Episode #196 ICAPS 2024 Recap, Part 5: Perioperative Brain Health, Pain Control, and More

Hello and welcome back to the Anesthesia Patient Safety Podcast.  My name is Alli Bechtel, and I am your host. Thank you for joining us for another show. We are continuing our coverage of the International Conference on Anesthesia Patient Safety 2024. The series starts with episode #190 and we are back for the fifth episode in this series today.

Before we dive into the episode today, we’d like to recognize Blink Device Company, a major corporate supporter of APSF. Blink Device Company has generously provided unrestricted support to further our vision that “no one shall be harmed by anesthesia care”. Thank you, Blink Device Company – we wouldn’t be able to do all that we do without you!”

To kick off the show today, we are going to hear from Steven Greenberg. Here he is now.

[Greenberg] “Good morning, everybody. My name is Steven Greenberg, and I’m an anesthesiologist and intensivist at Endeavor Health in Chicago, Illinois. I also serve as current APSF Vice President,  and I’m proud to talk to you today about the International Conference on Anesthesia Patient Safety that was just completed in Tokyo, Japan.”

[Bechtel] I asked Greenberg why he was interested in creating an international anesthesia patient safety conference. Let’s take a listen to his response.

[Greenberg] “Well, the APSF founders, as one of their major goals, wanted to focus on the international exchange of safety information.  And about 10 years ago, I met an individual at an anesthesia technology meeting in Tokyo, Japan, who wanted to collaborate to develop the first ever Japanese APSF newsletter.

And so we did just that. We not only translated the APSF Newsletter in Japanese, but several other languages. We also at that conversation wanted to develop an international conference on anesthesia patient safety. And I’m proud today that we completed just a few weeks ago this meeting in collaboration with the Japanese Society of Anesthesiologists, the Japanese Federation of Anesthesiologists, the APSF and the ASA.

We had nearly 700 participants engage in exchanging patient safety information.  So, the next question I want to answer is what is next or what do we envision for the future with regards to international patient safety? Well, I hope that this is the first of several international conferences on anesthesia patient safety around the world and in collaboration with the APSF and other international organizations as well as our translation partners to continue to exchange and enhance information to all safety leaders in the perioperative space.

Thank you so much.”

[Bechtel] And thank you for helping to organize this amazing conference and for contributing to the show today. Now, it’s time to get back into the conference sessions. The next session is “Anesthesia for aging society ~ focusing on the perioperative brain health.”

The first session is “Development of evidence-based practical guidelines for management of postoperative delirium by the Japanese Society of Anesthesiologists” by Tomoyuki Kawamata.

This is a pressing concern in Japan since Japan is facing an unprecedented aging society and this includes aging surgical patients. In 2021, over half of patients undergoing surgery were 65 years or older. With increasing age, we know that there are increased postoperative complications.

Postoperative Neurocognitive disorders are a spectrum. Here are the time frames:

• Postop delirium from immediately after surgery until discharge
• Delayed neurocognitive recovery from discharge until 30 days postop
• Postoperative Mild or major Neurocognitive Disorder from 30 days postop to one year after surgery
• Mild and major neurocognitive disorder which is present more than one year after surgery.

This is a threat to patients safety since postoperative delirium may lead to increased hospital stay, ICU admission, morbidity and mortality, and increased costs with decreased quality of life. There are also concerns that postop delirium may lead to dementia. In Japan, the increased costs and risk of dementia are concerning as national health care expenditures are rising for patients 65 years and old.

The JSA is working on a practical guide for the prevention and treatment of postop delirium given this pressing anesthesia patient safety concern. The guidelines will include a review of the epidemiology, Age-related biological functional changes, and recommendation for anesthetic management for prevention and treatment. Stay tuned for this future publication for more information. There are difficulties with the development of these guidelines however. There are few interventions with high level of evidence and there are only a few recommended treatments for postoperative delirium. Going forward, we need interventional studies to help determine how to prevent POD and we need basic research to help develop new treatments for POD. There is so much more we need to learn about why aging, surgery, anesthesia, and the environment can contribute to neuro-inflammation and the development of POD and what we can do to prevent this or treat it.

Our next speaker is Dan Cole to talk about “Perioperative Brain Health.” Cole opens with a reminder about the healthcare ecosystem. Health is made up of the following: social and economic factors (40%), healthy behaviors (30%) Physical environment (10%) and Clinical Care (20%) this includes access, quality, and safety. We want to take care of the entire patient. Remember, we were physicians before we were anesthesiologists. Now, let’s consider the older adult. We need to move from talking about lifespan to talking about health span with includes functional health, psychological health, and cognitive health. Patients want quality of life so that they can return home after their surgery with the best health. The US population is aging as well with projected over 94 million people age 65 years and older by the year 2060. In older adults, we are more likely to see chronic conditions of arthritis, coronary artery disease, and diabetes. Patients over the age of 65 may also have difficulty with hearing, vision, cognition, ambulating, self-care, and communication.

Think of surgery like running a marathon for our older patients. It is a major stressor. Patients need adequate preparation, building reserve, minimizing stress, and developing resilience.

What does the aging brain look like? Here are some of the characteristics:

• Atrophy in the prefrontal cortex and hippocampus
• Decreased Neurogenesis
• Impaired lymphatic function
• Neurotransmitter imbalances
• Vascular changes
• Glial cell dysfunction
• Dysfunction of the BBB
• Inflammaging

So, how can we approach perioperative brain health? Let’s look at an Integrated pathway.

Avoid certain drugs including benzodiazepines, anticholinergics, antipsychotics, meperidine, antihistamines, phenothiazines, an H2 receptor antagonists, maybe ketamine.

Preoperative: This is the time to define the risk by evaluating the miniCog and determining frailty. Prehabilitation and a geriatric consult are the marathon preparation that are needed before surgery. Prehabilitation can help to build cognitive reserve with exercise, sleep hygiene, diet, weight loss, smoking cessation, treatment for hypertension, reviewing medications.

Intraoperative considerations include using brain monitors which may help to tailor the anesthetics to the individual patient, avoiding hypotension, ensuring glycemic control. You may consider using near-infrared spectroscopy or NIRS to continuously monitor regional brain tissue oxygenation.

Postoperative factors include family visits, adequate pain control, sleep hygiene, physical activity, vision, hearing, and getting patients home. Remember, get your patients glasses back on and hearing aids in as soon as possible after surgery and get the home as soon as possible.

We are looking forward to a future with a focus on health span for our patients.

We are going to fast forward to the next session, Clinician safety – occupational health and the talk by Della Lin, “Safety: Change the Story, Change Everything.”

The talk opens with the cautionary advice to beware of drift of behaviors and move away from “normalization of deviance.”

Have you ever answered a question about why we do things with because that’s how we always do things here. This is likely a common answer. But, when new people with fresh eyes and ideas come to your institution or anesthesia department or operating room, there is an opportunity to make sure that we are taking appropriate action to uphold patient safety principles and not just doing things the way they have always been done.

Lin asks some thoughtful questions during her talk including “What was something unanticipated that happened that turned out to be lucky in a certain situation?”

For safety science, we need to look at the areas where we got lucky since these may be a vulnerability for future events. Let’s consider an example of an unrecognized difficult airway. Perhaps, the lucky break was that it occurred in the middle of the morning and the operating room next door was delayed so that there were extra available anesthesia professionals immediately available to help. Maybe another lucky break was that the anesthesia professional managing the airway had just been to a conference and recently reviewed the difficult airway management algorithm. Can you think about a critical situation when something unanticipated turned out to be lucky?

By reviewing these factors, we can evaluate the decision-making process to provide insight for future decision making to keep patients safe. If the lucky breaks don’t happen, what can we do next time to create a more robust system to address these vulnerabilities.

During debriefings at your institution, here are important questions to ask if you want to improve patient safety going forward:

• What were our lucky breaks?
• What was going on in your mind at this point?
• When you came into the room, how were you able to figure out what was going on?
• How did you communicate to others what was going on in your mind?
• What other resources could have been called and when?

As anesthesiologists, when we come into a room, we often have very little time to assess the situation and gather information. How do we learn what to say, that is not too little and not too much. You may need to ask, ‘Can I get a re-brief or Can we do a final check?’

Another important consideration for communication and patient safety is highlighted by the question, What would happen if we stopped putting everyone in boxes?

Suddenly, there is just us. United by common experiences. And maybe there’s more that brings us together than we think. We may put our patients in a separate box. As anesthesia professionals, are we providing care to our patients, for our. patients, and going forward perhaps with our patients.

Patients have reported on their experiences and revealed that everything in the OR is so amplified and overwhelming leading to feeling anxious and alone despite all the people around. The most important thing to give your patient is to listen and consider that patients are our partners. Lin leaves us with the idea that patient safety is not just about the broken pieces or people in the system, rather it is from our learned experiences that we can be stronger and better together.

The next session is “Acute pain service not limited to pain control.” Here is a run down of the speakers and highlights from the talks.

First up, Yoshiki Sento talks about “The Value of Post-anesthesia Care Unit (PACU) in Optimizing Pain Control.” The PACU is an important step between the OR and the ward. In Japan, there are barriers to establishing PACUs that include cost, shortage of space, nurses, and physicians, and fewer day surgeries. There has been increased utilization of PACUs in Japanese children’s hospitals from 42% in 2015 to 61% in 2019, and hopefully this trend will continue. When PACU are widely used across Japan, then postoperative management including acute pain management will be improved.

The next talk is “Safety management of acute pain service in Japan” by Harumasa Nakazawa. Here are some considerations to establish an Acute Pain Service in  Japan:

1. Refer to methods of developed countries including practice guidelines from the ASA, ESRA, and ERAS protocols. Check out PROSPECT by the ESRA and the Practice Guidelines for Acute Pain Management in Perioperative Settings by ASA. I will include links to these in the show notes as well.
2. Modify protocol and management for elderly patients since Japan has a large proportion of their population that is over 65 years old, especially when compared to other countries.

The goals are to:

• Develop an individual protocol for each patient.
• Identify complications that are more likely in the elderly including sedation, respiratory depression, and hypotension.
• And Establish a system for early detection of complications including education for ward nurses and routine APS rounds .

The final speaker for this session is Monica W. Harbell to talk about “Preventing and mitigating opioid-related harm in the perioperative period.” Opioid use and misuse in surgical patients is a threat to anesthesia patient safety that leads to an increase in morbidity and mortality.

What can we do to mitigate this in the perioperative period?

Here are some strategies to help:

1. Optimize non-opioid multimodal analgesia. Some options include acetaminophen, ketamine, glucocorticoids, NAIDS, lidocaine, Magnesium (which may decrease pain and reduce postop opioid consumption), dexmedetomidine, gabapentnenoids (but caution is needed with these medications for respiratory depression when combined with opioids), and regional anesthesia depending on the surgery.
   1. It is likely that for many options for pain control there are specific situations when certain combinations of medications should be used and when some medications should be avoided.
2. ERAS: remember, these are evidence-based interventions and multidisciplinary efforts to facilitate earlier recover after surgery. Essential components may include transition from IV to oral agents.
   1. Impact of ERAS includes decreased opioid consumption, lower rates of complications and morbidity, shorter length of stay and significant healthcare savings.
3. Opioid Stewardship: Coordinated interventions to improve, monitor, and evaluate opioid use
   1. Preop identify patients on high-dose opioids and identify patients at risk for postop opioid use, set expectations, use transitional services, consider supervised weaning
   2. Intra-op: maximize the use of non-opioids, procedure specific strategies and opioid sparing when possible.
   3. Post op: oral route for administration when possible, avoid co-sedatives, immediate release opioids for breakthrough pain, titrate opioids to promote improved functional status and adjust dosing for renal function and age and score sedation to prevent opioid induced ventilatory impairment.
   4. Prepare for discharge: who needs additional opioid weaning support, provide information, provide appropriate discharge analgesia with regular non-opioids, short-course IR tablets, surgery specific opioid doses, no compound analgesics and no modified release preparations
   5. After discharge: non-opioid analgesics when safe, use opioids to facilitate function, wean opioids with reverse pain ladder, use mobile apps to promote mobilization and opioid tapering, refer to pain team or surgical team if needing opioids for more than 3 months, provide training on safe opioid storage and disposal, and avoid drug driving.
   6. Leveraging the electronic health record to reduce postoperative opioid use: Just decreasing the default number of opioid pills prescribed from 30 down to 12. This is simple, cheap, and effective method to reduce postop opioid use
   7. National level: promote effective regulation of the pharmaceutical industry, promote standards for safe opioid prescribing, create evidenced-based enduring systems to support people with opioid use disorder, prioritize patient safety for any new analgesics, collaborate on a global level to mitigate opioids misuse worldwide
4. Patient Engagement: this includes education and partnership. Did you know that patient engagement and education can decrease opioid use? Pain card with one side that describes the pain rating scale and functional status with information about pain medication options and which medication may be used to help with pain. This intervention can decrease opioid use significantly. A short video can help patients to stop opioid use or discontinue chronic opioid use postop.

Are you using any of these strategies at your institution? Perhaps you can add ‘mitigate opioid related harm’ to the agenda at your next department meeting and discuss implementation of some of these strategies to help improve patient safety going forward.

If you have any questions or comments from today’s show, please email us at [email protected]. Please keep in mind that the information in this show is provided for informational purposes only and does not constitute medical or legal advice. We hope that you will visit APSF.org for detailed information and check out the show notes for links to all the topics we discussed today. We will be diving into the February 2024 APSF Newsletter next week so mark your calendars.

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Until next time, stay vigilant so that no one shall be harmed by anesthesia care.

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