Episode #242 Enhancing Anesthesia Patient Safety: Literature Reviews, Guidelines, and Recommendations

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. This is a high-yield podcast alert. That’s right, we are diving into the literature to talk about the latest in perioperative patient safety from the APSF’s In The Literature Column. We are reviewing the most recent summaries so stay tuned!

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

To kick off the show today, we are heading back to September 2024. This article summary will be of use for all anesthesia professionals who work in an ambulatory surgical center and take care of patients with diabetes. The summary was written by Agarwala. The article is “Society for Ambulatory Anesthesia Updated Consensus Statement on Perioperative Blood Glucose Management in Adult Patients With Diabetes Mellitus Undergoing Ambulatory Surgery,” which was published in March 2024. To follow along with us, head over to APSF.org and click on the Patient Safety Resources Heading. The seventh one down is In the Literature. From here, scroll down to this summary that was published in September 2024. I will include a link in the show notes as well.

How do you manage blood glucose for patients with diabetes? This is article is a great resource for anesthesia professionals since it contains updated guidelines created by the Society for Ambulatory Anesthesia. An expert task force was put together to review the evidence and update the guidelines. Let’s take a look at some of the strong recommendations.

• “Liberal intraoperative blood glucose concentration targets of 180-250 mg/dl are recommended based on patient and procedure characteristics.
• In the absence of diabetic ketoacidosis (DKA) or Hyperglycemic hyperosmolar non-ketotic syndrome (HHNS), cases do not need to be cancelled for hyperglycaemia.
• Water should be used in lieu of preoperative carbohydrate loading in diabetic patients
• Haemoglobin A1C levels should not be used to determine whether a case should be postponed
• The use of subcutaneous insulin administration for management of hyperglycaemia is recommended
• Low-dose dexamethasone (4mg) can be used for most diabetic patients if indicated.
• Point-of-care glucose monitoring should be used to confirm accuracy of continuous glucose monitors and automated insulin dosing systems”

Will you incorporate some of these recommendations into your practice? It is reassuring that even when patients present with high glucose levels, we do not need to cancel the case except for patients with DKA or hyperglycaemic hyperosmolar nonketotic syndrome. Plus, we can continue to administer dexamethasone for postoperative nausea and vomiting prophylaxis even for patients with diabetes.

Alright, it’s time to move on to our next summary. Are you feeling awake and energized right now? Perhaps, you are feeling the opposite and have been working long hours recently. If you are fatigued while practicing anesthesia, this may impact patient safety. Let’s turn to our next Literature Summary. Thank you to Sood and Panday for completing the summary of the article, “Effects of fatigue on anaesthetist well-being and patient safety: a narrative review” by Ippolito and colleagues. This summary was published in November 2024 and the article was published in the British Journal of Anesthesia in April 2024.  I will include the link in the show notes as well and you can follow along with us by scrolling up from the previous summary.

This time our article is a narrative review that evaluates that challenging working conditions that anaesthesia professionals may face leading to physical and mental exhaustion leading to compromised anaesthesia patient safety. Here are some of the key findings from the article:

• Did you know that fatigue at work is common for anesthesia professionals? According to the Australian Medical Association in 2016, 75% of intensivists and 31% of anaesthetists are at high risk for exhaustion due to their workload.
• Anesthesia professionals are in high demand and may be needed at any time of day for emergency care. As a result, the working hours may be long with frequent changes in duty and shift schedules and this can contribute to fatigue.
• Anesthesia professional fatigue is a threat to anesthesia patient safety. There was a survey of 6,000 anesthesia professionals that reported that 74% believe that their fatigue during a night shift could increase perioperative risk for their patients and an even higher percentage believed that quote “night work represents an additional risk per se for their patients.”
• Another study found that the incidence of death during weekend ICU admissions was higher than weekday admissions. Contributing factors may include workload and time pressure, disorganization, inadequate handover, and poor communication.
• Fatigue is also an important consideration for the health and well-being of anesthesia professionals. The American Society of Anesthesiologists completed a surgery of almost 4,000 anesthesiologist members, 59.2% were at elevated risk of burnout and 13.8% met the criteria for burnout syndrome on the Maslach Burnout Inventory.

We hope that you will check out the full article as well. The authors present several ideas for working to decrease and prevent fatigue for anesthesia professionals. Some considerations include the following:

• Supporting a no-blame culture and a policy of non-criticism when it comes to the need to rest.
• Team members must support each other with frequent check-ins for fatigue and be aware that fatigue may impact the team when it comes to communication, mood, and teamwork. Using closed-loop communication is recommended to help improve communication.
• Hospital administrators are charged with adopting a structured system to monitor and manage fatigue. The Fatigue Risk Management Systems or FRMS is one such system.

We are aware of the dangers of fatigue for patient safety and clinician well-being and going forward more research is needed to figure out how we can best manage and prevent fatigue while keeping patients safe.

Did you see the JAMA Surgery article that was published in June 2024, “Glucagon-Like Peptide-1 Receptor Agonist Use and Residual Gastric Content Before Anesthesia” by Sen and colleagues? Don’t worry, it was covered by the APSF and is our next In the Literature review. Thank you to Huang for the summary which was published in December 2024. I will include a link to the summary in the show notes. To follow along, you can scroll up once again from the previous summary!

We first started talking about GLP-1 receptor agonists on this podcast for Episodes #160 and 161 in 2023. You can also check out Episode #189 where we revisit this important topic. Continued research and information about the impact of these medications on anesthesia patient safety is critical. Let’s take a look at the summary now.

• Have you taken care of a patient who is taking a glucagon-like peptide-1 receptor agonist this week or maybe even today? These medications may be prescribed for the management of type 2 diabetes and obesity.
• Patients may be at increased risk for aspiration since GLP-1 receptor agonists delay gastric emptying.
• This is a cross-sectional study of 124 patients that looked at residual gastric content in patients undergoing elective procedures under anesthesia. 62 patients used a once-weekly GLP-1 receptor agonist and the other 62 patients did not. The participants were asked to follow fasting guidelines including 2 hours for clear liquids, 6 hours for a light meal, and 8 hours for a full meal. The GLP-1 receptor agonist group included patients who had discontinued the medication for up to 7 days, but many in the group had taken the medication within the past 5 days of the evaluation.
• The primary outcome was an increase in residual gastric content on gastric ultrasound. This was defined as the following: the presence of solids, thick liquids, or more than 1.5 mL/kg of clear liquids.
• The gastric ultrasounds were performed by anaesthesiologists with expertise in point-of-care gastric ultrasound and there was a second blinded anaesthesiologist who  independently reviewed the images.
• Now for the results. Without adjusting for confounding factors, there was a big difference between the groups. 56% of the patients taking GLP-1 RAs had an increased RGC, compared to 19% of the patients not taking these medications.
• Then, after adjusting for confounders, the investigators reported that GLP-1 receptor agonist use was linked to a 30.5% higher prevalence of increased residual gastric content compared to the control group.
• There was no association between the duration of holding the GLP-1 receptor agonists and the prevalence of increased residual gastric content up to the full 7 days. In addition, the specific type of GLP-1 receptor agonist did not influence the prevalence of residual gastric content.
• The authors conclude that the current practice of holding GLP-1 receptor agonist medications for 7 days before surgery is not sufficient to decrease residual gastric content. There is a call for more research to determine the optimal timing for discontinuation of GLP-1 receptor agonists before elective surgery to help decrease the risk for aspiration during anesthesia.

This study provides important information about the impact of GLP-1 receptor agonist therapy on residual gastric content after holding the medication for up to 7 days and following standard fasting guidelines. The risk for aspiration is a big threat to anesthesia patient safety for these patients. Going forward, the preoperative fasting guidelines may need to be modified for patients taking these medications and full stomach precautions may be considered to help keep patients taking GLP-1 receptor agonists safe during anesthesia care.

We have time to talk about one more summary today. Go ahead and scroll up again to the summary of the article, “Intraoperative Methadone in Next-day Discharge Outpatient Surgery: A Randomized, Double-blinded, Dose-finding Pilot Study” by Kharasch and colleagues published in Anesthesiology in October 2023. Thank you to Thomas for the summary which was published last month. I will include a link to the summary in the show notes as well.

We are returning to the outpatient surgery centre for this study. Do you use methadone for postoperative pain control as part of your practice? Many anesthesia professionals are committed to using less intraoperative opioids and decreasing postoperative pain and oral opioid use and decreasing postoperative opioid prescribing. This study focuses on the use of methadone as a high effective and opioid-sparing perioperative opioid. Did you know that intraoperative methadone results in 30-40% less postoperative pain and opioid use and greater patient satisfaction comparted to opioids with shorter duration of action such as morphine, fentanyl, and hydromorphone?

Is methadone an option for outpatient surgery? What are the clinical benefits, side effects, utility, and the appropriate dose? Let’s take a look at this study to find out more.

This is a single-centre, randomized, double-blind, parallel-group, dose-escalation, dose-finding study to determine the feasibility of single-dose intraoperative methadone for next-day discharge outpatient surgery. The goal was to find the dose that provided excellent analgesia and was well-tolerated and to see if this decreased postoperative opioid use as well.

Patients were randomized to receive a single dose of methadone upon arrival in the operating room or usual practice with short-acting opioids. The initial group of 20 patients in the methadone group receive 0.1mg per kg ideal body weight. Successive cohorts received methadone doses of 0.2, 0.25, and 0.3mg per kg ideal body weight. In the recovery room, patients were assessed for pain, sedation, and adverse events until discharge. For 30 days after discharge, patients were assessed for daily average pain, opioid analgesic use, quality of recovery, and opioid side effects.

The results of this study include the following:

• Decreased in-hospital opioid use for patients in the methadone group compared to those who received short-duration opioids.
• A trend towards decreased home pain and opioid use in the methadone group as well, but there was high interindividual variability.
• The optimal dose of methadone in the study to best combine the benefits of opioid-sparing, analgesia, and minimal adverse events was 0.25mg/kg ideal body weight for next-day discharge outpatient surgery.

What do you think about this study? Do you use methadone for patients undergoing next-day discharge surgery for improved pain control plus opioid-sparing benefits? Will you be making a change in your practice to administer methadone and move away from short-duration opioids? This study has some important considerations for perioperative opioid use and anesthesia patient safety.

And that’s all the tine we have for today. From, diabetes management to anesthesia professional fatigue and well-being to GLP-1 receptor agonists and methadone for next-day discharge patients, we have covered a lot of ground.

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.

The APSF Newsletter is the official journal of the Anesthesia Patient Safety Foundation. Readers include anesthesia professionals, perioperative providers, key industry representatives, and risk managers. It is free of charge and available in a digital format with a focus on anesthesia-related perioperative patient safety issues. The deadline for the June 2025 APSF Newsletter is right around the corner on March 1st! Check out the guide for authors over at APSF.org for more information and I will include a link in the show notes as well. Who knows, you could be the next APSF Newsletter author, and we might be featuring your article on a future Anesthesia Patient Safety Podcast! So, what are you waiting for, go ahead and submit your article today!

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

© 2025, The Anesthesia Patient Safety Foundation