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Volatile anesthetics play a crucial role in modern surgical procedures, offering reliable and reversible anesthesia for patients undergoing surgery. However, there are multiple factors affecting their use, ranging from clinical efficacy to safety profile to production cost. The production cost of volatile anesthetics is a complex interplay of raw material expenses, manufacturing processes, regulatory requirements, and environmental considerations. Understanding these factors is key to managing healthcare costs and ensuring the availability of safe and effective anesthetic agents.

The first major cost driver in the production of volatile anesthetics is the raw materials used in their formulation. These anesthetic agents are typically synthesized through halogenation processes, in which hydrocarbon compounds are chemically altered by the addition of halogen elements such as fluorine, chlorine, or bromine. These halogens are critical for the anesthetics’ efficacy and stability, but they are also expensive to obtain and handle safely ^1,2.

The manufacturing of volatile anesthetics is a highly specialized process, requiring advanced chemical engineering and quality control systems. State-of-the-art manufacturing facilities that produce volatile anesthetics involve sophisticated equipment for precision chemical reactions, distillation, and purification. These facilities are costly, often operating under strict sterile conditions, with numerous quality checks throughout the production cycle to ensure compliance with regulatory guidelines from agencies such as the U.S. Food and Drug Administration (FDA) or the European Medicines Agency (EMA) ³.

Volatile anesthetics have been scrutinized for their environmental impact, particularly their contribution to greenhouse gas emissions. Desflurane, for instance, has a global warming potential far higher than carbon dioxide, making its environmental footprint a concern for sustainability initiatives in healthcare. To reduce environmental impact, manufacturers are increasingly investing in more sustainable production methods and developing systems to capture and reduce the emission of volatile anesthetics during production and use, which increases production cost but with long-term benefits. Regulatory pressure to reduce emissions or transition to more environmentally friendly alternatives may lead to additional research and development expenses for companies producing volatile anesthetics ^4,5.

The production cost of volatile anesthetics is also influenced by market demand and competition. While sevoflurane, isoflurane, and desflurane are widely used, the market for volatile anesthetics is relatively small compared to other pharmaceutical products, leading to less competition. This can keep prices high, as manufacturers are fewer in number and are able to maintain control over pricing strategies. Additionally, patent protections on specific formulations of anesthetics can limit the entry of generic alternatives, keeping prices elevated. When patents expire, however, generic versions can help lower costs, although the complexity of producing these anesthetics often keeps their prices higher than other generic drugs ^6–8.

References

1.        Reichle, F. M. & Conzen, P. F. Halogenated inhalational anaesthetics. Best Pract. Res. Clin. Anaesthesiol. (2003). doi:10.1053/bean.2002.0265

2.        Fukazawa, K. & Lee, H. T. Volatile anesthetics and AKI: Risks, mechanisms, and a potential therapeutic window. Journal of the American Society of Nephrology (2014). doi:10.1681/ASN.2013111215

3.        Guidance on good manufacturing practice and good distribution practice: Questions and answers. Available at: https://www.ema.europa.eu/en/human-regulatory-overview/research-development/compliance-research-development/good-manufacturing-practice/guidance-good-manufacturing-practice-good-distribution-practice-questions-answers.

4.        Devlin-Hegedus, J. A., McGain, F., Harris, R. D. & Sherman, J. D. Action guidance for addressing pollution from inhalational anaesthetics. Anaesthesia (2022). doi:10.1111/anae.15785

5.        Gaya da Costa, M., Kalmar, A. F. & Struys, M. M. R. F. Inhaled anesthetics: Environmental role, occupational risk, and clinical use. Journal of Clinical Medicine (2021). doi:10.3390/jcm10061306

6.        Weinberg, L., Story, D., Nam, J. & McNicol, L. Pharmacoeconomics of volatile inhalational anaesthetic agents: An 11-year retrospective analysis. Anaesth. Intensive Care (2010). doi:10.1177/0310057×1003800507

7.        Inhalation Anesthetics Market Dynamics, Industry Report 2030 | The Brainy Insights. Available at: https://www.thebrainyinsights.com/report/inhalation-anesthetics-market-13164.

8.        Inhalation Anesthesia Market Size, Share Report, 2023-2030. Available at: https://www.grandviewresearch.com/industry-analysis/inhalation-anesthesia-market.

Sevoflurane is a common inhalational anesthetic that plays a critical role in modern surgical procedures due to its favorable properties, including rapid onset and minimal side effects. However, emerging evidence suggests that exposure to sevoflurane may have negative effects on cognitive function. In experimental animal models, sevoflurane has been linked to cognitive dysfunction¹, which may manifest as post-operative cognitive dysfunction (POCD) in elderly human patients and neurobehavioral abnormalities in younger subjects. This cognitive impairment, which can persist for weeks or even months post-surgery, raises significant concerns, particularly in aging populations who are already at higher risk for neurodegenerative conditions such as Alzheimer’s disease. Sevoflurane has also been shown to induce neuronal apoptosis and decrease adaptability in neonatal rats.² Understanding the mechanisms through which sevoflurane induces cognitive dysfunction enables the development of strategies to minimize its impact and improve patient outcomes in surgical settings.

The hippocampus is a critical neuronal structure well known to be involved in learning and memory.³ It is also an important target of general anesthetics. In 2016, researchers performed in vivo experiments on neonatal rats (n=88) to study the effect of sevoflurane anesthesia on hippocampal synaptic plasticity and, subsequently, learning and memory. 30 rat pups received 3% sevoflurane treatment for 1 hour, while another 28 received treatment for 6 hours. The remaining 30 pups served as the control group. Synaptic vesicle-associated proteins and dendrite spine density were assessed using Golgi staining, transmission electron microscopy (TEM), and western blotting. The researchers found neonatal exposure to sevoflurane treatment for 6 hours resulted in reduced spine density of apical dendrites and elevated expression of synaptic vesicle-associated proteins (SNAP-25 and syntaxin). Rats exposed to sevoflurane for 6 hours also performed worse than their counterparts in the Morris water maze and novel-object recognition tests, behavioral tasks meant to measure learning and memory performance. In the group who had received sevoflurane for 1 hour, significantly less structural and functional damage was observed in the hippocampus. The results demonstrate sevoflurane anesthesia may time-dependently induce cognitive dysfunction by deteriorating hippocampal function.⁴

A similar study on sevoflurane and its effects on hippocampal neurons was conducted on 42 adult rats. Results of an open field test showed decreased locomotor performance for both male and female rats treated with 3% sevoflurane, compared to their control counterparts. However, there was only a significant difference between the experimental and control groups at one day post-anesthesia, but not at 30, 60, or 90 days, indicating sevoflurane inhibits short-term locomotor activities but has little effect on long-term movement.⁵ For their molecular analysis, the researchers collected data on the cAMP response element binding (CREB) protein, a key gene that mediates downstream transcription imitation factors and regulates neuronal survival. Sevoflurane is known to exert its anesthetic effects through inhibition of hippocampal NMDA receptors, which are heavily connected to CREB protein signaling pathways. Western blotting revealed phosphorylation of CREB was significantly decreased at one week following treatment, whereas no distinct difference was detected in the rat hippocampus at three months post-anesthesia.⁵ Sevoflurane was also shown to increase levels of Caspase-3 and Caspase-8, death proteases that are crucial mediators of apoptosis.⁶ Collectively, the results suggest that sevoflurane may induce cognitive dysfunction through inhibiting CREB signaling pathways, which in turn blocks NMDA receptor function.

In general, the existing literature suggests that high levels of exposure to sevoflurane anesthesia may pose risks to cognitive function, possibly through its impact on the hippocampus. Murine studies indicate exposure to sevoflurane can cause neuronal apoptosis and structural damage to the hippocampus. These changes may contribute to post-operative cognitive dysfunction and other neurological deficits concerning learning and memory. However, it is important to note that many of these effects may be short-term, with many individuals recovering their lost cognitive function over time. Nonetheless, the possible time-dependent nature of these effects does not take away from the need for continued research to better understand the duration and reversibility of sevoflurane’s effects on cognitive dysfunction.

References

1. Bekker, Alex Y., and Edwin J. Weeks. “Cognitive Function after Anaesthesia in the Elderly.” Best Practice & Research Clinical Anaesthesiology, vol. 17, no. 2, June 2003, pp. 259–72. https://doi.org/10.1016/S1521-6896(03)00005-3
2. Zheng, S. Q., et al. “Sevoflurane Causes Neuronal Apoptosis and Adaptability Changes of Neonatal Rats.” Acta Anaesthesiologica Scandinavica, vol. 57, no. 9, Oct. 2013, pp. 1167–74.  https://doi.org/10.1111/aas.12163
3. Howland, John G., and Yu Tian Wang. “Chapter 8 Synaptic Plasticity in Learning and Memory: Stress Effects in the Hippocampus.” Progress in Brain Research, edited by Wayne S. Sossin et al., vol. 169, Elsevier, 2008, pp. 145–58. https://doi.org/10.1016/S0079-6123(07)00008-8
4. Xiao, Hongyan, et al. “Learning, Memory and Synaptic Plasticity in Hippocampus in Rats Exposed to Sevoflurane.” International Journal of Developmental Neuroscience, vol. 48, Feb. 2016, pp. 38–49. https://doi.org/10.1016/j.ijdevneu.2015.11.001
5. Xie, H., et al. “The Gender Difference in Effect of Sevoflurane Exposure on Cognitive Function and Hippocampus Neuronal Apoptosis in Rats.” European Review for Medical and Pharmacological Sciences, vol. 19, no. 4, Feb. 2015, pp. 647–57.
6. Porter, Alan G., and Reiner U. Jänicke. “Emerging Roles of Caspase-3 in Apoptosis.” Cell Death & Differentiation, vol. 6, no. 2, Feb. 1999, pp. 99–104. https://doi.org/10.1038/sj.cdd.4400476

Neuraxial anesthesia refers to a group of regional anesthesia techniques that involve the administration of anesthetic agents near the central nervous system’s neuraxial axis, specifically within the spinal canal. The primary types of neuraxial anesthesia are spinal anesthesia, epidural anesthesia, and combined spinal-epidural (CSE) anesthesia. Each technique has unique applications, benefits, and considerations, making them essential tools in modern anesthesiology ¹.

Spinal anesthesia involves injecting a local anesthetic into the cerebrospinal fluid within the subarachnoid space, usually between the L3-L4 or L4-L5 vertebrae, with the patient in a sitting or lateral decubitus position. It provides a rapid onset of sensory and motor blockade within 5-10 minutes, lasting 1-3 hours, depending on the anesthetic administered. Spinal anesthesia is commonly used for lower abdominal, pelvic, and lower extremity surgeries, including cesarean sections and hip replacements. Benefits include a predictable blockade and minimal systemic absorption, while risks include hypotension, post-dural puncture headache, and limited duration of action ².

Epidural anesthesia involves the injection of local anesthetics into the epidural space, which is located just outside the dura mater. Though both spinal and epidural anesthesia target the spinal cord, the two types of neuraxial anesthesia differ in how close to the spinal cord medication is injected. In epidural anesthesia, a catheter may be placed in the epidural space to allow continuous or intermittent administration of anesthetics. Epidural anesthesia has a slower onset compared to spinal anesthesia, typically taking 15-30 minutes to establish effective blockade, but it can be prolonged by adjusting the infusion of anesthetics through an epidural catheter. Epidural anesthesia is versatile and used for a wide range of surgeries, including thoracic, abdominal, and lower limb procedures, but also for labor analgesia and postoperative pain control. However, they involve technical complexity, potential for failed block, slower onset, and risks such as epidural hematoma or infection ^3–5.

CSE anesthesia combines the benefits of both spinal and epidural techniques—initially, a spinal needle is inserted through an epidural needle to deliver a single dose of local anesthetic into the subarachnoid space, after which an epidural catheter is placed for continuous or intermittent administration of anesthetics. CSE provides the rapid onset of spinal anesthesia with the prolonged and adjustable duration of epidural anesthesia: the spinal component offers immediate anesthesia, with the epidural catheter maintaining the blockade. CSE anesthesia is particularly useful for procedures requiring immediate and prolonged anesthesia, such as major abdominal surgeries and labor analgesia ^6,7. Advantages include its rapid onset and reliable block from the spinal component, prolonged anesthesia and postoperative analgesia through the epidural catheter, and flexibility. However, it requires a high level of skill and carries risks such as hypotension, post-dural puncture headache, and epidural catheter-related complications ^7,8.

The different types of neuraxial anesthesia are spinal, epidural, and combined spinal-epidural techniques, each offering distinct advantages for various surgical and pain management applications. The choice of neuraxial anesthesia depends on factors such as the type and duration of surgery, patient condition, and desired postoperative pain control.

References

1.          Regional Anesthetic Blocks – StatPearls – NCBI Bookshelf. Available at: https://www.ncbi.nlm.nih.gov/books/NBK563238/.

2.          Spinal Anesthesia – StatPearls – NCBI Bookshelf. Available at: https://www.ncbi.nlm.nih.gov/books/NBK537299/.

3.          Epidural Anesthesia – StatPearls – NCBI Bookshelf. Available at: https://www.ncbi.nlm.nih.gov/books/NBK542219/.

4.          Epidural – NHS. Available at: https://www.nhs.uk/conditions/epidural/.

5.          Epidural: What It Is, Procedure, Risks & Side Effects. Available at: https://my.clevelandclinic.org/health/treatments/21896-epidural.

6.        Roofthooft, E., Rawal, N. & Van de Velde, M. Current status of the combined spinal-epidural technique in obstetrics and surgery. Best Pract. Res. Clin. Anaesthesiol. 37, 189–198 (2023).doi: 10.1016/j.bpa.2023.04.004

7.          Combined Spinal Epidural (CSE). Available at: https://www.asra.com/news-publications/asra-updates/blog-landing/legacy-b-blog-posts/2019/08/07/combined-spinal-epidural-(cse).

8.          Combined spinal–epidural techniques – Continuing Education in Anaesthesia, Critical Care and Pain. Available at: https://www.bjaed.org/article/S1743-1816(17)30496-1/fulltext.

The practice of anesthesia involves the administration of powerful drugs to induce unconsciousness, manage pain, and support vital functions during surgery. Despite advancements in technology and clinical practices, anesthesia-related incidents can and do occur. To mitigate these risks and enhance patient safety, the Anesthesia Incident Reporting System (AIRS) was created to support the collection, analysis, and dissemination of information about anesthesia-related incidents, facilitating continuous learning and improvement in the field.

The Anesthesia Incident Reporting System is designed to capture data on adverse events, near misses, and any other anomalies related to anesthesia. By aggregating data from numerous incidents, AIRS helps identify common patterns and trends that might not be apparent from isolated cases. This can highlight areas where systemic improvements are needed. Understanding the underlying causes of incidents is crucial for preventing recurrence—AIRS facilitates detailed analyses to uncover deeper issues. The insights gained from the Anesthesia Incident Reporting System are then used to drive learning for anesthesia professionals. This ensures that past lessons are incorporated into future practice. Additionally, data from AIRS can inform the development of new policies and protocols, ensuring they are based on real-world evidence and address identified risks effectively ^1,2.

An effective incident reporting system such as AIRS relies on several key components. For the system to be effective, healthcare providers must feel safe reporting incidents without fear of punishment. This spurs comprehensive reporting and ensures that a wide range of data is captured. In addition, protecting the identity of reporters and patients involved in incidents is crucial. Comprehensive documentation of incidents, including the context, sequence of events, and contributing factors, is vital. This allows for a thorough analysis and greater understanding of how and why incidents occur. In parallel, providing feedback to those who report incidents and communicating findings to the wider anesthesia community ensures that lessons are shared and applied broadly ^3,4.

Several case studies and examples illustrate the value of learning from the Anesthesia Incident Reporting System.

Medication Errors

Analysis of AIRS data has revealed that medication errors, such as incorrect drug administration or dosing, are a relatively common type of adverse incident in anesthesia. By understanding the circumstances that lead to these errors, such as look-alike packaging or unclear labeling, strategies can be implemented to reduce their occurrence. This might include implementing barcode scanning or standardized labeling protocols ^5,6.

Airway Management

Incidents related to airway management are another significant concern. Reports from AIRS have highlighted issues such as difficult intubations and unanticipated airway obstructions. Training programs emphasizing advanced airway management techniques and simulation-based education have been developed in response to these findings ^7–9.

Equipment Malfunctions

Data from AIRS have identified equipment malfunctions as a frequent contributor to anesthesia-related incidents. This has led to improved maintenance schedules, regular equipment checks, and the development of more reliable and user-friendly anesthesia machines ^9,10.

The impact of the Anesthesia Incident Reporting System on patient safety cannot be overstated. By fostering a culture of continuous learning and improvement, AIRS has helped reduce preventable anesthesia-related complications. Healthcare facilities that actively engage with AIRS data often report lower rates of adverse events and higher levels of staff confidence in managing anesthesia safely ^11,12.

The Anesthesia Incident Reporting System represents a critical tool in the ongoing effort to enhance patient safety in anesthesia care. By capturing detailed data on incidents, facilitating root cause analysis, and informing education and policy development, AIRS helps healthcare providers learn from past experiences and implement effective strategies to prevent future incidents.

References

1.        AQI – Anesthesia Quality Institute. Available at: https://www.aqihq.org/airsIntro.aspx. (Accessed: 20th June 2024)

2.        Anesthesia Incident Reporting Systems – Anesthesia Services for Indiana. Available at: https://www.anesthesiaservicesin.com/anesthesia-incident-reporting-systems/. (Accessed: 20th June 2024)

3.        The Anesthesia Incident Reporting System (AIRS) – Anesthesia Patient Safety Foundation. Available at: https://www.apsf.org/article/the-anesthesia-incident-reporting-system-airs/. (Accessed: 20th June 2024)

4.        Saad, R. & Hanna, J. S. Reporting: Mandatory and Voluntary Systems, Legal Requirements, Anesthesia Quality Institute, and Physician Quality Reporting System. Case Stud. Clin. Psychol. Sci. Bridg. Gap from Sci. to Pract. 1–7 (2023). doi:10.1093/MED/9780197584521.003.0372

5.        Mutair, A. Al et al. The Effective Strategies to Avoid Medication Errors and Improving Reporting Systems. Medicines 8, 46 (2021). doi: 10.3390/medicines8090046

6.        Anesthesia Incident Reporting System (AIRS): Case 2021-3: All Orders Are Not Alike. ASA Monit. 85, 22–22 (2021).

7.        Avva, U., Lata, J. & Kiel, J. Airway Management – StatPearls – NCBI Bookshelf. StatePearlsPublishing (2021).

8.        Apfelbaum, J. L. et al. 2022 American Society of Anesthesiologists Practice Guidelines for Management of the Difficult Airway. Anesthesiology (2022). doi:10.1097/ALN.0000000000004002

9.        Anesthesia Incident Reporting System (AIRS) Case 2022-08: It’s All About the Airway. What Would You Do? ASA Monit. 86, 10–11 (2022).

10.      McIntyre, J. W. R. Anesthesia equipment malfunction: Origins and clinical recognition. Can. Med. Assoc. J. (1979).

11.      Arnal-Velasco, D. & Barach, P. Anaesthesia and perioperative incident reporting systems: Opportunities and challenges. Best Practice and Research: Clinical Anaesthesiology (2021). doi:10.1016/j.bpa.2020.04.013

12.      Bielka, K. et al. Critical incidents during anesthesia: prospective audit. BMC Anesthesiol. (2023). doi:10.1186/s12871-023-02171-4

The practice of anesthesia involves the administration of powerful drugs to induce unconsciousness, manage pain, and support vital functions during surgery. Despite advancements in technology and clinical practices, anesthesia-related incidents can and do occur. To mitigate these risks and enhance patient safety, the Anesthesia Incident Reporting System (AIRS) was created to support the collection, analysis, and dissemination of information about anesthesia-related incidents, facilitating continuous learning and improvement in the field.

The Anesthesia Incident Reporting System is designed to capture data on adverse events, near misses, and any other anomalies related to anesthesia. By aggregating data from numerous incidents, AIRS helps identify common patterns and trends that might not be apparent from isolated cases. This can highlight areas where systemic improvements are needed. Understanding the underlying causes of incidents is crucial for preventing recurrence—AIRS facilitates detailed analyses to uncover deeper issues. The insights gained from the Anesthesia Incident Reporting System are then used to drive learning for anesthesia professionals. This ensures that past lessons are incorporated into future practice. Additionally, data from AIRS can inform the development of new policies and protocols, ensuring they are based on real-world evidence and address identified risks effectively ^1,2.

An effective incident reporting system such as AIRS relies on several key components. For the system to be effective, healthcare providers must feel safe reporting incidents without fear of punishment. This spurs comprehensive reporting and ensures that a wide range of data is captured. In addition, protecting the identity of reporters and patients involved in incidents is crucial. Comprehensive documentation of incidents, including the context, sequence of events, and contributing factors, is vital. This allows for a thorough analysis and greater understanding of how and why incidents occur. In parallel, providing feedback to those who report incidents and communicating findings to the wider anesthesia community ensures that lessons are shared and applied broadly ^3,4.

Several case studies and examples illustrate the value of learning from the Anesthesia Incident Reporting System.

Medication Errors

Analysis of AIRS data has revealed that medication errors, such as incorrect drug administration or dosing, are a relatively common type of adverse incident in anesthesia. By understanding the circumstances that lead to these errors, such as look-alike packaging or unclear labeling, strategies can be implemented to reduce their occurrence. This might include implementing barcode scanning or standardized labeling protocols ^5,6.

Airway Management

Incidents related to airway management are another significant concern. Reports from AIRS have highlighted issues such as difficult intubations and unanticipated airway obstructions. Training programs emphasizing advanced airway management techniques and simulation-based education have been developed in response to these findings ^7–9.

Equipment Malfunctions

Data from AIRS have identified equipment malfunctions as a frequent contributor to anesthesia-related incidents. This has led to improved maintenance schedules, regular equipment checks, and the development of more reliable and user-friendly anesthesia machines ^9,10.

The impact of the Anesthesia Incident Reporting System on patient safety cannot be overstated. By fostering a culture of continuous learning and improvement, AIRS has helped reduce preventable anesthesia-related complications. Healthcare facilities that actively engage with AIRS data often report lower rates of adverse events and higher levels of staff confidence in managing anesthesia safely ^11,12.

The Anesthesia Incident Reporting System represents a critical tool in the ongoing effort to enhance patient safety in anesthesia care. By capturing detailed data on incidents, facilitating root cause analysis, and informing education and policy development, AIRS helps healthcare providers learn from past experiences and implement effective strategies to prevent future incidents.

References

1.        AQI – Anesthesia Quality Institute. Available at: https://www.aqihq.org/airsIntro.aspx. (Accessed: 20th June 2024)

2.        Anesthesia Incident Reporting Systems – Anesthesia Services for Indiana. Available at: https://www.anesthesiaservicesin.com/anesthesia-incident-reporting-systems/. (Accessed: 20th June 2024)

3.        The Anesthesia Incident Reporting System (AIRS) – Anesthesia Patient Safety Foundation. Available at: https://www.apsf.org/article/the-anesthesia-incident-reporting-system-airs/. (Accessed: 20th June 2024)

4.        Saad, R. & Hanna, J. S. Reporting: Mandatory and Voluntary Systems, Legal Requirements, Anesthesia Quality Institute, and Physician Quality Reporting System. Case Stud. Clin. Psychol. Sci. Bridg. Gap from Sci. to Pract. 1–7 (2023). doi:10.1093/MED/9780197584521.003.0372

5.        Mutair, A. Al et al. The Effective Strategies to Avoid Medication Errors and Improving Reporting Systems. Medicines 8, 46 (2021). doi: 10.3390/medicines8090046

6.        Anesthesia Incident Reporting System (AIRS): Case 2021-3: All Orders Are Not Alike. ASA Monit. 85, 22–22 (2021).

7.        Avva, U., Lata, J. & Kiel, J. Airway Management – StatPearls – NCBI Bookshelf. StatePearlsPublishing (2021).

8.        Apfelbaum, J. L. et al. 2022 American Society of Anesthesiologists Practice Guidelines for Management of the Difficult Airway. Anesthesiology (2022). doi:10.1097/ALN.0000000000004002

9.        Anesthesia Incident Reporting System (AIRS) Case 2022-08: It’s All About the Airway. What Would You Do? ASA Monit. 86, 10–11 (2022).

10.      McIntyre, J. W. R. Anesthesia equipment malfunction: Origins and clinical recognition. Can. Med. Assoc. J. (1979).

11.      Arnal-Velasco, D. & Barach, P. Anaesthesia and perioperative incident reporting systems: Opportunities and challenges. Best Practice and Research: Clinical Anaesthesiology (2021). doi:10.1016/j.bpa.2020.04.013

12.      Bielka, K. et al. Critical incidents during anesthesia: prospective audit. BMC Anesthesiol. (2023). doi:10.1186/s12871-023-02171-4

All APRNs are registered nurses who have earned a graduate degree that certifies them to practice advanced and specialized care. There are four classes of APRNs: certified nurse midwife (CNM), clinical nurse specialist (CNS), certified nurse practitioner (CNP), and certified registered nurse anesthetist (CRNA). Though all APRNs undergo extensive training to achieve their advanced degree, each type obtains a different skillset, with CRNAs focused on anesthesia care.

Prospective CRNAs must complete a master’s degree from a certified nurse anesthesia educational program and complete courses that focus on pharmacology, physiology, professional practices, and pain management. Comparatively, RNs must complete a Master of Science in nursing (MSN) to become a CNP and are recommended to do so to practice as a CNS. In most cases, both the CNS and CNP will subspecialize in a specific population, such as gerontology or pediatrics. Similarly, the CNM provider will obtain an MSN and then pass the midwifery exam offered by the American Midwifery Certification Board.¹ According to the Nurse Journal, CRNAs are the highest-paid APRNs, with an average annual take-home salary of $195,610, while CNMs earn $112,830 a year on average. The highest-paid CNP is a psychiatric CNP who earns $113,100 annually on average, whereas family and pediatric CNPs earn up to $98,000 annually on average.  Finally, the CNS provider can make up to $133,000 per year.²

With a highly attractive income potential and the ability to gain advanced skills, many RNs are motivated to earn a CRNA certification to meet the growing demand for anesthesia providers. In contrast to other APRNs, CRNAs are specially trained to provide anesthesia to patients in settings such as hospitals, clinics, private practices, and doctors’ offices. They also monitor vital signs throughout anesthesia, assist patients with recovery and side effects, and conduct post-procedure evaluations. The level of independence that CRNAs have varies according to state regulations, with some able to independently lead anesthesia care, while others require physician supervision.

In addition to their role in treating and diagnosing patients within their area of expertise, a CNS provider has a key role in education. CNS providers are often involved in educational programs to improve nurse performance, patient outcomes, and bedside nursing. This process involves the mentorship of nursing students and new nurse staff. They will also oversee evidence-based research and counsel patients and families when they act as resident experts on medically complex cases.^3,6

CNPs provide comprehensive care in their area of expertise. Their roles can include performing physical examinations, ordering prescriptions and procedures, ordering and interpreting laboratory and diagnostic results, and providing family planning services, prenatal care, health risk assessment, psychological counseling, healthcare service coordination, and/or health education.⁴

Finally, CNMs support patients in all areas of menarche, pregnancy, birth, and menopause. As providers, they can perform physical examinations independently, order prescriptions, and expedite patient therapy by admitting, managing, and discharging patients. They can interpret laboratory and diagnostic tests, order medical devices and equipment, and provide home health services.⁵

References

1. “NP vs. RN vs. CRNA (& More).” Adaptive Medical Partners, 23 May 2022, adaptivemedicalpartners.com/np-vs-rn-vs-crna-more/. Accessed 14 May 2024.
2. “Nurse Practitioner vs Clinical Nurse Specialist.” NurseJournal, 4 Dec. 2021, nursejournal.org/resources/np-vs-cns/.
3. “Medicare and CRNA Education – ProQuest.” Www.proquest.com, www.proquest.com/scholarly-journals/medicare-crna-education/docview/222116607/se-
4. AANP. “The Path to Becoming a Nurse Practitioner (NP).” American Association of Nurse Practitioners, 2020, www.aanp.org/news-feed/explore-the-variety-of-career-paths-for-nurse-practitioners.
5. “Nurse Anesthetists, Nurse Midwives, and Nurse – ProQuest.” Www.proquest.com, www.proquest.com/reports/nurse-anesthetists-midwives-practitioners/docview/2396587784/se-2. Accessed 14 May 2024.
6. “The Role of the Clinical Nurse Specialist in the – ProQuest.” Www.proquest.com, www.proquest.com/trade-journals/role-clinical-nurse-specialist-acute-care-setting/docview/3032757053/se-2. Accessed 14 May 2024.

Artificial Intelligence, or AI, is an umbrella term that encompasses technologies including deep learning, large language models, and natural language processing, that analyze large data sets in depth and learn from them, enabling the identification of subtle patterns¹. As AI technologies evolve, the potential applications of AI in medicine become increasingly versatile.

There are many potential applications for AI in medicine, with implementation of AI-powered tools in healthcare operations estimated to cut costs by $150 billion by 2026³. The most obvious application for AI is in streamlining and digitizing administrative tasks such as scheduling appointments, making reminder calls for pediatric immunizations and prenatal visits, and generating drug dosage algorithms and adverse effect warnings for patients on multiple drugs². Studies show that physicians who use documentation support tools such as voice-to-text dictation or medical scribe services have more face time with their patients³. Using AI to lessen the documentation and administrative burden therefore may improve patient care and satisfaction³. Additionally, AI may improve the precision of medical therapies by tailoring treatment to each patient based on a variety of patient factors such as age, gender, geography, race, family history, immune profile, metabolic profile, microbiome, and environment vulnerability³. This can be accomplished using complex algorithms that can take large datasets with patient information and analyze them for prognostic outcomes, in conjunction with patient information provided through health apps that monitor metrics such as food intake, vital signs, physical activity etc³. With improved genetic testing, AI can also incorporate patient genetic information to optimize treatment plans³. 

While the implications for AI use in clinical support tools are far-reaching and important, it is also a valuable technology for direct clinical work. Radiology and imaging diagnostics are one such area where AI can improve provider efficiency². While much work remains before AI can independently infer a diagnosis within complex clinical contexts with proven safety and accuracy, it can be used as a data point in provider decision-making, especially in distinguishing normal scans². This capability can be extremely helpful in places of high clinical volume, helping to reduce physician burnout². From a quality and safety standpoint, AI-driven video analysis is surprisingly effective at performing root-cause analysis³. One video analysis of a laparoscopic procedure was 92.8% accurate, not only in elucidating the steps of the procedure, but also in establishing missing or incorrect steps³. Finally, AI has been used to improve surgical robotics. Johns Hopkins University has developed a surgical robot called STAR (smart tissue autonomous robot), which has been shown in animal tissue to be able to consistently outperform human surgeons in tasks such as creating connections in bowel, suturing, and tying surgical knots³. While a fully autonomous robot surgeon still belongs to science fiction, implementing AI in surgery can enhance patient safety and successful surgical outcomes³.

Overall, the field of AI is exploding in terms of new technologies, and learning how to work with AI has the potential to enhance human endeavors in many disciplines. Advancements in AI have vast implications in medicine specifically, including improving clinical efficiency, reducing provider burnout, and improving surgical outcomes through diverse applications.

References

1. Alowais SA, Alghamdi SS, Alsuhebany N. et al. Revolutionizing healthcare: the role of artificial intelligence in clinical practice. BMC Med Educ 23, 689 (2023). doi:10.1186/s12909-023-04698-z.
2. Amisha MP, Pathania M, Rathaur VK. Overview of artificial intelligence in medicine. J Family Med Prim Care. 2019 Jul;8(7):2328-2331. doi:10.4103/jfmpc.jfmpc_440_19. PMID: 31463251; PMCID: PMC6691444.
3. Bohr A, Memarzadeh K. The rise of artificial intelligence in healthcare applications. Artificial Intelligence in Healthcare. 2020 Jun;25–60. doi:10.1016/B978-0-12-818438-7.00002-2. PMCID: PMC7325854.

Tranexamic acid (TXA) is an antifibrinolytic agent, a medication that reduces bleeding by preventing the lysis of a blood clot.¹ Originally developed for patients with hemophilia undergoing oral surgery, TXA is now also administered to reduce heavy menstrual bleeding, treat trauma patients at risk for hemorrhage, and to preoperatively minimize the need for blood transfusions during surgery.² TXA is an analog of the amino acid lysine and it functions by blocking the conversion of plasminogen to the enzyme plasmin, which breaks down blood clots by attacking fibrin.² TXA was first synthesized in 1962 and is currently on the World Health Organization’s Model List of Essential Medicines. ^3,4

In the surgical setting, TXA is commonly used for major orthopedic surgery, which often involves significant blood loss and requires transfusions.⁵ Specifically, a little less than a third of patients undergoing total joint arthroplasty require postoperative blood transfusions for anemia.⁶ Studies^7,8 have shown that intravenous TXA reduces blood loss and transfusion requirements for both total knee and hip arthroplasties. The safety and efficacy of topical and intra-articular TXA for total joint arthroplasty has also been established in the literature.⁹

In addition to orthopedic surgery, spine surgery can often entail a large volume of blood loss and is likewise often accompanied by the administration of TXA. Blood loss during posterior instrumented spinal fusion was found to be reduced by as much as 30% in patients given TXA before the operation.¹⁰ The efficacy of TXA for pediatric and adolescent patients has also been established in some situations: studies have shown that younger patients who receive intravenous TXA before scoliosis surgery demonstrate a dramatic decrease in blood loss.¹¹ While some studies, such as one investigating the perioperative use of TXA for fusion of the thoracic and lumbar spine,¹² have not found a significant difference in blood loss for patients given TXA, most clinical trials are in fact indicating that TXA can effectively control blood loss during spinal surgery.¹⁰

The use of TXA, while known to prevent the lysis of blood clots, may concurrently increase the risk of thromboembolism, the obstruction of a blood vessel by a blood clot dislodged from another site.  The 2012 “MATTER” study, which investigated the use of TXA in combat injury, demonstrated higher rates of thromboembolism in patients receiving TXA.¹³ Similarly, a 2018 study concluded that TXA administration was an independent risk factor for thromboembolism.¹⁴

However, these studies may be misleading. Myers et al.¹⁵ note that in those studies, TXA is only given to the sickest patients, who may already be at a much higher risk for thromboembolism, thus confounding any potential results. Many of these retrospective studies do not routinely screen for thromboembolism, which may present another methodological problem. Many more studies, in fact, have found that TXA does not present a significant risk for thromboembolism. For example, a recent systematic review and meta-analysis of hundreds of studies did not reveal an increased risk of thromboembolic events in any patient group.¹⁶ While patients should certainly be made aware of the potential for developing thromboembolic events upon receiving TXA, the risk appears to be quite low, and most researchers believe it should not prevent physicians from administering this vital drug.

References

1. McEvoy, M. “Tranexamic Acid (TXA): Drug Whys.” EMS1, Lexipol, 29 June 2015, www.ems1.com/ems-products/ambulance-disposable-supplies/articles/tranexamic-acid-txa-drug-whys-JHdJgbiQRX2zqonO/.

2. Thomas, J. “The Benefits of TXA.” EMS World, 5 Feb. 2015, www.emsworld.com/article/12042127/tranexamic-acid-for-prehospital-hemorrhage.

3. “TXA: History.” TXA Central, London School of Hygiene & Tropical Medicine, txacentral.lshtm.ac.uk/?page_id=98.

4. Gill, R., et al. “WHO Essential Medicines for Reproductive Health.” BMJ Global Health, vol. 4, no. 6, 2019, doi:10.1136/bmjgh-2019-002150.

5. Davey, J. Roderick, et al. “Tranexamic Acid for the Prevention and Management of Orthopedic Surgical Hemorrhage: Current Evidence.” Journal of Blood Medicine, 2015, p. 239., doi:10.2147/jbm.s61915.

6. Blumberg, N., et al. “A Cost Analysis of Autologous and Allogeneic Transfusions in Hip-Replacement Surgery.” The American Journal of Surgery, vol. 171, no. 3, 1996, pp. 324–330., doi:10.1016/s0002-9610(97)89635-3.

7. Ekbäck, G., et al. “Tranexamic Acid Reduces Blood Loss in Total Hip Replacement Surgery.” Anesthesia & Analgesia, vol. 91, no. 5, 2000, pp. 1124–1130., doi:10.1097/00000539-200011000-00014.

8. Good, L., et al. “Tranexamic Acid Decreases External Blood Loss but Not Hidden Blood Loss in Total Knee Replacement.” British Journal of Anaesthesia, vol. 90, no. 5, 2003, pp. 596–599., doi:10.1093/bja/aeg111.

9. Wong, J., et al. “Topical Application of Tranexamic Acid Reduces Postoperative Blood Loss in Total Knee Arthroplasty.” The Journal of Bone and Joint Surgery-American Volume, vol. 92, no. 15, 2010, pp. 2503–2513., doi:10.2106/jbjs.i.01518.

10. Yoo, J. S., et al. “The Use of Tranexamic Acid in Spine Surgery.” Annals of Translational Medicine, vol. 7, no. S5, 2019, doi:10.21037/atm.2019.05.36.

11. Verma, K., et al. “The Relative Efficacy of Antifibrinolytics in Adolescent Idiopathic Scoliosis.” Journal of Bone and Joint Surgery, vol. 96, no. 10, 2014, doi:10.2106/jbjs.l.00008.

12. Farrokhi, M. R., et al. “Efficacy of Prophylactic Low Dose of Tranexamic Acid in Spinal Fixation Surgery.” Journal of Neurosurgical Anesthesiology, vol. 23, no. 4, 2011, pp. 290–296., doi:10.1097/ana.0b013e31822914a1.

13. Morrison, J. J. “Military Application of Tranexamic Acid in Trauma Emergency Resuscitation (MATTERs) Study.” Archives of Surgery, vol. 147, no. 2, 2012, p. 113., doi:10.1001/archsurg.2011.287.

14. Johnston, L. R., et al. “Evaluation of Military Use of Tranexamic Acid and Associated Thromboembolic Events.” JAMA Surgery, vol. 153, no. 2, 2018, p. 169., doi:10.1001/jamasurg.2017.3821.

15. Myers, S. P., et al. “Venous Thromboembolism after Tranexamic Acid Administration: Legitimate Risk or Statistical Confounder?” ANZ Journal of Surgery, vol. 90, no. 4, 2020, pp. 425–426., doi:10.1111/ans.15670.

16. Taeuber, I., et al. “Association of Intravenous Tranexamic Acid With Thromboembolic Events and Mortality.” JAMA Surgery, vol. 156, no. 6, 2021, doi:10.1001/jamasurg.2021.0884.

Restless Leg Syndrome (RLS) is a common neurological disorder that affects approximately 5-10% of the population (1). It is characterized by an irresistible urge to move the legs, often accompanied by uncomfortable sensations, such as tingling, itching, or crawling. These symptoms typically worsen during periods of rest or inactivity, leading to sleep disturbances and a significant impact on patients’ quality of life (2). For patients with restless leg syndrome undergoing anesthesia, the involuntary leg movements and discomfort can pose challenges for anesthesiologists, requiring specialized techniques and considerations to ensure safe and effective anesthesia administration. Additionally, certain medications commonly prescribed to manage RLS symptoms may interact with anesthetic drugs, necessitating a thorough understanding of potential drug interactions and adjustments in dosage (3). By addressing these challenges, anesthesiologists can provide optimal care for patients with RLS and ensure a smooth and successful anesthesia experience.

One way that anesthesiologists can adapt their techniques for patients with restless leg syndrome is by utilizing regional anesthesia. Regional anesthesia involves using nerve blocks to numb specific areas of the body, such as the legs, while the patient remains awake. This can help minimize the discomfort caused by RLS and reduce the risk of involuntary leg movements during surgery (3). Another technique that can be employed is the use of sedatives or muscle relaxants prior to anesthesia administration. These medications can help relax the muscles and reduce the severity of RLS symptoms (1).

Additionally, anesthesiologists should carefully review a patient’s medication history and consult with their primary care physician or neurologist to ensure that there are no potential interactions between RLS medications and any anesthetic drugs that may be used. For instance, dopamine agonists (pramipexole, ropinirole, etc.), which are commonly prescribed for RLS, may interact with anesthetic drugs, leading to increased sedation or hypotension (2). On the other hand, certain opioids used during anesthesia may worsen RLS symptoms or trigger an RLS episode. Anesthesiologists should be aware of these potential interactions and make necessary adjustments in medication dosages or choose alternative medications to ensure patient safety and optimize anesthesia outcomes.

In addition to the challenges during surgery, patients with RLS may also experience difficulties with post-operative pain management (1). The discomfort and restlessness associated with RLS can make it challenging for patients to find a comfortable position or to stay still, which can impede the healing process. Anesthesiologists and other healthcare providers must take this into consideration when developing a pain management plan for these individuals. By tailoring pain relief strategies to address both the surgical and RLS-related discomfort, patients can experience a smoother recovery and better overall outcomes (3). This may involve adjusting medication dosages or using alternative pain management techniques such as physical therapy or acupuncture. In some cases, it may be necessary to involve a multidisciplinary team of healthcare professionals, including neurologists or sleep specialists, to ensure comprehensive care. By addressing both the surgical and RLS-related pain, patients can not only recover more comfortably but also reduce the risk of complications and improve their overall quality of life (1). It is crucial for anesthesia providers to have open communication with patients regarding restless leg syndrome and to work together to develop an individualized pain management plan that meets the unique needs of each patient.

References

1. Gossard TR, Trotti LM, Videnovic A, St Louis EK. Restless Legs Syndrome: Contemporary Diagnosis and Treatment. Neurotherapeutics. 2021;18(1):140-155. doi:10.1007/s13311-021-01019-4
2. Amir A, Masterson RM, Halim A, Nava A. Restless Leg Syndrome: Pathophysiology, Diagnostic Criteria, and Treatment. Pain Med. 2022;23(5):1032-1035. doi:10.1093/pm/pnab253
3. Raux M, Karroum EG, Arnulf I. Case scenario: anesthetic implications of restless legs syndrome. Anesthesiology. 2010;112(6):1511-1517. doi:10.1097/ALN.0b013e3181de2d66

Bronchoscopy is an investigative or therapeutic procedure that involves inserting an instrument into the lungs via the airway and is often performed under anesthesia. Rigid bronchoscopy generally warrants general anesthesia, while flexible bronchoscopy can be carried out under sedation supplemented with topical anesthesia [1]. It is critical for the practicing anesthetist to use the best method for each individual patient [2].

Prior to any procedure, since patients may be of American Society of Anesthesiologists III-IV physical status given the conditions that typically call for bronchoscopy, appropriate pre-operative tests need to be carried out. This will inform the best approach to anesthesia for the bronchoscopy depending on the context [3].

For rigid bronchoscopy

The ideal anesthetic regimen involves analgesia, an appropriate decrease in awareness or consciousness, and muscle relaxation. General anesthesia is usually used for rigid bronchoscopy. Anesthesia may be induced with propofol, etomidate or ketamine, with fentanyl or remifentanil in adults, or with inhalational agents in children. The patient’s vocal cords should be treated with lignocaine in order to prevent the occurrence of post-operative laryngospasm. In addition, fentanyl boluses and short acting beta blockers can be administered in order to prevent a pressor response.

Anesthesia is then maintained with remifentanil and an intravenous or inhalational agent. Target controlled infusion as part of a total intravenous anesthesia (TIVA) protocol may also be used.

The reversal of a patient’s neuromuscular block is carried out postoperatively, with neostigmine, glycopyrrolate or atropine based on the clinical situation and physician choice. It is important to completely reverse the block since most patients undergoing a bronchoscopy will not have the respiratory reserve to tolerate any residual block [3].

Following completion of the procedure and prior to the administration of a reversal agent, it is best to implement a cuffed endotracheal tube or a laryngeal mask airway. An endotracheal tube is generally preferred as an emergency flexible bronchoscopy may be needed.

For flexible bronchoscopy

In most cases, sedation is sufficient for flexible bronchoscopy. Depending on state regulations and facility protocol, light to moderate sedation may be provided directly by the proceduralist. A moderate level of sedation allows the patient to respond to verbal commands and recover more quickly compared to deeper anesthesia. The dose of sedative should generally be decreased in elderly patients. As there is always a small risk of bradycardia, patients need to be monitored for any signs of hypotension or respiratory depression. Additionally, the American College of Clinical Pharmacology has published detailed guidelines for the administration of anesthesia for flexible bronchoscopy [3].

Topical anesthesia is critical in flexible bronchoscopy since it helps with patient comfort. To this end, the nostrils, oropharynx and hypopharynx are anesthetized, and anesthesia beyond the glottis can also blunt the cough reflex and allow for the bronchoscopy procedure to take place as smoothly as possible. Lignocaine is the most common agent used for topical anesthesia, but topical anesthesia regimens tend to vary across clinics [3].

Providing sedation and anesthesia for patients undergoing a bronchoscopy requires a thorough understanding of pulmonary anatomy and physiology, clear communication between the anesthesia provider, proceduralist, and patient, and a patient-tailored anesthetic regimen in order to ensure the best possible patient outcomes [4].

References

1. Lentini, C. & Granlund, B. Anesthetic Considerations for Bronchoscopic Procedures. StatPearls (2023).

2. Galway, U. et al. Anesthetic considerations for bronchoscopic procedures: a narrative review based on the Cleveland Clinic experience. J. Thorac. Dis. 11, 3156–3170 (2019). doi: 10.21037/jtd.2019.07.29

3. Chadha, M., Kulshrestha, M. & Biyani, A. Anaesthesia for bronchoscopy. Indian J. Anaesth. 59, 565 (2015). doi: 10.4103/0019-5049.165851

4. Goudra, B. G., Singh, P. M., Borle, A., Farid, N. & Harris, K. Anesthesia for Advanced Bronchoscopic Procedures: State-of-the-Art Review. Lung 193, 453–465 (2015). DOI: 10.1007/s00408-015-9733-7