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Effective decision-making in crisis events is challenging due to time pressure, uncertainty, and dynamic decisional environments. We conducted a systematic literature review in PubMed and PsycINFO, identifying 32 empiric research papers that examine how trained professionals make naturalistic decisions under pressure. We used structured qualitative analysis methods to extract key themes. The studies explored different aspects of decision-making across multiple domains. The majority (19) focused on healthcare; military, fire and rescue, oil installation, and aviation domains were also represented. We found appreciable variability in research focus, methodology, and decision-making descriptions. We identified five main themes: (1) decision-making strategy, (2) time pressure, (3) stress, (4) uncertainty, and (5) errors. Recognition-primed decision-making (RPD) strategies were reported in all studies that analyzed this aspect. Analytical strategies were also prominent, appearing more frequently in contexts with less time pressure and explicit training to generate multiple explanations. Practitioner experience, time pressure, stress, and uncertainty were major influencing factors. Professionals must adapt to the time available, types of uncertainty, and individual skills when making decisions in high-risk situations. Improved understanding of these decisional factors can inform evidence-based enhancements to training, technology, and process design.

As noted in part 1 of this series, periprocedural cardiac arrest (PPCA) can differ greatly in etiology and treatment from what is described by the American Heart Association advanced cardiac life support algorithms, which were largely developed for use in out-of-hospital cardiac arrest and in-hospital cardiac arrest outside of the perioperative space. Specifically, there are several life-threatening causes of PPCA of which the management should be within the skill set of all anesthesiologists. However, previous research has demonstrated that continued review and training in the management of these scenarios is greatly needed and is also associated with improved delivery of care and outcomes during PPCA. There is a growing body of literature describing the incidence, causes, treatment, and outcomes of common causes of PPCA (eg, malignant hyperthermia, massive trauma, and local anesthetic systemic toxicity) and the need for a better awareness of these topics within the anesthesiology community at large. As noted in part 1 of this series, these events are always witnessed by a member of the perioperative team, frequently anticipated, and involve rescuer–providers with knowledge of the patient and the procedure they are undergoing or have had. Formulation of an appropriate differential diagnosis and rapid application of targeted interventions are critical for good patient outcome. Resuscitation algorithms that include the evaluation and management of common causes leading to cardiac in the perioperative setting are presented. Practicing anesthesiologists need a working knowledge of these algorithms to maximize good outcomes.

Cardiac arrest in the operating room and procedural areas has a different spectrum of causes (ie, hypovolemia, gas embolism, and hyperkalemia), and rapid and appropriate evaluation and management of these causes require modification of traditional cardiac arrest algorithms. There is a small but growing body of literature describing the incidence, causes, treatments, and outcomes of circulatory crisis and perioperative cardiac arrest. These events are almost always witnessed, frequently known, and involve rescuer providers with knowledge of the patient and their procedure. In this setting, there can be formulation of a differential diagnosis and a directed intervention that treats the likely underlying cause(s) of the crisis while concurrently managing the crisis itself. Management of cardiac arrest of the perioperative patient is predicated on expert opinion, physiologic rationale, and an understanding of the context in which these events occur. Resuscitation algorithms should consider the evaluation and management of these causes of crisis in the perioperative setting.

A third of all patients are at risk for a serious adverse event, including death, in the first month after undergoing a major surgery. Most of these events will occur within 24 hours of the operation but are unlikely to occur in the operating room or postanesthesia care unit. Most opioid-induced respiratory depression events in the postoperative period resulted in death (55%) or anoxic brain injury (22%). A future state of mature artificial intelligence and machine learning will improve situational awareness of acute clinical deterioration, minimize alert fatigue, and facilitate early intervention to minimize poor outcomes.

Supplemental Digital Content is available in the text.Published ahead of print March 24, 2015

Critically ill patients are prescribed sedatives and analgesics to decrease pain and anxiety, improve patient–ventilator dyssynchrony and ensure patient safety. These medications may themselves lead to delirium and ICU-acquired weakness, which are associated with worse clinical outcomes. This review will focus on the epidemiology of these two disease processes and discuss strategies aimed at reducing these devastating complications of critical illness.

A simulation-based training intervention to improve patient handovers between anesthesia providers (APs) and Post-Anesthesia Care Unit (PACU) nurses (RNs) in adult (VUH) and pediatric (VCH) PACUs, was developed, implemented, and evaluated. The intervention included didactic webinars, an electronic handover report tool, a 2-hour simulation-based training session and a 1-hr “refresher” course several months later. Training focused on interpersonal skills and overcoming obstacles to effective handovers. Trained nurses observed and evaluated 981 actual PACU handovers over 12 months using a standardized rating tool. A different blinded observer scored pre- and post-training simulated handovers. A culture survey was administered before and after the intervention. After training, handover quality improved significantly with more than 70% of handovers rated as “effective” in both PACUs (P<0.001). The training status of the handover giver (AP) was the critical determinant of handover effectiveness. Following full implementation, new (untrained) clinicians performed effective handovers suggesting culture change and/or implicit training.

Critically ill patients are frequently prescribed sedatives and analgesics to ensure patient safety, to relieve pain and anxiety, to reduce stress and oxygen consumption, and to prevent patient ventilator dysynchrony. Recent studies have revealed that these medications themselves contribute to worsening clinical outcomes. An evidence-based organizational approach referred to as the ABCDE bundle (Awakening and Breathing Coordination of daily sedation and ventilator removal trials; Choice of sedative or analgesic exposure; Delirium monitoring and management; and Early mobility and Exercise) is presented in this commentary.