As a profession, anesthesia is recognized as one of the leaders in, and early adopters of, patient safety practices.The term ''patient safety'' is said to have been coined by the former American Society of Anesthesiologists' President Ellison (Jeep) Pierce who also founded the Anesthesia Patient Safety Foundation (APSF) in 1985, one of the first patient safety organizations ever created.To this day, the APSF continues to work with clinicians, organizations, and industry to improve patient safety surrounding anesthetic care.It was not for another decade and a half that ''To Err is Human: Building a Safer Health System'' was published revealing that preventable medical errors were responsible for thousands of patient deaths.Healthcare is increasing in complexity with countless opportunities for error.Patient safety is not only a concern for the patients themselves, but also for everyone involved in the healthcare system.Building on this anesthesia legacy, and in recognition of the importance of multidisciplinary care, OK to Proceed?What Every Health Care Provider Should Know About Patient Safety was developed by three anesthesiologists: Keith Lewis, Robert Canelli, and Rafael Ortega.The overall purpose of this work was to equip healthcare providers with a basic knowledge of patient safety and to introduce the ''OK to Proceed'' model.This text is written by authors from multiple disciplines, including those not traditionally associated with healthcare, such as lawyers, administrators, and educators.This work recognizes the importance of the different perspectives of

INTRODUCTION:Obstructive sleep apnea (OSA) may increase the incidence of postoperative complications when undiagnosed. The purpose of this study was to evaluate the perspectives of Canadian anesthesiologists regarding the perioperative management of patients with diagnosed or suspected OSA.METHODS:This study was conducted as a survey of Canadian anesthesiologists using a self-administered scenario-based questionnaire. We initially mailed the survey questionnaire and then mailed it again to non-respondents six weeks later. Subsequently, we e-mailed the online version of our survey to active members of the Canadian Anesthesiologists' Society.RESULTS:The response rates were 35% and 26% for the postal and online modes of administration, respectively. About 50% of the respondents relied on clinical suspicion rather than on a systematic screening to identify patients who may have undiagnosed OSA preoperatively. Forty-seven percent of all respondents either did not know of any institutional policy to guide their perioperative management of patients with OSA or reported an absence of an institutional policy. Fifteen percent of the respondents would discharge diagnosed OSA inpatients with compliant use of continuous positive airway pressure (CPAP) to the ward without monitoring. Nevertheless, a more conservative approach was observed for CPAP non-compliant inpatients. We indeed observed that more than 40% of respondents would send an ambulatory OSA patient home, while another 60% would favour hospital admission.CONCLUSIONS:The majority of anesthesiologists continue to rely on clinical suspicion alone to identify OSA. Moreover, the lack of institutional policy is concerning. A concerted effort to develop an evidence-based guideline may be the next step to assist institutions.

Sir: Despite the assurance of a well-designed and rigorous meta-analysis showing no increased overall risk of perioperative surgical bleeding with ketorolac, we would echo and emphasize the authors’ caveat that one be selective in its use as determined by the type of procedure and patient risk. We recently published the experience at our center with the use of ketorolac in reduction mammaplasty, demonstrating a significant increase in surgical bleeding complications in patients treated with this agent.1 Admittedly, our study design lacked the precision of a randomized and blinded trial, but the data are compelling enough to arguably preclude one even being attempted. We feel that ketorolac should not be used in outpatient and short-stay surgical procedures where there is extensive surgical undermining in subcutaneous and prefascial tissue planes where large bleeding surfaces obscured by subcutaneous fat are created. Notwithstanding the obvious opioid-sparing benefit of ketorolac in these settings, we have stopped the routine use of this agent for reduction mammaplasty and abdominoplasty procedures. However, the authors have convincingly demonstrated a wide array of surgical settings in plastic surgery where ketorolac remains a useful therapeutic adjunct for postoperative analgesia. DISCLOSURE The authors have no financial interest in any of the products, devices, or drugs mentioned in this communication. John S. D. Davidson, M.D. Department of Surgery Division of Plastic Surgery Kim Turner, M.D. Departments of Anesthesiology and Perioperative Medicine Queen’s University Kingston, Ontario, Canada

BACKGROUND: Several studies addressing intrathecal morphine (ITM) use following spine surgery have been published either involving the pediatric population, using mid- to high-dose ITM, or not in conjunction with morphine patient-controlled analgesia (PCA). OBJECTIVES: To determine whether low-dose ITM is a useful adjunct to PCA for postoperative pain control following elective lumbar spine surgery in adults. METHODS: Thirty-two patients were enrolled in a double-blinded randomized controlled trial, and received either ITM or intrathecal placebo. Postoperatively, all patients were given a PCA pump and observed for the first 24 h in a step-down unit. Measurements of: total PCA morphine consumed in the first 24 h; intensity of pain; pruritus; nausea at 4 h, 8 h and 24 h; time to first ambulation; length of hospital stay; and occurrences of respiratory depression were recorded. RESULTS: The total PCA use was significantly lower in the ITM group. There were lower average pain scores in the ITM group, which increased to that of the intrathecal placebo group over 24 h; however, this failed to attain statistical significance. There were no differences in nausea, pruritus, time to first ambulation or hospital length stay. There were no cases of respiratory depression in either group. CONCLUSIONS: ITM may be a useful adjunct to PCA, but did not decrease time to ambulation or length of stay.

Surv Anesthesiol 2016;60(2):75–75 Postoperative residual neuromuscular blockade (RNMB), at normalized train-of-4 (TOF) ratios of less than 0.9, is associated with increased risk of aspiration, airway obstruction, hypoxia, pharyngeal/esophageal complications, and prolonged postanesthesia care unit stay. Residual neuromuscular blockade incidence has not been examined before in Canada, but can range from 26% to 88%, depending on various factors.

BACKGROUND: Postoperative residual neuromuscular blockade (NMB), defined as a train-of-four (TOF) ratio of <0.9, is an established risk factor for critical postoperative respiratory events and increased morbidity. At present, little is known about the occurrence of residual NMB in Canada. The RECITE (Residual Curarization and its Incidence at Tracheal Extubation) study was a prospective observational study at 8 hospitals in Canada investigating the incidence and severity of residual NMB.METHODS: Adult patients undergoing open or laparoscopic abdominal surgery expected to last <4 hours, ASA physical status I-III, and scheduled for general anesthesia with at least 1 dose of a nondepolarizing neuromuscular blocking agent for endotracheal intubation or maintenance of neuromuscular relaxation were enrolled in the study. Neuromuscular function was assessed using acceleromyography with the TOF-Watch (R) SX. All reported TOF ratios were normalized to the baseline values. The attending anesthesiologist and all other observers were blinded to the TOF ratio (T4/T1) results. The primary and secondary objectives were to determine the incidence and severity of residual NMB (TOF ratio <0.9) just before tracheal extubation and at arrival at the postanesthesia care unit (PACU).RESULTS: Three hundred and two participants were enrolled. Data were available for 241 patients at tracheal extubation and for 207 patients at PACU arrival. Rocuronium was the NMB agent used in 99% of cases. Neostigmine was used for reversal of NMB in 73.9% and 72.0% of patients with TE and PACU data, respectively. The incidence of residual NMB was 63.5% (95% confidence interval, 57.4%-69.6%) at tracheal extubation and 56.5% (95% confidence interval, 49.8%-63.3%) at arrival at the PACU. In an exploratory analysis, no statistically significant differences were observed in the incidence of residual NMB according to gender, age, body mass index, ASA physical status, type of surgery, or comorbidities (all P > 0.13).CONCLUSIONS: Residual paralysis is common at tracheal extubation and PACU arrival, despite qualitative neuromuscular monitoring and the use of neostigmine. More effective detection and management of NMB is needed to reduce the risks associated with residual NMB.

Résumé Objectif Actuellement, les lignes directrices sont absentes et la preuve insuffisante pour guider les anesthésiologistes dans la prise en charge périopératoire des patients atteints ďapnée du sommeil ďorigine obstructive (ASO). Notre but était ďexaminer la démarche périopératoire actuelle et de sonder les anesthésiologistes sur des directives fondées sur la preuve/un consensus pour les assister auprés de ces patients. Méthode Un questionnaire postal a été envoyé aux anesthésiologistes canadiens à cet effet. Les répondants devaient indiquer quel monitorage postopératoire ils choisiraient selon deux scénarios cliniques représentant ľadministration ďune anesthésie générale et régionale et modifiés pour illustrer: le traitement de ľASO, ľusage ďopioïdes postopératoires, la présence ďobésité morbide et la sévérité croissante ďASO. Résultats Le taux de réponse a été de 70 % (746/1 063). Parmi les répondants, 67 % donnaient des soins périopératoires à un patient sur cinq, par mois, atteint ďASO et 72 % mentionnaient ľabsence de politique départementale sur ľASO. Quatrevingt-douze pour cent interrogeaient leur patient sur ľASO avant ľopération. Il y a eu une concordance de ≥ 75 % pour deux modifications sur cinq du scénario de ľanesthésie générale et pour une des modifications du scénario de ľanesthésie régionale. Quatrevingt-deux pour cent ont rapporté que des directives les aideraient à traiter les patients atteints ďASO. Conclusion Ľétude démontre des variations dans le monitorage postopératoire des patients atteints ďASO, réalisé par les anesthésiologistes. La majorité des répondants a rapporté ľabsence de politique départementale et croit que des directives faciliteraient le traitement de ľASO.

Purpose We conducted a retrospective review following concerns involving a suspected increase in the requirement for surgical re-exploration for hematoma evacuation when ketorolac was administered perioperatively in patients undergoing reduction mammoplasty. Methods Following ethics approval, a retrospective chart review was conducted of all patients who underwent reduction mammoplasty at our two institutions from the time ketorolac became available in 2004 until surgeons requested its use discontinued in 2007. The data we collected included patient demographics, ketorolac administration, requirement for surgical re-exploration, documented hematoma formation not requiring surgical re-exploration, and excessive bleeding in the perioperative period. Three hundred and seventy-nine patient records were reviewed; 127 of the patients received a single intravenous dose of ketorolac (15 or 30 mg), and 252 of the patients did not receive ketorolac. Results Patients who received ketorolac were at an increased risk of requiring surgical re-exploration for hematoma evacuation (relative risk [RR] = 3.6; 95% confidence interval [CI], 1.4 to 9.6) and hematoma formation not requiring re-exploration (RR = 2.2; 95% CI, 1.3 to 3.6). Conclusions A single perioperative intravenous dose of ketorolac was associated with a greater than three-fold increase in the likelihood of requirement for surgical hematoma evacuation. Our data suggest that it may be prudent to consider carefully whether the potential risks associated with the use of ketorolac outweigh the potential benefits of using ketorolac in patients undergoing reduction mammoplasty.

Wood Library Museum as well as the Canadian Medical Association's John B. Nielson Award, which recognized his contribution to the study of the history of medicine.While

From Craft to Specialty: A Medical and Social History of Anesthesia and Its Changing Role in Health Care . By David Shephard, M.B., F.R.C.P.C., in association with Alan Sessler, M.D., Francis Whalen, M.D., Tuhin Roy, M.D., Ph.D. Bloomington, Indiana, Xlibris Corporation, 2009. Pages: 451. Price: $35.00 (hardcover); $24.00 (paperback).From Craft to Specialty is a carefully written and meticulously referenced history of the birth and development of surgical anesthesia. The book begins with the premise that surgical anesthesia became possible only after men and women conceived of its possibility. This seminal idea came to life in a very special social and political setting, and Dr. Shephard's focus in this book is as much about how the developments in anesthesiology came to pass as it is on the actual events and the major players responsible for these events. In the second chapter, in the section "1800–1840: The Nonuse of Nitrous Oxide and Ether," Dr. Shephard makes the point that, although they were available, no one thought of using these agents for surgical anesthesia, stating "In short, early in the nineteenth century, the moral climate was not compatible with the idea of inducing unconsciousness for surgical purposes. Patients needing surgery just had to withstand the pain, perhaps with the aid of established anodynes. Some were able to do so; others just collapsed; and others simply succumbed." The second facet that the book covers is the evolutionary development of anesthesia outside the operating room, in areas such as obstetrics, critical care, and pain management. These areas of specialization are discussed carefully within the social and political context in which they developed. Finally, the growth of professionalism in anesthesiology is explored, encompassing the establishment of professional societies, such as the American Society of Anesthesiologists, the genesis of academic departments worldwide, and the birth and development of formal training programs and the accreditation processes, such as those governed by the American Board of Anesthesiology. The focus of the text is international, and the author elucidates events as they occur in the United Kingdom, Germany, Australia, and elsewhere.This book is, in many ways, the "big little book" of anesthesia history. The text itself comprises 329 pages. The balance of the book, a little more than 100 pages, consists of two appendices, a glossary, a bibliography, endnotes (specific textual references), and two indices: one entitled "Personal Names" and the other "Objects and Topics." Overall, the author's plan for the book is to trace the development of the practice of anesthesia from a craft (from the discovery and public demonstration of ether in 1846) to a discipline (beginning in 1900 to the mid-1930s) to a specialty and, finally, to the growth and development of the subspecialties that are in existence today. The topics are covered within the social and political context in which they occurred.Dr. Shephard covers this material in 15 chapters, which are dense with details and referenced extensively. The first chapter covers the period until 1800 and discusses ancient anodynes, such as the poppy and opium, mandragora, henbane, cannabis, and spongia somnifera. Even ether may have been an ancient anodyne. We found this chapter quite fascinating and comprehensive, a formidable task given the antiquity of the material. In subsequent chapters, the topics are divided primarily by periods: 1800–1846, 1846–1896, 1896 to the mid-1950s, and the 1950s to the present era. Rather than trying to explore and delineate every development in anesthesia in these distinct periods, important events are grouped by category, for example, chapter 3 is entitled "Laying a Foundation of Anesthetic Practice: 1846–1896." Chapter 4 covers the development of general anesthesia in the 20th century. Separate chapters cover the birth of local anesthesia, airway management (including laryngoscopes, the endotracheal tube, and the Laryngeal Mask Airway [LMA™; LMA Worldwide, Netherlands Antilles]), and the introduction and evolution of anesthesia machines and monitors. In the other chapters, the author covers the emergence of anesthesia as a professional specialty with subsequent subspecialization. The text is rich with figures and legends and brief biographical sketches. Notable names in the first chapter alone include Vesalius, Paracelsus, Harvey, Boyle, Beddoes, and Priestley. The final chapter brings the whole book together, reexploring topics such as positive and negative forces and specialty recognition, the influence of science and technology on anesthesia, expansion of the nature and scope of anesthesia, and the relationship between anesthesia and society.The book succeeds on many levels and is delightful, although challenging, to read. It has so much information, and each subject is explored in such great detail that the book is a tough read at times. In any event, it is a great reference for those looking for pieces to the puzzle of anesthesia history, and readers at all levels will find much to delight them. It is a welcome addition to the literature chronicling our heritage.*University of Alabama Birmingham School of Medicine, Birmingham, Alabama. mmandabach@uab.edu