A novel checklist for anesthesia in neurosurgical cases.

Throughout their training, anesthesiology residents are exposed to a variety of surgical subspecialties, many of which have specific anesthetic considerations. According to the Accreditation Council for Graduate Medical Education requirements, each anesthesiology resident must provide anesthesia for at least twenty intracerebral cases. There are several studies that demonstrate that checklists may reduce deficiencies in pre-induction room setup. We are introducing a novel checklist for neuroanesthesia, which we believe to be helpful for residents during their neuroanesthesiology rotations. Our checklist provides a quick and succinct review of neuroanesthetic challenges prior to case setup by junior residents, covering noteworthy aspects of equipment setup, airway management, induction period, intraoperative concerns, and postoperative considerations. We recommend displaying this checklist on the operating room wall for quick reference. Copyright:

INTRODUCTION

Throughout their training, anesthesiology residents are exposed to a variety of surgical subspecialties, many of which have specific anesthetic considerations. Given the high pace of anesthesia, it can be difficult to ensure that the setup for the case is done efficiently and taking into account each aspect of a complex case. We are introducing a tool we believe to be helpful for residents during their neuroanesthesiology rotations. A checklist for neurosurgery cases could be posted on a wall of a neurosurgery-dedicated operating room for quick reference during case setup by a resident. We believe that it would reduce inadequate preparation and the stress and delays caused by missing equipment during the case.

According to the Accreditation Council for Graduate Medical Education requirements, each anesthesiology resident must perform anesthesia for at least twenty intracerebral cases.[1] Although there are no minimums for spine cases, they are even more common than intracerebral cases. At the end of residency training, residents are expected to be proficient in providing anesthesia for a wide variety of cases. Nonetheless, early in a subspecialty rotation, it may be challenging to incorporate all relevant anesthetic considerations in an efficient manner. At our institution, checklists are displayed on the wall to ensure uniform room setup in the trauma room and the obstetric operating rooms, which our residents have found helpful. We have presented an initiative to expand such checklists to cover other subspecialties.

EVIDENCE FOR CHECKLISTS

Checklists are ubiquitously used in medicine, however, they are arguably not commonly used in anesthesia practice. There are several studies that demonstrate that checklists may reduce deficiencies in pre-induction room setup.

Thomassen et al. created a 26-point pre-induction checklist, which was used in 502 inductions during a 13-week study period.[8] The study identified that approximately 34% of inductions had one or more missing items, a number that decreased to near 5% by the end of the study. The implementation of the checklist did not significantly affect time to induction. The authors conclude that checklist use is possible in a hectic and stressful clinical environment, and reduces a surprisingly large number of missing items in a standard induction.[8]

Wetmore et al. studied a pre-anesthetic induction patient safety (PIPS) checklist in a simulation setting.[9] The PIPS checklist is a 22-point checklist developed by the Anesthesia Patient Safety Foundation. This randomized, controlled, observer-blinded trial compared the performance of 38 anesthesiology residents. The participants were sorted into two groups, one with the checklist embedded into the simulated operating room’s electronic medical record, and the other group without the checklist. The study demonstrated that residents at each level of training omitted significantly fewer steps in pre-anesthetic setup when using the PIPS checklist, albeit at the expense of increasing time to induction by 1–2 min.[9]

Beck et al. investigated whether self-training with an electronic audiovisual checklist app on a smartphone would improve safe pre-induction setup in anesthesiology residency beginners in the first 8 weeks of their training.[3] The study demonstrated improved safety behaviors in residents using the checklist app, however, that difference disappeared after 8 weeks of training. The authors recommend the use of a self-training checklist tool in the first 3 months of the curriculum to improve safety during anesthesia inductions.[3]

NEUROANESTHESIA

To the best of our knowledge, there are no published checklists for neuroanesthesia, which has multiple considerations distinguishing it from more basic cases. We hope that our checklist can provide a quick and succinct review of neuroanesthetic challenges prior to case setup by junior residents [Table 1].

Table 1:

Ghaly Checklist for General and Neuro-Anesthesia.

Neurosurgery cases are frequently long, positioning is prone, the head of the bed may be rotated away from the anesthesia provider, and the patient’s head may be stabilized with a horseshoe or pins.[2] These aspects emphasize the importance of securing the endotracheal tube and adequate intravenous (IV) access, typically with an additional IV line (s). Most patients tend to be older and have multiple comorbidities. Tight blood pressure control tends to be particularly important, warranting placement of an arterial line, and in some cases, a central line. Vasopressor and antihypertensive drips need to be available. If extensive blood loss is expected, plans for a possible transfusion must be in place.

Some neurosurgical patients have a history of prior cervical spine surgeries, making neck extension for direct laryngoscopy limited; other patients may have trauma that requires inline cervical stabilization. These patients typically require video laryngoscopy or fiberoptic intubation.[4] Endotracheal tube (ETT) must be selected as well, such as a suctioning ETT for possible intensive care unit (ICU) admission, or neuromonitoring ETT if recurrent laryngeal nerve monitoring is expected, such as the anterior approach to the cervical spine. Other induction considerations include elevated intracranial pressure (ICP), which is a contraindication for medications such as succinylcholine and ketamine, or neuromonitoring, which precludes the use of long-acting neuromuscular blockers, as they interfere with the measurements.[5,7]

Following induction and positioning, the anesthesiologist must prepare for intraoperative use of navigation systems and imaging, as the equipment can share the space with the breathing circuit, IV lines, and monitor cords, which must be secured to prevent accidental dislodgement. Cases that require neuromonitoring or cerebral vasoconstriction may require total IV anesthesia (TIVA) as opposed to inhalational anesthesia with neuromuscular blockade.[6] Surgeons may have specific preferences regarding end-tidal CO2 and blood pressure parameters, and some cases may require therapeutic hypothermia for neuroprotection. Many cases require administration of neurosurgery-specific medications, such as high-dose steroids, antiepileptics (levetiracetam, phenytoin), osmodiuretics (mannitol), or 3% hypertonic saline. Finally, the anesthesiologist should tailor the anesthetic plan for postoperative considerations, such as need for early neurological assessment.

CONCLUSION

Checklists have been demonstrated to improve safety and efficacy in delivery of anesthesia. They are particularly important early in training when residents lack the experience to take into consideration every aspect of a complex and challenging case. We believe that organizing typical neuroanesthetic concerns into a checklist could prove beneficial for residents, standardize operating room setups prior to cases, decrease missed items that would have to be retrieved later in the case, and improve patient safety by reducing common mistakes.