Safety and Quality in Anesthesia: Are We There Yet?

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  • Methangkool, Emily, MD
| Nov 06, 2015

methangkoolThe spotlight never strayed far from patient safety at ANESTHESIOLOGY 2015 in San Diego.

debatersRobert Lagasse, MD, of Yale University, and Richard Dutton, MD, MBA, former Executive Director of the ASA’s Anesthesia Quality Institute, sparred in a vigorous point-counterpoint debate, “Anesthesia Safety – Are We Really Getting Better?” They took opposite sides on the question of whether anesthesia safety has really improved over the last 20 to 30 years.

Dr. Lagasse is the Director of Quality Improvement and Perioperative Safety in Yale’s Department of Anesthesiology, and has written numerous articles on anesthesia safety. Dr. Dutton joined US Anesthesia Partners, Inc., in August as the new Chief Quality Officer of the Ft. Lauderdale-based physician services organization.

Have new technologies improved outcomes?

While new technologies, such as pulse oximetry, have undoubtedly improved our ability to monitor patients during and after anesthesia care, it is unclear whether their use has translated into reduced patient morbidity and mortality.

Dr. Dutton presented data supporting the case that anesthesia safety has improved. A retrospective study just published in Anesthesiology in October, looking at more than 2,900,000 cases reported in the National Anesthesia Clinical Outcomes Registry (NACOR), found that the mortality rate within 48 hours of anesthesia induction was only 33 in 100,000. Lee-lynn Chen, MD, CSA’s Director of District 6, was one of the co-authors of the study. But Dr. Dutton noted that improved anesthesia safety has encouraged the performance of higher risk, more complex cases.

In Dr. Lagasse’s opinion, morbidity and mortality rates in anesthesia practice have not changed since his 2002 paper in Anesthesiology, “Anesthesia Safety: Model or Myth?” He noted that numerous papers that have been published in the past 10 to 15 years claimed to demonstrate decreased perianesthetic mortality. But when their results were reanalyzed using Dr. Lagasse’s definitions from 2002, he said, they showed similar mortality rates.

While the debate concluded in a draw, audience members were encouraged to think critically about the true safety of anesthetic practices.

Controversies in central line insertion

Anesthetic risk extends not just to mortality, but to complications as well. Avery Tung, MD, Professor and Quality Chief at the University of Chicago’s Department of Anesthesia & Critical Care, presented an exciting talk entitled “Controversies and Best Practices in Central Line Insertion.”

tungGiven that physician anesthesiologists are the most likely to insert central lines in a hospital system (with interventional radiologists and cardiologists probably not far behind), central line complications can represent a significant proportion of anesthesia complications, Dr. Tung said. While the incidence of central line complications has decreased, in part due to fewer central line-associated bloodstream infections and increased use of ultrasound technology, complications may still occur.

In an exhaustive literature review, Dr. Tung presented risk factors for central line complications, including increased number of passes, inexperience, prior unsuccessful attempts, femoral or left internal jugular placement, and low or high patient body mass index.

Patients with accidental carotid line placements who underwent prompt surgical repair generally did not experience any complications, Dr. Tung said, while those whose lines were pulled immediately by the anesthesia team were more likely to develop stroke, hematoma, pneumothorax, or other untoward events. However, if a guide wire is placed accidentally in the carotid artery, he said, whether or not you should pull it out at once is a good question and lies in the “gray zone.” If line insertion was uncomplicated, then pulling the guide wire out and holding pressure “would be OK.”

In addition to carotid puncture, Dr. Tung explained, cardiac tamponade is also a feared complication of central line insertion. Placing the line high in the SVC, while increasing the incidence of thrombosis, could potentially decrease the risk of tamponade, he said.

With increasing national scrutiny on patient safety, the ASA continues to be at the forefront of promoting quality improvement. This endeavor will continue on November 21 to 22, at the ASA’s upcoming Quality Meeting at the Loews Chicago O’Hare Hotel in Rosemont, Illinois, where attendees will hear more about innovations and ideas for systems improvements.

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