Anesthesia Patient Safety Foundation

Abstract IntroductionIndianapolis Coalition for Patient Safety, Inc. (ICPS) identified practice variation across participating health‐systems related to intravenous Patient‐Controlled Analgesia (PCA) in 2018. No evidence‐based published recommendations were available to provide optimization for the medication use process during this evaluation, leading to development of an ad hoc interdisciplinary group to address gaps.ObjectivesPrimary objectives were to operationalize safe use of PCA and evaluate implementation of ICPS PCA consensus recommendations at an academic medical center by assessing PCA prescribing patterns following policy and electronic health record (EHR) changes. Secondary objectives focused on markers of adoption changes and employee engagement.MethodsICPS formed an interdisciplinary, diverse group of content experts representing six health‐systems to review current PCA processes. Significant variations were identified, and a gap‐analysis was completed to develop consensus recommendations. To evaluate implementation of these recommendations, a retrospective pre‐/post‐analysis was completed of patients at a safety‐net, academic medical center from March 2021 to July 2022 who received an order for PCA. Prescribing patterns and electronic documentation were analyzed.ResultsThe ICPS PCA Safety Summit developed 45 consensus recommendations addressing the following PCA medication use processes: ordering, patient assessment, administration, EHR design, documentation tools, smart pump drug library settings, policies, adverse event monitoring, and education. Evaluation included a total of 155 patients. The ordered total number of morphine milligram equivalent (MME) potentially available per day to a patient from PCA, electronic documentation of opioid tolerance, and PCA smart infusion pump review all significantly improved post‐implementation.ConclusionCity‐wide standardization and development of PCA consensus guidelines filled a gap in practice to provide direction and optimization for the medication use process surrounding these high‐alert medications. Organizational results following implementation provide evidence that using new EHR order sets and incorporating opioid tolerance resulted in more intentional PCA prescribing and more thorough electronic nursing documentation.

While studying neurotoxicity in rats, we observed that the anesthetic minimum alveolar anesthetic concentration (MAC) of isoflurane decreases with increasing duration of anesthesia in 7-day-old but not in 60-day-old rats. After 15 min of anesthesia in 7-day-old rats, MAC was 3.5% compared with 1.3% at 4 h. We investigated whether kinetic or dynamic factors mediated this decrease. In 7-day-old rats, we measured inspired and cerebral partial pressures of isoflurane at MAC as a function of duration of anesthesia. In 60-day-old rats, we measured inspired partial pressures of isoflurane at MAC as a function of duration of anesthesia. Finally, we determined the effect of administering 1 mg/kg naloxone and of delaying the initiation of the MAC determination (pinching the tail) on MAC in 7-day-old rats. In 7-day-old rats, both inspired and cerebral measures of MAC decreased from 1 to 4 h. The inspired MAC decreased 56%, whereas the cerebral MAC decreased 33%. At 4 h, the inspired MAC approximated the cerebral MAC (i.e., the partial pressures did not differ appreciably). Neither administration of 1 mg/kg naloxone nor delaying tail clamping until 3 h reversed the decrease in MAC. In 60-day-old rats, inspired MAC of isoflurane was stable from 1 to 4 h of anesthesia. MAC of isoflurane decreases over 1-4 h of anesthesia in 7-day-old but not in 60-day-old rats. Both pharmacodynamic and a pharmacokinetic components contribute to the decrease in MAC in 7-day-old rats. Neither endorphins nor sensory desensitization mediate the pharmacodynamic component.