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Annals of Surgery Apr 2024To examine the association of anesthesiologist sex on postoperative outcomes.
OBJECTIVE
To examine the association of anesthesiologist sex on postoperative outcomes.
BACKGROUND
Differences in patient postoperative outcomes exist, depending on whether the primary surgeon is male or female, with better outcomes seen among patients treated by female surgeons. Whether the intraoperative anesthesiologist's sex is associated with differential postoperative patient outcomes is unknown.
METHODS
We performed a population-based, retrospective cohort study among adult patients undergoing one of 25 common elective or emergent surgical procedures from 2007 to 2019 in Ontario, Canada. We assessed the association between the sex of the intraoperative anesthesiologist and the primary end point of the adverse postoperative outcome, defined as death, readmission, or complication within 30 days after surgery, using generalized estimating equations.
RESULTS
Among 1,165,711 patients treated by 3006 surgeons and 1477 anesthesiologists, 311,822 (26.7%) received care from a female anesthesiologist and 853,889 (73.3%) from a male anesthesiologist. Overall, 10.8% of patients experienced one or more adverse postoperative outcomes, of whom 1.1% died. Multivariable adjusted rates of the composite primary end point were higher among patients treated by male anesthesiologists (10.6%) compared with female anesthesiologists (10.4%; adjusted odds ratio 1.02, 95% CI: 1.00-1.05, P =0.048).
CONCLUSIONS
We demonstrated a significant association between sex of the intraoperative anesthesiologist and patient short-term outcomes after surgery in a large cohort study. This study supports the growing literature of improved patient outcomes among female practitioners. The underlying mechanisms of why outcomes differ between male and female physicians remain elusive and require further in-depth study.
Topics: Adult; Humans; Male; Female; Anesthesiologists; Cohort Studies; Retrospective Studies; Postoperative Complications; Ontario
PubMed: 38264927
DOI: 10.1097/SLA.0000000000006217 -
Best Practice & Research. Clinical... Sep 2023The number of patients with congenital heart disease (CHD) undergoing ambulatory surgery is increasing. Deciding whether a CHD patient is suitable for an ambulatory... (Review)
Review
The number of patients with congenital heart disease (CHD) undergoing ambulatory surgery is increasing. Deciding whether a CHD patient is suitable for an ambulatory procedure is still challenging. Several factors must be considered, including the type of planned procedure, the complexity of the underlying pathology, the American Society of Anesthesiologists' Physical Status classification of the patient, and other patient-specific factors, including comorbidity, chronic complications of CHD, medication, coagulation disorders, and issues related to the presence of a pacemaker (PM) or cardioverter-defibrillator. Numerous studies reported higher perioperative mortality and morbidity rates in surgical patients with CHD than non-CHD patients. However, most of these studies were conducted in a cohort of hospitalized patients and may not reflect the ambulatory setting. The current review aims to provide the anesthesiologist with an overview and practical recommendations on selecting and managing a CHD patient scheduled for an ambulatory procedure.
Topics: Humans; Ambulatory Surgical Procedures; Heart Defects, Congenital; Anesthesiologists; Patients
PubMed: 37938087
DOI: 10.1016/j.bpa.2022.11.006 -
Minerva Anestesiologica Dec 2023Human factors and non-technical skills (NTS) have been identified as essential contributors to both the propagation and prevention of medical errors in the operating... (Review)
Review
Human factors and non-technical skills (NTS) have been identified as essential contributors to both the propagation and prevention of medical errors in the operating room. Despite extensive study and interventions to nurture and enhance NTS in anesthesiologists, gaps to effective team practice and patient safety remain. Furthermore, the link between added NTS training and clinically significant improved outcomes has not yet been demonstrated. We performed a narrative review to summarize the literature on existing systems and initiatives used to measure and nurture NTS in the clinical operating room setting. Controlled interventions performed to nurture NTS (N.=13) were identified and compared. We comment on the body of current evidence and highlight the achievements and limitations of interventions published thus far. We then propose a novel education and training framework to further develop and enhance non-technical skills in both individual anesthesiologists and operating room teams. We use the cardiac anesthesiology environment as a starting point to illustrate its use, with clinical examples. NTS is a key component of enhancing patient safety. Effective framing of its concepts is central to apply individual characteristics and skills in team environments in the OR and achieve tangible, beneficial patient outcomes.
Topics: Humans; Anesthesiologists; Anesthesiology; Educational Status; Heart; Medical Errors
PubMed: 38019175
DOI: 10.23736/S0375-9393.23.16729-0 -
Anesthesiology Clinics Dec 2023Health care requires the effort of a team, and nowhere is this more evident than in the care of the surgical patient. No single clinician can perform all aspects of the... (Review)
Review
Health care requires the effort of a team, and nowhere is this more evident than in the care of the surgical patient. No single clinician can perform all aspects of the continuum of surgical care. The basic operating room (OR) team consists of nurses, technicians, surgeons, and anesthesiologists with unique and well-defined roles and expertise in perioperative care. The modern OR team continues to grow and evolve in size, diversity, and complexity to meet the needs of growing patient and procedural complexity. This growing complexity makes achieving optimal team performance paramount and challenging.
Topics: Humans; Operating Rooms; Surgeons; Anesthesiologists; Perioperative Care; Patient Care Team
PubMed: 37838383
DOI: 10.1016/j.anclin.2023.05.004 -
Minerva Anestesiologica 2023
Topics: Humans; Anesthesiologists; Anesthesiology
PubMed: 36884343
DOI: 10.23736/S0375-9393.23.17225-7 -
International Anesthesiology Clinics Jul 2024Increasingly, both healthcare leaders and studies of healthcare outcomes recommend a medical workforce that is representative of the patient population as a method to... (Review)
Review
Increasingly, both healthcare leaders and studies of healthcare outcomes recommend a medical workforce that is representative of the patient population as a method to reduce health disparities and medical costs. Anesthesiology remains a specialty with lower proportions of women and underrepresented in medicine (URiM) physicians as compared to the overall physician workforce, with 26.1% of anesthesiologists identifying as women and 31.3% of anesthesiologists as URiM. Two areas of focus are commonly identified when discussing inadequate representation in the workforce: recruitment into the specialty and retention in the profession. As medical educators, we provide a critical role in the recruitment and retention of women and URiM anesthesiologists, through implementation of processes, programs, and cultural change. Here, we will discuss the current problems of recruitment and retention of women and URiM anesthesiologists and suggest action plans for now and the future to enhance our specialty's diversity.
Topics: Humans; Anesthesiology; Anesthesiologists; Personnel Selection; Female; Physicians, Women; Minority Groups; Workforce
PubMed: 38785107
DOI: 10.1097/AIA.0000000000000442 -
JAMA Network Open Dec 2023There is marked variability in red blood cell (RBC) transfusion during the intraoperative period. The development and implementation of existing clinical practice...
IMPORTANCE
There is marked variability in red blood cell (RBC) transfusion during the intraoperative period. The development and implementation of existing clinical practice guidelines have been ineffective in reducing this variability.
OBJECTIVE
To develop an internationally endorsed consensus statement about intraoperative transfusion in major noncardiac surgery.
EVIDENCE REVIEW
A Delphi consensus survey technique with an anonymous 3-round iterative rating and feedback process was used. An expert panel of surgeons, anesthesiologists, and transfusion medicine specialists was recruited internationally. Statements were informed by extensive preparatory work, including a systematic reviews of intraoperative RBC guidelines and clinical trials, an interview study with patients to explore their perspectives about intraoperative transfusion, and interviews with physicians to understand the various behaviors that influence intraoperative transfusion decision-making. Thirty-eight statements were developed addressing (1) decision-making (interprofessional communication, clinical factors, procedural considerations, and audits), (2) restrictive transfusion strategies, (3) patient-centred considerations, and (4) research considerations (equipoise, outcomes, and protocol suspension). Panelists were asked to score statements on a 7-point Likert scale. Consensus was established with at least 75% agreement.
FINDINGS
The 34-member expert panel (14 of 33 women [42%]) included 16 anesthesiologists, 11 surgeons, and 7 transfusion specialists; panelists had a median of 16 years' experience (range, 2-50 years), mainly in Canada (52% [17 of 33]), the US (27% [9 of 33]), and Europe (15% [5 of 33]). The panel recommended routine preoperative and intraoperative discussion between surgeons and anesthesiologists about intraoperative RBC transfusion as well as postoperative review of intraoperative transfusion events. Point-of-care hemoglobin testing devices were recommended for transfusion guidance, alongside an algorithmic transfusion protocol with a restrictive hemoglobin trigger; however, more research is needed to evaluate the use of restrictive triggers in the operating room. Expert consensus recommended a detailed preoperative consent discussion with patients of the risks and benefits of both anemia and RBC transfusion and routine disclosure of intraoperative transfusion. Postoperative morbidity and mortality were recommended as the most relevant outcomes associated with intraoperative RBC transfusion, and transfusion triggers of 70 and 90 g/L were considered acceptable hemoglobin triggers to evaluate restrictive and liberal transfusion strategies, respectively, in clinical trials.
CONCLUSIONS AND RELEVANCE
This consensus statement offers internationally endorsed expert guidance across several key domains on intraoperative RBC transfusion practice for noncardiac surgical procedures for which patients are at medium or high risk of bleeding. Future work should emphasize knowledge translation strategies to integrate these recommendations into routine clinical practice and transfusion research activities.
Topics: Humans; Anesthesiologists; Blood Transfusion; Canada; Erythrocyte Transfusion; Hemoglobins; Consensus; Intraoperative Care; Surgical Procedures, Operative; Surgeons
PubMed: 38153742
DOI: 10.1001/jamanetworkopen.2023.49559 -
Journal of Clinical Anesthesia Aug 2023The ASA physical status (ASA-PS) is determined by an anesthesia provider or surgeon to communicate co-morbidities relevant to perioperative risk. Assigning an ASA-PS is...
OBJECTIVE
The ASA physical status (ASA-PS) is determined by an anesthesia provider or surgeon to communicate co-morbidities relevant to perioperative risk. Assigning an ASA-PS is a clinical decision and there is substantial provider-dependent variability. We developed and externally validated a machine learning-derived algorithm to determine ASA-PS (ML-PS) based on data available in the medical record.
DESIGN
Retrospective multicenter hospital registry study.
SETTING
University-affiliated hospital networks.
PATIENTS
Patients who received anesthesia at Beth Israel Deaconess Medical Center (Boston, MA, training [n = 361,602] and internal validation cohorts [n = 90,400]) and Montefiore Medical Center (Bronx, NY, external validation cohort [n = 254,412]).
MEASUREMENTS
The ML-PS was created using a supervised random forest model with 35 preoperatively available variables. Its predictive ability for 30-day mortality, postoperative ICU admission, and adverse discharge were determined by logistic regression.
MAIN RESULTS
The anesthesiologist ASA-PS and ML-PS were in agreement in 57.2% of the cases (moderate inter-rater agreement). Compared with anesthesiologist rating, ML-PS assigned more patients into extreme ASA-PS (I and IV), (p < 0.01), and less patients in ASA II and III (p < 0.01). ML-PS and anesthesiologist ASA-PS had excellent predictive values for 30-day mortality, and good predictive values for postoperative ICU admission and adverse discharge. Among the 3594 patients who died within 30 days after surgery, net reclassification improvement analysis revealed that using the ML-PS, 1281 (35.6%) patients were reclassified into the higher clinical risk category compared with anesthesiologist rating. However, in a subgroup of multiple co-morbidity patients, anesthesiologist ASA-PS had a better predictive accuracy than ML-PS.
CONCLUSIONS
We created and validated a machine learning physical status based on preoperatively available data. The ability to identify patients at high risk early in the preoperative process independent of the provider's decision is a part of the process we use to standardize the stratified preoperative evaluation of patients scheduled for ambulatory surgery.
Topics: Humans; Anesthesiology; Anesthesia; Risk Assessment; Machine Learning; Retrospective Studies
PubMed: 36898279
DOI: 10.1016/j.jclinane.2023.111103 -
Anasthesiologie, Intensivmedizin,... Jul 2023Electroconvulsive therapy (ECT) is an established therapeutic method for the treatment of severe mental disorders refractory to pharmaco- and psychotherapy. ECT is a...
Electroconvulsive therapy (ECT) is an established therapeutic method for the treatment of severe mental disorders refractory to pharmaco- and psychotherapy. ECT is a first-line treatment option in delusional disorders, severe depression with acute suicidal tendency or life-threatening catatonia. Usually, ECT is performed as a treatment series. Under short-term anaesthesia and muscle relaxation, tonic-clonic seizures are induced using an external stimulation electrode. Convulsion can be exerted by uni- or bipolar stimulation using an electric charge up to 1000 millicoulomb (mC) with an amperage of 900 mA. Muscular relaxation is necessary to prevent injuries caused by uncontrolled movements during convulsion. During paralysis, consciousness is blocked by general anaesthesia, although ECT is associated with antegrade amnesia for seizure induction and the seizure itself. In the context of ECT, the ideal hypnotic should be characterised by rapid onset, short duration of action and negligible anticonvulsive effects (i.e., least possible impact on seizure quality and duration). As mutual awareness of psychiatric and anaesthesiologic techniques is essential for safe and effective conduction of ECT, this article presents ECT both from the psychiatrist's and the anaesthesiologist's perspective.
Topics: Humans; Electroconvulsive Therapy; Anesthesia, General; Seizures
PubMed: 37582353
DOI: 10.1055/a-1925-6993 -
Journal of Anaesthesiology, Clinical... 2024Health-care settings have an important responsibility toward environmental health and safety. The operating room is a major source of environmental pollution within a... (Review)
Review
Health-care settings have an important responsibility toward environmental health and safety. The operating room is a major source of environmental pollution within a hospital. Inhalational agents and nitrous oxide are the commonly used gases during general anesthesia for surgeries, especially in the developing world. These greenhouse gases contribute adversely to the environmental health both inside the operating room and in the outside atmosphere. Impact of these anesthetic agents depends on the total consumption, characteristics of individual agents, and gas flows, with higher levels increasing the environmental adverse effects. The inimical impact of nitrous oxide is higher due to its longer atmospheric half-life and potential for destruction of the ozone layer. Anesthesiologist of today has a choice in the selection of anesthetic agents. Prudent decisions will help in mitigating environmental pollution and contributing positively to a greener planet. Therefore, a shift from inhalational to intravenous-based technique will reduce the carbon footprint of anesthetic agents and their impact on global climate. Propofol forms the mainstay of intravenous anesthesia technique and is a proven drug for anesthetic induction and maintenance. Anesthesiologists should appreciate growing concerns about the role of inhalational anesthetics on the environment and join the cause of environmental responsibility. In this narrative review, we revisit the pharmacological and pharmacokinetic considerations, clinical uses, and discuss the merits of propofol-based intravenous anesthesia over inhalational anesthesia in terms of environmental effects. Increased awareness about the environmental impact and adoption of newer, versatile, and user-friendly modalities of intravenous anesthesia administration will pave the way for greener anesthesia practice.
PubMed: 38666164
DOI: 10.4103/joacp.joacp_283_22