t is safer to undergo an anesthetic today in 2006 than at any other time, and the reasons for this are multifactorial. Anesthesia training and education are better, and education is maintained throughout our careers. Our preoperative evaluations are extensive, and we make interventions preoperatively to minimize perioperative risks. Equipment, monitors and drugs are better. We are outcomes-driven, and we carefully evaluate closed claims to enhance patient safety. Our airway management is better, not only because of newer equipment but also because of the development and implementation of the ASA Difficult Airway Algorithm. So some might question whether the “good old days of anesthesia” were really all that good.

When anesthesiology residents complete their training now, they are better prepared to provide outstanding, safe anesthesia than ever before. The Residency Review Committee for Anesthesiology (RRC) mandates a rigorous didactic curriculum, and it establishes the minimum number of various cases and procedures that the residents must perform in a three-year time period. Beginning in July 2008, new RRC requirements will be implemented, and they are based on a four-year curriculum versus three. One area of added emphasis is additional intensive care unit (ICU) training — and enhanced ICU training will translate into safer perioperative care. Throughout the training, the residency program director ensures that the resident has accomplished the Accreditation Council for Graduate Medical Education competencies and possesses the essential attributes that are crucial to the practice of anesthesiology. At the end of the training, the program director attests to the competency of the resident and states that the resident is capable of practicing independently. The American Board of Anesthesiology (ABA) requires that the anesthesiology resident pass both a rigorous written examination and oral examination in order to be board-certified. Many anesthesiology residents elect to take fellowships in the various subspecialties of anesthesiology. When they go into practice, they provide state-of-the-art care to very specific subpopulations of patients such as pediatric, neurosurgical, obstetric, cardiac, pain and intensive care patients. Their additional training enhances subspecialty patient safety.

After completing an anesthesiology residency or fellowship, learning and improving continue to be lifelong. Those ABA diplomates with a time-limited certificate are immediately enrolled in the Maintenance of Certification in Anesthesiology (MOCA) program, which mandates professional standing assessment, lifelong learning and self-assessment (continuing medical education hours), successful completion of a cognitive examination and a self-directed program of practice performance assessment and improvement. Thus, in today’s anesthesia environment, education, training and maintenance of certification requirements are more rigorous than ever.

Anesthesiologists have taken a very active role in the preoperative evaluation and preparation of patients for surgery. Our specialty was one of the first to preoperatively stratify patients based on their underlying disease by developing and implementing the ASA Physical Status Classifications (PS1-PS6). Many patients are seen preoperatively in an outpatient setting with immediate access to sophisticated laboratories, imaging and consultants. Based upon our findings, we make appropriate interventions to minimize the risk for the patient during the perioperative period. One notable area of success is the perioperative beta blockade of patients with cardiac risk factors, which has enhanced patient safety.

During my quarter century in the field, anesthesia equipment and monitors have come a long way. When I entered anesthesia in 1980, it was fairly easy to deliver 32 percent halothane, 31 percent isoflurane or 23 percent enflurane with copper kettle vaporizers. With older anesthesia machines, it was possible to deliver 100 percent nitrous oxide and zero percent oxygen. We did not have pulse oximetry or capnography, and we relied heavily on the “art of anesthesia.” Cyanosis and/or bradycardia were occasionally the first signs of an inadvertent esophageal intubation. New anesthesia delivery systems meet rigorous standards of the American Society of Testing and Materials. Modern vaporizers and ventilators are substantially safer than older ones, and many of the new intraoperative ventilators provide almost all of the ICU-type ventilator modalities that may lead to better patient outcomes. Newer anesthesia delivery systems have a prioritized alarm system that helps to prevent information overload of anesthesia care providers. In 1993, the U.S. Food and Drug Administration introduced the Anesthesia Apparatus Checkout Recommendations, which have helped to detect anesthesia machine problems preoperatively.

Pulse oximetry and capnography have made anesthesia substantially safer. In addition to these monitors, other monitors have helped considerably. Multigas analyzers have widespread use, and they assess the inspired and exhaled concentrations of oxygen and inhaled anesthetics. Quantitating the concentration of an inhaled anesthetic minimizes the chance of overdose or patient awareness under anesthesia. Most electrocardiography monitors are now capable of ST analysis, which helps to detect cardiac ischemia sooner. The perioperative use of transesophageal echocardiography, which was once used exclusively for cardiac patients, is now gaining more widespread use for noncardiac patients throughout the perioperative period, enhancing patient safety.

In 2006 our drugs and inhaled anesthetics are better. Propofol has proven to be a useful and reliable drug. Newer muscle relaxants are more predictable than older ones in a variety of disease states, and neuromuscular junction function can be better assessed by our newer, sophisticated nerve stimulators. Our new insoluble inhaled anesthetics have rapid onset, and they help to provide rapid emergence with very little metabolism or toxicity. In the operating room setting, our drug labels are either color-coded or bar-coded to minimize the chance of medication errors. Our modern intravenous infusion pumps virtually eliminate the chance of free flow, minimizing side effects of unharnessed vasoactive drugs. Today potassium chloride is supplied in relatively dilute concentrations, minimizing the chance of a hyperkalemic arrest.

Our specialty reviews closed claims on an ongoing basis to help identify areas where we can improve. In my opinion, we have made the most progress in the area of airway management. We now evaluate several physical criteria to help identify the difficult airway. In the operating room, we have an ever-expanding armamentarium of airway-management devices such as the fiberoptic bronchoscope, the Bullard laryngoscope, jet-ventilation devices, laryngeal mask airways and gum elastic stylets to handle just about any difficult airway. More importantly, however, was the development, implementation and refinement of the ASA Difficult Airway Algorithm for the management of the difficult airway. In my opinion, widespread use of this algorithm has greatly enhanced patient safety.

Sophisticated simulators are gaining widespread use, and they are a valuable resource not only for training anesthesiology residents but also for maintaining skills and developing new skills throughout our careers. Fortunately certain types of anesthesia emergencies occur very infrequently. A few examples include malignant hyperthermia (1:30,000), thyroid storm, certain equipment malfunctions, etc. A practitioner may go years without encountering any of these emergencies in his/her practice. In a matter of just a few minutes, simulations of many emergencies and appropriate management techniques can occur. The practitioner can learn to deal with these emergencies in an expeditious manner. It is my opinion that widespread use of simulators now and in the future will enhance patient safety.

ASA has always been a leading advocate for patient safety issues, and several ASA committees are specifically dedicated to patient safety. The Anesthesia Patient Safety Foundation has brought to the forefront numerous important patient safety issues. In 2005, the Joint Commission on Accreditation of Healthcare Organizations identified a dozen national patient safety goals, and eight of 12 are directly applicable to perioperative care.

The anesthesiology community has done a remarkable job in the area of patient safety, and most anesthesiologists are aware of our progress. We would all like to see the public become more aware of the safety of our specialty. Thus, this year, the ASA Committee on Patient Safety and Risk Management has focused upon preparing additional literature to help educate our anesthesiologist colleagues as well as patients about our advances in safety. Articles by Jerry A. Cohen, M.D., in this issue of the ASA NEWSLETTER (page 7) serve as a preview of some of the information that the committee is working on to assist our Committee on Communications with its patient/public education program.

J. Jeffrey Andrews, M.D., is the R. Brian Smith Professor and Chair, Department of Anesthesiology, University of Texas Health Science Center at San Antonio.