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Background: The health care systems of low-income countries have severely limited capacity to treat surgical diseases and conditions. There is limited information about which hospital mortality outcomes are suitable metrics in these settings., Methods: We did a 1-year observational cohort study of patient admissions to the Surgery and the Obstetrics and Gynecology departments and of newborns delivered at a Ugandan secondary referral hospital. We examined the proportion of deaths captured by standardized metrics of mortality., Results: There were 17,015 admissions and 9612 deliveries. A total of 847 deaths were documented: 385 (45.5%) admission deaths and 462 (54.5%) perinatal deaths. Less than one-third of admission deaths occurred during or after an operation (n = 126/385, 32.7%). Trauma and maternal mortality combined with perioperative mortality produced 79.2% (n = 305/385) of admission deaths. Of 462 perinatal deaths, 412 (90.1%) were stillborn, and 50 (10.9%) were early neonatal deaths. The combined metrics of the trauma mortality rate, maternal mortality ratio, thirty-day perioperative mortality rate, and perinatal mortality rate captured 89.8% (n = 761/847) of all deaths documented at the hospital., Conclusions: The combination of perinatal, maternal, trauma, and perioperative mortality metrics captured most deaths documented at a Ugandan referral hospital., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2021 International Anesthesia Research Society.)

Background: Recently, a very low incidence of 3 per 10,000 and a mortality of 30% were reported for pediatric perioperative cardiac arrest (POCA). However, high-risk patients, namely children already anesthetized on the intensive care unit (ICU), were excluded. This study investigates the incidence and mortality of POCA in children in whom anesthesia was induced in the ICU or in the operating room using real-world data. In addition, different classifications of POCA were compared with respect to outcome relevance., Methods: This is a retrospective observational study conducted at a German level 1 perinatal center and tertiary care hospital between 2008 and 2018. Children ≤15 years who underwent an anesthetic procedure and suffered from POCA (defined as any condition requiring chest compressions and/or defibrillation) from the beginning of care provided by an anesthesiologist to 60 minutes after anesthesia or sedation were included. Primary end points were incidence and mortality of POCA in children with anesthesia induced in the ICU versus in the operating room. Secondary end points included incidences and outcomes with respect to the pathophysiological cause (respiratory versus circulatory associated)., Results: There were 18 POCA during 22,650 anesthetic procedures (incidence 7.9 per 10,000; 95% confidence interval [CI], 4.7-12.5). Thirty-day mortality was 3.5 per 10,000 (95% CI, 1.5-6.9). Incidence and mortality were higher in children in whom anesthesia was induced in the ICU versus in the operating room (incidence: 131.6; 95% CI, 57 to 257.6 versus 4.5; 95% CI, 2.2-8.3; P < .001; and mortality: 82.2; 95% CI, 26.7-190.8 versus 1.4; 95% CI, 0.3-3.9; P < .001). Mortality in circulatory-induced POCA (n = 8; 44%) was 100%, in respiratory-induced POCA (n = 9; 50%) 0% (P < .001)., Conclusions: Children with anesthesia induction in the ICU represent a high-risk population for POCA and POCA-associated mortality. POCA classification should be based on the individual cause (respiratory versus circulatory) rather than on the perioperative phase or the responsible specialty., Competing Interests: Conflicts of Interest: See Disclosures at the end of the article., (Copyright © 2021 International Anesthesia Research Society.)

Background: The introduction of electronic health records (EHRs) has helped physicians access relevant medical information on their patients. However, the design of EHRs can make it hard for clinicians to easily find, review, and document all of the relevant data, leading to documentation that is not fully reflective of the complete history. We hypothesized that the incidence of undocumented key comorbid diseases (atrial fibrillation [afib], congestive heart failure [CHF], chronic obstructive pulmonary disease [COPD], diabetes, and chronic kidney disease [CKD]) in the anesthesia preoperative evaluation was associated with increased postoperative length of stay (LOS) and mortality., Methods: Charts of patients >18 years who received anesthesia in an inpatient facility were reviewed in this retrospective study. For each disease, a precise algorithm was developed to look for key structured data (medications, lab results, structured medical history, etc) in the EHR. Additionally, the checkboxes from the anesthesia preoperative evaluation were queried to determine the presence or absence of the documentation of the disease. Differences in mortality were modeled with logistic regression, and LOS was analyzed using linear regression., Results: A total of 91,011 cases met inclusion criteria (age 18-89 years; 52% women, 48% men; 70% admitted from home). Agreement between the algorithms and the preoperative note was >84% for all comorbidities other than chronic pain (63.5%). The algorithm-detected disease not documented by the anesthesia team in 34.5% of cases for chronic pain (vs 1.9% of cases where chronic pain was documented but not detected by the algorithm), 4.0% of cases for diabetes (vs 2.1%), 4.3% of cases for CHF (vs 0.7%), 4.3% of cases for COPD (vs 1.1%), 7.7% of cases for afib (vs 0.3%), and 10.8% of cases for CKD (vs 1.7%). To assess the association of missed documentation with outcomes, we compared patients where the disease was detected by the algorithm but not documented (A+/P-) with patients where the disease was documented (A+/P+). For all diseases except chronic pain, the missed documentation was associated with a longer LOS. For mortality, the discrepancy was associated with increased mortality for afib, while the differences were insignificant for the other diseases. For each missed disease, the odds of mortality increased 1.52 (95% confidence interval [CI], 1.42-1.63) and the LOS increased by approximately 11%, geometric mean ratio of 1.11 (95% CI, 1.10-1.12)., Conclusions: Anesthesia preoperative evaluations not infrequently fail to document disease for which there is evidence of disease in the EHR data. This missed documentation is associated with an increased LOS and mortality in perioperative patients., Competing Interests: Conflicts of Interest: See Disclosures at the end of the article., (Copyright © 2021 International Anesthesia Research Society.)

Background: The analysis of adverse events, including morbidity and mortality (M&M), helps to identify subgroups of children at risk and to modify clinical practice. There are scant data available from low- and middle-income countries. Our aim was to estimate the proportion of pediatric patients with various severe adverse events in the perioperative period extending to 48 hours and to describe the clinical situations and causes of those events., Methods: We reviewed the M&M database of the Department of Anesthesiology between 1992 and 2016. A data collection tool was developed, and the outcomes were standardized. Each case was reviewed independently and subsequently discussed between 2 reviewers to identify a major primary causative factor., Results: The total number of pediatric cases during this period was 48,828. Seventy-six significant adverse events were identified in 39 patients (8 patients [95% confidence interval {CI}, 5.7-10.9] per 10,000). Thirteen patients had multisystem involvement, and hence the total number of events exceeded the number of patients. Respiratory events were the most common (33.5%). Thirteen patients had perioperative cardiac arrest within 48 hours of surgery (2.6 [95% CI, 1.3-4.3] per 10,000), 7 of these were infants (54%), 5 of whom had congenital heart disease (CHD). Eleven of these 39 patients died within 48 hours (2.0 [95% CI, 1.1-4.0] per 10,000).In 13 cases, anesthesia was assessed to be the predominant cause of morbidity (2.6 per 10,000), whereas in 26 cases, it contributed partially (5.32 per 10,000). There was only 1 death solely related to anesthesia (0.2 per 10,000), and this death occurred before the start of surgery., Conclusions: Adverse events were uncommon. Respiratory complications were the most frequent (33%). Infants, especially those with CHD, were identified as at a higher risk for perioperative cardiac arrest, but this association was not tested statistically. Twenty-eight percent of the patients who suffered events died within 48 hours. Increased access to anesthesia drugs and practice improvements resulted in a decline in perioperative cardiac arrests.

Purpose of Review: The prevalence of procedures performed outside of the operating room is steadily growing around the world, especially in the United States. This review aims to discuss the risks and safety of anesthesia performed in remote locations based on an up-to-date literature review, with a focus on the results from closed claims and other database analyses., Recent Findings: The published literature in the last decade shows that there is an increase in nonoperating room anesthesia cases and that the highest number of these cases are in gastroenterology endoscopy suites. There are safety concerns in nonoperating room cases that involve both anesthesia and nonanesthesia providers. Specific complications found in closed claims analyses include airway compromise, aspiration pneumonia, and dental injuries., Summary: The current literature demonstrates that procedures performed in the endoscopy suite make up the largest number of nonoperating room closed claims anesthesia cases. Oversedation and subsequent inadequate oxygenation/ventilation account for the majority of malpractice claims. Conclusions from the current literature emphasize the importance of complying with monitoring standards and having well prepared providers to improve patient outcomes in nonoperating room locations.

Background: Previous meta-analyses assessing anesthetic techniques in adult patients undergoing hip fractures surgery are available. However, whether the anesthetic technique is associated with risk of mortality and complications in geriatric patients with hip fractures remains unclear. This study was conducted to assess postoperative outcomes of anesthesia technique in geriatric patients undergoing hip fracture surgery., Methods: Cochrane Library, PubMed, EMBASE, MEDLINE, CNKI, and CBM were searched from inception up to May 25, 2018. Observational studies and randomized controlled trials (RCTs) that assessed the perioperative outcomes of technique of anesthesia (general or regional [epidural/spinal/neuraxial]) in geriatric patients (≥60 years old) undergoing hip fracture surgery were included. Two investigators independently screened studies for inclusion and performed data extraction. Heterogeneity was assessed by the I and Chi-square tests. The odds ratio (OR) of the dichotomous data, mean difference (MD) of continuous data, and 95% confidence intervals (CI) were calculated to assess the pooled data., Results: Eleven retrospective and 2 RCTs were included. There was no difference in 30-day mortality (OR = 0.96; 95% CI 0.86-1.08; P = .51) between the general and regional anesthesia groups. In-hospital mortality (OR = 1.26; 95% CI 1.17-1.36; P < .001), acute respiratory failure (OR = 2.66; 95% CI 2.34-3.02; P < .001), length of hospital stay (MD = 0.33; 95% CI 0.24-0.42; P < .001), and readmission (OR = 1.09; 95% CI 1.01-1.18; P = .03) were significantly reduced in the regional anesthesia group. Pneumonia (OR = 0.99; 95% CI 0.91-1.07; P = .79), heart failure (OR = 0.97; 95% CI 0.86-1.09; P = .62), acute myocardial infraction (OR = 1.07; 95% CI 0.99-1.16; P = .10), acute renal failure (OR = 1.32; 95% CI 0.97-1.79; P = .07), cerebrovascular accident (OR = 1.08; 95% CI 0.82-1.42; P = .58), postoperative delirium (OR = 1.51; 95% CI 0.16-13.97; P = .72), and deep vein thrombosis/pulmonary embolism (OR = 1.42; 95% CI 0.84-2.38; P = .19) were similar between the two anesthetic techniques., Conclusion: General anesthesia is associated with increased risk of in-hospital mortality, acute respiratory failure, longer hospital stays, and higher readmission. There is evidence to suggest that regional anesthesia is associated with improved perioperative outcomes. Large RCTs are needed to explore the most optimal anesthetic techniques for geriatric patients with hip fractures before drawing final conclusions., Prospero Registration Number: CRD42018093582.

Quality has been defined by six domains: effective, equitable, timely, efficient, safe, and patient centered. Quality of anesthesia care can be improved through measurement, either through local measures in quality improvement or through national measures in value-based purchasing programs. Death directly related to anesthesia care has been reduced, but must be measured beyond simple mortality. To improve perioperative care for our patients, we must take shared accountability for all surgical outcomes including complications, which has traditionally been viewed as being surgically related. Anesthesiologists can also impact public health by being engaged in improving cognitive recovery after surgery and addressing the opiate crisis. Going forward, we must focus on what patients want and deserve: improved patient-oriented outcomes and satisfaction with our care. By listening to our patients and being engaged in the entire perioperative process, we can make the greatest impact on perioperative care.

Background: Perioperative anemia is challenging during hospital stay because anemia and red blood cell (RBC) transfusions are associated with an increased morbidity and mortality. With the implementation of patient blood management (PBM), a preanesthesia assessment clinic to screen and treat anemia before elective surgery was institutionalized at Muenster University Hospital, Germany. The main objective of this study was to evaluate the association between treating preoperative anemic patients with intravenous iron (IVI) and (primarily) presurgical hemoglobin levels and (secondarily) use of RBCs and mortality., Methods: Between April 1, 2014, and July 4, 2016, patients scheduled for elective surgery with a risk for RBC transfusions >10% in 2013 were screened for preoperative anemia and, if indicated, treated with IVI. Patients' data, time span between visit in the anesthesia/PBM clinic and surgery, demographic data, type of surgery, the difference of hemoglobin levels between visit and surgery, RBC transfusion, infectious-related International Classification of Disease codes during hospital stay, and 1-year survival were determined retrospectively by screening electronic data files. In addition, patients were interviewed about adverse events, health-related events, and infections via telephone 30, 90, and 365 days after visiting the anesthesia/PBM clinic., Results: A total of 1101 patients were seen in the anesthesia/PBM clinic between days -28 and -1 (median [Q1-Q3], -3 days [-1, -9 days]) before elective surgery. Approximately 29% of patients presented with anemia, 46.8% of these anemic patients were treated with ferric carboxymaltose (500-1000 mg).In the primary analysis, hemoglobin levels at median were associated with a reduction between the visit in the anesthesia/PBM clinic and the surgery in all nonanemic patients on beginning of medical treatment (nonanemic patients at median -2.8 g/dL [-4, -0.9 g/dL], while anemic patients without IVI presented with median differences of -0.8 g/dL [-2, 0 g/dL] and anemic patients with IVI of 0 g/dL [-1.0, 0.5 g/dL]). Hemoglobin levels raised best at substitution 22-28 days before surgery (0.95 g/dL [-0.35, 1.18 g/dL]). Due to the selection criteria, transfusion rates were high in the cohort. Overall, there was no association between IVI treatment and the use of RBC transfusions (odds ratio for use of RBCs in anemic patients, no IVI versus IVI: 1.14; 95% confidence interval, 0.72-1.82). Patients treated with or without IVI presented a comparable range of International Classification of Disease codes related to infections. Telephone interviews indicated similar adverse events, health-related events, and infections. Cox regression analysis showed an association between anemia and reduced survival, regardless of IVI., Conclusions: An anemia clinic within the preanesthesia assessment clinic is a feasible and effective approach to treat preoperative anemia. The IVI supplementation was safe but was associated with decreased RBC transfusions in gynecology/obstetric patients only. The conclusions from this retrospective analysis have to be tested in prospective, controlled trials.

Background: Perianesthetic mortality (death occurring within 48 hours of an anesthetic) continues to vary widely depending on the study population examined. The authors study in a private practice physician group that covers multiple anesthetizing locations in the Southeastern United States. This group has in place a robust quality assurance (QA) database to follow all patients undergoing anesthesia. With this study, we estimate the incidence of anesthesia-related and perianesthetic mortality in this QA database., Methods: Following institutional review board approval, data from 2011 to 2016 were obtained from the QA database of a large, community-based anesthesiology group practice. The physician practice covers 233 anesthetizing locations across 20 facilities in 2 US states. All detected cases of perianesthetic death were extracted from the database and compared to the patients' electronic medical record. These cases were further examined by a committee of 3 anesthesiologists to determine whether the death was anesthesia related (a perioperative death solely attributable to either the anesthesia provider or anesthetic technique), anesthetic contributory (a perioperative death in which anesthesia role could not be entirely excluded), or not due to anesthesia., Results: A total of 785,467 anesthesia procedures were examined from the study period. A total of 592 cases of perianesthetic deaths were detected, giving an overall death rate of 75.37 in 100,000 cases (95% CI, 69.5-81.7). Mortality judged to be anesthesia related was found in 4 cases, giving a mortality rate of 0.509 in 100,000 (95% CI, 0.198-1.31). Mortality judged to be anesthesia contributory were found in 18 cases, giving a mortality of 2.29 in 100,000 patients (95% CI, 1.45-3.7). A total of 570 cases were judged to be nonanesthesia related, giving an incidence of 72.6 per 100,000 anesthetics (95% CI, 69.3-75.7)., Conclusions: In a large, comprehensive database representing the full range of anesthesia practices and locations in the Southeastern United States, the rate of perianesthestic death was 0.509 in 100,000 (95% CI, 0.198-1.31). Future in-depth analysis of the epidemiology of perianesthetic deaths will be reported in later studies.

Progress in achieving "universal access to safe, affordable surgery, and anesthesia care when needed" is dependent on consensus not only about the key messages but also on what metrics should be used to set goals and measure progress. The Lancet Commission on Global Surgery not only achieved consensus on key messages but also recommended 6 key metrics to inform national surgical plans and monitor scale-up toward 2030. These metrics measure access to surgery, as well as its timeliness, safety, and affordability: (1) Two-hour access to the 3 Bellwether procedures (cesarean delivery, emergency laparotomy, and management of an open fracture); (2) Surgeon, Anesthetist, and Obstetrician workforce >20/100,000; (3) Surgical volume of 5000 procedures/100,000; (4) Reporting of perioperative mortality rate; and (5 and 6) Risk rates of catastrophic expenditure and impoverishment when requiring surgery. This article discusses the definition, validity, feasibility, relevance, and progress with each of these metrics. The authors share their experience of introducing the metrics in the Pacific and sub-Saharan Africa. We identify appropriate messages for each potential stakeholder-the patients, practitioners, providers (health services and hospitals), public (community), politicians, policymakers, and payers. We discuss progress toward the metrics being included in core indicator lists by the World Health Organization and the World Bank and how they have been, or may be, used to inform National Surgical Plans in low- and middle-income countries to scale-up the delivery of safe, affordable, and timely surgical and anesthesia care to all who need it.

This retrospective case series analyzed 45 malpractice claims for delayed detection of esophageal intubation from the Anesthesia Closed Claims Project. Inclusion criteria were cases from 1995 to 2013, after adoption of identification of CO2 in expired gas to verify correct endotracheal tube position as a monitoring standard by the American Society of Anesthesiologists. Forty-nine percent (95% confidence interval 34%-64%) occurred in the operating room or other anesthesia location where CO2 detection equipment should have been available. The most common factors contributing to delayed detection were not using, ignoring, or misinterpreting CO2 readings. Misdiagnosis, as with bronchospasm, occurred in 33% (95% confidence interval 20%).

Background: Perioperative mortality rate is regarded as a credible quality and safety indicator of perioperative care, but its documentation in low- and middle-income countries is poor. We developed and tested an electronic, provider report-driven method in an East African country., Methods: We deployed a data collection tool in a Kenyan tertiary referral hospital that collects case-specific perioperative data, with asynchronous automatic transmission to central servers. Cases not captured by the tool (nonobserved) were collected manually for the last two quarters of the data collection period. We created logistic regression models to analyze the impact of procedure type on mortality., Results: Between January 2014 and September 2015, 8,419 cases out of 11,875 were captured. Quarterly data capture rates ranged from 423 (26%) to 1,663 (93%) in the last quarter. There were 93 deaths (1.53%) reported at 7 days. Compared with four deaths (0.53%) in cesarean delivery, general surgery (n = 42 [3.65%]; odds ratio = 15.80 [95% CI, 5.20 to 48.10]; P < 0.001), neurosurgery (n = 19 [2.41%]; odds ratio = 14.08 [95% CI, 4.12 to 48.10]; P < 0.001), and emergency surgery (n = 25 [3.63%]; odds ratio = 4.40 [95% CI, 2.46 to 7.86]; P < 0.001) carried higher risks of mortality. The nonobserved group did not differ from electronically captured cases in 7-day mortality (n = 1 [0.23%] vs. n = 16 [0.58%]; odds ratio =3.95 [95% CI, 0.41 to 38.20]; P = 0.24)., Conclusions: We created a simple solution for high-volume, prospective electronic collection of perioperative data in a lower- to middle-income setting. We successfully used the tool to collect a large repository of cases from a single center in Kenya and observed mortality rate differences between surgery types.

Background: Situational awareness errors may play an important role in the genesis of patient harm. The authors examined closed anesthesia malpractice claims for death or brain damage to determine the frequency and type of situational awareness errors., Methods: Surgical and procedural anesthesia death and brain damage claims in the Anesthesia Closed Claims Project database were analyzed. Situational awareness error was defined as failure to perceive relevant clinical information, failure to comprehend the meaning of available information, or failure to project, anticipate, or plan. Patient and case characteristics, primary damaging events, and anesthesia payments in claims with situational awareness errors were compared to other death and brain damage claims from 2002 to 2013., Results: Anesthesiologist situational awareness errors contributed to death or brain damage in 198 of 266 claims (74%). Respiratory system damaging events were more common in claims with situational awareness errors (56%) than other claims (21%, P < 0.001). The most common specific respiratory events in error claims were inadequate oxygenation or ventilation (24%), difficult intubation (11%), and aspiration (10%). Payments were made in 85% of situational awareness error claims compared to 46% in other claims (P = 0.001), with no significant difference in payment size. Among 198 claims with anesthesia situational awareness error, perception errors were most common (42%), whereas comprehension errors (29%) and projection errors (29%) were relatively less common., Conclusions: Situational awareness error definitions were operationalized for reliable application to real-world anesthesia cases. Situational awareness errors may have contributed to catastrophic outcomes in three quarters of recent anesthesia malpractice claims.Situational awareness errors resulting in death or brain damage remain prevalent causes of malpractice claims in the 21st century.

Purpose of Review: Ensuring the quality and safety of anaesthesia in the face of budgetary restrictions and changing demographics is challenging. In France, the environment is regulated by the legislation, and it is often necessary to find solutions that seize opportunities to break with the traditional organization., Recent Findings: Postoperative mortality remains excessively high. The move towards ambulatory care is being adequately integrated into all the stages of patient management in the context of a single therapeutic plan that is mutually agreed upon by all caregivers. The French National Health Authority, which provides certification for healthcare establishments, encourages this 'seamless' approach between private practice and the hospital setting, based on teamwork and interdisciplinary consultation. By daring to break with traditional organizational structures, and by taking account of human factors and staged strategies, it is possible to deliver appropriate care, with a level of quality and safety that meets users' demands., Summary: The management of a patient undergoing surgery with anaesthesia is a seamless spectrum from the patient's home to the hospital and back to home. Decision-making must be multidisciplinary. Increased use of ambulatory care, breaks with traditional organizational structures, and efforts to reduce postoperative mortality represents opportunities to improve overall system performance. Demographic and economic constraints are potential threats to be identified.

Background: Anesthesia in West Africa is associated with high mortality rates. Critical shortages of adequately trained personnel, unreliable electrical supply, and lack of basic monitoring equipment are a few of the unique challenges to surgical care in this region. This study aims to describe the anesthesia practice at 2 tertiary care hospitals in Sierra Leone., Methods: We conducted an observational study of anesthesia care at Connaught Hospital and Princess Christian Maternity Hospital in Freetown, Sierra Leone. Twenty-five percent of the anesthesia workforce in Sierra Leone, resident at both hospitals, was observed from June 2012 to February 2013. Perioperative assessments, anesthetic techniques, and intraoperative clinical and environmental irregularities were noted and analyzed. The postoperative status of observed cases was ascertained for morbidity and mortality., Results: Between the 2 hospitals, 754 anesthesia cases and 373 general anesthetics were observed. Ketamine was the predominant IV anesthetic used. Both hospitals experienced infrastructural and environmental constraints to the delivery of anesthesia care during the observation period. Vital sign monitoring was irregular and dependent on age and availability of monitors. Perioperative mortality during the course of the study was 11.9 deaths/1000 anesthetics., Conclusions: We identified gaps in the application of internationally recommended anesthesia practices at both hospitals, likely caused by lack of available resources. Mortality rates were similar to those in other resource-limited countries.

Abusive head trauma (AHT) is the most common cause of severe traumatic brain injury (TBI) in infants and the leading cause of child abuse-related deaths. For reasons that remain unclear, mortality rates after moderate AHT rival those of severe nonintentional TBI. The vulnerability of the developing brain to injury may be partially responsible for the poor outcomes observed after AHT. AHT is mechanistically more complex than nonintentional TBI. The acute-on-chronic nature of the trauma along with synergistic injury mechanisms that include rapid rotation of the brain, diffuse axonal injury, blunt force trauma, and hypoxia-ischemia make AHT challenging to treat. The anesthesiologist must understand the complex injury mechanisms inherent to AHT, as well as the pediatric TBI treatment guidelines, to decrease the risk of persistent neurologic disability and death. In this review, we discuss the epidemiology of AHT, differences between AHT and nonintentional TBI, the severe pediatric TBI treatment guidelines in the context of AHT, anesthetic considerations, and ethical and legal reporting requirements.

Background: Poliomyelitis is a viral infectious disease caused by 1 of the 3 strains of poliovirus. The World Health Organization launched an eradication campaign in 1988. Although the number of cases of poliomyelitis has drastically declined, eradication has not yet been achieved, and there are a substantial number of survivors of the disease. Survivors of poliomyelitis present a unique set of challenges to the anesthesiologist. The scientific literature regarding the anesthetic management of survivors of poliomyelitis, however, is limited and primarily experiential in nature. Using a retrospective, matched cohort study, we sought to more precisely characterize the anesthetic implications of poliomyelitis and to determine what risks, if any, may be present for patients with a history of the disease., Methods: Using the Mayo Clinic Life Sciences System Data Discovery and Query Builder, study subjects were identified as those with a history of paralytic poliomyelitis who had undergone major surgery at Mayo Clinic Rochester between 2005 and 2009. For each case, 2 sex- and age-matched controls that underwent the same surgical procedure during the study period were randomly selected from a pool of possible controls. Medical records were manually interrogated with respect to demographic variables, comorbid conditions, operative and anesthetic course, and postoperative course., Results: We analyzed 100 cases with 2:1 matched controls and found that the peri- and postoperative courses were very similar for both groups of patients. Pain scores, postanesthesia care unit admission, length of postanesthesia care unit stay, intensive care unit admission, length of intensive care unit stay, and initial extubation location were not significantly different between the 2 groups. Looking at pulmonary complications in our primary outcome, there was no significant difference between the 2 groups (17% vs 14% for polio versus control, respectively; conditional logistic regression odds ratio = 1.5; 95% confidence interval, 0.7-3.3; P = 0.33). In addition, no difference was noted in those requiring a code or rapid response team intervention (4% vs 3% for polio versus control; P = 0.46) and the 30-day mortality rate was also not significantly different, with 2% of polio patients dying compared with 3% of controls (P = 0.79). The analysis of the primary outcome was repeated for the subset of patients with a history of poliomyelitis who had persistent neurologic deficits preoperatively (n = 36) and their matched controls (n = 72). In this subset analysis, there were 4 (11%) polio patients and 8 (11%) control patients who experienced pulmonary complications (conditional logistic regression odds ratio = 1.00; 95% confidence interval, 0.27-3.72; P = 1.00). The percentage of patients experiencing specific pulmonary complications of interest was similar between groups (postoperative mechanical ventilation: 6% vs 8% for polio and control patients, respectively; prolonged mechanical ventilation: 0% vs 1%; reintubation: 8% vs 4%; pulmonary infection: 6% vs 6%; and aspiration: 0% vs 1%)., Conclusions: This study suggests that patients with a history of poliomyelitis do not seem to have an increased risk of pulmonary complications in the perioperative period. However, an odds ratio as great as 3.3-fold may be present.

Background: In creating the Merit-Based Incentive Payment System, Congress has mandated pay-for-performance (P4P) for all physicians, including anesthesiologists. There are currently no National Quality Forum-endorsed risk-adjusted outcome metrics for anesthesiologists to use as the basis for P4P., Methods: Using clinical data from the New York State Cardiac Surgery Reporting System, we conducted a retrospective observational study of 55,436 patients undergoing cardiac surgery between 2009 and 2012. Hierarchical logistic regression modeling was used to examine the variation in in-hospital mortality or major complications (Q-wave myocardial infarction, renal failure, stroke, and respiratory failure) among anesthesiologists, controlling for patient demographics, severity of disease, comorbidities, and hospital quality., Results: Although the variation in performance among anesthesiologists was statistically significant (P = 0.025), none of the anesthesiologists in the sample was classified as a high- or low-performance outliers. The contribution of anesthesiologists to outcomes represented 0.51% of the overall variability in patient outcomes (intraclass correlation coefficient [ICC] = 0.0051; 95% confidence interval [CI], 0.002-0.014), whereas the contribution of hospitals to patient outcomes was 2.90% (ICC = 0.029; 95% CI, 0.017-0.050). The anesthesiologist median odds ratio (MOR) was 1.13 (95% CI, 1.08-1.24), suggesting that the variation between anesthesiologist was modest, whereas the hospital MOR was 1.35 (95% CI, 1.25-1.48). In a separate analysis, the contribution of surgeons to overall outcomes represented 1.76% of the overall variability in patient outcomes (ICC = 0.018, 95% CI, 0.010-0.031), and the surgeon MOR was 1.26 (95% CI, 1.19-1.37). Twelve of the surgeons were identified as performance outliers., Conclusions: The impact of anesthesiologists on the total variability in cardiac surgical outcomes was probably about one-fourth as large as the surgeons' contribution. None of the anesthesiologists caring for cardiac surgical patients in New York State over a 3+ year period were identified as performance outliers. The use of a performance metric based on death or major complications for P4P may not be feasible for cardiac anesthesiologists.

In 2006, a previous study at our institution reported high perioperative and anesthesia-related mortality rates of 21.97 and 1.12 per 10,000 anesthetics, respectively. Since then, changes in surgical practices may have decreased these rates. However, the actual perioperative and anesthesia-related mortality rates in Brazil remains unknown. The study aimed to reexamine perioperative and anesthesia-related mortality rates in one Brazilian tertiary teaching hospital.In this observational study, deaths occurring in the operation room and postanesthesia care unit between April 2005 and December 2012 were identified from an anesthesia database. The data included patient characteristics, surgical procedures, American Society of Anesthesiologists (ASA) physical status, and medical specialty teams, as well as the types of surgery and anesthesia. All deaths were reviewed and grouped by into 1 of 4 triggering factors groups: totally anesthesia-related, partially anesthesia-related, surgery-related, or disease/condition-related. The mortality rates are expressed per 10,000 anesthetics with 95% confidence intervals (CIs).A total of 55,002 anesthetics and 88 deaths were reviewed, representing an overall mortality rate of 16.0 per 10,000 anesthetics (95% CI: 13.0-19.7). There were no anesthesia-related deaths. The major causes of mortality were patient disease/condition-related (13.8, 95% CI: 10.7-16.9) followed by surgery-related (2.2, 95% CI: 1.0-3.4). The major risks of perioperative mortality were children younger than 1-year-old, older patients, patients with poor ASA physical status (III-V), emergency, cardiac or vascular surgeries, and multiple surgeries performed under the same anesthetic technique (P < 0.0001).There were no anesthesia-related deaths. However, the high mortality rate caused by the poor physical conditions of some patients suggests that primary prevention might be the key to reducing perioperative mortality. These findings demonstrate the need to improve medical perioperative practices for high-risk patients in under-resourced settings.

Background: The National Anesthesia Clinical Outcomes Registry collects demographic and outcome data from anesthesia cases, with the goal of improving safety and quality across the specialty. The authors present a preliminary analysis of the National Anesthesia Clinical Outcomes Registry database focusing on the rates of and associations with perioperative mortality (within 48 h of anesthesia induction)., Methods: The authors retrospectively analyzed 2,948,842 cases performed between January 1, 2010, and May 31, 2014. Cases without procedure information and vaginal deliveries were excluded. Mortality and other outcomes were reported by the anesthesia provider. Hierarchical logistic regression was performed on cases with complete information for patient age group, sex, American Society of Anesthesiologists physical status, emergency case status, time of day, and surgery type, controlling for random effects within anesthesia practices., Results: The final analysis included 2,866,141 cases and 944 deaths (crude mortality rate, 33 per 100,000). Increasing American Society of Anesthesiologists physical status, emergency case status, cases beginning between 4:00 PM and 6:59 AM, and patient age less than 1 yr or greater than or equal to 65 yr were independently associated with higher perioperative mortality. A post hoc subgroup analysis of 279,154 patients limited to 22 elective case types, post hoc models incorporating either more granular estimate of surgical risk or work relative value units, and a post hoc propensity score-matched cohort confirmed the association with time of day., Conclusions: Several factors were associated with increased perioperative mortality. A case start time after 4:00 PM was associated with an adjusted odds ratio of 1.64 (95% CI, 1.22 to 2.21) for perioperative death, which suggests a potentially modifiable target for perioperative risk reduction. Limitations of this study include nonstandardized mortality reporting and limited ability to adjust for missing data.

Background: One of every 150 hospitalized patients experiences a lethal adverse event; nearly half of these events involves surgical patients. Although variations in surgeon performance and quality have been reported in the literature, less is known about the influence of anesthesiologists on outcomes after major surgery. Our goal of this study was to determine whether there is significant variation in outcomes between anesthesiologists after controlling for patient case mix and hospital quality., Methods: Using clinical data from the New York State Cardiac Surgery Reporting System, we conducted a retrospective observational study of 7920 patients undergoing isolated coronary artery bypass graft surgery. Multivariable logistic regression modeling was used to examine the variation in death or major complications (Q-wave myocardial infarction, renal failure, stroke) across anesthesiologists, controlling for patient demographics, severity of disease, comorbidities, and hospital quality., Results: Anesthesiologist performance was quantified using fixed-effects modeling. The variability across anesthesiologists was highly significant (P < 0.001). Patients managed by low-performance anesthesiologists (corresponding to the 25th percentile of the distribution of anesthesiologist risk-adjusted outcomes) experienced nearly twice the rate of death or serious complications (adjusted rate 3.33%; 95% confidence interval [CI], 3.09%-3.58%) as patients managed by high-performance anesthesiologists (corresponding to the 75th percentile) (adjusted rate 1.82%; 95% CI, 1.58%-2.10%). This performance gap was observed across all patient risk groups., Conclusions: The rate of death or major complications among patients undergoing coronary artery bypass graft surgery varies markedly across anesthesiologists. These findings suggest that there may be opportunities to improve perioperative management to improve outcomes among high-risk surgical patients.

Background: Pulmonary hypertension (PHT) is a significant risk factor for major adverse events during anesthesia, with a reported incidence of 5% to 7%, secondary to acute pulmonary hypertensive crises or right ventricular ischemia. Newer therapies for treating PHT have reduced mortality. In this single-center study, we investigated the frequency of major and minor events during anesthesia under the current strategies to manage PHT., Methods: We reviewed the records of children with PHT who underwent noncardiopulmonary bypass procedures from 2008 to 2012. Clinically important symptoms, physical signs, and results of investigations present before anesthesia were recorded. The incidence and type of intraoperative complications and death (up to 7 days) were collected., Results: Data were collected for 122 patients undergoing 284 procedures. Minor (3.9%) and major (3.2%) complication rates were unchanged from previous publications. The etiology of PHT was not significant for complications (P = 0.14). Disease-modifying agents were not associated with reduced complications: 4.1% in treated versus 8.6% untreated (all P > 0.14). Patients receiving home oxygen had more complications (P = 0.02). Multiple logistic regression identified age and degree of PHT as significant predictors of complications (all P ≤ 0.03)., Conclusions: The risk for adverse events during anesthesia in patients with PHT remains high, despite newer disease-modifying treatments. Risk factors for complications include age and severity of PHT.

The increasing volume of office-based medical and surgical procedures has fostered the emergence of office-based anesthesia (OBA), a subspecialty within ambulatory anesthesia. The growth of OBA has been facilitated by numerous trends, including innovations in medical and surgical procedures and anesthetic drugs, as well as improved provider reimbursement and greater convenience for patients. There is a lack of randomized controlled trials to determine how office-based procedures and anesthesia affect patient morbidity and mortality. As a result, studies on this topic are retrospective in nature. Some of the early literature broaches concerns about the safety of office-based procedures and anesthesia. However, more recent data have shown that care in ambulatory settings is comparable to hospitals and ambulatory surgery centers, especially when offices are accredited and their proceduralists are board-certified. Office-based suites can continue to enhance the quality of care that they deliver to patients by engaging in proper procedure and patient selection, provider credentialing, facility accreditation, and incorporating patient safety checklists and professional society guidelines into practice. These strategies aiming at patient morbidity and mortality in the office setting will be increasingly important as more states, and possibly the federal government, exercise regulatory authority over the ambulatory setting. We explore these trends, their implications for patient safety, strategies for minimizing patient complications and mortality in OBA, and future developments that could impact the field.

Background: In April 2010, in response to a change in Centers for Medicare and Medicaid Services regulation placing deep sedation under hospital anesthesia services, our institution began providing anesthesia care for all advanced endoscopic procedures. Because it remains unknown whether anesthesia care reduces sedation-related complications or improves quality of care versus nurse-administered sedation for endoscopic retrograde cholangiopancreatography and endoscopic ultrasound patients, we retrospectively compared complications in a 5-year historical cohort before and after the policy change., Methods: We reviewed a historical cohort of 9598 consecutive endoscopic retrograde cholangiopancreatography and endoscopic ultrasound examinations for adult patients at a single institution during a 5-year period (October 2007-October 2012). We compared procedures performed before and after the policy change for the incidence of sedation, endoscopic, and total complications, and for major morbidity and mortality., Results: The incidence of reported sedation-related complications was 0.38% (17 of 4514) before the policy change and 0.08% (4 of 5084) after the policy change, which was statistically significant (P = 0.002, diff = 0.3, 95% confidence interval, 0.11%-0.53%). Endoscopic complications were not significantly different before versus after: 0.66% vs 0.87% (P = 0.293, diff = 0.2, 95% confidence interval, -0.16% to 0.56%). Total complications (1.11% vs 1.00%, P = 0.618) and major morbidity and mortality (0.27% vs 0.33%, P = 0.581) did not differ between the 2 time periods., Conclusions: Anesthesia care for advanced endoscopy in a high-risk population significantly reduced sedation complications compared with nurse-administered sedation. Endoscopic complications were unchanged. The sedation risk reduction did not reduce major morbidity, mortality, or total complications.

Background: Mortality is a basic measure for quality and safety in anesthesia. There are few anesthesia-related mortality data available for pediatric practice. Our objective for this study was to determine the incidence of 24-hour and 30-day mortality after anesthesia and to determine the incidence and nature of anesthesia-related mortality in pediatric practice at a large tertiary institution., Methods: Children ≤ 18 years old who had an anesthetic between January 1, 2003, and August 30, 2008, at the Royal Children's Hospital, Melbourne, Australia, were included for this study. Data were analyzed by merging a database for every anesthetic performed with an accurate electronic record of mortality of children who had ever been a Royal Children's Hospital patient. Cases of children dying within 30 days and 24 hours of an anesthetic were identified and the patient history and anesthetic record examined. Anesthesia-related death was defined as those cases whereby a panel of 3 senior anesthesiologists all agreed that anesthesia or factors under the control of the anesthesiologist more likely than not influenced the timing of death., Results: During this 68-month period, 101,885 anesthetics were administered to 56,263 children. The overall 24-hour mortality from any cause after anesthesia was 13.4 per 10,000 anesthetics delivered and 30-day mortality was 34.5 per 10,000 anesthetics delivered. The incidence of death was highest in children ≤ 30 days old. Patients undergoing cardiac surgery had a higher incidence of 24-hour and 30-day mortality than did those undergoing noncardiac surgery. From 101,885 anesthetics there were 10 anesthesia-related deaths. The incidence of anesthesia-related death was 1 in 10,188 or 0.98 cases per 10,000 anesthetics performed (95%confidence interval, 0.5 to 1.8). In all 10 cases, preexisting medical conditions were identified as being a significant factor in the patient's death. Five of these cases (50%) involved children with pulmonary hypertension., Conclusions: Anesthesia-related mortality is higher in children with heart disease and in particular those with pulmonary hypertension. The lack of anesthetic-related deaths in children who did not have major comorbidities reinforces the safety of pediatric anesthesia in healthy children.

Purpose of Review: To provide recent evidence of safety in anesthesia and appraise the role of established tools of safety improvement in anesthesia practice., Recent Findings: The current incidence of minor events or complications during anesthesia is estimated at 18-22%, for severe complications 0.45-1.4%, and for mortality of 1: 100 000. Evidence suggests that despite such low complication rates, further improvements can still be made by addressing systemic factors which are known to set up conditions for adverse events. In particular, improvements can be made in the areas of drug errors, and inadequate or lack of communication between different clinical teams during the process of handovers. In addition, the evidence is growing which highlights the importance of established tools such as critical incident reporting, quality management using plan-do-check-act cycles, use of checklists and use of simulation in training clinical staff in the areas of nontechnical skills., Summary: Anesthesia is one of the safest clinical specialties and remains at the top among leaders of patient safety. This review provides evidence for the areas in which further progress can be made, and usefulness of certain tools, such as critical incident reporting, checklists, plan-do-check-act cycles and simulation, can be used for continued improvements.

Purpose of Review: The purpose of this review is to summarize recommendations for the safe and efficient conductance of sedation and anesthesia at remote locations; and to define safety standards, monitoring techniques, quality of care and procedural eligibility., Recent Findings: Anesthesia outside of the operating room is rapidly increasing in numbers, which has seen a growth of older and sicker patients. These circumstances have created a need for guidelines, for both specialist anesthesia providers and nonanesthesia-trained practitioners, that define patient selection, minimum monitoring (hemodynamics and respiration), facility design and equipment, policy framework, recovery facilities and policies. The patient's safety throughout all stages of sedation and/or anesthesia is the most pertinent goal. Recent data emphasize the importance of monitoring pulse oximetry and end-tidal carbon dioxide for any sedating or anesthetic procedure. Substandard monitoring combined with oversedation and subsequent respiratory depression are implicated as the main reasons for catastrophic sedation and anesthetic outcomes at remote locations., Summary: Patient selection, procedure appropriateness and location appropriateness are the key elements defining the provision of safe anesthesia care outside the operating room. Titratable, short-acting intravenous drugs are preferred such as propofol and remifentanil.

Purpose of Review: The worldwide adoption of live liver donors as a source of donor organs for transplantation has been curtailed by the very real risk of complications in otherwise healthy people. Our objective in this review is to outline the perioperative management of the live liver donor for adult-to-adult transplantation., Recent Findings: The incidence and severity of complications following live liver donation is extremely variable, and reporting needs to be standardized if we are to improve the perioperative management and outcomes. Agreed definitions would clarify the incidence and severity of postoperative complications, allow identification of areas in which management can be improved and suggest areas for future investigation. Such an effort will require the cooperation of centers around the world., Summary: Live liver donation is a valuable option for organ donation that can be conducted safely with a multidisciplinary perioperative approach. Future considerations should focus on the recovery period and how the intraoperative management can be optimized to minimize the impact of surgery on donors' quality of life.

Purpose of Review: Anesthesia is a three-step process: preoperative evaluation, the intervention itself and postanesthetic care. In France, this scheme has been legally regulated since 1994. Since then, significant progress has been made in terms of safety. Nevertheless, challenges in the delivery and financing of anesthesia services persist; in particular, demographic (patients and medical staff, as in other western countries), budgetary and organizational restrictions., Recent Findings: The poor efficiency (i.e. low utilization rate) of operating sites remains problematic. Results of published surveys yield the same observations: low productivity (anesthesia personnel present and paid but insufficiently occupied with mean occupied-time rate of approximately 60%), absence or poor planning and inadequate risk management. The failure to define policies to obtain better distribution of anesthesiologists throughout the country and to optimize operating-suite use are major barriers. In addition, the appropriate composition of anesthesia teams, for example nurses and physicians, for specific procedures remains undefined. Moreover, the number of anesthesia cases has grown constantly over the past 20 years, and in some situations they are not medically justified. Finally, pressure to increase productivity is becoming a potential threat to safety and deserves more discussion., Summary: Paths to improvement of delivery of anesthesia in France may include: more optimal sharing of medical resources; better utilization of operating sites, perhaps by consolidating and reducing locations; applying improved organizational skills; and improved risk management.

Background: Previous research on anesthesia-related mortality in the United States was limited to data from individual hospitals. The purpose of this study was to examine the epidemiologic patterns of anesthesia-related deaths at the national level., Methods: The authors searched the International Classification of Diseases, 10th Revision manuals for codes specifically related to anesthesia/anesthetics. These codes were used to identify anesthesia-related deaths from the US multiple-cause-of-death data files for the years 1999-2005. Rates from anesthesia- related deaths were calculated based on population and hospital surgical discharge data., Results: The authors identified 46 anesthesia/anesthetic codes, including complications of anesthesia during pregnancy, labor, and puerperium (O29.0 -O29.9, O74.0-74.9, O89.0-O89.9), overdose of anesthetics (T41.0 -T41.4), adverse effects of anesthetics in therapeutic use (Y45.0, Y47.1, Y48.0 - Y48.4, Y55.1), and other complications of anesthesia (T88.2- T88.5, Y65.3). Of the 2,211 recorded anesthesia-related deaths in the United States during 1999-2005, 46.6% were attributable to overdose of anesthetics; 42.5% were attributable to adverse effects of anesthetics in therapeutic use; 3.6% were attributable to complications of anesthesia during pregnancy, labor, and puerperium; and 7.3% were attributable to other complications of anesthesia. Anesthesia complications were the underlying cause in 241 (10.9%) of the 2,211 deaths. The estimated rates from anesthesia-related deaths were 1.1 per million population per year (1.45 for males and 0.77 for females) and 8.2 per million hospital surgical discharges (11.7 for men and 6.5 for women). The highest death rates were found in persons aged 85 yr and older., Conclusion: Each year in the United States, anesthesia/anesthetics are reported as the underlying cause in approximately 34 deaths and contributing factors in another 281 deaths, with excess mortality risk in the elderly and men.

Purpose of Review: The purpose of this review is to define risks for anesthesia and sedation outside the operating room, and to suggest how to prevent these risks and maintain quality of care., Recent Findings: There are no recent data on risk for anesthesia outside the operating room, except information derived from the American Society of Anesthesia Closed Claims project, which indicates there is a higher risk for office-based anesthesia., Summary: Complications of anesthesia outside the operating room are not well studied, although a few closed claims are appearing in the literature suggesting there is a higher risk. Topics discussed focus on MRI and surgical procedures, principally dental, plastic, and gastrointestinal endoscopy. Risk factors for these procedures are identified and quantified and measures to reduce them discussed, with emphasis on full oxygenation and end-tidal carbon dioxide monitoring. Nonoperating room anesthesia requires skills, experience and organization. Quality can only be assured by ensuring all alternative locations adhere to operating room standards.

Background: Anesthesia is associated with complications, and some of them may be fatal. The authors investigated the circumstances under which deaths were associated with anesthesia. In Denmark, the specialty anesthesiology encompasses emergency medicine, chronic and acute pain medicine, anesthetic procedures, perioperative care medicine, and intensive care medicine., Methods: The authors retrospectively investigated anesthesia related deaths registered by the Danish Patient Insurance Association., Results: From 1996 to 2004, 27,971 claims were made by the Danish Patient Insurance Association covering all medical specialties, of which 1,256 files (4.5%) were related to anesthesia. In 24 cases, the patient's death was considered to result from the anesthetic procedure: 4 deaths were related to airway management, 2 to ventilation management, 4 to central venous catheter placement, 4 as a result of medication errors, 4 from infusion pump problems, and 4 after complications from regional blockades. Severe hemorrhage caused 1 death, and in 1 case the cause was uncertain., Conclusions: Several of the 24 deaths could potentially have been avoided by more extended use of airway algorithm, thorough preoperative evaluation, training, education, and use of protocols for diagnosis and treatment.

Background: The authors used the American Society of Anesthesiologists Closed Claims Project database to determine changes in the proportion of claims for death or permanent brain damage over a 26-yr period and to identify factors associated with the observed changes., Methods: The Closed Claims Project is a structured evaluation of adverse outcomes from 6,894 closed anesthesia malpractice claims. Trends in the proportion of claims for death or permanent brain damage between 1975 and 2000 were analyzed., Results: Claims for death or brain damage decreased between 1975 and 2000 (odds ratio, 0.95 per year; 95% confidence interval, 0.94-0.96; P < 0.01). The overall downward trend did not seem to be affected by the use of pulse oximetry and end-tidal carbon dioxide monitoring, which began in 1986. The use of these monitors increased from 6% in 1985 to 70% in 1989, and thereafter varied from 63% to 83% through the year 2000. During 1986-2000, respiratory damaging events decreased while cardiovascular damaging events increased, so that by 1992, respiratory and cardiovascular damaging events occurred in approximately the same proportion (28%), a trend that continued through 2000., Conclusion: The significant decrease in the proportion of claims for death or permanent brain damage from 1975 through 2000 seems to be unrelated to a marked increase in the proportion of claims where pulse oximetry and end-tidal carbon dioxide monitoring were used. After the introduction and use of these monitors, there was a significant reduction in the proportion of respiratory and an increase in the proportion of cardiovascular damaging events responsible for death or permanent brain damage.