Anesthesiology

Innovation in sedation and analgesia training Purpose of review We reviewed evidence of recent innovations in sedation education and discuss experiences with sedation training in Taiwan. Recent findings Current Status of Sedation Training: Didactic training and supervised clinical mentoring are common methods of sedation training. Although training course designed by professional societies to meet individual hospital credentialing requirements, the course content and training expectations vary and are likely inadequate to non-anesthesiologist sedation practitioners. Less Common Forms of Sedation Training: These include screen-based simulation, high-fidelity manikin-based simulation. Screen-based simulation sedation training is popular, convenient, and relatively inexpensive. Although there are numerous courses available, course content has not been standardized. High-fidelity simulation has been accepted to improve knowledge, self-confidence, awareness of emergency, crisis resource management, and teamwork, but it is costly, time intensive, and requires expertise in using simulation equipment. Although screen-based training is attractive and convenient, there is no evidence to suggest that it can replace high-fidelity simulation. Another recently developed education modality is virtual reality simulation. It has gained recent popularity as an immersive approach to medical training, but minimal content has been developed for sedation training. Beyond training, several other potential innovations may improve sedation effectiveness and patient safety. These include adherence to practice guidelines established by professional organizations, utilization of a pre-procedure sedation checklist, interpreting capnography, and implementation of real-time bedside drug displays that provide predictions of concentrations and their associated effects. Summary Effective sedation education and training, especially for nonanesthesiologists, is essential to improve patient safety for procedural sedation. Several innovative approaches have been proposed and are relatively early in their development and implementation. Further studies designed to assess the impact of these new training modalities on patient safety and outcomes are warranted. Correspondence to Hung-Wei Cheng, MD, Department of Anesthesiology, Taipei Veterans General Hospital, No. 201, Sec. 2, Shipai Rd., Taipei, Taiwan ROC. Tel: +886 2 28757549; fax: +886 2 28751597; e-mail: hwc1127@gmail.com Copyright © 2019 YEAR Wolters Kluwer Health, Inc. All rights reserved.

Moderate and deep sedation training and pharmacology for nonanesthesiologists: recommendations for effective practice Purpose of review The purpose of this review is to discuss current drugs used for intravenous moderate and deep sedation by nonanesthesiologists in the United States. We also explore training expectations for moderate and deep sedation as they play key roles in anesthetic selection and preprocedural planning. Recent findings Although opioids and benzodiazepines are considered the standard for moderate sedation, increased interest in propofol, dexmedetomidine, and other sedative-hyptonic drugs require additional attention in terms of training providers and complying with current practice guidelines. Summary Moderate sedation providers should be familiar with titrating benzodiazepines and opioids to achieve targeted sedation. The use of propofol and ketamine is generally reserved for deep sedation by qualified professionals. However, the role of dexmedetomidine in procedural sedation continues to evolve as its use is explored in moderate sedation. Providers of all sedation types should be aware of hypotension, apnea, hypoventilation, and hypoxia that can develop and they should be able to manage the patient under these circumstances. Preprocedural planning is an integral training expectation to minimize patient risks. Correspondence to Richard D. Urman, MD, MBA, Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, 75 Francis Street – CWN L1, Boston, MA 02115, USA. Tel: +1 617 732 8222; e-mail: rurman@bwh.harvard.edu Copyright © 2019 YEAR Wolters Kluwer Health, Inc. All rights reserved.

Airway rescue during sedation: a proposed airway rescue pathway for nonanesthesiologists Out-of-operating room procedures that require sedation are expanding in number and scope. With this expansion, the number of nonanesthesiologist sedation practitioners is growing as well. Professional societies and governing bodies have issued extensive sedation guidelines and practice recommendations. Despite these guidelines and the significant harm that can result from adverse events in patients undergoing sedation, training for nonanesthesiologist sedation practitioners is inconsistent and largely inadequate to prepare them for rare but severe adverse events they may encounter. Purpose of review This review summarizes key features of adverse airway and respiratory events for which sedation providers must be prepared to diagnose and treat in a timely manner. Key features include elements of the presedation patient evaluation that are predictive of adverse airway and respiratory events; patient profiles, target sedation levels, and procedure types that should prompt a consult with an anesthesiologist; necessary clinical skills, essential equipment, and reversal drugs necessary to manage adverse airway and respiratory events; and a proposed airway rescue pathway that describes a sequence of interventions and prompts to call for help when encountering an adverse airway or respiratory event. Recent findings Several studies have reported adverse events from sedation. Although the overall rate can approach 4.5%, the incidence of events associated with severe harm is low (e.g., <0.5%). Some of those that are most harmful are prolonged ventilatory compromise leading to hypoxic brain injury or death. Inadequate clinical skills that contribute to these poor outcomes include undetected or delayed detection of hypopnea or apnea, undetected or delayed detection of partial or complete airway obstruction, inadequate rescue skills to manage drug-induced ventilatory depression or airway obstruction, and/or a delay or no attempt to call for expert help followed by a timely response and intervention from that expert help. Summary To improve outcomes in detecting and managing adverse airway and respiratory events, nonanesthesiologists sedation practitioners must be trained in patient selection, monitoring, pharmacology, physiology, and airway management. One gap in sedation training curriculum is a roadmap to use when managing an adverse airway or respiratory events. This review puts forth a suggested airway rescue pathway for nonanesthesiologist sedation practitioners to use as a decision aid during an adverse airway or respiratory event associated with procedural sedation. Correspondence to Elizabeth M. Thackeray, MD, MPH, Department of Anesthesiology, University of Utah, 30 North 1900 East, Room 3C444, Salt Lake City, UT 84132, USA. Tel: +1 801 581 6393; e-mail: Elizabeth.thackeray@hsc.utah.edu Copyright © 2019 YEAR Wolters Kluwer Health, Inc. All rights reserved.

The rise, fall, and future direction of computer-assisted personalized sedation Purpose of review The first computer-assisted personalized sedation (CAPS) device was developed to address the growing demand for routine endoscopy procedures in the United States in the early 2000s. This review will describe the environment that gave rise to CAPS and summarize the design of that first device. It will then discuss the market forces that led to the fall of CAPS, with sales of the device ending 2 years after commercialization. Recent findings CAPS was initially conceived as a means to enable proceduralists to administer conscious sedation with propofol safely. In the nearly 20 years since its conception, the expectations of patients and proceduralists for endoscopy sedation, have evolved from conscious sedation to deep. Due to the increased risk inherent in deep sedation, future CAPS devices should be tools for anesthesiologists, not proceduralists. Summary Over $2 billion are spent annually for anesthesia services in routine endoscopic procedures for low-risk patients; a spending rate that is not sustainable. CAPS, in an 'anesthesia oversight' model similar to medical supervision, has a future as a cost-efficient means for anesthesia services to provide sedation in endoscopy and other nonoperating room venues. Anesthesiologists should work with medical device companies and payers to develop a CAPS 'anesthesia oversight' model. Correspondence to Paul J. Niklewski, PhD, CARE/Crawley Building, Suite E-870 3230, Eden Avenue, Cincinnati, OH 45267, USA. Tel: +1 513 558 7333; e-mail: niklewpj@ucmail.uc.edu Copyright © 2019 YEAR Wolters Kluwer Health, Inc. All rights reserved.

Hyperventilation in neurological patients: from physiology to outcome evidence Purpose of review Hyperventilation is commonly used in neurological patients to decrease elevated intracranial pressure (ICP) or relax a tense brain. However, the potentially deleterious effects of hyperventilation may limit its clinical application. The aim of this review is to summarize the physiological and outcome evidence related to hyperventilation in neurological patients. Recent findings Physiologically, hyperventilation may adversely decrease cerebral blood flow (CBF) and the match between the cerebral metabolic rate and CBF. In patients with severe traumatic brain injury (TBI), prolonged prophylactic hyperventilation with arterial carbon dioxide tension (PaCO2) less than 25 mmHg or during the first 24 h after injury is not recommended. Most patients (>90%) with an aneurysmal subarachnoid hemorrhage undergo hyperventilation (PaCO2 <35 mmHg); however, whether hyperventilation is associated with poor outcomes in this patient population is controversial. Hyperventilation is effective for brain relaxation during craniotomy; however, this practice is not based on robust outcome evidence. Summary Although hyperventilation is commonly applied in patients with TBI or intracranial hemorrhage or in those undergoing craniotomy, its effects on patient outcomes have not been proven by quality research. Hyperventilation should be used as a temporary measure when treating elevated ICP or to relax a tense brain. Outcome research is needed to better guide the clinical use of hyperventilation in neurological patients. This is an open access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. http://creativecommons.org/licenses/by-nc-nd/4.0 Correspondence to E. Wang, Department of Anesthesiology, Xiangya Hospital Central South University, Xiangya Road 87#, Changsha 410008, PR China. Tel: +86-0731-84327413; fax: +86-0731-84327413; e-mail: ewang324@csu.edu.cn Copyright © 2019 YEAR Wolters Kluwer Health, Inc. All rights reserved.

The impact of frailty and sarcopenia on patient outcomes after complex spine surgery Purpose of review Frailty and sarcopenia represent a state of increased fragility and decreased reserve, and both have been associated with worse outcomes after surgery. The present review focuses on the definitions and measurement tools used to assess frailty and sarcopenia in patients with spinal disorder, and the relationships between frailty, sarcopenia, and postoperative outcomes in patients undergoing complex spine surgery. Recent findings Complex spine surgery is associated with a high rate of adverse events when using a validated, prospective data collection system. Recent studies have demonstrated that patients with spine surgery with frailty and sarcopenia have a higher risk of adverse events, although this relationship varies depending on the measurement tool and specific population studied. Both general and specific frailty assessment tools have been used in the spine surgery population, however the optimal tool is not known. Spinal disorders such as lumbar stenosis contribute to the frailty phenotype, and may be reversible with surgery. Summary Frailty and sarcopenia are increasingly recognized as important predictors of adverse outcomes after complex spine surgery. The optimal tool to measure frailty and sarcopenia in patients with spinal disorders remains unclear, and the role of surgery as an intervention to reverse frailty requires further investigation. Correspondence to Dr Alana M. Flexman, Department of Anesthesiology and Perioperative Care, Vancouver General Hospital, Room 2449 JPP 899 West 12th Avenue, Vancouver, BC, Canada, V5Z 1M9. Tel: +1 604 875 4304; fax: +1 604 875 5209; e-mail: alana.flexman@vch.ca Copyright © 2019 YEAR Wolters Kluwer Health, Inc. All rights reserved.

Monitoring standards in sedation and analgesia: the odyssey of capnography in sedation for gastroenterology procedures Purpose of review Capnography is an excellent tool for early detection of hypoxemia and apnea in patients undergoing sedation for gastrointestinal endoscopy. The current American Society of Anesthesiology (ASA) guidelines recommend the use of capnography in any patient undergoing moderate sedation. The purpose of this review was to compile the most recent data available on capnography use in gastrointestinal endoscopy with the focus primarily on the use of capnography in moderate sedation cases. Recent findings Recent high-quality studies have evaluated the utility of capnography in low risk patients undergoing moderate sedation and have found no benefit with addition of capnography. Summary Capnography is beneficial when used for patients who are at a higher risk for sedation-related complications. There is no benefit when capnography is used in low risk patients undergoing routine upper endoscopy and colonoscopy under moderate sedation but there is benefit when used in advanced endoscopic procedures that require deeper sedation and have longer procedure times. Correspondence to John J. Vargo, MD, MPH, Director, Endoscopy Operations Enterprise, Digestive Disease Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA. Tel: +1 216 445 5012; e-mail: vargoj@ccf.org Copyright © 2019 YEAR Wolters Kluwer Health, Inc. All rights reserved.

Safety in the nonoperating room anesthesia suite is not an accident: lessons from the National Transportation Safety Board Purpose of review To review the findings of National Transportation Safety Board-related airline near misses and catastrophes and apply these principles to the nonoperating room anesthesia (NORA) suite. Recent findings NORA is a specialty that has seen tremendous growth. In 2019, NORA contributes to a larger proportion of anesthesia practice than ever before. With this growth, the NORA anesthesiologist and team are challenged to provide safe, high-quality care for more patients, often with complex comorbidities, and are forced to utilize deeper levels of sedation and anesthesia than ever before. These added pressures create new avenues for human error and adverse outcomes. Summary Safety in modern anesthesia practice often draws comparison to the aviation industry. From distinct preoperational checklists, defined courses of action, safety monitoring and the process of guiding individuals through a journey, there are many similarities between the practice of anesthesia and flying an airplane. Consistent human performance is paramount to creating safe outcomes. Although human errors are inevitable in any complex process, the goal for both the pilot and physician is to ensure the safety of their passengers and patients, respectively. As the airline industry has had proven success at managing human error with a dramatic improvement in safety, a deeper look at several key examples will allow for comparisons of how to implement these strategies to improve NORA safety. Correspondence to Jason D. Walls, MD, Department of Anesthesiology and Critical Care, Hospital of the University of Pennsylvania, 3400 Spruce St., Philadelphia, PA 19104, USA. Tel: +1 215 662 3773; e-mail: jason.walls@uphs.upenn.edu Copyright © 2019 YEAR Wolters Kluwer Health, Inc. All rights reserved.

Transfusion in adults and children undergoing neurosurgery: the outcome evidence Purpose of review Transfusion is a common practice during neurosurgery. However, there is no evidence-based consensus on transfusion practice in neurosurgery. This review summarizes the evidence pertinent to the commonly used transfusion triggers in neurosurgical patients. Recent findings In the field of neurosurgery, there is only one randomized controlled trial, performed in patients with traumatic brain injury, to investigate the transfusion trigger of red blood cells. There is a lack-of-quality evidence pertinent to the transfusion triggers of other blood products. Most of the transfusion triggers used for neurosurgical patients are extrapolated from the evidence based on studies performed in nonneurosurgical patients. Clinical experience and expert opinions have played a major role in transfusion practice in neurosurgery. Summary There is a scarcity of high-quality outcome-based evidence for transfusion practice in neurosurgery. In the absence of quality evidence, the transfusion practice in neurosurgical patients should be based on the understanding of the complex pathophysiology related to anemia and coagulopathy and the balance between the risks and benefits associated with blood product transfusion. The practice guided by tissue oximeter and viscoelastic tests appears promising, but needs to be validated by future studies. Correspondence to Tianlong Wang, MD, PhD, Department of Anesthesiology, Xuanwu Hospital of Capital Medical University, 45 Changchun Street, Beijing 100053, China. Tel: +86 139 1052 5304; e-mail: w_tl5595@hotmail.com Copyright © 2019 YEAR Wolters Kluwer Health, Inc. All rights reserved.

Do you remember 'supply and demand'? No abstract available

Alexandros Sfakianakis
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