Updates on Neuromuscular Transmission (NMT) monitoring | ANESTHESIOLOGY® 2023

Top Med Talk.

Desiree Chappell: Well, hello, and welcome back to Anaesthesiology 2023, the annual meeting of the American Society of Anaesthesiologist. Top Med Talk is here in the exhibit hall at the Moscone Center in beautiful San Francisco, it's been a fabulous two days of anesthesiology. I'm Desiree Chapel. I'm your host today and my co-host, the new coeditor and chief, joining me today is Mike Grocott. Hello, Mike.

Mike Grocott: Good afternoon.

Desiree Chappell: Congratulations on your promotion. We are on it.

Mike Grocott: I am on it. It's nice that you managed to retain the accent. Was that a qualification for the coeditor?

Desiree Chappell: You could only be a coeditor and chief if you have a British accent or Guy. Guy Ludbrook, who is our guest co-host today. Thanks so much for sitting down with us.

Guy Ludbrook: Great to be here.

Desiree Chappell: And only because you have that accent can you be here.

Guy Ludbrook: I could put on my New Zealand accent next.

Desiree Chappell: And, of course, you've heard now our esteemed guest, a fan fave, actually, on Top Med Talk. I know, Rick Dutton. Rick, thanks for coming back and sitting down with us. So, Rick, you are Chief Quality Officer for USAP. We've had many conversations over the years at anesthesiology and other meetings, too, sitting down talking about the amazing work. You are, I hate to say the quality guru, because there's a lot of quality guru in anesthesia, but you are the quality guru in anesthesiology.

Rick Dutton: Well, thank you for saying so.

Desiree Chappell: You are. You've done a lot of really good work. So, and I'm referring to some of the work that you've done in the past. Tell us a little bit about your background, what you've been doing, and where you are now, because you've actually recently had a change.

Rick Dutton: Yes. So, yes, I had a relapse. So I used to say I was a recovering traumatologist. My first career was a trauma anesthesiologist in Baltimore at the Shock Trauma Center. And I did research in resuscitation and did the whole academic track.

In 2010-ish, I shifted gears, went to work for the ASA as their quality officer, chief quality officer, I guess. Set up the Anesthesia Quality Institute, started a national registry, got involved in all sorts of big picture stuff in anesthesia.

And then in 2015, took that background and joined US Anesthesia Partners, which is a nationwide private practice, physician run, and it really is a private practice, but about 5,000 clinicians right now, they wanted a chief quality officer. They wanted to be the best practice in the country. They said, tell us how to do that. And yeah, there was a compelling job description. So I've been with USAP since then, so about eight years now, enjoying it very much. I have the resources and the scope to do some cool things. Right, so we built our infrastructure and that was built. And then we had COVID and that was exciting. And then I was bored.

Yeah, so I have, as I say, relapsed. And I am still a Chief Quality Officer and still engaged on the national front. But I am also now going back to being a traumatologist and being a site chief at a community hospital in Washington, D. C, in the OR every day. It's fun.

Desiree Chappell: Yeah, enjoying it. You can tell it that whenever you talk about it, you're like getting your hands dirty again.

Rick Dutton: Yes, very much. That's cool.

Desiree Chappell: That's great. Well, Rick, we've had lots of conversations, like I said, over the years about differing things. We actually worked together on a project this last year, and we were talking about that, presented last year, IOH, Intraoperative Hypotension and the incidence of IOH really based in a community setting, not necessarily academia. One of the topics that I know we have not actually discussed much here on Talk Med Talk with you, we have had several discussions about it, is neuromuscular blockade and the monitoring of that. And I know that's something that you have spoken a lot about. And you were on the published guidelines that just came out this year from the ASA, Practice Guidelines for Monitoring and Antagonism of Neuromuscular Blockade report by the ASA task force. I thought it would be good for us to walk through that just a little bit and talk about neuromuscular monitoring and what's actually happening in the OR right now. Because I think what the guidelines say and what's happening, there may be a little bit of a difference. I don't know, that just could be me.

Rick Dutton: Oh, no. Yeah, very much. Yeah. So this was... I'm still not exactly sure how I got pulled into that guideline process. Friends in the wrong place.

Desiree Chappell: Exactly.

Rick Dutton: But it was a great... That was actually a very good ASA guideline and perfect, because we had the advantage of a great body of very strong scientific evidence about the risks of residual neuromuscular blockade and the value of monitoring and reversal strategies. So there's a lot been published on it, and I don't know how many thousand papers we reviewed as part of the guideline, but the evidence base is very solid. And at the same time, the application of that evidence base was essentially zero.

Desiree Chappell: A big gap in the knowledge versus doing kind of thing.

Rick Dutton:  Yes. So we got to publish a guideline with a very strong recommendation that absolutely nobody in the country is following at this moment.

Desiree Chappell: Oh no. Absolutely no one.

Rick Dutton: And so it's over a quality improvement guide. This is a wonderful implementation project. And now we are getting into the implementation side of what do we do? How do we reconcile this?

Desiree Chappell: Well, let's walk back and talk about what the actual problem that this is addressing. Because as team anesthesia, we take care of our patients, we drop them off in PACU and depending... Yeah, and see you later. So you may, as an anesthesiologist, stick around for a little while. As a nurse anesthetist or an NA, you may drop them off and go to your very next case and never see that patient again. And so do we think that there's actually a problem with what you were highlighting this as retain residual neuromuscular blockade?

Rick Dutton: Yes, absolutely. So again, very good science that, first of all, that you have a high incidence of residual blockade. If you manage your neuromuscular blockade in the normal fashion, you give some Rocuronium. Every so often, the surgeon barks at you, you give some more Rocuronium, or the patient starts breathing and you pile it on. And then at the end of the case, we reverse it somehow and send the patient to the PACU. And as long as we got the endotracheal tube out, we're done.

Desiree Chappell: Pretty. Right.

Rick Dutton: So it turns out there's a substantial incidence. Again, first piece of evidence. If you go and measure those people in the PACU as they hit there, there are substantial number, and it's 10-30% depending on what you read, that are still weak and measurably weak. And then the next state, which is, and those weak people do worse, and they have a higher incidence of aspiration, they have a higher incidence of pneumonia, subsequent pulmonary complications down the road, and a small incidence of needing to be reintubated, which is the only part we ever see. They also, it turns out—and this is something I can measure—have a lower patient satisfaction.

Desiree Chappell: I would imagine.

Rick Dutton: And the patients don't like being weak either. So they're less happy about their anesthetics. So as I said, very good evidence base is bad.

Desiree Chappell: Yeah, Guy, from an international perspective and Mike too, is this something that you guys are dealing with?

Guy Ludbrook: Yeah, this is a journey we've traveled for a while. So I remember our College Safety and Quality Committee meeting looking at our guidelines a few years back. And there was a huge debate about whether we should - and should is the right word - recommend that they should be used if you're planning to reverse an extubate. And there was great debate about that. And in particular, some people were concerned that there won't be the resources to have the monitors. But we felt we're not going to get the traction towards that funding unless we do it. So we said we should. But equally, the gap between that and what I see in our operating rooms is enormous. And we have quantitative monitoring in every operating room in my hospital. Use maybe 10 % of the time if you're lucky. To the point that an implementation, what we've been discussing lately is, well, and what I do in my private practice is my anesthesia nurse puts it on for me. In the same way that the EKG, the oximeter, the blood pressure, we wouldn't start a case without it. Do I put it on? No, they put it on.

So we're going to try and get the people who are actually incredibly reliable, which is our anesthesia nurses or techs, depending on where you are, and make that part of what their standard practice is because we're not very good at standard practice very often. So it's a journey where we're traveling and we're not at the other side yet.

Desiree Chappell: Yeah. And Mike, similar?

Mike Grocott: It's far from perfect. We usually have the kit available, but the level of use is highly variable. It depends on individual practitioners and institutional culture.

Desiree Chappell: Yeah. So we have residual blockade. Patients don't like it. It's not good for them. It's not good for the system, costly all the things. The guidelines and what Mike and Guy were referring to is that now it specifies that we should be monitoring.

Rick Dutton: Yeah, that if we're using non-polarizing blocking drugs, we should have quantitative monitoring. And this is a high-grade recommendation that will become a standard of care in the US. I shouldn't use that word, here in the ASA's halls, but it will become a standard of care, and it should. I am a smarter doctor with quantitative monitoring, and having used it myself and gotten my hands on it, it helps.

Desiree Chappell: Yeah. Not just the little Twitch monitor that everyone uses that's not as useful.

Rick Dutton: Not effective. There are, I think, eight specific recommendations in the document, the most important one being you should use quantitative monitoring. You should confirm that the patient is fully recovered before you excavate them, which is train-of-four ratio over 90 in very round numbers. And how do we get from that to actually doing it every day in the operating room is, as I say, that's the big challenge.

Desiree Chappell: Well, I guess let's talk about technology at this point, because in my ORs, we don't even have the monitors. I mean, Guy, I know you said you have them everywhere. We don't have them in my OR.

Rick Dutton: You may feel bad about where you all are, but that's a step ahead of where we are in America. We're in private practice world, where they don't exist. And most of our graduating residents have seen it, and what they have seen is largely the clunky old accelerometers or mechano monitors that you can't tuck the arms, they're very finicky, they need to be calibrated, you have to get a baseline. And this is just too much work, as you were implying, this is just too much, and people won't do that for the perceived benefit. What we're now looking out at is a whole exhibitors hall full of better monitors now with a much better form factor a single sticker, slap it on, plug it in, you get a number from zero to 100. This is very easy to think about and manage.

Desiree Chappell: Yeah. And that's being included on a lot of new anesthesia machines, correct?

Rick Dutton: It should be. I don't honestly, I haven't bought new anesthesia machines in a while. But, yes,

Desiree Chappell: it's being integrated, I think Into a lot of them.

Rick Dutton:  And it needs to be it needs to become part of our standard of care and just be everywhere as it is for you guys. And I think as it gets easier to use, it will be more commonly used.

Desiree Chappell: Yeah. Well, as a quality guru, you're also a change management guru. Well you are.

Rick Dutton: Yeah, okay.

Desiree Chappell: You've had to do this a lot and roll these types of things out. And as we've all said, it's hard. Adoption of this is hard. It's a newer technology. It's not complicated to use, it's pretty easy. How do we roll this out and get adoption of this? I mean, once we get technology in our hands, then what do we do next?

Rick Dutton: Yeah, so I told you, I'm back running a small hospital, so I'm the perfect guinea pig. I want this at my hospital, how do I make that happen?

Desiree Chappell: Yeah, exactly.

Rick Dutton: So the stepwise path, I find a local champion. So one of my CRNAs. You're going to be our expert on quantitative neuromuscular blockade monitoring, call these five vendors. Get demos in any of them who want to come here and bring their box and a bunch of disposables and do a bunch of cases with us. Let's do that. That's the first step. That'll get everybody a little comfortable with it. They'll start to see how it works. They will like, as I have experience, that's pretty easy, right? I get 90 out of 100. That's kind of straightforward.

Desiree Chappell: I understand that.

Rick Dutton: And they'll be able to see the other benefits. So the better titration of the medicine during the case, the cleaner wake up at the end of the case, they'll start to sense that. And then I'll go fight the battle with the hospital about getting the technology. It's not that expensive. And particularly the advantage is we do have five different vendors, right. So we will get the technology, we'll get the disposable, and we'll start using it. And again, I'll pick a particular project. We'll pick colorectal surgery or joint replacement or something. We'll start on a single focus service line. We'll build it into the protocol for that kind of patient, and it will become routine.

Desiree Chappell: Yeah. As a clinician and a person that drives quality at my facility, and that a lot. It's hard to go to the C suite to ask for more money right now. Even if it's not very much, it's still as hard. So, value proposition of, like, I think we've had previous discussions about how you get in front of a PT committee or a capital committee or something like that to really make the case. What is the case for this?

Rick Dutton: I don't know how this plays in Australia or England, but one of the advantages we have is that I'm getting daily flack from my hospital administrators about the cost of Sugammadex. So I can say, look, you want to use less Sugammadex? Here's a way. If we did this, if we were using this technology every case, every day, 20% of our patients wouldn't need reversal, and we'd be able to not reverse them confidently that they're going to be fine, right? Because we have a number, and reducing that much Sugammadex use will completely pay for this. So it's different budgets in my hospital. So there's still I got to get out of the money, out of the pharmacy bucket, into the OR bucket, but effectively that'll make this argument a little easier.

Desiree Chappell: But pharmacy would be happy.

Rick Dutton: Yes.

Desiree Chappell: And if pharmacy is happy, it's like, if mommy is happy, everybody else can be happy.

Rick Dutton: There's some bright enough light there in hospital administration to recognize that making pharmacy happy is worth spending a little money in the OR.

Desiree Chappell: Yeah. So the guidelines, when they came out, we know now that this is what we're supposed to be doing. What were some of the other things that it talked about? It talked about neuromuscular blockade monitoring. It talked about Sugammadex use.

Rick Dutton: Yeah. So monitor and use that to guide extubation. Use the wrist, not the eyeball.

Desiree Chappell: That's right. That was an important one laid out.

Rick Dutton: And as we reviewed all the literature monitoring the Orbicularis oculi or whatever muscle you actually happen to get, which is not clean.

Desiree Chappell: Yeah, very.

Rick Dutton: Is essentially worthless.

Desiree Chappell: Yeah. So it's always at the so wrist.

Rick Dutton: So wrist, or you can do the adductor in the leg or the posterior tibial nerve in the leg as well. Those are all pretty consistent. And that's where all the literature, the sound literature, is that's a minor recommendation for the nerds in the audience?

Desiree Chappell: Yeah. What makes the difference?

Rick Dutton: And then the other big one has to do with reversal. So any block that's more than mild. So if your train-of-four ratio is under 80, which it usually is, you should be using Sugammadex and not Neostigmine. And that's the other big recommendation in the thing. And that's several different lines, but that's what it boils down to.

Desiree Chappell: And the information that we gather from the objective monitor is really what we have to use. I mean, you can't just use the twitch monitor that we've always used and said, oh, that looks like a mild block.

Rick Dutton: It's not stated as a specific line item, but throughout the whole document, it's very clear that the traditional way of doing it is worthless.

Desiree Chappell: Yeah. And that does not work to guide reverse

Rick Dutton: The human eyeball and feeling the patient's thumb, you cannot discriminate any level of block above 40. So it doesn't help.

Guy Ludbrook: It's interesting. So having helped define the guidelines, I thought I better practice what I preach that would be helpful. So I did that, and it was interesting, it wasn't so much about the reversal, which is relevant, but it was also about, as you mentioned, during the case. And I realized how badly I was practicing my neuromuscular...

Desiree Chappell: Waiting for the surgeon to say, I need more relaxation.

Guy Ludbrook: Exactly. I mean, it's not perfect because the diaphragm is sort of pretty resistant. And of course, with laparoscopic surgery, they can see every little bits pieces. But that aside, I realized I was far from perfect in using it during the case, and I felt I was giving better anesthesia in that phase. And I can't prove that. It's hard to measure, but I realized that what I was doing wasn't logical. So it did lead to a change in practice. But I do have to certainly in my private practice, my regular kind of anesthesia nurse will be the one that puts it on and reminds me, which is really good, because I'm just generally unreliable, as you know.

Desiree Chappell: Oh, that's not true. You've been extremely reliable for Top Med Talk.

Guy Ludbrook: The guideline was for one reason, but funnily enough, it had a different sort of impact, at least that's what I sense. And both being positive.

Desiree Chappell: Yeah, that's interesting.

Guy Ludbrook: But we have had a couple of cases. I mean, now I practice more and more kind of post-operative care. So we pick up a lot of patients in the recovery room and management from there on in. And we've had two or three very dramatic cases of weakness, completely unnoticed. I mean, really serious weakness, really unnoticed and probably should have been if you look at the dose regimen provided, wouldn't be a surprise, but renal impairment, laparoscopic surgery with the creatinine clearance, decimated during positive pressure in the abdomen and so on. Everything's kind of changing and getting a bit more unreliable, but some really quite profound ones unrecognized by the clinicians, even sort of when called. But those of us have been around the block a few times can see it. I think the need is there. I think you're absolutely right. I think compliance is the key. And what we need to do that. Talking carrots and sticks, how do we do that best? But, yeah, we've got the gear. But to not use it is, I think, a shame. And I think it comes at a cost.

Desiree Chappell: Yeah, well, we've again talked a lot about using different technology and software and all these different things to really help standardize practice, because it's the variation. It's those people that don't recognize that their patient's weak or that they're not reversed well. We have a lot of younger people coming into the field that have not seen that. Like, we recognize that very easily. I can see someone having it struggling a little bit, but maybe someone who's not been doing this for a while, they don't.

Rick Dutton: Yeah. And I think the answer to this one and some of this is epiphany from this weekend. No, yeah, really. But I think the answer to this one is going to be to make it the easy and expected thing to do. So it's just routine for every case like this, the same way you put the pulse limit on. We put this on easiest possible technologies, the form factor really matters. And just make it an expectation in the next generation of anesthesiologists that this is part of delivering general anesthesia, and it will always be there.

And so, I mean, anytime you're trying to change, you want what you're trying to change too to be the easiest way to do it. And the more we can set it up that way, the better we're going to do. And the epiphany is we have a lot of problems right now, but not just on the downside. On the upside, we have enormous opportunities to give better patient care. Medicine is advancing very rapidly right now, and we have an issue. So the change management business in general has an issue with, I call it headspace, in our clinicians' brains. It's not so much having the burning platform, it's which platform is burning more.

Desiree Chappell: The worse, yeah.

Rick Dutton:  That I need to address. And that's the problem. So am I focusing on intraoperative hypotension today or neuromuscular blockade reversal or on just having enough people to my OR, and the care ratios and everything else?

Desiree Chappell: Maslow's hierarchy comes into this too.

Rick Dutton:  Correct, exactly. That's the biggest problem right now is our clinic, you can call it, it manifests burnout, right? There's too many problems to solve. And how do I decide which one is the most.

Desiree Chappell: I can't deal with all this other stuff. I just got to show up. Yeah.

Rick Dutton:  Everybody likes progress. Nobody likes change.

Desiree Chappell: Yeah. Absolutely.

Rick Dutton:  So making it from my point of view, if I want to get this one implemented, I am really focusing hard on making it routine. You don't have to think about this. It's not taking up extra headspace. It's just how we do it.

Desiree Chappell: Yeah, that's great. One of the questions I wanted to say... Like I said, we're together in IOH and work on some other projects. And I know we've had lots of discussion about what the future of anesthesia care looks like and bringing technology in not to replace us, but to create our tools and make them work together. So we have blood pressure monitoring, we have process EEG and depth of anesthesia monitoring. Now we have this. Can you see all this coming together?.

Rick Dutton: That observation remains 100 %, and every year we get a little closer to it. Dr. Muckerby's talk yesterday, the plenary for the meeting, augmented intelligence is the term he is using. So not AI, but augmented intelligence. How do we make the doctor smarter? And the huge opportunity we have as technologists in the OR is to have all our technology talking to itself and synthesizing thinking for us.

Desiree Chappell: Yeah, for sure.

Guy Ludbrook: Oh, right. Because also they interact. There's been a lot of talk around the relationship between neuromuscular blockade and processed EEG as well. Exactly. And at the extremes, it's weird. In normal circumstances, I'm not sure it's a big factor, but you can sort of see it, but you can see it. But that probably speaks to that point. They're not isolated monitors, actually, because they are slightly dependent on each other.

Desiree Chappell: Yeah. Well, let's talk about before we wrap here, I think you just touched on it, how to make our anesthesia clinicians, those who are taking care of patients every day, smarter? And how do we integrate this technology? Because it's similar to what we've been talking about, but it's really taking it to the next level.

Rick Dutton: Yeah. Right now, the concept of machine learning or AI in our monitors is very scary to a lot of people, including our FDA, on the regulatory side. But in fact, it just needs to be and will be completely baked in and invisible to us, right? When I started medicine, if I wanted hematocrit, I went to the lab and put blood in a centrifuge and spun it and looked at the hematocrit, right? And now I don't do that anymore. And when I was a kid and you stepped on the brake pedal, there was a mechanical connection to the wheels of your car that made it stop. But that hasn't been true for 20 years now. When I step on the brakes, a computer decides how much brake force to apply to the wheels of my car.

Desiree Chappell: Or if you don't step on the brake, it actually stops the car for you.

Rick Dutton:  Or yeah, and today it stops the car anyway, whether I step on the brake or not. Exactly right. So this will become normal background in the ORs, our monitors talking to each other and giving you a synthesized opinion about anesthetic depth and fluid status and risk factors for lots of different things. State of blockade will be part of that, and making specific recommendations to me. And who knows, maybe the generation after that, it'll give the rock, your own.

Desiree Chappell: I was just going to say it'll be a closed loop or actually an open loop system that it says this is what you're trained for, and this is the amount of reversal that you need to give, or you need to keep your patient at this level of block. And so then at the end, we'll reverse it for you.

Rick Dutton: Yeah, exactly. I'll just tell it, keep the person relaxed.

Desiree Chappell: Yeah. And then we're done.

Rick Dutton: I don't even have to say that because it will be looking at the feed from the laparoscope, and when the camera comes out, it will reverse the patient on its own. Why should I have to make that decision? That one's easy.

Guy Ludbrook: Will we have to read the newspaper during the case then?.

Rick Dutton: Maybe we'll set it up so it's read to you.

Desiree Chappell: Listen, but what it will not know is who is actually having to close and what layers they're closing. Correct. So no way.

Rick Dutton: We have a student in the OR today. Right. So maybe the system we want is it reads the RFID tag of everybody coming into the operating room. And if there's a student standing within one foot of the incision.

Desiree Chappell: Oh, wow.

Rick Dutton: it gives the reversal later than if it's

Desiree Chappell: Oh, my God.

Rick Dutton: Nestle, you can play this game for a long time.

Desiree Chappell: You can play this game for a long time, I know. But I don't think that's any time soon that any of us are going to be replaced to be given anesthesia. Well, Rick, I feel like there's so many topics I would love to be able to talk to you about today. The IOH project, I know I keep coming back to that and talking about that, but I think it's something we put a lot of work into this last year and talking about where we want to go in the future with that. Where do you see that really moving and where do you think we can go next on that?

Rick Dutton: Yeah. So better connection of process to outcomes. So the presence of IOH and then who gets kidney failure? Because it's not everybody, obviously. And it probably is a more selected population that is at the highest risk. So getting that connection better built. And then mitigation, right? That's nice to know, and that'll be important for some parts of the project. But on the other hand, who cares? We know our intraoperative hypotension is bad, let's just fix it. And that's the implementation side of it. So it's the same change management of how do we recognize the problem earlier? There are technology solutions, as I know you've been talking about, and how do we get people to react to it in the right way?

Desiree Chappell: Yeah. One of the questions I'm trying to ask you, do you think we need to reframe this instead of saying IOH or intraoperative hypotension it´s bad? Because now we know that some people are trying to fix it. The N-Pog paper came out with Troy talking about that they didn't have much IOH, but then they ended up... They reduced IOH, but they actually ended up having more AKI after. Is it more of hemodynamic instability, you think?

Rick Dutton: low, but no perfusion at the tissue level, and getting the right balance of pressors, anesthetic, agent, and volume. Which is the art of what we do every day in the OR is trying to juggle that. I think there's enormous possibility for machine learning AI to help us know that. Yeah, the N-POG paper, we fixed IOH by giving a lot of pressors.

Desiree Chappell: But maybe not the right

Rick Dutton:  That wasn't right either.

Mike Grocott: It's had consequences. Yeah, at.

Desiree Chappell: The end, that's what I actually was titling. Our conversation was going to be the unintended consequences of what we do and how we do it.

Rick Dutton:  Yeah, the law of unintended consequences has not been repealed.

Guy Ludbrook: Yeah. We were talking about this last year, I think, when I was over. We're doing a straw poll across various continents. Our CEO have seemed to be very scared of fluids, very keen on Vasopressors.

Rick Dutton:  Yes, the pendulum is way over there on the dry side right now.

Guy Ludbrook: And it's really swung. And it's hard to know what to do because you can dial a blood pressure with a Vasopressor. But you do see some serious mismatches between what's on the floor and what's been put in, which you can patch up. So the numbers look good. I guess to your words, Desiree. Is it hypogential? What is the thing that describes what we're talking about? Yeah, it seems to be a trend. It's not ideal. Just protecting your blood pressure doesn't seem to always do it. But again, it can be a bit tricky in the operating room to know exactly where you are.

Mike Grocott: I have to reflect. Rick, we do these POQIS, the Perioperative Quality Initiative, and we did a refresh in London of blood pressure fluids, gold-directed therapy. And it's an experiment for the first time, so excuse my voice, I think I'm wearing out.

Desiree Chappell: We're talking too much

Mike Grocott: But it's an experiment for the first time. We road-tested the outputs of the what is a relatively small, so 20, 30-person expert consensus group on an audience of 350-400 people. They voted, and in the vast majority of cases, we would 90 % plus support for whatever the recommendation was. And the single, there were a couple, but the really standout recommendation, which didn't get widespread support, was the one with arguably the greatest evidential support in the form of Paul Miles' relief study, which is give roughly how much fluid do you give, lots of disagreement.

Desiree Chappell:  Yeah, actually, it's just really the only one, maybe one or two that there was not unanimous. It was just crazy.

Mike Grocott: Other things with no evidence, absolute support...

Desiree Chappell: 100 %. People said, yes, they agree.

Rick Dutton: Really interesting. Yeah, well, having been around for a while, the pendulum, we're at a very dry swing of the pendulum right at the moment in a lot of the popular mindset. But that's just as wrong as the wet end of the pendulum.

Mike Grocott: I think enhanced recovery, great as it's been in many ways, enhanced recovery has driven that in part.

Desiree Chappell: Yeah. Well, we've banged on a lot about this. But we talked to Henrick, Kellet, actually five years ago here at the meeting and asked specifically this question. He's like, I never said anything about fluid restriction. Avoid fluid overload. That's what I said. Exactly. He said, we did not say restrict, but we did a wonderful conversation with Brigita Brandstrup at EBPOM last year. Because really that terminology of restriction, that's when it really started to creep in. And she's like, That is not at all what I meant. I did not mean... And so I think it's just been over the years, people say, let's just fluid restrict. And that's what goal-directed therapys and there's been a real mismatch of what it really is and what people think it is.

Rick Dutton: Yeah, if you want my wild speculation on that. So the pendulum will come back to the Goldilocks' right amount of fluid, which will then let us get to the next important question, which is what fluid?

Desiree Chappell: Oh. Yeah.

Rick Dutton: And again, having resuscitated trauma patients, we figured out eventually that blood was the right fluid. For a lot of our OR patients, I'm not sure we know what the right fluid is, and it probably isn't normal saline. And some of the evils we attribute-fluid overloader has actually probably normal saline poisoning in some way. So whether we need a better isotonic crystalloid or whether we should be using some non-coagulogenic plasma variant or that does a good job of preserving, like Ocalyx and Perfusion and all, I don't know. But I think there's a bunch of work that will happen there eventually.

Desiree Chappell: That's great. Well, I'm teeing up our next conversation... Not next. I think our conversation is going to be at 3:15 today. Louise, Son, Dan, Cole, Mike, Scott, talking about an initiative through the Anesthesia Patient Safety Foundation or work that they have done around intraoperative hypotension, hemodynamics. Mike, you actually were part of that as well, correct?

Mike Grocott: I was, yeah. I had a meeting in Philadelphia towards the end of last year.

Desiree Chappell: Yeah. Rick, were you there, too?

Rick Dutton: Yes.

Desiree Chappell: Okay. I'm sorry. We're teeing up this conversation because we're going to talk a little bit about some of those recommendations and thoughts that came out of that group. So we'll save that for that group. Thank you so much. I hope you had a good time here in San Francisco.

Rick Dutton: Oh, yeah. Always fun. It's always good to visit with all my friends and do this. I love it. Keep inviting me.

Mike Grocott: You will. You've avoided the jeopardy because there's no way people online would know this, but we have pigeons flying by over here, inside this ASA building. I'm just waiting for one of them to 

Desiree Chappell: i've always heard it's good luck.

Rick Dutton: Thank you. I'll be leaving now

Desiree Chappell: Well, thanks again. Great conversation. You can also find all of our conversations that we've done here at the ASA and in previous anesthesiology meetings at topmedtalk.com. We are on X, which formerly known as Twitter, in case you haven't heard, LinkedIn, Facebook, we're there. Follow us. Give us a thumbs up whenever you see one of our videos. We always appreciate that. Again, a huge shout out. Thank you to the ASA for supporting us to be here this year. We could not do it without you. It's a beautiful booth, beautiful setting. Wonderful guests here in San Francisco. It's been absolutely fantastic. So thank you. And of course, thank you to our sponsors that have been there for us over the years, especially GE HealthCare, we couldn't do it without you, Medtronic and one of our founding sponsors, Edwards Life Sciences. Cheers. Thanks so much, everybody. Have a great day.

Mike Grocott: Thank you Rich.

Rick Dutton: Thank you.

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