Indications, contraindications, and safety aspects of procedural sedation

PURPOSE OF REVIEW: There is a steadily increasing demand for procedural sedation outside the operating room, frequently performed in comorbid high-risk adult patients. This review evaluates the feasibility and advantages of sedation vs. general anesthesia for some of these new procedures. RECENT FINDINGS: Generally, sedation performed by experienced staff is safe. Although for some endoscopic or transcatheter interventions sedation is feasible, results of the intervention might be improved when performed under general anesthesia. For elected procedures like intra-arterial treatment after acute ischemic stroke, avoiding general anesthesia and sedation at all might be the optimal treatment. SUMMARY: Anesthesiologists are facing continuously new indications for procedural sedation in sometimes sophisticated diagnostic or therapeutic procedures. Timely availability of anesthesia staff will mainly influence who is performing sedation, anesthesia or nonanesthesia personal. While the number of absolute contraindications for sedation decreased to almost zero, relative contraindications are becoming more relevant and should be tailored to the individual procedure and patient

Cognitive aids: 'a must' for procedures performed by multidisciplinary sedation teams outside the operation room?

The human brain might not perform optimally during stressful situations. Cognitive aids can help in such situations to carry out all necessary treatment steps in a correct order. We present the case of a severe anaphylactic reaction during a percutaneous radiological intervention to drain an echinococcosis cyst on the radiology suite outside the operation room (OR), in which cognitive aids were successfully used to optimise patient care by a multidisciplinary team. Cognitive aids do not replace experience and skills of the individual caregivers, but can be invaluable tools for multidisciplinary teams dealing with crisis situations outside the O

Development of a Model for Video-Assisted Postoperative Team Debriefing

Background: Video-assisted debriefing may be a powerful tool to improve surgical team performance. Nevertheless, a true operating team debriefing culture is lacking to date. This study aimed to find evidence on how to debrief the surgical team and develop a model suitable for debriefing using a video and medical data recorder (MDR) in the operating room (OR). Methods: A review of the PubMed and Embase databases and Cochrane Library was performed. The identified literature was studied and combined with a conceptual framework to develop a model for postoperative video-assisted team debriefing. Thirty-five surgical cases were recorded with an MDR and debriefed with the operating team using the proposed debrief model and a standardized video-assisted performance report. A questionnaire was used to assess the participants' satisfaction with this debrief model. Results: Debrief models and methods are extensively described in the current medical literature. An overview was provided. The OR team needs a structured debrief model, minimizing resource, effort, and motivational constraints. A structured six-step team debrief model suitable for video-assisted OR team debriefing was developed. The model was tested in 35 multidisciplinary MDR-assisted debriefing sessions and the debriefing sessions were overall rated with a mean of 7.8 (standard deviation 1.4, 10-point Likert scale) by participants. Conclusions: Debriefing surgical teams using a video and MDR in the OR requires a model on how to use such recordings optimally. To date, no such model existed. The proposed debrief model was tested using a multisource MDR and may be used to facilitate OR debriefing across various settings

Exploration of a method to validate surrogate safety measures with a focus on vulnerable road users

Abstract Background. Traditional crash-based analysis of road safety at individual sites has its shortcomings due to low numbers and the random nature of crashes at individual sites and the related statistical issues, as well as the under-reporting of crashes and lack of information on contributing factors and the process preceding crashes. To get around the problem, road safety analysis based on surrogate measures of safety, i.e. not based on crashes, can be used. However, the question whether surrogate measures are valid indicators for safety remains unanswered and only a few attempts have actually been made to carry out proper large-scale validation studies. Aim. This work presents a methodological approach for a large-scale validation study of surrogate safety indicators focusing on vulnerable road users. With only one site analyzed so far, it presents the exploration of the data and of the performance of the technical tools used in the study. Method. Video-filming and consequent video analysis are used to measure the surrogate safety indicators. In the first step, the video is “condensed” using a watchdog software RUBA that selects situations with an encounter of a cyclist or pedestrian and a motor vehicle. At a later stage, the trajectories of the individual road users are produced using a semi-automated tool T-Analyst and several surrogate safety indicators are tested to set a severity score for an encounter. The performance of the surrogate indicators will be compared to the expected number of accidents at each site and availability of the data for developing a safety performance function (SPF) that is country-, manoeuvreand type of VRU-specific are explored. Results & Conclusion. From methodological perspective, limited accident data available seriously complicates building a reliable SPF (“ground truth”) against which the surrogate safety measures could be validated; some other, “indirect” methods of validation might be required. We present also the performance of the software tools and applicability of the various surrogate safety indicators that were tested

Effect of Cognitive Aids on Adherence to Best Practice in the Treatment of Deteriorating Surgical Patients: A Randomized Clinical Trial in a Simulation Setting

Importance: Failure to rescue causes significant morbidity and mortality in the surgical population. Human error is often the underlying cause of failure to rescue. Human error can be reduced by the use of cognitive aids. Objectives: To test the effectiveness of cognitive aids on adherence to best practice in the management of deteriorating postoperative surgical ward patients. Design, Setting, and Participants: Randomized clinical trial in a simulation setting. Surgical teams consisted of 1 surgeon and 2 nurses from a surgical ward from 4 different hospitals in Amsterdam, the Netherlands. Data were analyzed between February 2, 2017, and December 18, 2018. Interventions: The teams were randomized to manage 3 simulated deteriorating patient scenarios with or without the use of cognitive aids. Main Outcomes and Measures: The primary outcome of the study was failure to adhere to best practice, expressed as the percentage of omitted critical management steps. The secondary outcome of the study was the perceived usability of the cognitive aids. Results: Of the total participants, 93 were women and 51 were men. Twenty-five surgical teams performed 75 patient scenarios with cognitive aids, and 25 teams performed 75 patient scenarios without cognitive aids. Using the cognitive aids resulted in a reduction of omitted critical management steps from 33% to 10%, which is a 70% (P <.001) reduction. This effect remained significant (odds ratio, 0.63; 95% CI, -0.228 to -0.061; P =.001) in a multivariate analysis. Overall usability (scale of 0-10) of the cognitive aids was scored at a median of 8.7 (interquartile range, 8-9). Conclusions and Relevance: Failure to comply with best practice management of postoperative complications is associated with worse outcomes. In this simulation study, adherence to best practice in the management of postoperative complications improves significantly by the use of cognitive aids. Cognitive aids for deteriorating surgical patients therefore have the potential to reduce failure to rescue and improve patient outcome. Trial Registration: ClinicalTrials.gov identifier: NCT03812861