Mitral regurgitation is a common valvular pathology that can lead to heart failure, so surgical correction is advised. However, some patients are unable to receive mitral valve surgical repair due to the increased perioperative risk. Percutaneous edge to edge mitral valve repair (PMVR) using the MitraClip system has been demonstrated to be a safe and effective alternative to treat severe mitral regurgitation in these patients. Unlike other percutaneous interventions, such as transcatheter aortic valve replacement (TAVR) that is getting more commonly performed under conscious or deep sedation, most PMVR procedures are currently being performed under general anesthesia. While general anesthesia provides advantages such as guaranteed immobility, ability to give breath holds for challenging anatomic conditions, and control of the airway, disadvantages include greater hemodynamic swings, greater incidence of perioperative hypotension, and increased duration of anesthesia. These disadvantages have been shown to be risk factors for prolonged hospital stay and increased morbidity.

Two European prospective studies were published last year comparing general anesthesia to deep sedation for PMVR. Each consisted of over 200 patients. Patients were not randomized in either study, but in the Patzelt study they were individually evaluated by the cardiology and anesthesia teams regarding suitability for deep sedation (patients selected for general anesthesia may have a more challenging anatomy, for example, which may have benefited from controlled ventilation). The Horn study used its scheduling system to assign patients to either group regardless of patient characteristics, though more patients ended up being in the deep sedation group. Both studies used midazolam and propofol as primary sedatives for the deep sedation group.

Despite significant differences between patient groups in the Patzelt study (general anesthesia patients were younger but tended to have more severe disease and comorbidities, though pulmonary hypertension was more prevalent in the deep sedation group), both studies nevertheless found similar outcomes. There was no difference found between the two groups in terms of procedure success, surgical complications, major cardiac and cerebrovascular events, or postoperative pneumonia. Both studies found advantages to deep sedation, including shorter preparation time in the cath lab and ICU stay duration. The Horn study found longer procedure time and fluoroscopy time for the general anesthesia group, however this may be confounded by baseline patient characteristic differences between the two groups.

These two single institution prospective studies provide encouraging data for the safety of deep sedation for percutaneous mitral valve repair procedures. For eligible patients, it may be worth discussing whether this anesthetic approach may be appropriate.

References:

Horn P, Hellhammer K, Minier M, Stenzel MA, Veulemans V, Rassaf T, Luedike P, Pohl J, Balzer J, Zeus T, Kelm M, Westenfeld R. Deep sedation Vs. general anesthesia in 232 patients undergoing percutaneous mitral valve repair using the MitraClip® system. Catheter Cardiovasc Interv. 2017 Dec 1;90(7):1212-1219.

Patzelt JI, Ulrich M, Magunia H, Sauter R, Droppa M, Jorbenadze R, Becker AS, Walker T, von Bardeleben RS, Grasshoff C, Rosenberger P, Gawaz M, Seizer P, Langer HF. Comparison of Deep Sedation With General Anesthesia in Patients Undergoing Percutaneous Mitral Valve Repair. J Am Heart Assoc. 2017 Dec 2;6(12)

Surgical site infections (SSIs) affect 1-3% of patients within 30 days after surgery.¹ While some infections are superficial and associated with mild irritation and discharge, deeper infections can impair wound healing, causing incisions to re-open and infection to spread. For most surgeries involving a significant skin incision, follow-up visits are typically scheduled within 2 weeks. However, sometimes compliance with follow-up is not perfect, and brewing infections can go unnoticed for a long period of time.

Prior to surgery, the anesthesiologist and surgeon evaluate for conditions that predispose a patient to SSI, including diabetes, cancer, kidney and liver disease, as well as habits including cigarette use, heavy alcohol or intravenous drug use. Longer procedures, especially near the intestines which normally harbor bacteria, can progressively increase the risk of bacterial infection and abscess formation. A risk calculator has been developed (and freely available) to assist surgeons, patients, and families in understanding the risks of major complications after surgical procedures.³

Such infections after surgery require a thorough evaluation (with an assessment for the need for re-operation) and several weeks of antibiotics, contributing significantly to healthcare costs that can exceed $20,000.⁴ For example, SSIs are a cost burden to the healthcare system; it adds more than $20,000 to the patient’s bill and contributes to almost $2 billion in additional healthcare expenditures nationally each year.^4,5 For this reason, anesthesia and perioperative care teams emphasize multiple evidence-based strategies during the pre-operative visit and enforce them during the day of surgery:

– Patient pre-operative instructions:

– Patients are instructed to shower the night before many surgeries using an antiseptic rinse, typically chlorhexidine gluconate.

– Hand-washing:

– Hand hygiene protocols in hospitals call for adequate hand washing and scrubbing in a sub-sterile environment immediately prior to entering the operating room.

– Hand sanitizers are recommended for intermittent use during and after procedures, especially when the anesthesia team goes between different equipment and medications.

– Sterile precautions:

– The anesthesia and operating room management have standardized the use of sterile gloves, autoclaved instruments, and large blue surgical barrier drapes.

– In addition, skin preparation with chlorhexidine (i.e. Chloraprep) or iodine (i.e. Betadine) is mandatory.

– Antibiotic prevention:

– Cefazolin (i.e. Ancef, Kefzol) is given by the anesthesiologist within 30-60 minutes of the anticipated start of surgery to prevent potential infections in the vast majority of procedures involving skin incision. Different antibiotics may be given as “prophylaxis” if the operative team anticipates exposure to specific types of bacteria.

– Wound irrigation and post-operative antibiotics:

– The surgeon will thoroughly explore for any potential debris and instill irrigation fluid prior to closing the surgical incision.

– Patients with a compromised immune system and those deemed to already have a severe infection will be continued on antibiotics after surgery, sometimes receiving multiple doses a day through an intravenous catheter for several weeks.

REFERENCES

1. Klevens, R.M., Edwards, J.R., Richards, C.L. Jr., Horan, T.C., Gaynes, R.P., Pollock, D.A. et al. Estimating health care-associated infections and deaths in US hospitals, 2002. Public Health Rep. 2007;122:160–166.
2. Razavi SM, Ibrahimpoor M, Sabouri Kashani A, Jafarian A. Abdominal surgical site infections: incidence and risk factors at an Iranian teaching hospital. BMC Surgery. 2005;5:2
3.  Walraven C, Musselman R (2013) The Surgical Site Infection Risk Score (SSIRS): A Model to Predict the Risk of Surgical Site Infections. PLOS ONE 8(6): e67167.
4. Reichman DE, Greenberg JA. Reducing Surgical Site Infections: A Review. Rev Obstet and Gynecol. 2009;2(4):212-221.
5.  Lissovoy G, Fraeman K, Hutchins V, Murphy D, Song D, Vaugn BB. Surgical site infection: incidence and impact on hospital utilization and treatment costs. Am J Infect Control. 2009 Jun;37(5):387-397.

In July 2018, the American Society of Regional Anesthesia and Pain Medicine (ASRA), American Academy of Pain Medicine (AAPM), and American Society of Anesthesiologists (ASA) released the groundbreaking consensus guidelines for the use of IV ketamine in acute pain cases. Ketamine is an NDMA receptor antagonist that has a strong anesthetic effect. In 1970, it was approved for use in humans in the United States. Since then, it has been utilized in operating rooms for both adult and children, as well as battlefields. It has gained prominence in medical literature over time as clinicians have explored its use for a variety of conditions such as treatment-resistant major depressive disorder (MDD), mood disorders, and post-traumatic stress disorder (PTSD). Evidence suggests that in small doses, ketamine can improve the symptoms of patients suffering from depressive disorders by affecting the glutamate neurotransmitter system.

Anesthesiologists, certified registered nurse anesthetists (CRNAs), and pain clinicians across the United States have increasingly started to administer ketamine to patients with acute and chronic pain. Given its safety, efficacy, and limited side effect profile, ketamine can serve as an effective drug for pain management.

Several major professional societies in the United States jointly developed guidelines for administering ketamine. In the guidelines published by the Regional Anesthesia and Pain Medicine journal, physician investigators outlined acceptable uses for IV ketamine. A group of patients undergoing invasive surgery might have an expected high level of pain post-operatively; according to the authors, they are good candidates for ketamine. In addition, the authors recommended that physicians consider patients who have tolerance or sensitivity/dependence to opioids as candidates for IV ketamine. The authors also identified several specific patient subgroups that could benefit from ketamine. These include patients with sickle cell disease, obstructive sleep apnea, and those with the potential for opioid-related respiratory depression. For each segment, the guidelines recommend specific dosing protocols.

Anesthesia providers should consider incorporating IV ketamine into their current practice based on the recommended indications.

As technological advances ensue in the medical field, medical specialists continue to improve upon historical processes for delivering healthcare. For anesthesiologists, issues around access and delivery of essential medications are critical to the discussion of innovation. In many medical centers across the nation, the vial-and-syringe technique is predominant in the operating room. In this method, anesthesiologists or clinically-trained Certified Registered Nurse Anesthetists (CRNAs) carefully transfer the assigned and coded medications from the vial, or a large quantity manufacturer container, to the syringe, a small unit of medication that is then administered directly to the patient. However, inherent in this process is a degree of waste. Along with medical waste, there is also an economic impact to the system. Underscoring each of these items is an effect on resource utilization at the hospital level, elucidating the argument for anesthesia professionals to transition from a vial to a pre-filled syringes system of care delivery.

To commence, the historical utilization of vials over syringes results in direct medical waste, impacting the patient, practitioner, and hospital. Upon transferring the medication from the vial to the syringe, often the entire quantity of medication in the vial does not divide evenly among the syringe. Thus, for each vial that is transferred to one or multiple syringes, a small amount of the medication is then left in the vial and disposed as biomedical waste. Medical waste impacts the patient because it requires a greater number of vials for the same net value of medication, resulting in a higher ratio of medical waste to patient. For the practitioner, the use of vials to syringes also has an effect on time. The anesthesiologist must include the conversion as an item on his or her roster of tasks, while the CRNA, nurses, or related operative staff must also ensure this is completed as a line item. Of course, the medical waste to the system is important to note because it reduces the level of efficacy and operative excellence. Rather than the vial-to-syringe method, pre-filled syringes would mitigate the level of waste by promoting a quantity-limited, separate amount of medication per patient and per procedure — allowing anesthesia management to streamline operative processes.

In addition to the operative benefits of reducing medical waste, there is also a strong cost consideration for adhering to pre-filled syringes. This cost impact may be viewed in terms of direct cost, or the dollars allocated to the drug itself, along with the indirect cost, or the number of allocated hours that clinicians devote to preparing medications. Numerous studies have indicated that pre-filled vials reduce the amount of preparation time per vial, while also minimizing the error impact during surgery.

Patient safety is also a strong concern, particularly in critical surgical cases that anesthesia providers may encounter. A study from the Journal of Patient Safety found that pre-filled syringes reduces patient risk, including that of dosage errors and contamination, and it also resulted in a reduction of healthcare practitioner errors, such as needle stick injury. Based on this seminal study, additional case reports, and institution cost-analyses, experts agree that pre-filled syringes are necessary to continue advancing patient care and safety from anesthesiologists and CRNAs perspective.

Moving forward, anesthesiologists, CRNAs, and other anesthesia care professionals should strongly consider pre-filled syringes as a technique to optimize care for all patients across institutions and centers of care.

Anesthesiologists and Certified Registered Nurse Anesthetists (CRNAs) are important contributors to success in the operating room (OR). However, novel changes in healthcare delivery in the United States are modifying the ways in which anesthesia professionals contribute to the operating room team. As a result of an increased emphasis on surgical outcomes, medical management experts recommend several team training intervention programs to increase efficiency and quality of care in the O.R. Across the literature, team training interventions in the OR are implemented via impactful changes in the practices of information technology systems and non-technical skills acquisition. The following article will describe recent developments in these arenas, while suggesting the path forward in reference to the role of anesthesia professionals.

Anesthesia Information Management Systems (AIMS) are a specialized form of technology that allow anesthesiologists and CRNAs to track, monitor, and gauge the administration of and effect from anesthesia throughout the perioperative cycle. The most typical form of AIMS is a software or hardware addition to the normal electronic medical records (EMR) system. AIMS can integrate information from multiple streams, led by the anesthesiologist, at multiple time points throughout the operative journey. Moreover, during surgery, most sophisticated AIMS can adapt to real-time changes in order to allow the anesthesiologist and surgeon to focus less on vital signs and more on the patient, allowing for greater capacity for decision-making. AIMS also formulate intensely accurate records of administered medications throughout the surgery, which is useful for post-operative billing, inventory, and reimbursement processes. In this way, AIMS increases the availability of historical records for surgeries, both fulfilling insurance reimbursement requirements and post-operative recovery. Changes with AIMS have sought to integrate the technologies as a team training intervention. A recently published study examined the impact of linking AIMS with the operating room data management system. The authors found that when access to AIMS data was increased, non-anesthesia medical professionals in the OR also increased the utilization and accuracy of the anesthesia data. In addition, the intersection of AIMS and operating room data management systems allow practitioners to refer back to focused data, aiding in the realms of retrospective and clinical research.

Team training interventions can also take the form of non-technical skills acquisition. In 2017, the Journal of Patient Safety published a paper which explored the effects of a brief team training intervention on the care teams’ observed NOTSS score, or nontechnical skills in surgery score. The researchers sought to find a potential solution to address the statistic that nearly 60% of adverse events that occur during surgery are the result of less than optimal teamwork and communication. So, the researchers devised an intervention. The study was designed as a pre-test, post-test interrupted time series design that had repeated measures analysis to evaluate presence and strength of longitudinal changes in surgical team members’ NOTSS score. The intervention was executed in a large tertiary hospital with over twenty operating rooms to attain a strong statistical power. The team training program involved a narrative training DVD with live follow-up. In the end, the researchers found a strong post-test rise in NOTSS score among intervention recipients, increasing confidence in the team training intervention program. Future studies will validate the use of this specific form of team training, while recognizing the context for different anesthesia and surgical professionals.

Anesthesiologists and CRNAs have a vital role to play in the evolution of surgical teams in the OR. As cornerstones of the surgical experience, anesthesia practitioners are valuable candidates for leadership in terms of patient advocacy alongside intra-practitioner communication and unity. As research into optimal ways to improve operational excellence in the OR continues, anesthesia management companies, anesthesiologists, and CRNAs can emerge as leaders in the journey for excellence and accurate patient care.

Sources

1. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3387486/
2. https://www.ncbi.nlm.nih.gov/pubmed/29596094
3. https://journals.lww.com/journalpatientsafety/Abstract/publishahead/Effects_of_a_Brief_Team_Training_Program_on.99504.aspx