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Background: Perianesthetic death or sedation death in companion animals is an infrequent but devastating complication. Few studies have investigated the pathology associated with these deaths., Objective: To determine clinical features and postmortem findings for submissions to multiple Canadian diagnostic laboratories from perianesthetic/sedation deaths in dogs and cats., Animals and Procedure: Laboratory Information Management Systems were retrospectively reviewed for cases of perianesthetic/sedation death in dogs and cats. Inclusion criteria were: i) whole-body submissions and ii) death within 7 d after the procedure., Results: Pathology reports determined the cause of death in 43% of dogs (73/168) and 34% of cats (50/147). Spay/neuter surgeries were the most common procedure for which animals were submitted (dogs: n = 72, 31%; cats: n = 111, 58%). The American Society of Anesthesiologists physical status in these animals was low (ASA status I or II) in 94% of dogs (68/72) and 93% of cats (103/111). Clinical history was considered incomplete in 60.3% of cases (242/401)., Conclusion and Clinical Relevance: These results had similar trends to those in previous studies that identified an important proportion of submissions for perianesthetic/sedation deaths lacked significant lesions to explain the cause of death. This study also identified spay/neuter procedures were involved in the largest proportion of submissions, despite their low pre-anesthetic/sedation risk., (Copyright and/or publishing rights held by the Canadian Veterinary Medical Association.)

Background: Centralisation of perioperative care for small children to a limited number of specialised paediatric centres has many theoretical advantages, but neither the optimal balance nor the current distribution of paediatric anaesthesia on a national scale are well elucidated. The aim of this study was to describe the distribution, adverse events, and mortality in children undergoing anaesthesia in Sweden., Methods: In this cohort study, data from all paediatric anaesthesia procedures registered in Sweden during the years 2019-22 were extracted from the Swedish Perioperative Register (SPOR). Data were analysed according to hospital level of care and ASA physical status., Results: Data from 81 hospitals were analysed. During the 4-yr period, 214,964 procedures were registered. Most procedures in neonates and infants were managed in paediatric (73%) and other university hospitals (21%). Adverse events occurred in 2.71% of cases and severe adverse events in 0.067%. The all-cause 24-h mortality rate was 6.6:10,000 anaesthetics and the all-cause 30-day mortality was 14.7:10,000 anaesthetics. The 30-day all-cause estimated mortality was highest in paediatric hospitals (95% confidence interval [CI] 30-39) compared with other university hospitals (95% CI 6.1-12), county (95% CI 1.9-4.8), district (95% CI 0.07-2.2), and smaller hospitals (95% CI 0.0-22)., Conclusions: Most procedures in neonates and infants were performed in tertiary centres, with county hospitals managing mainly older children, in accordance with national recommendations. Mortality was more common in tertiary centres, reflecting increased comorbidity and centralisation of anaesthesia of neonates and infants., (Copyright © 2024 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Background: Prehospital anaesthesia is a complex intervention performed for critically ill patients. To minimise complications, a standard operating procedure (SOP) outlining the process is considered valuable. We investigated the implementation of an SOP for prehospital anaesthesia in helicopter emergency medical services (HEMS)., Methods: We performed a retrospective observational study of patients receiving prehospital anaesthesia by Finnish HEMS from January 2012 to August 2019. The intervention studied was the implementation of an SOP at two of the five bases during 2015-2016. Patients were stratified according to whether they were anaesthetised before, during or after implementation and the primary outcomes were 1- and 30-day mortality. Secondary outcomes included anaesthesia quality indicators. Confounding factors was assessed via logistic regression., Results: A total of 3902 tracheal intubations were performed without an SOP, 430 during implementation and 1525 after implementation. The SOP had a significant effect on 1-day mortality during implementation with an odds ratio (OR) of 0.56, 95% confidence interval (95% CI) 0.37-0.81 and a further trend towards benefit after implementation (OR 0.84, 95% CI 0.68-1.04), but no difference in 30-day mortality (OR after implementation 1.10, 95% CI 0.92-1.30). Implementation of an SOP improved first-pass success rate from 87.3% to 96.5%, p < 0.001., Conclusion: Implementation of an SOP for prehospital anaesthesia was associated with a trend towards lower 1-day mortality and an improved first-pass success but did not affect 30-day mortality. Despite this, we advocate prehospital systems to consider implementation of a prehospital anaesthesia SOP as immediate performance markers improved significantly., (© 2024 The Author(s). Acta Anaesthesiologica Scandinavica published by John Wiley & Sons Ltd on behalf of Acta Anaesthesiologica Scandinavica Foundation.)

Background: Patient safety is essential in small animal anaesthesia. This study aimed to assess anaesthesia-related deaths in cats worldwide, identify risk and protective factors and provide insights for clinical practice., Methods: A prospective multicentre cohort study of 14,962 cats from 198 veterinary centres across different countries was conducted. Data on anaesthesia-related deaths, from premedication up to 48 hours postextubation, were collected. Logistic regression was used to analyse patient demographics, American Society of Anesthesiologists (ASA) classification, procedure type and anaesthetic drugs., Results: The anaesthesia-related mortality was 0.63%, with 74.5% of deaths occurring postoperatively. Cats with cachexia, a higher ASA status or who underwent abdominal, orthopaedic/neurosurgical or thoracic procedures exhibited elevated mortality. Mechanical ventilation use was associated with increased mortality. Mortality odds were reduced by the use of alpha 2 -agonist sedatives, pure opioids in premedication and locoregional techniques., Limitations: Limitations include non-randomised sampling, potential biases, unquantified response rates, subjective death cause classification and limited variable analysis., Conclusions: Anaesthetic mortality in cats is significant, predominantly postoperative. Risk factors include cachexia, higher ASA status, specific procedures and mechanical ventilation. Protective factors include alpha 2 -agonist sedatives, pure opioids and locoregional techniques. These findings can help improve anaesthesia safety and outcomes. However, further research is required to improve protocols, enhance data quality and minimise risks., (© 2024 The Authors. Veterinary Record published by John Wiley & Sons Ltd on behalf of British Veterinary Association.)

Background: Ensuring patient safety during small animal anaesthesia is crucial. This study aimed to assess anaesthetic-related deaths in dogs globally, identify risks and protective factors and inform clinical practice., Methods: This prospective cohort multicentric study involved 55,022 dogs from 405 veterinary centres across various countries. Data on anaesthesia-related deaths from premedication to 48 hours post-extubation were collected. Logistic regression was used to analyse patient demographics, American Society of Anesthesiologists (ASA) classification, procedure type and anaesthetic drugs used., Results: Anaesthetic-related mortality was 0.69%. Most deaths occurred postoperatively (81%). Age, obesity and a higher ASA classification score were associated with increased mortality. Urgent procedures, non-urgent but unscheduled anaesthesias and short procedures also had higher mortality. Some sedatives, systemic analgesics, hypnotics and the use of locoregional anaesthesia were linked to a decrease in mortality., Limitations: The limitations of the study include the non-randomised sample, potential selection bias, lack of response rate quantification, variable data quality control, subjectivity in classifying causes of death and limited analysis of variables., Conclusion: Careful patient evaluation, drug selection and monitoring can be associated with reduced mortality. These findings can be used to develop guidelines and strategies to improve patient safety and outcomes. Further research is needed to refine protocols, enhance data quality systems and explore additional risk mitigation measures., (© 2023 The Authors. Veterinary Record published by John Wiley & Sons Ltd on behalf of British Veterinary Association.)

Objective: We aimed to investigate the effects of anesthesia methods and perioperative procedures on mortality in geriatric patients operated for hip fracture., Patients and Methods: This retrospective study included patients over 65 years of age who underwent hip fracture surgery. Demographic data, risk scores, perioperative and anesthesia management were analyzed in terms of mortality., Results: Data from 451 patients who were eligible for the study were analyzed. It was determined that there was no difference in mortality between the anesthesia methods administered to the patients in hip fracture surgery (p>0.05).  Being male increased the mortality risk by 4.568 times (95% CI: 1.215-17.168), and a one-unit increase in the number of erythrocyte suspensions given perioperatively increased the mortality risk by 2.801 times (95% CI: 1.509-5.197). Additionally, an American Society of Anesthesiologists (ASA) II score increased the mortality risk by 0.120 times (95% CI: 0.021-0.690), and a higher modified Charlson comorbidity index (mCCI) of 5-7 increased the mortality risk by 0.052 times (95% CI: 0.009-0.289)., Conclusions: Although high ASA and mCCI scores, male sex, and blood transfusion were associated with mortality in geriatric hip fracture surgery, we found that the method of anesthesia did not affect mortality.

Importance: Handovers of anesthesia care from one anesthesiologist to another is an important intraoperative event. Despite its association with adverse events after noncardiac surgery, its impact in the context of cardiac surgery remains unclear., Objective: To compare the outcomes of patients who were exposed to anesthesia handover vs those who were unexposed to anesthesia handover during cardiac surgery., Design, Setting, and Participants: This retrospective cohort study in Ontario, Canada, included Ontario residents who were 18 years or older and had undergone coronary artery bypass grafting or aortic, mitral, tricuspid valve, or thoracic aorta surgical procedures between 2008 and 2019. Exclusion criteria were non-Ontario residency status and other concomitant procedures. Statistical analysis was conducted from April 2021 to June 2021, and data collection occurred between November 2020 to January 2021., Exposures: Complete handover of anesthesia care, where the case is completed by the replacement anesthesiologist., Main Outcomes and Measures: The coprimary outcomes were mortality within 30 days and 1 year after surgery. Secondary outcomes were patient-defined adverse cardiac and noncardiac events (PACE), intensive care unit (ICU), and hospital lengths of stay (LOS). Inverse probability of treatment weighting based on the propensity score was used to estimate adjusted effect measures. Mortality was assessed using a Cox proportional hazard model, PACE using a cause-specific hazard model with death as a competing risk, and LOS using Poisson regression., Results: Of the 102 156 patients in the cohort, 25 207 (24.7%) were women; the mean (SD) age was 66.4 (10.8) years; and 72 843 of surgical procedures (71.3%) were performed in teaching hospitals. Handover occurred in 1926 patients (1.9%) and was associated with higher risks of 30-day mortality (hazard ratio [HR], 1.89; 95% CI, 1.41-2.54) and 1-year mortality (HR, 1.66; 95% CI, 1.31-2.12), as well as longer ICU (risk ratio [RR], 1.43; 95% CI, 1.22-1.68) and hospital (RR, 1.17; 95% CI, 1.06-1.28) LOS. There was no statistically significant association between handover and PACE (30 days: HR 1.09; 95% CI, 0.79-1.49; 1 year: HR 0.89; 95% CI, 0.70-1.13)., Conclusions and Relevance: Handover of anesthesia care during cardiac surgical procedures was associated with higher 30-day and 1-year mortality rates and increased health care resource use. Further research is needed to evaluate and systematically improve the handover process qualitatively.

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.)

Non-operating room anaesthesia (NORA) describes anaesthesia delivered outside a traditional operating room (OR) setting. Non-operating room anaesthesia cases have increased significantly in the last 20 yr and are projected to account for half of all anaesthetics delivered in the next decade. In contrast to most other medication administration contexts, NORA is performed in high-volume fast-paced environments not optimised for anaesthesia care. These predisposing factors combined with increasing case volume, less provider experience, and higher-acuity patients increase the potential for preventable adverse events. Our narrative review examines morbidity and mortality in NORA settings compared with the OR and the systems factors impacting safety in NORA. A review of the literature from January 1, 1994 to March 5, 2021 was conducted using PubMed, CINAHL, Scopus, and ProQuest. After completing abstract screening and full-text review, 30 articles were selected for inclusion. These articles suggested higher rates of morbidity and mortality in NORA cases compared with OR cases. This included a higher proportion of death claims and complications attributable to inadequate oxygenation, and a higher likelihood that adverse events are preventable. Despite relatively few attempts to quantify safety concerns, it was possible to find a range of systems safety concerns repeated across multiple studies, including insufficient lighting, noise, cramped workspace, and restricted access to patients. Old and unfamiliar equipment, lack of team familiarity, and limited preoperative evaluation are also commonly noted challenges. Applying a systems view of safety, it is possible to suggest a range of methods to improve NORA safety and performance., (Published by Elsevier Ltd.)

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: Intraoperative EEG suppression duration has been associated with postoperative delirium and mortality. In a clinical trial testing anaesthesia titration to avoid EEG suppression, the intervention did not decrease the incidence of postoperative delirium, but was associated with reduced 30-day mortality. The present study evaluated whether the EEG-guided anaesthesia intervention was also associated with reduced 1-yr mortality., Methods: This manuscript reports 1 yr follow-up of subjects from a single-centre RCT, including a post hoc secondary outcome (1-yr mortality) in addition to pre-specified secondary outcomes. The trial included subjects aged 60 yr or older undergoing surgery with general anaesthesia between January 2015 and May 2018. Patients were randomised to receive EEG-guided anaesthesia or usual care. The previously reported primary outcome was postoperative delirium. The outcome of the current study was all-cause 1-yr mortality., Results: Of the 1232 subjects enrolled, 614 subjects were randomised to EEG-guided anaesthesia and 618 subjects to usual care. One-year mortality was 57/591 (9.6%) in the guided group and 62/601 (10.3%) in the usual-care group. No significant difference in mortality was observed (adjusted absolute risk difference, -0.7%; 99.5% confidence interval, -5.8% to 4.3%; P=0.68)., Conclusions: An EEG-guided anaesthesia intervention aiming to decrease duration of EEG suppression during surgery did not significantly decrease 1-yr mortality. These findings, in the context of other studies, do not provide supportive evidence for EEG-guided anaesthesia to prevent intermediate term postoperative death., Clinical Trial Registration: NCT02241655., (Copyright © 2021 British Journal of Anaesthesia. Published by Elsevier Ltd. All rights reserved.)

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: Neonates and infants requiring anaesthesia are at risk of physiological instability and complications, but triggers for peri-anaesthetic interventions and associations with subsequent outcome are unknown., Methods: This prospective, observational study recruited patients up to 60 weeks' postmenstrual age undergoing anaesthesia for surgical or diagnostic procedures from 165 centres in 31 European countries between March 2016 and January 2017. The primary aim was to identify thresholds of pre-determined physiological variables that triggered a medical intervention. The secondary aims were to evaluate morbidities, mortality at 30 and 90 days, or both, and associations with critical events., Results: Infants (n=5609) born at mean (standard deviation [sd]) 36.2 (4.4) weeks postmenstrual age (35.7% preterm) underwent 6542 procedures within 63 (48) days of birth. Critical event(s) requiring intervention occurred in 35.2% of cases, mainly hypotension (>30% decrease in blood pressure) or reduced oxygenation (SpO 2 <85%). Postmenstrual age influenced the incidence and thresholds for intervention. Risk of critical events was increased by prior neonatal medical conditions, congenital anomalies, or both (relative risk [RR]=1.16; 95% confidence interval [CI], 1.04-1.28) and in those requiring preoperative intensive support (RR=1.27; 95% CI, 1.15-1.41). Additional complications occurred in 16.3% of patients by 30 days, and overall 90-day mortality was 3.2% (95% CI, 2.7-3.7%). Co-occurrence of intraoperative hypotension, hypoxaemia, and anaemia was associated with increased risk of morbidity (RR=3.56; 95% CI, 1.64-7.71) and mortality (RR=19.80; 95% CI, 5.87-66.7)., Conclusions: Variability in physiological thresholds that triggered an intervention, and the impact of poor tissue oxygenation on patient's outcome, highlight the need for more standardised perioperative management guidelines for neonates and infants., Clinical Trial Registration: NCT02350348., (Copyright © 2021 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background: Neonates and infants are susceptible to hypoxaemia in the perioperative period. The aim of this study was to analyse interventions related to anaesthesia tracheal intubations in this European cohort and identify their clinical consequences., Methods: We performed a secondary analysis of tracheal intubations of the European multicentre observational trial (NEonate and Children audiT of Anaesthesia pRactice IN Europe [NECTARINE]) in neonates and small infants with difficult tracheal intubation. The primary endpoint was the incidence of difficult intubation and the related complications. The secondary endpoints were the risk factors for severe hypoxaemia attributed to difficult airway management, and 30 and 90 day outcomes., Results: Tracheal intubation was planned in 4683 procedures. Difficult tracheal intubation, defined as two failed attempts of direct laryngoscopy, occurred in 266 children (271 procedures) with an incidence (95% confidence interval [CI]) of 5.8% (95% CI, 5.1-6.5). Bradycardia occurred in 8% of the cases with difficult intubation, whereas a significant decrease in oxygen saturation (SpO 2 <90% for 60 s) was reported in 40%. No associated risk factors could be identified among co-morbidities, surgical, or anaesthesia management. Using propensity scoring to adjust for confounders, difficult anaesthesia tracheal intubation did not lead to an increase in 30 and 90 day morbidity or mortality., Conclusions: The results of the present study demonstrate a high incidence of difficult tracheal intubation in children less than 60 weeks post-conceptual age commonly resulting in severe hypoxaemia. Reassuringly, the morbidity and mortality at 30 and 90 days was not increased by the occurrence of a difficult intubation event., Clinical Trial Registration: NCT02350348., (Copyright © 2021 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Pediatric anesthesia is large part of anesthesia clinical practice. Children, parents and anesthesiologists fear anesthesia because of the risk of acute morbidity and mortality. Modern anesthesia in otherwise healthy children above 1 year of age in developed countries has become very safe due to recent advance in pharmacology, intensive education, and training as well as centralization of care. In contrast, anesthesia in these children in low-income countries is associated with a high risk of mortality due to lack of basic resources and adequate training of health care providers. Anesthesia for neonates and toddlers is associated with significant morbidity and mortality. Anesthesia-related (near) critical incidents occur in 5% of anesthetic procedures and are largely dependent on the skills and up-to-date knowledge of the whole perioperative team in the specific needs for children. An investment in continuous medical education of the perioperative staff is required and international standard operating protocols for common procedures and critical situations should be defined., Competing Interests: Declaration of competing interest JdG is President-elect of the European Society for Pediatric Anesthesiology., (Copyright © 2021 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background and Aims: The choice of anesthesia method may influence mortality and postoperative urological complications after open groin hernia repair. We aimed to investigate the association between type of anesthesia and incidence of urinary retention, urethral stricture, prostate surgery, and 1-year mortality after open groin hernia repair., Materials and Methods: Data were linked from the Danish Hernia Database, the national patient register, and the register of causes of death. We investigated data on male adult patients receiving open groin hernia repair from 1999 to 2013 with either local anesthesia, regional anesthesia, or general anesthesia. In relation to the type of anesthesia, we compared mortality and urological complications up to 1 year postoperatively. We adjusted for covariates in a logistic regression assessing urological complications and with the Cox regression assessing mortality., Results: We included 113,069 open groin hernia repairs in local anesthesia, regional anesthesia, or general anesthesia. The risk of urinary retention adjusted for covariates was higher after both general anesthesia (adjusted odds ratio = 1.64, 95% confidence interval = 1.05-2.57, p  = 0.031) and regional anesthesia (odds ratio = 2.99, 95% confidence interval = 1.67-5.34, p  < 0.0005) compared with local anesthesia. The adjusted risk of prostate surgery was also higher for both general anesthesia (odds ratio = 1.58, 95% confidence interval = 1.23-2.03, p  < 0.0005) and regional anesthesia (odds ratio = 1.90, 95% confidence interval = 1.40-2.58, p  < 0.0005) compared with local anesthesia. Type of anesthesia did not influence 1-year mortality or the risk for urethral stricture., Conclusion: Patients undergoing open groin hernia repair in local anesthesia experience the lowest rate of urological complications and have equally low mortality compared with patients undergoing repair in general anesthesia or regional anesthesia.

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: Interstitial lung disease (ILD) management guidelines support lung biopsy-guided therapy. However, the high mortality associated with thoracoscopic lung biopsy using general anesthesia (GA) in patients with ILD has deterred physicians from offering this procedure and adopt a diagnostic approach based on high-resolution CT. Here we report that thoracoscopy under regional anesthesia could be a safer alternative for lung biopsy and effectively guide ILD treatment., Methods: This was a single-center retrospective review of prospectively maintained database and consisted of patients who underwent thoracoscopic lung biopsy between March 2016 and March 2018. Patients were divided into two groups: (A) GA, and (B) regional anesthesia using monitored anesthesia care (MAC) and thoracic epidural anesthesia (TEA)., Results: During the study period, 44 patients underwent thoracoscopic lung biopsy. Of these, 15 underwent MAC/TEA. There were no significant differences between the two groups with regard to pulmonary function test and clinicodemographic profile. However, operative time and hospital stay were shorter in MAC/TEA group (32.5±18.5 min vs 50.8±18.4; p=0.004, 1.0±1.3 days vs 10.0±34.7 days; p<0.001, respectively). Eight patients in the GA group, but none in the MAC/TEA group, experienced worsening of ILD after lung biopsy (p=0.03). Additionally, one patient in the GA group died due to acute ILD worsening. No cases of MAC/TEA group had to be converted to GA. In all cases a pathological diagnosis could be made., Conclusions: Thoracoscopy using regional anesthesia might be a safer alternative to lung biopsy in patients with ILD., Competing Interests: Competing interests: None declared., (© American Society of Regional Anesthesia & Pain Medicine 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Pediatric living donor liver transplantation (LDLT) has become the gold standard for patients with end-stage liver disease. With improvements in organ preservation, immunosuppression, surgical and anesthesia techniques, the survival rates and long-term outcomes of patients after LDLT have significantly improved worldwide. However, data on anesthetic management and postoperative survival rate of pediatric LDLT in China are rare., Aim: To review the status of pediatric LDLT in Shanghai and investigate the factors related to anesthetic management and survival rate in pediatric LDLT., Methods: We conducted a retrospective observational study to investigate the status of pediatric LDLT in Shanghai by reviewing 544 records of patients who underwent pediatric LDLT since the first operation on October 21, 2006 until August 10, 2016 at Renji Hospital and Huashan Hospital., Results: The 30-d, 90-d, 1-year, and 2-year survival rates were 95.22%, 93.38%, 91.36%, and 89.34%, respectively. The 2-year patient survival rate after January 1, 2011 significantly improved compared with the previous period (74.47% vs 90.74%; hazard ratio: 2.92; 95% confidence interval (CI): 2.16-14.14; P = 0.0004). Median duration of mechanical ventilation in the intensive care unit (ICU) was 18 h [interquartile range (IQR), 15.25-20.25], median ICU length of stay was 6 d (IQR: 4.80-9.00), and median postoperative length of stay was 24 d (IQR: 18.00-34.00). Forty-seven (8.60%) of 544 patients did not receive red blood cell transfusion during the operation., Conclusion: Pediatric end-stage liver disease (PELD) score, anesthesia duration, operation duration, intraoperative blood loss, and ICU length of stay were independent predictive factors of in-hospital patient survival. Pediatric end-stage liver disease score, operation duration, and ICU length of stay were independent predictive factors of 1-year and 3-year patient survival., Competing Interests: Conflict-of-interest statement: We have no financial relationships to disclose., (©The Author(s) 2020. Published by Baishideng Publishing Group Inc. All rights reserved.)

Background: Anaesthesia-related mortality is an important, potentially avoidable cause of perioperative mortality. A procedure-related death notification (PRDN) instrument is completed by relevant medical practitioners after a procedure-related death and is used to audit practice and identify areas of care that require improvement. It is also used in medicolegal investigations when establishing cause of death, and in the case of litigation. The current South African (SA) PRDN instrument, designated the GW7/24 form, contains both surgical and anaesthetic sections and is considered to be outdated, inadequate and in need of revision., Objectives: To develop and validate a revised anaesthetic section of the SA PRDN instrument that can be used for procedure-related deaths in future and be used to update the GW7/24 form for epidemiological, forensic or academic use., Methods: Lynn's two-stage model was utilised. After an extensive literature review, a provisional PRDN instrument was developed. This provisional instrument was debated and reviewed at a peer group discussion in which 6 local experts took part. These experts were anaesthetic and forensic pathology specialists who specifically have expert knowledge on procedure-related deaths. A revised PRDN instrument was developed, which was then rated by 8 national experts using a Likert scale. The content validity index (CVI) for each item and for the instrument as a whole was then established. Items with a CVI &lt;0.88 were removed to formulate the final PRDN instrument., Results: The provisional PRDN instrument consisted of 14 domains and 66 items. The revised PRDN instrument consisted of 13 domains and 65 items, of which 3 items with a CVI &lt;0.88 were removed. The final PRDN instrument, after minor revisions based on suggestions from the 8 national experts, consisted of 18 domains and 79 items. Every item on the form was declared relevant and important by the national experts, with the final instrument scoring an overall CVI of 1., Conclusions: A comprehensive, updated and validated anaesthetic section of the SA PRDN instrument was developed. This could be used as a government and anaesthesiology society-endorsed template when updating the current GW7/24 form.

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.

The practice of anesthesia includes multiple competing practice models, including services delivered by anesthesiologists, independent practice by certified registered nurse anesthetists (CRNAs), and team-based approaches incorporating anesthesiologist supervision or direction of CRNAs. Despite data demonstrating very low risk of death and complications associated with anesthesia, debate among professional societies and policymakers persists over the superiority or equivalence among these models. The American Society of Anesthesiologists uses published findings as evidence for claims that anesthesia is safer when anesthesiologists lead in providing care. The American Association of Nurse Anesthetists cites its own research on safety and cost-efficiency outcomes to defend against these claims. We review and critique studies of the safety outcomes and cost-effectiveness of anesthesia delivery that have been cited in the Federal Trade Commission comment letters related to competition in health care, where each profession has laid out their case for how they ought to be recognized in the market for anesthesia services. The Federal Trade Commission has a role in protecting consumers from anticompetitive conduct that has the potential to impact quality and cost in health care. Thus, it is important to evaluate the evidence used to make claims about these topics. We argue that while research in this area is imperfect, the strong safety record of anesthesia in general and CRNAs in particular suggest that politics and professional interests are the main drivers of supervision policy in anesthesia delivery.

Background: Increased age, obesity, and American Society of Anesthesiologists (ASA) Physical Status class III and IV have been reported as predictors for mortality and perioperative complications. High-volume institutions rely on central referral services as first contact point for patients. The current study reports on a simple four-step questionnaire to identify patients with ASA-physical status class III and IV to improve referral processes and optimize perioperative work ups., Materials and Methods: Seven hundred and seventy-five patients who called the physician referral service (PRS) at the author's institution and subsequently underwent surgery were enrolled in this study. The answers to the initial PRS questionnaire were analyzed. The study cohort consisted of 414 women (53.4%) and 361 men (46.6%) with an average age of 61.4 years (range 44-90 years) at the time of surgery., Results: Binary logistic regression revealed hypertension, diabetes mellitus (using medication), using blood thinner (other than Aspirin) and a number of 4-9 prescribed medication, respectively, as predictors for ASA III and IV. Receiver-operating characteristic (ROC) curve analysis identified a sensitivity of 82.4%, a specificity of 82.9%, and an accuracy of 82.8%, when two of these four questions are answered "yes". The area under the curve for this analysis was 0.876 [95% confidence interval (CI) 0.845-0.908]. Positive and negative likelihood ratios were 4.8 (95% CI 4.0-5.8) and 0.2 (95% CI 0.1-0.3), respectively., Conclusions: This study revealed a simple four-step questionnaire to identify patients with ASA III or IV before a medical appointment. This helps to balance referrals between multiple providers in high-volume medical groups.

Background: Studies suggest volatile anesthetics and opioids may enhance the malignant potential of cancer cells. The objective of this single institution retrospective study was to evaluate the survival impact of a multimodal opioid-sparing nonvolatile anesthetic technique (MA) in a group of patients who had undergone cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) for appendiceal carcinomatosis., Methods: Propensity score matching (PSM) and Cox proportional hazard models were used to compare the survivals of patients who received MA (MA group), to those who received volatile-opioid anesthesia (volatile-opioid group)., Results: Of the 373 patients, 110 (29%) were in the MA group and 263 (71%) in the volatile-opioid group. The MA group was older (mean ± standard deviation (SD): 55 ± 11 versus 53 ± 10 years, p = .035) and had more patients with ASA scores 3 or 4 (90% versus 81%, p = .032), and those with high grade tumors (18% versus 12%, p = .009). Intraoperative opioid consumption was lower in the MA group (mean morphine equivalents ± SD: 13 ± 10 versus 194 ± 789, p < .0001). After PSM, 107 patients remained in each group. In the adjusted Cox proportional hazards model after PSM, MA was not associated with improved progression free survival (PFS) (HR 1.45, 95% CI [0.94-2.22], p = .093) or overall survival (OS) (HR 1.66, 95% CI [0.86-3.20], p = .128), when compared to volatile-opioid anesthesia., Conclusions: In this retrospective study, a multimodal opioid-sparing nonvolatile anesthetic approach was not associated with improved survival. Precis' statement: In this study of patients undergoing major cancer surgery, the use of multimodal anesthetic and analgesic agents, while avoiding volatile anesthetics and minimizing opioid use was not associated with improved survival.

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: Perioperative complications occur in 30-40% of non-cardiac surgical patients and are the leading cause of early postoperative morbidity and mortality. Regular visits by trained health professionals may decrease the incidence of complications and mortality through earlier detection and adequate treatment of complications. Until now, no studies have been performed on the impact of routine postsurgical anesthesia visits on the incidence of postoperative complications and mortality., Methods: TRACE is a prospective, multicenter, stepped-wedge cluster randomized interventional study in academic and peripheral hospitals in the Netherlands. All hospitals start simultaneously with a control phase in which standard care is provided. Sequentially, in a randomized order, hospitals cross over to the intervention phase in which patients at risk are routinely followed up by an anesthesia professional at postoperative days 1 and 3, aiming to detect and prevent or treat postoperative complications. We aim to include 5600 adult patients who are at high risk of developing complications. The primary outcome variable is 30-day postoperative mortality. Secondary outcomes include incidence of postoperative complications and postoperative quality of life up to one year following surgery. Statistical analyses will be performed to compare the control and intervention cohorts with multilevel linear and logistic regression models, adjusted for temporal trends and for clusters (hospitals). The time horizon of the economic (cost-effectiveness) evaluation will be 30 days and one year following surgery., Discussion: TRACE is the first to study the effects of a routine postoperative visit by an anesthesia healthcare professional on mortality and cost-effectiveness of surgical patients. If the intervention proves to be beneficial for the patient and cost-effective, the stepped-wedge design ensures direct implementation in the participating hospitals., Trial Registration: Nederlands Trial Register/Netherlands Trial Registration, NTR5506 . Registered on 02 December 2015.

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.

Objective: The aim of this study was to determine the incidence and the associated risk factors of peri-anaesthetic mortality and gastrointestinal complications in pet rabbits., Study Design: Retrospective cohort study., Animals: A total of 185 pet rabbits admitted to the Exotic Referal Service of Beaumont Sainsbury's Animal Hospital over the period 2009-2016., Methods: The clinical records of the rabbits were obtained from the database. To evaluate the incidence of peri-anaesthetic mortality, three possible outcomes were considered: alive, dead or euthanized within the 72 hours following the anaesthetic event. Food intake and stool production during the first 72 hours following the anaesthetic event were evaluated to investigate the occurrence of gastrointestinal complications. Thereafter, various hypothesized risk factors, including administration of alpha-2 agonists, body weight, American Society of Anaesthesiologists classification and endotracheal intubation were tested against peri-anaesthetic mortality and gastrointestinal complications, with both univariate and multivariate binary logistic regression., Results: Twenty-five out of 185 rabbits underwent two anaesthetic events; therefore, data from 210 cases were used. Of these 210 cases, six died during sedation or general anaesthesia and four (one of which euthanized) died during the first 72 postoperative hours, accounting for an actual mortality rate equal to 4.8% (95% confidence interval, 0.025-0.086). Peri-anaesthetic gastrointestinal complications developed in 77 (38%) out of the 204 anaesthetic events whose outcome was not intraoperative death (95% confidence interval, 0.314-0.446). Species-specific risk factors could not be identified for peri-anaesthetic mortality; however, the odds for post-anaesthetic gastrointestinal complications increased significantly with body weight (p = 0.01)., Conclusions and Clinical Relevance: Our findings confirm that rabbits continue to have a higher incidence of peri-anaesthetic mortality than dogs and cats, and highlight a high risk for nonfatal peri-anaesthetic gastrointestinal complications in this species., (Copyright © 2018 Association of Veterinary Anaesthetists and American College of Veterinary Anesthesia and Analgesia. Published by Elsevier Ltd. All rights reserved.)

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.

As a young anaesthetic trainee in 1959 Ross Holland persuaded the Minister of Health in NSW, Australia, to establish SCIDUA, which by law required compulsory reporting for all deaths occurring during anaesthesia or up to 24 hours after cessation of the anaesthetic. The committee was multidisciplinary and, most importantly, had statutory privilege so that no discussions or findings were able to be subpoenaed for other legal investigations or case law. Holland was the foundation secretary of SCIDUA and later Chair. Apart from three years in the 1980s when there were political issues with legal privilege, the committee has met monthly and still meets. Holland was a major figure in antipodean anaesthesia, setting up in 1978 the clinical department at Westmead Hospital Sydney, then in 1987 becoming the foundation Professor to the Department of Anaesthesiology at the University of Hong Kong, and in 1990 foundation Professor and Chair, Department of Anaesthesia and Intensive Care at the University of Newcastle, NSW. Holland had strong historical interests and was responsible for founding the Society for the Preservation of Artefacts of Surgery and Medicine (SPASM) and its associated museum. He also served an important term as Dean of the Faculty of Anaesthetists, Royal Australasian College of Surgeons prior to that Faculty becoming independent as the Australian and New Zealand College of Anaesthetists (ANZCA). Professor Holland received many accolades for these activities during his life, which are noted. It is fitting to recognise his seminal contributions to patient safety over more than 50 years.

Background: Risk assessment prior to elective surgery is an important tool in the context of perioperative patient care; however, only a few studies have been carried out to address the processes and problems during preoperative assessment for anesthesia., Aim: Over a period of several weeks all preoperative anesthesia evaluations prior to elective surgery were prospectively recorded in order to generate a data pool with a view to identifying options for process optimization., Material and Methods: All preoperative evaluations over a period of 38 working days at the University Medical Center Regensburg were recorded and analyzed with respect to waiting time for the patient and the duration of the preoperative consultation on medication. Also documented were the patient age, ASA score, the faculty carrying out the operation, type and risk of surgery, planned time of surgery, professional experience of the anesthesiologist and the approval status for surgery. In addition, all problems which occurred during the preoperative anesthesia evaluation were documented using a questionnaire., Results: Overall 2233 preoperative assessments for anesthesia were recorded and analyzed. The number of patients attending the preoperative assessment clinic differed markedly in the course of a day and was lower at the end of the week. Approval for surgery with no reservations was given more frequently by anesthesiologists with more than 5 years professional experience and consultants compared to younger colleagues. The main reason for approval with reservations or no approval was the lack of patient records and test results, which should have been presented according to the in-house standard for preoperative assessment for anesthesia. The mean waiting time was 58.6 ± 30.3 min, the mean duration of the patient documentation review and physician-patient consultation together was 33.6 ± 16.3 min. Anesthesiologists with 2-5 years professional experience needed significantly less time for patient documentation reviews and physician-patient consultations than younger and more experienced colleagues. The duration of the preoperative assessment for anesthesia correlated with the ASA score and risks of surgery., Conclusion: The analysis of processes and problems in the context of preoperative assessment for anesthesia revealed several options for optimization. Major efforts should be the implementation of an appointment system for the preoperative assessment clinic in order to generate a homogeneous distribution of patients during the course of a day. Furthermore, surgeons and case managers should be requested to refer patients to the preoperative assessment clinic only with complete records and test results according to the in-house standard.

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%).

Objective: The population of elderly patients and the amount of geriatric anesthesia have been growing rapidly in China. Thus, understanding the morbidity and mortality associated with geriatric anesthesia in China is critical to the improvement of anesthesia quality and outcome. The aim of the review was to discuss the geriatric anesthesia-related morbidity and mortality in China, as well as to point out the future trend., Data Sources: Articles in this review were all searched from Wanfang, China National Knowledge Infrastructure (CNKI), VIP, PubMed, and Web of Science databases, based on the reports originated in China from January 2011 to December 2016., Study Selection: A total of 57 studies were selected for further study, including 12 retrospective studies, 35 prospective studies, 3 meta-analyses, 4 reviews, 1 viewpoint, and 2 case reports. Of the total studies, 42 studies were in Chinese while 15 were in English., Results: The mortality and morbidity associated with geriatric anesthesia in China are not yet completely reported. Some factors have been recognized, while some are yet to be identified and confirmed. Several studies addressed postoperative cognitive dysfunction and postoperative delirium, whereas only a few studies can be found on renal complications. Thus, a nationwide registry is essential for geriatric anesthesia-associated adverse outcomes. The mortality associated with geriatric anesthesia in China should be reported promptly. In the future, the perspective of geriatric anesthesia needs to be expanded into perioperative geriatric medicine to improve the perioperative management strategy based on the postoperative outcome-directed concept transformation., Conclusions: Anesthesiologists should evaluate the physiological and medical status and focus on the prevention of potential complications in the perioperative setting with the goal to enhance elderly patients' long-term well-being and survival quality.

Objective: Limited data exist regarding the outcomes of non-cardiac procedures (NCPs) in adult patients after Fontan operations (Fontan patients)., Methods: To compare procedural outcomes after NCPs in Fontan patients with outcomes for two matched control groups: patients with repaired congenital heart disease and biventricular circulation (CHD-BiV) and patients with no heart disease (NHD). We defined cyanosis as oxygen saturation <90% and procedural hypoxia as saturation <80% or a decrease in saturation >10% from baseline., Results: There were 538 NCPs in 154 Fontan patients (mean age, 30 years) performed in 1990-2015. Sedation and anaesthesia types were monitored anaesthesia care (256,48%), general anaesthesia (51,9%), minimal sedation (105,20%), local anaesthesia (75,14%) and regional anaesthesia (51,9%). Ninety-three complications occurred in 79 procedures (15%) and included arrhythmia requiring intervention (9), hypotension (14), bradycardia (8), hypoxia (38), heart failure requiring intravenous diuretics (2), acute kidney injury (3), bleeding requiring blood transfusion (1), unplanned procedures for dialysis catheter placement (2), readmission (2), unplanned hospitalisation for hypoxia (8) and unplanned transfer to intensive care unit (1). Baseline cyanosis was the only multivariable risk factor for complications (HR, 1.87 (95% CI 1.14 to 3.67), p=0.04). Procedural complications were more common in the Fontan group (18%) than in the CHD-BiV (5%) and NHD groups (1.4%) (p=0.001)., Conclusions: Complications after NCPs were more common in Fontan patients, and baseline cyanosis was a risk factor for complications. All-cause mortality was low and may be related to the multidisciplinary care approach used for Fontan patients at our centre., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

In general, the anesthesia in neonates involves high risk. Although hypothermic anesthesia is recommended in rats up to the age of 7 days, neonatal anesthesia for later periods has not been standardized. The present study investigated the pharmacological properties of conventional anesthetic protocols in 10-day-old SD rats. The rats were anesthetized with four anesthetics: a combination of ketamine and xylazine (K/X); a combination of medetomidine, midazolam, and butorphanol (M/M/B); isoflurane; and sevoflurane. Anesthetic depth was scored by reflex response to noxious stimuli. Induction and recovery times were recorded. Vital signs and mortality rate were evaluated for safety assessment. All rats died after administration of K/X at a dose of 60/6 mg/kg, whereas K/X at 40/4 mg/kg resulted in insufficient anesthetic depth, indicating inappropriate for neonatal anesthesia. Although M/M/B at the adult rat dose (0.15/2/2.5 mg/kg) did not provide surgical anesthetic depth, the mouse dose (0.3/4/5 mg/kg) showed sufficient anesthetic depth with relatively stable vital signs. Isoflurane required a long induction period, and caused remarkable respiratory depression and hypothermia, resulted in a 25% mortality rate. In contrast, sevoflurane provided consistent surgical anesthetic depth with rapid induction. Although respiratory rate decrease was markedly observed, all rats survived. Among the anesthetic protocols investigated in the present study, sevoflurane and M/M/B at the mouse dose were recommended for the neonatal anesthesia. Compared with adult rats, the required dose of both anesthetics in neonates was higher, possibly associated with their lower anesthetic sensitivity.

OBJECTIVE To determine the outcome in birds undergoing inhalation anesthesia and identify patient or procedure variables associated with an increased likelihood of anesthesia-related death. DESIGN Retrospective case series. ANIMALS 352 birds that underwent inhalation anesthesia. PROCEDURES Medical records of birds that underwent inhalation anesthesia from January 1, 2004, through December 31, 2014, at a single veterinary referral hospital were reviewed. Data collected included date of visit, age, species, sex, type (pet, free ranging, or wild kept in captivity), body weight, body condition score, diagnosis, procedure, American Society of Anesthesiologists status, premedication used for anesthesia, drug for anesthetic induction, type of maintenance anesthesia, route and type of fluid administration, volumes of crystalloid and colloid fluids administered, intraoperative events, estimated blood loss, duration of anesthesia, surgery duration, recovery time, recovery notes, whether birds survived to hospital discharge, time of death, total cost of hospitalization, cost of anesthesia, and nadir and peak values for heart rate, end-tidal partial pressure of carbon dioxide, concentration of inhaled anesthetic, and body temperature. Comparisons were made between birds that did and did not survive to hospital discharge. RESULTS Of 352 birds, 303 (86%) were alive at hospital discharge, 12 (3.4%) died during anesthesia, 15 (4.3%) died in the intensive care unit after anesthesia, and 22 (6.3%) were euthanatized after anesthesia. Overall, none of the variables studied were associated with survival to hospital discharge versus not surviving to hospital discharge. CONCLUSIONS AND CLINICAL RELEVANCE Results confirmed previous findings that indicated birds have a high mortality rate during and after anesthesia, compared with mortality rates published for dogs and cats.

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.

Achievements in anaesthesiology form the basis for the tremendous development of surgical therapy. Reliable monitoring technology, which is scrutinized on a regular basis using checklists, is allowing anaesthesia at the borders of physiology. During the last decades, anaesthesia-related mortality has been decreasing considerably. Well-trained anaesthesiology staff, who considers patient- and procedure-specific risks in anaesthetic management, is of major importance. Furthermore, postoperative care in specialised units and intensive care wards is a key factor of improved patient outcome after surgery. In the future, unravelling the interactions of anaesthesia, surgical trauma and postoperative complications will further contribute to improved patient safety., Competing Interests: Interessenkonflikt: Die Autoren erklären, dass kein Interessenkonflikt besteht., (Georg Thieme Verlag KG Stuttgart · New York.)

Competing Interests: Disclosure The authors report no conflicts of interest in this work.

Objective: To explore the major risk factors linking preoperative characteristics and anaesthesia-related death in dogs in referral hospitals in Japan., Study Design: Observational cohort study., Animals: From April 1, 2010 to March 31, 2011, 4323 dogs anaesthetized in 18 referral hospitals in Japan., Methods: Questionnaire forms were collated anonymously. Death occurring within 48 hours after extubation was considered as an anaesthesia-related death. Patient outcome (alive or dead) was set as the outcome variable. Preoperative general physical characteristics, complete blood cell counts, serum biochemical examinations and intraoperative complications were set as explanatory variables. The risk factors for anaesthesia-related death were evaluated using chi-square test or Fisher's exact test, followed by multivariable logistic regression analysis of the data. Significance was set at p < 0.05., Results: Thirteen dogs that died from surgical error or euthanasia were excluded from statistical analysis. The total mortality rate in this study was 0.65% [28/4310 dogs; 95% confidence interval (CI), 0.41-0.89]. Furthermore, 75% (95% CI, 55.1-89.3) of anaesthesia-related deaths occurred in dogs with pre-existing diseases. Most of the deaths occurred postoperatively (23/28; 82.1%; 95% CI, 63.1-93.9). Preoperative serum glucose concentration <77 mg dL -1 (6/46; 13.0%; 95% CI, 4.9-26.3), disturbance of consciousness (6/50; 12.0%; 95% CI, 4.5-24.3), white cell count >15,200 μL -1 (16/499; 3.4%; 95% CI, 1.9-5.5) and American Society of Anesthesiologists grade III-V (19/1092; 1.7%; 95% CI, 1.1-2.7) were identified as risk factors for anaesthesia-related death. Intraoperative hypoxaemia (8/34; 23.5%; 95% CI, 10.7-41.2) and tachycardia (4/148; 2.7%; 95% CI, 0.7-6.8) were also risk factors for anaesthesia-related death., Conclusions and Clinical Relevance: The results revealed that certain preoperative characteristics were associated with increased odds of anaesthesia-related death, specifically low serum glucose concentration and disturbances of consciousness. Greater attention to correcting preanaesthetic patient abnormalities may reduce the risk of anaesthesia-related death., (Copyright © 2017 Association of Veterinary Anaesthetists and American College of Veterinary Anesthesia and Analgesia. Published by Elsevier Ltd. All rights reserved.)

Objective: Electroconvulsive therapy (ECT) remains underutilized because of fears of cognitive and medical risks, including the risk of death. In this study, we aimed to assess the mortality rate of ECT by means of a systematic review and pooled analysis., Method: The study was conducted in adherence with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline. The ECT-related mortality rate was calculated as the total number of ECT-related deaths reported in the included studies divided by the total number of ECT treatments., Results: Fifteen studies with data from 32 countries reporting on a total of 766 180 ECT treatments met the inclusion criteria. Sixteen cases of ECT-related death were reported in the included studies yielding an ECT-related mortality rate of 2.1 per 100 000 treatments (95% CI: 1.2-3.4). In the nine studies that were published after 2001 (covering 414 747 treatments), there was only one reported ECT-related death., Conclusion: The ECT-related mortality rate was estimated at 2.1 per 100 000 treatments. In comparison, a recent analysis of the mortality of general anesthesia in relation to surgical procedures reported a mortality rate of 3.4 per 100 000. Our findings document that death caused by ECT is an extremely rare event., (© 2017 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)