavicular space of clinically significant PNP.Still, a greater number of clinical (CCS) include the requirement of low volume as the cords trials on a large number of patients is the need of the hour are densely packed, reduce the possibility of pneumothorax to push its boundaries for shoulder anesthesia/analgesia. 1 and ipsilateral phrenic nerve palsy (PNP). It has been shown The understanding of dermatomal, myotomal, and to produce effective anesthesia/analgesia in various upper osteotomal innervations are essential to provide procedure- limb surgeries below the shoulder joint. Continuous CCB specific optimal anesthesia or analgesia of the shoulder using a perineural catheter can be used for intraoperative area. Suprascapular and axillary nerves supply a significant surgical anesthesia and/or postoperative analgesia. Aliste part of the osteotome and myotome around the shoulder et al. first used CCB for analgesia in arthroscopic shoulder and proximal humerus. Subscapular, medial pectoral, lat- surgery and compared its efficacy with interscalene block eral pectoral, musculocutaneous, thoracodorsal, and radial 2 (ISB). CCB provided early-onset equipotent analgesia with- nerves also contribute to supply myotomes. Although ISB is out any incidence of ipsilateral PNP.The rostral spread of the considered as the gold standard in shoulder analgesia, the LA from CCS towards the roots of brachial plexus could block inherent risks of ipsilateral PNP limit its use in patients with the neural innervation of the shoulder in a retrospective pre-existing pulmonary compromise.5 Several modifications manner without causing PNP. of ISB or other diaphragm-sparing nerve blocks have been A recent human cadaveric study also supported these investigated for shoulder surgeries but failed to achieve 3 clinical findings. Ultrasound-guided injection of 20 mL dye either surgical anaesthesia or 0% incidence of PNP. The var- (0.1% methylene blue) in the CCS was found to spreads ious innervations of shoulder joint covered and spared in towards cephalad part of brachial plexus. It stained all ISB, selective superior trunk block (STB), and CCB are men- trunks and cords of the brachial plexus, including the tioned in Table 1. It is now evident from anatomical and
193 LETTER TO THE EDITOR
Table 1 Innervations covered and spared of shoulder area in different blocks.
Brachial plexus ISB Selective STB CCB √√ Roots C5 √√ X C6 √ X√ C7 X √ C8 X X √ T1 √X √X √ Trunk Upper √ √ Middle X √ Lower X√ X √ Cords Medial √√X √ Lateral √ √/ X √ Posterior √ √/X √ Branches Suprascapular nerve (C5---C6) √ √ √ Subscapular nerve (C5---C6) √ √ √ Axillary nerve (C5---C6) √ √ Musculocutaneous nerve (C5---C7) √ X √ Lateral pectoral nerve (C5---C7) X √ Medial pectoral nerve (C8---T1) X X √ Radial nerve (C5---C8,T1) X√√X √ Dermatomal innervation Superior lateral cutaneous nerve Intercostobrachial nerve (T1---T2) X X X Intercostal nerves (T2---T4) X X X
ISB, Interscalene√ block; STB, Superior trunk block; CCB, Costoclavicular block; Tick ( ), Innervation covered; Cross (X), possible sparing. clinical studies that CCB can be used as an alternative to References ISB for shoulder joint analgesia as both covers almost all the myotome and osteotome innervations of the shoulder 1. Mistry T, Balavenkatasubhramanian J, Natarajan V, et al. joint.2,3 Ultrasound-guided bilateral costoclavicular brachial plexus The majority of the shoulder joint innervations come blocks for single-stage bilateral upper limb surgeries: Abstain or from C5, C6 nerve roots except for the contribution from lat- indulge. J Anaesthesiol Clin Pharmacol. 2019;35:556---7. 2. Aliste J, Bravo D, Layera S, et al. Randomized comparison eral pectoral and musculocutaneous nerves that originates between interscalene and costoclavicular blocks for arthro- from C5---C7. Although low volume (5 mL) ISB and selec- scopic shoulder surgery. Regional Anesthesia & Pain Medicine. tive STB decrease the incidence of PNP to 45% and 4.8% 2019;44:472---7. 5 respectively, the lower roots or trunks of brachial plexus 3. Koyyalamudi V, Langley NR, Harbell MW, et al. Evaluating the may get spared. Sparing of C7 root could be due to low LA spread of costoclavicular brachial plexus block: an anatomical volume, the distant location from C5 and intervening con- study. Regional Anesthesia & Pain Medicine. 2021;46:31---4. nective tissue barrier between C6 and C7 roots. As described 4. Sivashanmugam T, Maurya I, Kumar N, et al. Ipsilateral hemidi- in the cadaveric study, all cords were stained, but upper aphragmatic paresis after a supraclavicular and costoclavicular roots were not involved.3 Hence, branches coming out from brachial plexus block: A randomised observer blinded study. Eur the cords which are supplying the shoulder will also get J Anaesthesiol. 2019;36:787---95. 5. Tran DQ, Layera S, Bravo D, et al. Diaphragm-sparing nerve blocked. Thus, the rostral spread of injected LA from CCS to blocks for shoulder surgery, revisited. Reg Anesth Pain Med. C5 and C6 roots are not needed. 2020;45:73---8. Dermatomal innervation comes from the supraclavic- ular nerve, anterior cutaneous branches of intercostal Kartik Sonawane a, Tuhin Mistry a,∗ nerves (T2---T4), and superior lateral cutaneous nerve (Table 1). For which additional supplementary block or a Ganga Medical Centre & Hospitals Pvt Ltd, Department of infiltrations required as per the surgical approach. This Anaesthesiology, Coimbatore, India supplementation is needed when these blocks are used ∗ for sole anaesthesia purpose. Hence, CCB may be con- Corresponding author. sidered as a promising option to avoid ipsilateral PNP E-mail: [email protected] (T. Mistry). in patients for shoulder surgery with compromised lung Received 19 October 2020; accepted 29 November 2020 function. https://doi.org/10.1016/j.bjane.2020.11.006 0104-0014/ © 2021 Sociedade Brasileira de Anestesiologia. Conflicts of interest Published by Elsevier Editora Ltda. This is an open access article under the CC BY-NC-ND license The authors declare no conflicts of interest. (http://creativecommons.org/licenses/by-nc-nd/4.0/).
194 Brazilian Journal of Anesthesiology 2021;71(2) 188---203
Macintosh laryngoscope: time Perhaps it is too early to say because it is very difficult to specify the timing of the contamination, although there is for retirement? a direct relationship between the performance of tracheal intubation and the appearance of symptoms of COVID-19 Dear Editor, among the doctors involved in the procedure, until now it has not been possible to compare the risks with the airway One of the most long-lived medical instruments still in use, management technique.5 the Macintosh laryngoscope is present in trauma rescue Our impression is that it is of paramount importance that teams, emergency rooms, intensive care units and surgical videolaryngoscopes are available as an alternative in the centers. various care scenarios, and that there is adequate train- Developed in the 1940s by Sir Robert Macintosh, a British ing for all those involved for their safety and best result anesthesiologist, its revolutionary design with the curved in orotracheal intubation. blade allowed the elevation of the epiglottis and visualiza- tion of the vocal cords without the need for an anesthetic plan as deep as the others available at the time, especially Conflicts of interest before the advent of neuromuscular blockers being a great advantage.1 Nowadays, 80 years after its launch, it is the The authors declare no conflicts of interest. gold standard instrument and most used worldwide in airway management.1 References Impossibility of ventilation and maintenance of oxygena- tion due to difficulties in managing the airways and tracheal 1. Lewis SR, Butler AR, Cook TM, et al. Videolaryngoscopy intubation remain important factors for increasing morbid- versus direct laryngoscopy for adult patients requiring tra- ity and mortality in the perioperative period, even with the cheal intubation: a Cochrane systematic review. Br J Anaesth. advent of algorithms and new techniques and equipment, 2017;119:369---83. including videolaryngoscopes.2 2. Joffe AM, Aziz MF, Posner KL, et al. Management of difficult When compared to conventional laryngoscopy, vide- tracheal intubation. A closed claims analysis. Anesthesiology. olaryngoscopes are associated with less trauma to the 2019;131:818---29. airways, however the success in tracheal intubation does 3. Chen X, Gong Y, Guo X, et al. Perioperative management of not appear to be different. patients infected with the novel coronavirus. Recommendation from the Joint Task Force of the Chinese Society of Anesthesiol- Different variables such as the location of the intu- ogy and Chinese Association of Anesthesiologists. Anesthesiology. bation (intensive care, emergency room), difficult airway 2020;132:1307---16. planned in advance, type of patient (obese), objectives 4. Hall D, Steel A, Young P, et al. Videolaryngoscopy increases (success in intubation, maintenance of oxygenation), need ‘‘mouth to mouth distance compared with direct laryngoscopy’’. for medical training as well as the planning of team Anaesthesia. 2020;75:822---3. strategies3 cause bias and hinder the analysis between 5. El Boghadadly K, Wong DJN, Owen R, et al. Risks to healthcare studies that compare conventional laryngoscopy with video- workers following tracheal intubation of patients with COVID-19: laryngoscopy. Conflicting results between different brands a prospective international multicentre cohort study. Anaesthe- and types of videolaryngoscopes and large differences in sia. 2020;75:1437---47. market prices also make it necessary to individualize the a,∗ b devices. Dante Ranieri Junior , Paulo do Nascimento Junior First choice for tracheal intubation, the Macintosh laryn- a Hospital Unimed Litoral, Balneario Camboriu, SC, Brazil goscope was replaced by videolaryngoscopes in times of b Universidade Estadual Paulista (Unesp), Departamento de 4 the COVID-19 pandemic. Anesthesia societies worldwide Anestesiologia, Botucatu, SP, Brazil have made this recommendation to decrease the risk of contagion among healthcare professionals at the time of ∗ Corresponding author. intubation, because videolaryngoscopes allow a greater dis- E-mail: [email protected] (D. Ranieri Junior). tance between the attending physician and the patients’ Received 15 August 2020; accepted 29 November 2020 airways --- 35.6 (9.9) cm versus 16.4 (11.1) cm, with no dif- 4 ference in intubation time. https://doi.org/10.1016/j.bjane.2020.11.008 Despite questionable superiority in the literature, 0104-0014/ © 2021 Sociedade Brasileira de Anestesiologia. concerning the patient and health professionals, Published by Elsevier Editora Ltda. This is an open access article could the conventional laryngoscope be considered under the CC BY-NC-ND license obsolete? (http://creativecommons.org/licenses/by-nc-nd/4.0/).
195
LETTER TO THE EDITOR
techniques, perioperative normothermia and normoxia, as
ERA(S) protocols in the
well as prevention of postoperative nausea/vomiting, ileus
pandemic era: need of the hour
and early mobilization, shall help in affirmation of dire need
5
to enforce the change. The checklist of ERAS protocols can
Dear Editor,
be put up in patient files to be ticked by perioperative care
team to ensure compliance. Clinical trials and observational
Enhanced Recovery After Surgery (ERAS) protocol has con-
studies in this regard shall further make evolutionary mod-
ceptualised the idea of creating Perioperative Surgical
ifications to standardize pandemic-specific ERAS protocol.
Homes (PSH) with the objective of maintaining physiologi-
Indeed, it is important to fast-track perioperative course
cal continuum from admission to discharge, corroborating as
1 in the COVID-19 hospitals and this can only be achieved
shorter Length of Stay (LOS) and lesser complication rate.
by the pre-existing evidence protocolized in the form of
It is a set of evidence-based multidisciplinary periopera-
ERAS.
tive care pathways challenging the preceding methodology
centered at preemptively controlling events resulting in sur-
gical stress response and prolonged post-surgical recovery. Conflicts of interest
Since its inception, each individual surgical subspecial-
ties have recommended their own plausible modifications The authors declare no conflicts of interest.
to the protocol and conducted trials as well as meta-
analysis confirming its superiority over the traditional References
standards.2,3
However, there exists a stark difference between the
1. Kehlet H, Slim K. Future of fast-track surgery. Br J Surg.
level of awareness and implementation of these proto- 2012;99:1025---6.
cols worldwide. Various ongoing challenges have been to
2. Pedziwiatr˛ M, Mavrikis J, Witowski J, et al. Current status of
overcome resistance from members of core team owing to enhanced recovery after surgery (ERAS) protocol in gastrointesti-
failure in demonstrating clinically significant benefit with nal surgery. Med Oncol. 2018;35:95.
regards to all elements of the protocol and its operational- 3. Hajibandeh S, Hajibandeh S, Bill V, et al. Meta-analysis of
Enhanced Recovery After Surgery (ERAS) protocols in emergency
ity in emergency procedures, institution-specific barriers,
abdominal surgery. World J Surg. 2020;44:1336---48.
as well as interdepartmental collaboration and compliance
4 4. Hoffman H, Kettelhack C. Fast-track surgery - Conditions and
to the cause. The slow and staggered progress in this field
challenges in post-surgical treatment: review of elements of
with lack of worldwide propagation and commitment to the
translational research in enhanced recovery after surgery. Eur
new development has made ERAS merely an experimental
Surg Res. 2012;49:24---34.
option rather than a new primary approach to perioperative
5. Moningi S, Patki A, Padhy N, et al. Enhanced recovery after
medicine.
surgery: an anesthesiologist’s perspective. J Anaesthesiol Clin
Now that the pandemic has changed day-to-day function- Pharmacol. 2019;35 Suppl 1:S5---13.
ing of hospitals, the patient footfall in COVID-19 suspect,
a b,∗ a
confirmed and non-COVID-19 areas is being improvised with Chashamjot Bawa , Rashi Sarna , Mehak Dureja ,
b
minimum cross-exposure. All tertiary care centers across Rajeev Chauhan
nations have become a potential source of transmission of
a
Maharishi Markandeshwar Deemed University, Maharishi
COVID-19 infection with great emphasis laid on minimum
Markandeshwar Institute of Medical Sciences and
period of exposure in crowded outpatient departments and
Research, Department of Anaesthesiology and Critical
wards. In the current scenario, it is even more pertinent to
Care, Ambala, India
strongly consider ERAS in elective and emergency surgical
b
Post Graduate Institute of Medical Education and
procedures. This will not only reduce per-patient exposure
Research, Department of Anaesthesiology and Critical
but also curb perisurgical humoral, metabolic, inflamma-
Care, Chandigarh, India
tory, and immune response which shall improve outcome
especially in COVID-19 infected symptomatic patients, ∗
Corresponding author.
asymptomatic carriers by preventing cytokine storm. An ini-
E-mail: [email protected] (R. Sarna).
tiation in this regard can be made by forming an alliance
Received 4 August 2020; accepted 24 December 2020
with all surgical departments and propose to adopt the
methodology in an integrative manner throughout peri-
https://doi.org/10.1016/j.bjane.2020.12.022
operative course. Discussing the benefits of surgical and
0104-0014/ © 2021 Sociedade Brasileira de Anestesiologia.
anesthetic aspects of ERAS, including minimally invasive
Published by Elsevier Editora Ltda. This is an open access article
surgical approach, preoperative nutritional optimization, under the CC BY-NC-ND license
premedication to allay anxiety, carbohydrate loading, short- (http://creativecommons.org/licenses/by-nc-nd/4.0/).
acting anesthetic drugs and opioid-sparing pain management
196 Brazilian Journal of Anesthesiology 2021;71(2) 188---203
Immunonutrition in system. Although immunonutrition is usually started preop- eratively in scheduled surgery, during the ongoing COVID-19 perioperative care of COVID-19 pandemic, most surgical interventions have been urgent patients: an old weapon for a procedures, making it difficult to initiate immunonutrition new disease? adequately in advance of surgery (an ideal time frame would be seven days). Dear Editor, Whenever possible, immunonutrition should be admin- istered through the enteric route, favouring per os if the Coronavirus infection disease-2019 (COVID-19) triggers a patient is able to swallow, or via the nasogastric route if massive immune response in certain hosts.1 This reaction, not. There are few contraindications to the enteric route when not adequately counterbalanced by anti-inflammatory (namely, bowel obstruction, bowel ischemia, and gastroin- molecules, leads to an inflammatory state that resem- testinal bleeding): in such cases, the parenteral route must bles the so-called systemic inflammatory response syndrome be considered as early as possible. (SIRS). Involving the abnormal regulation of numerous In summary, considering that no adverse outcomes of inflammatory cytokines, this condition leads to the loss of immunonutrition have been reported in either the surgical or lean mass through the breakdown of proteins, lipolysis, and postoperative ICU setting, this adjunctive tool should not be an increase in oxidative stress. These factors may also impair discarded a priori, but instead considered and immediately the patient’s potential to recover from surgery or chronic applied in the perioperative care of COVID-19 patients. critical illness, increasing the COVID-19 mortality rate.2 Although this ‘‘old’’ therapy is not expected to provide During the pandemic, a proportion of COVID-19 patients any definitive solutions whilst new ‘‘weapons’’ are being have had to undergo scheduled or urgent surgery, and sought, it is certainly worth a shot, in the hope that it may evidence has demonstrated these patients to be more just tip the balance in the patients favour! inflamed and procoagulant. As a consequence, mortality risk is increased since they present a higher risk of develop- Conflicts of interest ing thrombotic and postoperative respiratory complications compared with COVID-19 negative patients. In some cases, The author declares no conflicts of interest. postoperative respiratory complications have resulted in symptoms of acute respiratory failure very similar to those of acute respiratory distress syndrome (ARDS), thus requiring References prolonged mechanical ventilation and ICU stay.3 An intriguing, but as yet unanswered, question regards 1. Chen Y, Liu Q, Guo D. Emerging coronaviruses: Genome structure, whether immunonutrition could constitute an adjunctive replication, and pathogenesis. J Med Virol. 2020;92:418---23. tool in the perioperative care of COVID-19 patients. 2. Phua J, Weng L, Ling L, et al. Intensive care management of coronavirus disease 2019 (COVID-19): challenges and recommen- Defined as the administration of nutrients able to modulate dations. Lancet Respir Med. 2020;8:506---17. the immune system, immunonutrition has previously been 3. Doglietto F, Vezzoli M, Gheza F, et al. Factors Associated With demonstrated to improve clinical outcome in many sched- Surgical Mortality and Complications Among Patients With and uled oncological surgical settings. Immunonutrition includes Without Coronavirus Disease 2019 (COVID-19) in Italy. JAMA Surg. the administration of short-chain fatty acids, -3 polyun- 2020;155:1---14. saturated fatty acids, arginine, glutamine, and nucleotides. 4. Yu K, Zheng X, Wang G, et al. Immunonutrition vs Standard Nutri- The primary aim of immunonutrition is to improve gut tion for Cancer Patients: A Systematic Review and Meta-Analysis function after surgery, control the systemic inflammatory (Part 1). JPEN J Parenter Enteral Nutr. 2020;44:742---67. response, and enhance the removal of bacteria by the innate 5. Gritsenko K, Helander E, Webb MPK, et al. Preoperative frailty immune response, thus avoiding postoperative infections. assessment combined with prehabilitation and nutrition strate- gies: Emerging concepts and clinical outcomes. Best Pract Res A recent meta-analysis of immunonutrition versus stan- Clin Anaesthesiol. 2020;34:199---212. dard nutrition for cancer patients demonstrated its efficacy in reducing postoperative infection complications, lowering Cristian Deana (MD) ∗ the risk of anastomotic leakage and shortening the length of hospital stay.4 Anesthesia and Intensive Care 1, Azienda Sanitaria In COVID-19 patients, given their enhanced state of Universitaria Friuli Centrale, Udine, Italy inflammation, -3 polyunsaturated fatty acids probably rep- ∗ resent the most important component of immunonutrition: Piazzale S. M. dells Misericordia 15, 33100, Udine, Italy. these nutrients have been demonstrated to reduce the E-mail: [email protected] secretion of proinflammatory cytokines by macrophages, Received 19 June 2020; accepted 5 December 2020 modulate neutrophil function, and stabilize cytokines and reactive oxygen species.5 https://doi.org/10.1016/j.bjane.2020.12.018 For this reason, we suggest immunonutrition to be started 0104-0014/ © 2021 Sociedade Brasileira de Anestesiologia. as soon as possible in cases of COVID-19 because, in Published by Elsevier Editora Ltda. This is an open access article under the CC BY-NC-ND license addition to being malnourished, these patients present a (http://creativecommons.org/licenses/by-nc-nd/4.0/). severe negative nitrogen balance and a deregulated immune
197
LETTER TO THE EDITOR
to improve clinical status of COVID-19 patients and decrease
Linezolid a potential treatment
mortality caused by coinfections.
for COVID-19 coinfections
Dear Editor, Conflicts of interest
The authors declare no conflicts of interest.
The novel coronavirus (COVID-19) was first reported in China
in December 2019 and rapidly spread to other parts of
the world. Since then, many efforts have been made to Acknowledgment
identify the disease behavior. Based on published litera-
We would like to thank all the personnel of the ward of
tures, the most common symptoms of this disease were
COVID-19 infected patients at the Forghani Hospital for their
fever and cough followed by dyspnea and myalgia. Headache
cooperation in the performance of this project.
and digestive system symptoms were less common. Lung
involvement caused by pneumonia is also a common find-
References
ing in about 70% of patient’s CT scans and in severe cases;
COVID-19 can be complicated by acute respiratory disease
1. Wu Z, McGoogan JM. Characteristics of and important lessons
syndrome (ARDS), sepsis and septic shock, multiple organ
1,2 from the coronavirus disease 2019 (COVID-19) outbreak in China:
failure, including acute kidney injury and cardiac injury.
summary of a report of 72 314 cases from the Chinese Center for
Bacterial coinfections may also accompany this viral dis-
Disease Control and Prevention. JAMA. 2020;323:1239---42.
ease that need to be treated by antibiotics based on clinical
2. Huang W-H, Teng L-C, Yeh T-K, et al. 2019 novel coronavirus dis-
demonstration.
ease (COVID-19) in Taiwan: reports of two cases from Wuhan,
Since this disease affects various organs and the behavior
China. J Microbiol Immunol Infect. 2020;53:481---4.
of the virus is unknown, many coinfections may accompany 3. Zhang J, Ma X, Yu F, et al. Teicoplanin potently blocks the cell
COVID-19. One of them may be bacterial infections, such as entry of 2019-nCoV. BioRxiv. 2020.
the ones caused by gram-positive pathogenic bacteria. Some 4. Wehner C, Abrahamson P, Kambskard M. Demography of the fam-
ily: the case of Denmark. University of York; 2003.
researchers showed activity of teicoplanin against SARS-
CoV and proposed it as a potential treatment for COVID-19.
a
Vahid Damanpak Moghadam ,
Ticoplanin is a glycopeptide antibiotic routinely used to
b b,c,∗
3 Zohre Momenimovahed , Maryam Ghorbani , treat bacterial infections. d
Javad Khodadadi
Now, we propose another antibiotic of this fam-
ily which has activity against staphylococci, including a
Department of Anesthesiology and Critical Care, Qom
methicillin-resistant staphylococcus aureus (MRSA), gly-
University of Medical Sciences, Qom, Iran
copeptides, enterococci, including vancomycin resistant b
Department of Midwifery and Reproductive
strains, penicillin-susceptible Streptococcus pneumoniae, S.
Health,School of Nursing and Midwifery, Qom University of
pyogenes, and other antibacterial agents. This antibiotic
Medical Sciences, Qom, Iran
named linezolid was a good treatment for bacterial noso- c
Student Research Committee, School of Nursing and
comial pneumonia in our COVID-19 patients. We used it
Midwifery, Shahroud University of Medical Sciences,
in COVID-19 patients who were suffering from bacterial
Shahroud, Iran
pneumonia with intravenous dose of 600 mg of linezolid d
Department of Infectious Diseases, School of Medicine,
every 12 hours for 7 to 10 days and they all recovered
Kamkar-Arabnia Hospital, Qom University of Medical
and discharged from hospital. In addition, old researches
Sciences, Qom, Iran
have confirmed better clinical and microbiological efficacy
∗
of linezolid compared to vancomycin, which is a common Corresponding author.
3
and popular antibiotic prescribed by doctors. Linezolid E-mail: maryam [email protected] (M. Ghorbani).
superiority is due to its better penetration into the res-
Received 18 October 2020; accepted 6 December 2020
piratory secretion compared to vancomycin. Spinoni et al
also used linezolid to treat a COVID-19 patient who was ini- https://doi.org/10.1016/j.bjane.2020.12.019
tially treated with ticoplanin and ceftazidime/avibactam. 0104-0014/ © 2021 Published by Elsevier Editora Ltda. on behalf of
4
Then they replaced ticoplanin by linezolid. Thus, in our Sociedade Brasileira de Anestesiologia. This is an open access
article under the CC BY-NC-ND license
experience, linezolid is effective for treating pneumonia in
(http://creativecommons.org/licenses/by-nc-nd/4.0/).
COVID-19 patients, and our goal was sharing this experience
transmission via aerosols and droplets, demanded adjust-
GAWA during COVID-19
ments by all medical and surgical specialties, particularly
pandemic: a setback?
Anesthesiology, by its presence in the so-called frontline.
In Portugal, the majority of patients are tested for SARS-
Dear Editor,
CoV-2 (Reverse Transcription-Polymerase Chain Reaction
SARS-CoV-2). However, since the test is not preceded by
The year of 2020 will undoubtedly be marked by the begin-
isolation, and given its low sensitivity (around 70%), pre-
ning of the SARS-CoV-2 pandemic which, by the risk of
198 Brazilian Journal of Anesthesiology 2021;71(2) 188---203 cautions to minimize exposure are maintained despite a of the surgical mask, fentanyl 50 mcg was administered negative test result. and a propofol perfusion was initiated using TCI, with a Thus, given the presented information, Regional Anes- target concentration of 4 --- 5 mcg.mL-1. The surgery lasted thesia is currently given preference --- both Neuraxial and 45 minutes. No hemodynamic or ventilatory compromise was Peripheral --- to General Anesthesia with the need for airway observed, as well as no delay in emergence from anesthesia. management. Airway management represents one of the In this context, it is important to anticipate a scenario moments of highest risk of transmission through generation in which the patient loses spontaneous ventilation. The use of aerosols, hence requiring the use of Personal Protective of capnography, an ASA standard form of monitorization, Equipment (PPE) by all parties involved, as well as allowing should provide early detection of bradypnea or apnea, and for time of air renewal and hygienisation of the room. Both guide the titration of anesthetic agents. If necessary, prompt the optimization of the Operating Room times and the ratio- airway management is essential and may be difficult when nal use of the PPEs are important factors to consider when the patient is in the prone position, as presented in the first finally returning to elective surgery. case. The presence of an anesthesiologist skilled in airway However, there are some circumstances where general management in prone position is critical and quick access to anesthesia cannot be avoided. The definition of general a supraglottic device is essential. In extreme situations, this anesthesia, according to the American Society of Anesthe- may require interruption of the procedure and repositioning siologists (ASA),1 which was reviewed in 2019, mandates of the patient in the supine form --- which is why we always for the loss of consciousness, with lack of response to allow for an extra bed outside the operating room. painful stimuli which might be associated with: need for Patient selection is key for the success of GAWA. The airway interventions in a way to keep its patency; possibil- technique should not be used in patients with increased ity of inadequate spontaneous ventilation or neuromuscular risk for respiratory depression, those with sleep apnea, obe- depression with need of positive pressure ventilation; and sity, pulmonary disease and predicted difficult airway.3 Such eventual deterioration of cardiovascular function. precautions are common concerns in settings outside the The following two clinical cases, both occurring during operating room, as in endoscopic retrograde cholangiopan- the pandemic, will present the use of general anesthesia creatography, which often requires deep sedation bordering without the need of airway management, named by some on general anesthesia with the patient in prone position.4 authors as General Anesthesia Without Airway (GAWA).2 Emphasis must be placed on an open, multidisciplinary Once it is not a study, an institution’s Ethics Committee communication from the start of the procedure (e.g., to approval was not necessary. The patients were not selected, discuss anesthetic choice and safety concerns) through the but rather the result of circumstances. application of the WHO Surgical Safety Checklist. The first case is of a female, age 45, BMI 32 kg.m-2, ASA With the return to elective surgery in times of pandemic, II, with a non-detectable RT-PCR SARS-CoV-2 test result, considering inadequacy of regional anesthesia techniques or diagnosis of unilateral bimalleolar fracture and proposed their failure, GAWA certainly presents advantages, partic- for ankle arthroscopy and osteosynthesis with tourniquet ularly in short duration surgeries in which neuromuscular application above the knee. A spinal anesthesia was per- blockade is considered unnecessary. Simultaneously, consid- formed using levobupivacaine 10 mg and sufentanyl 2,5 mcg, ering the specifics of each case, this modality might both be with subsequent prone positioning of the patient for surgery. used as a primary strategy as well as a rescue when regional After 10 minutes, no sensitive, motor, or sympathetic block anesthesia fails. was accomplished. Due to failure of the spinal block and the patient being in prone position, we converted to gen- Conflicts of interest eral anesthesia, starting by applying an oxygen cannula with analysis of expired gases (SentriTM ETCO2 nasal can- nulae) with a flow of 3 L.min-1, which allowed the patient The authors declare no conflicts of interest. to maintain her surgical mask. Induction was performed with intravascular ketamine 20 mg, fentanyl 100 mcg, and References propofol perfusion using Target Controlled Infusion (TCI), -1 Marsh model and target concentration of 3 --- 4 mcg.mL . 1. American Society of Anesthesiologists, Available at: https:// The surgery lasted 2,5 hours with tourniquet duration of www.asahq.org/standards-and-guidelines/continuum-of-depth 108 minutes. Breathing was regular --- without tachypnea or -of-sedation-definition-of-general-anesthesia-and-levels-of hypopnea --- as was the capnography curve, and no increase -sedationanalgesia, 2019. in end-tidal carbon dioxide (EtCO2) was verified. Emergence 2. Napoli V, Napol E, Parino E. General anesthesia with spontaneous time was not longer than that usually verified with airway ventilation without intubation for short-stay operations. Minerva management. Anestesiol. 2002;68:669---80. The second case refers to a female patient, 12 years old, 3. Hillman D, Platt P, Eastwood P. The upper airway during anaes- thesia. Br J Anaesth. 2003;91:31---9. BMI 17 kg.m-2, ASA I, with a non-detectable RT-PCR SARS- 4. Walls J, Weiss M. Safety in Non-Operating Room Anesthesia CoV-2 test result, diagnosis of a volar ganglion cyst of the (NORA). Anesthesia Patient Safety Foundation. 2019;34:3---4. wrist, proposed for its excision. After a nasal oxygen can- TM nula with analysis of expired gases (Sentri ETCO2 nasal Sofia Almeida Carvalho ∗, Inês Fernandes Ferraz , -1 cannulae) with a flow of 2 L.min and without the removal Filipa Pires Duarte , Miguel Ghira
199
LETTER TO THE EDITOR
https://doi.org/10.1016/j.bjane.2020.12.021
Hospital Beatriz Ângelo, Loures, Portugal 0104-0014/ © 2021 Sociedade Brasileira de Anestesiologia.
∗
Corresponding author. Published by Elsevier Editora Ltda. This is an open access article
under the CC BY-NC-ND license (http://creativecommons.org/ E-mail: sofi[email protected] licenses/by-nc-nd/4.0/).
(S.A. Carvalho).
Received 28 July 2020; accepted 9 December 2020
Transesophageal the care of all patients during the COVID-19 pandemic. At
our institution, this included N-95 respirators (or powered
echocardiography probe cover:
air-purifying respirators) and gowns for the cardiologist,
implementation of a assisting circulating nurse, and anesthesia team for all
cross-contamination patients requiring TEE --- asymptomatic, under investigation,
or COVID-19 positive. Additionally, technical precautions
containment strategy during
(e.g., avoiding deep sedation, rapid sequence induction for
the COVID-19 pandemic
general anesthesia, avoidance of mask ventilation during
induction, use of videolaryngoscopy for intubation, place-
Dear Editor,
ment of barrier drapes during intubation, and the use of a
TEE probe cover, etc.) were adopted. The American Society
In early 2020, in response to the COVID-19 pandemic, the
of Echocardiography later released a statement describing
American Society of Echocardiography released its State-
a similar tiered process to the selection of patients for
ment on Protection of Patients and Echocardiography Service
1 TEE and the reintroduction of echocardiography services
Providers During the 2019 Novel Coronavirus Outbreak.
at each institution. This statement reaffirms the idea that
Shortly after, additional information was made avail-
the TEE examination is an aerosolizing procedure with air-
able in the Perioperative/Periprocedural Transesophageal
borne precautions recommended for COVID-19 positive or
Echocardiography (TEE) Statement and the Sonographer 2
high-risk patients. In the perioperative environment, the
Statement. These three statements contained multiple
TEE probe is intermittently and frequently manipulated over
recommendations regarding patient selection and strati-
a period of several hours during the surgical procedure,
fication, handwashing, droplet, and airborne precautions,
resulting in the possible contamination of multiple operat-
limiting examination time and exposure of unnecessary
ing room surfaces. Several studies have demonstrated that
equipment, and following recommended disinfection pro-
anesthesiologists may be responsible for the possible spread
tocols.
of pathogens from the patient to the operating room envi-
Based on the statements and recommendations from
ronment, which may result in cross-contamination between
other national medical organization guidelines including 3,4
providers and patients.
those from the American Society of Anesthesiologists and
The technique utilized for covering each TEE probe at our
the Anesthesia Patient Safety Foundation, cardiologists at
institution is described below.
our institution adopted a screening process to more care-
After inserting a clean TEE probe tip into the open end of
fully select patients who truly require and will benefit from
a standard ultrasound probe cover and placing a rubber band
TEE evaluation. Cases deemed neither urgent nor emer-
above the wheel to secure the cover to the probe, we cut the
gent were postponed. Depending on personal protective
opposite (closed) end of the probe cover with sterile scis-
equipment availability and preservation strategies, many
sors. We verify the cut portion of the probe cover is neat and
hospitals implemented a heightened level of precaution in
Figure 1 Modified ultrasound probe cover used as a transesophageal echocardiography probe cover.
200 Brazilian Journal of Anesthesiology 2021;71(2) 188---203 tear-free, and then anchor it with a rubber band onto a bite 2. Hung J, Abraham TP, Cohen MS, et al. ASE statement on the block (Figure 1). The TEE probe is advanced beyond the bite reintroduction of echocardiographic services during the COVID-19 block into the esophagus. The bite block is then positioned pandemic. J Am Soc Echocardiogr. 2020;33:1034---9. in the patient’s mouth. Because the exposed (contaminated) 3. Loftus RW, Koff MD, Burchman CC, et al. Transmission of portion of the TEE probe remains within the probe cover, pathogenic bacterial organisms in the anesthesia work area. Anesthesiology. 2008;109:399---407. direct contact with secretions and potential for inadvertent 4. Birnbach DJ, Rosen LF, Fitzpatrick M, et al. The use of a novel spread to the operating room environment is minimized. As technology to study dynamics of pathogen transmission in the elective TEE cases have resumed, we have continued to use operating room. Anesth Analg. 2015;120:844---7. an ultrasound probe cover (Figure 1) as a protective barrier 5. Jain A. Preventing contamination during transesophageal on each TEE probe and for many examinations. echocardiography in the face of the COVID-19 pandemic. J Car- Although this method was developed independently at diothorac Vasc Anesth. 2020;34:2849---51. our institution, a similar method was proposed by Dr. Jain, an anesthesiologist from the Medical College of Georgia.5 We John S. Bozek a, Heather K. Hayanga a, believe that this is a viable technique to both perform a high Partho Sengupta b, Mir Ali Abbas Khan a, quality echocardiographic exam and to prevent exposure of Matthew B. Ellison a,∗ the provider performing the TEE to oral secretions from the a West Virginia University, Department of Anesthesiology, patient. Division of Cardiovascular and Thoracic Anesthesiology, Morgantown, United States Conflicts of interest b Division of Cardiology, Department of Internal Medicine, West Virginia University, Morgantown, United States The authors declare no conflicts of interest. ∗ Corresponding author. References E-mail: [email protected] (M.B. Ellison). Received 4 September 2020; accepted 12 December 2020 1. Kirkpatrick JN, Mitchell C, Taub C, et al. ASE statement on https://doi.org/10.1016/j.bjane.2020.12.023 protection of patients and echocardiography service providers 0104-0014/ © 2021 Published by Elsevier Editora Ltda. on behalf of during the 2019 novel coronavirus outbreak: endorsed by the Sociedade Brasileira de Anestesiologia. This is an open access American College of Cardiology. J Am Soc Echocardiogr. 2020;33: article under the CC BY-NC-ND license 648---53. (http://creativecommons.org/licenses/by-nc-nd/4.0/).
COVID-19 pandemic mental rienced during the pandemic that increased the risk to develop burnout. health risks among First of all, the emotional exhaustion is due to the anesthesiologists: it is not only massive influx of patients into the wards, the high num- burnout ber of deaths, and the enormous difficulty of caring for infected patients.2 Secondly, the depersonalization, due Dear Editor, to the inevitable repetitiveness of standardized protocols, the use of individual protection devices that make people During COVID-19 pandemic the anesthesiologists and critical anonymous, and the reduction of moments of workplace care forces have been fighting against a hitherto completely debriefing. Finally, the reduced personal accomplishment is unknown enemy. This ‘‘call to arms’’ to fight COVID-19 has due to the forced transfer of the department, the provision, affected the anesthesia workforce in different psycholog- albeit temporary, of expertise acquired, to the reduction of ical aspects depending on the level of involvement in the the possibilities of practicing hobbies, and interests by the COVID-19 emergency. Anesthesiologists who are in the most quarantine. affected areas are facing an unprecedented emergency, Burnout, however, is not the only mental risk for anesthe- even that they have been always highly motivated to help. siologists, especially in the long term. There are grounds for However, this has a price. this unique experience to result in post-traumatic stress dis- Physical fatigue due to the heavy workload is consider- order (PTSD), which can also occur six months after the end able and could affect the person’s own health and the care of the pandemic. The possible onset of PTSD is related to the provided to the patients. The lack of staff and unfavorable tangible feeling of being in constant danger of life, ampli- conditions in which anesthesiologists are forced to work, and fied by the emphasis of the mass media on the pandemic. the quarantine could be threatening to the mental health. Indeed, the stressful elements in the workplace cannot find In addition, the risk of burnout is concrete and tangible. an external relief valve given the quarantine life and the In fact, even if the challenge is high, and stimulating from constant talk about the topic of the moment, there is a an intellectual point of view, the risk factors for burnout lack of possibilities for distraction. In addition, some anes- are all there.1 Emotional exhaustion, depersonalization, thesiologists are working many kilometers away from their and reduced personal accomplishment are situations expe- family, concerned of the possibility of never seeing their
201 LETTER TO THE EDITOR families again. Many others have chosen a self-quarantine repercussions on every aspect of our working and relation- to safeguard their relatives and avoid the risk of becoming ship life. The element of novelty was the global lockdown infectors. This situation risks configuring a family mobbing, in which each individual was somehow touched by the in which anesthesiologists feel alone to face a high-stress emergency. By focusing only on macroscopic psychological and very dangerous working situation, with the addition of problems there is a risk of underestimating the seque- the sense of guilt of family neglecting, and becoming poten- lae that can emerge and invalidate the restarting of the tial infectors. health activity or the response to an upsurge of the infec- The COVID-19 pandemic represents an event for which tion. an anesthesiologist prepares a lifetime, in the same way as In the short term, besides burnout and PTSD, it is also Commander Sullenberger in the Hudson Miracle. Anesthesi- necessary to test for anxiety, depression, and guilt of health- ologists directly involved in fighting the infection, like the care professionals to obtain a starting baseline. In this way Commander Sullemberger, exposed to risks of PTSD and crit- we can have a picture of the current situation and monitor icism for their work are at higher risk of developing mental the trends. In the medium to long term, psychological sup- disorders even months after the emergency. On the other port tools must be offered to the anesthesiologists involved hand, the situation for the anesthesiologists who are not at in the most affected areas, for those who have continued to the frontline in the most affected areas may not be eas- ensure their work with professionalism and diligence.4 Fur- ier, either. For these anesthesiologists, COVID-19 could be a ther research is necessary to identify which programs will factor as frustrating as for the rest of the population. Anes- best suit the needs of anesthesiologists and to measure their thesiologists who are not on the frontlines feel privileged effects on patient care and health care system quality. because they are not exposed to the same risks and the It is possible that cognitive behavioral therapy (CBT), same emotional pain, and they are overwhelmed with guilt. which is a short and simple approach to problem solving, In fact, anesthesiologists are trained with high sense of duty is the more suitable item for anesthesiologists who are and very high standards: they work in an environment where affected. This therapy aimed to help making decisions and errors are not acceptable and in a culture of dedication and to solve problems without finery. Additionally, CBT is vali- self-sacrifice disposition that create a concerning mix. dated for PTSD, guilt, shame and anxiety treatment, with Scientific societies are also rescheduling annual meetings short therapies that can be compatible with a work life.5 and congress programs to give ample space to pandemic, These measures should not remain exceptional but should with the danger to overlap the problem and create two lay the foundations for a support protocol by National classes of anesthesiologists: involved and not involved. This Healthcare systems. In this way, the experience of the risk can ingenerate a work---social stigma like veterans’ COVID-19 pandemic will be able to bear good results of stigma. resilience. Anesthesiologists at high and low risk areas with COVID-19 infections shared one additional mental risk: the Stockholm Conflict of interest Syndrome. The pandemic has overturned the normal pre- existing relationship life: both in the emotional and working The authors declare no conflicts of interest. environment. This has provoked a reduction of the elective activities and a homogeneity in the pathologies present in the intensive care units. The return to ‘‘normality’’ means, References for those who have been directly involved in the pandemic, to upset the organization of work again. If on one hand this 1. Maslach C, Leiter MP. Understanding the burnout experience: means reducing the risks to physical health, reducing the recent research and its implications for psychiatry. World Psy- chiatry. 2016;15:103---11. workload, and releasing tension, on the other hand, changes 2. Vergano M, Bertolini G, Giannini A, et al. SIAARTI recom- can trigger an anxiety response. It is possible to believe mendations for the allocation of intensive care treatments in that anesthesiologists involved in the COVID-19 emergency, exceptional, resource-limited circumstances. Minerva Aneste- hostages of the virus, will get used to this emergency sit- siol. 2020;86:469---72. uation in which emotions are strong and teamwork tends 3. Vittori A, Lerman J, Cascella M, et al. COVID-19 Pandemic Acute to smooth out personal divergences. However, anesthesiol- Respiratory Distress Syndrome Survivors: Pain After the Storm? ogists who have not been directly involved in the pandemic Anesth Analg. 2020;131:117---9. are also hostages of the virus, not at work but at home. The 4. Lapa TA, Madeira FM, Viana JS, et al. Burnout syndrome and well- pandemic, in fact, by reducing the normal elective surgical being in anesthesiologists: the importance of emotion regulation activity, has reduced the working hours of many profession- strategies. Minerva Anestesiol. 2017;83:191---9. 5. Bisson JI, Roberts NP,Andrew M, et al. Psychological therapies for als, forcing them to stay at home. This new adaptation to chronic post-traumatic stress disorder (PTSD) in adults. Cochrane a domestic life previously irreconcilable with intense work Database Syst Rev. 2013;2013:CD003388. can trigger fear and anxiety for the return to a full-scale working activity. Alessandro Vittori a,∗, Giuliano Marchetti a, Many papers nowadays are rightly focusing on the burnout Roberto Pedone b, Elisa Francia a, and PTSD of health workers, making a parallel with what Ilaria Mascilini a, Franco Marinangeli c, 3 happened with Severe Acute Respiratory Syndrome (SARS). Sergio Giuseppe Picardo a Although COVID-19 has instead hit the entire world, with
202 Brazilian Journal of Anesthesiology 2021;71(2) 188---203
∗ a Ospedale Pediatrico Bambino Gesù IRCCS, Department of Corresponding author. Anesthesia and Critical Care, Rome, Italy E-mail: [email protected] (A. Vittori). b University of Campania Luigi Vanvitelli, Department of Received 10 November 2020; accepted 23 January 2021 Psychology, Caserta, Italy c University of L’Aquila, Intensive Care and Pain https://doi.org/10.1016/j.bjane.2021.01.002 0104-0014/ © 2021 Sociedade Brasileira de Anestesiologia. Treatment, Department of Anesthesiology, Aquila, Italy Published by Elsevier Editora Ltda. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
203
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