Safety

Gabapentinoids and suicidal behaviour, unintentional overdoses, injuries, road traffic incidents, and violent crime

A population study in Sweden raises concerns regarding the widespread use of gabapentinoids for pain, sometimes with poor evidence bases, and in an effort to curb opioid overuse. However they bring issues of their own in terms of adverse effects, drug interaction and even misuse (search this blog!).

“This study suggests that gabapentinoids are associated with an increased risk of suicidal behaviour, unintentional overdoses, head/body injuries, and road traffic incidents and offences. Pregabalin was associated with higher hazards of these outcomes than gabapentin.”

“When stratifying on age, increased hazards of all outcomes were associated with participants aged 15 to 24 years.”

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Alarm Fatigue

Alarms serve to increase patient safety but they are many types: false alarms, nuisance alarms, inopportune alarms and actionable alarms. This APSF article finds an average of 1.2 alarms per minute and discusses the need for better design and machine learning algorithms to increase their utility.

The author notes: “Clinicians can also make simple changes to their practice that will help to mitigate the effects of alarm fatigue.”

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Stress, burnout, depression and work satisfaction among UK anaesthetic trainees

There is increasing awareness of mental health and well-being in physicians. This full text article studies some of the worrisome statistics in UK trainees in Anesthesia.

The authors “observed a high prevalence of perceived stress; 37% (95%CI 32–42%), burnout risk 25% (21–29%) and depression risk 18% (15–23%), and found that these issues frequently co‐exist. Having no children, > 3 days sickness absence in the previous year, ≤ 1 h.week−1of exercise and > 7.5 h.week−1 of additional non‐clinical work were independant predictors of negative psychological outcomes”.

Hopefully these results will help inform the identification and management of risk factors. However this should not substitute for improving safe workplaces and work scheduling, workload and practice.

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Malignant Hyperthermia in Pregnancy

A European group issues guidelines for MH in Pregnancy. As always, neuraxial anesthesia is preferred, and guidelines are otherwise similar to the non-obstetric population.

Of note:

  1. The mother is known or suspected to be MH-susceptible (in this case even the fetus may be MH-susceptible)
  2. The fetus may be MH-susceptible but not the mother (because the father of the child is known or suspected to be MH-susceptible).

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Tramadol and Persistent Opioid Use

Faced with the opioid epidemic, many have turned to postoperative use of Tramadol in the belief it has less misuse potential.

This observational study finds however that: “People receiving tramadol alone after surgery had similar to somewhat higher risks of prolonged opioid use compared with those receiving other short acting opioids”.

They advocate reclassifying Tramadol and urge caution in its prescription.

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Lymphedema Risk And IV Placement

Recently reposted by the APSF, post-mastectomy lymphedema is a burdensome and sometimes intractable risk that has led to the advice to avoid all intravenous placements and blood pressure recording on the involved side.

Although some evidence has deemed it is acceptable practice, the response in this article emphasizes that the risk of lymphedema is lifelong and they condone taking all risk reduction measures to mitigate against the potential. Therefore it seems prudent to continue avoiding the mastectomy side limb unless circumstances dictate the risk is acceptable, eg. an emergency.

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Caring for the mental health of the medical workforce

The title from the BMA survey into doctors’ and medical students’ mental health applies to all specialties but Anesthesia has ranked in the top in many surveys.

40% reported symptoms of depression, anxiety, burnout, stress, emotional distress or a mental health condition that is impacting on their work/training/study.

27% of respondents reported being diagnosed with a mental health condition at some point in their life.

Doctors work when they know they are unwell and are reluctant to take sick leave.
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Most participants, if they could avoid it, did not disclose their illness to their educational supervisor or anybody else who might have any influence over their career progression. D

Access to appropriate support was impeded for the interviewees in a number of ways including cultural barriers.G

Returning from sick leave was difficult for a number of respondents. Experiences varied with regards to support from their line managers and occupational health services. 

The paper emphasizes building a supportive culture, enhancing access to support, and encouraging self-support and peer-support.

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Opioid Dose Variability and Opioid Overdose

This study on those on long term opioid therapy found high variability in opioid dose was associated with a greater than 3-fold increased risk of opioid overdose even after controlling for dose.

This occurred even on low dose opioids. Several mechanisms are postulated, including tapering leading to withdrawal effects that precipitated recommencing higher doses, seeking other opioid prescriptions or sources etc.

Individuals with sustained opioid therapy discontinuation (defined as 3 continuous months with 0 mg of morphine equivalents before the index date) were 51% less likely to have experienced an overdose than individuals who had not discontinued opioid therapy

The authors warn that physicians should consider the risks that may be associated with dose variability when designing and implementing new policies to reduce opioid prescribing.

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Night-time Extubation

Night-time extubation is generally fraught, with less expertise, staffing and resources and has been linked to adverse clinical outcomes.

This was a retrospective cohort study of mechanically ventilated adults at a single university-affiliated hospital, extubated between 7:00 PM and 6:59 AM the following day.

Reintubation and mortality did not differ compared to daytime extubation, and was associated with a shortened duration of mechanical ventilation and hospital length of stay.

This was a large urban hospital and may not necessarily apply in smaller centres, but in similar settings may help to improve resource utilization.

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WHO Surgical Safety Checklist & Mortality

A large population cohort study in a surgical setting in Scotland finds a remarkable 36% relative decrease in perioperative mortality since implementation of the WHO Surgical Safety Checklist.

No such trend in improvement was observed in the non‐surgical cohort. While causality is always difficult to prove, no other baseline demographics changed to explain the results. Most importantly, “This study provides further evidence that the success of checklist implementation is more pronounced when it is supported by a cohesive and wider approach to patient safety”, and also stresses the importance of “creating a culture of communication and teamwork that supports patient safety”.

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