Tuesday, March 30, 2021
de Graaff JC, Johansen MF, Hensgens M, Engelhardt T. Best practice & research clinical anesthesiology: Safety and quality in perioperative anesthesia care. Update on safety in pediatric anesthesia. Best Pract Res Clin Anaesthesiol. 2021 May;35(1):27-39. d
OK, so the “journal” Best Practice & Research Clinical Anaesthesiology doesn’t present much in the way of original research, but this review article recently caught my eye. It’s well-written and up to date, so I highly recommend spending a spare 20 minutes with it. De Graff et al, from Sophia Children’s Hospital, University Medical Center Rotterdam, in the Netherlands, and Montreal Children’s Hospital, have given us a succinct update on pediatric anesthesia safety. It’s a little heavy with numbers in different studies, but the authors emphasize the most salient points: healthy children have virtually no risk, and of course, unhealthy children have a relatively high risk for intraoperative respiratory and cardiac critical events, and postoperative mortality. In this latter group, younger age, higher ASA-PS class status, cardiothoracic, and emergency, or multiple surgeries are common risk factors. So is provider experience.
I thought of this article while reading a great book recommended to me by John Fiadjoe, who is always on the cutting edge of ways to improve safety. The book is called Black Box Thinking, Marginal Gains and the Secrets of High Performance, by Matthew Syed. It consists of a compilation of case studies that focus on learning from failure. One of the most important chapters describes Team Sky, the British professional cycling team. They leaped from mediocre to world champions in just a few years. Their secret? Marginal gains. Minor tweaks here and there with the end result of improving so many tiny incremental components, that in the end, they add up to a winning combination. I thought of the typical low risk ASA 1 patient we take care of routinely. They always do well, but what marginal gains are still there for the taking? Turns out, there are plenty. Some that come easily to mind include less postoperative pain, less PONV, fewer corneal abrasions, and many more you already know and are described nicely by de Graff, but that we don’t always think about for every case we do.
The concept of marginal gain has not been talked about much in the anesthesia literature. But a Google Scholar search on the subject revealed a great editorial on the subject by Leng and Mariano in Regional Anesthesia & Pain Medicine, refuting a study that showed “only” marginal gains from performing TAP blocks in bariatric surgery patients. It’s short and also worth a read.
So, your homework for today: read the de Graff and Leng papers, and think about how you can achieve marginal gains in your patients, even if no one ever notices.