Daily Anesthesiology Research Analysis

BACKGROUND: Cognitive errors are known contributors to poor decision-making in healthcare. However, their incidence and extent of their contribution to negative outcomes during difficult airway management are unknown. We aimed to identify cognitive errors during paediatric difficult airway management using data from the Pediatric Difficult Intubation (PeDI) registry, to determine patient and clinician factors associated with these errors, and their contribution to complications. METHODS: We conducted a retrospective analysis of the PeDI registry data including cases with at least three intubation attempts. Cognitive error definitions were adapted to airway management, and predefined clinical endpoints were used to identify cognitive errors. A subanalysis was performed for children weighing <5 kg. Our primary outcome was the overall incidence of cognitive errors. Secondary outcomes included the incidence of specific cognitive error subtypes, associations with patient and clinician factors, and the relationship between cognitive errors and complications. RESULTS: Cognitive errors were identified in 17.4% (487/2801) of cases, with fixation errors being the most common (11.5%), followed by omission bias (5.9%) and overconfidence bias (4.5%). Non-anaesthesiologist clinicians had the highest odds of cognitive errors. The presence of at least one cognitive error was independently associated with a higher risk of complications (adjusted odds ratio, 1.86 [95% confidence interval, 1.53-2.27]; P<0.001), and multiple errors increased the likelihood of severe complications (adjusted odds ratio, 2.48 [95% confidence interval, 1.24-4.94]; P=0.01). CONCLUSIONS: Cognitive errors occurred in nearly 20% of paediatric difficult airway encounters and were linked to increased complications. Further research should refine error definitions and develop mitigation strategies to improve outcomes.

STUDY OBJECTIVE: To develop and externally validate a risk prediction model for postoperative acute kidney injury (PO-AKI) in elderly patients undergoing noncardiac surgery, addressing the current gap in predictive tools for this vulnerable population. DESIGN: A multicenter retrospective cohort study presented according to TRIPOD + AI statement. SETTING: Conducted in 21 tertiary hospitals across 11 provinces in China from January 2009 to April 2022. PATIENTS: Elderly patients (≥ 65 years) undergoing noncardiac procedures. INTERVENTIONS AND MEASUREMENTS: The endpoint was PO-AKI within seven days post-surgery, diagnosed using the KDIGO criteria. Data were extracted from electronic medical records for model derivation and validation. MAIN RESULTS: The study included 163,131 elderly patients, with 52,494 for model discovery, 7,899 and 80,641 for external validation. The model incorporated nine variables: age, heart disease history, preoperative hyponatremia, renal surgery (yes/no), surgery type, surgery duration, intraoperative diuretics usage, first-aid vasopressors usage, and blood transfusion. The model demonstrated acceptable discriminative ability with AUROC values of 0.803, 0.793, 0.770, and 0.774 across the training, internal validation, and two external validation datasets, respectively. The calibration plots and decision curve analyses yielded commendable results in both training and validation sets. To streamline usability, we employed risk scores and categorized the population into low-, medium-, and high-risk subgroups. CONCLUSIONS: Clinicians could implement this externally validated risk prediction model to stratify PO-AKI risks in elderly patients during the early postoperative phases of noncardiac surgery.

BACKGROUND: Prehospital anaesthesia is a challenging procedure, and the outcome depends on the quality of the process. Hospital-acquired anaesthesia experience does not necessarily translate to high performance in the prehospital setting. We aimed to assess the quality and practice patterns in prehospital anaesthesia related to cumulative experience amongst new prehospital critical care physicians. In this study, we aimed to evaluate whether quality indicators for prehospital anaesthesia and related mortality improve as new prehospital critical care physicians become more experienced with this intervention. METHODS: We conducted a registry-based observational study including all patients who underwent anaesthesia and airway management by physicians who started working in the national HEMS between January 2013 and August 2019. Patients were grouped and compared based on the provider's cumulative case volume at the time of the mission: 1-10, 11-20, 21-40, 41-80 and > 80 cases. The association between cumulative experience and 30-day mortality was assessed using multivariate logistic regression analysis. Secondary outcomes included first-pass intubation success, post-intubation hypoxia and hypotension, the combined use of a neuromuscular blocking agent and anaesthetic, on-scene time, mechanical ventilation usage, and rates of normocapnia, hypoxia, and hypotension at handover. RESULTS: 1,638 patients (median age 59, 64% male) were treated by 32 physicians. Median on-scene time decreased with increasing experience from 33 (interquartile range [IQR] 23-44) to 28 (IQR 19-38) minutes, P = 0.03. Higher experience was associated with increased use of mechanical ventilation (P < 0.001) and a combination of neuromuscular blocking agents and anaesthetics (P = 0.03). Other secondary outcomes did not show a statistically significant difference between the groups. Crude mortality decreased from 38 to 26% in the lowest to highest experience groups. In the multivariate logistic regression analysis, the same trend was still seen with the odds ratio of the highest experience group for 30-day mortality 0.59 (95% CI 0.38-0.94, lowest experience group as a reference). CONCLUSIONS: In a prehospital critical care service, outcomes improve after a high number of prehospital cases, even when physicians with a solid foundation in in-hospital anaesthesia are employed. Limiting physician turnover may improve the quality of care.