Dec 16
0

Biomarkers of Anesthesia Adverse Events

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While modern anesthesia is very safe, anesthesia adverse events, or complications from anesthesia unrelated to a patient’s underlying medical condition, remain. These can include nausea, vomiting, confusion, neurotoxicity, and respiratory complications, all of which can worsen patient outcomes.1 In order to predict how a patient might respond to anesthesia, or to infer what predisposed a patient to an adverse event after the fact, researchers look to biomarkers—any measurable substance or molecule that is indicative of a disease or health outcome. Recently, researchers have identified several promising biomarkers for various anesthesia adverse events, including the few that are outlined below.
Emergence agitation (EA), sometimes known as emergence delirium, is a state of restlessness, disorientation, and incoherence that can set in as a patient wakes up from general anesthesia.2 It can lead to respiratory and circulatory problems, in addition to physical injury to patients and their caregivers.3 A team of researchers from China aimed to identify biomarkers significantly altered in the blood of patients who experienced EA.3 They found a total of 12 biomarkers significantly elevated in the EA patient group, most of which are involved in chemical reactions of fatty acids and lipids. For example, one of the biomarkers, a molecule called decanoylcarnitine, is involved in a host of essential physiological processes, including some that take place in the brain. These biomarkers, the researchers suggest, could underlie the pathology of EA and potentially serve as targets for treatments aiming to reduce the incidence of anesthesia adverse events.
In some cases, biomarkers can indicate that anesthesia may not to blame for adverse postoperative outcomes. Researchers conducted a meta-analysis of trials studying biomarkers of inflammation caused by surgery.4 The biomarkers included the immune system proteins IL6, IL10, and tumor necrosis factor alpha and were measured in over 1,600 patients of various ages and surgery types across more than 20 trials. They found that although inflammatory biomarker levels rise following surgery, there was no difference in inflammation depending on whether propofol or sevoflurane was used. This indicates that the type of anesthesia may not have influenced inflammation.
It is important to note that biomarkers can be substances or signals other than the levels of a certain molecule in the blood. A May 2024 publication in the journal Anesthesiology5 described how researchers measured patients undergoing general anesthesia using an electroencephalogram (EEG), a test that captures electrical activity in the brain, in an effort to see if there might be any observable differences in those who experienced postoperative delirium, a significant change in behavior or cognition typically considered more severe than EA.6 Of the 151 patients evaluated, all of whom were 70 years or older, 50 patients, or 33%, developed postoperative delirium. EEGs were performed the day before surgery (baseline) and as anesthesia-induced unconsciousness set in. On average, compared with the baseline, patients with postoperative delirium had lower intensity alpha waves—a type of brainwave associated with a relaxed state—while on anesthesia during the operative phase. This could indicate that EEG biomarkers obtained at the beginning of anesthesia induction could enable the early identification of patients at risk of developing postoperative delirium.

References
 

  1. Steadman, J., Catalani, B., Sharp, C. & Cooper, L. Life-threatening perioperative anesthetic complications: major issues surrounding perioperative morbidity and mortality. Trauma Surg. Acute Care Open 2, e000113 (2017), DOI: 10.1136/tsaco-2017-000113

 

  1. Lee, S.-J. & Sung, T.-Y. Emergence agitation: current knowledge and unresolved questions. Korean J. Anesthesiol. 73, 471 (2020), DOI: 10.4097/kja.20097

 

  1. Mi, X. et al. Identification of Serum Biomarkers Associated With Emergence Agitation After General Anesthesia in Adult Patients: A Metabolomics Analysis. Front. Med. 9, 828867 (2022), DOI: 10.3389/fmed.2022.828867

 

  1. O’Bryan, L. J. et al. Inflammatory Biomarker Levels After Propofol or Sevoflurane Anesthesia: A Meta-analysis. Anesth. Analg. 134, 69 (2022), DOI: 10.1213/ANE.0000000000005671

 

  1. Pollak, M. et al. Electroencephalogram Biomarkers from Anesthesia Induction to Identify Vulnerable Patients at Risk for Postoperative Delirium. Anesthesiology 140, 979–989 (2024), DOI: 10.1097/ALN.0000000000004929

 

  1. Menser, C. & Smith, H. Emergence Agitation and Delirium: Considerations for Epidemiology and Routine Monitoring in Pediatric Patients. Local Reg. Anesth. 13, 73 (2020), DOI: 10.2147/LRA.S181459

 

Nov 13
0

Preventing Gas Leakage During Mechanical Ventilation

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A mechanical ventilator, also known as a respirator or breathing machine, provides life-saving support for patients with respiratory failure. However, the efficacy and safety of this intervention can be compromised by gas leakage, which occurs when anesthetic or medical gases unintentionally escape from the ventilation system or anesthesia equipment. Therefore, applying effective strategies to prevent gas leakage during mechanical ventilation is essential for optimizing patient care and outcomes.

A gas leakage can originate from several points within the mechanical ventilation system. Ventilator circuit connections, particularly those between the ventilator and the patient interface, are frequent culprits. In invasive mechanical ventilation—where a tube is inserted into the patient’s airway through the mouth, nose, or directly into the trachea—one common source of leakage is the endotracheal tube cuff. This small inflatable balloon, located near the end of the tube, can allow air to escape if it is inadequately inflated or damaged. On the other hand, in non-invasive ventilation, leaks are more common, often resulting from a poor mask fit or inadequate seal (1).

When gas leakage occurs during mechanical ventilation, it can severely impact the ventilation process, which involves moving air in and out of the lungs. Ventilation is determined by the respiratory rate (the number of breaths a person takes per minute) multiplied by the tidal volume (the amount of air moved in and out of the lungs with each breath) (2). Although minor leaks may not significantly affect ventilation, larger leaks can reduce the delivered tidal volume. This can lead to patient-ventilator asynchrony, a condition where the ventilator fails to work in harmony with the patient’s natural breathing efforts, resulting in inadequate oxygenation, impairing the removal of carbon dioxide from the body, and worsening respiratory failure.

To prevent gas leakage and its associated complications, proper adjustment of the patient interface and pressurization levels in the mechanical ventilation system is crucial. This involves ensuring the correct assembly of ventilator components, secure connections, and proper tubing management. Additionally, modern ventilators are equipped with intrinsic systems that detect and compensate for pressure and volume changes, further minimizing the risk of leaks.

In invasive ventilation, the management of the endotracheal tube plays a pivotal role in leak prevention. Proper tube placement, coupled with maintaining appropriate cuff pressure, is critical to preventing both over- and under-inflation, which can lead to leaks or tracheal damage (3). In non-invasive ventilation, ensuring a well-fitted mask and adjusting the headstrap tension can significantly reduce gas leakage (4).

Furthermore, advanced ventilators are now equipped with built-in leak detection features and compensation technologies, which ensure the patient receives the correct amount of air or oxygen even in the presence of leaks. These technologies typically employ pressure control and

volume control compensation algorithms. Pressure control compensation maintains a set pressure during each breath, increasing the inspiratory flow when a leak is detected to preserve that target pressure. In contrast, volume control compensation focuses on delivering a specific tidal volume, compensating for any air lost during leaks by delivering additional air. While both strategies are effective, pressure control compensation often offers superior leak management. Investigations into how different ventilators handle these algorithms can guide clinicians in choosing machines that better minimize risks associated with gas leaks (5).

In conclusion, preventing gas leakage during mechanical ventilation is vital to ensuring effective respiratory support for patients. By maintaining proper equipment management, applying appropriate preventive strategies, and utilizing modern ventilator technologies, clinicians can significantly reduce the risks posed by gas leaks.

 

References

 

1. Oto, J., Chenelle, C. T., Marchese, A. D., & Kacmarek, R. M. (2013). A comparison of leak compensation in acute care ventilators during noninvasive and invasive ventilation: a lung model study. Respiratory Care, 58(12), 2027-2037.

2. Carpio, A. L. M., & Mora, J. I. (2023). Ventilator management. In StatPearls [Internet]. StatPearls Publishing.

3. Fallatah, S. M., Al-metwalli, R. R., & Alghamdi, T. M. (2021). Endotracheal tube cuff pressure: An overlooked risk. Anaesthesia, Pain & Intensive Care, 25(1), 88-97.

4. Mehta, S., McCool, F. D., & Hill, N. S. (2001). Leak compensation in positive pressure ventilators: a lung model study. European Respiratory Journal, 17(2), 259-267.

5. De Luca, A., Sall, F. S., & Khoury, A. (2017). Leak compensation algorithms: the key remedy to noninvasive ventilation failure?. Respiratory Care, 62(1), 135-136.

Nov 01
0

Types of Malicious Software Used in Healthcare Cyber Attacks

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Cybersecurity threats have become a growing concern for healthcare organizations worldwide. With sensitive patient data and critical systems at risk, healthcare institutions have become prime targets for cybercriminals. Malicious software, or malware, is one of the most common tools used in healthcare cyber attacks, compromising patient information, disrupting operations, and damaging the reputation of healthcare providers. Understanding the types of malicious software used in healthcare cyber attacks is essential for developing effective cybersecurity strategies to protect patient data and maintain secure operations.
Ransomware: The Most Notorious Malware in Healthcare
Ransomware has become one of the most devastating forms of malicious software in healthcare cyber attacks. In a ransomware attack, hackers deploy malware to encrypt the data on a healthcare organization’s network, effectively blocking access to vital information and systems. Once encrypted, the cybercriminals demand a ransom—often in cryptocurrency—to restore access to the data. This can lead to significant disruptions in patient care, as healthcare providers may lose access to electronic health records (EHRs), scheduling systems, and even life-saving medical devices.
The WannaCry ransomware attack in 2017, which affected healthcare providers worldwide, highlighted the severe impact of ransomware in healthcare. Many healthcare organizations, unable to access critical systems, were forced to turn away patients and cancel appointments. Since then, ransomware attacks on healthcare facilities have continued to rise, prompting increased focus on cybersecurity measures.
Trojans: The Silent Data Thieves
Trojans, also known as Trojan horses, are a form of malicious software that disguises itself as a legitimate application or file to trick users into downloading it. Once inside a healthcare network, Trojans can allow attackers to steal sensitive patient information, including medical histories, billing details, and insurance information. Unlike ransomware, Trojans often operate quietly, collecting and transmitting data back to the attackers without the user’s knowledge.
In healthcare, Trojans can be particularly harmful due to the amount of personally identifiable information (PII) and protected health information (PHI) stored in digital systems. Attackers may sell this stolen data on the dark web or use it for identity theft and fraudulent insurance claims. The stealthy nature of Trojans makes them difficult to detect and even harder to remove, highlighting the need for strong antivirus and intrusion detection systems in healthcare networks.
Phishing and Malware Injections
Phishing remains a common method for delivering malware into healthcare systems. In a phishing attack, cybercriminals use deceptive emails or messages to trick healthcare staff into clicking on malicious links or downloading infected attachments. Phishing attacks often use familiar branding and language to appear legitimate, increasing the likelihood that unsuspecting users will fall victim to them.
Phishing emails may carry various types of malware, including ransomware, Trojans, or spyware, depending on the attacker’s objective. For instance, a phishing email may direct a healthcare employee to a fake login page to harvest their credentials or trick them into downloading a file infected with spyware that records keystrokes and sends confidential information to the attackers. Phishing is particularly concerning in healthcare because it exploits human error and requires ongoing staff training to prevent.
Spyware: Surveillance on Patient Data
Spyware is a type of malware that allows attackers to monitor and capture information on a target’s device or network. In healthcare, spyware can be used to capture sensitive patient information, including EHRs, doctor-patient communications, and billing information. Once installed, spyware can monitor user activity, record keystrokes, and even take screenshots, providing attackers with valuable intelligence on a healthcare organization’s operations and data.
Spyware is challenging to detect because it often operates in the background, silently collecting data without alerting the user. Given the sensitive nature of patient information, spyware poses a significant risk in healthcare, as compromised data can lead to privacy violations and financial losses for both the healthcare provider and the affected patients.
Advanced Persistent Threats (APTs)
Advanced Persistent Threats, or APTs, are a sophisticated form of malware used in healthcare cyber attacks to infiltrate networks and maintain unauthorized access over an extended period. APTs are often deployed by highly skilled attackers with the intention of stealing vast amounts of data or sabotaging critical infrastructure. In healthcare, APTs can target medical records, research data, and intellectual property, potentially jeopardizing patient privacy and compromising clinical research.
The danger of APTs lies in their stealthy nature; attackers use a combination of malware types, including Trojans, rootkits, and spyware, to establish a foothold and evade detection. Healthcare organizations are particularly vulnerable to APTs due to their reliance on connected medical devices and electronic record systems. Preventing APTs requires advanced network monitoring, intrusion detection systems, and prompt responses to any signs of unusual activity.
Rootkits: Hidden Malware in System Software
Rootkits are another type of malware used in healthcare cyber attacks, designed to hide within a computer’s operating system to provide attackers with unauthorized access. Once installed, rootkits can allow cybercriminals to control a healthcare organization’s systems remotely, stealing sensitive data or causing disruptions without being detected. Rootkits can be embedded in system files, making them difficult to identify and remove without specialized cybersecurity tools.
In healthcare, rootkits can be especially harmful if they infiltrate devices used for diagnostics or patient monitoring. By gaining access to these devices, attackers could manipulate or disrupt their functions, posing a serious threat to patient safety. Protecting against rootkits requires stringent endpoint security measures and regular system checks to ensure malware has not compromised the network.
Botnets: Malicious Networks of Compromised Devices
Botnets are networks of compromised devices, controlled by cybercriminals to launch large-scale attacks, including Distributed Denial of Service (DDoS) attacks. In a healthcare setting, botnets can be used to overwhelm an organization’s network, disrupting access to patient data, communications, and critical systems. Botnets often include internet-connected medical devices, making healthcare networks susceptible to attacks that can shut down entire facilities.
The presence of botnets in a healthcare network can compromise patient care, delaying procedures and putting patient lives at risk. Implementing device-level security, securing medical devices with strong passwords, and regularly updating software can help mitigate the risk of botnet-related attacks.
Conclusion
Malicious software, or malware, presents a significant threat to healthcare organizations, endangering patient safety, privacy, and operational efficiency. Ransomware, Trojans, spyware, phishing, APTs, rootkits, and botnets are some of the most common types of malicious software used in healthcare cyber attacks. Each type of malware presents unique challenges and requires comprehensive cybersecurity strategies to defend against potential threats. By investing in advanced security measures, continuous employee training, and robust incident response plans, healthcare organizations can safeguard their networks and ensure the protection of sensitive patient data in an increasingly digital world.
Oct 03
0
Oral Medication

Pre-Operative Oral Medication under NPO Guidelines

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Traditionally, NPO guidelines were established to reduce the risk of aspiration and other complications during anesthesia by restricting food and liquid intake prior to surgery. NPO guidelines have evolved over time, particularly with the growing understanding of the safety and implications of allowing certain oral medication closer to surgery time. Current evidence suggests that permitting oral medications with a small sip of water up to two hours before surgery does not significantly increase aspiration risk and may improve patient outcomes (1).

 

NPO guidelines have traditionally required patients to abstain from all food and liquids, including oral medication, beginning at midnight prior to surgery. However, this approach has been increasingly questioned due to the potential negative effects on patient well-being, such as dehydration, hypoglycemia, and increased anxiety, along with potential impacts from medication stoppage, which may subsequently affect surgical outcomes (1). Updated NPO guidelines now advocate a more nuanced approach, particularly with regard to oral medications that are critical to the management of chronic conditions. Medications for conditions such as hypertension, asthma, and heart disease can lead to perioperative complications if withheld; therefore, their continuation with minimal water intake is often recommended (2).

 

Current research supports the administration of certain oral medications preoperatively, as long as they are taken with a small amount of water – typically 30 ml or less – within two hours of surgery. This approach is not considered a violation of NPO guidelines and aims to strike a balance between minimizing the risk of aspiration and avoiding exacerbation of underlying medical conditions (2). For example, patients taking beta-blockers for cardiac conditions should generally continue their medication to avoid adverse cardiovascular events associated with sudden withdrawal.

 

Despite the evidence, application of updated NPO guidelines varies widely among institutions and practitioners. Resistance to change is due, in part, to ingrained practices and the slow adoption of new guidelines into routine clinical practice. Surveys of U.S. hospitals have revealed significant discrepancies between current evidence and clinical practice, with many providers still adhering to “NPO after midnight” rules (3). Such outdated practices can negatively impact patient safety and comfort, highlighting the need for ongoing education and dissemination of guidelines to ensure that evidence-based practices are followed.

 

In addition, the debate around NPO guidelines extends beyond medications to include other forms of oral intake, such as clear liquids, which some recent studies have shown can be safely consumed up to two hours before surgery without increasing the risk of aspiration (Wilson, 2017). This evolving understanding emphasizes the importance of individualized patient care, where decisions about preoperative medications and fluid intake are tailored to the patient’s specific medical conditions, type of surgery, and anesthetic requirements.

 

The administration of preoperative oral medications under NPO guidelines should be approached with an evidence-based mindset that allows for necessary medications with minimal fluid intake close to surgery. This approach minimizes the risks associated with omitting critical medications, while maintaining the fundamental goal of preventing aspiration. Consistent updating and dissemination of NPO guidelines to healthcare providers is essential to bridge the gap between research and clinical practice, ultimately improving patient safety and surgical outcomes.

 

References

 

  1. Fawcett WJ, Thomas M. Pre-operative fasting in adults and children: clinical practice and guidelines. Anaesthesia. 2019;74(8):83-88. doi:10.1111/anae.14500.
  2. Kramer K, Bennett J. NPO guidelines. In: Bennett J, ed. Anesthesia Complications in the Dental Office. 1st ed. Wiley; 2015:85-102. Available from: https://onlinelibrary.wiley.com/doi/abs/10.1002/9781119053231.ch4.
  3. Abola RE, Gan TJ. Preoperative fasting guidelines: Why are we not following them? The time to act is now. Anesth Analg. 2017;124(4):1041-1043. doi:10.1213/ANE.0000000000001853.
  4. Wilson H. Pre-operative management. In: Falaschi P, Marsh D, eds. Orthogeriatrics. 1st ed. Springer; 2017:45-58. doi:10.1007/978-3-319-43249-6_5. Available from: https://link.springer.com/chapter/10.1007/978-3-319-43249-6_5

 

 

Aug 07
0

Major Shifts in Anesthesia Groups

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Driven by changing market dynamics and a growing provider shortage, the field of anesthesia has sustained significant upheaval in recent years. These shifts, characterized in part by large, consolidated anesthesia firms replacing local groups in hospital systems, represent an unprecedented departure from traditional anesthesia field practices, with significant implications for anesthesia providers and their patients.

 

One of the major underlying causes of these shifts in the landscape of anesthesia groups — the national anesthesia provider shortage — is not new. In the early 2000s, the demand for anesthesia providers began to outgrow the supply (1). The aging American population that required more procedures and the expansion of hospital surgical staff across the country put pressure on the medical field, which responded by increasing residency positions by 12% and increasing medical school class sizes (1, 2). Despite these efforts, demand has continued to outpace supply, with over half of anesthesiologists over the age of 55, signaling an impending exodus of retirees that will exceed the influx of younger anesthesiologists (1). While the number of physicians in other specialties have grown an estimated average of 7% between 2016 and 2021, anesthesiologists have increased by only 1%, leading to an expected shortage of 12,500 in 2033 (3). This shortage has resulted in increased wait times for routine and urgent procedures, financial impact on hospital systems and anesthesia firms, and provider dissatisfaction (4).

 

In the wake of this shortage and its negative impacts on hospital systems, a new form of anesthesia firm management has emerged, represented by the wave of consolidation (5). This new form — large, consolidated anesthesia groups purchased, assembled, and directed by national for-profit healthcare organizations or private equity firms — has rapidly grown from roughly 3% of all anesthesia firms in 2009 to nearly 19% in 2019 (6). This percentage has increased due to large companies’ and private equity firms’ interest in highly specialized, relatively expensive medical specialties — including anesthesia groups, dental offices, and ophthalmology clinics — due to their high profit margins (7). Historically, hospital systems have staffed anesthesia services by contracting with local firms, but these new, large, consolidated firms appear attractive to hospitals, with promises of adequate staffing and decreased cost (7). In fact, between 2023 and 2024, more than 10 large hospital systems across the country severed ties with local firms and entered contracts with consolidated groups, representing an unprecedented shift in the anesthesia industry (8).

 

Unfortunately, some of these groups have been unprepared, resulting in worsened shortages, exorbitant surgery wait times, and criticism (9, 10). For example, in 2023, a hospital system in Oregon suddenly terminated its agreement with a local group and began contracting with a consolidated group backed by a private equity firm (10). Despite appearing more efficient, the new firm had cut necessary costs and jobs, resulting in a massive anesthesiologist shortage and a significant delay in surgeries (10).

 

Despite hospitals’ increasing preferences for ostensibly lower-cost, better-staffed consolidated anesthesia groups, shifts toward this model has been met with scrutiny from anesthesia providers, their communities, and the federal government. For example, in Texas, two private equity firms allegedly colluded to consolidate anesthesia firms across the state to create a monopoly, eliminate local groups, and hike up prices for hospitals and patients, resulting in the Federal Trade Commission filing lawsuits against the firms in 2023 (11). This lawsuit represents many anesthesia providers’ sentiments about the wave of consolidation, with many critics arguing that this shift from local physician-managed firms to national corporation-managed groups results in higher costs for patients, lower-quality care, job losses, and the pursuit of profits at the expense of patients and their providers (7, 12). The future of the industry remains unclear as many hospital systems evaluate the performance of their contracted anesthesia groups.

 

References

 

1: Menezes, J. and Zahalka, C. 2024. Anesthesiologist shortage in the United States: a call for action. Journal of Medicine, Surgery, and Public Health, vol. 2. DOI: 10.1016/j.glmedi.2024.100048;

 

2: American Association of Medical Colleges (AAMC). 2024. “Physician specialty data report.” AAMC Data and Reports. URL: 2016-2021https://www.aamc.org/data-reports/workforce/data/percentage-change-first-year-acgme-residents-fellows-specialty-2016-2021.

 

3: Kaplan, K. and Polanco, K. 2023. “Where have all the anesthesia specialists gone? Insights for healthcare leaders.” Veralon Healthcare Management Advisors. URL: https://www.veralon.com/wp-content/uploads/2023/10/Veralon-Blog-Where-Have-All-the-Anesthesia-Specialists-Gone-Insights-for-Healthcare-Leaders-Oct2023.pdf.

 

4: Peters, J. 2022. The physician leader’s role in navigating the anesthesia provider shortage. American Association for Physician Leadership, vol. 9. DOI: 10.55834/plj.9178639149.

 

5: Paone, J. 2022. “Trend to watch: inside the consolidation of anesthesia services.” Outpatient Surgery Magazine. URL: https://www.aorn.org/outpatient-surgery/article/2022-February-anesthesia-services.

 

6: Adler, L., Milhaupt, C. and Valdez, S. 2023. Measuring private equity penetration and consolidation in emergency medicine and anesthesiology. Health Affairs Scholar, vol. 1. DOI: 10.1093/haschl/qxad008.

 

7: Kotsonis, S. and Chakrabarti, M. 2023. “How private equity is changing American health care.” WBUR. URL: https://www.wbur.org/onpoint/2023/11/07/how-private-equity-is-changing-american-health-care.

 

8: Hollowell, A. 2024. “Why US hospitals are breaking up with anesthesiology groups.” Becker’s Hospital Review. URL: https://www.beckershospitalreview.com/care-coordination/why-us-hospitals-are-breaking-up-with-anesthesiology-groups.html.

 

9: Coleman, A. 2024. “Methodist delays surgeries after breakup with anesthesia provider.” WREG. URL: https://wreg.com/news/local/methodist-delays-surgeries-after-breakup-with-anesthesia-provider/.

 

10: Newitt, P. 2024. “Oregon hospitals’ surgeries plummet amid anesthesiologist shortages.” Becker’s ASC Review. URL: https://www.beckersasc.com/anesthesia/oregon-hospitals-surgeries-plummet-amid-anesthesiologist-shortages.html#:~:text=Surgeries%20at%20two%20Providence%20hospitals,equity%2Dbacked%20physician%20staffing%20firm.

 

11: Federal Trade Commission. 2023. “FTC challenges private equity firm’s scheme to suppress competition in anesthesiology practices across Texas.” FTC press release. URL: https://www.ftc.gov/news-events/news/press-releases/2023/09/ftc-challenges-private-equity-firms-scheme-suppress-competition-anesthesiology-practices-across.

 

12: Answine, J. 2023. “War games: private anesthesia group versus hospital system versus private equity firm.” OR Management News. URL: https://www.ormanagement.net/Opinion/Article/09-23/War-Games-Private-Anesthesia-Group-Versus-Hospital-System-Versus-Private-Equity-Firm/72302.