ASA Monitor Today
The latest news and updates from ASA.
March 24 | March 9 | March 1 | February
The ASA Monitor+ is now online!
ASA Monitor staff
The ASA Monitor+ supplement, “Redefining Our Future Through Economics, Equity, and Patient Safety,” is now available! Read articles about economics and access to care, how business will disrupt health care, and geographic monopolization of physician practices. This issue was guest edited by Christopher Troianos and Grant Lynde to promote collaboration among ASA committees, to explore the economic issues affecting the specialty, and to share how ASA Sections are addressing these issues.
Foundation for Anesthesia Education and Research Establishes Endowed NAM Fellowship
ASA Public Relations
The Foundation for Anesthesia Education and Research (FAER) announced it has established an endowed National Academy of Medicine (NAM) fellowship to provide early-career anesthesiology scholars with the opportunity to experience and participate in committee, workshop, and roundtable activities of NAM and the National Academy of Sciences (NAS).
Offering a robust catalogue of research grants and programs for early-career anesthesiology investigators, FAER – an American Society of Anesthesiologists foundation – is always exploring new avenues of support for up-and-coming researchers. The NAM Fellowship Program was recognized as one such exceptionally valuable opportunity. Because of this, FAER has donated $1 million to the NAM for the establishment of the endowed FAER-NAM Fellowship.
“I speak for all of FAER when I express how excited we are for this collaboration,” said FAER Board Chair Roger A. Johns, MD, MHS, PhD. “Early career support is critical to ensuring anesthesiology’s future leaders have the tools they need to flourish, and NAM Fellowships offer a phenomenal opportunity for career growth and development. It is wonderful to see and help facilitate this program’s growth to encompass the anesthesiology community and open another avenue for success for promising physician-investigators.”
NAM Fellowships are excellent part-time opportunities for participants to become directly involved with the NAM and the National Academies and accelerate their own career development in becoming national leaders in their field. This fellowship will serve to enhance participants’ knowledge and skills necessary to work across disciplines to help shape sound strategies and policies based on evidence; expand their network of experts and leaders in health and medicine; and prepare them to shape the future of health care throughout their careers.
"We are pleased to launch this important new fellowship with the Foundation for Anesthesia Education and Research," said NAM President Victor J. Dzau. "The NAM is committed to building leadership capacity across disciplines, and we are excited to expand NAM Fellowships to support early career anesthesiology researchers. This fellowship will help these future leaders advance their own career development and prepare them to shape the future of health care in our nation."
Starting in 2024, each FAER-NAM Fellowship will be awarded for a two-year period. Candidates will be drawn from the field of anesthesiology and must have completed their post-graduate work two to ten years prior and shown an interest in and focus on research, policy, and scholarship in the specialty.
National Board of Echocardiography announces enhanced website
ASA Monitor staff
The NBE has announced the launch of a new website to incorporate a technology upgrade: echoboards.org.
NBE is introducing an upgraded state-of-the-art process that will improve efficiency and increase customer success. You can see and learn more about NBE’s technology updates by clicking here.
NBE Executive Director Sherry Barrow, MPA, said, “We are thrilled to announce a new information technology enhancement that meets future growth, improves efficiencies and the user experience.”
New Competition for Paxlovid
Steve Shafer, ASA Monitor Editor-in-Chief
In my past few columns, I’ve been lamenting the difficulty of getting Paxlovid and now it looks like Paxlovid may get some competition.
VV116 is an orally bioavailable form of remdesivir. A study in the New England Journal of Medicine found it was non-inferior to Paxlovid. I was surprised by this, because remdesivir has been a useful but not awesome drug for Covid-19. The mechanism of action is interference with viral RNA replication. That is the same MOA as molnupiravir, which doesn’t work very well. However, the data from the study are pretty convincing:
Meplazumab is a monoclonal antibody directed against the human CD147 protein, which plays a major role in the cellular entry of SARS-CoV-2. A study in patients with severe Covid-19 found that meplazumab reduced mortality by 83%. Developed in China, meplazumab appears to now be in phase 3 clinical trials.
A paper in the New England Journal of Medicine documented the efficacy of subcutaneous pegylated interferon lambda for Covid-19. Pegylated interferon reduced the risk of hospitalization or ER visit by 50%.
Several drugs have emerged from screening existing pharmaceuticals for binding to various SARS-CoV-2 proteins. A study from Caltech identified methotrexate as a promising drug candidate, with picomolar (!) binding affinity to the receptor binding domain of the spike protein. Although much of the focus has been on the spike protein, the NSP-1 protein is a sneaky little devil that blocks the ribosomal tunnel for mRNA transcription, blocking synthesis of native proteins (See articles in Science and Nature, respectively). A study from India found that montelukast stably bound nsp1. Several studies are registered on clinicaltrials.gov for montelukast as a treatment for Covid-19, but none show results. Lastly, another screen study found that the antihistamine fexofenadine (“Allegra”) tightly bound the receptor binding domain. It seems to have an unusually benign clinical profile as an antihistamine.
Nanobodies are antibody fragments that can bind epitopes inaccessible to standard antibodies. Nanobodies are usually derived from camelids (dromedaries, camels, llamas, and alpacas). A number of nanobodies have been identified binding to highly conserved epitopes in the SARS-CoV-2 spike protein. A paper in Nature Communications identified two anti-spike nanobodies derived from sharks immunized against Covid-19 (I’d love to watch that study) that were highly potent against all sarbeviruses. The science is wonderful, amazing, jaw-dropping, etc. However, with the pandemic gradually waning, I don’t envision any push by government or industry to advance nanobodies into clinical development.
North American Partners in Anesthesia Risk Alerts System Wins Coveted Joint Commission Patient Safety Award
ASA Monitor staff
It’s momentous enough to earn The Joint Commission’s prestigious 2022 Eisenberg Award National Level, but North American Partners in Anesthesia (NAPA) holds the additional distinction of being the first anesthesia provider honored with this recognition. This is considered the nation’s highest honor for patient safety and past winners hailed from informatics, oncology, pediatrics, and other clinical areas.
The award recognized NAPA for its Anesthesia Risk Alerts (ARA) program, developed through its NAPA Anesthesia Patient Safety Institute (NAPSI), one of only 99 national Patient Safety Organizations (PSOs) listed by the Agency for Healthcare Research and Quality (AHRQ). NAPSI collects clinical outcomes data on every patient cared for by NAPA’s approximately 6,000 anesthesia clinicians at hundreds of hospitals, ambulatory surgery centers (ASCs), and offices, representing millions of patients each year, and analyzes this data to develop patient safety and quality initiatives such as the Anesthesia Risk Alerts program.
The wisdom of NAPA’s ARA program, launched practice wide in 2019, lies in its simplicity. The organization selected five high- risk clinical scenarios which resulted in a number of significant adverse events and where interventions could be applied proactively to prevent harm. These included:
- Known/suspected difficult airway
- High BMI patients (>45)
- Pulmonary hypertension
- ASA > 4
- Patients at risk for OR fire
According to Leo Penzi, MD, NAPA’s Chief Medical Officer, this was a project that developed organically after NAPA began expanding to outside the OR anesthesia locations. “We were fortunate to have two tertiary care centers collecting quality data,” Dr. Penzi recalled. “Our guts were telling us risks were higher as we moved out of the traditional OR locations with less resources. We needed to do something different.”
The data showed that many of the critical adverse events were related to five categories of high-risk clinical scenarios. Preoperatively, if a high-risk scenario is identified, a specific mitigation intervention is recommended. Each strategy is rooted in “Safety II,” or the proactive monitoring for variation in clinical processes that could lead to a negative adverse event. For patients at risk for OR fire, the intervention involved increased education and awareness about OR fires when using ignition sources in the setting of open-source oxygen or flammable prep solutions, as well as following the mitigation recommendations of organizations such as the Anesthesia Patient Safety Foundation and the American Society of Anesthesiologists.
Second Clinician Collaboration
For the other interventions—known/suspected difficult airway patients and high BMI patients, a second clinician should be present to offer assistance at induction and emergence from general anesthesia. For pulmonary hypertension and ASA > 4 patients—anesthesia clinicians are encouraged to have a conversation about the case with a second practitioner. The thinking behind this was that the second practitioner discussion would intentionally slow down the thought processes and help the primary anesthesia provider avoid a “cookbook,” or intuitive approach to the case. It also serves as a “debiasing” strategy to allow the primary anesthesia provider to recognize suppositions that could potentially lead to cognitive errors in decision-making or planning. NAPA employed a red team/blue team methodology (similar to good cop/bad cop) used in military exercises as well as cybersecurity penetration testing to guide these clinical conversations.
Mitigation strategies involving airway management (known/suspected difficult airway and high BMI) followed recommendations by the American Society of Anesthesiologists Practice Guidelines for Management of Difficult Airways to “ensure that a skilled individual is present or immediately available to assist with airway management when feasible,” as well as the Difficult Airway Society Guidelines for the Management of Tracheal Extubation which also recommends the presence of “skilled help/assistance” at high-risk extubations.
Second practitioner consultations were recommended for patients with pulmonary hypertension and patients with significant co‐morbidities (ASA > 4). Physicians were encouraged to discuss complex cases with a colleague to review the patient’s clinical status, preop preparation and optimization, anesthetic plan and proposed surgical procedure, intra‐operative monitors, and postoperative disposition prior to the case. The concept sounds simple but is fraught with complexity. One of the biggest challenges was finding and connecting with an anesthesia colleague to discuss the case.
Brent Lee, MD, MPH, FASA, Director of Clinical Excellence and Performance Improvement, explained, “Ideally, physicians should discuss the case, postop disposition, monitoring, etc. with another anesthesia provider. We’ve developed a system whereby physicians can discuss the case with another provider not physically in the facility such as an on-call anesthesiologist at a sister hospital or the department chief at home, if necessary. Since the ARA program falls under the PSO, discussions about the case are federally protected. It’s also acceptable to consult with, say, the cardiac surgeon about an open heart case, to discuss the plan.”
Another hurdle to jump was convincing more seasoned physicians to collaborate with colleagues with fewer years of experience. Providing the evidence in support of “dual decision-making processes” helped lead to a cultural change within the organization. NAPA leaders heard many anecdotal stories from clinicians on both ends of the experience spectrum; young newly minted junior attendings and seasoned multiyear veterans, who felt empowered to ask for assistance and discuss anesthetic plans without fear of “appearing weak” or being seen as a “worrywart.”
While it’s difficult to retrospectively calculate critical adverse event incidence rates for all patients anesthetized who had pre‐existing known/suspected difficult airways or diagnosed pulmonary hypertension, anecdotal evidence of the program’s reduction in patient harm is strong. Two years after initiation of the program, compliance had increased to more than 95% and there was a concurrent gradual decrease in the incidence rate of relevant critical adverse events for the population of patients with high BMI and ASA > 4. In 2021, after NAPA acquired another large anesthesia practice and effectively tripled the number of anesthesia clinicians utilizing the ARA program, there was a dip in compliance with the program. As we educated our new clinicians however, compliance trends quickly rebounded.
“These five interventions selected for NAPA’s Anesthesia Risk Alerts (ARA) program were the spark that started the fire,” shared Dr. Penzi. “Our clinicians have done a remarkable job at executing this ARA program at the bedside, but the large halo effect that surrounds this project is the cultural change that promotes a more global culture of safety.”
NAPA will be recognized at NQF23, NQF’s annual conference hosted in Washington, D.C., on February 21, 2023.
Brent Lee, MD, MPH, FASA,
Director of Clinical Excellence
and Performance Improvement
Leo Penzi, MD,
Executive Vice President and
Chief Medical Officer, NAPA
“Irregular” Covid-19 Update from Steven Shafer
Steven Shafer, ASA Monitor Editor-in-Chief
Greetings from Hanoi. My last update was December 24. Sorry for the lump of coal in your Christmas stocking!
Here is a very quick summary, which is followed by additional detail below:
- Covid continues to claim > 10,000 deaths worldwide and >2,500 deaths in the USA every week. This is an improvement, but Covid continues to be a worldwide killer. As Yogi Berra said, “it ain’t over ‘till it’s over.” It ain’t over.
- Per capita cases and deaths are currently highest in Taiwan. (Pamela and I fly to Taipei on Thursday.)
- No new variants have arisen in the past month. BQ.1 and XBB continue to dominate Covid-19 cases worldwide. There was a lot of concern that the surge in China when the Covid-19 restrictions were lifted would produce yet more variants. So far that does not seem to have happened.
- Paxlovid,Paxlovid, Paxlovid. It is the only effective oral treatment for Covid, and it reduces the risk of serious illness, hospitalization, long-Covid, and death in vaccinated and unvaccinated patients. If you get Covid, get Paxlovid. If you are a physician and a friend or colleague gets Covid, prescribe Paxlovid. In the United States most patients who die from Covid-19 never receive Paxlovid. As a physician, I am outraged by this. We can and must do better. I’ll discuss this further in my next Microgram.
Worldwide Summary: Worldwide there were 1,169,693 new cases and 11,525 deaths last week. I’m not sure what caused the spike in the data below, but typically this is an accounting issue from a single country. The trend in cases is reassuring (although it partly reflects decreased cases because of at-home testing).
Taiwan has reported the most new cases per capita last week, followed by Austria, New Zealand, South Korea, Japan, Germany, and Costa Rica.
Taiwan also has reported the most new deaths per capita last week, followed by Ireland, Finland, Sweden, Japan, Australia, and the USA.
Deaths are decreasing in Western Europe. For the most part, cases are decreasing everywhere.
U.S. Summary: In the United States there were 246,679 new cases and 2,732 deaths last week. There was a spike in deaths in early January, the “Winter Surge”, but deaths have been declining in the past few weeks. The oscillations reflect the non-reporting of cases and deaths over the weekend.
This is consistent with the wastewater SARS-CoV-2 RNA analysis (asamonitor.pub/3jVbMPb). The “winter surge” was pretty mild compared to other surges.
Covid Act Now has identified increased risk levels in Wyoming, South Dakota, Missouri, Alabama, and Florida, as shown below.
Over the past 21 days, Alabama has reported the most cases per capita per day over the past 7 days, followed by Wyoming, Louisiana, New Jersey, Rhode Island, and Kentucky. Virginia has reported the most deaths per capita per day over the past 7 days, followed by Maine, Wyoming, Delaware, South Carolina, and West Virginia.
Covid Act Now reports 28,375 individuals hospitalized and 2,975 patients in the ICU hospitalized with Covid-19 as of 2023-02-12. This has been mostly stable for the past few months.
According to the CDC, XBB and BQ.1 have remained the primary variants over the past 2 months.
California and Stanford Catchment Area: In California, there were 31,995 new cases and 298 deaths last week. In San Mateo and Santa Clara Counties, there were 2,272 new cases and 14 deaths last week. These rates have been stable for the past month.
Countries of Interest: In South Africa, there were 510 new cases and 0 deaths last week. In Israel, there were 2,764 new cases and 21 deaths last week. In the United Kingdom, there were 22,061 new cases and 314 deaths last week. In Japan, there were 204,646 new cases and 1,218 deaths last week. In China, there were 10 new cases and 2,810 deaths last week. (Does that look suspicious… 10 cases and 2810 deaths? Something is amiss in the data). In India, there were 1,971 new cases and 8 deaths last week. (I am skeptical of these numbers as well). In Brazil, there were 65,429 new cases and 352 deaths last week.
Thank you for following my continued Covid coverage! I distributed an update of SARS-CoV-2 every day from April 2020 through April 2021. At the time, I also received regular updates from colleagues and academic institutions. Most have stopped. With chagrin I discovered today that the Institute of Healthcare Metrics and Evaluation at the University of Washington, one of my main “go to” sources for insight, has stopped modeling the pandemic and producing policy updates. I will miss their detailed analyses and insights. I plan to continue my updates, albeit irregularly, until the death toll from Covid-19 approaches the “usual” death from influenza and other respiratory diseases. If you’d like to subscribe, please do so through my Google Group. If you’d like to see PowerPoint files, processed data and raw downloaded data, it’s all available here. Be well!
Peter Nagele Elected Fellow of the American Association for the Advancement of Science (AAAS)
Peter Nagele, Professor in the Department of Anesthesia and Critical Care at the University of Chicago, has been named a 2022 Fellow of the American Association for the Advancement of Science (2022 Fellows), the world’s largest general scientific society and publisher of the Science family of journals. This distinction is among the highest in the scientific community and honors scientists, engineers, and innovators whose efforts on behalf of science and its applications are scientifically or socially distinguished. A tradition dating back to 1874, election as an AAAS Fellow is a lifetime honor, and all Fellows are expected to maintain the highest standards of professional ethics and scientific integrity.
Professor Nagele has built a pioneering interdisciplinary research program that interfaces with anesthesiology, psychiatry, neuropharmacology, and behavioral sciences, where he and his colleagues made the seminal discovery that the oldest anesthetic in medical use – nitrous oxide – is a rapid and effective treatment for otherwise treatment-resistant depression. His research has opened a new field of scientific investigation with a potential to provide help for millions of patients who suffer from one of the most severe forms of major depression. The AAAS cited his “distinguished contributions to translational neuropsychiatric pharmacology, particularly for work on the utility of nitrous oxide in managing symptoms of treatment-resistant major depression.”
Dr. Nagele is a former recipient of a FAER Mentored Research Training Grant (2008), the ASA Presidential Scholar Award (2012), NARSAD Independent Investigator Award from the Brain and Behavior Research Foundation (2016), the Ziskind-Somerfeld Research Award from the Society for Biological Psychiatry (2016), a $1 million national focus grant from the American Foundation for Suicide Prevention (2017), and the Austrian Cross of Honor for Science and Arts (2021). He is an associate editor of Anesthesiology, elected member of the FAER Academy of Research Mentors in Anesthesiology, and a member of the ASA Committee on Research.