Peri-operative night-time work of anaesthesiologists: A qualitative study of critical issues and proposals

Medication errors and mitigation strategies in obstetric anesthesia

PURPOSE OF REVIEW

Medication administration errors represent a significant yet preventable cause of patient harm in the peripartum period. Implementation of best practices contained in this manuscript can significantly reduce medication errors and associated patient harm.

RECENT FINDINGS

Cases of medication errors involving unintended intrathecal administration of tranexamic acid highlight the need to improve medication safety in peripartum patients and obstetric anesthesia.

SUMMARY

In obstetric anesthesia, medication errors can include wrong medication, dose, route, time, patient, or infusion setting. These errors are often underreported, have the potential to be catastrophic, and most can be prevented. Implementation of various types of best practice cost effective mitigation strategies include recommendations to improve drug labeling, optimize storage, determine correct medication prior to administration, use non-Luer epidural and intravenous connection ports, follow patient monitoring guidelines, use smart pumps and protocols for all infusions, disseminate medication safety educational material, and optimize staffing models. Vigilance in patient care and implementation of improved patient safety measures are urgently needed to decrease harm to mothers and newborns worldwide.

Programmed Intermittent Epidural Bolus vs Manual Epidural Bolus for Labor Analgesia Initiation: A Randomized Non-Inferiority Trial

Purpose

Typically, labor analgesia is initiated with a manual loading dose. The programmed intermittent epidural bolus (PIEB) effectively maintains labor analgesia. However, no PIEB method has been studied for the initial loading dose. This study aimed to compare the effectiveness of loading doses administered via a PIEB versus a manual bolus.

Patients and Methods

In total, 164 full-term singleton parturients were randomly assigned to receive a 12 mL loading dose (0.1% ropivacaine and 0.3 μg·mL-1 sufentanil) via manual or pump-driven injection. A standardized maintenance protocol was employed. The primary outcome was the percentage of parturients with adequate analgesia 20 min after the initial epidural injection. Adequate analgesia was defined as a numeric rating score (NRS) of ≤3 during two consecutive uterine contractions, without an additional analgesia request. Kaplan-Meier survival curves were constructed for the time interval needed to achieve adequate analgesia. A non-inferiority analysis was conducted by comparing the 90% confidence interval of the pain score difference with the non-inferiority margin.

Results

The percentage of parturients achieving adequate analgesia was comparable (75.61% manual injection vs 76.83% pump injection, P=0.05 for non-inferiority). The median NRS was similar, except at 2 min (7 [5-8] manual injection vs 8 [6-9] pump injection, P=0.04). Median time to adequate analgesia, median ropivacaine consumption, median duration of epidural analgesia, incidence of requests for patient-controlled epidural analgesia (PCEA), median number of PCEA boluses, percentage of bilateral S2 blocks at 20 min, incidence of breakthrough pain, percentage of highest block level ≥T6 at 20 min, adverse effects, and obstetric and neonatal outcomes were similar between the groups.

Conclusion

Within 20 min of administering a loading dose through a PIEB pump, non-inferior analgesia comparable to that achieved with manual injection was observed. This hands-free approach could help mitigate the impact of individual operational differences on analgesic efficacy.

Registration

This trial was registered at chictr.org.cn (ChiCTR2300074063).

Effects of fatigue on anaesthetist well-being and patient safety: a narrative review

The elements that render anaesthesia a captivating profession can also foster stress and fatigue. Professionals considering anaesthesia as a career choice should have a comprehensive understanding of the negative consequences of fatigue and its implications for clinical performance and of the available preventive measures. Available evidence suggests that factors unrelated to patient characteristics or condition can affect clinical outcomes where anaesthetists are involved. Workload, nighttime work, and fatigue are persistent issues in anaesthesia and are perceived as presenting greater perioperative risks to patients. Fatigue seems to negatively affect both physical and mental health of anaesthetists. Existing evidence justifies specific interventions by institutions, stakeholders, and scientific societies to address the effects of anaesthetist fatigue. This narrative review summarises current knowledge regarding the effects of fatigue on anaesthetist well-being and patient safety, and discusses potential preventive solutions.

European Society of Anaesthesiology and Intensive Care consensus document on sustainability: 4 scopes to achieve a more sustainable practice

Climate change is a defining issue for our generation. The carbon footprint of clinical practice accounts for 4.7% of European greenhouse gas emissions, with the European Union ranking as the third largest contributor to the global healthcare industry's carbon footprint, after the United States and China. Recognising the importance of urgent action, the European Society of Anaesthesiology and Intensive Care (ESAIC) adopted the Glasgow Declaration on Environmental Sustainability in June 2023. Building on this initiative, the ESAIC Sustainability Committee now presents a consensus document in perioperative sustainability. Acknowledging wider dimensions of sustainability, beyond the environmental one, the document recognizes healthcare professionals as cornerstones for sustainable care, and puts forward recommendations in four main areas: direct emissions, energy, supply chain and waste management, and psychological and self-care of healthcare professionals. Given the urgent need to cut global carbon emissions, and the scarcity of evidence-based literature on perioperative sustainability, our methodology is based on expert opinion recommendations. A total of 90 recommendations were drafted by 13 sustainability experts in anaesthesia in March 2023, then validated by 36 experts from 24 different countries in a two-step Delphi validation process in May and June 2023. To accommodate different possibilities for action in high- versus middle-income countries, an 80% agreement threshold was set to ease implementation of the recommendations Europe-wide. All recommendations surpassed the 80% agreement threshold in the first Delphi round, and 88 recommendations achieved an agreement >90% in the second round. Recommendations include the use of very low fresh gas flow, choice of anaesthetic drug, energy and water preserving measures, "5R" policies including choice of plastics and their disposal, and recommendations to keep a healthy work environment or on the importance of fatigue in clinical practice. Executive summaries of recommendations in areas 1, 2 and 3 are available as cognitive aids that can be made available for quick reference in the operating room.