Meeting Notes From the 2012 ASA Annual Meeting Kim Kraft, BSN, RN, CPAN ASPAN HAS LONG benefited from a collegial relationship with the American Society of Anesthesiologists (ASA) and the Anesthesia Patient Safety Foundation (APSF). Each year, ASPAN leadership attends the ASA Annual Meeting at the invitation of the seated ASA President. ASPAN President, Susan Carter, BSN, RN, CPAN, CAPA, and Vice President/President-Elect Twilla Shrout, BSN, MBA, RN, CPAN, CAPA, attended the 2012 ASA Annual Meeting held October 13-17, 2012, in Washington, DC. The theme of the annual meeting was Transforming Patient Safety Through Education and Advocacy. As the APSF liaison, I attended the inaugural ASA/APSF Ellison (Jeep) C. Pierce Lecture on Patient Safety and the APSF Workshop, and represented ASPAN at the APSF Board of Directors’ meeting after the sessions. The APSF’s vision is to ensure that no patient shall be harmed by anesthesia, and the foundation is guided by its mission statement ‘‘to improve continually the safety of patients during anesthesia care by encouraging and conducting the following: safety research and education; patient safety programs and campaigns and national and international exchange of information and ideas.’’1 This aligns closely with ASPAN’s strategic goal to ‘‘be the influential force for perianesthesia patient safety, public policy, and practice standards.’’2 This can be achieved by partnering with such organizations as APSF to explore safety initiatives and represent the safety interests of perianesthesia practice. The Ellison (Jeep) C. Pierce Lecture on Patient Safety was presented by Donald Berwick, MD, forKim Kraft, BSN, RN, CPAN, APSF Liason, is a Perianesthesia Nurse Clinician, Surgical Services, Mercy Hospital St. Louis, St. Louis, MO. Conflict of interest: None to report. Address correspondence to Kim Kraft, Surgical Services, Mercy Hospital St. Louis, 615 South New Ballas Road, St. Louis, MO 63141; e-mail address: [email protected]
Ó 2013 by American Society of PeriAnesthesia Nurses 1089-9472/$36.00 http://dx.doi.org/10.1016/j.jopan.2013.03.006
mer Administrator of the Centers for Medicare and Medicaid Services. He offered his views on how anesthesiologists can continue to lead in patient safety while reducing or eliminating waste in health care spending. Although Dr Berwick addressed anesthesiologists, many of his comments were applicable to nurses in general and perianesthesia nurses specifically. Dr. Berwick’s presentation can be summarized by the following statements: (1) professionals have a duty to improve the systems in place at work; (2) leaders have a duty to make the first item feasible and supported; (3) there is no excuse not to make the previous two items happen; (4) the duty to improve systems encompasses safety, effectiveness, efficiency, equity, and patient centeredness; and (5) those of us who educate professionals have a duty to prepare them for the improvement work. The annual APSF Board of Directors Workshop was held Saturday afternoon and entitled, ‘‘When and How to Challenge the Hierarchy: Speaking Up for Patient Safety.’’ Moderator Jeffrey Cooper, PhD, opened the session by asking participants if they would be able to effectively speak up if confronted with a patient safety situation. Using role playing, he led the audience through an exercise using techniques for speaking up that were discussed and demonstrated by members of the APSF earlier in the session. Detailed results can be found in the Winter 2013 issue of the APSF Newsletter, which is distributed electronically to all ASPAN members (http://www.apsf.org/news letters/e-newsletter/winter2013/index.html). The APSF hopes to continue to find ways to assist anesthesia providers to speak up for patient safety. I have provided abstracts for some of the research findings presented at the 2012 annual meeting that are of heightened interest to perianesthesia nurses. You may visit the ASA Web site at http:// www.asahq.org to read more about the annual meeting, review abstracts of presentations and poster submissions, and obtain general information about the ASA. (The following information is compiled
Journal of PeriAnesthesia Nursing, Vol 28, No 3 (June), 2013: pp 180-184
from news releases produced and copyrighted by the ASA for the 2012 ASA Annual Meeting.)
Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
Major Morbidity and Mortality After Common Outpatient Surgical Procedures: A Study of Preoperative Risk Factors
In recent years, knowledge about oral rehydration and infusion management during the perioperative period has been disseminated as it contributes to patients’ early recovery. However, the relationship between the length of the intake restriction period and circulating blood volume is not fully understood. Stroke volume variation (SVV) is the index of circulating blood volume and has received much attention regarding perioperative fluid optimization. The aim of this study was to investigate the relationship between the length of the intake restriction period and circulating blood volume, using estimation of SVV value.
Michael Mathis, MD, Norah N. Naughton, MD, Amy M. Shanks, MS, Robert Freundlich, MD, Yijia Chu, MD, Jason Haus, MD, Christopher Pannucci, MD, Sachin Kheterpal, MD University of Michigan, Ann Arbor, MI Driven by improvements in perioperative care and ongoing economic pressures, the proportion of ambulatory surgeries performed annually in the United States has increased dramatically over the past three decades, currently comprising more than 60% of all the surgical procedures. Although ambulatory procedures are associated with an exceedingly low complication rate, the patient population has evolved over time, increasing in both size and complexity. The authors used a national database of prospectively collected data to evaluate the preoperative patient factors associated with increased risk for major morbidity or mortality after common outpatient surgical procedures. Of the 245,935 cases in the study, 644 (0.3%) experienced major morbidity or mortality, corresponding to an incidence of approximately 1 in 382. Seven independent preoperative risk factors were identified: disseminated cancer, paraplegia/quadriplegia, age 81 years and older, renal failure, steroid use, chronic obstructive pulmonary disease, and history of transient ischemic attack or stroke. The study confirms the safety of performing outpatient surgical procedures, as demonstrated by low rates of morbidity and mortality. Through this evaluation, it is hoped that improved preoperative patient screening will serve to reduce the incidence of morbidity and mortality in the outpatient setting.
Even 2-Hour Restriction of Clear Liquid Intake Before General Anesthesia May Induce Some Dehydration Maiko Tomita, MD, Yoshihito Fujita, MD, PhD, Saya Yoshizawa, MD, Megumi Harima, MD, Kazuya Sobue, MD, PhD
Estimation of SVV showed some dehydration in both study groups, with the degree of dehydration being lower in the short period group (SPG) than long period group (LPG). Less infusion tended to be required to return circulating blood volume to normal range in SPG than in LPG. When patients are allowed to drink clear liquids depending on their thirst, even a 2-hour restriction of clear liquid intake may induce some dehydration.
Association Between Perioperative Hemoglobin and Acute Kidney Injury in Patients Having Noncardiac Surgery Alexander Y. Fu, BS, Hooman Honar, MD, Amit X. Garg, MD, PhD, Maged Y. Argalious, MD, MBA, Michael Walsh, MD, PhD Cleveland Clinic Foundation, Cleveland, OH Acute kidney injury (AKI) is a common complication of noncardiac surgery and associated with excess morbidity and mortality, yet there are no interventions known to prevent or reduce the severity of AKI. Identification of common modifiable risk factors that are strongly associated with AKI is an important first step in identifying potential therapeutic targets. Preoperative anemia and perioperative transfusions are known to be associated with AKI in cardiac surgery, but risk factors for noncardiac surgery have not been established. The authors studied the association between hemoglobin before and 24 hours after noncardiac surgery and postoperative AKI.
AKI developed in 2,478 (7.4%) surgeries. Preoperative hemoglobin concentrations were less than 12.0 g/dL in 9,566 (29%) patients. Hemoglobin concentrations decreased by greater than 4.0 g/dL in 10,808 (32%) patients. Compared with patients with a preoperative hemoglobin greater than 12.0 g/dL, the adjusted odds ratio (OR) for AKI was 2.0 (95% confidence interval [CI], 1.8 to 2.3) for those with a preoperative hemoglobin between 10.1 and 12.0 g/dL and 3.7 (95% CI 2.6 to 5.4) for those with a preoperative hemoglobin less than 8.0 g/dL. Compared with no decrement in postoperative hemoglobin, a decrement of 1.1 to 2.0 g/dL was associated with an adjusted OR of 1.5 (95% CI, 1.2 to 2.0) and a decrement greater than 4.0 g/dL was associated with a ratio of 4.7 (95% CI, 3.6 to 6.2) for AKI. Low preoperative hemoglobin concentrations and decrements in postoperative hemoglobin are strongly associated with postoperative AKI in a graded manner. Given the frequency of low perioperative hemoglobin and the potential for mitigation, research is needed to develop and test safe treatment strategies.
High Risk of Obstructive Sleep Apnea is Associated With Increased Perioperative Pain Satya Krishna Ramachandran, MD, FRCA, Leela Mirafzali, Student, Michelle Morris, MS, Chad Brummett, MD University of Michigan, Ann Arbor, MI Obstructive sleep apnea (OSA) is estimated to afflict 9% to 24% of the general population, up to 90% of whom are typically undiagnosed and have a greater risk of developing chronic pain. Anesthesia and surgery cause complex changes in sleep architecture with significant reduction of total sleep time and a greater reduction in restorative sleep. Perioperative sleep deprivation adds to the overall sleep fragmentation of patients with OSA. Based on the reciprocal relationship between sleep deprivation and pain, the authors hypothesized that patients with high risk of OSA would present with increased preoperative and postoperative pain as measured by opioid consumption.
After exclusion of primary spinal or epidural anesthetics and adjunct regional techniques, 172 patients with data on risk factors for OSA were analyzed. Preoperative opioid usage, preoperative pain scores, and postoperative pain scores were equally distributed between groups. High risk of OSA was associated with increased preoperative and intraoperative, but not postoperative, opioid dose requirement for comparable pain scores. High risk of OSA determined by the Perioperative Sleep Apnea Prediction score was associated with increased preoperative pain in patients undergoing total knee or hip arthroplasty. Features of OSA, namely truncal obesity and hypertension, were independently associated with postoperative opioid consumption. This is the first study to demonstrate a relationship between risk features of OSA and clinically relevant measures of perioperative pain sensitivity. These findings point to a potential dose-dependent mechanism for increased postoperative respiratory morbidity in patients with OSA.
Determining the Relationship Between Pain and Emergence Delirium in Young Children Andrew J. Davidson, MD, Alison Lam, Student, Stephanie Malarbi, BSc, Suzette Sheppard, BSc Royal Children’s Hospital, Parkville, Australia The aim of this study was to better determine if pain plays a contributory role in the development of emergence delirium (ED) in children. It is unclear if pain increases the likelihood of ED, partly because of the inability of established measures of ED to differentiate pain from delirium. For treatment purposes, it is important to determine whether pain contributes to the development of ED. To determine the role of pain in ED, the authors compared the incidence of ED between groups of children who had painless procedures, and procedures that might be painful, using a measure of ED, which is more likely to differentiate pain from delirium. They found weak evidence for a higher incidence of ED in the surgical group compared with the imaging group (26.8% compared with 13.6%), and there was strong evidence for an association
between pain scores and the presence of ED. Postsurgical pain may lead to ED. These findings reinforce the importance of providing effective and preemptive analgesia to children during surgery. It suggests that analgesics should be considered when managing children with established ED.
A Simplified Risk Score to Predict Severe Pain After Ambulatory Surgery Christian C. Apfel, MD, PhD, Alparslan Turan, MD, Beverly K. Philip, MD, Joseph Ruiz, MD, Anthony Kovac, MD, Jan Odom-Forren, PhD, Rachel Whelan, BS, Christine Miaskowski, PhD University of California, San Francisco, San Francisco, CA Predictive risk scores can significantly reduce the incidence of postoperative outcomes like nausea and vomiting. There is currently one risk score for postsurgical pain in the postanesthesia care unit that Kalkman et al developed in European inpatients. Given the increasing number of surgeries performed on an outpatient basis, the authors wanted to develop a risk score in ambulatory patients that could be used across a wide range of surgeries to predict severe acute pain in the postdischarge period here in the United States. The strongest predictors for postsurgical pain after discharge were smoking status, patients’ concern about severe postsurgical pain, duration of surgery, and acute severe pain in the postanesthesia care unit (PACU). When zero, one, two, three, or four of these risk factors are present, the incidence of severe postsurgical pain in the validation data set was 15%, 26%, 48%, 70%, and 100%, respectively.
Postoperative Oxygenation Pattern in Patients With Obstructive Sleep Apnea Fredrik Boer, MD, PhD, Saidja L. Noter, MD, Albert Dahan, MD, PhD Leiden University Medical Center, Leiden, The Netherlands OSA patients are noted to be at risk of severe respiratory compromise in the postoperative period, particularly if opioids are used for pain treatment.
Therefore, if the use of opioids for pain treatment is probable in patients with OSA, it is the authors’ department policy that patients with confirmed or suspected OSA are monitored in the PACU during the first postoperative night. This policy puts a heavy burden on limited PACU resources. The aim of the study was to evaluate postoperative oxygenation patterns in patients with OSA during the first three postoperative nights and 6 weeks after operation. The results were compared with patients with body mass index greater than 35 and a control group. Patients in the study had less hypoxia during the first night than during the next two nights, and there were no interventions for respiratory depression/apnea. More than half of the patients had continuous positive airway pressure masks in use that could have protected them from hypoxia. The data suggest that the policy to observe patients in the PACU for the first night had no added value in the studied OSA group.
Intravenous Acetaminophen Reduces Postoperative Nausea and Vomiting: A Systematic Review and Meta-Analysis Christian C. Apfel, MD, PhD, Cyrill Hornuss, MD, Alparslan Turan, MD University of California, San Francisco, CA Intravenous (IV) acetaminophen has been shown to reduce postoperative opioid requirements. Given that opioids are main triggers for postoperative nausea and vomiting (PONV), one would expect that IV acetaminophen reduces PONV. Nonsteroidal anti-inflammatory drugs reduce postoperative opioid requirements and PONV, but a recent meta-analysis concluded that IV acetaminophen did not reduce PONV. As only a handful of studies were included in those PONV analyses, the authors tried to understand whether there is truly evidence for the absence of an effect or just insufficient evidence to prove a clinically relevant antiemetic effect. Studies were grouped according to the timing of the first administration, that is, IV acetaminophen reduced nausea when given prophylactically, either before surgery or intraoperatively or immediately after the end of surgery, but not when given
at the onset of pain. When patients received IV acetaminophen prophylactically, that is, before entering the PACU, the relative risk for nausea was similar for single and repeated doses of IV acetaminophen. Results were similar for vomiting.
Prophylactically administered IV acetaminophen reduces postoperative nausea and postoperative vomiting. The effect size to reduce PONV is comparable with the relative risks of antiemetics used for the prevention of PONV.
References 1. Anesthesia Patient Safety Foundation. About us: mission statement. Available at: http://www.apsf.org/about.php. Accessed February 20, 2013.
2. American Society of Perianesthesia Nurses. Strategic goals. Available at: http://www.aspan.org/ClinicalPractice/ SafetyinPractice/StrategicGoals/tabid/3260/Default.aspx. Accessed February 20, 2013.