Safety

Operating Room Humidity

Some ORs experience rises in humidity in summer. This APSF free answer to a query discusses the rationale and impact of working outside the generally recommended humidity levels 20 – 60%.

Low humidity could affect shelf life or generate electrostatic sparks. High humidity is uncomfortable for staff and could increase wound infection or cause mildew or mild in the longer term. The evidence on both fronts is sparse but equipment and supplies often specify ranges that prudent organizations adhere to, which may involve suspending operations.

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In utero exposure to antibiotics and risk of congenital malformations

This population based study compared 10 commonly prescribed antibiotics and compared first trimester exposure to a cohort exposed to either of four penicillins considered safe during pregnancy (ampicillin, pivampicillin, benzylpenicillin and phenoxymethylpenicillin.

No increased risk of congenital malformations was found between the two. Compared to non-exposed pregnancies, small increased risks for major malformations and cardiac malformations were apparent for pivmecillinam, sulfamethizole, and azithromycin.

The overall conclusions are somewhat reassuring.

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Unprofessional Behavior by Surgeons and Surgical Complications

Unprofessional or what is known as disruptive behaviour has been shown to be rife in hospitals. This retrospective study tested the hypothesis that patients of surgeons with higher numbers of reports from coworkers about unprofessional behaviors are at greater risk for postoperative complications.

The conclusion: “Patients whose surgeons had higher numbers of coworker reports about unprofessional behavior in the 36 months before the patient’s operation appeared to be at increased risk of surgical and medical complications. ”

The authors point out that “optimal performance depend on effective communication, mutual respect, and continuous situational awareness. Surgeons who model unprofessional behaviors may undermine a culture of safety, threaten teamwork, and thereby increase the risk for medical errors and surgical complications.”

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Association of Opioid Overdose With Opioid Prescriptions to Family Members

It is known that opioid use often stems from family or friend prescriptions.

“In this analysis, opioid prescriptions to family members were associated with overdose among individuals who do not receive opioid prescriptions”.

“Prior opioid dispensing to family members was associated with 2.89-fold higher odds of individual overdose, which persisted in young children and increased with greater quantities of opioid medications dispensed to family members.”

Increased education as to the risks, safe storage of opioids, and availability of opioid antagonists is suggested.

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Complications related to peri‐operative transesophageal echocardiography

Trans-esophageal echocardiography (TEE, TOE) has become a standard monitor for real time cardiac assessment in cardiac and other major surgery and critical care hemodynamic management. However it does have a complication rate.

The Association of Cardiothoracic Anaesthesia and Critical Care carried out a one year prospective audit in cardiac surgery cases in the UK and Ireland. Complications included nine upper gastro‐intestinal perforations and eight upper gastro‐intestinal bleeds. Esophageal stenting, video‐assisted thoracoscopic surgery, gastrostomy, and open surgical repair were listed in the management.

Upper GI injuries are more likely during insertion and lower GI injuries during probe manipulation.

The incidence of peri‐operative TOE‐related complications in the included population was 0.08% and the incidence of death due to a TOE‐related complication was 0.03%.

The implication is that major complications have a 40% risk of death. The authors suggest greater training, use of checklists for safe insertion, and laryngoscope use during insertion, as well as incorporating the risks into consent discussions.

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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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