Between Issues

That Which Is Old Is New Again – APSF Newsletter “In the Literature” Synopsis Summaries Reappear

August 1, 2022

John H. Eichhorn, MD

In the Literature

When the APSF Newsletter Editorial Board recently considered the proposal to publish a column compiling summaries of current relevant literature regarding perioperative patient safety, the founding Editor, who has been referred to as the “institutional memory” of the APSF, immediately supported the idea enthusiastically, noting that the original Newsletter created in 1986 included precisely that same concept, and the column then was called “From the Literature.”

In the inaugural issue of the APSF Newsletter in March, 1986, the first “From the Literature” column opened with an Editor’s Note stating: “In each APSF Newsletter, a pertinent publication from the anesthesia patient safety literature will be summarized. Suggestions for future issues are welcome.” That column provided a synopsis of and commentary on an important review paper that had been largely under-appreciated, in part because it appeared in JAMA rather than an anesthesia journal, but mostly because it was an early example of an objective discussion of severe complications during anesthesia care and the resulting patient safety implications. Some practitioners openly questioned this type of review as the airing of “dirty laundry” that would diminish the profession, encourage plaintiff’s lawyers to sue over such cases, and scare patients. However, its appearance fit perfectly with the birth of the modern patient safety movement1 and the creation of the APSF.2 The column summarized the article (Keenan RL, Boyan CP: Cardiac arrest due to anesthesia. JAMA 1985;253:2373-2377):

At the Medical College of Virginia, Richmond, 27 cardiac arrests judged due solely to anesthesia occurred in 163,240 total anesthetics over a fifteen-year period (1.7 per 10,000) causing fourteen deaths (0.9 per 10,000). Among the 27: six were under twelve years old, nineteen were 12-65 years, and only two were over 65; also, ASA physical status classifications were I-two, II-five, III-ten, IV-ten, (V not included). Note that Classes I and II account for only seven arrests in 163,240 cases and only two deaths (1/81,620). Cardiac arrest during emergency surgery was six times more likely than during elective surgery. Of the 27 cases, nine had absolute overdoses of inhalation agent and six relative overdoses of intravenous agent. Twelve included inadequate ventilation: four difficult airway, four esophageal intubations, two ventilator disconnects, and one each displaced endotracheal tube and bronchospasm.

Judgments about the likely preventability of the accidents were recorded. Among the 27 cases of cardiac arrests: 20 were “avoidable” (eleven inadequate ventilation and nine inhalation overdoses), six were “questionable” (the relative intravenous overdoses in hemodynamically unstable patients three each cardiac and septic), and one was felt to be “unavoidable” (intractable asthma). Thus, a specific anesthetic “error” was identified in 75% (20 of 27) of the arrest cases. A strong point was made that progressive bradycardia preceded the cardiac arrest in all but one of the cases. The authors suggest that when there is unexplained bradycardia, increased ventilation with 100% oxygen should automatically be the first response considered. Drug idiosyncrasy, anaphylaxis, and succinylcholine induced hyperkalernia were seen but did not cause arrest. Malignant hyperthemia was not seen.

Though these data were published more than 37 years ago, it is easy to imagine that a somewhat similar review (with perhaps lower rates), but a strikingly similar analysis, could appear today. Definitely food for anesthesia patient safety thought.

Similarly, the second issue of the Newsletter contained a review of another landmark article (ECRI Technology Assessment. Deaths during general anesthesia. Health Care Tech. 1985;1:155-175), one of the early assemblages of “preventable death” reports and the enormous cost of these cases. Several of the then-emerging technologies that later would become the cornerstones of basic intraoperative monitoring standards were mentioned as potentially helpful, but not specifically recommended because of the cost of implementation.

The tradition “From the Literature” in the APSF Newsletter had been established, and it continued. A careful, detailed, comprehensive review from one hospital (Cohen MM, Duncan PG, et al. A survey of 112,000 anesthetics at one teaching hospital (1975-83). Can Anaesth Soc J 1986;33:22-31) showed that nearly 18% of patients experienced at least one “anesthesia complication.” E.C. “Jeep” Pierce, inaugural President of APSF, reviewed a seminal book (Lunn, J.N. (ed): Epidemiology in Anesthesia. Edward Arnold Ltd, 1986) from one of the original academic anesthesiologists who addressed anesthesia mortality and morbidity. The original monitoring standards (Eichhorn JH, Cooper JB, Cullen DJ, et al. Standards for patient monitoring during anesthesia at Harvard Medical School. JAMA 1986;256:1017-1020) were reviewed in early 1987, in the same issue announcing the formal adoption of an expanded version of those standards by the ASA. Soon thereafter, debate about minimal intraoperative monitoring (Gravenstein, J.S. Essential monitoring examined through different lenses. J Clin Mon 1986;2:22-29) was presented, a harbinger of multiple pro-con debates that would come later. Further, analysis of an important paper (Gaba DM, Maxwell M, DeAnda A. Anesthetic mishaps: Breaking the chain of accident evolution. Anesthesiology 66:670-676, 1987) introduced the concepts of system failure, coupling, and resource management, again foreshadowing a major subsequent evolution in anesthesia patient safety.

After the earliest years, literature reviews became somewhat less frequent, but persisted in reporting multiple landmark contributions (e.g., Buck N, Devlin HB, Lunn JN. The Report of a Confidential Enquiry into Perioperative Death. London, Nuffield Provincial Hospitals Trust, 1987), and the groundbreaking first report from the ASA Closed Claims study (Caplan RA, Ward RJ, Posner K, Cheney FW. Unexpected cardiac arrest during spinal anesthesia: a closed claims analysis of predisposing factors. Anesthesiology 1988;68:5-11), documenting elucidation of a previously undescribed anesthesia pathophysiology, as well as the first comprehensive report and analysis of OR fires (ECRI. The Patient Is On Fire! Health Devices 1992;21:19-34). Further, books on capnography, as well as anesthesia safety strategies and their cost were also featured.

Interestingly, with the introduction of the extremely popular “Current Questions in Patient Safety” column in the Newsletter at the end of the 1980’s, the “in My Opinion” column at the beginning of the 1990’s, as well as more emphasis on APSF research grants, on safety reports from meetings, and on the development and adoption of monitoring standards throughout the world, and, particularly, the multitude of “Letters to the Editor” as more and more anesthesia professionals engaged with the Newsletter, there was less space and, possibly, somewhat less reader interest in the “From the Literature” column. However, a provocative review (Bacon, AK. Death on the Table. Anesthesia 1989;44:245-248) about multiple aspects of the aftermath of an anesthesia catastrophe was an example of columns that provoked great interest. Likewise, the sad report of a successful malpractice suit following a catastrophic hypoxic injury (“Failure to Provide Capnograph.” Anesthesiology Malpractice Reporter 1991;10(2):1-2) explored and intensified the debate about evolving intraoperative monitoring standards.

The last formal “From the Literature” column in the original series appeared in March of 1995. It stands as an excellent springboard to 27 years later, now, because it is a compilation of seven brief summaries of literature related to anesthesia patient safety, including several epidemiologic/risk analyses, one of which was an important early discussion emphasizing human factor elements in clinical catastrophes (Leape LL: Error in medicine. JAMA 1994;272:1851-1857). That Newsletter column concluded with an Editor’s Note requesting ideas regarding or even completed synopses/reviews of anesthesia patient safety literature. It took quite a while for that to come to fruition, but the revival of the concept now will be much appreciated by APSF Newsletter readers.

Reincarnation Realization

A subcommittee of the current Editorial Board has assumed responsibility for seeking out and presenting publications relevant to anesthesia patient safety and potentially of interest to Newsletter readers by presenting summaries under the category “In the Literature.” As the summaries are created, they first appear online on the APSF website ( ) in the “Patient Safety Resources” section. The first presentation of these summaries appears in the October 2022, APSF Newsletter. Links to the summaries are attached to this article. The synopses cover a very wide variety of entries from different types of literature sources.

Several clinical questions are addressed in the articles summarized. A major paper from the New England Journal on the relative safety of alternate types of anesthesia for a vulnerable population (Neuman MD et al. Spinal Anesthesia or General Anesthesia for Hip Surgery in Older Adults. N Engl J Med. 2021;385(22):2025-2035.) showed that death or debility was the same at 60 days post-op. It was concluded that spinal anesthesia was not superior to general anesthesia for hip fracture repair in this patient population.

In: Sencan S et al. The Immediate Adverse Events of Lumbar Interventional Pain Procedures in 4,209 Patients: An Observational Clinical Study. Pain Med. 2022;23(1):76-80, the safety of these blocks was affirmed in that no major adverse events occurred.

In: Chen DX et al. Comparison of a Nasal Mask and Traditional Nasal Cannula During Intravenous Anesthesia for Gastroscopy Procedures: A Randomized Controlled Trial. Anesth Analg. 2022;134(3):615-623, the data revealed better oxygenation using a nasal mask.

In: Weatherall AD, et al. Developing an Extubation Strategy For The Difficult Pediatric Airway-Who, When, Why, Where, And How?. Paediatr Anaesth. 2022;32(5):592-599, plans for extubation of difficult airways in pediatric patients are summarized. Further, the elements of the most recent iteration of the ASA Difficult Airway Algorithm are outlined in a summary of: Rosenblatt WH, Yanez ND. A Decision Tree Approach to Airway Management Pathways in the 2022 Difficult Airway Algorithm of the American Society of Anesthesiologists. Anesth Analg. 2022;134(5):910-915.

In: Buis ML, et al. The new European resuscitation council guidelines on newborn resuscitation and support of the transition of infants at birth: An educational article. Paediatr Anaesth. 2022;32(4):504-508, is a comprehensive summary of the publication.

The potential danger of provoking thromboembolism by synergistically mixing agents intended to reverse factor Xa inhibitor anticoagulants is discussed in: Liu J et al. Four-factor prothrombin complex concentrate plus andexanet alfa for reversal of factor Xa inhibitor-associated bleeding: Case series [published online ahead of print, 2022 Mar 15]. Am J Health Syst Pharm. 2022;zxac079.

An important paper: Sun LY et al. Association Between Handover of Anesthesiology Care and 1-Year Mortality Among Adults Undergoing Cardiac Surgery. JAMA Netw Open. 2022;5(2):e2148161. Published 2022 Feb 1 (and accompanying editorial) reported the finding of a statistically significant increase in morbidity and mortality when an intra-anesthetic handover occurred and offered recommendations for mitigation.

One of the papers central to a currently discussed issue: Murphy GS, Brull SJ. Quantitative Neuromuscular Monitoring and Postoperative Outcomes: A Narrative Review. Anesthesiology. 2022; 136:345-361, presents a detailed review and analysis that supports routine adoption of this practice.

The patient safety implications of anesthesia professionals’ burnout during the COVID-19 pandemic are considered in: Lea J et al. Predictors of Burnout, Job Satisfaction, and Turnover Among CRNAs During COVID-19 Surging. AANA J. 2022;90(2):141-147.

Three papers from British literature covering larger systemic questions are summarized. The value of implementing clinical guidelines is stressed in: Emond YEJJM et al. Increased adherence to perioperative safety guidelines associated with improved patient safety outcomes: a stepped-wedge, cluster-randomised multicentre trial. Br J Anaesth. 2022;128(3):562-573, and the accompanying editorial. Application of artificial intelligence (AI) is highlighted in a summary of: Sibbald M et al. Should electronic differential diagnosis support be used early or late in the diagnostic process? A multicentre experimental study of Isabel. BMJ Qual Saf. 2022;31(6):426-433. Also: Dave N et al. Interventions targeted at reducing diagnostic error: systematic review. BMJ Qual Saf. 2022;31(4):297-307, covers several strategies, including, particularly, technology such as artificial intelligence. Another aspect of that AI theme from a law journal: Kamensky S. Artificial Intelligence and Technology in Health Care: Overview and Possible Legal Implications. DePaul J Health Care L. 2020;21(3), provides a corollary American perspective considering whether liability laws could apply to patients claiming injury from errors involving AI technology.

The reappearance of literature summaries such as these in the APSF Newsletter is a welcome addition to the panoply of valuable knowledge and insight continually presented for the benefit of our profession. As is the case with a great many, if not, in fact, most articles in the scientific/medical literature that conclude with the essentially universal truth that “further research is indicated,” so too is it analogous for these literature summaries. Readers are encouraged to forward suggestions of articles to be summarized or actual completed literature summaries to the Newsletter editors at any time.


John H. Eichhorn, MD, was the founding Editor and publisher of the APSF Newsletter. Living in San Jose, CA, as a retired Professor of Anesthesiology, he continues to serve on the APSF Editorial Board.


  1. Eichhorn JH. The History of Anesthesia Patient Safety. In: Ball C, Bacon D, Featherstone P (eds.). Broad Horizons – the History of Anesthesia beyond the Operating Room. International Anesthesiology Clinics, Vol. 56 (No. 2). 2018, 56-93.
  2. Eichhorn The Anesthesia Patient Safety Foundation at 25: a pioneering success in safety; 25th anniversary provokes reflection, anticipation. Anesth Analg 2012;114:791-800.