APSF.ORG NEWSLETTER THE OFFICIAL JOURNAL OF THE ANESTHESIA PATIENT SAFETY FOUNDATION

Volume 35, No. 1, 1–32 Circulation 122,210 February 2020 Local Anesthetic Systemic Toxicity (LAST) Revisited: A Paradigm in Evolution by Guy Weinberg, MD; Barbara Rupnik, MD; Nitish Aggarwal, MD, MBA; Michael Fettiplace, MD, PhD; and Marina Gitman, MD

INTRODUCTION INCIDENCE Combined clinical and basic science efforts LAST can happen in any practice setting, but it over several decades have enhanced our is often ignored or underappreciated by practi- understanding of the underlying mechanisms tioners until experienced firsthand. Reported and clinical spectrum of local anesthetic sys- estimates of its frequency vary greatly. Although temic toxicity (LAST). The APSF Newsletter has some single-site studies at academic institutions played an important role in educating clini- report extremely low rates of LAST,1 recent anal- cians and increasing awareness of the various yses of large registry2 and administrative3,4 data- presentations and optimal treatment of LAST, In particular, the adoption of ultrasound guid- bases generally agree on a rate of approximately undoubtedly improving patient outcomes from ance, catheter and intravenous infusions, local 1 per 1000 peripheral nerve blocks. However, this life-threatening iatrogenic complication. infiltration, and the expanding roles of regional given the strong likelihood of under-reporting, The changing landscape of regional anesthe- anesthesia and local anesthetics in ERAS, multi- misdiagnosis, or other causes of failed case sia, characterized by new uses and forms modal analgesia, and possible cancer risk mod- capture, it is possible the actual rate is higher. of local anesthetics, has led to recent shifts in ification, require attention to the changing the clinical features and context of LAST. features of LAST. See “LAST Revisited,” Page 5

A Patient With E-Cigarette Vaping Associated Lung Injury (EVALI)—Coming to an Operating Room Near You! by Todd Dodick, MD, and Steven Greenberg, MD INTRODUCTION THE CASE The use of e-cigarettes, commonly referred Recently, in our institution, a 30-year-old male to as vaping, has increased exponentially in the presented to our emergency department with past several years. E-cigarettes were initially shortness of breath, daytime sweats, chills, and marketed as a smoking cessation aid, but their use among adolescents and young adults progressive shortness of breath. He reported doubled from 2017 to 2019. In early 2019, cases “vaping all day” and admitted to vaping both tet- of e-cigarette, or vaping, product use associated rahydrocannabinol (THC) and nicotine for the last lung injury (EVALI) began to be presented to 5 years. After a battery of tests were negative, hospitals across the United States. Although severe EVALI was presumed, which required other chemicals have been implicated in EVALI, ICU admission with high FiO2 and PEEP require- The Centers for Disease Control and Prevention ments. The patient was started on IV methyl- (CDC) has now suggested that vitamin E acetate, commonly added to illicit cannabis vaping prednisolone 40 mg twice per day. During his liquids, is the most likely cause of EVALI.1 As of ICU stay, he developed an acute left tension December 10, 2019, a total of 2409 cases have pneumothorax while on non-invasive ventilation been reported to the CDC.1 requiring chest tube placement and endotra- cheal intubation. The patient was found to have In the operating room, he was appropriately AANA and Other Readers: bilateral apical blebs on chest computer tomog- preoxygenated, but rapidly desaturated to an SpO2 of 51% following induction of anesthesia, If you are not on our mailing list, please raphy scan. After being weaned from the ventila- recovering to SpO2 >90% with manual ventila- subscribe at https://www.apsf.org/subscribe tor, our thoracic surgeons scheduled pleurodesis tion. Oxygenation and ventilation during one- and the APSF will send you an email of the and resection of a large bleb due to a persistent large left pneumothorax despite persistent chest lung ventilation were expectedly difficult. current issue. tube therapy. See “Vaping,” Page 4

TABLE OF CONTENTS, NEXT PAGE APSF NEWSLETTER February 2020 PAGE 2

TABLE OF CONTENTS ARTICLES: NEWSLETTER Local Anesthetic Systemic Toxicity (LAST) Revisited: A Paradigm in Evolution...... Cover A Patient With E-Cigarette Vaping Associated Lung Injury (EVALI)—Coming to an Operating Room Near You!...... Cover The Official Journal of the 2020 President's Report: What APSF is Doing to Promote Perioperative Patient Safety and How Each of Us Can Make a Positive Impact ...... Page 3 Anesthesia Patient Safety Foundation Healthy Relationships Between Anesthesia Professionals and Surgeons Are Vital to Patient Safety...... Page 8 The Anesthesia Patient Safety Foundation Newsletter Rapid Response: Airway Emergencies and Safety in Magnetic Resonance Imaging (MRI) Suite...... Page 10 is the official publication of the nonprofit Anesthesia APSF Awards 2020 Grant Recipients...... Page 12 Patient Safety Foundation and is published three times per year in Wilmington, Delaware. Individuals Rapid Response: An Incident of GlideScope® Stat Cover Failure...... Page 14 and corporations may subscribe for $100. If multiple Portable Point of Care Ultrasound (PPOCUS): An Emerging Technology for Improving Patient Safety...... Page 15 copies of the APSF Newsletter are needed, please Q&A: Navigating Perioperative Insulin Pump Use ...... Page 19 contact: [email protected]. Contributions­ to the How Can We Tell How “Smart” Our Infusion Pumps Are?...... Page 21 Foundation are tax-deductible.­ ©Anesthesia Patient Patient Blood Management Program Reduces Risks and Cost, While Improving Outcomes...... Page 23 Safety Foundation, 2020. APSF-Sponsored 2019 ASA Panel on "Practical Approaches to Improving Medication Safety"...... Page 24 The opinions expressed in this Newsletter are not A Difficult Airway Early Warning System in Patients at Risk for Emergency Intubation: A Pilot Study...... Page 26 necessarily those of the Anesthesia Patient Safety PRO and CON: Foundation. The APSF neither writes nor promul- gates standards, and the opinions expressed herein PRO: Artificial Intelligence (AI) in Health Care...... Page 27 should not be construed to constitute practice stan- CON: Artificial Intelligence is Not a Magic Pill...... Page 28 dards or practice parameters. Validity of opinions pre- Balancing Sustainability and Infection Control: The Case for Reusable Laryngoscopes...... Page 29 sented, drug dosages, accuracy, and completeness Rapid Response: Perils and Pitfalls With the Rapid Infusion Catheter (RIC)...... Page 30 of content are not guaranteed by the APSF. APSF Executive Committee 2019: APSF ANNOUNCEMENTS: Mark A. Warner, MD, President, Rochester, MN; Daniel Guide for Authors...... Page 2 J. Cole, MD, Vice President, Los Angeles, CA; Matthew APSF Stoelting Conference 2020 Announcement...... Page 13 B. Weinger, MD, Secretary, Nashville, TN; Douglas A. APSF Donor Page...... Page 18 Bartlett, Treasurer, Boulder, CO; Maria van Pelt, CRNA, Crowdfunding Announcement...... Page 31 PhD, Director At-Large, Boston, MA. Legacy Members...... Page 31 APSF Newsletter Editorial Board 2019: 2019 Board Members and Committee Members:...... https://www.apsf.org/about-apsf/board-committees/ Steven B. Greenberg, MD, Editor-in-Chief, Chicago, IL; Edward A. Bittner, MD, PhD, Associate Editor, Boston, MA; Jennifer M. Banayan, MD, Associate Editor, Chi- cago, IL; Meghan Lane-Fall, MD, Assistant Editor, Phila- Guide for Authors and have appropriate referencing (see http://www.apsf.org/ delphia, PA; Trygve Armour, MD, Rochester, MN; JW authorguide). The articles should be limited to 2,000 words with Beard, MD, Wilmette, IL; Heather Colombano, MD, The APSF Newsletter is the official journal of the Anesthesia Patient no more than 25 references. Figures and/or tables are strongly Winston-Salem, NC; Jan Ehrenwerth, MD, New Haven, Safety Foundation. It is widely distributed to a variety of anesthesia encouraged. CT; John H. Eichhorn, MD, San Jose, CA; Nikolaus Gra- professionals, perioperative providers, key industry representatives, 2. Q&A articles are submitted by readers regarding anesthesia venstein, MD, Gainesville, FL; Joshua Lea, CRNA, and risk managers. Therefore, we strongly encourage publication of patient safety questions to knowledgeable experts or desig- Boston, MA; Bommy Hong Mershon, MD, Baltimore, those articles that emphasize and include the multidisciplinary, mul- nated consultants to provide a response. The articles should be MD; Tricia A. Meyer, PharmD, Temple, TX; Glenn S. tiprofessional approach to patient safety. It is published three times limited to 750 words. Murphy, MD, Chicago, IL; Brian Thomas, JD, Kansas a year (February, June, and October). Deadlines for each issue are 3. Letters to the editor are welcome and should be limited to 500 City, MO; Jeffrey S. Vender, MD, Winnetka, IL; Wilson as follows: 1) February Issue: November 15th, 2) June Issue: words. Please include references when appropriate. Somerville, PhD, Editorial Assistant, Winston-Salem, March 15th, 3) October Issue: July 15th. The content of the news- 4. Rapid Response (to questions from readers), formerly known as, NC. Please see the links of international editors at letter typically focuses on anesthesia-related perioperative patient "Dear SIRS," which was the “Safety Information Response https://www.apsf.org/wp-content/uploads/newsletter/ safety. Decisions regarding content and acceptance of submissions System,” is a column that allows for expeditious communication APSF-International-Editors.pdf for publication are the responsibility of the editors. Some submis- of technology-related safety concerns raised by our readers, with sions may go in future issues, even if the deadline is met. At the dis- Address all general, contributor, and sub­scription input and response from manufacturers and industry representa- correspondence to: cretion of the editors, submissions may be considered for tives. Dr. Jeffrey Feldman, current chair of the Committee on publication on our APSF website and social media pages. Technology, oversees the column and coordinates the readers’ Stacey Maxwell, Administrator Articles submitted that are not in accordance with the following Anesthesia Patient Safety Foundation inquiries and the response from industry. Charlton 1-145 instructions may be returned to the author prior to being reviewed 5. Invited conference reports summarize clinically relevant anesthe- for publication. Mayo Clinic sia patient safety topics based on the respective conference 1. Please include a title page which includes the submission’s title, 200 1st Street SW discussion. Please limit the word count to less than 1000. authors' full name, affiliations, conflicts of interest statement for Rochester, MN 55905, U.S.A. Commercial products are not advertised or endorsed by the APSF each author, and 3–5 keywords suitable for indexing. Please [email protected] Newsletter; however, upon exclusive consideration from the edi- include word count on the title page (not including references). tors, articles about certain novel and important safety-related tech- Address Newsletter editorial comments, questions, 2. Please include a summary of your submissions (3–5 sentences) letters, and suggestions to: nological advances may be published. The authors should have no which can be used on the APSF website as a way to publicize commercial ties to, or financial interest in, the technology or com- Steven B. Greenberg, MD your work. mercial product. Editor-in-Chief, APSF Newsletter 3. All submissions should be written in Microsoft Word in Times [email protected] New Roman font, double-spaced, size 12. If accepted for publication, copyright for the accepted article is 4. Please include page numbers on the manuscript. transferred to the APSF. Except for copyright, all other rights such Edward A. Bittner, MD, PhD as for patents, procedures, or processes are retained by the author. Associate Editor, APSF Newsletter 5. References should adhere to the American Medical Association [email protected] citation style. Permission to reproduce articles, figures, tables, or content from Example: Prielipp R, Birnbach D. HCA-Infections: Can the anes- the APSF Newsletter must be obtained from the APSF. Jennifer M. Banayan, MD thesia provider be at fault? APSF Newsletter. 2018; 32: 64–65. Additional information: Associate Editor, APSF Newsletter https://www.apsf.org/article/hca-infections-can-the-anesthesia 1. Please use metric units whenever possible. [email protected] provider-be-at-fault/ Accessed August 13, 2019. 2. Please define all abbreviations. Meghan Lane-Fall, MD 6. References should be included as superscript numbers within 3. Please use generic drug names. Assistant Editor, APSF Newsletter the manuscript text. 4. Please be aware of HIPAA and avoid using patient names or per- [email protected] 7. Please include in your title page if Endnote or another software sonal identifiers. Send contributions to: tool for references is used in your submission. 5. Plagiarism is strictly prohibited. Individuals and/or entities interested in submitting material for Anesthesia Patient Safety Foundation Types of articles include (1) Invited review articles, Pro/Con Debates Charlton 1-145 and Editorials, (2) Q and As, (3) Letters to the Editor, (4) Rapid publication should contact the Editor-in-chief directly at green- Mayo Clinic Response, and (5) Conference reports. [email protected]. Please refer to the APSF Newsletter link: http:// 200 1st St SW 1. Review articles, invited Pro/Con debates, and Editorials are www.apsf.org/authorguide that will provide detailed information Rochester, MN 55905, U.S.A. ­original manuscripts. They should focus on patient safety issues regarding specific requirements for submissions. Or please donate online at www.apsf.org. APSF NEWSLETTER February 2020 PAGE 3

2020 President's Report: What APSF is Doing to Promote Perioperative Patient Safety and How Each of Us Can Make a Positive Impact by Mark A. Warner, MD There are many opportunities available to us consistently high. We also are collaborating as a specialty as well as individually to improve with the Patient Safety Movement Foundation the safety of our patients as they go through to develop an anesthesia-specific patient safety their perioperative episodes of care. As a spe- curriculum for training programs and for indi- cialty, and for APSF, specifically, we must priori- vidual practitioners, with adaptations that will tize high-value issues that need to be make it applicable for use in both high- and addressed. As individuals, we must focus limited-resource countries. Thanks to the acutely on the safety of each and every one of efforts of our newsletter and social media lead- our patients…every day. ers, Steven B. Greenberg, MD, and Marjorie P. Stiegler, MD, respectively, APSF’s patient safety APSF’S PATIENT SAFETY PRIORITIES recommendations and articles now reach more AND PARTNERSHIPS than 600,000 anesthesia professionals world- There are specific issues that we all know wide, in every country and on every continent need to be addressed. Table 1 provides a list of of the globe, with information on important the top perioperative patient safety issues that topics in perioperative patient safety. the APSF believes need targeted attention, dis- cussion, and support at this time, no matter WHAT EACH OF US CAN DO TO where you live and work. We use this set of HAVE A POSITIVE IMPACT ON global priority issues to help us determine the PATIENT SAFETY topics of our Stoelting Conferences, solicit arti- Dr. Mark Warner, APSF President Beyond the efforts of APSF and many of our cles for our APSF Newsletter, drive social specialty’s professional organizations to media content, and allocate resources for addressed through global as well as regional or improve perioperative patient safety, there are research and education projects. local partnerships. The APSF is partnering with actions we all can take to improve patient Beyond these global topics on perioperative the World Federation of Societies of Anaesthe- safety­—individually and every day. For exam- patient safety, there are local issues that impact siologists (WFSA) and other global and regional ple, we can simply follow the Golden Rule, patient safety. Examples include limitations on organizations to assist with improving educa- “Treat others as you would like to be treated.” personnel, equipment, and medications. While tion opportunities for anesthesia professionals. This rule is not tied to any culture and appears present to some degree everywhere, these Specific to the WFSA, we are supporting efforts in some modification in all of the world’s major limitations are most prevalent in lower resource to ensure that the value of subspecialty fellow- religions and regions. countries. These issues often must be ships offered by the WFSA around the world is Basically, we need to take a few deep breaths before patients come under our care and consider how we would wish to be treated Table 1: APSF’s 2020 Top Ten Perioperative Patient Safety Priorities if we were in their places. Over the years I’ve had the good fortune to be able to study sev- 1. Preventing, detecting, and mitigating clinical deterioration in the perioperative period eral major perioperative morbidities in detail a. Early warning systems in all perioperative patients (e.g., pulmonary aspiration, ulnar neuropathy, b. Monitoring for patient deterioration and pneumonias). I’ve also had the misfortune i. Postoperative continuous monitoring on the hospital floor to have cared for patients who have suffered ii. Opioid-induced ventilatory impairment and monitoring from these and other significant perioperative iii. Early sepsis complications. Like many of you, I’ve seen c. Early recognition and response to decompensating patient patients receive medications in error, some- 2. Safety in out-of-operating room locations such as endoscopy and interventional radiology times with significant detrimental events asso- suites ciated with them. I can tell you from personal experience that an unanticipated perioperative 3. Culture of safety: the importance of teamwork and promoting collegial personnel interac- infection is not the outcome you wish to have. tions to support patient safety While many of these morbidities have complex, 4. Medication safety confounding etiologies that involve patient a. Drug effects characteristics and patient care that spans the b. Labeling issues perioperative continuum, we can and must do c. Shortages better at reducing our personal errors or omis- d. Technology issues (e.g., barcoding, RFID) sions that can negatively impact the safety of e. Processes for avoiding and detecting errors our patients. It is the right thing to do for our 5. Perioperative delirium, cognitive dysfunction, and brain health patients. It is what we would want from our col- 6. Hospital-acquired infections and environmental microbial contamination and transmission leagues when we are the patients. 7. Patient-related communication issues, handoffs, and transitions of care Before providing care for individual patients, we might ask ourselves: 8. Airway management difficulties, skills, and equipment • Have we used checklists to ensure that we 9. Anesthesia professionals and burnout have everything we need at hand when we 10. Distractions in procedural areas proceed with anesthetic care? See “President's Report,” Next Page APSF NEWSLETTER February 2020 PAGE 4

Follow the Golden Rule: "Treat Others As You Would Like To Be Treated"

From “President's Report,” Preceding Page For all of our patients, we might ask: to assist clinician investigators and others to • Have we actively avoided contamination of • Have we participated in our local institutions develop new knowledge that can improve our equipment and medications to reduce to develop the clinical pathways, practices, patient safety. These organizations can help the risk of microorganism transmission peri- and policies that increase their safety develop recommendations that can be used to operatively? throughout the perioperative period? guide care and potentially improve patient • Have we made the effort to know our safety. Our industry partners can develop the • Have we worked within our institutions and new equipment and medications that contrib- patients and their risk factors for potential with our colleagues to improve team interac- ute to safer care. However, each of us has a intraoperative or postoperative complica- tions and implement the cultural changes tions? that allow all members of the perioperative personal responsibility to contribute to • Have we allowed production pressures or team to point out actions that might cause improved perioperative patient safety. Deliber- distractions (e.g., cell phones) to interfere patient harm? ate consideration of the Golden Rule before providing care to each patient seems essential. with our focused efforts to provide the best • Have we taken leadership roles, locally or care we can? beyond, that allow us to make a positive Dr. Mark Warner is currently president of the • Have we provided the appropriate handoff impact on the perioperative safety of the APSF and the Annenberg Professor of Anesthe- communication before leaving the patients in populations we serve? siology, Mayo Clinic, Rochester, MN. another anesthesia professional’s care? Perioperative patient safety is not something • Are we “treating our patients as we would that someone else can resolve. The APSF and Dr. Warner has no disclosures with regards to like to personally be treated”? other organizations can provide the resources the content of the article.

Perioperative Management of EVALI Patients is Challenging

From “Vaping,” Cover Page Table 1: Suggested Diagnostic Criteria for EVALI3,4

Physiologic derangements included a PaCO2 Use of e-cigarettes of 78 mmHg with an ETCO2 of 47 mmHg, indi- cating significant dead space, and a PaO of 2 Pulmonary infiltrate on chest radiograph or ground glass opacities on computerized 69 mmHg on an FiO2 of 1.0 indicating a signifi- tomography (CT) scan cant A-a gradient. The PEEP was 8 cm H20 and plateau pressure was 32 mmHg. The proce- Elevated WBC count and inflammatory markers (c-reactive protein, erythrocyte sedimentation dure was successful and he was returned to the rate) ICU. Several days later, while he was no longer Absence of pulmonary infection—negative for respiratory viruses including influenza, requiring positive pressure ventilation, he negative HIV or HIV-related infections, negative blood, sputum and/or bronchial alveolar developed another tension pneumothorax in lavage (BAL) cultures the contralateral lung. He again underwent pleurodesis and bleb resection. Foamy macrophages containing vitamin E acetate on BAL/lung pathology4

DISCUSSION No evidence of alternative medical causes (e.g., heart failure, rheumatologic disease, cancer) To our knowledge, no case reports describe the intraoperative management of a patient corticosteroids may be beneficial, and have the Department of Anesthesia and Critical Care with EVALI, with only one other EVALI-associ- been widely administered in published reports.4 at the University of Chicago Pritzker School of 2,3 ated pneumothorax noted previously. Intra- Thus far, the CDC has documented 52 deaths Medicine, Chicago, IL. operative ventilation of these patients may be across the United States.1 While much remains challenging, and high levels of FiO2 and PEEP to be elucidated regarding EVALI, e-cigarette Dr. Greenberg is editor-in-chief of the APSF may be required to maintain adequate gas use is increasingly prevalent. We are likely to Newsletter. exchange. If significant difficulty is expected, see more cases in our hospitals and increas- venovenous extracorporeal membrane oxy- ingly, our operating rooms in the future. REFERENCES genation may be warranted in capable centers. Dr. Dodick is an anesthesiologist in the Depart- 1. CDC. Outbreak of lung injury associated with the use of Patients with EVALI present almost univer- ment of Anesthesiology, Critical Care and Pain e-cigarette, or vaping, products. https://www.cdc.gov/ tobacco/basic_information/e-cigarettes/severe-lung-dis- sally with constitutional, respiratory, and gastro- Medicine at NorthShore University HealthSys- intestinal symptoms. Common presenting ease.html Accessed November 13, 2019. tem, Evanston, IL, and is clinical instructor in the 2. Lewis N, McCaffrey K, Sage K, et al. E-cigarette use, or symptoms and findings are detailed in Table 1. Department of Anesthesia and Critical Care at vaping, practices and characteristics among persons with Severity can range from mild, not requiring hos- the University of Chicago Pritzker School of associated lung injury—Utah, April–October 2019. MMWR. pitalization (5–10%) to severe, requiring ICU Medicine, Chicago, IL. 2019;68:953–6. admission (44–58%) and, often, non-invasive 3. Layden JE, Ghinai I, Pray I, et al. Pulmonary illness related to ventilation (32–36%) or intubation with mechan- Dr. Dodick has no conflicts of interest. e-cigarette use in Illinois and Wisconsin—preliminary report. ical ventilation (11–32%).2-4 Management of N Engl J Med. DOI: 10.1056/NEJMoa1911614. these patients is largely supportive, with lung Dr. Greenberg is vice chair of Education in the 4. Blagev DP, Harris D, Dunn A, et al. Clinical presentation, treatment and short-term outcomes of lung injury associ- protective ventilation with low tidal volumes and Department of Anesthesiology, Critical Care and ated with e-cigarettes or vaping: a prospective observa- high PEEP employed similar to those used in Pain Medicine at NorthShore University Health- tional cohort study. Lancet. DOI: 10.1056/S0140-6736 Acute Respiratory Distress Syndrome. Empirical System, Evanston, IL, and is clinical professor in (19)32730–8. APSF NEWSLETTER February 2020 PAGE 5

Risk Factors For LAST From “LAST Revisited,” Cover Page Table 1: Management of LAST Notably, Morwald et al. identified an overall rate for signs and symptoms consistent with LAST of CLINICAL FEATURES OF LOCAL ANESTHETIC TOXICITY 1.8/1000 peripheral nerve blocks during joint replacement; however, for the use of lipid emul- Risk Factors Prevention sion, considered a surrogate for LAST, in the • Hypoxia or acidosis • Use of lowest effective dose same population, they identified, for 2014, a rate • Extremes of age • Use of vascular marker (e.g., epi) during knee replacement of 2.6/1000 or 1 in 384 • Small patient size or muscle mass surgeries with a block.3 For a "rare event," that's • Adequate monitoring not so rare! This reminds us of the need to • Frailty • Incremental injection remain vigilant for the possibility of LAST in virtu- • Heart disease: • Intermittent aspiration ally any patient receiving local anesthetic. – Coronary artery disease, low cardiac out- • Individualized dosing put, arrhythmias, bundle branch blocks RISK • Mitochondrial dysfunction • System safety (e.g., preparedness) Understanding factors that increase risk is • Educating doctors and nurses vital, as identifying patients with an elevated sus- • Liver or kidney disease ceptibility to LAST enables clinicians to modify • Carnitine deficiency • Assessing patient risk factors treatment and reduce the risk. Hypoxia and aci- dosis were recognized decades ago as factors Presenting Symptoms and Signs predisposing to LAST.5 More recently identified co-morbidities include pre-existing heart disease Prodrome Major CNS Major CV (especially ischemia, arrhythmias, conduction • Tinnitus • Agitation/confusion • Bradycardia/heart block abnormalities, and low ejection fraction), extremes of age, frailty, and conditions that • Metallic taste • Obtundation • Hypotension cause mitochondrial dysfunction (e.g., carnitine • Hypertension • Seizure • Ventricular tachycardia or fibrillation deficiency); liver or kidney disease can also • Tachycardia • Coma increase the risk of delayed LAST by depressing • Asystole local anesthetic metabolism or disposition.5 Interestingly, Barrington and Kruger2 examined a Treatment of Local Anesthetic Systemic Toxicity registry of ~25,000 peripheral nerve blocks per- 1. Stop administering local anesthetic/call for help formed in Australia from January 2007 to May 2. Manage airway 2012 and identified 22 cases of LAST (overall incidence, 0.87 per 1000). They found that ultra- 3. Control seizures with benzodiazepine sound guidance lowered the risk of LAST (odds 4. CPR as needed ratio, 0.23, CI: 0.088–0.59, p=0.002)—presum- 5. 20% lipid emulsion 1.5 mL/kg (bolus given over 2–3 min) ably a result of fewer unidentified intravascular injections and possibly lower volumes of the Initial resuscitation of LAST differs from standard CPR by focusing on reversing underlying drug used to achieve a block. Nevertheless, no toxicity rather than or in addition to sustaining coronary perfusion. Hence, initial emphasis is on single method can completely eliminate these seizure suppression and establishing normal arterial oxygen saturation since both acidosis and events and roughly 16% of reported LAST hypoxia aggravate LAST. For severe LAST, contact a perfusion team early to assure a path to occurred despite the use of ultrasound. Bar- extracorporeal support should CPR fail. During CPR, avoid local anesthetic anti-arrhythmics (they rington and Kruger also noted that small patient worsen LAST), beta blockers and calcium channel blockers (they depress contractility), and vaso- size was a risk factor for LAST. The role of skele- pressin (increasing afterload alone is undesirable since the poisoned heart doesn’t contract well). tal muscle as a large reservoir compartment for Epinephrine is acceptable for treating hypotension but should be used in small doses since it can local anesthetic may explain this phenomenon impair lipid resuscitation, e.g., boluses <1 mcg/kg. Following the initial bolus of lipid emulsion and was confirmed in a rat model by Fettiplace given over 2–3 minutes, persistent LAST can be managed with repeated boluses and/or infusing et al.6 It is reasonable to adjust local anesthetic lipid (0.25 mL/kg/min until stable or 200–250 mL/15–20 min). MAX DOSE: 12 mL/kg, ideal body weight. Propofol is not a substitute for lipid emulsion. dose in all such “at-risk” patients or possibly avoid peripheral nerve block or local anesthetic 10 infusion entirely if the risk is deemed too conse- ber 2016). Data from these papers paints a pic- dorsal penile block. They adopted system quential. Surprisingly, Barrington and Kruger ture of the evolving context of LAST with the improvements in administering local anesthesia found 16 cases involving ropivacaine and the latter two specifically covering the past decade. that led to an abrupt cessation of these events. remainder were lidocaine-induced; notably, the Between 1979 and 2009, epidural anesthesia The reviews indicate LAST has also been LAST rate with lidocaine was approximately 5 and brachial plexus block each comprised described after continuous intravenous infusion; times greater than that for ropivacaine. around one-third of LAST cases. However, over paravertebral, peribulbar, transabdominis plane, the last decade, neuraxial (epidural and caudal) and maxillary nerve blocks; topical administra- SETTING anesthesia has contributed only about 15% of tion in gel form; and after oral, esophageal, or Three large-scale studies have reviewed published cases of LAST. Extremity blocks now tracheal mucosal application. A recent report published case reports to identify the clinical make up about 20% of cases, and there are sig- described cardiac arrest after submucosal nasal spectrum of LAST over the past 40 years: nals of concern related to both the penile block 11 DiGregorio et al.7 (Oct 1979–Oct 2009); and local infiltration, each accounting for roughly injection of 120 mg of lidocaine. Clearly, LAST Vasques et al.8 (March 2010–March 2014); and 20% of reported cases. Interestingly, one institu- can occur anytime local anesthetics are used. Gitman and Barrington9 (January 2014–Novem- tion reported a spike in LAST associated with See “LAST Revisited,” Next Page APSF NEWSLETTER February 2020 PAGE 6

LAST Can Have Delay in Onset

From “LAST Revisited,” Preceding Page Administration of non-bupivacaine local Roughly 80% of LAST cases over the past anesthetics within 20 minutes of Exparel, which can occur when a surgeon and an anesthesia decade occurred in hospitals, ~10% in offices, and the remainder in emergency rooms or professional fail to communicate, may cause a even at home. Anesthesia professionals or sudden release of liposomal bupivacaine, dan- trainees were involved in about 60% of cases, gerously increasing free plasma bupivacaine with surgeons involved in approximately 30%, concentrations; the exact mechanism of this and the remainder spread among dentists, phenomenon is not elucidated. Toxicity of the two local anesthetics is then additive. Burbridge emergency physicians, pediatricians, cardiolo- 13 gists, and dermatologists. This reminds us of and Jaffe emphasize the importance of safety the need to take every opportunity to educate measures such as educating the operating our colleagues about the risks and manage- room staff as well as a “time-out” label on the ment of LAST. drug vial to prompt discussion around avoiding simultaneous administration of other local anes- TIMING thetics within 20 minutes of Exparel injection. The three large-scale studies show a trend to The FDA Adverse Event Reporting System progressive delay in the onset of LAST over the (FAERS) database contains reports submitted past 40 years, reflecting the advent of both increase in LAST secondary to absorption or by practitioners and consumers. An analysis of ultrasound guidance and catheter-based tech- gradual onset during infusion. The most FAERS data received between January 1, 2012, niques. Competent use of ultrasound can common presenting features of CV toxicity and March 31, 2019, where Exparel was listed reduce the chance of intravascular injection and were arrhythmias (including bradycardia, as the suspect medicinal product and signs or immediate-onset LAST. Delays of more than 10 tachycardia, VT/VF), conduction disturbances symptoms of LAST occurred (seizure or both CNS symptoms and CV disturbance), were minutes in single-shot blocks occurred in only (bundle branch block, AV conduction block, studied by disproportionality analysis—a phar- ~12% of cases before 2009 but in ~40% of widened QRS), hypotension, and cardiac arrest macovigilance tool that measures the “Informa- those published in the last decade. Recent (including nonshockable rhythms, PEA, and reports describe LAST with an onset that is tem- tion Component” (IC025) and is used by the asystole). Progressive toxicity (especially hypo- World Health Organization.14 This compares the porally removed from the start of treatment by tension and bradycardia) with rapid deteriora- rate at which a particular event of interest co- several hours or even days for catheter or intra- tion over minutes is typical of severe LAST. It is occurs with a given drug versus the rate this venous infusion. This presumably occurs as the impossible to predict which patients will prog- event occurs without the drug in the event data- result of drug accumulation in target tissues and ress. However, early treatment can delay or pre- base. If the lower limit of the 95% confidence is a particular concern since both the timing and vent progression; therefore, it is important to be interval of the IC025 is greater than zero, then setting are problematic. The long interval can prepared to intervene early in any patient there is a statistically significant signal. Such an obscure the connection to local anesthetic receiving local anesthetic who has signs or adverse event signal was found between LAST administration; moreover, when LAST occurs symptoms consistent with LAST. and liposomal bupivacaine. From January 1, “off-site,” away from the operating rooms, 2012, to March 31, 2019, the analysis yielded an where it is rarely seen, the responsible caregiv- LIPOSOMAL FORMULATION overall IC025 of 1.65. Splitting the dataset into ers are probably less mindful or knowledgeable Liposomal bupivacaine (LB) harbors local two time periods (January 2012 to December of the problem, its detection, and treatment. anesthetic in a nanoparticle carrier matrix 2015 and January 2016 to March 2019) showed designed to prolong its action by slow release. persistence of a significant signal in both time PRESENTATION Exparel® (Pacira Pharmaceuticals, San Diego, periods. While this does not prove a causal rela- LAST provokes a variable array of signs and CA) comes in a 20-mL vial containing a total of tionship, it nevertheless points to a statistically symptoms of central nervous system (CNS) and 266 mg (1.3%) bupivacaine, which is the manu- significant signal between Exparel and signs or cardiovascular (CV) toxicity (Table 1). These can facturer’s maximum recommended dose for an symptoms of LAST. be mild or severe and can occur separately or adult patient. It was approved by the Food and together. Isolated CNS symptoms occur in Drug Administration (FDA) in 2011 for injection REPORTING OF LAST IS PROBLEMATIC approximately half of reported cases, combined directly into the operative site to augment post- A recent Cochrane Library update of periop- CNS and CV symptoms in about one-third and operative analgesia and later in 2018 for inter- erative intravenous lidocaine infusion by Weibel 15 isolated CV symptoms in the remainder. Many scalene brachial plexus block.12 Three percent et al. found that of 68 clinical trials comparing of the latter occurred under general anesthesia of the drug is free and presumably initiates a lidocaine infusion with thoracic epidural analge- or heavy sedation where CNS toxicity is difficult certain level of analgesia upon administration. sia, 18 did not comment on adverse events at all. to ascertain. Seizure was the most common ini- Blood levels of bupivacaine can last up to 96 Unfortunately, the degree of heterogeneity in the tial sign overall, occurring in roughly 50% of hours after injection of LB; therefore, patients reporting methods of the remaining 50 studies cases. Minor CNS features or “prodromes” must be adequately monitored for delayed tox- precluded a meta-analysis of these data. There is such as tinnitus, metallic taste, hallucinations, icity. As with any local anesthetic, patients with clearly a need to improve and standardize ascer- slurred speech, limb twitching, extremity pares- specific co-morbidities are at an increased risk tainment and reporting of LAST in clinical trials thesia, intention tremor, facial sensorimotor, and for developing acute or delayed toxicity, either involving local anesthetics. This applies particu- eye movement abnormalities were noted in as a result of increased sensitivity (e.g., isch- larly to studies of catheter and intravenous infu- only about 16% of patients by DiGregorio et al., emic heart disease) or impaired metabolism sions where systems for identifying LAST are not but about 30% in combined data from Vasques (e.g., liver disease) with resulting increased as robust as in the operating room. Until this et al. and Gitman et al.; this is consistent with an plasma levels of bupivacaine. See “LAST Revisited,” Next Page APSF NEWSLETTER February 2020 PAGE 7

Treating LAST Involves Administering Large Quantities of Lipid Emulsion Quickly From “LAST Revisited,” Preceding Page perfusion team at the outset of a severe event so REFERENCES occurs, understanding the associated risks will that alternative, extracorporeal methods of circu- 1. Liu SS, Ortolan S, Sandoval MV, et al. Cardiac arrest and remain hampered by reliance on anecdotal latory support can be readied should initial seizures caused by local anesthetic systemic toxicity after resuscitation fail. peripheral nerve blocks: should we still fear the reaper? reports and personal experience. Reg Anesth Pain Med. 2016;41:5–21. 2. Barrington MJ, Kluger R. Ultrasound guidance reduces the TREATMENT CONCLUSIONS LAST can occur anytime local anesthetics are risk of local anesthetic systemic toxicity following peripheral In 2010 the Association of Anaesthetists of nerve blockade. Reg Anesth Pain Med. 2013;38:289–97. used. Even with appropriate dosing and perfect Great Britain and Ireland (AAGBI) and the Amer- 3. Morwald EE, Zubizarreta N, Cozowicz C, et al. Incidence of ican Society of Regional and Pain Medicine technique, patient susceptibility, system prob- local anesthetic systemic toxicity in orthopedic patients (ASRA) Working Group on Local Anesthetic Tox- lems, and random errors prevent its eradication. receiving peripheral nerve blocks. Reg Anesth Pain Med. icity separately published first-ever recommen- The increasing use of regional anesthesia in an 2017;42:442–445. agng population, and the advent of catheter 4. Rubin DS, Matsumoto MM, Weinberg G, et al. Local anes- dations for a systematic approach to treating thetic systemic toxicity in total joint arthroplasty: incidence 16 and intravenous infusion of local anesthetic for LAST. Both groups focused on airway man- and risk factors in the United States from the national inpa- agement and seizure suppression along with opiate-sparing anesthesia, multimodal analge- tient sample 1998–2013. Reg Anesth Pain Med. 2018; the rapid infusion of lipid emulsion as key ele- sia, or cancer risk modification assure that LAST 43:131–137. 5. Neal JM, Barrington MJ, Fettiplace MR, et al. The third ments specific to treating LAST (Table 1). will continue to occur increasingly at unex- pected sites and with delayed timing despite American Society of Regional Anesthesia and Pain Medi- Interestingly, the rate of published reports cine practice advisory on local anesthetic systemic toxicity: our best efforts. Identifying “at-risk” patients increased from ~3 LAST cases per year before executive summary 2017. Reg Anesth Pain Med. and improving system safety will reduce the 2018;43:113–123. 2009 to 16/year in the last decade. If reporting ~ likelihood of LAST. 6. Fettiplace MR, Lis K, Ripper R, et al. Multi-modal contribu- bias is constant, this could reflect greater will- tions to detoxification of acute pharmacotoxicity by a triglyc- ingness to report events as patient outcomes Clinicians should have a treatment plan eride micro-emulsion. J Control Release. 2015;198:62–70. improved over the past decade. ASRA has ready for LAST wherever local anesthetics are 7. Di Gregorio G, Neal JM, Rosenquist RW, et al. Clinical pre- updated their advisory twice since 2010 with used. Any unusual CNS signs or CV instability in sentation of local anesthetic systemic toxicity: a review of published cases, 1979 to 2009. Reg Anesth Pain Med. modifications that include the adoption of a the setting of regional anesthesia, anesthetic 2010;35:181–187. checklist approach and a simpler method for infiltration, or infusion should be considered 8. Vasques F, Behr AU, Weinberg G, et al. A review of local infusing lipid emulsion.5 Two key points possible LAST until proven otherwise, since anesthetic systemic toxicity cases since publication of the early intervention can prevent or slow progres- American Society of Regional Anesthesia recommenda- deserve mention. First, mechanism informs tions: to whom it may concern. Reg Anesth Pain Med. method. Infusing lipid emulsion reverses LAST sion. Anesthesia professionals must actively 2015;40: 698–705. by accelerating the redistribution of local anes- educate other health care providers who 9. Gitman M, Barrington MJ. Local anesthetic systemic toxicity: thetic.6 This results from partitioning and a direct administer local anesthetics to patients. This a review of recent case reports and registries. Reg Anesth Pain Med. 2018;43:124–130. inotropic effect exerted by lipid emulsion17 that includes informing those in other specialties 10. Yu RN, Houck CS, Casta A, et al. Institutional policy changes combine to “shuttle” drug away from sensitive having a syringe in hand and staff on the floor to prevent cardiac toxicity associated with bupivacaine organs (brain, heart) to reservoir organs (skeletal responsible for care of patients receiving local penile blockade in infants. A A Case Rep. 2016;7:71–75. muscle, liver). This requires infusing a relatively anesthetic infusion. Improved models of LAST 11. Weber F, Guha R, Weinberg G, et al. Prolonged pulseless electrical activity cardiac arrest after intranasal injection of large quantity of lipid quickly (e.g., ~1.5 mL/kg and its treatment will continue to inform mea- sures we can adopt to improve patient safety lidocaine with epinephrine: a case report. A A Pract. 2019; over ~2 minutes) to establish a lipid “bulk phase” 12:438–440. in the plasma. The bolus infusion may be and save lives. 12. Balocco AL, Van Zundert PGE, Gan SS, et al. Extended repeated or followed by an infusion at a slower Dr. Weinberg is a professor of Anesthesiology at release bupivacaine formulations for postoperative analge- sia: an update. Curr Opin Anaesthesiol. 2018;31:636–642. rate—the difference in method is likely not as the University of Illinois College of Medicine at 13. Burbridge M, Jaffe RA. Exparel®: a new local anesthetic with important as the need to sustain a bulk phase. Chicago and staff physician at the Jesse Brown special safety concerns. Anesth Analg. 2015;121:1113–1114. 18 An important study by Liu et al. showed in a rat VA Medical Center, Chicago, IL. 14. Aggarwal N. Local anesthetics systemic toxicity association model of bupivacaine toxicity that repeated with Exparel® (bupivacaine liposome)—a pharmacovigi- Dr. Rupnik is a consultant anesthetist at the Bal- bolus dosing is superior to bolus + infusion in lance evaluation. Expert Opin Drug Saf. 2018;17:581–587. grist University Hospital, Zurich, Switzerland. 15. Weibel S, Jelting Y, Pace NL, et al. Continuous intravenous reversing LAST. However one chooses to deliver perioperative lidocaine infusion for postoperative pain and lipid, it is important to respect the upper dosing Dr. Aggarwal is a hospital resident at Yale New recovery in adults. Cochrane Database Syst Rev. 2018;6: limit of ~10–12 mL/kg ideal body weight to avoid Haven hospital, New Haven, Connecticut.. CD009642. fat overload. That is, don’t forget to turn it off! 16. Weinberg GL. Treatment of local anesthetic systemic toxic- Dr. Fettiplace is a resident in Anesthesiology at ity (LAST). Reg Anesth Pain Med. 2010;35:188–93. Second, the treatment strategy for CV instability Massachusetts General Hospital, Boston, MA. 17. Fettiplace MR, Ripper R, Lis K, et al. Rapid cardiotonic in LAST differs from that used for ischemic car- effects of lipid emulsion infusion.* Crit Care Med. 2013;41: diac arrest since the underlying pathophysiology Dr. Gitman is an assistant professor of Anesthe- e156–162. of ischemia and pharmaco-toxicity differ. There- siology at the University of Illinois College of 18. Liu L, Jin Z, Cai X, et al. Comparative regimens of lipid fore, it is preferable to treat the underlying toxicity Medicine, Chicago, IL. rescue from bupivacaine-induced asystole in a rat model. Anesth Analg. 2019;128:256–263. by infusing lipid and, if needed, use reduced Dr. Weinberg is an officer and shareholder of 19. Weinberg GL, Di Gregorio G, Ripper R, et al. Resuscitation doses of epinephrine (boluses 1 mcg/kg) to sup- ~ ResQ Pharma, Inc., and maintains the educa- with lipid versus epinephrine in a rat model of bupivacaine port blood pressure.­19 Vasopressin should be overdose. Anesthesiology. 2008;108: 907–913. tional website, www.lipidrescue.org. Drs. avoided since increasing afterload alone has no 20. Di Gregorio G, Schwartz D, Ripper R, et al. Lipid emulsion is Rupnik, Aggarwal, Fettiplace, and Gitman have superior to vasopressin in a rodent model of resuscitation benefit and a deleterious effect has been con- no conflicts of interest. from toxin-induced cardiac arrest. Crit Care Med. 2009;37: firmed in animal models.20 It is sensible to alert a 993–999. APSF NEWSLETTER February 2020 PAGE 8

Healthy Relationships Between Anesthesia Professionals and Surgeons Are Vital to Patient Safety by Jeffrey B. Cooper, PhD

Effective teamwork in perioperative teams is a prerequisite for patient safety. Yet, what is rarely discussed openly is the special importance of dyads in teams—the relationship between two individuals. If you’re an anesthesia professional, you likely are aware, at least subliminally, of the erosion of patient safety when you are working with a surgical colleague with whom your rela- tionship is not a pleasant one. At the least, it can make for an unpleasant workday experience; at worst, a dysfunctional relationship can be a criti- cal element that enables or causes an adverse outcome. On the flip side, when one is working with a trusted, respected colleague and the feel- ing is mutual, you are much more likely to have a happy day and your patient is more likely to have an optimal outcome.1* I addressed this topic in a commentary published simultaneously in Anes- have been prevented by a positive relationship. Considering how important it is that surgeons thesiology and The Journal of the American Col- More importantly, I’d heard one too many disre- and anesthesiologists work collaboratively, it is lege of Surgeons (an unusual occurrence) and spectful remarks that represented stereotypes surprising that there is little research about this more recently, in my presentation for the annual that anesthesia professionals have about sur- topic, almost none specifically about the anes- Ellison C. Pierce, Jr., MD, Lecture hosted by the geons. I don’t have as much opportunity to hear thesiologist-surgeon dyad. Lorelei Lingard and 2,3 APSF and the ASA. I summarize here key similar comments from surgeons, but when I’ve colleagues have, in several studies, examined observations and suggestions for action. probed, I have found similar stereotypes there situations where the discourse within the peri- as well. While the stereotypes and disrespectful In the presentation and the article, I focus on operative team revolves around conflict.4 One remarks are not in themselves potentially harm- the dyad between the physicians in the team, comment arising from those studies is that ful to patients, the attitudes they represent can anesthesiologists and surgeons. I do note that “Subjects’ constructions of other professions’ lead to communication failures and lack of col- the other dyads are also of high importance to roles, values, and motivations were often dis- laboration and collegiality that can either cause, patient safety, i.e., that between surgeon and enable, or fail to prevent an adverse event. sonant with those professions’ constructions of OR nurse and between surgeon and any anes- themselves.” Related to that comment is the thesia professional. Yet, my gut tells me that Some of the specific negative stereotypes observation that “Team members use assump- there are aspects of the physician dyad that are listed in Table 1. These come from years of tions about speaker motivation to interpret listening as well as my seeking input from sur- create the potential for particularly problematic communicative exchanges.” dysfunction; that is my current focus (maybe I’ll geon and anesthesiologist colleagues, near get to the others soon). Why did I choose to and far, with both private practice and academic Jonathan Katz has specifically addressed focus attention on this topic? Over the years (47 experiences. Again, I have no data on which to conflict in the OR.5 He notes that “cancellation… plus since I began working in health care), in provide concrete evidence, but no one I’ve pre- for additional evaluation… is among the most various quarters, I’d heard one too many anec- sented this to has challenged any of the com- frequent causes of conflict between surgeon dotes about adverse events that were either ments nor pushed back on my assertion that and anesthesiologist.” He also notes that caused by relationship dysfunction or could this is too prevalent and not healthy. sources of conflict present an opportunity for *If you want to organize a focus group or presentation, I can send you a link to the animations I used during the collaboration. A goal should be to turn all such lecture, including a shortened version of “There is a Fracture.” (You can find the original on Youtube.) The other two opportunities into productive collaboration in animations are of the view surgeons have of anesthesiologists and of what a healthy collaboration would look like.” (No charge. You just have to promise to use them for good.) the interest of the patient, seeking to learn what is right, not who is right. Table 1: Negative stereotyping Diana McLain Smith writes about how func- Examples of anesthesia professionals’ Examples of surgeons’ stereotypes tional and dysfunctional dyads in leadership stereotypes of surgeons: of anesthesia professionals: teams are critical to either success or failure in • They never admit how much blood they’ve • They just want to go home early—don’t care organizations.6 The characteristics and out- lost. about my patient. comes she describes are clearly applicable to • They just want to make a lot of money doing • They are ready to cancel a case at the drop perioperative care and to the leadership team more cases. of a hat. in the OR. What is different about this construct • They don’t know anything about medical • They’re often distracted, not paying attention. from the usual discussion about teams is that issues. the focus is on relationships between two indi- • They never tell us about the pressors they’re • They always underestimate how long the using. viduals rather than on the team as a whole. case will be. See “Healthy Relationships,” Next Page APSF NEWSLETTER February 2020 PAGE 9

Building Healthy Perioperative Relationships

From “Healthy Relationships,” Preceding Page practical; yet, taking the first step isn’t easy. In relationships, e.g., “Difficult Conversations,”9 Both are important. What I'm suggesting is that most relationships needing improvement, or “Thanks for the Feedback.”10 Relationships relationships between individuals are equally, if each party needs to “buy in.” You might think, are hard. There’s a lot to learn. Fortunately, not more important, to understand and improve. “it’s not mostly my fault; it’s the surgeons who there are lots of good models to learn from. need to behave better.” I’m not judging who is What are specific ways that the interactions more at fault when things aren’t going well. I’m not promising you a rosy world if you in this dyad impact patient safety for better or But I can say for sure that nothing will get work at this. But I think it’s worth your time for worse? I've heard many stories in my almost 35 better if at least one person doesn’t try to start your patients’ safety to try as much as you can. year's experience as a member of a quality a constructive dialogue. Doing nothing will mean nothing will change. If assurance review committee and via many Here’s some suggestions, any one of which your efforts succeed, you’ll have made a huge vignettes told to me as I’ve probed more into advance for patient safety, and you're likely to this topic. Consider an anesthesiologist, who you could consider trying (I didn’t make these all up. Many of your colleagues already do find more joy and meaning in your professional even though junior, may be more expert than some of these. You can think of your own too): daily life. the surgeon in physiology, and who tried to communicate to the surgeons that their diagno- 1. Take a surgeon to lunch or dinner. (this is an Dr. Cooper is professor of Anaesthesia, Harvard sis did not comport with the data. Not having an especially productive thing to do when a new Medical School and the Department of Anaesthe- established, trusting relationship with the sur- surgeon joins your hospital) sia, Critical Care and Pain Medicine, Massachu- geon, the surgeon disregarded his sugges- 2. Form a focus group to discuss one of the setts General Hospital. He is a founder of the tions. When the anesthesiologist was right, the articles in the references. Listen more than APSF, retiring from the Board of Directors and patient outcome was much worse than it might you talk. Seek to understand why behaviors Executive Committee in 2018 after 32 years of ser- have been if the surgeon collaborated with him. you observe may come from different vice. This article is a summary of a portion of his Or the anesthesiologist who, despite the sur- sources than you imagine.* lecture for the Ellison C. Pierce, Jr., MD, Memorial geon’s extensive experience in performing cri- Lecture at the American Society of Anesthesiolo- cothyrotomy, disregarded the surgeon’s 3. Work together on common issues, e.g., low- suggestion that it was time to move the difficult- ering the risk of surgical infection, which gists Annual Meeting, October 19, 2019. airway algorithm along and the situation dan- anesthesia professionals might contribute to; Dr. Cooper reports no conflicts of interest. gerously went downhill. These were true stories implement emergency manuals together. , as in the “basic that are likely familiar to you. 4. Assume the best intentions REFERENCES assumption”7 now widely taught in simulation There is the flip side: I heard independently 1. Katz D, Blasius K, Isaak R, et al. Exposure to incivility hinders and modified for this application as: “my sur- from an anesthesiologist and surgeon about a clinical performance in a simulated operative crisis. BMJ gical colleagues are intelligent, doing things Qual Saf. 2019;28:750–757. situation where their prior trusting relationship in the best interest of their patients, and 2. Cooper JB. The critical role of the anesthesiologist-surgeon was clearly an enabler for success. A needle trying to improve.” It’s not always so, but it relationship for patient safety. Anesthesiology. 2018; with a pop-off suture had separated prema- 129:402–405. (Pub ahead of print) (co-publication in J Amer mostly is. turely. The surgeons, unable to locate the Coll Surg. 2018;227:382–86) http://anesthesiology.pubs. asahq.org/article.aspx?articleid=2695026 needle, were fixated deep in the wound seek- 5. When someone does something that makes 3. Cooper JB. Respectful, trusting relationships are essential ing to find it. The anesthesiologist, watching the you think “WTF,” the “F” should stand for for patient safety, especially the surgeon-anesthesiologist struggle, waited for an appropriate moment to “frame.”8 Instead of attributing a negative ste- dyad. Ellison C. Pierce, Jr. Memorial Lecture. Annual Meet- suggest a brief regrouping and consideration of reotype, be curious, seek to find out what the ing of the American Society of Anesthesiologists, October 19, 2019. Accessed November 11, 2019. https://www.apsf. options. That led to the use of fluoroscopy to rationale behind the action is. You are likely org/news-updates/watch-jeffrey-b-cooper-ph-d-give-the- find the needle. I’ve heard of situations as well to learn something new; even if what the anesthesiology-2019-asa-apsf-ellison-c-pierce-memorial- where a surgeon gave his or her anesthesia person is doing isn’t optimal or right, it’s usu- lecture/ colleague a heads-up the day before, or earlier, ally for a good reason. If there's not a good 4. Lingard L, Reznick R, DeVito I, et al. Forming professional reason, you’ll have an easier time getting identities on the health care team: discursive constructions about a patient issue with anesthesia-related of the “other” in the operating room. Med Educ. implications that averted a patient safety issue. I them to see things differently versus just 2002;36:728–734. suspect that most anesthesiologists reading assuming they are irrational. 5. Katz JD. Conflict and its resolution in the OR. J Clin Anes. 2007;19:152–158. this have had similar experiences. Indeed, 6. Train together in simulation with the entire 6. McLain Smith D. The elephant in the room. San Francisco: some of you are fortunate enough to have reg- team. It’s a proven way to improve the team’s Jossey-Bass; 2011. ular experiences of this latter type rather than crisis management skills. In addition, it puts 7. Rudolph J. What’s up with the basic assumption. https://har- the former. Every patient should be so lucky. you in a position to have dialogue at an equal vardmedsim.org/search-results/?swpquery=basic+assump tion Accessed November 11, 2019. If what I’m describing rings true for you, level. More simulation programs are doing this. You could even take the lead and sug- 8. Rudolph J. Helping without harming. SMACC, Berlin, June what can be done to make this dyad function 26, 2017. https://www.youtube.com/watch?v=eS2aC_ more routinely effective? I’m not aware of gest a team try it out. Sure, it costs money yyORM Accessed October 29, 2019. empirical evidence to guide suggestions, but and takes a lot to organize (just getting the 9. Stone D, Patton B, Heen S. Difficult conversations: how to discuss what matters most. Penguin Books, Ltd., London, there are some general principles about rela- people there is tough), but it’ll pay off in lots of ways. 1999. tionship-building that can apply. I’ve sug- 10. Stone D, Heen S. Thanks for the feedback. Penguin Books, gested in the article a few things that are 7. Read a book about communicating across New York, 2014. RAPID Response TO YOUR IMPORTANT QUESTIONS

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to questions from readers Airway Emergencies and Safety to questions from readers in Magnetic Resonance Imaging (MRI) Suite by Heather McClung MD, and Rajeev Subramanyam MBBS, MD, MS, FASA N

Dear Rapid Response, is being provided. Further, the process for The most recent ASA Practice Advisory on airway rescue during emergencies in the MRI anesthesia care in MRI provides useful guid- Are MRI-compatible laryngoscopes scanner needs to be clearly defined. ance for preparing to manage airway emer- recommended or required in the MRI 4 RAPID RAPID R APIDR RESPONSE APIDRESPONSE RESPONSE RESPONSE Providing safe care in the MRI arena requires a gencies in MRI. During an airway emergency, environment? anesthesia professionals and other health care to your important questions Nthorough understanding of the environment and I am an anesthesiologist presently working potential hazards to patients and staff. The MRI providers must be prepared to enter Zone IV in a community hospital and care for patients environment is conceptually divided into four quickly. Though not listing specific devices, the who receive anesthesia as part of their MRI Zones designated I through IV. Zone III is typi- advisory states that “Alternative MRI safe/con- exam. We have conventional laryngoscopes cally reserved for MRI personnel and public ditional airway devices should be immediately 4 and blades available in MRI zone III and an access is restricted. The control room is in Zone available in the MRI suite.” Given the sense of MRI-compatible anesthesia machine in zone III. Zone IV is the MRI scanner magnet room.3 urgency, personnel must recheck themselves IV. If we need to intubate a patient, the expec- The MRI magnetic field is invisible, always on, for presence of ferromagnetic objects and tation is that we can move the patient to zone and can affect ferromagnetic equipment of any equipment prior to entering the scanner. To III for intubation and return to zone IV to com- size in Zone IV, potentially converting it to a pro- avoid confusion and the risks of MR-unsafe pleteR theAPID study.R APIDI believeR APID R weR shouldESPONSE APIDR purchaseESPONSE R ESPONSE jectileR thatESPONSE is drawn into the scanner with a devices inadvertently getting into Zone IV, MRI-conditional laryngoscopes and blades to strength and speed that can be deadly. Not only airway equipment immediately available to the beto available your inimportant zone III, but am questions told it is not can patients be injured or killed, but damage to team in Zone III should be MR-conditional for essential and many other institutions do not the scanner results in temporary closure and ser- all scanners in the location. If it is safe, the have MRI-compatible laryngoscopes. vicing or a costly and dangerous magnet airway should be supported with bag mask quench. The unique safety concern of the mag- ventilation while the patient is removed from Please let me know your thoughts on this netic field has significant impact on the care of patient safety question. Zone IV to a nearby location in Zone III or Zone patients presenting for anesthesia in MRI, and II where a full complement of airway and resus- Regards, can become particularly challenging during an citation equipment can be used and emer- Dheeraj Nagpal, MD airway or medical emergency. gency personnel summoned for help. If Dr. Nagpal is an attending anesthesiologist at Very few airway devices have been specifi- securing the airway is deemed emergent in the New York Presbyterian Queens, Flushing, NY. cally designed for safe use in MRI. Medical scanner (e.g., profound vomiting with risk of devices and equipment that might be used in aspiration, inability to ventilate, etc.), it can be Dr. Nagpal has no conflicts of interest. the MR environments should be labelled as MR done only if MR-safe and -conditional equip- unsafe, MR conditional, or MR safe (Figure 1). ment is available. If MR-safe and -conditional Reply: Laryngeal mask airways and endotracheal equipment is not available, the patient must be tubes contain small amounts of ferromagnetic moved out of Zone IV risking the complications This is an important question to address since material in the pilot balloon, but are considered of hypoxia. In any situation, medical emergen- modern anesthesia practice must meet the MR conditional as they will not cause patient cies are difficult to manage in Zone IV, and the present and growing demand to provide harm but may affect image quality. These patient should be brought out of Zone IV as anesthesia care to adults and children who airway devices have been used safely along soon as feasible. Until the patient is safe or 1 require MRI. Further, the American Society of with plastic oropharyngeal airways and bag removed from Zone IV, at least one person Anesthesiologists (ASA) closed claims project mask ventilation units. Classic metal laryngo- should be designated to police the heightened evaluated the risk and safety of anesthesia in scopes are considered unsafe as malfunction traffic entering Zone IV during an emergency. remote locations and found that claims for with sudden failure to operate can occur in On some newer MRI machines, the MRI table death and specifically respiratory damaging Zone IV and nickel in the laryngoscope battery can be undocked from the magnet to move 4 events were more common in remote is ferromagnetic. Although expensive, single- the patient from Zone IV and minimize the loss locations, most often during monitored use and reusable MRI-conditional devices are of precious time. anesthesia care. In addition, the majority of available.5 The quality of disposable laryngo- radiology claims were in MRI (7/10) and four of scopes is variable but there are products avail- There is considerable variation in the physi- those claims were related to oversedation.2 able which are MRI-conditional and can be cal layout, need for sedation, types of MRI pro- Given the unique patient safety concerns in the trialed to confirm that they are clinically accept- cedures, and sedation services across the MRI environment, we believe laryngoscopes able. Whether single-use or reusable, MRI-con- globe, and hence, there is no standard way to that are safe to use in the MRI environment ditional laryngoscopes can be brought into provide anesthesia or sedation care in MRI. should be available whenever anesthesia care Zone IV safely. See “Airway Emergencies,” Next Page

The information provided is for safety-related educational purposes only, and does not constitute medical or legal advice. Individual or group responses are only commentary, provided for purposes of education or discussion, and are neither statements of advice nor the opinions of APSF. It is not the intention of APSF to provide specific medical or legal advice or to endorse any specific views or recommendations in response to the inquiries posted. In no event shall APSF be responsible or liable, directly or indirectly, for any damage or loss caused or alleged to be caused by or in connection with the reliance on any such information. RAPID Response TO YOUR IMPORTANT QUESTIONS

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APSF NEWSLETTER February 2020 PAGE 11

Airway Emergencies and Safety in Magnetic to questions from readers Resonance Imaging (MRI) Suite, Cont'd.

From “Airway Emergencies,” Preceding Page Airway emergency response in MRI may look somewhat differentN in each hospital. Key components of a comprehensive plan for safe emergency care in MRI involves partnering with the radiology department to determine the safety of equipment available for use in ZoneAPID IV,APID and APID a resuscitativeESPONSE APIDESPONSE ESPONSE areaESPONSE outside of, but Rnot farR fromR ZoneRRR IV. TheR StandardR Operating to your important questions Procedures and Hospital Policy for managing emergencies in MRI should be revisited as new guidelines emerge or demands for anes- thesia services in MRI change. Simulations can help to insure the entire team can safely manage patient emergencies in Zone IV. Routine availability of MR-safe-conditional laryngoscopes and other airway equipment in the MR environment will avoid inadvertent entry of MR-unsafe devices into Zone IV. This may involve purchasing additional equipment to maintain safety in the MRI environment. Injury to patients, staff, or MRI scanners is both unacceptable and expensive. As anesthesia care and complexity of patients continues to increase in the MRI suite, it is necessary to maintain vigilance for the distinct hazards pres- ent in the MR environment and create systems that protect our patients and staff from tragic but preventable accidents. MRIs cannot be easily shut down, and “quench” is an expen- sive and potentially dangerous operation. Con- sistent safety standards should be followed in all non-operating room locations, intraopera- tive MRI scanners or free-standing radiologic centers where anesthesia is provided. MRI safety is both an institutional and an individual responsibility. Figure 1: United States Food and Drug Administration. Understanding MRI Safety Labelling. https://www.fda.gov/ Dr. McClung is an assistant professor in the media/101221/download Accessed on Dec 7, 2019. Department of Anesthesiology and Critical Care Medicine, Children’s Hospital of Philadel- phia, Perelman School of Medicine, University REFERENCES of Pennsylvania, Philadelphia, PA. 1. United States Food and Drug Administration. Magnetic 4. The Joint Commission, Sentinel Event Alert: Preventing resonance imaging (MRI) safety and effectiveness. accidents and injuries in the MRI suite. Issue 38, Feb 14, Dr. Subramanyam is an associate professor in https://www.fda.gov/medical-devices/cdrh-research- 2008. https://www.jointcommission.org/assets/1/18/ programs/magnetic-resonance-imaging-mri-safety- SEA_38.PDF. Accessed November 17, 2019. the Department of Anesthesiology and Critical and-effectiveness Accessed November 17, 2019. 5. mrisafety.com. Accessed November 17, 2019. Care Medicine, Children’s Hospital of Philadel- 2. Metzner J, Posner KL, Domino KB. The risk and safety phia, Perelman School of Medicine, University of anesthesia at remote locations: the US closed 6. Practice advisory on anesthetic care for magnetic reso- of Pennsylvania, Philadelphia, PA. claims analysis. Curr Opin Anesth. 2009;22:502–508. nance imaging: an updated report by the American 3. Kanal E, Barkovich JA, Bell C, et al. Expert panel on MR Society of Anesthesiologists task force on anesthetic care for magnetic resonance imaging. Anesthesiology. The authors have no conflicts of interest. safety: ACR guidance document on MR safe practices: 2013. J Magn Reson Imaging. 2013;37:501–530. 2015;122:495–520.

The information provided is for safety-related educational purposes only, and does not constitute medical or legal advice. Individual or group responses are only commentary, provided for purposes of education or discussion, and are neither statements of advice nor the opinions of APSF. It is not the intention of APSF to provide specific medical or legal advice or to endorse any specific views or recommendations in response to the inquiries posted. In no event shall APSF be responsible or liable, directly or indirectly, for any damage or loss caused or alleged to be caused by or in connection with the reliance on any such information. APSF NEWSLETTER February 2020 PAGE 12

APSF Awards 2020 Grant Recipients by Steven K. Howard, MD

The APSF’s Investigator-Initiated Research 1 in 10 patients die and 1 in 3 experience compli- APSF/ASA Presidents’ Research Award. Dr. Program supports the Mission Statement that cations.1,2 Thus, preventing exposure to trigger- Riazi is also the recipient of the Ellison C. “Jeep” includes the goal to continually improve the ing anesthetics is crucial in patients who are Pierce, Jr., MD, Merit Award, which provides an safety of patients during anesthesia care by susceptible to MH. However, screening patients additional, unrestricted amount of $5,000. encouraging and conducting safety research for MH remains challenging as genetic testing REFERENCES and education. The APSF has funded over 9 identifies only half of all susceptible individuals.2 1. Larach MG, Gronert GA, Allen GC, et al. Clinical presenta- million dollars on patient safety research since The current standard diagnostic test for MH sus- tion, treatment, and complications of malignant hyperther- 1987 to help achieve these goals. This year’s ceptibility—the caffeine-halothane contracture mia in North America from 1987 to 2006. Anesth Analg. 2010;110:498–507. grants get at the heart of two long-standing test (CHCT)—is sensitive (97–100%) but invasive 2. Riazi S, Kraeva N, Hopkins PM. Malignant Hyperthermia in anesthesia-related safety issues: malignant and costly. Furthermore, it requires travel to one the postgenomic era: new perspective on an old concept. hyperthermia and evaluation of the airway. of the few specialized centers worldwide Anesthesiology. 2018;128:168–180. because the test must be completed within 5 3. Jones PM, Allen BN, Cherry RA, et al. Association between The 2019–20 APSF Investigator-Initiated hours after the muscle biopsy. Therefore, only known or strongly suspected malignant hyperthermia sus- Research Grant Program received 27 letters of ceptibility and postoperative outcomes: an observational about 4% of those with suspected MH suscepti- Can J Anaesth intent submitted in early February 2019. After a population-based study. . 2019;66:161–181. bility undergo the standard diagnostic test.3 4. Oku S, Mukaida K, Nosaka S, et al. Comparison of the in thorough evaluation, five teams were invited to vitro caffeine-halothane contracture test with the Ca- submit full proposals. On October 19, the Scien- The calcium-induced calcium release (CICR) induced Ca release rate test in patients suspected of test is an alternative, less-invasive means to having malignant hyperthermia susceptibility. J Anesth. tific Evaluation Committee met in Orlando, FL, 2000;14:6–13. during the American Society of Anesthesiolo- diagnose MH susceptibility. Unlike the CHCT, gists national meeting to make funding recom- the CICR test requires a small muscle sample mendations to the APSF Board of Directors. that could be harvested in a physician’s office Two recommendations were reviewed and and shipped for analysis at a specialized testing subsequently accepted. center up to 72 hours after the biopsy. In addi- tion to these advantages, the CICR test is the The principal investigators of this year’s APSF standard for MH susceptibility diagnosis in grant provided the following description of their Japan, despite lacking rigorous validation proposed work. against the standard CHCT.4 Our MH testing center is currently the only site worldwide with the expertise to conduct both the CHCT and the CICR test, placing our research team in an advantageous position. We therefore propose a single-center, prospective cohort study to validate the alternative CICR test against the standard CHCT by performing both tests simul- taneously in samples from every patient referred to our center. Aims: Our overall goal is to demonstrate that Scott Segal, MD the alternative CICR test is a suitable replace- ment for the standard CHCT for diagnosing MH Thomas H. Irving Professor and Chair, susceptibility. Given the advantages of CICR Department of Anesthesiology over CHCT, our primary aim is to evaluate Wake Forest School of Medicine whether the sensitivity of the alternative CICR Dr. Segal’s project is entitled “Development test is greater than 80%, using the CHCT as the of machine learning algorithms to predict dif- reference standard. Our preliminary data have ficult airway management.” proved the feasibility of CICR and have shown Sheila Riazi, MSc, MD, FRCPC promising results. Background: Successful airway manage- Associate Professor, Department of ment is fundamental to safe anesthetic perfor- Implications: This research will be the first to Anesthesia, University Health Network, mance, and airway management failure validate CICR against CHCT, taking advantage University of Toronto, Toronto, Canada continues to be the one of the leading causes of our unique position as the only laboratory of anesthesia-related death and severe morbid- Dr. Riazi’s proposal is entitled “A Minimally worldwide with expertise in both tests. Not only ity.1 While preoperative airway assessment is Invasive Diagnostic Test for Malignant Hyper- could this work increase use of a less expen- considered the worldwide standard of care, thermia.” sive and less invasive diagnostic test, it could 75–93% of difficult intubations are unantici- Background: Malignant hyperthermia (MH) is also increase the uptake of MH-susceptibility pated, and all easily performed airway examina- a potentially fatal hereditary disorder that is testing beyond the current 4%, ultimately tion systems in clinical practice perform only 2 induced by certain anesthetics. Although rare, a improving patient safety. modestly to detect difficult intubations. We propose to create a machine learning system malignant hyperthermia crisis is one of the most Funding: $137,449 (January 1, 2020–Decem- feared adverse anesthetic outcomes because ber 31, 2021). This grant was designated the See “2020 Grant Recipients,” Next Page APSF NEWSLETTER February 2020 PAGE 13

2020 Grant Recipients

From “2020 Grant Recipients,” Preceding Page anticipated difficult airway.4 Therefore any APSF Stoelting improvement in airway prediction is likely to based on analysis of facial photographs which Conference 2020 could outperform conventional bedside tests improve patient safety. Failed airway manage- and human experts and improve airway man- ment is even more common outside the OR, agement and patient safety. Previous work by and the safety improvement may be even more our group has demonstrated that an algorithm profound in the emergency department, ICU, or based on supervised (i.e., human-assisted) prehospital setting. Our proposal is closely computer analysis of facial images combined aligned with the APSF’s current funding priori- with thyromental distance (TMD) can outper- ties, as it involves large numbers of patients, form classical bedside tests and human including the healthiest, uses advanced infor- experts.3 Here we propose to extend this work mation technology to prevent harm, and by the development of completely unsuper- focuses on a low-frequency but devastating vised computer algorithms based on feature complication, difficult or failed intubation. In the extraction from facial photographs by convo- future, prediction of difficulty with additional luted neural networks (CNNs). aspects of airway management, including bag- mask ventilation, could also be modeled. The Aims: CNN technology already exists for data entry tool could be coupled to a cloud- highly accurate deterministic feature extraction based feature extraction and prediction calcula- of frontal views of the face and is widely tor, returning a prediction to end-users. employed in facial recognition applications. We will develop a similar CNN-based feature Funding: $150,000 (January 1, 2020– extractor from profile views of the face, which December 31, 2021). This grant was designated likely contains important information about the APSF/Medtronic Research Award. potential intubation difficulty (Aim 1). We will REFERENCES “Addressing Crucial then fuse this information with frontal facial 1. Joffe AM, Aziz MF, Posner KL, et al. Management of difficult information and patient demographics and tracheal intubation: a closed claims analysis. Anesthesiol- Patient Safety Issues in bedside airway data (TMD and Mallampati class ogy. 2019;131:818–29. [MP]) and train an advanced algorithm to clas- 2. Cook TM, MacDougall-Davis SR. Complications and failure Office-Based and sify faces as easy- or difficult-to-intubate based of airway management. Br J Anaesth. 2012;109 Suppl on prospective observation of ground truth 1:i68–i85. Non-Operating Room during induction of general anesthesia (Aim 2). 3. Connor CW, Segal S. Accurate classification of difficult intu- We will compare performance of the derived bation by computerized facial analysis. Anesth Analg. 2011;112:84–93. Anesthesia (NORA)” algorithm to MP+TMD in both the derivation 4. Apfelbaum JL, Hagberg CA, Caplan RA, et al. Practice dataset as well as an independent validation guidelines for management of the difficult airway: an dataset. We will test the hypothesis that the updated report by the American Society of Anesthesiolo- Conference Host: computer-derived algorithm will outperform gists Task Force on Management of the Difficult Airway. Mark A. Warner, MD classical bedside tests and improve prediction Anesthesiology. 2013;118:251–270. of difficult intubation. Finally, we will build a smartphone-based data entry tool to capture The APSF would like to thank the above September 9–10, 2020 photographs, patient demographic information, researchers and all grant applicants for their Royal Palms Resort & Spa and bedside airway examination data and dedication to improve patient safety. transmit it to an HIPAA-compliant, encrypted Phoenix, AZ online database (Aim 3). This will form the basis Dr. Howard is staff anesthesiologist at the VA of a future completely automated airway pre- Palo Alto Health Care System, professor of diction tool, based on our methods derived in Anesthesiology at Stanford University School of For registration and conference inquiries, this investigation. Medicine and chair of the APSF Scientific Evalu- please contact Stacey Maxwell ([email protected]). Implications: Airway failure is still the #1 ation Committee. cause of anesthesia-related mortality, and most Hotel reservation block to be opened Dr. Howard serves on the Board of Directors of difficult intubations are unanticipated, but there at a later date. the APSF and has no other conflicts of interest are well-established guidelines and ever- to declare. expanding options for the management of the

Did you know? APSF accepts stock donations. We work with our investment firm to take care of the details. You will need the following information to give to your investment advisor/ broker dealer. Please let us know of your generosity by notifying Stacey Maxwell at [email protected] so that we may properly acknowledge your contribution.

Firm: BNY Mellon/Pershing Account Name: Anesthesia Patient Safety Foundation DTC #: 8420 Account #: UDR900084 RAPID Response TO YOUR IMPORTANT QUESTIONS

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APSF NEWSLETTER February 2020 PAGE 14

An Incident of GlideScope® Stat to questions from readers Cover Failure to questions from readers by Martha Hensley, DNAP, CRNA

Dear Rapid N Response, cognizant of potential equipment failures when (parts per million, 0.00021%) failure rate for a utilizing video laryngoscopy, as GlideScope® broken tip. GlideScope® Stat Tip Breaks in Patient’s blade fractures can lead to disastrous conse- Airway quences (e.g., migration of the fractured tip into REFERENCES the lungs, perforation of the esophagus or tra- 1. Knee, P. Fracture of a GlideScope® Cobalt Blade. Anaes- I would like to present a scenario in which the thesia. 2012;67:190–191. chea) for the patient. One hypothesis that might tip of a disposable GlideScope® Stat cover inad- 2. Panacek EA, Laurin EG, Bair AE. Fracture of a GlideScope® explain this occurrence is that the fracture RvertentlyAPID RAPID Rbroke APIDR R offESPONSE APIDR inESPONSE aR patient’sESPONSE RESPONSE airway. Figure 1 Cobalt GVL® Stat disposable blade during an emergency occurred from a manufacturing flaw or damage intubation. The Journal of Emergency Medicine. 2009; todepicts your important an intact questionsVerathon GlideScope® N (North doi:10.1016/j.jemermed.2009.05.034. In press. during production or shipment. According to Creek Parkway, Bothwell, WA) Stat cover. 3. Yanovski B., Soroka G., Khalaila J., et al. Fracture of a Glide- Verathon Medical, eight blade failures have Scope® Cobalt Blade. Anaesthesia. 2012:67;190–191. A 76-year-old, 62 in., 60 kg, ASA class 3, occurred from 2007–2012.1 Only two cases woman presented for an elective direct laryn- have been published. Due to the limited infor- goscopy with biopsy due to a neoplasm at the mation available since 2012, there is a need for base of the tongue. Video laryngoscopy was further research on the design and durability of performed at the request of the Ears, Nose, and the distal tip of GlideScope® Stat blade covers. Throat (ENT) surgeon with the GlideScope® All three fractures (this case and the two pub- positioned midline using a Stat 3 cover by the lished cases) occurred at the distal tip. The pub- student registered nurse anesthetist (SRNA), lished cases of GlideScope® cover failure withR theAPID certifiedRAPID registeredR APIDR R nurseESPONSE APIDR anesthetistESPONSE R ESPONSE describeRESPONSE the use of upward, rotational force to (CRNA) and ENT surgeon in attendance. The reposition the blade.2,3 In this case, the blade surgeonto your assessed important the airway structuresquestions and was positioned midline with no upward or rota- vocal cords while the GlideScope® was still in tion force required. It is unclear, from Verathon place. No other instruments were placed in the Medical, where the fracture occurred in the airway. Thereafter, the patient was intubated other 6 cases reported to the company. There is no updated information, since 2012, to deter- with a 6.0 endotracheal tube without complica- Figure 1: Depicts an intact Verathon GlideScope® Stat tion. The correct position of the endotracheal mine if this is an ongoing problem or if the inci- cover. tube was verified by presence of ETCO2 and dents remain isolated. bilateral breath sounds, and the patient was This personal experience of an equipment placed on volume control mechanical ventila- malfunction involving the GlideScope® notwith- tion. The case proceeded without difficulty. standing, video laryngoscopy remains a reliable At the end of the procedure, the surgeon option for difficult airways and routine proce- identified a foreign object in the airway, which dures. However, caution should be used to was removed with graspers. After further carefully inspect the GlideScope® Stat cover for inspection, it was obvious that the clear plastic any defects or breakage before and after each object was the distal tip of the disposable Vera- use—especially at the distal tip. thon GlideScope® Stat cover. The distal one- Martha Henley is a certified nurse anesthetist at third of the tip of the Stat cover had fractured off Lonesome Pine Hospital in Big Stone Gap, VA. in the patient’s airway (Figure 2,3). The patient was successfully extubated and transferred to She has no conflicts of interest to disclose. Figure 2: Depicts broken tip of GlideScope® Stat cover. the post anesthesia care unit (PACU) in stable condition. PACU recovery was uneventful. No Reply: bleeding, edema, or complaints of sore, scratchy throat were elicited from the patient. The content of this letter was shared with The patient was discharged to same-day surgi- Verathon, the manufacturer of the GlideScope® cal services without further incident. An incident video laryngoscope who provided the following report was filed with the facility’s risk manage- information for readers. ment team, and the CRNA contacted the Glide- • Verathon maintains a robust and compliant Scope® company about the incident. quality management system including a com- plaint and vigilance reporting system. We DISCUSSION: take all complaints seriously. Complaints can In reviewing the literature, GlideScope® be reported directly to our Customer care cover defects and failures are rare events that team at +1-800-331-2313. occur during intubation.1-3 Nevertheless, it is imperative that the anesthesia professional be • GlideScope STATs maintain less than 2.1 ppm Figure 3: Depicts broken tip of GlideScope® Stat cover.

The information provided is for safety-related educational purposes only, and does not constitute medical or legal advice. Individual or group responses are only commentary, provided for purposes of education or discussion, and are neither statements of advice nor the opinions of APSF. It is not the intention of APSF to provide specific medical or legal advice or to endorse any specific views or recommendations in response to the inquiries posted. In no event shall APSF be responsible or liable, directly or indirectly, for any damage or loss caused or alleged to be caused by or in connection with the reliance on any such information. APSF NEWSLETTER February 2020 PAGE 15

Portable Point of Care Ultrasound (PPOCUS): An Emerging Technology for Improving Patient Safety by Patrick Lindsay, MB, BS; Lauren Gibson, MD; Edward A. Bittner, MD, PhD; and Marvin G. Chang, MD, PhD

INTRODUCTION now fit seamlessly in a clinician’s back scrub Many of the technological advancements pocket (Figure 1) at a price point as low as adopted by our specialty such as the pulse $2000 USD. Furthermore, the imaging capa- oximeter, capnography, brain function monitor- bilities far exceed many of the best ultrasound ing, and video laryngoscopy have revolution- machines of decades ago. ized patient care and safety and have been The revolution in PPOCUS is facilitated not adopted by other clinicians involved in acute just by the portable nature of the hardware of care. In the recent past, there was heated current pocket-sized ultrasound devices, but 1 debate, including in this Newsletter, regarding also by the software available to support the the impact of ultrasound in increasing patient user and its adoption. Many of the conventional safety for the placement of central lines and ultrasound devices require rudimentary meth- nerve blocks. Similarly, we believe that Portable ods such as USB cables to download and store Point of Care Ultrasound (PPOCUS) which images. However, the newer PPOCUS devices Figure 1: Extreme portability afforded by portable involves the use of handheld, portable, afford- ultrasound devices (Panel A) and use of PPOCUS in are now able to directly upload acquired perioperative settings such as in the operating room able, easy-to-use ultrasound devices to per- images to the cloud via WiFi or cellular network. (Panel B). form point of care ultrasound (POCUS) is an This new technological capability can seam- emerging technology that has the potential to lessly be integrated into the Picture and throughout the US. Nevertheless, this easy inte- improve perioperative patient safety. Archiving Communication System (PACS) and gration that meets HIPAA-compliant standards PPOCUS is undergoing a revolution similar patient’s electronic medical record system. allows for immediate collaboration with other to what computing technology experienced in PPOCUS studies are able to be de-identified health care providers as well as providing new the 20th century, an acceleration in the devel- with a single click2 in order to maintain patient real-time opportunities for quality assurance of opment of portable, efficient, and affordable privacy and confidentiality. However, specific the studies obtained. In addition, some of the systems. Ultrasound technology has evolved to institutional guidelines to protect patient privacy handheld devices have novel teleguidance the point that portable ultrasound devices can regarding storing this information is variable technologies that allow ultrasound experts to guide novice ultrasound users through an ultra- sound exam remotely and allow for live image Table 1: Emerging Indications for PPOCUS Use by the Anesthesia Professional acquisition, interpretation, and feedback.3 Artifi- cial intelligence is expected to further facilitate • Environments with significant time constraints, production pressure, and limited space (i.e., preoperative bay, for instance after a regional block, preoperative evaluation clinic, OR, OB, image acquisition and interpretation, providing PACU, ICU, and floor) real-time clinically relevant capabilities such as • Qualitative assessment using a focused binary decision-making approach sufficient to the determination of left ventricular function answer the clinical question (i.e., Is there severely reduced LV function? Yes or No) and the presence of pulmonary edema.

• Facilitate preoperative evaluation when a preoperative echo is desired but has not been INDICATIONS AND LIMITATIONS obtained to avoid significant case delays and cancellations associated with obtaining a formal echo study OF PPOCUS The increased accessibility of PPOCUS • Confirm clinically significant physical exam findings (i.e., undocumented murmur consistent with aortic stenosis) devices has allowed for its meaningful use in a variety of patient care situations where periop- • Ultrasound guidance of procedures such as IV access, CVC and arterial line placement, erative ultrasound may impact patient out- regional blocks, thoracentesis, paracentesis, cricothyroidotomy comes.4 In our practice at the Massachusetts • To perform emergent lifesaving procedures in nonideal conditions (e.g., placing arterial line General Hospital (MGH), we have adopted under the drapes in a crashing patient, on a hospital floor in a patient’s room, or in a non- operating room procedural area) handheld ultrasound devices within all periop- erative domains to make time-sensitive diagno- • Differentiating between various types of shock ses, perform serial assessments, and guide • Quickly ruling out life-threatening pathology (i.e., tamponade, pneumothorax, and pulmonary important management decisions. Table 1 embolism) in critically unstable patients shows the many indications for the periopera- • Verifying endotracheal vs. esophageal intubation during cardiac arrest when capnography tive use of PPOCUS by anesthesia profession- may not be a reliable indicator of endotracheal intubation13 als. Table 2 compares PPOCUS with POCUS • Differentiating PEA vs. pseudo-PEA during cardiopulmonary arrest which highlights many of the advantages and limitations of this technology. • Optimizing left and right heart function while avoiding invasive procedures and monitors (i.e., PA line, TEE) and their associated complications FACILITATING ADOPTION AND • Rapid evaluation and assessment of volume status in critically unstable patients14-16 COMPETENCY FOR PPOCUS • Assess gastric volume to determine aspiration risk Widespread adoption of a new technology like ultrasound can be daunting due to lack of • Evaluation for pulmonary edema or pneumothorax to facilitate optimization in the perioperative period See “PPOCUS,” Next Page APSF NEWSLETTER February 2020 PAGE 16

PPOCUS May Answer Clinical Questions Rapidly

From “PPOCUS,” Preceding Page Table 2: Summary of the similarities and differences of POCUS with portable familiarity, formal training, or a conditioned reli- ultrasound devices (PPOCUS) compared to conventional ultrasound platforms ance on formal services staffed by cardiologists and cardiac anesthesiologists. Surveys of anes- Characteristic PPOCUS Conventional US thesiologists have revealed the fear of missed Cost $2,000 to $12,500 $30k to 100k+ diagnoses and the lack of formal training or cer- Portability/space requirements Extreme portability/Devices Not always portable/Devices tification as important barriers to the adoption can fit in a scrub pocket and may weigh up to hundreds of of focused TTE in their practice.5 Understand- many weigh less than a pound pounds ably there are many who may be concerned Bootup time Seconds Up to minutes about the medical/legal ramifications of “nonex- perts” performing PPOCUS. This is a valid con- Time to successful Quick, given extreme Slow, given labor intensive to cern for both users and hospital administrators. deployment and use portability mobilize However, it is reassuring that the known mal- Electrical outlet requirement No Some practice lawsuits to date have related not to the Quality of imaging Good enough for binary Generally higher quality misdiagnosis and misinterpretation of POCUS, decision-making imaging but rather to the entire lack or delay in the use of POCUS.6–8 EKG synchronization No Yes capability At MGH, PPOCUS was initially employed by ultrasound enthusiasts who were looking to be Ability to use in situations Yes No where space is limited self-reliant in evaluating and rescuing their own patients before things “spiraled out of control.” Transesophageal Not presently Yes Anesthesia professionals who were PPOCUS echocardiography capability enthusiasts increasingly began to respond to Potential for disruption to Low High “anesthesia stats” and emergencies in a variety ongoing critical care support of clinical arenas in which we practice, and (i.e., chest compressions) PPOCUS demonstrated its utility to others by Wireless and/or 3G integration Some Some answering clinically important questions in a with the PACS rapid time frame. PPOCUS was shown to be instrumental in the rapid assessments of acute Allows for quick Yes No conditions, allowing patients to be rescued de-identification of studies to even before our formal rescue echo service facilitate external collaboration could be fully mobilized, which helped to facili- Teleguidance and AI capability Many Limited tate its adoption in the department. Further sup- to facilitate data acquisition, port for PPOCUS was achieved in our interpretation, and department after it demonstrated its utility in collaboration avoiding unnecessary transfer of patients to Knobology (or the functionality Limited, which may facilitate Extensive, which may higher levels of care such as the ICU, resulting of controls on ultrasound use by novice users complicate use in better utilization of limited hospital resources device) with the rapid identification of reversible causes Ability to use M-mode and Yes Yes of deterioration gleaned by clinicians using it. color doppler One of the major advantages of PPOCUS is Ability to use PWD, CWD, and No Yes that it can be readily used by all, without a sig- TDI nificant amount of training. Prior studies sug- Integration with EMR, PACS Many Most gest that physicians with limited prior ultrasonographic experience can gain profi- Abbreviatons: Artificial Intelligence (AI), Continuous Wave Doppler (CWD), Electronic Medical Record (EMR), ciency in focused ultrasound with limited train- Picture Archiving and Communication System (PACS), Pulse Wave Doppler (PWD), Tissue Doppler Imaging (TDI), ultrasound (US) ing, such as a 1-day workshop and as few as 20 9,10 practice scans. Of note, the American Col- RECOMMENDATIONS AND STRATEGIES required to teach novice users ultrasound skills, lege of Chest Physicians (ACCP) requires 20 TO FACILITATE PPOCUS USE and for novice users to practice those skills, is TTE studies to earn the certificate of completion Our PPOCUS philosophy is that “anyone can significantly reduced due to the extreme porta- for POCUS. The American College of Emer- do it”—not just cardiac anesthesiologists and car- bility, affordability, and ease of use. gency Physicians (ACEP) requires a minimum of diologists. Our educational strategy has been to 25 studies per imaging application. Similarly, target clinicians that are interested in implement- At the MGH, we have found that PPOCUS has the Society of Point of Care Ultrasound recom- ing this technology in their daily practice and helped to facilitate ultrasound training of over 40 mends a minimum of 25 studies for certification subsequently champion its use throughout the anesthesia professionals over the last 6 months in POCUS. Similar competencies might be department. PPOCUS is ideal for ultrasound without requiring significant departmental support developed for PPOCUS. education because the “activation energy” See “PPOCUS,” Next Page APSF NEWSLETTER February 2020 PAGE 17

Limited Training May Be Required To Use PPOCUS From “PPOCUS,” Preceding Page this technology into clinical practice and ensur- 2. Sharing studies. Website of the Butterfly Network. 2019. ing that it is used correctly by building appropri- 3. Blood AM, Judy R. The latest in cardiovascular hand-held and a formalized structured training program. point-of-care ultrasound: the power of echocardiography While we have formal training modules available, ate training curriculums. For example, early anytime, anywhere. Website of the American College of we do not initially require their use so as to avoid targets for implementation might include inte- Cardiology: Latest in Cardiology. August 12, 2019. gration into simulation training, emergency 4. Canty DJ, Royse CF, Kilpatrick D, et al. The impact on car- dissuading the learners before they’ve had diac diagnosis and mortality of focused transthoracic echo- enough hands-on training with an expert to manuals, residency training programs, and peri- cardiography in hip fracture surgery patients with increased develop some self-confidence and enthusiasm operative domains where feasible. Our spe- risk of cardiac disease: a retrospective cohort study. Anaes- thesia. 2012;67:1202–9. applying the new skill in clinical practice. cialty, which has been a pioneer in patient safety should promote proficiency in PPOCUS 5. Conlin F, Connelly NR, Eaton MP, et al. Perioperative use of Enthusiastic novice users often find their own focused transthoracic cardiac ultrasound: a survey of cur- interesting resources (i.e., YouTube, podcasts, similar to the field of emergency medicine over rent practice and opinion. Anesth Analg. 2017;125:1878– 11,12 1882. websites, etc.) to facilitate their self-learning, a decade ago. Anesthesia professionals should embrace and innovate its use as a new 6. Blaivas M, Pawl R. Analysis of lawsuits filed against emer- independently practice on our high fidelity TTE gency physicians for point-of-care emergency ultrasound simulator, and perform a minimum of 5–10 stud- paradigm for patient safety and education in examination performance and interpretation over a 20-year ies one-on-one with an expert user until they are perioperative medicine. period. Am J Emerg Med. 2012;30:338–41. 7. Nguyen J, Cascione M, Noori S. Analysis of lawsuits related able to adequately perform a limited study on Dr. Lindsay is a resident in the Department of to point-of-care ultrasonography in neonatology and pedi- their own. Most achieve competence in obtain- Anesthesia, Critical Care, and Pain Medicine at atric subspecialties. J Perinatol. 2016;36:784–6. ing the standard cardiopulmonary views (para- the Massachusetts General Hospital, Boston, MA. 8. Stolz L, O'Brien KM, Miller ML, et al. A review of lawsuits sternal long axis, parasternal short axis, apical related to point-of-care emergency ultrasound applications. Dr. Gibson is a resident in the Department of West J Emerg Med. 2015;16:1–4. four-chamber view, subcostal four-chamber Anesthesia, Critical Care, and Pain Medicine at 9. Cowie B, Kluger R. Evaluation of systolic murmurs using view, IVC view, and lung ultrasound) within 20 transthoracic echocardiography by anaesthetic trainees. the Massachusetts General Hospital, Boston, MA. studies that are performed in a short period of Anaesthesia. 2011;66:785–90. Dr. Bittner is an associate professor in the 10. Spencer KT, Flachskampf FA. Focused cardiac ultrasonog- time (within a month). We attempt to facilitate raphy. JACC Cardiovasc Imaging. 2019;12:1243–1253. Department of Anesthesia, Critical Care and access to portable ultrasound devices so that 11. Ultrasound guidelines: emergency, point-of-care and clini- learners can sustain the momentum necessary Pain Medicine at the Massachusetts General cal ultrasound guidelines in medicine. Ann Emerg Med. to achieve rapid growth of their POCUS skills. Hospital, Boston, MA. He is an associate editor 2017;69:e27–e54. of the APSF Newsletter. 12. American College of Emergency Physians. Emergency Interestingly, many of the clinicians most recep- ultrasound guidelines. Ann Emerg Med. 2009;53:550–70. tive to learning PPOCUS are early in their anes- Dr. Chang is the assistant program director of the 13. Gottlieb M, Holladay D, Peksa GD. Ultrasonography for the thesia training (i.e., CA-1). We hope that the junior Critical Care Anesthesiology Fellowship and a confirmation of endotracheal tube intubation: a systematic member of the faculty in the Department of Anes- review and meta-analysis. Ann Emerg Med. 2018;72:627– anesthesia trainees will go on to train both the 636. thesia, Critical Care and Pain Medicine at the current and the next generation of anesthesia 14. Lanspa MJ, Grissom CK, Hirshberg EL, et al. Applying professionals so that our entire department will Massachusetts General Hospital, Boston, MA. dynamic parameters to predict hemodynamic response to become experts in POCUS. volume expansion in spontaneously breathing patients with The authors do not have any disclosures. septic shock. Shock. 2013;39:155–60. 15. Airapetian N, Maizel J, Alyamani O, et al. Does inferior vena CONCLUSION cava respiratory variability predict fluid responsiveness in The incorporation of PPOCUS into perioper- REFERENCES spontaneously breathing patients? Crit Care. 2015;19:400. ative care seems inevitable given its potential to 1. Overdyk FJ. Ultrasound guidance should not be standard of 16. Muller L, Bobbia X, Toumi M, et al. Respiratory variations of care. APSF Newsletter. Winter 2002;17. https://www.apsf. inferior vena cava diameter to predict fluid responsiveness enhance patient safety. It is therefore important org/article/ultrasound-guidance-should-not-be-standard-of- in spontaneously breathing patients with acute circulatory to consider the optimal means of incorporating care/ Accessed December 4, 2019. failure: need for a cautious use. Crit Care. 2012;16:R188.

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The APSF is eager to connect with patient safety enthusiasts across the internet on our social media platforms. Over the past year, we have made a concerted effort to grow our audience and identify the best content for our community. We've seen increases in followers and engagement by several thousand percent, and we hope to see that trajectory continue into 2020. Please follow us on Facebook at http://www.facebook.com/APSForg and on Twitter at www.twitter.com/ APSForg. Also, connect with us on Linked In at http://www.linkedin.com/company/anesthesia- patient-safety-foundation-apsf. We want to hear from you, so please tag us to share your patient safety related work, including your academic articles and presentations. We’ll share those high- lights with our community. If you are interested in joining our efforts to amplify the reach of APSF across the internet by becoming an Ambassador, please reach out via email to Marjorie Stiegler, MD, our Director of Digital Strategy and Social Media at [email protected], Emily Methangkool, MD, the APSF Ambassador Program Director at [email protected], or Amy Pearson, Social Marjorie Stiegler, MD, APSF Director of Digital Media Manager at [email protected]. We look forward to seeing you online! Strategy and Social Media. APSF NEWSLETTER February 2020 PAGE 18 Anesthesia Patient Safety Foundation Founding Patron ($500,000) American Society of Anesthesiologists (asahq.org)

2020 Corporate Advisory Council Members (current as of November 30, 2019) Platinum ($50,000) Gold ($30,000)

ICU Medical Medtronic (medtronic.com) (icumedical.com) Preferred Physicians Fresenius Kabi Medical Risk (fresenius-kabi.us) Retention Group (ppmrrg.com) GE Healthcare (gehealthcare.com) PharMEDium Services (pharmedium.com)

Bronze ($5,000) Masimo (masimo.com) Medasense Codonics Dräger

Special recognition and thank you to Medtronic for their support and funding of the APSF/Medtronic Patient Safety Research Grant ($150,000).

For more information about how your organization can support the APSF mission and participate in the 2020 Corporate Advisory Council, go to: apsf.org or contact Sara Moser at: [email protected]. Community Donors (includes Specialty Organizations, Anesthesia Groups, ASA State Component Societies, and Individuals)

Specialty $200 to $749 Hawaii Society of Meghan Lane-Fall, MD, MSHP Elizabeth Drum (in honor of Joshua Lea, CRNA James William Schlimmer (in Organizations Department of Anesthesia, NYC Anesthesiologists Kathleen Leavitt and Johan Rediet Shimeles, MD) Sheldon Leslie memory of John Tinker, MD) $5,000 to $14,999 Health + Hospitals/Harlem Maine Society of Suyderhoud Mike Edens and Katie Megan Della M. Lin, MD Hedwig Schroeck, MD Hawkeye Anesthesia, PLLC Anesthesiologists Cynthia A. Lien, MD David E Eibling, MD Gary Schwartz, MD American Academy of Kevin and Janice Lodge Wichita Anesthesiology Mississippi Society of Anesthesiologist Assistants Michael D. Miller, MD Anila B. Elliott, MD Robert Loeb, MD (in honor of Brence A. Sell, MD Chartered Anesthesiologists Patty Mullen Reilly, CRNA Bola Faloye, MD Dwayne Westenskow) Leilani Seltzer, MD $2,000 to $4,999 New Hampshire Society of Mark C. Norris, MD Jeffrey Feldman, MD, MSE Francie Lovejoy Jeffrey Shapiro, MD Society of Academic ASA State Anesthesiologists Component Societies Parag Pandya, MD Jennifer Feldman-Brillembourg, Robert Lovitz, MD Deepak Sharma, MD Associations of Anesthesiology New Jersey State Society of MD $5,000 to $14,999 Anesthesiologists James M. Pepple, MD Edwin Mathews, MD Emily Sharpe, MD and Perioperative Medicine Cynthia A. Ferris, MD (in honor of Mark Warner, MD) Indiana Society of New Mexico Society of May Pian-Smith, MD, MS Stacey Maxwell Society for Ambulatory (in honor of Jeffrey Cooper, PhD) Lee A. Fleisher, MD Mary Shirk Marienau Anesthesia Anesthesiologists Anesthesiologists Michael McCallum, MD Elizabeth Rebello, MD Steven Frank Afreen Siddiqui, MD The Academy of Minnesota Society of North Dakota Society of Gregory McComas, MD Anesthesiologists Anesthesiologists (in honor of Drs. Mark Warner Cassie Gabriel, MD Kristin McCorkle, MD (in honor of Kim Walker, MD) Anesthesiology and Jerome Adams) Tennessee Society of Texas Society of Lauren Gavin, MD Jeffrey McCraw, MD Saket Singh, MD $750 to $1,999 Lynn Reede, CRNA Anesthesiologists Anesthesiologists Marjorie Geisz-Everson, PhD, Emily Methangkool, MD Raymond Sroka, MD Drs. Ximena and Daniel Sessler American Dental Society of $2,000 to $4,999 (in memory of J. Lee Hoffer, MD CRNA (in honor of Drs. Mark Warner, Marjorie A. Stiegler, MD Anesthesiology and Harve D. Pearson, MD) Ronald George, MD Marjorie Stiegler, and Amy Arizona Society of $200 to $749 Shepard B. Stone, DMSc, PA American Society of Dentist Virginia Society of Pearson) Anesthesiologists Arnoley Abcejo, MD Mary Beth Gibbons, MD James F. Szocik, MD Anesthesiologists Anesthesiologists Jonathan Metry, MD Massachusetts Society of Aalok Agarwala, MD, MBA Jeffrey M. Gilfor, MD Joseph W. Szokol, MD (in honor Ohio Academy of Tricia Meyer, PharmD of Steven Greenberg, MD) Anesthesiologists Individuals Daniela Alexianu, MD Ian J. Gilmour, MD Anesthesiologists Assistants Randall D Moore, DNP, MBA, Gilbert Tang, MD California Society of $15,000 and Higher Shane Angus, AA-C Michael Greco, PhD, DNP, Society for Airway Management Anesthesiologists CRNA CRNA Michael Taylor, MD, PhD Steven J. Barker, MD, PhD Matangi Priyasri Bala, MD Society for Pediatric Anesthesia Michigan Society of Bev and Marty Greenberg Sara Moser (in honor of Jeffrey Brian J. Thomas, JD Siker Charitable Fund Marilyn L. Barton (in memory of B. Cooper, PhD) $200 to $749 Anesthesiologists (in memory of Dr. E.S. and (in honor of Steven Greenberg, Stephen J. Thomas, MD Darrell Barton) MD) Deborah A. Moss, MD Florida Academy of New York State Society of Eileen Siker) Paloma Toledo Anesthesiologists William A. Beck, MD Barbara Greyson, MD David Murray, MD Anesthesiologist Assistants $5,000 to $14,999 Bui T. Tran, MD, MBA Wisconsin Society of Richard H. Blum, MD, MSE, Linda K Groah, MSN RN FAAN Shobana Murugan, MD (in Mary Ellen Warner, MD and FAAP (in honor of Jeffrey memory of Dr. Sanjay Datta) Richard D. Urman, MD, MBA Anesthesia Groups Anesthesiologists Allen N. Gustin, MD (in honor of Jeffrey Cooper, PhD) Mark A. Warner, MD Cooper, PhD) Jay Nachtigal, MD $15,000 and Higher $750 to $1,999 Alexander Hannenberg, MD Timothy Vanderveen, PharmD $2,000 to $4,999 Sarah Bodin, MD (in honor of Mark A. Warner, Emily Natarella Connecticut State Society of Andrea Vannucci, MD (in honor US Anesthesia Partners Susan E. Dorsch, MD Shauna W. Bomer, MD (in MD) John B. Neeld, Jr, MD Anesthesiologists memory of Dr. Katie Donahue) of René Tempelhoff, MD) $5,000 to $14,999 Debbie and Mark Gillis, MD Gary and Debra Haynes David Nieto, MD District of Columbia Society of Lisa Bowe, MD Maria van Pelt, PhD, CRNA Associated Anesthesiologists Anesthesiologists Robert K. Stoelting, MD John F. Heath, MD Christine Noble Mark D. Brady, MD, FASA Albert J Varon, MD, MHPE Envision Physician Services Florida Society of Genie Heitmiller Nancy Nussmeier, MD $750 to $1,999 K. Page Branam, MD (in memory of Graciela Victoria North American Partners in Anesthesiologists Sean Adams, MD Molly MH Herr, MD (in honor of Ducu Onisei, MD Levy) (in memory of Donna M Holder, Drs. Mason, Warner & Cole) Anesthesia Georgia Society of Donald Arnold, MD MD) Frank Overdyk, MD Stephen Vaughn, MD Anesthesioloigsts Steven K. Howard, MD NorthStar Anesthesia Douglas A. Bartlett Amanda Brown D. Janet Pavlin, MD Christopher Viscomi, MD Illinois Society of PhyMed Healthcare Group (in memory of Diana Davidson, (in memory of Rhonda Alexis) Mark Hudson, MD Amy Pearson, MD (in honor of Joseph Weber, MD Anesthesiologists Students of CWRU’s Master of CRNA) Bryant Bunting, DO Erin Hurwitz, MD Drs. Mark Warner, Marjorie Matthew B. Weinger, MD Iowa Society of Science in Anesthesia, DC Casey D. Blitt, MD Jason Byrd, JD Allen Hyman, MD (in memory of Stiegler, Emily Methangkool, James M. West, MD Anesthesiologists Henrik Bendixen, MD) David P. Martin, & Ms. Sara Location Raymond J. Boylan, Jr, MD Edward Cain, MD John Williams Kentucky Society of Adam K. Jacob, MD Moser) $2,000 to $4,999 Anesthesiologists Amanda Burden, MD Jeff Carroll, CAA G. Edwin Wilson, MD (in honor of Jeffrey Cooper, Rebecca L. Johnson, MD Dhamodaran Palaniappan, MD Nebraska Society of Vidya Chidambaran, MD, MS Kenneth A. Wingler, MD MEDNAX (American PhD) Cathie T. Jones, MD Lee S. Perrin, MD Anesthesiology) Anesthesiologists Destiny Chau, MD Fred Cheney, MD Collette Jones, MD Cathleen Peterson-Layne, PhD, Legacy Society Old Pueblo Anesthesia Ohio Society of (in honor of Robert Caplan, MD) Marlene V. Chua, MD MD https://www.apsf.org/ Anesthesiologists Zachary Jones, MD, FASA Daniel J. Cole, MD Kathleen Connor, MD Mark Pinosky, MD $750 to $1,999 Oklahoma Society of Catherine Jung, MD (in memory donate/legacy-society/ Jeremy Cook, MD Hoe T. Poh, MD Anesthesia Associates of Anesthesiologists Jeffrey B. Cooper, PhD of Eugene Fibuch, MD) Karma and Jeffrey Cooper, PhD Dennis W. Coombs, MD Columbus GA Oregon Society of Mrs. Jeanne and Dr. Robert A. Zeest Khan, MD Paul Pomerantz Marsha and John Eichhorn, MD Cordes Christian David Cunningham Anesthesia Associates of Anesthesiologists James Kindscher Paul Preston, MD Burton A. Dole, MD Kansas City South Carolina Society of Deborah Culley, MD Julia DeLoach, MD Ms. Sandra Kniess and David Richard C. Prielipp, MD Deanna and David Gaba, MD Kaiser Permanente Nurse Anesthesiologists Kenneth Elmassian, DO Paul Brunel Delonnay Solosko, MD Aaron N. Primm, MD Dr. Ephraim S. (Rick) and Anesthetists Association of Wyoming Society of David M. Gaba, MD John K. DesMarteau, MD Benjamin Kohl, MD, FCCM Neela Ramaswamy, MD Eileen Siker Southern California Anesthesiologists James D. Grant, MD, MBA Andrew E. Dick, MD Bracken Kolle, MD Roberta Reedy, DNSc, CRNA Robert Stoelting, MD Physician Specialists in $200 to $749 Steven B. Greenberg, MD Karen B. Domino, MD Gopal Krishna, MD David Rotberg, MD Mary Ellen and Mark Anesthesia Arkansaas Society of Catherine Kuhn, MD Michelle Downing, MD Ruthi Landau, MD Steven Sanford, JD Warner, MD TeamHealth Anesthesiologists James Lamberg, DO Richard P. Dutton, MD, MBA Kathryn Lauer, MD Amy Savage, MD Matthew B. Weinger, MD Note: Donations are always welcome. Donate online (https://www.apsf.org/donate/) or mail to APSF, Mayo Clinic, Charlton 1-145, 200 First Street SW, Rochester, MN 55905. (Donor list current as of December 1, 2018–December 19, 2019.) APSF NEWSLETTER February 2020 PAGE 19

Navigating Perioperative Insulin Pump Use

Dear Q&A, next-day surgery: comparing three strategies.” Journal of Clinical Anesthesia. 2012; 24: 610–617. Over the last decade, patients with insulin- requiring diabetes are increasingly using contin- REFERENCES uous subcutaneous insulin infusion (CSII) pumps. 1. Sobel SI, Augustine M, Donihi AC, et al. Safety and efficacy These pumps fundamentally provide continuous of a perio-operative protocol for patients with diabetes insulin to meet basal requirements with the abil- treated with continuous subcutaneous insulin infusion who are admitted for same-day surgery. Endocrine Practice. ity to manually bolus additional insulin. Increas- 2015;21:1269–76. ing sophistication has added continuous 2. Rotruck S, Suszan L, Vigersky R, et al. Should continuous subcutaneous glucose monitoring (CGM) and subcutaneous insulin infusion (CSII) pumps be used during insulin delivery driven by CGM (e.g., Minimed™ the perioperative period? Development of a clinical deci- 670G, Medtronic, Northridge, CA). CSII pumps sion algorithm. AANA Journal. 2018;86:194–200. are commonly used in the perioperative period 3. Long MT, Coursin, DB, Rice MJ. Perioperative consider- ations for evolving artificial pancreas device. Anesthesia & to provide insulin therapy based upon institu- Analgesia. 2019;128:902–6. 1,2 tional guidelines. In a recent literature search, 4. Goodwin G, et al. Challenges in implementing hybrid one published criterion to guide utilization of closed loop insulin pump therapy (medtronic 670g) in a more sophisticated devices and automated fea- 3. Is there an increased likelihood that anesthe- ‘real-world’ clinical setting. ENDO 2019; Abstract OR14-5 3 Journal of the Endocrine Society, Volume 3, Issue Supple- tures was found. Long et al. suggested that the sia professionals must identify and respond ment_1, April–May 2019, https://doi.org/10.1210/js.2019- pump should run intraoperatively. States with to device alarms? OR14-5 altered perfusion, shock, hypothermia, technical 4. Is special training required if anesthesia pro- 5. Umpierrez GE, Klonoff, DC. Diabetes technology update: use of insulin pumps and continuous glucose monitoring in problems, and very high or low glucose values fessionals are to use these pumps safely? are determinants for discontinuing the device.3 the hospital. Diabetes Care. 2018;41:1579–89. https://doi. 5. How reliable is CGM technology? CGM inter- org/10.2337/dci18-0002 The Minimed™ 670G is a hybrid closed loop stitial values lag behind blood glucose system (HCLS). In the AutoMode, the pump uses values. Some CGMs lose accuracy with cer- Response: CGM to automatically adjust basal and correc- tain medications, including acetaminophen. tional insulin delivery while the patient manually CGMs are not recommended for decision- Increasing numbers of patients are using selects prandial boluses. Patients can disable the making in the inpatient setting.5 insulin pumps and require anesthetic care, and AutoMode in temporary favor of Manual Mode. therefore, the concerns raised by the author (In the Manual Mode, pre-programmed continu- Hybrid closed-loop systems are a new rap- above in her letter are timely and worthy of con- ous basal insulin delivery remains, but both the idly developing technology with little in the lit- sideration. The growth in adopting continuous prandial and correctional insulin boluses are cal- erature to guide their perioperative use. Indeed, subcutaneous insulin infusion (CSII) technology culated and acknowledged first by the patient). it is quite possible that some surgeries are is a testament to the added convenience and Although this hybrid closed loop system has being performed in AutoMode without the quality of glucose control this technology been applauded as a huge technology advance, knowledge of the anesthesia professional. With affords patients. These advantages can be just there are challenges to using it. Goodwin found a high glucose result, the anesthesia profes- as useful in the perioperative period as they are that over one-third of the 83 patients studied sional may bolus a correctional subcutaneous in the outpatient setting. With improvements abandoned use of the 670G due to “calibration or IV insulin dose via syringe, while at the same and advances in pump technology, including requirements, problems with sensor durability or time the AutoMode has increased insulin deliv- the hybrid closed-loop system (HCLS), glucose adhesion, skin irritation, and forced exits from ery via the insulin pump. management is transitioning from an active AutoMode.”4 responsibility of the anesthesia professional to I realize that an hourly point-of-care blood a (semi-)automated process.1 In AutoMode, near continuous interstitial glu- glucose measurement is a key safety factor cose readings (every 5 minutes) automatically when caring for a patient receiving insulin ther- Before addressing specific questions about alter insulin delivery toward a pre-programmed apy while anesthetized. With HCLS technology HCLS for glucose management, it is worthwhile blood glucose target. This automated function- likely to proliferate, it would be helpful to have to consider the benefits of maintaining CSII in ality raises questions about its safety in the recommendations on the use of AutoMode and the perioperative setting as compared to provider- managed glucose control. CSII-controlled anesthetized patient. similar automatic modalities in the perioperative period for inclusion in our institution’s Perioper- insulin at a basal rate is personalized to provide 1. Is the AutoMode able to more precisely miti- ative Insulin Pump Guidelines. the closest possible physiologic replacement gate or correct for blood glucose derange- for the patient’s nonfunctional pancreas. ments than an anesthesia professional who Thank you for your time. Although it is yet to be studied scientifically, adheres to institutional guidelines on periop- Tamra Dukatz, MSN, CRNA switching to a previously untested empiric erative insulin pump management? Beaumont Health, Royal Oak, Michigan strategy abruptly prior to surgery is intuitively less ideal than continuing the method or tech- 2. Can AutoMode better abate surgical stress Ms. Dukatz has received an investigator initi- hyperglycemia? ated grant from Sanofi, US, for her co-authored nique that has been optimized for the patient. work entitled “Insulin glargine dosing before See “CSI Pumps,” Next Page

The APSF sometimes receives questions that are not suitable for the Rapid Response column. This Q and A column allows the APSF to forward these questions to knowledgeable committee members or designated consultants. The information provided is for safety-related educational purposes only, and does not constitute medical or legal advice. Individual or group responses are only commentary, provided for purposes of education or discussion, and are neither statements of advice nor the opinions of the APSF. It is not the intention of the APSF to provide specific medical or legal advice or to endorse any specific views or recommendations in response to the inquiries posted. In no event shall the APSF be responsible or liable, directly or indirectly, for any damage or loss caused or alleged to be caused by or in connection with the reliance on any such information. APSF NEWSLETTER February 2020 PAGE 20

More

CSI Pumps Deliver Very Accurate Insulin Doses From “CSI Pumps” Preceding Page ing the patient to replace the infusion set with a The calculated bolus (based on entered blood Furthermore, insulin pumps can deliver doses of full reservoir 12–24 hours before anesthesia sugar) will display and must be confirmed insulin with a precision of 0.1, or even 0.05 units. and to calibrate the sensor no more than six before delivery. Although the pumps are easy This degree of precision cannot be achieved by hours before the anesthetic. to learn, when confronted with one, if a provider providers. Administering intraoperative insulin Automated insulin administration is designed is unsure how to manage it, endocrinology con- boluses for hyperglycemia via the pump is the with safety in mind. Medtronic’s AutoMode does sultants can be enlisted to assist with the proper optimal way to administer an exact dose, particu- not deliver a basal infusion; rather, the algorithm use of these pumps. The patient or patient’s larly in pediatric patients who may be exquisitely determines whether to give a “microbolus” family can also demonstrate the features to the sensitive to small doses of insulin.2,3 based upon CGM readings and trends every five anesthesia professional and quick-start guides minutes.4 The pump will not deliver a bolus to are readily available on the manufacturer’s The physiologic benefits notwithstanding, correct hyperglycemia, but will increase the website if needed. Guidance for perioperative patients (and their families) with insulin pumps microbolus dose to an algorithmically deter- use of these pumps is typically institutional spe- are generally extremely “connected” to their mined maximum in response to a rising blood cific, but may include collaboration with the pri- pumps and are skeptical when medical provid- sugar. Concomitantly, it will reduce or withhold mary care physician and/or endocrinologist. ers insist on removing their pumps prior to a pro- microboluses in response to declining blood cedure. Online discussions are replete with One important caveat is that the pump must sugar, so the likelihood of hypoglycemia due to complaints from patients who were “forced” to be located to afford access by the anesthesia AutoMode is low. Ideally, manual correction professional during the procedure. Additionally, remove their insulin pumps for surgery and boluses should be delivered via the insulin pump the infusion set cannot be located within the sur- strongly worded advice to resist relinquishing both for the safety concerns mentioned earlier gical field, and patients should be instructed in insulin management to the anesthesia team. The and so that the HCLS will be able to incorporate advance to insert their infusion set in an appro- willingness to work together with the patient to the additional insulin into its algorithm. priate site. There may be situations where the continue insulin pump therapy throughout the infusion pump location is impractical and contin- perioperative period is invaluable in establishing Training may be required to use these pumps ued usage of CSII may not be possible. An alter- rapport and alleviating fear and anxiety. effectively but they are not complex devices. Despite the advanced technology that these native management plan should be prepared in Returning to the HCLS issues, device alarms insulin pumps rely upon, managing and using conjunction with the patient’s endocrinologist mainly fall into two categories: notifications of the pump is actually quite simple. In fact, young and diabetes management team in that sce- extreme blood sugar changes (e.g., warnings of children are able to use their insulin pumps nario. Table 1 depicts the author's suggested rapid change, approaching high/low limits, high independently, and an anesthesia professional principles to guide a perioperative institutional or low blood sugar) and insulin pump/CGM should be able to quickly learn how to read the policy for patients with insulin pumps. system requests (e.g., low reservoir, calibration pump screen, administer manual boluses, or Just as anesthesia professionals have required, weak or poor signal). The former type suspend insulin delivery. The pump’s home learned to manage devices like pacemakers or is clinically useful, although confirmation by fin- screen will display important information, implanted pumps that benefit patients, we gerstick with the facility’s own blood glucose including current CGM reading, active insulin should embrace insulin pump technology to monitor before intervention is recommended. therapy, and Automode status. Programming a provide ideal perioperative care to our patients. System requests for reservoir refill or calibration bolus requires just a few presses of the button can usually be avoided or reduced by instruct- to open the menu and enter the Bolus activity. Ari Y. Weintraub, MD Children’s Hospital of Philadelphia; Perelman Table 1: Author's suggested principles to guide an institutional policy for patients with School of Medicine at the University of insulin pumps in the perioperative period Pennsylvania, Philadelphia, PA 1. Blood sugar monitoring should be performed for all insulin-dependent patients in the perioperative period regardless of the method of providing insulin therapy. Dr. Weintraub has no disclosures to report. 2.  The patient’s insulin pump should continue to be used unless there is an absolute contraindication (e.g., the MRI environment, setting of diabetic ketoacidosis requiring IV insulin and fluid management, shock, REFERENCES marked hypothermia, vasopressor use, severe dysglycemia). 1. de Bock M, McAuley SA, Abraham MB, et al. Effect of 6 months hybrid closed-loop insulin delivery in young people 3. Relative contraindications such as the infusion set being in the surgical field and theoretical risk of with type 1 diabetes: a randomised controlled trial protocol. electrical injury from electrocautery in patients with metal needle infusion sets can be addressed by BMJ Open. 2018;8:e020275. instructing the patient to place a plastic infusion set in an alternative site. The pump should be shielded 2. Partridge H, Perkins B, Mathieu S, et al. Clinical recommen- with a lead apron when ionizing radiation is used.5 dations in the management of the patient with type 1 diabe- tes on insulin pump therapy in the perioperative period: a 4. If the patient uses a pump with HCLS, the automatic mode should be continued with frequent primer for the anaesthetist. Br J Anaesth. 2016;116:18–26. monitoring of the pump’s glucose measurements and close attention to pump alarms. If the 3. Ma D, Chen C, Lu Y, et al. Short-term effects of continuous CGM indicates hyper- or hypoglycemia or quickly changing blood sugar, confirmation by subcutaneous insulin infusion therapy in perioperative fingerstick or other reliable technology should be performed to guide clinician intervention. patients with diabetes mellitus. Diabetes Technol Ther. Use of the HCLS may not be appropriate in states of altered perfusion, shock, or hypothermia.5 2013;15:1010–18. 4. Medtronic. Minimed 670G system user guide. https://www. 5.  When insulin boluses for treatment or correction of hyperglycemia are required, the insulin medtronicdiabetes.com/sites/default/files/library/download- pump should be used to deliver a precise dose and to maintain the accuracy of the HCLS library/user-guides/MiniMed%20670G%20System%20 algorithm when applicable. User%20Guide.pdf. Accessed November 26, 2019. 6.  Consultation with endocrinology or other resources should be sought as needed to help with 5. Long MT, Coursin DB, Rice MJ. Perioperative consider- pump operation. ations for artificial pancreas devices. Anesth Analg. 2019;128:902–906. APSF NEWSLETTER February 2020 PAGE 21

How Can We Tell How “Smart” Our Infusion Pumps Are? by Tim Vanderveen, PharmD, MS; Sean O’Neill, PharmD; and JW Beard, MD, MBA

INTRODUCTION capabilities and limitations of the infusion Medication errors are a leading cause of devices.9 patient harm in hospitals and operating rooms. Greater than 50% of medication errors that lead HOW INTELLIGENT ARE SMART to patient injury occur during the medication INFUSION PUMPS IN YOUR administration phase.1 Historically, medication ORGANIZATION? infusion devices served simply as a mechanical Infusion pumps collect information ranging device to infuse medications intravenously. The from discrete keystroke data to information advent of smart infusion pumps allowed for regarding clinicians’ responses to alerts. This clinical decision support tools to be integrated data is frequently communicated wirelessly to a into the medication administration process. This central server. However, this data can be chal- decision support in smart infusion pumps lenging to access and interpret and is often includes minimum and maximum alerts for underutilized by clinicians that are responsible dose, concentration, duration, and rate alerts for the oversight of these devices. The Institute and is part of the dose error reduction software for Safe Medication Practices (ISMP) completed (DERS) that exists in the majority of infusion a survey in 2018 to learn about the current utili- pumps on the market today. This decision sup- zation of smart pump data analytics. This survey port can prevent misprogramming of pumps or included responses from pharmacists and keystroke errors (examples of this type of error nurses at 126 hospitals and concluded that 96% 5 would be programming 55 mg instead of 5 mg). the DERS programming. Understanding the of respondents believe that using data from barriers to compliance with DERS use is the smart infusion pumps was vital to driving quality Smart pumps with drug libraries have most vital step when evaluating the impact of improvement. However, only 22% of respon- increasingly gained adoption in acute care smart infusion pumps in any organization. dents felt that their organization had the correct patient settings including the perioperative resources and skills to capture meaningful and area. A survey completed in 2017 by the Ameri- 2. Building and maintaining custom drug actionable insights from this data. ISMP recom- can Society of Health System Pharmacists libraries—The drug library which comprises mended that organizations utilize external (ASHP) identified that 88.1% of hospitals have the limits in DERS often need to be created resources, such as data companies or infusion adopted smart infusion pumps. This was a sub- from scratch. This library includes which medications are included as well as the pump manufacturers, to assist with data evalua- stantial increase from 2005 when only 35% of 10 hospitals reported using smart infusion pumps.2 safety alert thresholds for dose, concentra- tion when needed. tion, and duration/rate alerting. The process In 2010, over 100 stakeholders were invited to build these libraries is time-consuming and WHAT INFORMATION IS CAPTURED to attend an ASPF-sponsored medication resource-intensive. Unfortunately, this IN INFUSION DEVICES? safety conference to develop new strategies resource-intensive process of building a drug Conventional Data Evaluation and Compliance for improving medication safety in the operat- library is just the first step. Maintaining and with DERS ing room. The output of that meeting was a updating this content is of vital importance to When clinicians program infusion pumps, paradigm that focused on Standardization, achieve optimal results from this technology they are presented with a choice to either use Technology, Pharmacy/Prefilled/Premixed, and and if not completed can be an impediment the DERS or use a “no drug selected” or “basic Culture (STPC). Key recommendations from this of full smart pump adoption. infusion” mode. When DERS is not utilized, clini- meeting involved: 1) ensuring that all medication 3. Alarm/Alert fatigue—Smart infusion pumps cians remove all clinical decision support and and fluid infusions are administered via a smart safety limits from the process. Most infusion infusion device; and 2) facilitation of adequate are no different than any other health care technologies in that excessive alerts/alarms pump devices provide data on the percentage training and improved standardization of smart of infusions using the DERS. Clinicians may not 3 can lead to health care provider alarm or alert infusion pumps. A subsequent 2018 APSF realize how often programming errors occur fatigue.6–8 Stoelting Conference on medication safety rec- and how often DERS is bypassed. It is vitally ommended developing consensus between important to share this data with frontline clini- professional and patient safety organizations INTERVENTIONS TO OVERCOME BARRIERS TO SMART PUMP ADOPTION cians to provide an adequate feedback loop to on standardization of drug concentrations used support continuous quality improvement. in infusion administration.4 In 2010, the APSF Newsletter reported on a large health system’s implementation of smart Alert and Alarm Data CHALLENGES AND BARRIERS TO infusion pumps. Using the paradigm of STPC Alert fatigue and subsequent severe adverse SUCCESSFUL USE OF SMART PUMPS described above, Wake Forest University Bap- events have been associated with smart infu- tist Medical Center was able to successfully 6–8 There are a variety of challenges and barriers sion pump use. Alert fatigue is characterized standardize infusion-related practices across to achieving 100% adoption of smart infusion by clinician desensitization to alerts or alarms multiple patient care areas including the operat- pumps.5 These challenges include: which can lead to missed clinical alerts, delayed ing room. Key interventions leading to success assessment of patients and the potential for 1. Usability and workflow barriers—Not using in this implementation included: 1) Multidisci- serious patient harm.11,12 This desensitization the smart infusion pumps or using them plinary engagement incorporating pharmacy, occurs due to presence of clinically meaning- incorrectly diminishes their value in reducing nursing, intensive care providers, and anesthe- less or nuisance alerts.13 medication administration errors. Virtually all sia professionals; 2) A focus on standardization infusion pumps in the acute care setting now of all IV medications concentrations, dosing Infusion pump logs capture each alert and contain DERS. They also contain the ability to units, and adoption of smart pump technology the clinician's response to facilitate alert man- bypass this decision support. Key contribu- across the continuum of care in the organiza- agement to reduce fatigue. Infusion pump tors to noncompliance include outdated tion; and 3) An emphasis on training staff to associated clinical alerts can include minimum interfaces and the ability to easily opt out of ensure there was an understanding of the See “Smart Infusion Pumps,” Next Page APSF NEWSLETTER February 2020 PAGE 22

“Smart” Infusion Pumps

From “Smart Infusion Pumps,” Preceding Page Figure 1: Smart Pump Considerations for Anesthesia Professionals and maximum alerts for dose, concentration, and duration or rate alerts. Clinician responses • Dose Error Reduction Software (DERS) should be utilized for all medications administered via an can include overriding an alert and proceeding, infusion pump cancelling the infusions and preprogramming • Anesthesia and Pharmacy should collaborate on the following: as a basic infusion, or altering the infusion – Build of the Anesthesia medication drug library parameters to be within the alert limits. Assess- – Periodic review of the anesthesia medication alert and alert response data ing alert data has value to understand if alert – Maintenance and modification to drug library – Assessment of medication usage patterns when drug shortages occur fatigue exists, if limits need adjusting, or if there – Review of appropriate preparation and dispense volume for controlled substances are potential unsafe practices surrounding spe- – Evaluate dispensed versus administered drug amounts for “right sizing” to prevent waste cific medications. • Ensure that standard concentrations and dosing units exist between the perioperative anesthesia and critical care areas MEDICATION PRACTICE STANDARDIZATION sion pump data records the exact amount of Dr. Beard is medical director and shareholder of In 2015, ASHP initiated their Standardize 4 drug administered. The unused medication ICU Medical and a member of the APSF Editorial Safety campaign.14 This was the first national, could potentially be diverted and must be Board. interprofessional effort to help reduce the inci- dence of medication errors by standardizing accounted for as wasted. Controlled substance diversion monitoring can compare the dis- REFERENCES medication concentrations. Access and under- 1. Leape LL, Bates DM, Cullen DJ, et al. Systems analysis of adverse standing of infusion device data can provide pensed volume with the administered and the drug events. JAMA. 1995;274:35–43. details that can facilitate this standardization. wasted volumes to monitor for possible diver- 2. Schneider PJ, Pedersen CA, Scheckelhoff DJ. ASHP national sion. Minimizing opioid dispensing has been survey of pharmacy practice in hospital settings: dispensing and This data includes the following elements of administration—2017. AJHP. 2018;75:1203–1226. medication administration: 1) the overall usage associated with a reduction in opioid-related 3. Eichhorn, JH. APSF hosts medication safety conference. APSF 17–19 of specific agents; 2) the location where these complications in other patient care settings. Newsletter. 2010;25:1–20. https://www.apsf.org/article/apsf-hosts- medication-safety-conference/ Accessed November 4, 2019. medications are administered; 3) the dose and 4. Recommendations of the four work groups at the 2018 APSF concentrations that were commonly used; and DRUG SHORTAGE Stoelting conference on medication safety. APSF https://www.apsf. 4) the total volume administered. For example, Drug shortages have unpredictable onsets org/medication-safety-recommendations/. Accessed November 6, and have become a national patient safety 2019. analysis of infusion pump data might reveal 5. Giuliano KK, Ruppel H. Are smart pumps smart enough? Nursing. commonly used medications in anesthesia care crisis. From 2010 to 2018, there were almost 2017;47:64–66. areas and their concentrations. Having insight 1500 new shortages reported. Up to 63% of 6. Cho OM, Kim H, Lee YW, et al. Clinical alarms in intensive care units: into these practices can play a significant role in these shortages are related to injectable medi- perceived obstacles of alarm management and alarm fatigue in nurses. Health Inform Res. 2016;22:46–53. 20 achieving standardization. Standardizing con- cations. Drug shortages potentially force clini- 7. Tran M, Ciarkowski S, Wagner D, et al. A case study of the safety centrations and dosing units between anesthe- cians to use less familiar alternatives that may impact of implementing smart patient controlled analgesic pumps sia and inpatient units is a critical element of at a tertiary care academic medical center. J Qual Patient Saf. impact patient safety. Infusion pump data analy- 2012;38:112–119. medication safety as this might reduce the risk sis might provide a more precise measurement 8. Manrique-Rodriquez S, Sanchez-Galindo A, Fernandez-Llamazares of a medication error when a patient transitions of what drugs patients are being administered CM, et al. Smart pump alerts: all that glitters is not gold. Int J Med from one care area to another (Figure 1). and amounts that are actually wasted which Inform. 2012;81:344–350. 9. Vanderveen T, Graver S, Noped J, et al. Successful implementation might aid in conserving the drug supply during of the new paradigm for medication safety: standardization, technol- NOVEL DATA EVALUATION a national shortage. ogy, pharmacy, and culture (STPC). APSF Newsletter. 2010;25:26-28. Infusion pump data describes the total https://www.apsf.org/article/successful-implementation-of-the-new- paradigm-for-medication-safety-standardization-technology-phar- volume of an infusion administered to a patient CONCLUSIONS macy-and-culture-stpc/ Accessed December 23, 2019. and may serve to right-size dispensed amounts. Smart infusion pump use has been shown to 10. Smetzer J, Cohen M, Shastay A, et al. Survey results: smart pump For example, if Drug X is dispensed to a proce- data analytics. Acute Care ISMP Medication Safety Alert. reduce patient harm from injectable medica- 2018;23:1–4. dural area from the pharmacy or an automated tions, but safety features must be utilized to real- 11. ECRI Institute. Top 10 health technology hazards for 2014. Health dispensing cabinet in 100 mL, how do we know ize the full benefits of the technology. Health Devices. 2013;42:1–3. how much of this drug was administered? Tradi- 12. Joint Commission on Accreditation of Healthcare Organizations. care organizations might seek additional ways to tionally, clinicians have been left to manually The Joint Commission announces 2014 patient safety goal. Jt optimize use of this technology including the Comm Perspect. 2013;33:1–4. examine OR and EHR records to extract this management of dispensed container volumes, 13. Agency for Healthcare Research and Quality. Alert fatigue. https:// information. However, the data from the infu- psnet.ahrq.gov/primer/alert-fatigue. Accessed November 4, 2019. opioid diversion, and drug shortage manage- sion devices may provide an additional or more 14. American Society of Health Systems Pharmacists. Standardize 4 precise measurement of how much medication ment. A multidisciplinary effort to build effective Safety Initiative. https://www.ashp.org/pharmacy-practice/standard- anesthesia drug libraries, standardize infusions, ize-4-safety-initiative. Accessed November 4, 2019. was administered. 15. Fan M, Tscheng D, Hamilton M, et al. Diversion of controlled drugs and engage in a process of ongoing data analy- in hospitals: a scoping review of contributors and safequards. J NARCOTIC DIVERSION MITIGATION sis will maximize the effectiveness of the devices Hosp Med. 2019;14:419–441:28. and reduce the probability of medication errors. 16. Brummond PW, Chen DF, Churchill W, et al. ASHP guidelines on The impact of opioid diversion from health preventing diversion of controlled substances. AJHP. 2017;74:325– care facilities has been widely documented, but Tim Vanderveen, PharmD, MS is a consultant to 348. vulnerabilities in monitoring the use of con- ICU Medical. He is a past member of the APSF 17. Chen X, Ma Q, Barron J. Effect of controlled substance use man- 15 agement on prescribing patterns and health outcomes among trolled substances still exist. ASHP currently Board of Directors and is a member of the APSF high-risk users. J Manag Care Spec Pharm. 2019;25:392–401. recommends implementing a surveillance pro- Committee on Technology. He was previously 18. Bohert AS, Valenstein M, Bair MJ. Association between opioid pre- gram, which effectively monitors data from vice president, Center for Safety and Clinical scribing patterns and opioid overdose-related deaths. JAMA. medication technologies in high-risk areas such 2011;305:1315–1321. 16 Excellence for Becton Dickinson, and is a cur- 19. Groenewald CB, Zhou C, Palermo TM, Van Cleve WC. Associations as the OR. Understanding how much drug is rent shareholder. between opioid prescribing patterns and overdose among pri- dispensed versus how much is administered to vately insured adolescents. Pediatrics. 2019; 144:e20184070. a patient can be vital to a narcotic diversion Dr. O’Neill is the co-founder and chief clinical 20. American Society of Health Systems Pharmacists. Drug short- ages. Drug shortage statistics. https://www.ashp.org/Drug- monitoring program. For example, if fentanyl is officer at Bainbridge Health. He is a current Shortages/Shortage-Resources/Drug-Shortages-Statistics. dispensed in a 2500 mcg/250 mL bag, the infu- shareholder of Bainbridge Health. Accessed November 4, 2019. APSF NEWSLETTER February 2020 PAGE 23

Patient Blood Management Program Reduces Risks and Cost, While Improving Outcomes by Tymoteusz J. Kajstura and Steven M. Frank, MD

The 2019 first-place Ellison C. Pierce, Jr., MD, 500 Award for Best Abstract in Patient Safety was 450 awarded to Kajstura and colleagues for their work entitled “Best Practice Advisories Increase 400 Transfusion Guideline Compliance, Reduce 350 Blood Utilization, and Save Cost.” In this review, 300 2014 they describe how the patient blood manage- 2015 ment program across the Johns Hopkins Health 50 2016 System has had positive impacts on patient 200 2017 safety, guideline compliance, and cost savings.

Blood Utilization 150

Within the Johns Hopkins Health System, a patients) (units/1,000 100 variety of approaches have been implemented under the patient blood management program 50 which are summarized in Table 1.1,2 At the heart 0 of the program is education, since over the past RBC FFP PLTS decade multiple landmark studies have been published supporting the concept that “less is Figure 1: Across the entire health system, for each of the three blood components, changes in utilization (number of units per 1,000 patients) are shown over time. RBC–red blood cell, FFP–plasma, PLTS–platelets. more” when it comes to transfusion.3 In addi- tion, transfusion guidelines were reinforced by Permission to reuse granted by Wolters Kluwer Health. Reprinted from Frank SM, et al. Anesthesiology. 2017;127: 754-764.2 best practice advisories (pop-up alerts) in the electronic order sets, to inform clinicians when 2,4 comparing fiscal year 2017 (after most of these diverse array of health care professionals and orders were placed outside of guidelines. efforts were implemented) to 2014. There was allies coming together with the common goal of These individual efforts have resulted in a an annual savings of $2.4 million for the three optimizing the care of patients who may need large positive system-wide effect. Since the blood products combined, representing a transfusion. 400% return on investment for support of the implementation of the patient blood manage- Tymoteusz J. Kajstura is a medical student at program.2 Most importantly, these changes are ment program, overall transfusion rates have Johns Hopkins University and Dr. Frank is pro- having a positive impact on patient safety with decreased by 20% for red blood cells (P = fessor in the Department of Anesthesiology and measures such as length of stay showing no 0.0001), 39% for plasma (P = 0.0002), and 16% Critical Care Medicine and medical director of 2 change, morbidity/mortality decreasing from for platelets (P = 0.04) (Figure 1). Guideline com- the Blood Management Program at The Johns pliance has increased, with 35% fewer out-of- 1.5% to 0.75% (P = 0.035), and 30-day readmis- Hopkins Health System. guideline transfusion orders for red blood cells, sion rate decreasing from 9.0% to 5.8% (P = 0.0002).8 The success of this initiative at the 9% fewer for plasma, and 3% fewer for platelets. The authors have no conflicts of interest. By reducing unnecessary transfusions, the hos- Johns Hopkins Health System in patient blood management was in part predicated on the pital system has seen a significant cost savings; REFERENCES 1. Sadana D, Pratzer A, Scher LJ, et al. Promoting high-value Table 1. Methods Used to Improve Blood Utilization Across the Health System practice by reducing unnecessary transfusions with a patient blood management program. JAMA Intern Med. 2018;178:116–122. 1. Obtain financial support from health system leadership. 2. Frank SM, Thakkar RN, Podlasek SJ, et al. Implementing a 2. Assemble a multidisciplinary team for monthly meetings. health system-wide patient blood management program with a clinical community approach. Anesthesiology. 3. Education: Grand rounds and on-line tutorials emphasizing evidence-based transfusion guidelines. 2017;127:754–764. 3. Carson JL, Guyatt G, Heddle NM, et al. Clinical Practice 4. Harmonizing transfusion guidelines across the health system. Guidelines from the AABB: red blood cell transfusion thresholds and storage. JAMA. 2016;316:2025–2035. 5. A “Why Give 2 When 1 Will Do?” single-unit red cell transfusion campaign.5 4. Yang WW, Thakkar RN, Gehrie EA, et al. Single-unit transfu- 6. Screen saver images reinforcing transfusion guidelines. sions and hemoglobin trigger: relative impact on red cell utilization. Transfusion. 2017;57:1163–1170. 1 7. Clinical decision support with best practice advisories (best practice alerts, pop-up alerts). 5. Podlasek SJ, Thakkar RN, Rotello LC, et al. Implementing a "Why give 2 when 1 will do?" Choosing Wisely campaign. 8. Data acquisition and analytics. Transfusion. 2016;56:2164. 9. Transfusion guideline compliance audits with feedback (provider specific). 6. Grant MC, Resar LM, Frank SM. The efficacy and utility of acute normovolemic hemodilution. Anesth Analg. 10. Minimizing iatrogenic blood loss (smaller phlebotomy tubes and less testing). 2015;121:1412–1414. 7. Frank SM. Who benefits from red blood cell salvage?--Utility 11. Anesthetic management: (normothermia, controlled hypotension, antifibrinolytics, acute normovolemic and value of intraoperative autologous transfusion. Transfu- hemodilution).6 sion. 2011;51:2058–2060. 12. Surgical methods: (minimally invasive approaches, newer electrocauteries, topical hemostatic agents). 8. Gupta PB, DeMario VM, Amin RM, et al. Patient blood man- agement program improves blood use and clinical out- 13. Cell salvage.7 comes in orthopedic surgery. Anesthesiology. 2018;129:1082–91. APSF NEWSLETTER February 2020 PAGE 24

APSF-Sponsored 2019 ASA Panel on "Practical Approaches to Improving Medication Safety"

by John W. Beard, MD, MBA; Eliot Grigg, MD; Joyce A. Wahr, MD; and Elizabeth Rebello, Rph, MD, FASA, CPPS

As a follow-up to the 2018 Medication Safety Stoelting Conference, the APSF held a panel session titled “Practical Approaches to Improving Medication Safety” at the 2019 ASA Annual Meeting, in Orlando, FL. The goal of the APSF-sponsored safety panel was to provide front-line clinicians with actionable strategies to reduce medication errors.

Medication Safety Issues from a medication errors were related to infusion 5 physically prevent mistakes (like new Luer con- Manufacturer’s Perspective pumps. In a 2018 University of Washington nectors for regional anesthesia).10 by John W. Beard, MD, MBA study, infusion pump errors were identified and Dr. Grigg is associate professor of Anesthe­ Dr. Beard presented a view of medication significantly reduced by implementing a “smart siology at University of Washington and has no safety through the lens of manufacturing safety pump bundle” which included implementing financial disclosures. and the anesthesia medication workflow. He smart pumps for medication infusions, standard- identified key FDA safety principles, including izing infusion concentrations, and using central- ized pharmacy preparation of infusion Drug Shortages: Practical Substitutes the manufacturer’s obligation to introduce 6 products to market only after establishing that medications. When Your Most Important Anesthetic Medications are Missing they are safe and effective for the intended use. Dr. Beard recommended that anesthesia pro- He emphasized the importance of human fac- fessionals take the following actions to improve by Joyce A. Wahr, MD tors engineering in medical device design and infusion safety in the perioperative environment: Medication shortages have significantly product testing. By citing recommendations Table 1 : Author's Suggestions To impacted physicians in general and anesthesia from the European Union Medical Device Reg- professionals in particular, especially since the Improve Medication Infusion Safety ulation, he stressed that risk is preferably elimi- worst shortages involve sterile, generic medica- nated through design, and when residual risk Utilize smart pumps for the delivery of tions. Shortages are inherently dangerous exists it should be mitigated through additional medications and fluids* because providers must adapt to new and dif- methods such as protective equipment, alarms, ferent appearances or formulations of standard 1 Standardize smart pumps in operating labeling, and training. rooms and nonprocedural locations medications, or become familiar with the dosing, side effects, and nuances of a substi- Computerized physician order entry, double- Standardize concentrations of continuous 11 checked medication dispensing and prepara- medication infusions for use in anesthesia tute (e.g., glycopyrrolate for atropine). When tion, and bar code medication administration at and across units tracking shortages, the FDA only counts a med- ication in short supply when there is no other the time of administration for pills and injections Utilize centralized pharmacy preparation may add a higher level of safety to medication of continuous drips substitute available. The American Society of administration practices. Adoption of smart Hospital Pharmacists (ASHP), however, consid- Analyze smart pump data to evaluate ers whether a shortage causes pharmacies to pump-electronic health record (EHR) interopera- clinician compliance and smart pump bility technology may also provide an improve- effectiveness change how they provide that medication. ment in medication safety. The interface Since an acute change in the look, concentra- *This recommendation is consistent with draft ISMP tion, or expiration date of a medication poses between smart pumps and EHR works as a bidi- smart pump guidelines, which indicate that fluids are rectional wireless communication between the preferentially administered by smart infusion pump real risks for medication errors, the ASHP list of although gravity administration continues to have medications in short supply is more extensive smart pump and EHR, which enables “auto-pro- application in select circumstances.7 gramming” of infusion parameters onto the than the FDA’s shortage list . Dr. Beard is medical director and shareholder pump and “auto-documentation” of infusion of ICU Medical, Chicago, IL, and a member of The FDA has implemented a number of pump activity into the EHR. In non-OR environ- the APSF Editorial Board. approaches to mitigate the impact of medica- ments, smart pump-EHR interoperability has tion shortages but has little power to eliminate been shown to reduce medication errors, them.12 Nearly 40% of injectables are produced increase efficiency, and increase the accuracy Drug Administration Errors: Simple Steps to by only one manufacturer, and any disruption in 2-4 Improve the Anesthesia Workspace and and completeness of documentation. the supply chain or manufacturing may result in a Reduce the Risk of Medical Errors shortage. Natural disasters, such as Hurricane Infusion pump medication errors in anesthesi- by Dr. Eliot Grigg, MD ology were also highlighted. Although published Maria, which significantly impacted IV fluid man- Dr. Grigg highlighted the importance of data is limited, a 2010 New Zealand study dem- ufacturing, can cause an abrupt reduction in the streamlining processes and simplifying options onstrated that nearly one-third of self-reported supply of medications. Consolidation of manu- for medication handling in the OR.8 Many forms facturers, elimination of competition, changes in of safety countermeasures—like labels, alarms, distributors—all make management of medica- and two-provider checklists—provide feedback tion shortages extremely difficult. instead of more robust constraints. Prefilled syringes, for example, eliminate 6 sub-steps Often hospital pharmacies have to reach out- (prescribe, prepare, dispense, administer, side normal distribution chains to maintain a record, and monitor) and 19 possible failure normal supply of a critical drug. This process modes from medication preparation versus bar- can lead to falsified or substandard medica- coding, which does not provide a physical tions, such as the substandard heparin that was countermeasure but does require user compli- responsible for at least 10 deaths in the US, or 9 the chemotherapeutic agent that had no active ance. Ultimately, the goal of medication safety 13 design is to eliminate unnecessary options (like ingredient. Medication shortages are expen- excessive concentrations), automate processes sive: most hospitals have a full-time pharmacist (like wireless programming smart pumps), and See “Medication Safety,” Next Page APSF NEWSLETTER February 2020 PAGE 25

National Organizations Seek Solutions to Drug Concentration Standardization

From “Medication Safety,” Preceding Page In addition to the lack of concentration stan- 6. Bowdle, TA, Jelacic S, Nair B, et al. Facilitated self-reported dardization, drug mislabeling can increase anaesthetic medication errors before and after implementation to manage shortages and shortages allow of a safety bundle and barcode-based safety system. Br J manufacturers to increase prices.14 Table 2 pro- patient risk. The APSF has created a standard- Anaesth. 2018;121:1338–1345. vides some clinical suggestions on how to ization and innovation workgroup and has 7. Optimizing Safe Implementation and Use of Smart Infusion sponsored three conferences addressing over- Pumps. ISMP Post Summit Draft Safe Practice Statements. approach drug shortages. https://www.ismp.org/resources/draft-guidelines- all medication safety. The Food and Drug optimizing-safe-implementation-and-use-smart-infusion- Dr. Wahr is a professor and vice chair of Quality Administration has made provisions for loca- pumps. Accessed December 2, 2019 and Safety in the Department of Anesthesiology, tions where ­specific types of labeling, such as 8. Grigg, E.B., Litman, R.S. Feedback and constraints: rethinking University of Minnesota. Dr. Wahr speaks on the use of color-coded labels based on class of medication safety countermeasures. Br J Anaesth. behalf of medication safety for Aspen Medical. ,2018;121:1188-90. medication in the operating room, have an 16 9. Martin, LD, Grigg EB, Verma S, et al. Outcomes of a failure mode established use. The variance of medication and effects analysis for medication errors in pediatric anesthe- Standardization of Drug Labeling and administration in and out of the perioperative sia. Pediatr Anesth. 2017;27:571-80. Concentrations: Are We Different Than environment due to incremental versus com- 10. Grigg, EB, Roesler, A. Anesthesia medication handling needs a Other Groups Who Administer Drugs? plete administration further confounds the new vision. Anesth Analg. 2018;126:346–50. by Elizabeth Rebello, Rph, MD, FASA, CPPS issue. Anesthesia professionals have a unique 11. Fox ER, Sweet BV, Jensen V. Drug shortages: a complex health care crisis. Mayo Clin Proc 2014;89:361-7. understanding of the challenges and should Standardizing drug concentrations may miti- 12. Rinaldi F, de Denus S, Nguyen A, et al. Drug shortages: patients gate medication errors. This process should consider being engaged both at the local and and health care providers are all drawing the short straw. Can J focus on developing the fewest number of drug national level to provide input regarding this Cardiol. 2017;33:283-86. concentrations to provide safe clinical care. important patient safety issue. 13. Labadie J. Forensic pharmacovigilance and substandard or Standardization may include a limited set of con- counterfeit drugs. Int J Risk Saf Med. 2012;24:37-9. Dr. Rebello is associate professor in the 14. Hernandez I, Sampathkumar S, Good CB, et al. Changes in drug centrations for medications that have been Department of Anesthesiology and Perioperative pricing after drug shortages in the United States. Ann Intern Med. labeled as high-alert or are known to have pro- Medicine at the University of Texas MD Anderson 2019;170:74-76. duced a significant number of adverse events. Cancer Center and has no financial disclosures. 15. American Society of Health-System Pharmacists. Proceedings of a summit on preventing patient harm and death from I.V. The ASA Committee on Quality Management medication errors. July 14–15, 2008, Rockville, Maryland. Am J and Departmental Administration (QMDA) con- CONCLUSION Health-Syst Pharm. 2008;65:2367–79. vened a medication standardization safety work- The APSF has identified multiple techniques to 16. Bowdle TA. Drug administration errors from the asa closed group to explore solutions regarding drug improve medication safety in the operating room claims project. ASA Newsletter. 2003;67:11–13. concentration standardization to safeguard that are readily implemented in today’s proce- 17. Cooper L, Barach, P. Sweeping it under the rug: why medication dural environment. Anesthesia professionals can safety efforts have failed to improvement care and reduce patients with medication administration and to patient harm. ASA Monitor. 2018;82:36–38. adopt best practice medication safety tech- improve anesthesia professional workflow. An 18. Eichhorn JH. APSF hosts medication safety conference: Con- extensive literature review, closed claims studies, niques, including consideration of those summa- sensus group defines challenges and opportunities for and the REMEDI database served as important rized by the APSF Medical Safety Panel, to improved practice. APSF Newsletter. 2010;25:1–19. sources of data for the workgroup.9,10,15-29 These maximize patient safety and work to ensure that 19. Institute for Safe Medication Practices (ISMP). List of High-Alert “no one shall be harmed by anesthesia care.” Medications in Acute Care Settings. https://www.ismp.org/rec- efforts were highlighted in the 2018 Anesthesia ommendations/high-alert-medications-acute-list. Accessed Patient Safety Foundation (APSF) Stoelting Con- REFERENCES August 16, 2018. 27 ference, “Perioperative Medication Safety : 1. European Union Medical Device Regulation. 5 April 2017. 20. Institute for Safe Medication Practices (ISMP). Survey results: smart Advancing Best Practices,” and the following 10 2. Ohashi K, Dalleur O, Dykes PC, et al. Benefits and risks of using pump data analytics pump metrics that should be monitored to medications were identified with recommenda- smart pumps to reduce medication error rates: a systematic improve safety. July 12, 2018. https://www.ismp.org/resources/ review. Drug Saf. 2014;37:1011–1120. survey-results-smart-pump-data-analytics-pump-metrics-should- tions for drug concentration standardization: 3. Prusch AE, Suess TM, Paoletti RD, et al. Integrating technology be-monitored-improve-safety. Accessed July 27, 2018. to improve medication administration. Am J Health Syst Pharm. 21. Martin DE. Medication errors persist: summit addresses intrave- Insulin Dexmedetomidine 2011;68:835–842. nous safety. APSF Newsletter. 2008;2:37,39. Epinephrine Hydromorphone 4. Suess TM, Beard JW, Trohimovich B. Impact of patient-con- 22. Merry AF, Anderson BJ: Medication errors—new approaches to trolled analgesia (PCA) smart pump-electronic health record prevention. Paediatr Anaesth. 2011;21:743–53. (EHR) interoperability with auto-documentation on chart comple- Norepinephrine Lidocaine 23. Nanji, KC, Patel A, Shaikh S, et al. Evaluation of perioperative tion in a community hospital setting. Pain Ther. 2019;8:261–269. medication errors and adverse drug events. Anesthesiology. Phenylephrine Heparin 5. Webster CS, Larsson L, Frampton CM, et al. Clinical assessment 2016;124:25–34. of a new anaesthetic drug administration system: a prospective, Ketamine Remifentanil controlled, longitudinal incident monitoring study. Anaesthesia. 24. Phillips, MS. Standardizing I.V. infusion concentrations: national 2010;65:490–499. survey results. Am J Health-Syst Pharm. 2011;68:2176–82. 25. Sandnes DL, Stephens LS, Posner KL, Domino KB. Liability asso- ciated with medication errors in anesthesia: closed claims analy- Table 2: Author’s Suggested Approach to Drug Shortages sis. Anesthesiology. 2008;109:A770. 26. Wahr, JA, Abernathy JH, Lazarra EH, et al. Medication safety in Every anesthesia group should form a medication shortage committee that is led by the operating room: literature and expert-based recommenda- pharmacists and includes cardiologists and intensivists tions. Brit J Anaesth. 2017;118:32–43. The committee should meet on a biweekly or monthly schedule to review developing 27. https://www.apsf.org/past-apsf-consensus-conferences-and- and resolving shortages recommendations/ Accessed October 10, 2019. 28. Regenstrief National Center for Medical Device Informatics, Strategies for mitigation should be prepared, including waste reduction, use reduction, Regenstrief Center for Healthcare Engineering, Purdue Univer- supplier change, substitute identification, or formulation changes sity, 2019. https://catalyzecare.org/remedi Accessed October The committee should communicate shortage details to clinicians, including the mitigation 10, 2019. strategies 29. https://www.fda.gov/regulatory-information/search-fda-guid- ance-documents/safety-considerations-container-labels-and- Providers must also be alert to the possibility of substandard or falsified medications that may carton-labeling-design-minimize-medication-errors Accessed appear in our medication cart October 10, 2019. APSF NEWSLETTER February 2020 PAGE 26

A Difficult Airway Early Warning System in Patients at Risk for Emergency Intubation: A Pilot Study by Stephen Estime, MD; Anna Budde, MD; and Avery Tung, MD Management of a difficult airway during an such an early warning system has considerable out of operating room emergency intubation is potential to improve the care of inpatients who associated with high morbidity and mortality.1–5 require emergency intubation in the hospital. Such patients are often unstable, and This pilot study was limited in its a small sample advanced airway equipment and skilled assis- size and short timeframe. Defining a difficult tance are less available. Emergency airway airway is highly variable as is the use of prophy- management in the patient with an unantici- lactic video laryngoscopy and fiberoptic bron- pated difficult airway is particularly perilous choscopy during emergency intubations. when there is limited time to develop a plan or Future work will focus on better identifying bring additional equipment to the bedside. Cur- patients at high risk for emergency intubation. rent literature suggests that difficult airway Ultimately, we plan to test whether advanced management is associated with a high inci- dence of desaturations, failed attempts, and dif- lead time changes how intubations are ficult bag mask ventilation.1,3–5 ing room and difficulties with initial attempts approached and whether these improve mea- may quickly lead to patient morbidity. Docu- surable patient safety outcomes. In principle, advanced knowledge that a mentation of a difficult airway is often subjective Dr. Estime is an assistant professor of Anesthe- patient has a difficult airway should reduce the and inconsistent8,9 and by including the use of sia & Critical Care at the University of Chicago risk of emergency intubation. In such patients, a adjunctive airway equipment in our definition, Medical Center. plan can be formulated in advance, multidisci- we aimed for more objective criteria. plinary expertise can be arranged, equipment Dr. Budde is an assistant professor of Anesthesi- can be made ready, and the decision to intu- RESULTS ology at the University of Minnesota. bate can be made earlier to reduce time pres- During the two-month pilot period, twenty- Dr. Tung is a professor of Anesthesia & Critical sure. However, it is not cost-effective to assess one patients were identified by rapid response the airway of every patient in the hospital (or nursing assessments as having a known or sus- Care at the University of Chicago Medical even in the ICU) as only a small fraction of pected difficult airway. Nearly 62% (13/21) Center. Dr. Tung also serves as the quality chief patients will require an emergency intubation. required an emergency intubation during their for the Department of Anesthesia and Critical To improve the quality of out of operating hospitalization and 92% of those (12/13) had a Care at the University of Chicago. room difficult airway management, we part- difficult airway. Approximately 57% (12/21) of the nered with our rapid response nursing team to known or suspected difficult airway patients Drs. Estime and Budde have no conflicts of incorporate airway assessments into the rapid were intubated emergently and had a con- interest to disclose. Dr. Tung serves as section response evaluation. Nurses were asked to firmed difficult airway of which 58% (7/12) editor for Critical Care & Resuscitation and identify known difficult airway patients based required video laryngoscopy and 42% (5/12) Anesthesia & Analgesia. on medical history and by alerts such as brace- required fiberoptic bronchoscopy. None of the lets and electronic chart alerts. The rapid patients experienced failed airway manage- REFERENCES response nurses were also taught to perform ment. One death occurred during a difficult 1. Scott JA, Heard SO, Zayaruzny M, et al. Airway manage- an abbreviated airway exam based on the intubation though this was in the midst of a car- ment in critical illness: an update. Chest. November 2019. Look, Evaluate, Mallampati Score, Obstruction diac arrest requiring chest compressions from a doi:10.1016/j.chest.2019.10.026. and Neck Mobility (LEMON) score6 that could suspected pulmonary embolus prior to arrival of 2. Mort TC. Complications of emergency tracheal intubation: be utilized at the time of a rapid response eval- the emergency airway team. immediate airway-related consequences: part II. J Intensive Care Med. 2007;22:208–215. uation to identify suspected difficult airway Our data suggest that early warning of emer- patients (Table 1). 3. Schwartz DE, Matthay MA, Cohen NH. Death and other gency intubation in known and suspected diffi- complications of emergency airway management in criti- Patients identified by the rapid response cult airways is possible. Through strategic cally ill adults. A prospective investigation of 297 tracheal nurses as either known or suspected difficult partnering, we created an early warning system intubations. Anesthesiology. 1995;82:367–376. airways were placed on a difficult airway “list” which identified over half the patients who 4. De Jong A, Rolle A, Molinari N, et al. Cardiac arrest and mor- in the electronic medical record and their hos- would require an emergency intubation and tality related to intubation procedure in critically ill adult patients: a multicenter cohort study. Crit Care Med. pital course was monitored over a two-month have a confirmed difficult airway. If formalized, 2018;46:532–539. period. We assessed for the incidence of emer- 5. Joffe AM, Aziz MF, Posner KL, et al. Management of difficult gency intubation and difficult intubation on tracheal intubation: a closed claims analysis. Anesthesiol- post-intubation assessment. We defined a dif- Table 1: Questions for identifying ogy. 2019;131:818–829. ficult airway as an intubation requiring more patients with a suspected difficult airway 6. Reed MJ, Dunn MJG, McKeown DW. Can an airway assess- than two attempts of direct laryngoscopy by a ment score predict difficulty at intubation in the emergency senior anesthesia resident (PGY-3 and above) 1. Does the patient have limited neck range department? Emerg Med J. 2005;22:99–102. or attending and/or the use of adjunctive of motion (e.g., cervical collar, severe cer- 7. Apfelbaum JL, Hagberg CA, Caplan RA, et al. Practice airway equipment (e.g., video laryngoscopy, vical neck disease)? guidelines for management of the difficult airway: an fiberoptic bronchoscopy). Defining a difficult updated report by the American Society of Anesthesiolo- airway is variable,7,8 and we expanded the 2. Does the patient have limited mouth gists Task Force on Management of the Difficult Airway. Anesthesiology. 2013;118:251–270. ASA’s difficult airway definition9 of a conven- opening (e.g., connective tissue disorder, jaw wiring)? 8. Bradley JA, Urman RD, Yao D. Challenging the traditional tionally trained anesthesia professional experi- definition of a difficult intubation: what is difficult? Anesth encing difficulty to include a senior resident 3. Does the patient grossly appear difficult Analg. 2019;128:584–586. because unlike operating room intubations, (e.g., super morbid obesity, distorted 9. Meitzen SE, Benumof JL. Video laryngoscopy: positives, residents are often the first responders during negatives, and defining the difficult intubation. Anesth an emergency intubation outside of the operat- facial anatomy, airway bleeding)? Analg. 2019;128:399–401. APSF NEWSLETTER February 2020 PAGE 27

PRO-CON DEBATE PRO: Artificial Intelligence (AI) in Health Care by Michael Buist, MbChB, MD, FRACP, FCICM This Pro-Con Debate took place at the 2019 Stoelting Conference entitled "Patient Deterioration: Early Recognition, Rapid Intervention, and the end of Failure to Rescue." The two following authors have expertise in the field of adopting artifical intelligence for managing patients who are deteriorating in the hospital setting.

Artificial intelligence (AI), or machine intelli- and inform clinical practice guidelines using gence, has been defined as “intelligence dem- real-time patient data. onstrated by machines, in contrast to the At its simplest, AI can be thought of as a deci- natural intelligence displayed by humans” and sion rule: “what, if, then, and.” For example, the “…any device that perceives its environment “what” could be the patient with urosepsis, the and takes actions that maximize its chance of 1 “if” is the prescription of gentamicin, the “then” successfully achieving its goals.” is renal function, and the “and” is what are the Wikipedia goes on to classify AI into three dif- other prescribed medications. AI can then warn ferent types of systems1: about drug interactions and provide precise and safe dosage information, which can then be 1. Analytical tance from AI to aid health care professionals altered in real-time based on variations in drug 2. Human-inspired, and in the day-to-day decision making about their levels, other drug doses, and changes in renal 3. Humanized artificial intelligence patients. Health care professionals need to function.6 This capability exists in most elec- understand, and be involved in, the develop- AI was founded as an academic field in 1956. tronic prescribing systems. This author devel- ment of these machine-assisted decision Over the ensuing six decades, it has evolved to oped an AI approach in response to the develop systems capable of undertaking com- problem of Rapid Response Team (RRT) “affer- devices so that they are constructed to the plex real-time tasks that would be unachievable ent limb failure” (e.g., not calling for help despite highest technical standards focused on best by the unassisted human brain. Early adopters activation criteria being met).7 We identified practice patient outcomes. in AI include the military, which has used auton- several staff cultural problems that contributed Dr. Buist is professor of Health Services at the omous and semi-autonomous drones; finance, to this phenomenon.8 The solution required University of Tasmania, Tasmania, Australia. in which AI enables real-time fraud detection; electronic entry of patient’s physiological obser- and the automotive industry, in which AI facili- vations, real-time comparison of those observa- He is the founder, a previous director, and chief tates collision avoidance. tions to the RRT activation criteria, and then medical officer of Patientrack. This company The multitrillion-dollar industry of health care issuing a series of automated alerts to the pre- was sold to another health ICT company called has been slow to adopt information technology determined clinical team members. This system Alcidion (ALC) that is listed on the Australian (IT) in general and AI in particular. This might be facilitated individualization of activation criteria stock exchange. Professor Michael Buist is a due to some of the conflicting interests that for each patient as well as customization of the substantial stockholder in ALC. exist between the doctor/patient relationship mode and order in which clinical team mem- and the documentation requirements of the bers are alerted. With this innovative approach, REFERENCES health care profession, management and pro- clinical response as per a National Health Ser- 1. https://en.wkipedia.org/wiki/Artificial_intelligence. batory requirements, and the existence of vice (NHS) Trust Hospital Early Warning Score Accessed on October 29, 2019. 8 costly legacy IT systems.2 While skepticism (EWS) improved to 97% from a baseline of 68%. 2. Rudin RS, Bates DW, MacRae C. Accelerating innovation in Health IT. N Engl J Med. 2016;375:815–817. towards IT and AI solutions is understandable, The argument for AI in health care is not 3. Buist M, Middleton S. Aetiology of hospital setting adverse our continued struggles with preventable about the potential for better reasoning and 2 events 1: limitations of the Swiss cheese model. Br J Hosp adverse events, poor adoption of evidence- problem solving, knowledge presentation, nat- Med (Lond). 2016;7:C170–C174. based practice, and persistence in using non- ural language processing, and social intelli- 4. Ioannidis JP. Evidence-based medicine has been hijacked: 3 beneficial, sometimes harmful practices gence; it is about doing the things in health care a report to David Sackett. J Clin Epidemiol. 2016;73:82–86. argues for an earnest evaluation of the potential that, for whatever reason, we don’t do, in part 5. Harris A, Hicks LA, Qaseem A, High Value Care Task Force for AI to improve patient safety and outcomes. due to the frailties of the human brain. A com- of the American College of Physicians & Centers for Dis- pelling example is provided by Ruth Lollgen in ease Control and Prevention. Appropriate antibiotic use for The main argument for AI in health care is the acute respiratory tract infection in adults: advice for high- potential to provide better real-time solutions the New England Journal of Medicine, writing value care from the American College of Physicians and the for practitioners that improve outcomes for about her personal experience of intimate part- Centers for Disease Control and Prevention. Ann Intern 9 patients. One of the most important applica- ner violence. Despite being an emergency Med. 2016;164:425–434. tions is the translation of research findings into pediatric physician, she presents herself on 6. Qureshi I, Habayeb H, Grundy C. Improving the correct pre- numerous occasions to emergency depart- scription and dosage of gentamicin. BMJ Open Quality. consistent, reliable evidence-based practice 2012: 1, doi: 10.1136/bmjquality.u134.w317. https://bmjopen- occurring in the office and at the bedside. ments with injuries that are consistent with a quality.bmj.com/content/1/1/u134.w317 Accessed November Admittedly, the development of “evidence” is nonaccidental aetiology. Yet the pattern of the 4, 2019. fraught with inferential problems,4 but there are injuries on presentations and over time does 7. Marshall S, Shearer W, Buist M, et al. What stops hospital relatively uncontroversial evidence-based prac- not lead to any clinical suggestion of nonacci- clinical staff from following protocols? An analysis of the incidence and factors behind the failure of bedside clinical tices, such as avoidance of antibiotic prescrib- dental injury. She laments that no one asks the question of, “Do you feel safe at home?” Asking staff to activate the Rapid Response System (RRS) in a multi- ing for acute upper respiratory tract infections, campus Australian metropolitan health care. BMJ Qual Saf. where there remains a large evidence-to-prac- the important questions as above may provide 2012;21:569–575. tice gap.5 AI has the potential to, in real time, improved safety for our patients and providers. 8. Jones S, Mullally M, Ingleby S, et al. Bedside electronic cap- incorporate all patient data and outcomes rele- The complexities of health care, a rapidly ture of clinical observations and automated clinical alerts to improve compliance with a NHS Trust Early Warning Score vant to a given clinical question. Such an AI growing body of research knowledge, an (EWS) protocol. Crit Care Resusc. 2011;13:83–88. system could prompt or alert practitioners when internet-savvy client and patient population, 9. Lollgen, RM. Visible injuries, unrecognised truth—the reality they are deviating from practice guidelines. and, most importantly, the frailties of the of intimate partner violence. N Engl J Med. 2019;381:15: Conceivably, AI could also continually update human brain, necessitate the need for assis- 1408–1409. APSF NEWSLETTER February 2020 PAGE 28

CON: Artificial Intelligence is Not a Magic Pill by Piyush Mathur, MD, FCCM

Artificial Intelligence (AI) is supposed to hold Indeed, poor predictive values continue to the promise of curing many problems facing limit the adoption of well-researched AI algo- health care such as predicting morbidity and rithms. Results based on the "area under the mortality and outperforming physicians at diag- curve"—a statistical reflection of “model fit”— nosis. In reality, despite increasing research, have been extensively exploited to report accu- there are a limited number of clinically validated racy of these algorithms. However, multiple AI algorithms. Even as the number of U.S. Food other parameters should be considered, includ- and Drug Administration-approved AI applica- ing sensitivity and positive predictive value. tions grows, the implementation and wide- Without good predictive values and replicable spread use of these applications has been results, AI algorithms are unlikely to be adopted 8 challenging. Computer scientist Rodney by clinicians. Brooks described some of the challenges with Scalability and generalizability of AI algo- AI predictions. These include overestimating or rithms is another big challenge in health care. underestimating solutions, imagining magical While electronic health records are the primary algorithms, the scale of deployment, and per- means to deploy many of these algorithms, formance limitations.1,2 poor interfaces, limited support for IT teams, cially radiologists and oncologists, are already leading the development of many AI algorithms AI performance limitations are especially and lack of integrated solutions still limit the ease of adoption. to avoid ill-prepared solutions creeping into their important in diagnostic AI solutions. Many work environment. Anesthesia professionals researchers using artificial neural networks Marketing and hype created by some organi- and perioperative clinicians who have been have claimed to improve diagnosis and out- zations has also had a negative impact and early adopters of technology and live in a data- perform clinicians, as in diagnosis of diseases resulted in loss of credibility of AI amongst rich environment also need to lead research, visualized on chest X-rays.3 Often, these self- many clinicians. Some of the well-researched development, and deployment of sustainable AI limited, narrow spectrum algorithms can detect breakthroughs have been hyped enormously algorithms to provide safer care to our patients. lesions such as atelectasis or infiltrates on to leverage the current market value associated chest X-rays. Despite claims of high accuracy with AI. In a survey of European startups using Dr. Mathur is staff anesthesiologist/intensivist in however, these applications have been hard to AI by the London venture capital firm Marsh & the Department of General Anesthesiology and replicate and generalize.4 In other approaches McLennan Companies, Inc. (MMC), 40% were the quality improvement officer, Anesthesiology 9 to machine learning, the computer algorithm not actually using AI as a part of their product. Institute, Cleveland Clinic, Cleveland, Ohio. learns from clinician-labeled data. In many pub- AI does hold the promise of delivering poten- The author has no conflicts of interest to licly available chest X-ray data sets underpin- tially safer solutions for health care using the disclose. ning these algorithms, lesions are labelled by ever-increasing volume of data in an efficient radiologists as infiltrates, mass, atelectasis, etc. and reproducible manner. But realizing this REFERENCES These clinician assessments are considered potential requires clinician leadership and rigor- 1. Brooks R. https://www.technologyreview.com/s/609048/ the “gold standard,” but significant inter-rater ous clinical validation while developing and the-seven-deadly-sins-of-ai-predictions/. MIT technology differences have been noted,5 raising the spec- deploying AI algorithms (Table 1). review. 2017. Accessed December 9, 2019. ter of mislabeled datasets. Algorithms created 2. Panetta K. https://www.gartner.com/smarterwithgartner/5- Table 1: Solutions for Effective trends-appear-on-the-gartner-hype-cycle-for-emerging- from such mislabeled datasets are likely to Deployment of AI in Health Care technologies-2019/. Accessed August 29, 2019. have significant errors in their results which can 3. Rajpurkar P, Irvin J, Ball RL, et al. Deep learning for chest confound clinician decision-making. Patient- and care-provider-centric—first do radiograph diagnosis: a retrospective comparison of the no harm CheXNeXt algorithm to practicing radiologists. PLoS Med. AI-based prediction of disease is similarly 2018;15:e1002686. problematic. In the research done on predic- Clinician leadership 4. Zech JR, Badgeley MA, Liu M, et al. Variable generalization performance of a deep learning model to detect pneumo- tion of acute kidney injury by Tomasev et al., Rigorous model development and testing nia in chest radiographs: A cross-sectional study. PLoS prediction bias was introduced through the Explainable or Interpretable solutions— Med. 2018;15:e1002683. dataset itself. Their U.S. Veteran Affairs dataset avoidance of black box 5. Oakden-Rayner L. Exploring large-scale public medical contained only 6.4% female patients; model image datasets. Acad Radiol. 2019. Clinical validation for generalizability and performance in these patients was lower than 6. Tomasev N, Glorot X, Rae JW, et al. A clinically applicable scalability approach to continuous prediction of future acute kidney 6 the rest. Bias continues to be a challenge even injury. Nature. 2019;572:116–119. Cost-effective solutions in administrative datasets and solutions devel- 7. Obermeyer Z, Powers B, Vogeli C, et al. Dissecting racial oped for use by health care executives or insur- We are still in the early phases of research bias in an algorithm used to manage the health of popula- tions. Science. 2019;366:447–453. ance companies. As demonstrated by and development of AI algorithms for health 8. Ginestra JC, Giannini HM, Schweickert WD, et al. Clinician Obermeyer et al., these biases can be intro- care. Clearly, the growth in AI has been expo- perception of a machine learning-based early warning duced at the level of algorithm development, nential and the pace is likely to continue in the system designed to predict severe sepsis and septic shock. but can also be based on the dataset used or near future. We need to be prepared to dedi- Crit Care Med. 2019;47:1477–1484. 7 cate clinical, information technology, and finan- 9. Olson P. https://www.forbes.com/sites/parmyol- the way the algorithm is implemented. These son/2019/03/04/nearly-half-of-all-ai-startups-are-cashing- biased algorithms can lead to delivery of cial resources to see effective utilization of in-on-hype/#454f99e7d022. Forbes. Accessed March 4, improper unsafe treatment to our patients. these remarkable algorithms. Clinicians, espe- 2019. APSF NEWSLETTER February 2020 PAGE 29

Balancing Sustainability and Infection Control: The Case for Reusable Laryngoscopes by Diane Gordon, MD; Jodi D. Sherman, MD; Richard Beers, MD; and Harriet W. Hopf, MD

In their articles in the October issue of the goscope handle contains lithium batteries, a Dr. Beers is professor of Anesthesiology at the APSF Newsletter, Drs. Prielipp, Birnbach, light source, and metal and plastic that are State University of New York, Upstate Medical Schaffzin, Johnston, and Munoz-Price outline a rarely effectively recycled at present. Anesthe- Center and chair, ASA Committee on Occupa- comprehensive approach to infection control sia professionals have a duty to consider the tional Health and Safety. Dr. Hopf is professor of by anesthesia professionals.1,2 We agree with harm to global health associated with the man- Anesthesiology and adjunct professor of Bio- most of their recommendations, including fre- ufacturing, packaging, transport, and disposal medical Engineering at the University of Utah, quent hand hygiene, cleaning the intravenous of these single-use items.7 Salt Lake City, UT, and a member of the ASA hub before injection, aseptic practices during Committee on Equipment and Facilities. medication preparation and administration, and In a recent comprehensive life-cycle analysis, decontaminating environmental surfaces.3 We a compelling case is made for reusable laryngo- Dr. Sherman has received a speaking respectfully disagree, however, with the scopes on the basis of patient safety, environ- honorarium from Getinge USA. Drs. Gordon 4 authors’ conclusion that single-use disposable mental impact, and cost. When all costs were and Beers have no disclosures. (SUD) laryngoscopes are cost-effective com- compared, reusable laryngoscopes were pared to reusable laryngoscopes. 10-fold less expensive than SUD laryngo- REFERENCES scopes, and greenhouse gas emissions were 1. Prielipp RC, Birnback DJ. Health care-associated infections: The authors’ begin by calling for expanded 16–25 times less.4,8 Several studies suggest a call to anesthesia professionals. APSF Newsletter. reprocessing procedures for reusable laryngo- that disposable laryngoscopes have not been 2019;34:29–32. scope handles. Implementing these expanded 2. Schaffzin J, Johnston L, Munoz-Price LS. The hospital epi- shown to provide superior reliability or intubat- procedures would require disassembly and demiologist’s perspective on the anesthesia operating ing conditions compared with reusable laryngo- room work area. APSF Newsletter. 2019;34:37–39. transport of the handles to a central reprocess- 4,8-9 scopes. 3. Munoz-Price LS, Bowdle A, Johnston BL, et al. Infection pre- ing area. The authors go on to state that, “the vention in the operating room anesthesia work area. Infect cost of reprocessing reusable laryngoscopes to Without evidence of benefit, broad imple- Cont Hosp Ep. 2019;40:1–17. this new standard is substantial.” As a result of mentation of disposable laryngoscopes would 4. Sherman JD, Raibley LA, Eckelman M. Life Cycle assess- their “new standard,” the authors endorse substantially increase (and already has) anes- ment and costing methods for device procurement: com- paring reusable and single-use disposable laryngoscopes. “adopting single-use products [i.e., disposable thesia-related costs and pollution. Anesthesia Anesth Analg. 2018;127:434–43. laryngoscopes]” because they “may actually be professionals, as leaders in patient safety, have 5. Call TR, Auerback FJ, Riddell SW, et al. Nosocomial con- 1,2 quite cost favorable.” a duty to use evidence-based data to minimize tamination of laryngoscope handles: challenging current guidelines. Anesth Analg. 2009;109:479–83. Requiring that laryngoscope handles the incidence and impact of adverse out- comes.9,10 In its broadest context, this includes 6. Negri de Sousa AC, Levy CE, Freitas MIP. Laryngoscope undergo high-level disinfection is contrary to blades and handles as sources of cross-infection: an inte- the recommendations of the Centers for Dis- adverse outcomes that impact public health. grative review. J Hosp Infect. 2013;83:269–275. ease Control and Prevention (CDC) (https:// Dr. Gordon is assistant professor of Anesthesiol- 7. Chapter 2: Defining and assessing risks to health. In: The www.cdc.gov/infectioncontrol/guidelines/disin- World Health Report 2002: reducing risks, promoting ogy at the University of Colorado and member healthy life. Geneva: World Health Organization, 2002, pp. fection/rational-approach.html) of the ASA Environmental Task Force. 7–27. While laryngoscope blades are properly 8. Sherman JD. Reusable vs disposable laryngoscopes. APSF Dr. Sherman is associate professor of Anesthesi- Newsletter. 2019;33:91. required to undergo central reprocessing, we ology, and of Epidemiology (Environmental 9. Sherman JD, Hopf HW. Balancing infection control and contend that the evidence does not support Health Sciences), at the Yale School of Medicine, environmental protection as a matter of patient safety: the subjecting handles to the same standard. New Haven, CT, and member of the ASA Com- case of laryngoscope handles. Anesth Analg. 2018;127:576–579. Laryngoscope handle contamination with pri- mittee on Equipment and Facilities, and the marily normal skin flora is well-documented.4-6 10. Watts, N. et al. The 2019 report of the Lancet Countdown on Committee on Occupational Health and Safety. health and climate change: ensuring that the health of a However, to our knowledge, there has not been Dr. Sherman is also co-chair of the ASA Subcom- child born today is not defined by a changing climate. a documented case of a hospital-associated Lancet. November 13, 2019 https://doi.org/10.1016/S0140- mittee on Environmental Health. infection transmitted by either laryngoscope 6736(19)32596-6 handles or blades that were reprocessed as per current CDC guidelines. Introducing New Board of Directors Member Josh Lea We agree that laryngoscope handles should undergo a verifiable low-level disinfection pro- Josh Lea is a certified registered nurse anesthetist at Massa- cess for surface decontamination just as any chusetts General Hospital (MGH), Boston, MA, and serves on the other environmental surface, and that blades faculty at Northeastern University’s Nurse Anesthesia Program. should remain wrapped until their use on a His area of interest focuses on healthy work environments and patient. most recently exploring proficiency among anesthesia profes- sionals with advanced medical technology. Dr. Lea has pre- Cost-benefit calculations must include sented on these topics nationally and internationally and is a assessment of environmental harms and medi- member of MGH’s CRNA Educational Committee and a past cal waste costs. The World Health Organization member of the AANA’s Health and Wellness Committee. We are (WHO) endorses this approach; in its World proud to welcome Josh as a new member of the APSF Board of Health Report, WHO “strongly advocates the Directors. He has also been a very active member of the APSF assessment of population-wide risks…in strate- Editorial Board and as an APSF Social Media Ambassador. gies for risk reduction.” Each disposable laryn- Josh Lea, DNP, MBA, CRNA RAPID Response TO YOUR IMPORTANT QUESTIONS

RAPID RAPID ResponseResponse TOTO YOUR QUESTIONS IMPORTANT QUESTIONS FROM READERS

RAPID Response TO QUESTIONS FROM RAPID READERS Response RAPID Response

APSF NEWSLETTER February 2020 PAGE 30

to questions from readers Perils and Pitfalls With the to questions from readers Rapid Infusion Catheter (RIC) N by Eric McDaniel, MD; Roy Kiberenge, MD; Robert Gould, MD

INTRODUCTION DISCUSSION The rapid infusion catheter (RIC) is a device The preloaded dilator-catheter Dilator used to convert standard peripheral intrave- assembly of the RIC system nous (PIV) access into a large-volume resuscita- allows for efficient large bore RtionAPID R portal.APID R1 APIDTheR RESPONSE APIDplacementRESPONSE RESPONSE R ofESPONSE this large-bore peripheral venous access in to(8.5F) your intravenousimportant questions catheter is performed N in clini- patients. However, its pre- cal scenarios where clinicians anticipate the assembled dilator/catheter Catheter need for large volume resuscitation, and in our design led to a misunderstanding by the anesthesia professional in case, in preparation for a liver transplantation. this case; thus, the entire assem- This case illustrates once again how inexperi- bly was incorrectly left in vivo. ence or unfamiliarly with invasive devices such The Luer-lock connection to the as this “simple” intravenous catheter has the vascular dilator was interpreted potential for perioperative complications and as “confirmation” of this (errone- significant patient injury. ous) assumption of where to con- nect the IV tubing. A subsequent Figure 1: Depicts an 8 French Figure 2: The yellow arrow shows RAPID RCASEAPID RDESCRIPTION APIDR RESPONSE APIDRESPONSE RESPONSE rootR causeESPONSE analysis (RCA) deter- Rapid Infusion Catheter with the the connection between the RIC A 47-year-old man with past medical history mined four contributing factors: dilator (blue) in situ. dilator hub and infusion tubing. ofto atrial your fibrillation important and hepatocellular questions carcinoma 1. a lack of operator knowledge, skill, and expe- 2. Chou WH, Rinderknecht TN, Mohabir PK, et al. Skin necro- presented for a deceased donor liver trans- rience with RIC insertion, sis distal to a rapid infusion catheter: understanding possi- plant. After an uneventful induction of general 2. the supervising anesthesiologist was dis- ble complications of large-bore vascular access devices. Cureus. 2019;11:e3854. anesthesia, we inserted an 8.5 French Rapid tracted by two concurrent invasive proce- Infusion Catheter (RIC) (Figure 1) in anticipation dures, of large-volume resuscitation. A standard tech- 3. the preloaded dilator on the RIC was devoid REPLY: nique was utilized for RIC insertion; i.e., a 20G of any label warning it must be removed prior On behalf of Teleflex, I would like to thank peripheral intravenous (PIV) catheter was ini- to transfusion, and you and the Anesthesia Patient Safety Founda- tially inserted in the right antecubital brachial 4. the ability to successfully connect intrave- tion (APSF) for forwarding a letter, which you vein, providing access for the RIC guidewire. nous tubing to the dilator itself. The RIC vein dilator/8.5 F catheter assembly recently received from a physician describing We were fortunate that this event resulted in was then advanced to its normal position within an erroneous use of the Arrow® RIC® Rapid no permanent injury to the vascular system or Infusion Catheter Exchange Set. The concern the vein. To confirm venous placement, intrave- 2 soft tissue of the arm. However this incident raised by the clinician was that the sheath/dila- nous tubing was connected to the dilator hub to could have been catastrophic given that the tor assembly was left in the patient (without transduce vascular pressure and confirm system was attached to a high-volume, positive- venous placement. However, contrary to pressure fluid infusion pump. Medical centers removing the dilator) and then connected to a normal insertion procedures, the operator then and departmental directors should ensure ade- rapid infusion system. This adverse event has failed to remove the venous dilator, and incor- quate education of all OR staff and anesthesia been forwarded to the appropriate department rectly attached one limb of the rapid infusion professionals whenever new or novel devices within Teleflex and will go through the usual system tubing directly to the RIC dilator (Figure are introduced into the clinical arena. complaint management/risk evaluation pro- 2). The rapid infusion system ran smoothly, and Dr. McDaniel is a CA-2 anesthesiology resident at cess. In the meantime, we are committed to high-pressure alarms were not triggered the University of Minnesota. Dr. Kiberenge is an patient safety—as are you and the >122,000 despite infusion rates up to 400 mL/min. Patient assistant professor in the Department of Anesthe- anesthesia providers who will be receiving your positioning was reconfirmed throughout the siology at the University of Minnesota. Dr. Gould is publication—and we can only reinforce to clini- extended operation, and no swelling, edema, an associate professor in the Department of Anes- cians the importance of using the device as or signs of vascular extravasation were noted in thesiology at the University of Minnesota. instructed in the IFU. the affected limb. It was only upon transport to None of the authors have any conflicts of Best regards, the ICU the next day that the right arm was interest. noted to be edematous secondary to an infiltra- Chris C. Davlantes, MD, FACEP tion associated with the RIC dilator. The RIC REFERENCES Medical Director system was removed, and the dilator was con- 1. Brown NJ, Duttchen KM, Caveno JW. An evaluation of flow Vascular & Emergency Medicine rates of normal saline through peripheral and central firmed to have been left in place within the 8.5 F venous catheters [abstract]. Anesthesiology. Global Clinical & Medical Affairs catheter itself. 2008;109:A1484. Teleflex

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LAST Revisited: A Paradigm in Evolution

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Healthy Relationships Between Anesthesia Professionals and Surgeons Are Vital to Patient Safety

APSF Awards 2020 Grant Recipients

How Can We Tell How “Smart” Our Infusion Pumps Are?

PRO-CON: Artificial Intelligence in Health Care