Editorial| April 2024 Diabetic Patients, Assessment of Preoperative Gastric Contents, and Potential Reduction of Risk of Pulmonary Aspiration This article has an Audio Podcast Mark A. Warner, M.D. Mark A. Warner, M.D. 1Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota. Search for other works by this author on: This Site PubMed Google Scholar Author and Article Information Accepted for publication December 13, 2023. This editorial accompanies the article on p. 648. This article has a related Infographic on p. A16. Address correspondence to Dr. Warner: Anesthesiology April 2024, Vol. 140, 639–641. https://doi.org/10.1097/ALN.0000000000004878 Connected Content Article: Baseline Gastric Volume in Fasting Diabetic Patients Is Not Higher than That in Nondiabetic Patients: A Cross-sectional Noninferiority Study Infographic: NPO! Ready to Go?: Do Current Fasting Guidelines Ensure Empty Stomach in Diabetic Patients? Views Icon Views Article contents Figures & tables Video Audio Supplementary Data Peer Review Share Icon Share Facebook Twitter LinkedIn Email Cite Icon Cite Get Permissions Search Site Citation Mark A. Warner; Diabetic Patients, Assessment of Preoperative Gastric Contents, and Potential Reduction of Risk of Pulmonary Aspiration. Anesthesiology 2024; 140:639–641 doi: https://doi.org/10.1097/ALN.0000000000004878 Download citation file: Ris (Zotero) Reference Manager EasyBib Bookends Mendeley Papers EndNote RefWorks BibTex toolbar search Search Dropdown Menu toolbar search search input Search input auto suggest filter your search All ContentAll PublicationsAnesthesiology Search Advanced Search Topics: diabetes mellitus, gastric contents, preoperative care, pulmonary aspiration The use of gastric ultrasonography to assess stomach contents preoperatively and reduce the risk of perioperative pulmonary aspiration has been advocated for more than three decades,1 but initial reception into clinical practice was limited. That began to change in 2009 when a team led by Dr. Anahi Perlas at the University of Toronto began targeted studies to determine the efficacy and practicality of using ultrasound to identify patients who have liquid or solid stomach contents present immediately before their anesthetics.2 In this month's Anesthesiology, Perlas et al.3 have taken their studies a step further as they have attempted to answer a persistent question that confronts all anesthesia providers: "Do current preoperative fasting guidelines work for patients who have diabetes as well as they work for healthy patients?" The current preoperative fasting guidelines have proven to work well in reducing the fasting period from the traditional "... You do not currently have access to this content.

Article| October 2022 Steven H. Rose, MD, Recipient of the 2022 ASA Excellence in Education Award Mark A. Warner, MD Mark A. Warner, MD Search for other works by this author on: This Site PubMed Google Scholar ASA Monitor October 2022, Vol. 86, 17–23. https://doi.org/10.1097/01.ASM.0000890048.67321.22 Views Icon Views Article contents Figures & tables Video Audio Supplementary Data Peer Review Share Icon Share Facebook Twitter LinkedIn MailTo Cite Icon Cite Get Permissions Search Site Citation Mark A. Warner; Steven H. Rose, MD, Recipient of the 2022 ASA Excellence in Education Award. ASA Monitor 2022; 86:17–23 doi: https://doi.org/10.1097/01.ASM.0000890048.67321.22 Download citation file: Ris (Zotero) Reference Manager EasyBib Bookends Mendeley Papers EndNote RefWorks BibTex toolbar search Search Dropdown Menu toolbar search search input Search input auto suggest filter your search All ContentAll PublicationsASA Monitor Search Advanced Search Topics: awards and prizes, leadership It is my great honor to announce the recipient of the 2022 ASA Excellence in Education Award – Steven H. Rose, MD. Dr. Rose is a terrific academic leader in graduate medical education and in our specialty and is an outstanding anesthesiologist and educator. He is a wonderful role model for all of us, especially those involved in medical education. Dr. Rose completed his undergraduate studies at Concordia College in Moorhead, Minnesota, and matriculated at the Mayo Clinic School of Medicine in 1977 (Rochester, Minnesota). After medical school, he was a resident in anesthesiology at Mayo Clinic, then spent a year in Cape Town, South Africa, in a trauma anesthesia fellowship. Upon returning to Mayo Clinic, Dr. Rose took on progressively important leadership roles in anesthesia and general graduate medical education. Today, he is a Professor of Anesthesiology and Emeritus Dean, Mayo Clinic School of Graduate Medical Education. There are... You do not currently have access to this content.

Die perioperative Aspiration von Mageninhalt geht haufig mit hoher Morbiditat und Mortalitat einher. Um in diesem Zusammenhang Risikofaktoren auf Seiten der Patientinnen und Patienten sowie im Zuge des Behandlungsprozesses genauer definieren zu konnen, haben Warner und Team eine Beobachtungsstudie zum Thema durchgefuhrt. Weitere Ziele waren die Bewertung von Prozessfaktoren und des fallspezifischen Pflegestandards.

Patient safety is a core principle of anesthesia care worldwide. The specialty of anesthesiology has been a leader in medicine for the past half century in pursuing patient safety research and implementing standards of care and systematic improvements in processes of care. Together, these efforts have dramatically reduced patient harm associated with anesthesia. However, improved anesthesia patient safety has not been uniformly obtained worldwide. There are unique differences in patient safety outcomes between countries and regions in the world. These differences are often related to factors such as availability, support, and use of health care resources, trained personnel, patient safety outcome data collection efforts, standards of care, and cultures of safety and teamwork in health care facilities. This article provides insights from national anesthesia society leaders from 13 countries around the world. The countries they represent are diverse geographically and in health care resources. The authors share their countries’ current and future initiatives in anesthesia patient safety. Ten major patient safety issues are common to these countries, with several of these focused on the importance of extending initiatives into the full perioperative as well as intraoperative environments. These issues may be used by anesthesia leaders around the globe to direct collaborative efforts to improve the safety of patients undergoing surgery and anesthesia in the coming decade.

I read with great interest the excellent article on the Patient Safety Foundation.1 However, I think that your readers may be interested to learn of the origin of efforts to improve quality of care and patient safety.It began in the 1960s when the Board of Governors of the American College of Anesthesiologists, under the leadership of Dr. Tom Burnap, assumed the responsibility for evaluating quality of care and patient safety in anesthesiology. Members of the American College of Anesthesiologists attended national conferences on quality assessment to learn and apply the methodology to anesthesiology. These early activities led President “Rick” Siker to appoint a new committee on quality of care. I served as chair of the quality of care committee for 2 yr.The committee developed criteria for evaluating quality of care, engaged in on-site inspection of departments of anesthesia at the request of hospital administrators, and advanced the concept of “practice parameters.” When I became president during 1980 and 1981, the title of my presidential address was “Quality of Care: ASA’s Raison d’Etre.” Anesthesiology was the first medical specialty to develop a formal program for evaluating quality of care.A few years later, “Jeep” Pierce established the Patient Safety Foundation, which elevated quality of care and patient safety to a whole new level.The author declares no competing interests.

Background Perioperative pulmonary aspiration of gastric contents has been associated with severe morbidity and death. The primary aim of this study was to identify outcomes and patient and process of care risk factors associated with gastric aspiration claims in the Anesthesia Closed Claims Project. The secondary aim was to assess these claims for appropriateness of care. The hypothesis was that these data could suggest opportunities to reduce either the risk or severity of perioperative pulmonary aspiration. Methods Inclusion criteria were anesthesia malpractice claims in the American Society of Anesthesiologists Closed Claims Project that were associated with surgical, procedural, or obstetric anesthesia care with the year of the aspiration event 2000 to 2014. Claims involving pulmonary aspiration were identified and assessed for patient and process factors that may have contributed to the aspiration event and outcome. The standard of care was assessed for each claim. Results Aspiration of gastric contents accounted for 115 of the 2,496 (5%) claims in the American Society of Anesthesiologists Closed Claims Project that met inclusion criteria. Death directly related to pulmonary aspiration occurred in 66 of the 115 (57%) aspiration claims. Another 16 of the 115 (14%) claims documented permanent severe injury. Seventy of the 115 (61%) patients who aspirated had either gastrointestinal obstruction or another acute intraabdominal process. Anesthetic management was judged to be substandard in 62 of the 115 (59%) claims. Conclusions Death and permanent severe injury were common outcomes of perioperative pulmonary aspiration of gastric contents in this series of closed anesthesia malpractice claims. The majority of the patients who aspirated had either gastrointestinal obstruction or acute intraabdominal processes. Anesthesia care was frequently judged to be substandard. These findings suggest that clinical practice modifications to preoperative assessment and anesthetic management of patients at risk for pulmonary aspiration may lead to improvement of their perioperative outcomes. Editor’s Perspective What We Already Know about This Topic What This Article Tells Us That Is New

BACKGROUND: Retrospective and prospective studies 2 decades ago from the authors’ institution reported the incidence of perioperative ulnar neuropathy persisting for at least several months in a noncardiac adult surgical population to be between 30 and 40 per 100,000 cases. The aim of this project was to assess the incidence and explore risk factors for perioperative ulnar neuropathy in a recent cohort of patients from the same institution using a similar definition for ulnar neuropathy. METHODS: We performed a retrospective incidence and case-control study of all adults (≥18 years) undergoing noncardiac procedures with anesthesia services between 2011 and 2015. Each incident case of persistent ulnar neuropathy within 6 months of surgery was matched by age, sex, procedure date, and procedure type to 5 surgical patient controls. For the case-control study, separate conditional logistic regression analyses were performed to assess specific risk factors including the patient’s body position and arm position, as well as body mass index (BMI), surgical duration, and selected patient comorbidities. RESULTS: Persistent ulnar neuropathy of at least 2 months duration was found in 22 of 324,124 anesthetics for patients who underwent these procedures during the study period for an incidence rate of 6.8 (95% confidence interval [CI], 4.3-10.3) per 100,000 anesthetics. The incidence of ulnar neuropathy was higher in men compared to women (10.7 vs 3.0 per 100,000; P = .016). From the matched case-control study, the odds of ulnar neuropathy increased with higher BMI (odds ratio [OR] = 1.67 [1.16-2.42] per 5 kg/m2 increase in BMI; P = .006), history of cancer (OR = 6.46 [1.64-25.49]; P = .008), longer procedures (OR = 1.53 [1.18-1.99] per hour; P = .001), and when 1 or both arms were tucked during surgery (OR = 6.16 [1.85-20.59]; P = .003). CONCLUSIONS: The incidence of persistent perioperative ulnar neuropathy observed in this study was lower than the incidence reported 2 decades ago from the same institution and using a similar definition for ulnar neuropathy. Several of the previously reported risk factors continue to be associated with the development of persistent perioperative ulnar neuropathy, providing ongoing targets for practice changes that might further decrease the incidence of this problem.

Ellison C. Pierce, Jr., M.D., and a small number of specialty leaders and scientists formed a remarkable, diverse team in the mid-1980s to address a dual crisis: a safety crisis for anesthetized patients and a medical malpractice insurance crisis for anesthesiologists. This cohesive team's efforts led to the formation of the Anesthesia Patient Safety Foundation, the American Society of Anesthesiologists's Committees on Standards of Care and on Patient Safety and Risk Management, and the society's Closed Claims Project. The commonality of leaders and members of the Anesthesia Patient Safety Foundation and American Society of Anesthesiologists initiatives provided the strong coordination needed for their efforts to effect change, introduce standards of care and practice parameters, obtain financial support needed to grow patient safety-oriented new knowledge, integrate industry and other relevant leaders outside of anesthesiology, and involve all anesthesia professions. By implementing successful patient safety initiatives, they promoted the recognition that anesthesiology and patient safety are inextricably linked.

Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, and the Mayo Clinic College of Medicine and Science, Rochester, Minnesota Funding Support: None reported. Financial Disclosure: None reported Correspondence: William L. Lanier, M.D., Mayo Clinic, 200 First St, SW, Rochester, MN 55905. E-mail: [email protected]

Perioperative serotonin syndrome has been associated with a number of medications and herbal supplements. We report a patient who developed serotonin syndrome immediately after an endoscopic procedure in which the preoperative use of black seed oil appears to have played a role in stimulating the syndrome. Black seed oil has not been previously reported in association with perioperative serotonin syndrome. Anesthesia professionals should be aware that patients taking black seed oil supplements may develop serotonin syndrome postoperatively.

Anesthesiology, V 127 • No 3 410 September 2017 S IMULATION in the field of anesthesiology has proven useful in helping clinicians keep their practice skills current, particularly in the management of uncommon crises that they may encounter in their day-to-day work environment. Simulation is now an Accreditation Council for Graduate Medical Education requirement for residency programs, and its use as an educational tool has been well demonstrated. Recognizing its benefits to practicing anesthesiologists, simulation is an accepted component of Maintenance of Certification in Anesthesiology (MOCA), Part 4, which is aimed to improve medical practice. Although the use of simulation for assessment has been described in training situations, it has not been widely discussed as an assessment tool for practicing anesthesiologists. In this issue of ANESTHESIOLOGY, Weinger et al.1 assessed the performance of board-certified anesthesiologists in managing critical events that may occur in the course of the everyday practice of anesthesiology. What can we learn from this new use of highfidelity simulation? The results of their study raise concern. Many practicing anesthesiologists were rated as performing poorly in the management of uncommon but what should be familiar scenarios: local anesthetic systemic toxicity, hemorrhagic shock from occult peritoneal bleeding, malignant hyperthermia in the postanesthesia care unit, and acute onset of atrial fibrillation with hemodynamic instability followed by ST elevation myocardial infarction. In their study, 30% of the 284 practicing anesthesiologists could not manage these scenarios. On first reading, that sounds alarming. We know that the use of simulation in education has taken many different forms–task trainers, objective structured clinical examinations, and high-fidelity simulation among them. In education, simulation is an effective tool in teaching resuscitation skills2 and in introducing trainees to pediatric anesthesiology.3 However, a single exposure to a simulation-based educational experience in a training setting does not instill skills that are retained for the duration of one’s professional life,4 and repeated exposure–deliberate practice–is necessary to maintain skills. On reflection, the favorable performance of the majority of anesthesiologists in the study by Weinger et al.1 should be encouraging. Their findings may have identified variations in participants’ daily exposure to specific areas of anesthesiology and the lack of recent exposure or deliberate practice in areas where these anesthesiologists had not recently or repeatedly had exposure in their daily practices. The study by Weinger et al.1 adds credence to the concept that continuing professional development programs and, subsequently, assessment tools should be designed to support the delivery of care that improves patient outcomes.5 To be effective, these programs should generate enough interest that participants will voluntarily seek to use them as effective learning tools. They must appeal to the individual needs of a diverse group of learners. For practicing clinicians, simulation has been demonstrated to be an effective way to identify and address practice gaps.6 Simulation has also proven to be a cost-effective way to teach the management of infrequent adverse events, new surgical techniques, sterile central line insertion, and teamwork.5 However, the use of simulation as an assessment tool in high-stakes examinations or in evaluating the practice of individuals who completed their training years earlier has been limited. The world of medicine is constantly changing, and it takes significant and deliberate effort to stay current. New discoveries, changes in the practice of medicine, and the growth of disruptive technologies continue to drive the way that medicine is practiced. With these changes, continuing professional development is essential to master new advances and incorporate those that improve patient care into practice. Significant changes that impact perioperative patient Simulation for Assessment of the Practice of Board-certified Anesthesiologists

Patient safety secured by constant vigilance remains a primary responsibility of every anesthesia professional. Although significant attention has been focused on patient falls occurring before and after surgery, a potentially catastrophic complication is when patients fall off an operating room or procedure table during anesthesia care. Because such events are (fortunately) uncommon, and because very little information is published in our literature, we queried 2 independent closed claims databases (the American Society of Anesthesiologists Closed Claims Project and the secure records of a private, anesthesia specialty-specific liability insurer) for information. We acquired documentation of patient events where a fall occurred during anesthesia care, noting the surrounding conditions of the provider, the patient, and the environment at the time of the event. We identified 21 claims (1.2% of cases) from the American Society of Anesthesiologists Closed Claims Project, while information from a private liability insurer identified falls in only 0.07% of cases. The percentage of these patients under general, regional, or monitored anesthesia care anesthesia was 71.5%, 19.5%, and 9.5%, respectively. To educate personnel about these uncommon events, we summarized this cohort with illustrative examples in a series of mini-case reports, noting that both inpatients and outpatients undergoing a broad array of procedures with various anesthetic techniques within and outside operating rooms may be vulnerable to patient falls. Based on detailed reports, we created 2 supplementary videos to further illuminate some of the unique mechanisms by which these events and their resulting injuries occur. When such information was available, we also noted the associated liability costs of defending and settling malpractice claims associated with these events. Our goal is to inform anesthesia and perioperative personnel about the common patient, provider, and environmental risk factors that appear to contribute to these mishaps, and suggest key strategies to mitigate the risks.