Every anesthesia professional has encountered IV infiltration—but when neuromuscular blocking agents are involved, this common complication becomes a complex patient safety challenge with no established guidelines.

This episode delves into the critical management of infiltrated paralytics, a complication affecting 14% of peripheral IV catheterizations that can lead to delayed induction, compromised emergence, and potentially serious tissue injury. We're joined by Dr. Govind Rangrass, Professor of Anesthesiology and Critical Care, who shares why this overlooked issue deserves urgent attention: "When a paralytic is involved, the complexity skyrockets and there's almost no literature to guide us."

We break down a comprehensive management algorithm, from the counterintuitive first step of leaving the infiltrated catheter in place to attempt medication aspiration, through systemic absorption enhancement techniques using hyaluronidase and nitroglycerin paste. The episode covers detailed reversal strategies based on monitoring capabilities, explaining how to prevent recurarization and safely manage these patients postoperatively.

Beyond immediate management, we look toward a future where infiltration detection technologies and standardized guidelines are integrated into residency training and crisis checklists. This episode provides the missing guidance that anesthesia professionals need to navigate this surprisingly common complication with confidence.

Have you experienced neuromuscular blocker infiltration in your practice? What strategies have worked for you? Share your thoughts or questions at [email protected] and join us in building a safer future where no one is harmed by anesthesia care.

For show notes & transcript, visit our episode page at apsf.org: https://www.apsf.org/podcast/269-infiltrated-iv-crisis-managing-complications-and-keeping-patients-safe/

© 2025, The Anesthesia Patient Safety Foundation

Ever wondered what happens when neuromuscular blocking agents infiltrate into surrounding tissue instead of flowing smoothly through an IV? The consequences can be serious and potentially life-threatening for patients recovering from anesthesia.

We dive deep into a complication that affects nearly 14% of the 150 million peripheral IV catheter insertions performed annually in the United States. While most healthcare providers have experienced IV infiltrations, few understand the unique dangers posed when paralytics like rocuronium leak into surrounding tissues. This scenario creates unpredictable pharmacokinetics with delayed absorption that can lead to secondary recurarization – muscle weakness and respiratory compromise that may occur hours after a patient appears to have fully recovered.

Experts Dr. Andrea Vannucci and Dr. Karolina Brook share their insights and clinical experience on this important patient safety topic. They outline a comprehensive management approach including immediate interventions (attempting medication aspiration, establishing alternative IV access), treating the infiltration site (with nitroglycerin paste and hyaluronidase), and preventing recurarization through careful medication dosing and extended monitoring. Most critically, they recommend monitoring extubated patients for a minimum of four hours following infiltration of neuromuscular blocking agents – a practice not universally followed but essential for patient safety.

Whether you're an anesthesiologist, CRNA, resident, or any perioperative clinician, this episode provides crucial information to help you recognize, manage, and prevent complications from this common but potentially dangerous event. Subscribe to the Anesthesia Patient Safety Podcast for more evidence-based strategies to protect your patients from harm.

For show notes & transcript, visit our episode page at apsf.org: https://www.apsf.org/podcast/268-beyond-the-vein-the-dangers-of-infiltrated-muscle-relaxants/

© 2025, The Anesthesia Patient Safety Foundation

Navigating the fine line between effective pain control and minimizing harm from opioid medications remains one of anesthesiology's greatest challenges. This episode dives deep into the evolving landscape of perioperative pain management, examining how clinicians can achieve the delicate balance required for optimal patient outcomes.

Dr. Paul Guillod joins us to share his perspective as both an anesthesiologist and pain management specialist, highlighting how opioid-sparing techniques create opportunities for interdisciplinary collaboration and improved surgical recovery. We examine the substantial risks of traditional opioid-based approaches: respiratory depression, delayed bowel function, delirium, and paradoxically, opioid-induced hyperalgesia.

The episode showcases promising research on multimodal analgesia strategies that target multiple pain pathways simultaneously. By combining regional anesthesia techniques with medications like NSAIDs, acetaminophen, ketamine, dexmedetomidine, and newer options like suzetrigine, clinicians can dramatically reduce opioid requirements while maintaining effective pain control. Real-world implementation of these approaches through Enhanced Recovery After Surgery (ERAS) protocols has yielded impressive results: 50% reductions in in-hospital opioid use, shortened hospital stays, and improved pain scores across multiple surgical specialties.

Whether you're a clinician seeking to improve your pain management approach or simply interested in understanding how anesthesia care is evolving to address the opioid crisis, this episode offers valuable insights into creating safer, more effective perioperative experiences. Subscribe to the Anesthesia Patient Safety Podcast and join us in our commitment that no one shall be harmed by anesthesia care.

For show notes & transcript, visit our episode page at apsf.org: https://www.apsf.org/podcast/267-beyond-opioids-revolutionizing-perioperative-pain-control/

© 2025, The Anesthesia Patient Safety Foundation

Perioperative stroke represents a rare but potentially devastating complication of anesthesia care. While occurring in less than 1% of non-cardiac surgical patients, this complication fundamentally threatens not just patient outcomes but their very identity. As Dr. Jacob Nadler poignantly notes in our podcast, "By maintaining brain health, we're preserving the essence of who our patients are—their memories, their personality, their ability to connect with friends and family."

The most significant recent development in this field comes from the 2024 joint guidelines that have dramatically shortened the recommended waiting period following stroke before elective surgery. What was once a nine-month wait has been reduced to just three months based on compelling evidence from a cohort study of 5.8 million patients showing risk stabilization after 90 days. This change has profound implications for surgical planning and patient care timelines.

Anesthesia professionals must be vigilant about key risk factors including advanced age, previous stroke history, renal dysfunction, and anemia. The podcast explores critical medication management considerations, particularly regarding anticoagulation protocols, alongside specific intraoperative targets for blood pressure and hemoglobin levels. For suspected perioperative stroke, rapid multidisciplinary intervention with emergent brain imaging, possible thrombolytics, and mechanical thrombectomy may be indicated.

For every anesthesia professional, this episode provides essential insights to help fulfill our commitment that no one shall be harmed by anesthesia care. Subscribe on Spotify or YouTube and share with colleagues to spread this vital safety information.

For show notes & transcript, visit our episode page at apsf.org: https://www.apsf.org/podcast/266-protecting-the-brain-perioperative-stroke-prevention/

© 2025, The Anesthesia Patient Safety Foundation

A revolution in pain management has arrived. The FDA's approval of Suzetrigine in January 2025 introduces the first non-opioid analgesic for moderate to severe pain in over twenty years. This breakthrough medication targets the voltage-gated sodium channel, NAV1.8, effectively blocking pain signals at their source before they reach the brain.

What makes Suzetrigine remarkable is its precision. With over 30,000-fold selectivity for NAV1.8 channels, it delivers powerful analgesia without affecting the brain or heart, eliminating addiction risk, and minimizing side effects. Clinical trials involving over 2,100 patients demonstrated pain relief comparable to opioid-acetaminophen combinations but with a safety profile similar to placebo. For the more than 50% of surgical patients who experience moderate to severe postoperative pain, this non-addictive alternative represents a genuine breakthrough. Looking ahead, an exciting pipeline of additional NAV1.8 channel blockers, including intravenous formulations, promises to further transform perioperative pain management.

Have you struggled with limited options for managing your patients' postoperative pain? Subscribe to the Anesthesia Patient Safety Podcast for more on groundbreaking developments like Suzetrigine that are changing how we approach patient care and safety. Leave us a review to share your thoughts on this revolutionary advance in pain management.

For show notes & transcript, visit our episode page at apsf.org: https://www.apsf.org/podcast/265-the-breakthrough-drug-changing-perioperative-pain-management/

© 2025, The Anesthesia Patient Safety Foundation

Cardiac arrest in the operating room presents unique challenges that standard Advanced Cardiovascular Life Support (ACLS) protocols simply were not designed to address. This eye-opening exploration with APSF author, Zachary Smith, reveals why traditional resuscitation guidelines fall short when emergencies strike during surgery and anesthesia care.

The dynamics of cardiac arrest differ dramatically in the perioperative environment. While out-of-hospital arrests typically stem from arrhythmic events, OR emergencies often result from hemorrhage, embolism, hypoxemia, or critical drug reactions like malignant hyperthermia or local anesthetic toxicity. These scenarios demand immediate, specialized interventions beyond standard ACLS algorithms.

Physical constraints further complicate matters. What happens when cardiac arrest occurs while a patient is positioned prone, lateral, or in steep Trendelenburg? Traditional compressions become impossible, and emerging research suggests prone CPR might actually be superior in some scenarios. Moreover, the advanced monitoring capabilities in the OR – arterial lines, central venous pressure readings, and echocardiography – provide critical data not incorporated into standard protocols.

The American Society of Anesthesiologists has responded with their Perioperative Resuscitation and Life Support Certificate program, addressing these gaps through specialized training that combines ACLS principles with OR-specific knowledge.  Ready to enhance your skills beyond basic ACLS? Explore the ASA's certificate program to earn patient safety CME credits while gaining life-saving expertise tailored to the unique challenges of the operating room. Your specialized knowledge could make all the difference when seconds count.

For show notes & transcript, visit our episode page at apsf.org: https://www.apsf.org/podcast/264-rethinking-resuscitation-in-the-operating-room-beyond-acls/

© 2025, The Anesthesia Patient Safety Foundation

The standard of care for monitoring blood pressure during surgery hasn't changed in nearly 40 years, despite technological advances that could prevent serious complications and save lives. This eye-opening episode takes listeners inside a recent Capitol Hill briefing where healthcare professionals, lawmakers, and patient safety advocates made the case for continuous blood pressure monitoring as a critical patient safety measure.

Alarming statistics frame the urgency of this issue: one in nine Americans undergoes surgery annually, with 88% experiencing potentially dangerous hypotension. Traditional arm cuffs that measure blood pressure only every few minutes leave dangerous blind spots where rapid drops may go undetected. The consequences can be devastating – kidney injury, heart damage, stroke, and even death. For pregnant women undergoing cesarean sections, the risks extend to their babies, with maternal hypotension potentially causing fetal acidosis and neurological compromise.

With the United States maintaining the highest maternal mortality rate among wealthy nations and evidence showing that more than half of pregnancy-related deaths are potentially avoidable, this episode makes a powerful case for updating our standards. The technology exists, the evidence supports it, and the benefits are clear – it's time for healthcare providers, policymakers, and industry leaders to collaborate in making continuous blood pressure monitoring the new standard of care.

Ready to become a champion for continuous blood pressure monitoring at your institution? Visit APSF.org to learn more about this lifesaving technology and join the movement to ensure no one is harmed by anesthesia care.

For show notes & transcript, visit our episode page at apsf.org: https://www.apsf.org/podcast/263-blood-pressure-blind-spots/

© 2025, The Anesthesia Patient Safety Foundation

Ready for a refreshing summer dive into the latest anesthesia safety research? This episode explores three groundbreaking studies that could transform perioperative practice and patient outcomes.

First, we examine a fascinating randomized clinical trial on "just-in-time" training for inexperienced clinicians performing infant intubations. The results are impressive: trainees who received just 10 minutes of structured training immediately before the procedure achieved a 91.4% first-attempt success rate—significantly better than the 81.6% rate in the standard training group. Could this approach revolutionize how we prepare for all high-stakes medical procedures? The study suggests decreased cognitive load and improved competency with this targeted preparation technique.

Next, we explore a comprehensive meta-analysis of how intravenous antihypertensive medications affect cerebral blood flow. Good news: most medications maintain cerebral autoregulation even when reducing blood pressure. However, nitroprusside and nitroglycerin stand out as exceptions, potentially reducing cerebral perfusion even at appropriate doses. This critical information helps anesthesia professionals make more informed medication choices based on each patient's specific needs.

Finally, we investigate emerging research on GLP-1 receptor agonist medications (increasingly popular for diabetes, weight loss, and cardiovascular disease) and their potential link to vision problems. Several studies suggest these medications may increase the risk of non-arteritic ischemic optic neuropathy—a leading cause of vision loss. While the absolute risk remains small and no direct connection to postoperative vision loss has been established, additional research is needed going forward.

Each of these studies provides valuable insight into how we can continue improving anesthesia safety. Share this episode with your colleagues and join us next time as we work toward ensuring no one is harmed by anesthesia care.

For show notes & transcript, visit our episode page at apsf.org: https://www.apsf.org/podcast/262-medical-literature-deep-dive-from-infant-intubation-to-glp-1-agonist-risks-and-more/

© 2025, The Anesthesia Patient Safety Foundation

Navigating the complex landscape of patient safety requires vigilance, knowledge, and adaptability. Today's episode takes us on a journey through two critical safety concerns that exemplify the challenges anesthesiologists face in diverse clinical settings.

We begin with an eye-opening exploration of cosmetic surgery safety in Colombia, which has emerged as a top global destination for aesthetic procedures. Despite performing nearly 500,000 cosmetic surgeries annually, Colombia faces alarming safety statistics—mortality rates potentially ten times higher than global averages for anesthesia-related deaths. This stark disparity highlights how regulatory gaps, substandard facilities, and inadequate patient selection can create perfect storms for adverse outcomes. The discussion illuminates how anesthesiologists can serve as safety champions by implementing rigorous standards and protocols.

The conversation then pivots to a surprisingly common yet overlooked danger in pediatric anesthesia: the administration of oxymetazoline. What seems like a routine medication becomes hazardous when delivery systems designed for upright, conscious patients are used on supine, anesthetized children. Through practical demonstrations and creative problem-solving, we uncover how simple modifications to delivery methods—specifically using atomizers with precisely filled syringes—can prevent potentially dangerous overdoses and create standardized, position-independent dosing.

Both topics underscore a central theme: anesthesia safety demands thoughtful adaptation of standards to fit unique circumstances. Whether dealing with international variations in practice or the specialized needs of pediatric patients, the commitment to "no one shall be harmed by anesthesia care" requires constant vigilance and innovation. We'd love to hear your experiences with similar challenges—have you encountered safety variations in different practice settings, or developed creative solutions to common problems? Visit APSF.org to explore our resources and join the conversation about advancing anesthesia patient safety worldwide.

For show notes & transcript, visit our episode page at apsf.org: https://www.apsf.org/podcast/261-patient-safety-challenges-from-global-cosmetic-tourism-to-pediatric-medication-dosing/

© 2025, The Anesthesia Patient Safety Foundation

Dr. Elizabeth Malinzak takes us behind the scenes of a fascinating educational initiative bridging knowledge gaps in anesthesiology. As a pediatric anesthesiologist at Duke University and liaison between the Anesthesia Patient Safety Foundation and Open Anesthesia, she's spearheaded the development of over 30 patient safety and quality improvement summaries designed for today's learners.

Malinzak reflects on crucial topics like crisis resource management, fatigue mitigation, and handover protocols that weren't part of traditional training. This educational void inspired her to create accessible, concise resources that meet modern learning preferences. Gone are the days of textbook deep-dives; today's professionals need searchable, digestible content they can absorb between cases or during brief study sessions.

What makes these summaries particularly valuable is their breadth and collaborative development. Each summary is peer-reviewed and often created through mentoring relationships between experienced clinicians and trainees, creating educational value beyond the finished product. 

Malinzak offers a clarifying perspective on how quality improvement relates to patient safety: "Patient safety is the goal... That's what we want to accomplish with every single patient. Quality improvement is the process... how we get to the goal." As anesthesiologists face increasingly complex cases and efficiency pressures, this distinction helps practitioners develop systematic approaches to protect vulnerable patients. Looking ahead, she envisions technologies like AI reducing administrative burdens so clinicians can focus entirely on vigilant patient care. Discover these valuable resources by visiting Open Anesthesia's website and filtering for patient safety topics – you never know which summary might teach you something new today.

For show notes & transcript, visit our episode page at apsf.org: https://www.apsf.org/podcast/260-openanesthesia-and-the-apsf-achieving-safe-and-quality-anesthesia-care-with-education-innovation/

© 2025, The Anesthesia Patient Safety Foundation