Very Interesting Study

[Noyac]

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http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Retrieve&dopt=Abstract&list_uids=17525583

Read the last line of the abstract.

Obesity and African-American race were the two factors most commonly identified among the anesthesia-related mortalities. Each of these characteristics was present in 75% of patients. Complications associated with difficult or failed intubation during induction of general anesthesia have been reported as frequent causes of anesthesia-related maternal mortality in other studies. In this recent study from Michigan, however, no failed intubations during anesthesia induction were reported. The only case of difficult intubation occurred during a failed cardiopulmonary resuscitation several hours after a cesarean delivery performed under spinal anesthesia. Hypoventilation or airway obstruction was a contributing factor in five of the eight anesthesia-related deaths. An important, and perhaps surprising, finding was that all of these airway episodes occurred during emergence, extubation, or the postoperative recovery period.

No anesthesia-related deaths occurred in women who received epidural labor analgesia for a successful vaginal delivery. However, complications of spinal anesthesia for cesarean delivery, including high spinal anesthesia after an epidural test dose, were likely etiologies in two of the reported cases. All but one of the deaths occurred in women who underwent either cesarean delivery or dilation and curettage for retained placenta. Preeclampsia was present in only one patient.

The investigators' analysis of the anesthesia-related deaths produced other interesting conclusions. Cardiac disease that was undiagnosed or more severe than realized by the anesthesia provider was a contributing factor in three of the cases. The authors felt that inadequate postoperative monitoring or supervision by an anesthesiologist were important etiologic factors in five of the eight deaths. In two of eight of the anesthesia-related mortalities, the anesthesia care provider was a nurse anesthetist supervised by an obstetrician. In six of eight cases, the anesthesia provider was a nurse anesthetist supervised by an anesthesiologist. 😕

 

[Noyac]

As you can tell I am on-call this weekend.

 

[nutmegs]

How about the last TWO lines? Does that make 2+6 = 8/8 by CRNAs??

 

[Southpaw]

To me, the study says that the patient is better served when monitoring is done by the anesthesiologist or with them giving constant supervision. No big suprise there.

Also, is it strange that in all cases involved a CRNA? This was from UM, so where are all the residents, or where there simply no complications noted in cases involving the residents?

 

[eagle0990]

this paper was written at U of M, but it looked at all comers in the state of Michigan during the years quoted.

 

[dfk]

To me, the study says that the patient is better served when monitoring is done by the anesthesiologist or with them giving constant supervision. No big suprise there.

Also, is it strange that in all cases involved a CRNA? This was from UM, so where are all the residents, or where there simply no complications noted in cases involving the residents?

the study is quoted as saying 2 of 8 were supervised by an obstetrician.
6 of 8 were supervised by an anesthesiologist.
so, the answer is no, according to this study.

 

[Noyac]

the study is quoted as saying 2 of 8 were supervised by an obstetrician.
6 of 8 were supervised by an anesthesiologist.
so, the answer is no, according to this study.

No, it may be confusing to you but the report calls for greater supervision by anesthesiologists.

Read it again: "The authors felt that inadequate postoperative monitoring or supervision by an anesthesiologist were important etiologic factors in five of the eight deaths."

 

[isoman2000]

I FEEL otherwise. Does that make it valid? I mean other then to me?

 

[Noyac]

I FEEL otherwise. Does that make it valid? I mean other then to me?

What do you mean "otherwise"? Are you talking to me or dfk?

Are you saying that this paper is not saying that more supervision is warranted?

 

[radslooking]

the study is quoted as saying 2 of 8 were supervised by an obstetrician.
6 of 8 were supervised by an anesthesiologist.
so, the answer is no, according to this study.

Man, there are a lot of bad replies to this thread. Critically reading the literature is important.

All 8 cases of maternal death involved nurse anesthetists. 2 involved obstetrician oversight, 6 involved anesthesiologists oversight. No cases involved residents, as far as the report says.

If you want to disagree with anything, disagree that 4 nonblinded obstetric anethesiologists did the study and determined which deaths were "anesthesia related" or "anesthesia contributing". It is possible they cherry picked anesthetist cases, but I doubt it.

Their conclusions were pretty clear, they felt inadequate supervision was to blame.

 

[isoman2000]

Of concern, lapses in postoperative monitoring and inadequate supervision by an anesthesiologist seemed to contribute to more than half of the deaths. Finally, this report confirms previous work that obesity and African-American race are important risk factors for anesthesia-related maternal mortality.

The only thing this "report", not study confirms is that obesity and being African american are importent risk factors.

The authors "feel" that inadequate supervision was an issue. "feeling is not quantifiable and is not science, soooo no, I feel this report does not indicate more supervision.

 

[Noyac]

Of concern, lapses in postoperative monitoring and inadequate supervision by an anesthesiologist seemed to contribute to more than half of the deaths. Finally, this report confirms previous work that obesity and African-American race are important risk factors for anesthesia-related maternal mortality.

The only thing this "report", not study confirms is that obesity and being African american are importent risk factors.

The authors "feel" that inadequate supervision was an issue. "feeling is not quantifiable and is not science, soooo no, I feel this report does not indicate more supervision.

So are you saying that more supervision would not be a good thing?

That is not the opinion of the experts.

 

[isoman2000]

That may be the opinion of SOME experts, but it just that, opinion.

 

[Planktonmd]

Of concern, lapses in postoperative monitoring and inadequate supervision by an anesthesiologist seemed to contribute to more than half of the deaths. Finally, this report confirms previous work that obesity and African-American race are important risk factors for anesthesia-related maternal mortality.

The only thing this "report", not study confirms is that obesity and being African american are importent risk factors.

The authors "feel" that inadequate supervision was an issue. "feeling is not quantifiable and is not science, soooo no, I feel this report does not indicate more supervision.

It is very common and accepted practice for the authors of a study to include their personal interpretation of the data they collected based on their education and experience.
You as a reader also have the right to disagree with these conclusions but that doesn't make either of you right or wrong.

 

[Planktonmd]

That may be the opinion of SOME experts, but it just that, opinion.

When you say that only "some experts" in anesthesiology think that supervision of CRNA's by Anesthesiologists is a good thing does that mean that you are aware of other experts in Anesthesiology that think that supervision is not a good thing?
If you have such data please share it with us.

 

[Noyac]

Isoman, does this review threaten you in some way?

 

[radslooking]

Of concern, lapses in postoperative monitoring and inadequate supervision by an anesthesiologist seemed to contribute to more than half of the deaths. Finally, this report confirms previous work that obesity and African-American race are important risk factors for anesthesia-related maternal mortality.

The only thing this "report", not study confirms is that obesity and being African american are importent risk factors.

The authors "feel" that inadequate supervision was an issue. "feeling is not quantifiable and is not science, soooo no, I feel this report does not indicate more supervision.

while i agree with you that "feel" is not quantifiable, what is quantifiable is that all 8 deaths were done by anesthetists. If you want to argue about whether there was or wasn't adequate supervision, that's your prerogative. But it still doesn't change the fact all 8 were done by anesthetists. So, unless anesthetists are doing every case with obese black women in Michigan, then this looks worse for anesthetists.

do you see what I mean? Them being black and obese in and of itself means nothing.

i should explain this one more time, because I have a feeling I'm going to get a terribly thought out response. You say you don't like the word "feeling". So what would you suggest? That these people involved in the 8 deaths recieve less oversight?? Something contributed to their death, and it was either error in judgment or lack of oversight. In either case, it's bad for anesthetists.

 

[isoman2000]

Damn, sorry I said a thing, just knew I shouldnt have. This argument has gone round and round so many times over supervision. We will just have to agree to disagree.
1. No not threatned.
2. No I do not have names
3. No it does not make anesthitists look bad without knowing more such as number of cases perormed by anesthtists to residents, or attendings etc. etc.

I just gotta let it go. Have a pleasent eavning y'all

 

[radslooking]

Damn, sorry I said a thing, just knew I shouldnt have. This argument has gone round and round so many times over supervision. We will just have to agree to disagree.
1. No not threatned.
2. No I do not have names
3. No it does not make anesthitists look bad without knowing more such as number of cases perormed by anesthtists to residents, or attendings etc. etc.

I just gotta let it go. Have a pleasent eavning y'all

Ok, that's better, you are at least arguing the right things now. What you need is information about how many cases were done by each.

Secondly, you could argue with the power of the study (is 8 bad outcomes out of all the cases reviewed give enough power?)

Thirdly, it wasn't blinded.

Your previous arguments weren't particularly good. If you want to argue, use these instead.

 

[Planktonmd]

Damn, sorry I said a thing, just knew I shouldnt have. This argument has gone round and round so many times over supervision. We will just have to agree to disagree.
1. No not threatned.
2. No I do not have names
3. No it does not make anesthitists look bad without knowing more such as number of cases perormed by anesthtists to residents, or attendings etc. etc.

I just gotta let it go. Have a pleasent eavning y'all

Good evening to you too but I wish when you introduce an idea like: "only some experts in Anesthesiology favor supervision of CRNA" that you support your claims with indicating which experts say that supervision is not needed.
If you can't do that then you have to agree that no one with any scientific value has ever said that no supervision is a good thing.

 

[Noyac]

Secondly, you could argue with the power of the study (is 8 bad outcomes out of all the cases reviewed give enough power?)

Thirdly, it wasn't blinded.

But this wasn't a study. It was a review of mortality in OB. So power doesn't pertain here. Now if the authors want to make a statement as fact instead of opinion they should try to accomplish some of these things.

Also, why would anyone want ban the crna's from this site when they give you so much ammo. You gotta admit that this guy didn't help his cause one bit here. And any outside observer must have seen how ridiculous his argument was. Hell you could say that even having extra personnel available in these cases would be beneficial. And with his argument he'd have to say that this is not proven. But we all know that 4 hands are better than 2 especially with airway issues like these cases.

 

[radslooking]

But this wasn't a study. It was a review of mortality in OB. So power doesn't pertain here. Now if the authors want to make a statement as fact instead of opinion they should try to accomplish some of these things.

Also, why would anyone want ban the crna's from this site when they give you so much ammo. You gotta admit that this guy didn't help his cause one bit here. And any outside observer must have seen how ridiculous his argument was. Hell you could say that even having extra personnel available in these cases would be beneficial. And with his argument he'd have to say that this is not proven. But we all know that 4 hands are better than 2 especially with airway issues like these cases.

the study wasn't configured to give a power, although I think it could have been. You could have compared MD to anesthetist complications in this review, but they didn't. Take the total number of cases reviewed, and the number done by MD alone vs. anesthetist with supervision and then reviewed which had worse statistics, why couldn't this produce a power? (obviously making sure each group had similar patients)

As it is...as you say, they only review mortality and speculate that lack of supervision contributed to their deaths. As I said before, this looks bad because its either error in judgment or lack of supervision. If it's lack of judgment then you have to ask the question whether they should be performing anesthesia at all.