¨ NEWSLETTER www.apsf.org The Official Journal of the Anesthesia Patient Safety Foundation

Volume 20, No. 4, 61-88 Circulation 76,548 Winter 2005-2006

Patient Perspectives Personalize Patient Safety

The following report highlights patient and family perspectives of adverse events that were presented at the APSF Board of Directors Workshop on October 21, 2005. These unique and important accounts give clinicians a glimpse into how anesthesia complications affect our patients and their families and demonstrate the importance of good communication and disclosure.

by John H. Eichhorn, MD Because the October APSF workshop was inaugurate a new perspective for the APSF that will focused on the profound impact on patients and sur- be driven by the power of patients and the power of Three intensely personal presentations of tragic viving families of incidents perceived to represent stories. Dr. Cooper noted that this program was an anesthesia events were the nucleus of the APSF adverse outcomes specifically from anesthesia care, attempt to “open up the filters” that physicians Board of Directors (BOD) workshop, “The Role of and how the APSF can learn from these stories, the often automatically apply to patients’ views and Patients in the Mission of the APSF,” at the APSF presentations were accepted as offered by the non- avoid the reflex response of “that’s not how it’s Annual Meeting October 21, 2005, in Atlanta. The medical survivors. There were no “M and M” type done”/“that can’t be done” so often applied to ideas survivor of an anesthesia-related cardiac arrest, the reviews, no questioning to search for precise details from patients or their survivors. Further, he com- mother of an 11-year-old boy who suffered massive of the anesthesia care and possible mechanisms of mented that one of the reasons it had been difficult permanent brain damage from an anesthesia acci- injuries. The outcomes were what they were, even if to assemble a program of this nature was that (for- dent, and the wife of a 33-year-old marathon runner the presenters in some circumstances may not have tunately) anesthesia care catastrophes are exceed- who eventually was allowed to die after an anesthe- fully appreciated relevant aspects of physiology, ingly rare, and also that open public discussion can sia mishap, all told their stories to an empathic pharmacology, or anesthesia protocols. Rather, the be inhibited by medical-legal exigencies (there were audience that was appalled, entranced, and galva- APSF Board of Directors was primarily interested in no pending claims or proceedings involving any of nized, in an effort to determine what the APSF can the experiences, perceptions, and emotions of the the workshop presenters). One inspiration for Dr. do to help heal their wounds and prevent others presenters. The goal was to gain new insight from a Cooper was the open discussion by both the sur- from experiencing such trauma. new source to help establish a role for patients in the vivor of an anesthesia-induced cardiac arrest and While the APSF has sought patient input for APSF and also to guide and energize anesthesia care the involved anesthesiologist of an event that many years, this was the first time the foundation and patient safety efforts for the future. The stated occurred within the Harvard system (Dr. Cooper’s was able to organize a program reflecting the per- ultimate objectives were to provoke action that will academic affiliation), and that was the basis of the spective of patients or “victims” of injuries from make the APSF better understand the needs and con- first story. [NOTE: Following are brief summaries of accidents solely related to anesthesia care. As the cerns of patients/families who experience an adverse the presentations. First-person detailed accounts broader concept of patient safety and the efforts at anesthesia event and to develop methods for authored by the workshop presenters themselves blame-free full disclosure and discussion following patients/families to be more involved in helping are planned for an upcoming issue of the APSF medical accidents have been more widely publi- insure patient safety. Newsletter.] cized in the U.S., survivors of medical catastrophes The workshop was organized and moderated by See “Patients,” Page 63 (including families of patients who die) appear more Jeffrey B. Cooper, PhD, Executive Vice President of willing to publicly share their experiences. As a the APSF. He stressed that this is the “human side” reflection of this, several survivor support/advo- of the equation of anesthesia care—a balance to the cacy groups were recognized at the National Patient remarkable technologic and behavioral progress in Safety Foundation Annual Meeting in May 2005. patient safety. A key goal of the program was to

Inside: President’s Report ...... Page 62 Grant Awards for 2006...... Page 68 Dear SIRS - Absorbent Wrapper Design ...... Page 70 Officers, Directors, Committees - 2006 ...... Page 72 Donors ...... Page 73 2006 APSF Grant Application Guidelines...... Page 74 ASA Abstracts ...... Page 76 (Left to Right): Sue Stratman, Dr. Jeffrey Cooper, Dr. Scientific/Technical ASA Exhibits ...... Page 78 Julianne Chase, Dr. Frederick van Pelt, and Linda Kenney Labeling History ...... Page 86 present Patient and Family Perspectives at the 2005 APSF Board of Directors Workshop. APSF NEWSLETTER Winter 2005-2006 PAGE 62

APSF President Presents ¨ State of Foundation Report www.apsf.org NEWSLETTER by Robert K. Stoelting, MD Long-Term Outcomes The Official Journal of the Anesthesia Patient Safety Foundation As President of the Anesthesia Patient Safety An evolution of the APSF Long-Term Outcome ®

g 2005 NEWSLETTERSprin The Official Journal of the Anesthesia Patient Safety Foundation Foundation (APSF), it is my privilege to report annu- g conference in September 2004 is the APSF Task psf.or www.a Circulation 75,648 y esiolog , 1-24 th , No. 1 es me 20 An Volu e of c or i dit t t E c Gues a D, r d, M r P e Howa e Stev ally on the activities of the foundation during the past e & th by Force chaired by Marcel E. Durieux, MD. He and the Fatigu For example, watching a colleague fall

Everyone has seen it. asleep at a meeting or watching an intern struggle to remain alert while holding a surgical retractor. Everyone has felt it. Eyelids get heavy and the calendar year. I am pleased to report that 2005 has environment starts to “grey out.” Ask yourself if you desire to be cared for by e members of his task force are evaluating the scien- health care workers who look and feel this way. This clearlyesia isca ra dangerous h e anest f situation for our patients. It is also unsafe for and theth practitioneradre o when you fatigue red a c us on e gathe thesiol- consider the possibility of harmwill fdueoc to occupationale hav .injury Anes (e.g.,n sletter , and w is topic is agai SF New is topic on th d there needlesticks) andthe theAP increasedt in triskh of drivingmation while sleepy.ety, an m. We ion of interes infor of saf proble is edit newed ant new aspects vasive s to Th e is re import many is per with u r. Ther resent arding with th to join rovide will p ing reg ealing field p ls who d-look e” in d in our ividua orwar g edg others e ind very f “cuttin ourage s. h car as been at the ill enc patient l healt ogy h to be issue w are for ike al hen been a rewarding and successful year including advo- rtunity n this and c ers, l tients w po l i ice id a an op ateria e pract a prov e for p ight. at the m hich w sthesi to car ay or n tific basis of possible factors (inflammation, auto- ope th er in w Ane equired f the d gy h mann are r ime o ysiolo ge the iders, —anyt our ph chan prov for care what e and ety resent ition to t fatigu Saf they p oppos is tha ance and ry role ften in le fact rform igue ributo is is o efutab pact pe o- Fat or cont ntial Th An irr ely im thesiol causal reside ands. egativ e anes yed a 6, the P y dem tion n act, th igilant as pla 1 n 198 ing b priva ). In f a v tigue h ents. I on-mak leep de able 1 tient in cts Fa s accid decisi unto- s (see T the pa the effe famou t faulty to the mood itoring able to g some nd tha buted he and f mon vulner f bein in on fou contri nger. T role o ularly e act o missi nagers Challe - gist’s e partic d as th . The Com ed ma huttle d Cher may b define danger cacy of safety initiatives intended to fulfill our mission -depriv space s nd an anner nce is avoid is sleep f the ile Isla rning m .3 Vigila lly to eal and unch o hree M ly mo fatigue specia f the s - ard la ts at T he ear The of hful, e enter o hesiolo nomic nervous system activity, genetic profile, drug w cciden ring t leep. y watc t the c f Anest clear a red du ving s al alertl ce” is a ciety o iron- nu occur re cra ument vigilan can So ur env l both dies a a mon ord “ Ameri from o hen noby ur bo ez was rans- w of the gaged pen w when o n Vald ional T motto e disen at hap ours e Exxo he Nat able the becom eps” th h g of th he. T prob If we icrosle s lost. undin tastrop hat the n gists. the “m lance i age 5 gro ntal ca und t e perso uch as all vigi ronme ard fo e of th ent (s rived), envi ety Bo fatigu raffic m ep-dep See “Fatigue,” Page 3 ge 6 on Saf as the way T are sle portati ident w l High ,000 we his acc ationa ver 100 ge 9 use of t The N that o es ca ship. timates n crash ing the ons es year i r age 10 that no patient shall be harmed by anesthesia. sail nistrati each heel o e: rugs...... P mi red e w id fety Ad or inju ep at th - Ins hancing D age 13 Sa killed ell asle se exam e En s) ...... Pa ple are who f ss. The - manc ear Sir interventions [beta-blockers, alpha-agonists, statins], peo drivers owsine a prob Perfor re (D age 15 d to e dr e is ilu tribute sever fatigu ly r Fa c?...... Pa at ired by al that is deep entilato ey Do ge 17 e impa rs reve re and V op ...... Pa wer ny othe alth ca 8 nd ma ond he Cure for the D ue...... Patigue ...... P ples a ds bey tig to F t exten ociety. n the ging Fa proach 21 em tha n our s betwee Mana ’s Ap l withi lation and Ireland bedded corre ation em hown a epriv s Britain & ...... P have s leep d tinuou atigue tudies ts of s of con f F orkshop...... Page 1 S effec hours ivalent Costs o e W ance 2 At 24 s equ tcom erform tion. ion wa at m Ou p toxica r funct This is Donors ...... ng-Ter F ...... Page anol in omoto f 0.1%. s. Lo PS eth , psych ation o t state eport on ith A fulness ncentr in mos R orates W wake ohol co riving lity of llab anesthetic depth, body temperature) on long-term od alc it for d al liabi CS Co a blo l lim rson A to e lega and pe bove th sional or a profes of the icated! Think k intox to wor Audible Information Signals coming outcome following anesthesia and surgery. In addi- I am most pleased to report that the APSF “audible tion, a future issue of the Anesthesiology Clinics of The Anesthesia Patient Safety Foundation alarms” initiative has reached a successful outcome North America edited by Steffen E. Meiler, MD, will Newsletter is the official publication of the nonprofit that can only be viewed as the “right thing to do for be devoted to issues discussed at this conference. Anesthesia Patient Safety Foundation and is our patients.” As a result of your foundation’s published quarterly at Wilmington, Delaware. efforts, both the American Association of Nurse Data Dictionary Task Force Annual contributor status: Individual - $100.00, Anesthetists and the American Society of Anesthesi- Corporate - $500.00. This and any additional contri- The APSF Data Dictionary Task Force chaired by ologists have added audible alarms from pulse butions to the Foundation are tax deductible. Terri G. Monk, MD, has been successful in creating oximetry and capnography to their monitoring stan- © Copyright, Anesthesia Patient Safety Foundation, 2005. common anesthesia terms that have been adopted by dards. The evidence was compelling that this new The opinions expressed in this Newsletter are not monitoring requirement (standard) will save lives the Systematized Nomenclature of Medicine and necessarily those of the Anesthesia Patient Safety and improve patient safety. Without the APSF advo- licensed by the National Library of Medicine. Dr. Foundation or its members or board of directors. cating this change, it is unlikely that audible alarms Monk and her colleagues (again reflecting the coop- Validity of opinions presented, drug dosages, would have been added to the monitoring stan- erative efforts of industry and clinicians under the accuracy, and completeness of content are not guaranteed by the APSF. dards. I doubt if any one of us would knowingly fly sponsorship of the APSF) have now entered the next on an airplane on which the pilot silenced the audi- phase of the process in developing a schema of stan- APSF Executive Committee: ble alarms; our patients deserve no less. dardized terms (minimum data elements) for use on Robert K. Stoelting, MD, President; Jeffrey B. anesthesia records as part of automated information Cooper, PhD, Executive Vice President; George A. management systems. This is the next essential step Schapiro, Executive Vice President; David M. Gaba, ASA and AANA agree with to collect comparative data, from millions of anes- MD, Secretary; Casey D. Blitt, MD, Treasurer; Sorin J. APSF initiative and add thetics, to determine best practices leading to Brull, MD; Robert A. Caplan, MD; Nassib G. improved anesthesia patient safety. Chamoun; Robert C. Morell, MD; Michael A. audible alarms for pulse Olympio, MD; Richard C. Prielipp, MD. Board of Directors Workshop Newsletter Editorial Board: oximetry and capnography to Robert C. Morell, MD, Editor; Sorin J. Brull, MD; their monitoring standards. The APSF Board of Directors workshop in Octo- Joan Christie, MD; Jan Ehrenwerth, MD; John H. ber 2005 was organized by Jeffrey B. Cooper, PhD, Eichhorn, MD; Regina King; Lorri A. Lee, MD ; APSF Executive Vice President, and reflected the Rodney C. Lester, PhD, CRNA; Glenn S. Murphy, Carbon Dioxide Absorbent foundation’s initiative to include patients in the mis- MD; Denise O’Brien, BSN, RN; Karen Posner, PhD; Desiccation Conference sion of APSF. The topic of the workshop was “full Keith Ruskin, MD; Wilson Somerville, PhD; Jeffery Vender, MD. The report of the “Carbon Dioxide Desiccation disclosure” to patients when an adverse anesthesia event occurs. Participants included 3 families (a par- Address all general, contributor, and subscription Safety Conference” convened by the APSF in April correspondence to: 2005 was published in the Summer 2005 APSF ent, a patient, a spouse) and 1 anesthesiologist who cared for the patient participant. Their poignant sto- Administrator, Deanna Walker Newsletter. This conference was attended by repre- ries of how adverse events during anesthesia Anesthesia Patient Safety Foundation sentatives of industry (carbon dioxide absorbent Building One, Suite Two changed their lives was a moving and memorable manufacturers, machine manufacturers, producers 8007 South Meridian Street experience for the attendees. The common message of volatile anesthetics) along with clinicians, with Indianapolis, IN 46217-2922 from all the participants was the compelling human the single goal of creating a consensus statement for e-mail address: [email protected] need for explanations (as soon as possible) and ulti- dissemination to all anesthesia professionals. The FAX: (317) 888-1482 mately some recognition that what happened to recommendations of the conference demonstrate them or their family member would become a learn- Address Newsletter editorial comments, the APSF’s role in providing safety information to questions, letters, and suggestions to: ing experience to reduce the likelihood of a similar the anesthesia professional responsible for care of experience occurring to someone else in the future. Robert C. Morell, MD patients during anesthesia and surgery. Editor, APSF Newsletter A unique value of the APSF is its ability to bring Research Grants c/o Addie Larimore, Editorial Assistant Department of Anesthesiology together members of industry, nursing, and medi- The APSF has awarded more than $2 million Wake Forest University School of Medicine cine under a neutral umbrella without the issue of dollars since 1987 for support of investigators pur- 9th Floor CSB restraint of trade or conflict of interests that would suing patient safety research. Two grants for Medical Center Boulevard be present in other environments. The carbon diox- $75,000 were awarded for 2006, and 1 of these Winston-Salem, NC 27157-1009 ide absorbent conference was a rewarding example e-mail: [email protected] of this unique aspect of the APSF. See “President’s Report,” Page 67 APSF NEWSLETTER Winter 2005-2006 PAGE 63

Incredible Save Followed by Poor Communication “Patients,” From Page 61 “Incredible Save” The patient who survived a life-threatening anesthesia complication and her anesthesiologist stood shoulder to shoulder at the lectern to recount their perspectives of an anesthesia nightmare. The assembled APSF Board was spellbound by the gut- wrenching story. Ms. Linda Kenney, at age 37, was scheduled for one in a long series of foot/ankle surgeries and agreed to a popliteal nerve block as part of the anes- thetic. Frederick (Rick) van Pelt, MD, had extensive experience with such blocks. Using a nerve stimula- tor, he injected 30 ml of bupivacaine in a routine incremental manner, employing classic safeguards. However, subsequent evolving signs of bupiva- caine toxicity were followed by grand-mal seizure and cardiac arrest. After 10 minutes of ACLS proto- col without any impact, a fortuitous set of coinci- dences led to the resuscitation of the patient. Directly across the hall from the OR in which the Small group participants explore Board of Directors Workshop issues involving patient perspectives on adverse events. arrest occurred was an open-heart surgery OR, car- diopulmonary bypass (CPB) pump primed and Ms. Kenney knew she was lucky to be alive and Constructive interaction between the survivor of ready, waiting for a patient to arrive. CPR in knew if she had been at a different hospital, she an anesthesia catastrophe and the involved anesthe- progress, Ms. Kenney was wheeled across the hall likely would have died. Against advice, Dr. van Pelt siologist yielded a resolve to “do something” about and “crashed” on to CPB via an emergency ster- wrote her a letter about 10 days after her discharge the appalling lack of support and care revealed by notomy. Within a few minutes and approximately acknowledging the suffering she and her family had the aftermath of this event. Ms. Kenney founded 30 minutes after the injection, sinus rhythm experienced, apologizing for what he had done, and the Medically-Induced Trauma Support Services returned. After an hour on CPB, she was weaned. expressing a desire for open and honest communi- (MITSS - website), an organization dedicated to The incision was closed and she was taken to ICU, cation. He stated in his presentation that if the letter helping patients, families, and care providers where she recovered without neurological damage provoked her to sue, “so be it.” He did not believe involved in adverse medical events. MITSS focuses over the following days. he made an error, but he did feel responsible. Ms. on the need for 1) full disclosure in real time; 2) an Kenney at the time believed this letter was just apology or acknowledgment of responsibility and The parallel perspectives on the events follow- “damage control” and ignored it. She experienced recognition of the traumatic impact; 3) concrete ing the arrest and resuscitation were fascinating. “survivor guilt” and eventually devolved into sig- efforts to prevent similar occurrences in the future; Dr. van Pelt was told that he had done the block nificant post-traumatic stress disorder. The event and 4) support that is flexible and patient correctly, that even the best physicians get sued, was reviewed in the hospital QA system and in the directed—emotional, logistical, financial, or what- and not to talk to anyone about the event. Ms. Ken- debate over whether this was a reportable “sentinel ever is needed (excepting legal). To its credit, the ney’s husband was called to the hospital, event,” Dr. van Pelt felt “hung out to dry.” For a hospital that just wanted Ms. Kenney to go away sequestered alone in a small conference room for an number of reasons, he left that hospital and relo- after her event, now 6 years later, embraces MITSS extended period, and was offered no immediate or cated to Seattle 4 months later. Ms. Kenney was in its efforts to correct the glaring deficiencies long-term support for his distress, panic, and anger. depressed. Her multiple calls to the hospital for help exposed by her experiences. Dr. van Pelt reiterated Ms. Kenney recalls awakening in the ICU and later and support yielded nothing but uncompassionate that the “wall of silence” operative in his case just being told she had “an allergic reaction to the anes- form letters. She asked for the names of the people pushes patients and their families to sue. It also thesia,” which she found hard to believe, and that on the team that had saved her life so she could takes a huge toll on the involved caregivers. He was made her distrustful. There was no other discussion thank them and was refused. She grew very tired of not supported at all by his colleagues after the of the cause of the incident with her. She was most being asked by everyone she knew whether or not event (even though he felt some wanted to reach concerned about the emotional well-being of her 3 she was going to sue, and if she saw the white light. out to him, but they did not). He had no way to young children. After experiencing some minor but She ultimately decided not to sue because she saw express and deal with his feelings, which, he stated, annoying complications, she was discharged 10 the incident as a complication, not an error, and also is typical in the medical care system. Even though days after the arrest with wound care instructions because she wanted to move on with her life. She the idea that this case “was a phenomenal save” for her chest and a follow-up appointment for that, decided there would be benefit from finally was universally discussed, no one really considered but no counseling of any type. Dr. van Pelt wanted responding to Dr. van Pelt’s letter. Six months after the enormous impact it had on him. Consequently, very much to speak with the patient while she was the event she contacted him in Seattle and they had Dr. van Pelt has assembled a task force at his hospi- in the hospital, but was strongly discouraged from an uplifting phone conversation that was the start of tal to develop an OR pilot program to implement doing so by the hospital administration and, fearing healing for them both. He told her all the clinical after an event that will provide flexible peer-based, the negative emotional impact to the patient, also details, and she had understanding and forgiveness. emotional support (including group and individual by her caregivers. He was expected to go back to Dr. van Pelt eventually returned to his former hos- stress debriefing), and access to other resources. He work the next morning as if nothing had happened, pital in Boston, and 2 years following the event, they even though he was very emotional and distracted. met in a coffee shop to talk further. See “Patients,” Next Page APSF NEWSLETTER Winter 2005-2006 PAGE 64

Halothane Overdose Results in Cardiac Arrest

“Patients,” From Preceding Page really understood what had happened. Mrs. Strat- man came to believe that the anesthesiologist did believes the core concept of “integrity and compas- know what happened but did not disclose this. sion” will have a major beneficial impact. Ms. Stratman stated that they were kept com- Uncharacteristically, the APSF Board was virtu- ally speechless after this presentation. There was pletely in the dark about the incident, and she unanimous acknowledgment that there is a great learned that the hospital staff had been instructed deal the APSF specifically, and the medical care not to talk with anyone (family, friends, coworkers, establishment in general, can learn from thoughtful or other hospital personnel) while the investigation patient input. An obvious key element was the “dis- (initiated by the cardiologist) was conducted. She connect” of the starkly different perspectives and stated they were stunned to learn the truth about the priorities of the patient/family versus the medical event but, painful as that was, it was critical to know care establishment, and the potential damage this everything. The family did receive an out-of-court disconnect can cause. Overcoming this clearly can financial settlement. They did receive an acknowl- have helpful risk management implications, but the edgment from the hospital that mistakes had been emphasis is on promoting healing for all involved. made, but no acknowledgment from the anesthesiol- Likewise, the final note of the presentation was posi- ogist. Neither the hospital nor the anesthesiologist tive in that it was recognized that everything was ever admitted that the records had been altered. Ms. done exactly wrong regarding communication and Stratman stated that, even 9 years later, she would support, but that this fact led to awareness and con- like the opportunity to talk with the anesthesiologist structive changes that should help all those involved to help bring closure because she suspects that the in any future anesthesia care catastrophe. anesthesiologist is not doing well with the burden of the situation. “A Parent’s Nightmare” Ms. Stratman clearly outlined what she believes Ms. Sue Stratman opened with the observation should happen with the anesthetic for a surgery that she had seen both the best and worst of the med- such as Daniel’s: 1) take it seriously—as if it is the ical care system. She is the mother of Daniel, who was most complex major surgery imaginable, even born with congenital heart disease but had done though it’s a “minor case”; 2) the attending should spectacularly well with 3 open-heart surgeries over never leave the patient [although it appeared that the course of his first 11 years and in 1996 was well In the top photo, Dr. Julianne Chase recounts her expe- the function of anesthesia trainees in academic med- and vigorously active, successfully playing competi- riences, and in the bottom photo, Linda Kenney and Dr. ical centers was not fully appreciated]; 3) be sure the tive soccer. He was found to have an inguinal hernia Frederick Van Pelt discuss Ms. Kenney’s adverse event. equipment works and is used correctly; and 4) tell and the repair under general anesthesia was sched- All participants agreed that poor post-event communi- uled at the same very well-known large academic the truth. As seen in the previous presentation, there cation was a major problem. medical center where he had his heart repaired. There was a profound desire by this family to “do some- was a thorough discussion of Daniel’s history, cardiac thing” to help prevent tragedies such as this. The status, and the anesthesia plan with the attending set to cycle at intervals, and the single initial blood family has started the Daniel Stratman Foundation anesthesiologist prior to what was planned for a pressure value was recorded 3 times on the record to help educate about patient safety. They are mem- quick outpatient procedure. During the anesthetic, over nearly 15 minutes; an LMA was in place, but bers of a medical malpractice survivors’ support Daniel arrested and his heart was resuscitated, but he spontaneous breathing slowed so there was hand- group. Ms. Stratman stated they had served on a suffered permanent brain damage such that he today assisted bag ventilation; the surgeon remarked on hospital “parents board,” but abandoned that when is blind, cannot use his arms, can walk only with the dark-colored blood upon incision; cycling the NIBP it was clear to them the hospital was not really inter- assistance of 2 people, can barely speak, and needs revealed profound hypotension and heart block, ested in discussing substantive patient safety issues total 24-hour care. then arrest followed. with families. Ms. Stratman stated that she was not aware pre- There was little communication to the family Again, the APSF Board was moved. Note was operatively that a student nurse anesthetist would immediately after the event, and there was a delay again taken of the potential disconnect between be involved in the anesthetic and would be left in allowing them to see Daniel in the PACU, where patient/family understanding of events during alone with Daniel during the case by the attending he was intubated, ventilated, having seizures, and medical care, prospectively, and especially retro- who was also supervising another room. The anes- posturing. Beyond the panic, Ms. Stratman was spectively, and the providers’ realities. The damag- thesiologist was also distracted due to her own crushed because she had promised Daniel no tubes ing impact of failure of disclosure after the event ongoing family issues. Ms. Stratman stated that the or ventilator this time. After a week of little and overall failure of communication was unmistak- records had been altered “to make it look like his improvement and essentially no communication to able. Finally, as before, the drive by the survivors to heart had given out,” but that eventual analysis of the family, there was mention of the possibility of “do something,” to “make a difference” so similar the original records and the printout from the moni- discontinuing life support. Daniel’s cardiologist catastrophes would not afflict other families in the tor values suggested this scenario: Daniel climbed demanded an investigation at the hospital. The future, was heartfelt and strong, which is precisely up on the table himself and was given an inhalation attending anesthesiologist visited daily and was the element sought by the APSF Board in these pre- induction with 5% halothane; this induction dose emotionally distressed, including about events in sentations and, more importantly, as stimulus for was continued and not reduced to maintenance lev- her own family, which she discussed with Daniel’s future follow-up efforts by the foundation. els when the attending left the room; the non-inva- family. Ms. Stratman stated that the attending anes- sive blood pressure machine (NIBP) had not been thesiologist communicated to her that she never See “Patients,” Next Page APSF NEWSLETTER Winter 2005-2006 PAGE 65

Question of Competence Raised After Unrecognized Hypoventilation

“Patients,” From Preceding Page the surgeon was later asked why he accepted this Response to an Adverse Anesthesia Event” have personnel change, he replied that he thought it did been published and are available on the APSF web- “A Question of Competence” not matter. In the one conversation Dr. Chase had site: www.apsf.org, “Resource Center,” “Clinical Dr. Julianne Chase, Senior Assistant Dean for with the involved anesthesiologist, he had no expla- Safety Tools,” then “Adverse Events Protocol.” Medical Education at NYU School of Medicine, nation for the cause of the event, was defensive, and Another suggestion was the simple idea of survey- revealed to the APSF Board that this was the first offered no expression of remorse or regret. She never ing patients/families to help determine what type time she had discussed with a professional group of saw or spoke to him again. The surgeon expressed and how much information and communication physicians the event her husband experienced in deep regret and sorrow, particularly after Danny’s they really want, both in general and specifically the OR since it happened, in 1986. She then told the death, and this revealed to Dr. Chase the profound concerning an adverse medical event. powerful story of Danny Delio, 33, an exercise impact medical misadventure can have on the A primary specific initiative is to continue to physiologist in superb physical condition as an involved practitioners, recalling some of the points collect (possibly including through a “hotline” to active marathon runner. He had had previous hem- made by Dr. Van Pelt. the APSF) and publicize these potent “stories” of orrhoid surgery and the same surgeon suggested Dr. Chase was told that the involved anesthesi- patients/families who have experienced an adverse surgical treatment of an anal fistula after draining ologist retired soon after the event under pressure anesthesia event. Not only will this raise the aware- an abscess in the office. Over Dr. Chase’s objection, from the hospital. Her malpractice suit was settled ness of all those who read those accounts, it will Danny scheduled his surgery at a local community out of court. form a database that can be organized and mined hospital rather than an available teaching hospital. for common elements, much like the model of the She, at times, still feels guilty about not having An internist friend of theirs told them there were 2 ASA Closed Claims study that identified clinical been more insistent on the morning of surgery anesthesiologists at that hospital to avoid because trends (preventable hypoventilation as a cause of about being certain that her husband was getting of prior complications and incidents, and that he injury) and even specific syndromes (cardiac arrest the “good anesthesiologist,” but that revelation pro- would speak with the surgeon to advise him which during spinal anesthesia). A related initiative will anesthesiologists to request and which to avoid. voked her to share persistent questions about the be the use of the great power of the telling of these Danny had confusion on the day of the procedure internal regulation of the quality of practice within stories to develop a curriculum in “the patient side about which was which, but did not want to bother the medical profession, and the obvious patient of anesthesia patient safety” for distribution to all his internist friend early that morning to check. He safety implications. Why were there anesthesiolo- anesthesiology residency and nurse anesthesia did ask his surgeon if the procedure could be done gists practicing who should be avoided—particu- training programs, as well as to medical schools for without general anesthesia and was advised that larly when other doctors at the hospital knew of incorporation into their clinical teaching. Closely was not a good idea. The anesthesiologist who did their lapses? How does one stop doctors from prac- tied would be additions to modules used in anes- the preoperative evaluation was not the one who ticing when they are incompetent? Why is it so dif- thesia simulator training that add experience in would be administering the anesthetic, and Dr. ficult for physicians to monitor each other? post-event management of both the patient/family Chase did not believe this was proper, but Danny [Following Dr. Chase’s presentation, intense discus- and the involved anesthesia provider. This intense was prepared to go ahead and did so. Both believed sions ensued regarding these questions.] role-playing likely would evoke strong emotions the internist friend had arranged for one of the Again, as with the others, Dr. Chase expressed a and would be videotaped for the debriefing of the “good anesthesiologists” to do the case. strong desire to help implement measures that will participants in the specific simulation and also for Precise events in the OR were never clear to Dr. prevent similar catastrophes from striking other potential inclusion in curriculum modules for anes- Chase. Near the end of the case, with Danny breath- patients and families. She suggested a monitoring thesia trainees and medical students. Having these ing spontaneously, reportedly “with very little program to detect “near-misses” and physicians modules available on the web for all anesthesia assistance,” the anesthesiologist announced that who are “slipping repeatedly,” and then a remedia- providers through their respective national profes- there was a cardiac arrest. Danny’s heart was resus- tion program for them and also alternatives to sional organizations also would have a significant citated in 5 minutes, but he then suffered intractable divert physicians into jobs they could safely per- impact because their direct relevance and inherent grand mal seizures reflecting hypoxic brain dam- form. The APSF Board continued the thorny and drama would provoke widespread interest and age. After intubation and ventilation in the OR, complex discussion of the issues of measuring attention. Danny’s pCO2 was more than 80, and the pH was physician competence, setting criteria for action, One major recurrent theme was the failure of 7.0, suggesting that there had been unrecognized and implementing enforcement when a quality communication with the patient/family at the time hypoventilation and consequent respiratory acido- problem is documented. Finally, the related of the catastrophic event and thereafter. The overall sis. He was transferred out of the hospital where extended patient safety concept that injuries would concept of trying to shift from a “culture of blame” the event occurred to the ICU in the larger local be prevented by implementing such a program was to a “culture of learning” certainly applies. It was county hospital in a persistent vegetative state, raised but, predictably, there was no agreement. agreed that, in the spirit of “the patient’s bill of where he became the subject of a court case regard- rights,” there should be an expectation by the ing withdrawal of nutrition and hydration. Danny So Now What? patient/family of open communication and full dis- Delio died 13 months after his anesthetic for repair The high-impact and thought-provoking nature closure (even to the point that the surgical/anesthe- of an anal fistula, and following a landmark court of the 3 presentations was dramatically evident by sia consent forms should specify that after any case supporting his right to refuse medical treat- the length, breadth, and intensity of the discussion event, prompt full disclosure will be made). The ment if he were ever in a persistent vegetative state. among members of the APSF Board and also the expected concerns about risk management and the Following the catastrophe, the family’s internist presenters. Consistent with the goal of outlining potential legal liability implications of apologies and friend confirmed that the anesthesiologist involved possible action for the APSF, several themes and full disclosure were expressed, but reference was was one of the two he had said to avoid. Appar- suggestions emerged. One important item that then made to the study from the VA system demon- ently the anesthesiologist requested had been work- could immediately and directly help prevent or strating a significant reduction in liability costs asso- ing all weekend and had transferred this case to his mitigate patient injuries was again broadcasting a ciated with prompt full disclosure after an event. senior colleague on the morning of surgery. When reminder that “Administrative Guidelines for See “Patients,” Next Page APSF NEWSLETTER Winter 2005-2006 PAGE 66

Workshop Identifies Need Letter to the Editor to Tap Patient Resources Full Disclosure “Patients,” From Preceding Page Recommended how precisely this translates into documentable To the Editor: Related was the favorably-received suggestion that impact on patient safety prompted calls for further patient care facilities where anesthetics are adminis- discussion and research. A survey of anesthesia The Fall 2005 issue of the Anesthesia Patient tered should have an ombudsman or “patient advo- providers regarding how they would suggest eval- Safety Foundation (APSF) Newsletter includes the article “DepoDur™: A New Drug Formulation cate” always immediately available or on call so uating practice competency was proposed. Imple- With Unique Safety Considerations.” It is disclosed that this advocate can immediately interpret, facili- mentation of carefully crafted true “360 that the author is a paid scientific advisor for Endo tate communications, and organize support of all evaluations” for anesthesia clinicians was recog- nized as potentially very valuable, but cumbersome Pharmaceuticals, the U.S. marketer of DepoDur™, types for the involved patient/family in the event and has also received research support from Endo. to implement. Soliciting APSF Research Grant of an anesthesia accident, or any acute medical Most of the article describes the putative benefits of applications regarding this specific technique and adverse event for that matter. This tied in to the DepoDur™. A smaller portion deals with safety even a small pilot study conducted by the APSF projected goal that perioperative services should be issues and presents generic advice common to “high-empathy organizations” as well as high-relia- itself were considered. The APSF Executive Com- intravenous and neuraxial opioids. The opposing bility organizations. The proposal that patient/fam- mittee will address these ideas in January. Likewise, views of an unbiased author are not presented. ily representatives be included on the committee for offered for consideration was possible APSF spon- Given the tone of the article, one could mistake it as the peer-review analysis after an adverse event pro- sorship of a larger study that would start with an marketing literature. This cynical but realistic view voked significant discussion, but did not yield a attempt to define baseline anesthesia competency. could be avoided if APSF would select authors who consensus. However, the suggestion that the insti- Overall, the APSF Board of Directors Workshop are not influenced by such conflicts of interest. tution and the practice group involved with an on “The Role of Patients in the Mission of APSF” It is more concerning that the article does not anesthesia accident share with the affected was a remarkably rich and stimulating experience clearly state that Endo is a financial supporter of the patient/family the details of changes made follow- that appeared to have more impact on the partici- APSF. The financial relationship between APSF and ing the event (whether policy, procedure, behavior, pants than could have been imagined. The APSF Endo Pharmaceuticals should have been clearly equipment, or organizational) intended to prevent has resolved to have more awareness of and input revealed in the article. It is reasonable to ask if any recurrence of that type of accident met with from patients and families, both in general and Endo’s financial support played a role in the APSF widespread approval. specifically related to the aftermath of anesthesia decision-making and editorial process, especially since that support was not clearly disclosed. Promoting thoughtful, compassionate, and open catastrophes. Optimum utilization of this untapped support for anesthesia providers who have been resource can only enhance and encourage efforts to The specific concern expressed in this letter involved in a catastrophic anesthesia accident (even further the APSF stated mission that “no patient should not be generalized to other APSF activities one with an eventual good outcome) is another shall be harmed by anesthesia.” or publications. However, since APSF’s credibility and reputation could be seriously damaged with unanimously accepted proposal resulting from the Dr. Eichhorn, Professor of Anesthesiology at the only one mistake or ethical lapse, any indiscretion is APSF Board workshop. Clearly the front line and University of Kentucky, founded the APSF Newsletter important. It is also relevant that the American the bulk of this effort should be at the local level, in 1985 and was its Editor until 2002. He remains on the Society of Anesthesiologists (ASA) is a long-time within the institution and immediate group of the Editorial Board and serves as a senior consultant to the provider of significant financial support to the involved anesthesia provider(s). Prospective con- APSF Executive Committee. APSF. Since many APSF Newsletter readers are also crete plans that are widely disseminated to all the dues-paying ASA members providing that sup- involved should be in place in order to avoid a con- port, the APSF has an important obligation to main- fusing scramble of disparate resources at the time of tain editorial objectivity and avoid even the an event. Group leaders and facility administrators perception of bias or inappropriate influence. should immediately activate the pre-planned Jeff Mueller, MD response to provide support and counseling, as See Page 74 Scottsdale, AZ well as specific advice and encouragement about for APSF disclosure to the involved anesthesia personnel. Editor’s Response: Further, it was suggested that the APSF could Grant Application establish another type of “hotline” to offer situa- Dr. Mueller raises points to which the APSF and the Newsletter Editorial Board are sensitive. We believe we tion-specific suggestions to assist and support the Guidelines carefully attempt to avoid commercial bias in safety arti- personal needs and concerns of anesthesia cles that are written by our invited authors. However, if providers finding themselves under stress follow- informed readers such as Dr. Mueller conclude other- ing involvement in an adverse event. The more gen- Award Limit wise, we will reexamine our approach. As Dr. Mueller eral question of anesthesia providers under so points out, the article in question disclosed that the much personal stress as to be dangerously dis- Has Been Increased author has received investigative grant support from, tracted and a safety risk was also broached. and has been compensated as a scientific advisor by, Enhanced vigilance and sympathetic support from to $150,000 Endo Pharmaceuticals. In the future, the APSF Newslet- coworkers, promoted by articles such as this one, Per Application ter will also include, as appropriate, a statement that the was seen as the best immediate strategy. APSF receives financial support from an industry spon- Funded sor who could be perceived to benefit from a given article. Finally, possibly the thorniest issue closed out This statement will be in addition to our current practice the discussion. The question of measuring practi- of listing all corporate sponsors on the donor page. The tioner competence and quality of practice and, then, APSF thanks Dr. Mueller for his interest and letter. APSF NEWSLETTER Winter 2005-2006 PAGE 67

APSF Selects New President Welcomes Input Vice President as APSF Enters 20th Year At its October 2005 annual meeting, the APSF was pleased to announce the appointment of Paul “President’s Report,” From Page 62 Financial support to the APSF from individuals, Baumgart as its new Vice President. Paul Baumgart specialty and component societies, and corporate is General Manager of Respiratory Care for GE grants received an additional $5,000 as the Ellison partners in 2005 has been most gratifying. The Healthcare Clinical Systems, based in Madison, C. Pierce, Jr., MD, Education Award. The other increased level of support in 2005 will make new Wisconsin, with responsibility for GE’s global grant is designated the APSF/AHP Research initiatives possible and provide for ongoing initia- respiratory care business. Previously he held Award in recognition of the contribution from tives, as well as increase research funding. In partic- marketing roles at GE covering perioperative Anesthesia Healthcare Partners for support of this ular, the APSF wishes to recognize Anesthesia monitoring products and OR information systems. grant plus an additional amount for administrative Healthcare Partners for their generous contribution Prior to joining GE in December 2000, he spent support to the APSF. in 2005 making possible the co-sponsorship with nearly 20 years at Ohmeda in a variety of marketing the APSF of a research grant awarded in 2006. positions related to the company’s anesthesia Beginning in 2007, the APSF Research Grants Equally important, the October 2005 House of Dele- system business, including Director of Marketing for will be increased from the current level of $75,000 gates of the American Society of Anesthesiologists the Americas. to $150,000. This increased level of funding is approved increasing the funding of the APSF from Paul’s active involvement in the Anesthesia intended to reflect the quality of the research appli- $400,000 annually to $500,000 beginning in 2006. Patient Safety Foundation dates to 1987 when he cations and the importance of the grant process in Anesthesia is unique in American medicine in hav- joined the committee on Education at the suggestion the mission of the APSF. ing a foundation dedicated to anesthesia patient of W. Dekle Rountree, then President of Ohmeda, APSF Newsletter safety, and this is reflected by the vision and sup- who at that time was serving in the role of the first port of the American Society of Anesthesiologists Vice President of the APSF. Since then Paul has The APSF Newsletter, as the official journal of since the formation of the APSF in 1985. served on both the Committee on Education and on the APSF with Robert C. Morell, MD, as editor, con- As in the previous annual report, I wish to reit- the Committee on Technology. During the 2004 tinues to provide the most rapid dissemination of erate the desire of the APSF Executive Committee meeting of the ASA, Paul was elected to serve on the anesthesia patient safety information possible. The to provide a broad-based consensus on anesthesia Board of Directors of the APSF and will serve on the current circulation exceeds 76,000 recipients and patient safety issues. We welcome comments and Committee on Scientific Evaluation in 2006. reflects the fact that every anesthesia professional in suggestions from all those who participate in the Paul has been a recognized speaker at anesthesi- the United States receives the Newsletter and bene- common goal of making anesthesia a safe experi- ologist, nurse anesthetist, anesthesia technologist, fits from the information it provides. I am person- ence. There remains much to still accomplish, and and biomedical engineering meetings throughout ally committed to doing everything possible to everyone’s participation is important and valued as North America and Europe on topics that include insure that all anesthesia professionals continue to “your foundation” enters its 20th year. anesthesia safety, operating room information man- receive the APSF Newsletter as patient safety infor- agement, anesthesia gas delivery, and monitoring mation is valuable and important to everyone who Best wishes for a prosperous and rewarding year 2006. system design and evolution. He holds an MBA cares for patients in the operating room. degree from the University of Wyoming and is an A highly successful part of the APSF Newsletter Robert K. Stoelting, MD adjunct faculty member in the University of Wis- has been the “Dear SIRS” (Safety Information President, APSF consin Executive Education program. He and his Response System) column that is coordinated by wife Lynn reside in Madison, Wisconsin. Michael A. Olympio, MD, Chair of the APSF Com- mittee on Technology. Dr. Olympio and his com- mittee members provide timely responses to questions including equipment design and function that are submitted by recipients of the Newsletter. These responses also include the comments from colleagues representing industry and often the manufacturers of the equipment in question. Wall Street Journal Article On June 21, 2005, a front page article in the Wall Street Journal entitled, “Heal Thyself—Once Seen as Risky, One Group of Doctors Changes its Ways” described the success of the anesthesia patient safety movement in reducing professional liability insurance premiums by virtue of making anesthesia safer. The article was complimentary to the APSF and its role over the years in anesthesia safety. As President of the APSF, I recognize and salute the contribution of all anesthesia professionals for their role in making possible the safety successes described in this highly visible article.

Financial Support Dr. Robert Stoelting (left), APSF President, welcomes new APSF Vice President, Paul Baumgart. APSF NEWSLETTER Winter 2005-2006 PAGE 68 APSF Awards Two Grants for 2006 by Sorin J. Brull, MD that are broadly applicable and promise improved • The evaluation of the acceptance of a novel The Anesthesia Patient Safety Foundation (APSF) methods of patient safety with a defined and direct syringe-catheter connector system for spinal and is pleased to report that it continues to attract out- path to implementation into clinical care. Addition- epidural administration of medication. standing applications for funding. The educational ally, the APSF is encouraging the study of innova- • The effectiveness of perioperative beta-blockade focus of APSF includes innovative methods of tive methods of education and training to improve in morbidly obese patients in reducing education and training to improve patient safety, patient safety. intraoperative anesthetic requirements. development of educational content with application The applications that the Scientific Evaluation Com- • The investigation of the prolonged QT syndrome to patient safety, and development of testing of mittee received this year covered a variety of topics: in the perioperative period. educational content to measure and improve safe • The cost-effectiveness of reducing the incidence delivery of perioperative anesthetic care. • The development of digital video technology to of retained surgical sponges. improve the education, proficiency, and safety of The application process continues with an elec- • The investigation of a neuromuscular blocker anesthesia residents performing invasive clinical tronic, online submission format introduced last procedures. year. The applications, as well as all the required advisory system utilizing adaptive process attachments, are uploaded to the newly redesigned control technology. The APSF Scientific Evaluation Committee met APSF website (www.apsf.org), a process that • Improving patient safety during epidural needle during the ASA annual meeting on October 22, facilitates the application review by members of the insertion by creating an educational outline and 2005, in Atlanta for final evaluation of the propos- Scientific Evaluation Committee, improves the objective assessment of skills and judgment. als. Of the 8 finalists, the members of the APSF Sci- timeliness of response, and facilitates transmission entific Evaluation Committee selected 2 awardees: • Prediction of respiratory compromise during of reviewer feedback to the applicants. The Scien- patient-controlled analgesia by heuristic tific Evaluation Committee members continue to modeling of continuous oximetry and modify and perfect the electronic application and capnography. review process. • An investigation of the use of electronic patient Also of significance for the APSF grant applica- records to determine independent intraoperative tion process was the increase in funding to $75,000 predictors of perioperative mortality. per accepted application introduced in 2004. In addition to the Clinical Research and Education and • The detection of anaerobic metabolism during Training content that is the major focus of the fund- anesthesia using indirect calorimetry. ing program, the APSF continues to recognize the • Evaluation of lingual tonsil hyperplasia during patriarch of what has become a patient safety cul- the preoperative endoscopic exam. ture in the United States and internationally, and one of the founding members of the foundation— • Assessment of resident performance during Ellison C. “Jeep” Pierce Jr., MD. The APSF Scientific obstetric anesthesia using the human patient Evaluation Committee continues to designate 1 of simulator. Melanie C. Wright, PhD the funded proposals each year as the recipient of • The effects of depth of sedation on long-term Melanie C. Wright, PhD – Assistant Professor, this prestigious nomination, the Ellison C. Pierce, functional outcome and postoperative delirium Department of Anesthesiology, and Human Simu- Jr., MD, Research Award. The award carries with it in elderly orthopedic patients. lation and Patient Safety Center, Duke University, an additional, unrestricted prize of $5,000. New this Durham, NC. Her grant submission is entitled, funding cycle is the addition of the APSF/Anesthe- • An evaluation of the severity of illness as a predictive model of outcomes. “Objective Measures of Performance in Simulated Anes- sia Healthcare Partners Research Award, made thesia: A Comparison of Novices and Experts.” possible by an unrestricted grant from Anesthesia • The evaluation of an interdisciplinary OR team Healthcare Partners (AHP). in a malignant hyperthermia simulation scenario The use of human patient simulators in anesthe- siology training and assessment has been limited by to promote improved outcome. For the year 2005 (projects to be funded starting the lack of objective, validated measures of human January 1, 2006), two grants were selected for fund- • The analysis of anti-coagulant effects of three performance. Such measures are necessary if simu- ing by the APSF Scientific Evaluation Committee times daily (TID) low-dose heparin regimen on lators are to be used to evaluate the skills and train- (for names of committee members, please refer to removal of epidural catheters in surgical patients. ing of anesthesia providers and teams, or to the list in this issue). The APSF Scientific Evaluation evaluate the impact of new processes or equipment • The investigation of phenotyping the Committee members were pleased to note that they design on overall system performance. There are 2 susceptibility to malignant hyperthermia using a reviewed 21 applications in the first round, 8 of main goals of this project: the first is to quantita- microdialysis technique. which were selected for final review at the Ameri- tively compare objective measures of anesthesia can Society of Anesthesiologists (ASA) Annual • The evaluation of vocal cord immobility due to provider performance with regard to their sensitiv- Meeting in Atlanta, Georgia. As in previous years, recurrent laryngeal nerve paresis during anterior ity to both provider experience and simulated anes- the grant submissions addressed areas of high pri- cervical spine surgery. thesia case difficulty. The authors plan to compare ority in clinical anesthesia. The major objective of previously validated measures of anesthesia • An investigation of the association between the APSF is to stimulate the performance of studies provider performance to 2 objective measures that anesthesiologist age and incidence of malpractice that lead to prevention of mortality and morbidity are relatively novel to the environment of anesthe- litigation. from anesthesia mishaps. A particular priority con- sia care: an objective measure of provider situation tinues to be given to studies that address anesthetic • The development of a perioperative dental risk awareness, and a measure of providers’ eye scan problems in healthy patients, and to those studies recognition and prevention program. See “Grants,” Next Page APSF NEWSLETTER Winter 2005-2006 PAGE 69

Drs. Wright and London Each Receive Awards

“Grants,” From Preceding Page Martin J. London, MD — Professor of Clinical determine associations with the primary (perioper- patterns. The second goal of this project is to quali- Anesthesia, Department of Anesthesiology, Univer- ative mortality and outcomes) and secondary (1- tatively evaluate the situation awareness and eye sity of California, San Francisco, San Francisco, CA. year mortality and hospital length of stay) tracking data to identify key determinants of exper- His grant proposal is entitled, “Perioperative Pharma- outcomes. This pilot study will facilitate a greater tise in anesthesia providers. These determinants of cologic Prophylaxis for Cardiovascular Events in the understanding of current practices in a high-risk expertise may then be used to further enhance Department of Veterans Affairs: A Pharmacoepidemio- surgical population, and will lay the groundwork objective measures of performance as assessment logic Pilot Project.” for larger scale funding from federal agencies. This tools, and to improve training of anesthesia The objective of this proposal is to develop a project has a particular application to patient safety, providers. pharmacoepidemiologic study of the association of as it will better delineate specific areas in which The results of this study are directly applicable cardiovascular pharmacologic prophylaxis with focused, randomized controlled trials of particular to the assessment of anesthesia providers’ ability perioperative and 1-year outcomes after major non- drugs may be logistically practical and economi- and to training, and will ultimately lead to cardiac surgery in the Department of Veterans cally feasible. The collaborators listed in Dr. Lon- improved patient care and safety. This study pro- Affairs (DVA) population. Outpatient and inpatient don’s proposal are William G. Henderson, PhD, poses to validate 2 objective measures of perfor- prescription data from the system-wide Pharmacy Co-Director of the NSQIP from the Denver Data mance that may provide better scalability with Benefits Management–Strategic Healthcare Group Analysis Center, and Francesca Cunningham, respect to assessing multiple performers. In addi- for beta-blockers, statins, calcium channel blockers, PharmD, research coordinator. alpha-2 agonists, and antiplatelet agents will be tion, situation awareness and eye tracking measures In addition to receiving the requested funding may provide improved means for assessing the matched with risk factors, surgical details, and peri- of $75,000 for his project, Dr. London is the recipi- underlying dynamic knowledge of care providers operative outcomes (myocardial infarction, cardiac ent of the inaugural APSF/Anesthesia Healthcare and their performance with respect to accessing rel- arrest, pulmonary edema, stroke, all cause mortal- Partners Research Award. evant information. The validation of these measures ity, and length of stay) for patients undergoing may also serve to support efforts in the design and major general, vascular, thoracic, urologic, neuro- On behalf of APSF, the members of the Scientific evaluation of anesthesia displays for their safe and surgical, and orthopedic procedures in 4 fiscal years Evaluation Committee wish to congratulate all of effective use by care providers. (2002–2006) collected by the National Surgical Qual- the investigators who submitted their work to ity Improvement Program (NSQIP). One-year all- Perhaps more importantly, this study provides a APSF, whether or not their proposals were funded. cause mortality will be determined using the DVA’s basis for identifying specific determinants of exper- We hope that the high quality of the proposals and administrative death benefits database (BIRLS). The tise in anesthesia. Through qualitative evaluation of the important findings that will undoubtedly result authors will study approximately 100,000 major situation awareness query responses and eye track- from completion of these projects will serve as a ing data, the authors propose to identify specific surgical cases performed at approximately 123 hos- stimulus for other investigators to submit research indicators that are reflective of skill acquisition in pitals. Propensity scoring will be used to adjust for grants that will benefit all patients and our spe- anesthesia. Such information will be useful in medication prescribing biases, followed by risk cialty. enhancing training of anesthesia providers. adjustment using validated NSQIP methodology. Logistic regression models will be developed using Sorin J. Brull, MD, is Chair of the APSF Scientific Investigators listed in Dr. Wright’s research pro- patient and hospital covariates along with drug use Evaluation Committee and Professor of Anesthesiology posal include Jeffrey M. Teakman, MD, Jonathan B. (considering duration of therapy, dose, and class) to at the Mayo Clinic College of Medicine, Jacksonville, FL. Mark, MD, and Mark Stafford-Smith, MD. Other personnel include Eugene W. Hobbs, Laboratory Technician; Bryan Andregg, Analyst Programmer; and Barbara G. Phillips-Bute, Statistician. In addition to receiving the requested funding The APSF wishes to express of $74,959 for this project, Dr. Wright is also the recipient of the Ellison C. Pierce, Jr., MD, Research its sincere appreciation to Abbott Laboratories Award, which consists of an additional, unre- stricted grant of $5,000.

www.abbott.com for Abbott’s continued commitment to anesthesia patient safety and their generous support of this issue of the APSF Newsletter.

Martin J. London, MD APSF NEWSLETTER Winter 2005-2006 PAGE 70

Dear SIRS Absorbent Wrapper Design Questioned

Editor’s Note: Although Dr. Wright may have later Responses determined the manufacturer of the product in question, AFETY the Editors subsequently located at least 2 additional S Dear SIRS, reports of circuit obstruction by unwrapped absorbent canisters, apparently manufactured by other companies. Grace has taken several steps to ensure that end I NFORMATION Our focus, then, is not to implicate any particular users are aware of the wrapping around our pre- brands, but to allow manufacturers to address the issue pak cartridges and that said wrapping should be of safety. ~ Drs. Morell and Olympio removed prior to use. The first step is a clear, writ- R ESPONSE ten statement printed on the wrap stating clearly "STOP!!! - remove this shrink wrap before use." Sec- Dear SIRS: ond, we have a red "easy open" tear strip around YSTEM I am aware of 2 instances where the plastic the top of the package that has clearly written on it S wrapper on the soda lime was not removed prior "STOP - remove before use.” Third, and even more to installation into the machine. Both instances important, Grace does not tighten the wrapping to the point at which it fully adheres to the sides of the occurred late in the day and were accompanied container. We purposefully "blouse" the wrapping by unexpected ventilation problems. Both so it protrudes from the sides of the container, mak- instances were “solved” before a catastrophe ing the wrapping not only more evident, but also occurred, but there was much “running around” making it more difficult for the end user to put the during the trouble-shooting. cartridge into the delivery unit. I have attached a I am concerned that this will result in a patient photo as a visual aid to show you what I mean. death. I would very much like to get further details This could all be avoided if we always checked from Dr. Wright to determine whether it was a Sodasorb brand cartridge that was put into use our machines before induction, but I know that prior to the wrapping being removed, and if so, to my colleagues don't always do that once the day get additional details so we can enter this incident is underway. Also, we instituted a protocol into our formal quality follow-up process. whereby the anesthesia “aide” who changes the lime is to write a note and set it on the gas Jeff Mack machine warning the anesthetist that the lime has Global Sales & Marketing Manager, Sodasorb Michael Olympio, MD, Grace Performance Chemicals been changed. This was not done in the most Chair of the APSF Committee on Technology W.R. Grace & Co.-Conn and Co-Founder of the Dear SIRS Initiative. recent case. That case was also accompanied by a change in nursing personnel at 3:00 pm. The new nurse was not informed that the lime had been Dear SIRS refers to the Safety Information Dear SIRS, changed, nor was I. Carbolime is shipped with a shrink wrapper that Response System. The purpose of this column is The problem here is that the line of communica- incorporates a label within the wrapper material to expeditiously communicate technology-related tion can always be broken. itself. The label clearly states that the wrapper must be removed before use. Additionally, when the safety concerns raised by our readers, with input If, however, the canister could not be closed wrapper is shrunk onto the canister, the “corners” of with a properly designed wrapper on it, then it the wrapper protrude from the circumference of the and responses from manufacturers and industry would be impossible to close the cage over an canister making it difficult to insert the canister into representatives. This process was developed by unwrapped canister. The wrapper on these canis- an anesthesia machine without removing the wrap- ters is clear plastic with some fenestrations (which per. Despite these factors, there have been—albeit Drs. Michael Olympio, Chair of the Committee on allowed some airflow through them) and printed extremely infrequent—reports of users placing Car- bolime canisters in anesthesia machines without Technology, and Robert Morell, Editor of this on that plastic in red letters is the following: “THIS WRAPPER MUST BE REMOVED PRIOR TO USE.” removing the wrapper from the canister. Allied encourages users of its Carbolime product to read newsletter. Dr. Olympio is overseeing the column It is repeated numerous times on each canister, and and heed all labels associated with the product. is hard to miss. and coordinating the readers’ inquiries and the Eldon P. Rosentrater I would appreciate your thoughts. Thanks for responses from industry. Dear SIRS made its VP Administration listening, and thanks for the APSF. Allied Healthcare Products, Inc. debut in the Spring 2003 issue. Tom Wright, MD Minneapolis, MN See “Wrapper,” Next Page APSF NEWSLETTER Winter 2005-2006 PAGE 71

Design Changes May Have Unexpected Consequences “Wrapper,” From Preceding Page Dear SIRS: We are committed to working together with our distributors, equipment manufacturers, and design- ers, as well as the end users to ensure ease and proper use of our products and to participate in proper training. Sofnolime is shipped to this end with safety fea- tures in mind. 1) Clear markings are placed in the outer wrapper of cartridges to enable user-friendly reminders and facilitate training in the preparation and use of “one shot” cartridges. 2) Cartridges are shrink-wrapped with clear markings and instructions. We believe that the concept of “better by design” in combination with these 2 principles can make a difference. Molecular Products encourages all distributors and customers to spread the “good practice” of reading all labels and instructions before use of consumables. Continuous training and re-enforcement programs are an integral part of these good practice regimes. Our carton and product markings are under constant review, and we welcome suggestions as to more effective, internationally recognizable, and This photograph is an example of one manufacturer’s reminders to remove the wrapper on an absorbent canister before attention-seeking labels that would reduce further installation into the anesthesia machine. any instance that threatens patient safety. “Designed for purpose” is the ultimate goal of An apparently “simple” solution is not always today. The FDA procedure provides both an accu- every product and this incident has provoked “simple” and, without extensive field research, rate and reliable method to detect an anesthesia debate about removable packaging that could aid in does not always have the expected or desired effect. machine that is not functioning properly. The FDA procedure is designed to be conducted at the begin- avoiding repeat instances. David Baines ning of the work day and, in an abbreviated form, Sales and Marketing Director The “better by design” approach can have some prior to each subsequent anesthetic. Molecular Products Limited unexpected consequences. It is quite easy to intro- The FDA checkout procedure is currently being duce a safety feature that, while preventing one reviewed2 and recommendations for changes may form of misuse, inadvertently introduces an unex- Dear SIRS: be presented shortly. In the meantime, this check- pected effect. The letter from Tom Wright, MD, to the APSF out procedure should remain a crucial portion of These effects can include both safety and com- Newsletter describes what may most likely be seen by every safe anesthetic. mercial issues. Introducing a tear off safety tag that any anesthesia provider as an immediate high-prior- Michael Mitton prevents insertion of the absorber can lead to peo- ity problem, the unexpected inability to ventilate a Director of Clinical Affairs ple forcing the disposable cartridge into place, patient (the lack of visibility of the root cause, the GE Healthcare, Life Support Solution absorbent wrapper, complicated this event). Typical which causes damage to the ventilator equipment References and in turn potentially leads to an even larger haz- techniques may ultimately find the problem but, as the author states, “there was much ‘running around’ 1. Anesthesia Apparatus Checkout Recommendations, ard to the patient than the original issue. It may also during the trouble-shooting.” 1993. Available at: http://www.fda.gov/cdrh/hum- prevent insertion of further cartridges. fac/anesckot.html. Accessed November 28, 2005. The author further suggests possible solutions There is also the issue of increased cost. For that may help prevent this event from occurring in 2. Feldman J. Efforts under way to revise the preuse check- instance, apart from the extra cost of the safety the future and, while some solutions may be out recommendations. ASA Newsletter 2005;69(10): device itself, there can also be manufacturing explored, the preoperative checkout procedure Available at http://www.asahq.org/Newslet- process costs or packing density effects, which can required by the FDA1 provides users with an ters/2005/10-05/feldman10_05.html. Accessed Novem- alter the shipping costs and storage efficiency. appropriate method to help avoid these events ber 28, 2005. APSF NEWSLETTER Winter 2005-2006 PAGE 72

Anesthesia Patient Safety Foundation Officers, Directors, and Committees, 2006 Executive Committee Burton A. Dole, Jr. Consultants to Executive Peter J. Davis, MD Arrow International (Philip Croxford) (Officers) Pauma Valley, CA Pittsburgh, PA Committee Aspect Medical Systems (Nassib Robert K. Stoelting, MD Marcel E. Durieux, PhD, MD John H. Eichhorn, MD David B. Goodale, PhD, DDS G. Chamoun) APSF President University of Virginia University of Kentucky Jeana E. Havidich, MD Indianapolis, IN Charlottesville, VA Lexington, KY AstraZeneca (David B. Goodale, Barry A. Harrison, MD Jan Ehrenwerth, MD PhD, DDS) Jeffrey B. Cooper, PhD Jacksonville, FL APSF Executive Vice President Yale University APSF Committees Bayer Pharmaceuticals (Stanley Alfred Lupien, PhD, CRNA Massachusetts General Hospital New Haven, CT Newsletter Editorial Board Horton, PhD) Boston, MA Augusta, GA Norig Ellison, MD Robert C. Morell, MD, Editor Baxter Healthcare (Raul A. Trillo, University of Pennsylvania Christopher O’Connor, MD George A. Schapiro MD) APSF Executive Vice President Ardmore, PA Addie Larimore, Editorial Assistant Chicago, IL Winston-Salem, NC Hillsborough, CA David M. Gaba, MD David Paulus, MD Becton Dickinson (Michael S. Fer- Sorin J. Brull, M.D. rara) Paul A. Baumgart David B. Goodale, PhD, DDS, Gainesville, FL APSF Vice President AstraZeneca Joan M. Christie, MD Ira Rampill, MD Cardinal Healthcare (Tim Van- GE Healthcare Wilmington, DE Jan Ehrenwerth, MD Stony Brook, NY derveen) Madison, WI Alexander A. Hannenberg, MD John H. Eichhorn, MD Karen J. Souter, MB Datascope (Thomas W. Barford) David M. Gaba, MD Newton-Wellesley Hospital Lorri A. Lee, MD Seattle, WA APSF Secretary Newton, MA Dräger Medical (Robert Clark) Stanford University Seattle, WA Sally T. Trombly, RN, JD Elizabeth F. Holland Endo Pharmaceuticals (Brian Mul- Palo Alto, CA Rodney C. Lester, PhD, CRNA Robert A. Virag Abbott Laboratories nix) Casey D. Blitt, MD Abbott Park, IL Glenn S. Murphy, MD Matthew B. Weinger, MD APSF Treasurer Chicago, IL FPIC (Robert White) Walter Huehn Committee on Technology Tucson, AZ GE Healthcare (Paul A. Baumgart) Philips Medical Systems Denise O’Brien, MSN, RN Executive Committee Michael A. Olympio, MD, Chair Boeblingen, Germany Karen L. Posner, PhD Winston-Salem, NC Hospira (Tim Hagerty) (Members at Large) Seattle, WA R. Scott Jones, MD Abe Abramovich Kimberly Clark (Judson Boothe) Robert A. Caplan, MD University of Virginia Keith J. Ruskin, MD Virginia Mason Medical Center Charlottesville, VA Thomas W. Barford LMA North American (Steven C. Seattle, WA Wilson Somerville, PhD Datascope Mendell) Rodney C. Lester, PhD, CRNA Winston-Salem, NC Nassib G. Chamoun Houston, TX Nassib G. Chamoun Philips (Walter Huehn) Jeffery S. Vender, MD Aspect Medical Systems Robert Clark Newton, MA Edward C. Mills Evanston, IL Preferred Physicians Medical Risk Preferred Physicians Medical Dräger Medical Retention Group (Edward C. Matthew B. Weinger, MD Committee on Education and Risk Training Michael P. Dosch, CRNA Mills) Vanderbilt University Mission, KS Pontiac, MI Nashville, TN Richard C. Prielipp, MD, Chair ResMed (Ron Richard) Terri G. Monk, MD James D. Eisenkraft, MD Executive Committee Duke University Kenneth J. Abrams, MD New York, NY Smiths Medical (Andrew Rose) (Committee Chairs) Durham, NC Montville, NJ Patrick Foster, MD Spacelabs Medical (Joseph Davin) Sorin J. Brull, MD Robert C. Morell, MD Kevin J. Cardinal, CRNA Hershey, PA Mayo Clinic Minneapolis, MN The Doctors Company (Ann S. Ervin Moss, MD Julian M. Goldman, MD Lofsky, MD) Jacksonville, FL Joan M. Christie, MD New Jersey Society of Boston, MA Robert C. Morell, MD Anesthesiologists Alan M. Harvey, MD Tyco Healthcare (William T. Den- Niceville, FL Verona, NJ Springfield, MA Bill Jonnalee, CertAT man, MD) Lebanon, NH Michael A. Olympio Denise O’Brien, MSN, RN Timothy N. Harwood, MD Vital Signs (Terry Wall) Wake Forest University Siegfried Kastle ASPAN Winston-Salem, NC Data Dictionary Task Force Winston-Salem, NC Ypsilanti, MI Philips Medical Systems Jeana E. Havidich, MD Terri G. Monk, MD, Chair Richard C. Prielipp, MD John M. O’Donnell, CRNA Charleston, SC Michael Mitton, CRNA University of Minnesota University of Pittsburgh GE Healthcare R. Scott Jones, MD Clinical Advisory Group Minneapolis, MN Pittsburgh, PA Ervin Moss, MD Deborah Lawson, AA David L. Reich, MD Board of Directors Richard C. Prielipp, MD, FCCM Solon, OH Francis R. Narbone, CRNA Ronald A. Gabel, MD James F. Arens, MD Keith J. Ruskin, MD Chicago, IL University of Texas Samsun (Sem) Lampotang, PhD Dr. Martin Hurrell Yale University John M. O’Donnell, CRNA Houston, TX Gainesville, FL New Haven, CT Robert S. Lagasse, MD Thomas J. Mancuso, MD A. William Paulson, PhD Paul A. Baumgart George A. Schapiro Atlanta, GA Savannah, GA Dr. Anthony P. Madden Casey D. Blitt, MD Robert K. Stoelting, MD Tricia A. Meyer, PharmD Kenneth C. Plitt, CRNA Dr. Andrew C. Norton Sorin J. Brull, M.D Raul A. Trillo, MD Temple, TX Newton, MA Baxter Healthcare Dr. Roger Tackley Robert A. Caplan, MD Patty Reilly, CRNA New Providence, NJ Susan L. Polk, MD Nassib G. Chamoun Chicago, IL Tyco Healthcare Nellcor Homer Wang, MD Sally T. Trombly, RN, JD David Wax, MD Frederick W. Cheney, Jr., MD Dartmouth-Hitchcock Medical Keith J. Ruskin, MD Bonnie Reinke University of Washington Center Arthur J. C. Schneider, MD GE Healthcare Technical Group Seattle, WA Lebanon, NH Hershey, PA Chet I. Wyman, MD (Corporate Participants) Joan M. Christie, MD Rebecca S. Twersky, MD Michael Smith, MD Baltimore, MD Cerner Tampa, FL Lawrence, NY Cleveland, OH Corporate Advisory Council DocuSys Robert Clark Robert A. Virag N. Ty Smith, MD George A. Schapiro, Chair Dräger Medical Trifid Medical Group, LLC San Diego, CA APSF Executive Vice President Dräger Medical Telford, PA Chesterfield, MO Matthew B. Weinger, MD Robert K. Stoelting, MD Eko systems Jeffrey B. Cooper, PhD Mark A. Warner, MD David Wharton, RN APSF President Mayo Clinic GE Healthcare William T. Denman, MD Ada, OK Tyco Healthcare Nellcor Rochester, MN Corporate Members iMDsoft Committee on Scientific Boston, MA Matthew B. Weinger, MD Abbott Laboratories (Elizabeth F. Informatics Evaluation Holland) Albert L. deRichemond Robert Wise Philips Medical Systems ECRI JCAHO Sorin J. Brull, MD, Chair Anesthesia Healthcare Partners Plymouth Meeting, PA Oakbrook Terrace, IL Karen L. Posner, PhD, Vice Chair (Sean Lynch) Picis APSF NEWSLETTER Winter 2005-2006 PAGE 73

Anesthesia Patient Safety Foundation Corporate Donors Grand Patron ($15,000 to $24,999) Sponsoring Members ($1,000 to $4,999) Baxter Anesthesia and Critical Care (baxter.com) Anesthesia Business Consultants (anesthesiallc.com) Founding Patron ($400,000 and higher) Dräger Medical (nad.com) Allied Healthcare (alliedhpi.com) American Society of Anesthesiologists (asahq.org) Preferred Physicians Medical Risk Retention Group (ppmrrg.com) Armstrong Medical (armstrongmedical.net) Sustaining Patron Patrons ($10,000 to $14,999) Cerner Corporation (cerner.com) ($100,000 to $199,999) DocuSys (docusys.net) Cook Critical Care (cookgroup.com) Anesthesia Healthcare Partners, Inc. (AHP) (ahphealthcare.com) Endo Pharmaceuticals (endo.com) Intersurgical Ltd. (intersurgical.com) Sponsoring Patron Ethicon Endo-Surgery (ethiconendo.com) King Systems Corporation (kingsystems.com) ($75,000 to $99,999) iMDsoft (imd-soft.com) Masimo Corporation (masimo.com) GE Healthcare (gemedical.com) Spacelabs Medical (spacelabs.com) Medical Education Technologies, Inc. (meti.com) Foundation Patron Sustaining Members ($5,000 to $9,999) Molecular Products Ltd. (molecularproducts.co.uk) ($50,000 to $74,999) Anesthesiologists Professional Assurance Company Oridion (oridion.com) Abbott Laboratories (abbott.com) Arrow International (arrowintl.com) TRIFID Medical Group LLC (trifidmedical.com) Bayer Pharmaceuticals Corporation (bayer.com) W.R. Grace (wrgrace.com) Benefactor Patron ($25,000 to $49,999) Becton Dickinson (bd.com) Corporate Level Members ($500 to $999) Aspect Medical Systems (aspectms.com) Cardinal Health, Alaris Products (alarismed.com) Datascope Corporation (datascope.com) Belmont Instrument Corporation (belmontinstrument.com) AstraZeneca Pharmaceuticals, LP GlaxoSmithKline (gsk.com) Lippincott Williams and Wilkins (astrazeneca.com) Kimberly-Clark (kimberly-clark.com) Participating Associations Hospira (hospira.com) LMA of North America (lmana.com) American Association of Nurse Anesthetists (aana.com) ResMed (resmed.com) Organon (organon.com) Smiths Medical (smiths-medical.com) Subscribing Societies American Society of Anesthesia Technologists and Technicians Philips Medical Systems (medical.philips.com) The Doctors Company (thedoctors.com) Vance Wall Foundation (asatt.org) Tyco Healthcare (tycohealthcare.com) Vital Signs(vital-signs.com) American Academy of Anesthesiologist Assistants (anesthetist.org) Community Donors Steven F. Croy, MD Anesthesia Associates of St. Cloud New Hampshire Society of Anesthesiologists David M. Gaba, MD Robert Barth, MD New Jersey State Society of Anesthesiologists (includes Anesthesia Groups, Individuals, John H. Eichhorn, MD Susan Bender, CRNA New Mexico Society of Anesthesiologists Specialty Organizations, and State Societies) Illinois Society of Anesthesiologists Paul E. Burke, MD Beverly K. Nichols, CRNA Grand Sponsor ($5,000 and higher) Kentucky Society of Anesthesiologists Douglas Caceres, MD L. Charles Novak, MD American Association of Nurse Anesthetists John W. Kinsinger, MD California Society of Anesthesiologists Mark S. Noguchi, CRNA American Medical Foundation Thomas J. Kunkel, MD Robert A. Caplan, MD Denise O’Brien, RN Asheville Anesthesia Associates Rodney C. Lester, CRNA Cardiovascular Anesthesia, LLC Jill Oftebro, CRNA Florida Society of Anesthesiologists Edward R. Molina-Lamas, MD CHMC Anesthesia Foundation Michael A. Olympio, MD Indiana Society of Anesthesiologists Madison Anesthesiology Consultants Melvin A. Cohen, MD Newton E. Palmer Iowa Society of Anesthesiologists Maine Society of Anesthesiologists Stuart M. Cohen, MD Pennsylvania Association of Nurse Anesthetists Robert K. Stoelting, MD Maryland Society of Anesthesiologists Colorado Society of Anesthesiologists Physician’s Accounts Receivable Members of the Academy of Anesthesiology Commonwealth Anesthesia Associates Sustaining Sponsor ($2,000 to $4,999) Mukesh K. Patel, MD Alabama State Society of Anesthesiologists Michiana Anesthesia Care Paula A. Craigo, MD Gaylon K. Peterson, MD Anesthesia Associates of Massachusetts Missouri Society of Anesthesiologists Glenn E. DeBoer Physician Specialists in Anesthesia Anesthesia Consultants Medical Group Robert C. Morell, MD John DesMarteau, MD Richard C. Prielipp, MD Anesthesia Resources Management Nebraska Society of Anesthesiologists Walter C. Dunwiddie, MD Arizona Society of Anesthesiologists John B. Neeld, MD Norig Ellison, MD Debra D. Pulley, MD Nassib G. Chamoun Nevada State Society of Anesthesiologists Jan Ehrenwerth, MD Rhode Island Society of Anesthesiologists Georgia Society of Anesthesiologists New Mexico Anesthesia Consultants Joseph Gartner, MD Muthia Shanmugham, MD Glenn P. Gravlee, MD Northwest Anesthesia Physicians Georgia Anesthesia Associates Society for Technology in Anesthesia Massachusetts Society of Anesthesiologists Neshan Ohanian, MD Barry M. Glazer, MD Southern Tier Anesthesiologists, PC Michigan Society of Anesthesiologists Oklahoma Society of Anesthesiologists Griffin Anesthesia Associates South County Anesthesia Association Minnesota Society of Anesthesiologists Oregon Anesthesiology Group Peter Hendricks, MD David W. Todd, DMD, MD Ohio Society of Anesthesiologists Oregon Society of Anesthesiologists James S. Hicks, MD The Woodlands Anesthesia Association Old Pueblo Anesthesia Group Physician Anesthesia Service Dr. and Mrs. Glen E. Holley University of Maryland Anesthesiology Associates Pennsylvania Society of Anesthesiologists Pittsburgh Anesthesia Associates Victor J. Hough, MD Utah Society of Anesthesiologists Sanford Schaps, MD Society of Academic Anesthesia Chairs Howard E. Hudson, Jr., MD Vermont Society of Anesthesiologists Society of Cardiovascular Anesthesiologists Society for Ambulatory Anesthesia Idaho Society of Anesthesiologists Virginia Society of Anesthesiologists Contributing Sponsor ($750 to $1,999) Society of Neurosurgical Anesthesia and Critical Care Independence Anesthesia, Inc. Pamela K. Webb, PhD Academy of Anesthesiology Society for Pediatric Anesthesia Indianapolis Society of Anesthesiologists Matthew B. Weinger, MD Affiliated Anesthesiologists, Inc. South Carolina Society of Anesthesiologists Robert E. Johnstone, MD West Virginia Association of Nurse Anesthetists American Society of Critical Care Anesthesiologists South Dakota Society of Anesthesiologists Daniel J. Klemmedson, DDS, MD West Virginia Society of Anesthesiologists Stockham-Hill Foundation J. Jeffrey Andrews, MD Kansas Society of Anesthesiologists Dr. and Mrs. Wetchler Tennessee Society of Anesthesiologists Anesthesia Associates of Northwest Dayton, Inc. Scott D. Kelley, MD Lawrence Wobbrock, JD Texas Society of Anesthesiologists Anesthesia Services of Birmingham Roger W. Litwiller, MD Waterville Anesthesia Associates Drs. Mary Ellen and Mark Warner Arkansas Society of Anesthesiologists Alan P. Marco, MD West River Anesthesiology Consultants Association of Anesthesia Program Directors Washington State Society of Anesthesiologists John P. McGee, MD Sorin J. Brull, MD West Jersey Anesthesia Associates, PA Medical Anesthesiology Consultants Corporation In Memoriam Capital Anesthesiology Association Wisconsin Society of Anesthesiologists Mississippi Society of Anesthesiologists In memory of Gale E. Dryden, MD (friends of the Frederick W. Cheney, MD Sponsor ($100 to $749) Roger A. Moore, MD Dryden family) Connecticut State Society of Anesthesiologists Anesthesia Associates of Boise Ervin Moss, MD In memory of Margie Frola, CRNA (Sharon R. Jeffrey B. Cooper, PhD Anesthesia Associates of Chester County Joseph J. Naples, MD Johnson, MD)

Note: Donations are always welcome. Send to APSF; c/o 520 N. Northwest Highway, Park Ridge, IL 60068-2573 (Donor list current through December 27, 2005) APSF NEWSLETTER Winter 2005-2006 PAGE 74

Anesthesia Patient Safety Foundation (APSF) 2006 GRANT PROGRAM Guidelines for Grant Applications Scheduled to Be Funded January 1, 2007

The Anesthesia Patient Safety Foundation (APSF) Grant Program supports research directed toward enhancing anesthesia patient safety. Its major objective is to stimulate studies leading to prevention of mortality and morbidity resulting from anesthesia mishaps. NOTE: The grant award limit has increased to $150,000 per project (including up to 15% institutional overhead). Additionally, there have been changes in areas of designated priority, in requirements for materials, and specific areas of research. For the current funding cycle, the APSF is placing a specific emphasis on PATIENT SAFETY EDUCATION. To recognize the patriarch of what has become a model patient safety culture in the United States and internationally, the APSF inaugurated in 2002 the Ellison C. Pierce, Jr., MD, Research Award. The APSF Scientific Evaluation Committee will designate one of the funded proposals as the recipient of this nomination that carries with it an additional, unrestricted award of $5,000. The APSF is also proud to announce the inauguration of the APSF/Anesthesia Healthcare Partners (AHP) Research Award, made possible by a generous, unrestricted grant from AHP.

PRIORITIES • Adequacy of assurances detailing the demonstrate clearly the relationship of the work to safeguarding of human or animal subjects; patient safety are the most frequent reasons for The APSF accepts applications in 1 of 2 categories applications being disapproved or receiving a low of identified need: CLINICAL RESEARCH and • Uniqueness of scientific, educational, or priority score. EDUCATION AND TRAINING. Highest priority is technological approach of proposed research; given to • Applicability of the proposed research and BUDGET • Studies that address peri-anesthetic problems for potential for broad healthcare adoption; The budget request must not exceed $150,000 relatively healthy patients; or • Clinical significance of the area of research and (including a maximum of 15% institutional over- • Studies that are broadly applicable AND that likelihood of the studies to produce quantifiable head). Projects may be for up to 2 years in duration, promise improved methods of patient safety with improvements in patient outcome such as although shorter anticipated time to completion is a defined and direct path to implementation into increased life-span, physical functionality, or encouraged. clinical care; or ability to function independently, potential for reductions in procedural risks such as mortality ELIGIBILITY • Innovative methods of education and training to or morbidity, or significant improvements in Awards are made to a sponsoring institution, not improve patient safety. recovery time; to individuals or to departments. Any qualified AREAS OF RESEARCH • Ability of research proposals to maximize benefits member of a sponsoring institution in the United States or Canada may apply. Only 1 person may be while minimizing risks to individual human Areas of research interest include, but are not listed as the principal investigator. All co-investiga- research participants. Each proposal should limited to tors, collaborators, and consultants should be listed. proscriptively enunciate the criteria for instituting Applications will not be accepted from a principal • New clinical methods for prevention and/or early rescue therapy whenever there is the remotest investigator currently funded by the APSF. Re-appli- diagnosis of mishaps; possibility of an untoward adverse event to a cations from investigators who were funded by human research volunteer. In some instances, the • Evaluation of new and/or re-evaluation of old APSF in previous years, however, will be accepted rescue therapy may be triggered by more than 1 technologies for prevention and diagnosis of without prejudice. mishaps; variable (e.g., duration of apnea [in seconds], oxygen saturation <90%, etc.). Additionally, the Previous applicants are strongly encouraged to • Identification of predictors of negative patient protocol should specify the nature of the rescue respond to the reviewers’ comments in a letter indi- outcomes and/or anesthesiologist/anesthetist procedure(s), including the rescue therapy and cating point-by-point how the comments and sug- clinical errors; dosages, and the responsible personnel. If other gestions were addressed. • Development of innovative methods for the study departments are involved in the rescue process, Applications that fail to meet these basic criteria of low-frequency events; the application should specify if such departments will be eliminated from detailed review and are to be informed when a new volunteer is returned with only minimal comment. A summary • Measurement of the cost effectiveness of participating in the trial. techniques designed to increase patient safety; of reviewers’ comments and recommendations will • Priority will be given to topics that do not have be provided to applicants only if requested from the • Development or testing of educational content to other available sources for funding. Scientific Evaluation Committee Vice-Chair. measure, develop, and improve safe delivery of anesthetic care during the perioperative period; and • Proposals to create patient safety education AWARDS content or methods that do not include a rigorous • Development, implementation, and validation of evaluation of content validity and/or benefit will Awards for projects to begin January 1, 2007, will educational content or methods of relevance to be unlikely to attain sufficient priority for be announced at the meeting of the APSF Board of patient safety (NOTE: both patient and care funding. Directors on October 14, 2006 (2006 ASA Annual provider educational projects qualify). Meeting, Chicago, IL). NOTE: Innovative ideas and creativity are SCORING strongly encouraged. New applicants are advised to NOTE: No award will be made unless the state- seek guidance from an advisor/mentor skilled in ment of institutional human or animal studies' Studies will be scored on experimental design and preparation of grant appli- committee approval is received by the committee • Soundness and technical merit of proposed cations. Poorly conceived ideas, failure to have a prior to October 1, 2006. research with a clear hypothesis and research plan; clear hypothesis or research plan, or failure to See “Application,” Next Page APSF NEWSLETTER Winter 2005-2006 PAGE 75

Grant Application Submission Date — June 19, 2006

“Application, ” From Preceding Page 3. Specific aims: what questions will be answered I. List all current or pending research support by the investigation? If applicable, what (federal, foundation, industrial, departmental) PAPERLESS APPLICATIONS hypothesis will be tested? For an educational available for the proposed project to the All applications and accompanying documents project, what are the specific learning objec- principal investigator, his collaborators, or his MUST INCLUDE tives or objectives of the methodology being mentor. List all other research support for the developed? principal investigator, stating percentage of • application 4. Significance and applicability: briefly describe effort devoted to current projects, and percent • applicant's curriculum vitae the historical prevalence and severity of the effort expected for pending projects. • applicant's acceptance form morbidity and mortality of the studied anesthe- J. List the facilities, equipment, supplies, and • departmental chair letter of support sia mishaps. Quantify the potential improve- services essential for this project and indicate ments in patient outcome or recovery time and their availability. • budget justification identify how the proposed work can be • Institutional Review Board approval or broadly applied to reduce procedural risks in V. Abbreviated CV (maximum of 3 pages) of the submission letter. health care. principal investigator only. These documents will be accepted in ELECTRONIC 5. If the application is a resubmission, describe VI. Letter from the departmental chairperson format only. Electronic files in Microsoft Word, changes from prior application, and specifically indicating Excel, or Adobe Acrobat PDF format are acceptable address the reviewers' comments. for all text, charts, and graphics, and must be A. The number of working days per week uploaded to the APSF website: B. Methods to be employed available to the applicant for the proposed research, the degree of involvement of the http://apsf.org/grants/application/applicant/ 1. Describe data collection procedure, specific techniques, and number of observations or applicant in other research projects, and the Please follow the Application Format instruc- experiments. For educational projects, describe chair's degree of enthusiasm for the proposed tions carefully; applications not conforming to the how the effects of the intervention program project. requirements may be disallowed. will be assessed. Qualitative methodologies are B. The availability of facilities essential to the APPLICATION FORMAT acceptable. completion of the proposed research. I. Cover Page 2. Describe types of data to be obtained and their C. An agreement to return unused funds if the treatment, including statistical and/or power A. Title of research project applicant fails to complete the project. analyses, if indicated. B. Designation of proposal as "Clinical Research" VII. Sign and date the Acceptance of Conditions of 3. Point out and discuss potential problems and or "Education and Training" the Grant form and upload this form as an limitations of the project. C. Name of applicant with academic degrees, Adobe PDF file to the website along with the office address, phone number, fax number, and 4. If appropriate, include a statement of approval application. e-mail address of this proposal by the institutional committee VIII. Starting with the 2004 funding cycle, ONLY reviewing human or animal investigations, or a D. Name, office address, and phone number of statement that approval has been requested. ELECTRONIC APPLICATIONS (Microsoft departmental chairperson Word or Excel format and Adobe PDF format IV. Budget - include all proposed expenditures. E. Sponsoring institution and name, office for figures or drawings) will be accepted. address, phone number, and e-mail address of Indicate under each category the amount GUIDELINES FOR PREPARATION OF APPLI- the responsible institutional financial officer requested or provided from other sources. CATIONS AND ELIGIBILITY REQUIREMENTS A. Personnel (limit salaries of individuals to NIH F. Amount of funding requested CAN BE OBTAINED FROM THE APSF WEB PAGE: Guidelines) G. Start and end dates of proposed project. http://www.apsf.org B. Consultant costs II. Research Summary - a 1-paragraph description of The original application must be submitted elec- the project. C. Equipment tronically to the website no later than Monday, June III. Research Plan (limited to 10 pages, typed, D. Supplies 19, 2006. Once the completed application is double-spaced, excluding references; appendices uploaded, an automatic confirmatory e-mail will be E. Patient costs are discouraged): generated and sent to the Chair of the Scientific F. Other costs A. Introduction Evaluation Committee: G. Total funds requested (no indirect costs) 1. Objectives of the proposed clinical research or Sorin J. Brull, MD education and training project. H. Budget justification - CLEARLY and Chair, APSF Scientific Evaluation Committee Professor of Anesthesiology 2. Background: reference work of other authors completely justify each item, including the role leading to this proposal and the rationale of the of each person involved in the project. If Mayo Clinic College of Medicine proposed investigation or project. Describe the computer equipment is requested, explain why 4500 San Pablo Road, JAB-4035 relationship to the priorities highlighted in the such resources are not already available from Jacksonville, FL 32224 first paragraph of the APSF guidelines. Include the sponsoring department/institution. NOTE: Telephone: (904) 296-5688 copies of in-press manuscripts containing pilot Failure to adequately justify any item may lead Facsimile: (904) 296-3877 data, if available. to reduction in an approved budget. E-mail: [email protected] APSF NEWSLETTER Winter 2005-2006 PAGE 76

2005 Abstracts Include Many Safety Topics by Glenn S. Murphy, MD, and Jeffery S. Vender, MD complication in this high-risk population must be Airway considered. Nearly 1,500 scientific papers were presented at The incidence and predictors of difficult mask the 2005 American Society of Anesthesiologists Pediatrics ventilation have been poorly understood. Kheterpal Annual Meeting in Atlanta, Georgia. Important et al. (A-1415) examined the level of ease or diffi- studies relating to patient safety were discussed in Three abstracts from the Pediatric Sedation culty of mask ventilation during 15,923 general Research Consortium (PSRC) were presented (A- many of the 94 separate sessions. This review will anesthetics over a 1-year period. The ability to mask 1312, A-1312, A-1314). The PSRC is a collaborative highlight a few of these important presentations. ventilate was graded on a 4-point scale (1: ventila- group of 24 institutions organized to examine the tion without the need for an oral airway, 2: ventila- safety of pediatric sedation practices and practition- Intraoperative Awareness tion requiring an oral airway, 3: ventilation that was ers. A web-based data collection tool was used to Several abstracts examined the incidences and difficult, inadequate, or required 2 providers, or 4: collect data on all sedation procedures performed at consequences of intraoperative awareness. The Thai impossible ventilation). Grade 3 ventilation was each institution. Data were received on 10,552 pro- Anesthesia Incidence Study (A-1283) prospectively observed in 214 (1.3%) patients and Grade 4 cedures. Complications were defined as any of the collected data from 20 hospitals over a 1-year occurred in 24 (0.16%) cases. Independent predic- following; apnea, desaturation, unplanned mask period. Details of intraoperative awareness were tors of Grade 3 ventilation included a history of ventilation or intubation, prolonged sedation or recorded and analyzed to identify contributing fac- snoring, a BMI >25, limited jaw protrusion, the unplanned deep sedation, emesis, use of reversal tors and preventive strategies. Among over 150,000 presence of a beard, and an ASA status of 3-5. Pre- agents, or change in vital signs >30%. The incidence anesthetics, 99 cases of awareness were observed. dictors of Grade 4 ventilation were the presence of a of complications was lowest when sedation was Awareness was noted more frequently in certain neck mass or sleep apnea. These data suggest the provided by an anesthesiologist (2.6%) when com- patient populations (female gender, ASA I and II predictors for difficult intubation and ventilation pared to other clinicians (nurse/physician assistant patients, patients undergoing cardiac, obstetric, and may differ. 4.7%; ER physician 7.0%; intensivist 7.0%; pediatri- lower abdominal surgery). Although 50% of cian 8.7%; radiologist 5.7%). Adjusting complication Two studies by Mort and colleagues investi- patients reported experiencing pain during the rates for age, ASA status, and emergency status gated emergency airway management of the obese awareness episode, only 13% described postopera- increased these differences further. The results from patient outside the operating room setting. An tive emotional stress or anxiety. Pollard and col- the PSRC suggest that serious complications related emergency intubation database was reviewed to leagues (A-8) conducted a modified Brice interview to pediatric sedation are rare, and that the risk of examine the incidence of difficult intubation (A- in postoperative patients (within 24-48 hours) to complications may be influenced by the type of 1145), and the role of the LMA as a rescue device determine the incidence of intraoperative aware- provider administering sedative agents. (A-288), in this patient population. When compared ness. A total of 161,824 general anesthesia patients to a cohort of patients with a BMI <25, morbidly were interviewed over a 4-year period. Only 12 The Pediatric Perioperative Cardiac Arrest obese (MO) patients (BMI >40) had a higher inci- cases of intraoperative awareness (0.007% inci- (POCA) Registry was formed in 1994 to investigate dence of poor glottic visualization (Lehane-Cor- dence) were identified in this investigation, which causes and outcomes associated with perioperative mack grade 4: 28%-MO vs. 8%), unsuccessful suggests that the risk of awareness may be lower in cardiac arrest in children. Researchers from the intubation on first attempt (48%-MO vs. 28%), and certain practice settings. Researchers in Sweden (A- University of Washington School of Medicine requiring more than 3 intubation attempts (18% vs. 7) examined the severity of immediate and delayed examined the causes of cardiac arrest in pediatric 10%). The incidence of hypoxemia was also higher suffering due to intraoperative awareness. After patients over 2 time periods: 1994-1997 and 1998- in the MO group. The authors also reported on the interviewing 2,681 consecutive patients scheduled 2003 (A-1310). There was a decrease in the propor- use of the LMA as a rescue device in obese patients for general anesthesia, 98 patients were identified tion of infants and an increase in the proportion of (BMI >30) outside the OR. A total of 97% of obese who considered themselves to have experienced older children (6-18 years) suffering a perioperative patients were successfully ventilated with the LMA awareness. Detailed interviews were conducted in cardiac arrest over time. The severity of injury dur- within 3 attempts at placement. Overall, 91% of the 46 patients who appeared to have actually been ing the 2 time periods did not differ, with more patients were successfully intubated via the LMA. aware during a general anesthetic. Thirty patients than one-quarter of cardiac arrests resulting in The authors note that obese patients pose chal- described an acute emotional reaction, and 15 death. The proportion of medication-related deaths lenges to the airway manager outside the OR, and patients experienced late symptoms with a median was significantly lower in the 1998-2003 period that the LMA may be a useful device to establish severity score of 4 (on a scale of 12). Four patients (20%) compared to the 1994-1997 interval (32%). both ventilation and intubation in these situations. contacted medical personnel due to mental symp- The authors attribute this difference to the declin- toms relating to awareness. However, only 1 patient ing use of halothane in favor of sevoflurane in Miscellaneous was diagnosed with post-traumatic stress disorder. pediatric patients. Leslie et al. (A-9) presented details of awareness Jimenez and colleagues analyzed 525 pediatric The impact of type of anesthesia (inhalational vs. intravenous) on outcomes remains controver- cases in the B-Aware Trial. Patients with confirmed claims from the ASA Closed Claims database to sial. Investigators from the Netherlands studied the awareness in this trial were more likely to have pre- identify trends in types of patient injury and out- association between method of general anesthesia operative impaired cardiovascular status and intra- comes over the last 3 decades (A-1309). The propor- (propofol or volatile agents) and 1-year mortality operative hypotension requiring vasopressor tion of claims relating to respiratory events (A-1271). Adult patients (n = 1,508) undergoing treatment than patients without awareness. In addi- decreased over time (1970s - 57%; 1990-2000 - 25%; general or vascular surgery were examined. Multi- tion, these patients received lower concentrations of P < 0.001), as well as the proportion of claims for variate logistic regression analysis was used to inhaled volatile anesthetics (MAC equivalent of death or permanent brain damage (1970s - 78%; adjust for potential confounding variables. Overall 0.3%). Six of 13 patients reported adverse conse- 1990-2000 - 61%; P=0.03). Although the reasons for 1-year mortality was 5.2%. Mortality was associated quences resulting from the awareness episode. these changes in pediatric claims over time are not with comorbidities, age, and surgical procedure, These findings clearly demonstrate that hemody- established, the authors hypothesize that improve- but not with type of anesthesia. The authors note namically unstable patients are at greatest risk of ments in monitoring, drugs, or training (subspecial- awareness, and measures to reduce the risk of this ization) may have influenced patient outcomes. See “Abstracts,” Next Page APSF NEWSLETTER Winter 2005-2006 PAGE 77

Lee Presents Letter to the Editor POVL Data Labor Analgesia Needs to Be Available Solution to Challenge Deserves Careful Consideration “Abstracts,” From Preceding Page that inhalational agents were more frequently used To the Editor: during labor. Pain management should be provided in older patients with comorbidities, which may We read with interest, and much dismay, the whenever medically indicated.”1 While this docu- explain previous observations of higher mortalities letter by Dr. Thomas Parker, Jr., regarding labor ment goes on to note, “that of the various pharmaco- in patients administered volatile agents. epidurals in the summer 2005 issue of the APSF logic methods used for pain relief during labor and Ischemic optic neuropathy (ION) is the most Newsletter. Dr. Parker raises some issues that are delivery, regional analgesia techniques—epidural, common cause of postoperative visual loss (POVL) important and of very real concern to the specialty spinal, and combined spinal epidural—are the most after spine surgery. Lee and colleagues examined of anesthesiology. Daytime fatigue and patient- flexible, effective, and least depressing to the central the ASA POVL Registry to identify potential risk safety concerns owing to night-time work is an nervous system, allowing for an alert, participating factors for POVL (A-1). Seventy-one cases of ION obvious and important problem. Provision of com- following spine surgery were reviewed and com- mother and an alert neonate,” there is no require- prehensive, 24-hour-per-day anesthetic services in pared to 9 cases of central retinal artery occlusion. ment to use regional analgesia. Individual hospitals Of the 71 ION cases, the median age was 50, mean small, rural hospitals is a particular challenge. Lim- and anesthesia groups must determine what they anesthesia duration was 10 hours, the mean esti- ited anesthetic manpower and resources are a can practically and safely provide. This might source of stress for many practitioners in a variety mated blood loss was 3.8 liters, and 79% of cases include single shot-spinal opioids with additional IV ≥ of settings, both large and small. Appropriate reim- had 15 minutes of a systolic blood pressure <100 opioids as needed, as some smaller centers do, or mmHg. Cases of central retinal artery occlusion bursement for our services is an essential matter of simply IV opioids if regional analgesia is not feasi- were associated with a shorter anesthesia dura- fairness and important to all practitioners. tion (6.4 hours) and a lower estimated blood loss ble. We would further note that this document takes However, Dr. Parker's letter was a virtual diatribe compared to ION cases. Although ION may occur a strong stance on appropriate reimbursement. against labor epidurals, and more specifically, during prolonged spine surgery with significant Dr. Parker does raise issues of serious concern. blood loss and hypotension, the wide ranges in against the women requesting them. We feel this is These issues deserve ongoing, careful consideration these reported variables suggest a multi-factorial misdirected and inappropriate. Dr. Parker refers to etiology of ION. women requesting pain relief with labor epidurals and discussion among the leadership of our profes- as “incessant,” “entitled,” “demanding,” and “priv- sional societies. However, it is not in keeping with This brief review summarized only a small ileged,” and to labor epidurals themselves as “non- the spirit of professionalism that we expect from number of the important abstracts on patient safety essential.” Labor pain is one of the most severe presented at the 2005 Annual Meeting. To view our anesthesia colleagues to belittle, insult, and dis- pains a woman will ever experience in her lifetime, other abstracts on patient safety, or to obtain further parage women in labor for their entirely appropri- information on the abstracts discussed in this and relief of this pain is no less important than the ate requests for pain relief. These issues need to be review, please visit the Anesthesiology website at surgical anesthesia we provide in the operating faced by our obstetric colleagues as well as hospital room. The provision of obstetric analgesia or anes- www.anesthesiology.org. administrators, in consultation with the anesthesiol- thesia, either at night or during daylight hours, is Dr. Murphy is Director of Cardiac Anesthesia for ogist. Together, we can find solutions and provide one of the most important services that we as anes- Evanston Northwestern Healthcare and an Associate adequate pain relief for women in labor, and insure thesiologists can provide. The women who receive Professor at Northwestern University Medical School these services are no more or less deserving of pain safe, healthy deliveries for the children in our in Chicago. Dr. Vender is Chairman of the Department respective communities. of Anesthesia at Evanston Northwestern Healthcare relief than any other patient in the surgical suite. and Professor at Northwestern University Medical What, according to Dr. Parker, renders epidural William Camann, MD School in Chicago. analgesia in labor a “privilege”? What other ser- Boston, MA vices provided by Dr. Parker are considered “privi- Samuel Hughes, MD leges,” and who among his patients are “entitled” San Francisco, CA to receive these services? What is an “incessant demand”? Is the sound of a woman in excruciating David Birnbach, MD pain, pleading for relief, an “incessant demand”? Miami, FL Does the “request” for pain relief become a Reference The Anesthesia Patient “demand” when made by a patient without private Safety Foundation health insurance? Is labor pain somehow more 1. ACOG Committee Opinion, # 231," Pain Relief During amenable and appropriate to relieve by regional Labor," February 2000. This opinion replaces # 118, Jan- wishes to recognize and thank analgesia at 2 o’clock in the afternoon than at 2 uary 1993. (It is a joint statement from the ACOG Com- o’clock in the morning? When does a group of mittee on Obstetric Practice and the ASA Committee on Obstetric Anesthesia.) patients experiencing severe pain become “overly Asheville Anesthesia demanding”? Perhaps when they cannot pay for Associates the services that would provide relief? Editor’s Note: The APSF Newsletter wishes Asheville, NC The American Society of Anesthesiologists and the American College of Obstetricians and Gynecol- to thank Drs. Camann, Hughes, and Birnbach for their generous support ogists have issued a joint statement that, “In the for their thoughtful input on this important absence of a medical contraindication, maternal issue. of APSF in 2005 request is sufficient medical indication for pain relief APSF NEWSLETTER Winter 2005-2006 PAGE 78

Scientific/Technical Exhibits Replete With Safety Themes

by John H. Eichhorn, MD pre-op reference by subsequent anesthesia person- presentation cited the distribution of major errors nel. Another related exhibit from the Cleveland as: wrong site (76%), wrong patient (13%), and Patient safety again was a prominent theme in Clinic featured a website for airway teaching mater- wrong procedure (11%). While patient safety, not the exhibit hall at the American Society of Anesthe- ial, particularly video. [Such a website could be a legal liability, was the exhibit’s emphasis, the impli- siologists Annual Meeting October 22-26, even with potential archive of actual difficult airways—with cations were clear for anesthesia providers involved the hurried translocation from hurricane-ravaged video of how to manage them—that could be in such “surgical errors.” New Orleans to Atlanta. Both the Scientific/Educa- accessed by any anesthesia provider anywhere tional Exhibits and also the Technical Exhibits from The Technical Exhibits at the ASA meeting were when provided with the unlocking security code of vendors of anesthesia-related equipment and sup- nearly as numerous and elaborate as in a normal the subject difficult airway patient who needs addi- plies contained a few fresh concepts related to year, albeit rearranged from the original printed tional anesthesia care.] Specific airway management patient safety as well as many familiar themes with floor plan. The ASA-associated foundations were strategies for pregnant patients and for pediatric some new refinements. prominently located directly by the main entrance patients were featured in extensive exhibits. Strate- door with the APSF booth directly in the entry path. In the Scientific/Educational Exhibits, 9 of the gies for topical anesthetization of the airway were Attendee interest in the APSF patient safety exhibits 48 exhibits in some way related to airway concerns. featured as well as another exhibit devoted specifi- was significantly increased this year. This simply reinforces the intriguing suggestion cally to tools useful when extubating a patient (up that airway management remains likely the greatest to and including transtracheal jet ventilation and In the large exhibit hall, continuing the theme technical/mechanical challenge for anesthesia pro- cricothyrotomy). An exhibit from Yale featured from the Scientific/Educational Exhibits, there fessionals. Indeed, it is the one central component video through the LMA “C-Trach” device that is were no fewer than 29 technical/commercial of practice that has changed the least in the “mod- designed specifically to allow the anesthesia exhibits exclusively or largely devoted to equip- ern era” of anesthesia, as defined by the wide- provider to see via a fiberoptic bundle down into ment and supplies for airway management, again spread adoption nearly 20 years ago of electronic the airway and guide placement of an endotracheal dramatically emphasizing the major role of monitors such as oximeters and capnographs to tube via the LMA under “direct vision” in circum- improving airway handling as an ongoing compo- extend the power of human senses and allow much stances where traditional views of the larynx are nent of the evolution of anesthesia patient safety. earlier detection of dangerous intraoperative situa- impossible. Further, the new concept of specific Several very large displays exhibited a panoply of tions. The fact remains that general anesthesia con- self-customization of the widely accepted “difficult all manner of airway tools and equipment, possibly tinues to include induction of unconsciousness and airway algorithm” by different individual practi- raising the question that there may be too many then paralysis of a patient’s ventilatory musculature tioners was recommended in an exhibit from Mon- competing technologies and varieties of equipment when there is no specific guarantee that intubation tefiore Medical Center in New York. Finally, the available for there to be adequate investigation of of the trachea or even positive pressure ventilation importance of these and all the airway related their applications, risks, and benefits. As is fre- will be possible. Accordingly, virtually all anesthe- issues was specifically emphasized by the fact that quently characteristic of the commercial market- sia professionals still today experience “difficult air- “The Society for Airway Management” (founded in place in medical equipment, it appears that several way” situations with a frequency that depends on 1995 and pointedly billed as “apolitical”) had a manufacturers have rushed into production of new their type of patients and practice. Thus, airway booth in the exhibits and highlighted its promotion tools or technologies that have only been “tested” tools of a wide variety, airway models, airway sim- of airway education and research as well as its liai- by their inventor and have never been the subject ulators, airway educational efforts and the associ- son with other anesthesia-related professional of peer-reviewed publications or multi-center clini- ated Scientific/Educational Exhibits, as well as groups. cal trials. While this approach may be entrepreneuri- airway-related products for sale in the Technical ally understandable, it makes for a bewildering Other Scientific/Educational Exhibits with Exhibits continue to constitute a significant fraction array of choices for average anesthesia practitioners. safety themes included one from the University of of the displays. Frustratingly, there was no exhibit For many, it may seem much easier to stick with California at San Francisco with the intriguing title the familiar Mac 3 or Miller 2 rather than try to fig- this year of any type of future “Star-Trek”-like com- “How to Avoid Death for a Dollar,” which featured ure out what may be better, either in general or in puterized scanner that would fit over the patient’s the implementation of (inexpensive) perioperative “difficult airway” scenarios. head at the bedside or in an office setting and in cardiac risk-reduction strategies employing proven seconds generate a detailed 3-D map of the airway beneficial medication: beta blockers and clonidine. There were several updates and variations on and also a highly educated “smart algorithm” opin- A literature review as well as implementation pro- the fiberoptic and video-assisted laryngoscopes, ion of precisely how to manipulate and/or instru- tocols for medication administration were available. several of which were intended for routine every- ment the airway to facilitate successful airway The American Sleep Apnea Association had a booth day use. Some featured eyepieces and some other management. Invention, testing, approval, and promoting its “A.W.A.K.E. Network” of apnea sup- displays offered miniature cameras that projected implementation of such devices or their (realistic) port groups. The use of ultrasound guidance for either to very small (1.7 inch diagonal and attached functional equivalent would revolutionize anesthe- placement of arterial, central, and peripheral directly to the laryngoscope handle) or very large sia care in somewhat the same manner as the intro- venous vascular catheters as well as for assisting video monitors. Several were battery powered from duction of electronic monitoring did in the with peripheral nerve blocks was again presented rechargeable battery packs. Some systems featured mid-1980s. in 2 exhibits, but with more emphasis on the safety blades containing integral optics that would fit onto In any case, a comprehensive plan for a depart- strategies of preventing errors and untoward a traditional C battery-powered handle, claiming to mental airway workshop was outlined by sponsors patient outcomes. Finally, the evolution of molecu- give a view around the base of the tongue without from the Medical College of Wisconsin, with lar genetic testing for susceptibility to malignant the need to displace it as in traditional direct line- reports of enhanced confidence in airway manage- hyperthermia and its obvious anesthesia patient of-sight laryngoscopy. One flexible optical stylet ment gained by participants. Likewise, computer- safety implications was outlined in an exhibit pre- powered by 4 AA batteries claimed the ability to ized video of airway management situations were sented by Henry Rosenberg, MD, from New Jersey. turn difficult intubations into routine ones with presented from Rhode Island Hospital with the Note also that there was an exhibit from the Univer- “success on the first attempt every time.” added intention of creating a detailed video archive sity of Minnesota regarding “surgical errors” and a of the difficult airways of specific patients for future systems-based approach to help avoid them. The See “Exhibits,” Next Page AAPSF NEWSLETTER Winter 2005-2006 PAGE 79

Patient Warming, Infusion Pumps, and Letter to the Editor Monitoring Included Among Exhibits Reader Highlights

“Exhibits,” From Preceding Page hypercapnia intended to stimulate increased Value of Listening minute ventilation and, thus, the faster exhalation To the Editor: Patient warming was another very common of volatile anesthetics, and also by a second internal commercial theme in the Technical Exhibits. Sev- component that is an “anesthetic absorber” that Bravo to Dr. Terring W. Herionimus, III, MD, eral new brands and variations of warming blan- captures the exhaled volatile anesthetic and pre- FACA, FCCP, for his excellent letter published in kets or equivalents were displayed. Actively vents any return into the patient via the semi-closed the Spring 2005 APSF Newsletter. In his discussion warmed wraps for the patient’s arms as the sole circuit, thus increasing the excretion gradient and of the tragic cases described in Dr. Lofsky's article, source of warming were offered as a new solution, he noted his admonition to residents and students speeding emergence. Three abstracts with 45 total particularly for procedures in which traditional to not break contact with the patient. blankets could not be used. One genuinely new patients were cited as supporting clinical trials. I have made the observation that newly trained technology involved a flexible heating fabric con- Overall, patient safety remains a central focus of taining very thin low-voltage heating wires that anesthesiologists routinely forego the use of precor- the exhibits at the ASA Annual Meeting. This recog- dial and esophageal stethoscopes. I believe they make the slightly stiff fabric become toasty warm. nizes both the current success in improving safety have been trained to rely on the other monitoring This single-use system was touted as simpler, less and also the significant challenges still remaining, devices in use. While I applaud the ongoing devel- bulky and cumbersome, and much less expensive such as, for example, in making genuine changes in opment of sophisticated monitoring technology, I than the commonly employed forced-air/plastic practice, leading to lower risk of patient injury asso- have great difficulty understanding how anyone blanket system. Further, and apparently the subject ciated with issues in airway management. can have a secure feeling without this direct patient of intense interest at the exhibit booth from many contact. I have been in practice for 18 years and find meeting attendees, was the additional new product Dr. John Eichhorn, Professor of Anesthesiology at the these tools indispensable. Not only do they help that is a vest or jacket of the same heating material University of Kentucky, founded the APSF Newsletter avert disaster, but they are so important in the prac- for the anesthesia provider who is chilly (or “freez- in 1985 and was its editor until 2002. He remains on the tical management of patients. Some of the scenarios ing”) in the OR. The material gets fairly warm, but Editorial Board and serves as a senior consultant to the in which I feel they are critical are as follows: imme- not hot, and can be turned on and off by connect- APSF Executive Committee. diate detection of partial or complete airway ing or disconnecting a power cord to the same elec- obstruction; assessment of proper placement and tric power supply that is connected to the patient’s seating of LMAs; migration of endotracheal tube warming blanket. into the right mainstem bronchus, especially in Infusion pump displays touted patient safety pediatric cases during which I place the precordial with an increased emphasis and volume that has on the left chest; diagnosis of wheezing; need for not been seen before. Apparent sensitivity to case suctioning; disconnection; and light anesthesia with reports of patient injuries from infusion pump acci- APSF Executive swallowing and borborygmi. dents and subsequent regulatory and government No doubt, some or maybe all of these condi- inquiries seemed to be motivating some of the sales Committee tions may be noted with other monitors. But how discussions from representatives of these compa- much more rapidly does one hear a wheeze as nies. Likewise, new features and variations of rapid Invites opposed to noticing a change in the end-tidal car- infusion devices stressed safety issues, particularly Collaboration bon dioxide curve? Or what about noticing an improved ability to detect air in infusion lines and increased airway inflation pressure: isn't it much then prevent entry of that air into the patient’s From time to time the Anesthesia Patient more instantaneous to just hear secretions clogging blood stream. Safety Foundation reconfirms its the endotracheal tube? Ventilation monitoring during MAC and seda- commitment of working with all who These are just a few examples that come to tion seemed to reemerge as a targeted safety issue devote their energies to making anesthesia mind. I have been so troubled by this that I con- this year. Several companies heavily promoted the sulted my mentor from UCLA who told me that he potential safety benefits of qualitative or near-quan- as safe as humanly possible. Thus, the thinks the problem is starting in medical schools titative assessment of expired CO2 during sedated Foundation invites collaboration from all with less emphasis on auscultation. He feels that spontaneous ventilation. There was no specific ref- who administer anesthesia, and all who many residents are uncomfortable with ausculta- erence to reported hypoventilation accidents with provide the settings in which anesthesia is tion, and that even if they use an earpiece, they “deep sedation,” such as in plastic surgeons’ offices don't know what they are listening to. practiced, all individuals and all or even endoscopy or imaging suites, but the impli- I have also acted as a reviewer for malpractice cations were unmistakable. organizations who, through their work, cases in which these issues have been critical to affect the safety of patients receiving Finally, an intriguing new product that could patient outcome, although sometimes this is hard to have safety implications was featured. A mechani- anesthesia. All will find us eager to listen prove in retrospect. cal device inserted in the breathing circuit in place to their suggestions and to work with them What can we do to improve this situation? Do of the Y-connector is intended to speed up emer- toward the common goal of safe anesthesia we need to tighten the ASA standards? Or do oth- gence from the effects of inhalation anesthetics and, for all patients. ers feel I am completely off base? I look forward to for example, reduce the time in stage 2 delirium some answers. and reduce time to extubation at the end of a gen- eral anesthetic. It functions in 2 ways, by causing Danielle M. Reicher, MD some rebreathing and resulting deliberate mild Encinitas, CA APSF NEWSLETTER Winter 2005-2006 PAGE 80

Letter to the Editor Oxygen May Mask Hypoventilation— Patient Breathing Must Be Ensured To the Editor: this is only true when supplementary oxygen is meters one could monitor to keep the patient safe. being administered. In a patient breathing room air, We strongly support Overdyk's communication1 Following that rationale leads to the inescapable pulse oximetry is highly effective in signaling about the many patients daily at risk of respiratory conclusion that much, if not the majority of respira- hypoventilation and/or airway obstruction! The depression, and would like to elaborate on 3 issues tory morbidity and mortality that has occurred in problem, again, is that clinicians who use pulse he raised in order to pinpoint some of the problems. the current era (of IV sedation with monitoring via oximetry to monitor ventilation may fail to appreci- pulse oximetry) could have been avoided simply First, he states that “Cashman reported an inci- ate the relevant physiology of the Hb-oxygen disso- via the deliberate and purposeful exclusion of the dence of respiratory depression of. . . 1.3% by ciation curve, and how it affects such a practice (i.e., use of supplemental oxygen (which would effec- bradypnea (RR <10).” In sedated patients, both res- that the application of oxygen, even 1 or 2 liters by tively put a brake on the level of sedation a clinician piratory rate and tidal volume, and even ETCO2, as nasal cannulae, moves the patient to the right on was willing to administer). isolated indices, fail to correlate consistently with the Hb-oxygen dissociation curve, in which case the Clinical medicine does need a better mousetrap alveolar ventilation (VA), and therefore pCO2. This PaO no longer linearly correlates with the SpO , 2 2 to directly measure ventilatory sufficiency in non- of course makes sense when one considers the effect and as a result, the SpO2 then no longer correlates of tidal volume on dead space (VD/VT) and there- with alveolar ventilation). intubated patients, and we would agree that the fore VA, and the clinical observation that narcotic- APSF is the ideal organization to tackle the prob- The Practice Guidelines for Sedation and Anal- induced respiratory slowing is frequently lem. Transcutaneous carbon dioxide monitors may gesia by Non-Anesthesiologists5 recommend that associated with an increase in tidal volume. The lat- provide a solution and certainly warrant further supplemental oxygen be administered to all ter, in turn, reduces VD/VT and ameliorates the validation. In the meantime, pulse oximetry can be patients undergoing deep sedation. Unfortunately, effect of the decrease in respiratory rate on VA. an effective solution, as long as clinicians under- the Guidelines, which thousands of practitioners This, in fact, is the rationale for using opiates as a stand how to use it appropriately. If PCA use on look to for guidance, are entirely silent on the com- cornerstone of therapy in managing the early phase room air results in hypoxemia, then the fix is not to plications of this practice. Interestingly, a recent of respiratory failure and fatigue characterized by apply oxygen as de facto treatment, but to either report in the emergency medicine literature high- rapid shallow breathing in acutely ill patients. Bot- decrease the opiate allowed, or if supplemental lighted this issue.6 Apparently, these practitioners tom line: Bradypnea is certainly a signal that opiate oxygen is administered,* move the patient to a seem to have more insight into the relationship therapy may be endangering the patient, but if only more closely monitored environment. between the SpO and hypercapnea—and the con- for better physiologic understanding, nobody 2 founding influence of supplemental oxygen—than Leo I. Stemp, MD should be under the impression that bradypnea cor- other clinicians who deal with exactly this interface, Springfield, MA relates directly with VA and pCO . Further, even 2 in every patient they treat, on a daily basis. For ETCO monitoring is problematic since adequate Michael A. Ramsay, MD, FRCA. 2 example, Ramsay was criticized (Anesthesiology tidal volumes are required to reflect the alveolar Dallas, TX 75246 2005;102:1066) for failing to use supplemental oxy- pCO , and shallow breathing may result in a low 2 gen in patients administered a dexmedetomidine (*The decision to use supplemental oxygen ETCO because of poor mixing of expired gas. 2 infusion for airway surgery, the communicating should be clinically based, as with any other drug, Therefore, careful trained interpretation of ETCO2 is authors completely missing the point that pulse not reflexive just because the SpO2 drops. The necessary in using this as a measure of ventilation oximetry, expressly on room air, was a vitally—if benign nature of isolated hypoxemia was noted in in nonintubated sedated patients. not the only—accurate monitor of respiratory an earlier communication.7) Second, Overdyk states that, “Supplemental depression in the reported cases. References oxygen. . . merely postpones the patient’s insidious As Overdyk indicated, respiratory depression progress from bradypnea to apnea.” Since supple- 1. Overdyk, FJ. PCA presents serious risks. APSF Newsletter continues to be a frequent liability event in many 2005;20(2):33. mental oxygen has no significant effect on ventila- settings, with PCA use alone translating into “thou- tion, it has no direct causative effect on the 2. Freeman, ML, et. al. Carbon dioxide retention and oxy- sands of patients with potentially catastrophic res- progression from bradypnea to apnea (other than gen desaturation during gastrointestinal endoscopy. piratory depression per day.” Similarly, during eliminating hypoxic drive). What it does do is mask Gastroenterology 1993;105:331-9. procedural IV sedation, respiratory complications that natural opiate-induced progression from 3. Ayas N, et al. Unrecognized severe postoperative continue to occur commonly, despite a veritable bradypnea to apnea, by failing to allow the patient hypercapnia: a case of apneic oxygenation. Mayo Clinic industry of regulations and policies designed to to become hypoxemic, which would otherwise Proceedings 1998;73:51-4 prevent such critical incidents. Clearly, clinicians cause a pulse oximeter alarm, thereby alerting clini- and guidelines are missing the critical practical 4. Frumin MJ, Epstein RM, et al. Apneic oxygenation in cians to the respiratory danger. It is crucial to man. Anesthesiology 1959;20:789-98. message that breathing is the only thing that counts. In appreciate these points—that clinicians, without fact, it could be argued that instead of making opi- 5. American Society of Anesthesiologists Task Force on realizing that they are doing so, are using the pulse ate use and IV sedation safer, pulse oximetry has Sedation and Analgesia by Non-Anesthesiologists. Prac- oximeter as a gauge of ventilation, and that oxygen introduced an unforeseen complication, because tice Guidelines for Sedation and Analgesia by Non- Anesthesiologists. Anesthesiology 2002;96:1004-17. masks hypoventilation as detected by pulse oxime- now clinicians are misled by a number, instead of try, by maintaining the SpO , even to the point of 2 being singularly attentive to the physical act of 6. Witting MD, Hsu S, Andres CA. The sensitivity of 2-4 apnea. breathing and airway patency—watching the chest room-air pulse oximetry in the detection of hypercap- Finally, Overdyk writes that using pulse oxime- go up and down, and listening to the hiss of air nia. Am J Emerg Med 2005;23:497-500. ters is a “deceptively ineffective approach” to pre- through the nose or mouth—as they were in the old 7. Stemp L. Etiology of hypoxemia often overlooked. venting catastrophic respiratory depression—but days, because back then, those were the only para- APSF Newsletter 2004;19(3):38-9. APSF NEWSLETTER Winter 2005-2006 PAGE 81

Perioperative Temperature Management: Roundtable Discussion Identifies Need to Avoid Hypothermia The following are the minutes of a roundtable discussion held in Louisville, KY, on June 11, 2005, chaired by Scott Robinson, MD, and Kushagra Katariya, MD. Also participating were Dan Sessler, MD, Andrea Kurz, MD, William Edward Hodges, CCP, and Jan Odom-Forren, MS, RN.

The panel commented on documented causes Technical factors especially concerning the Some patients are just difficult to warm. Dur- and effects (summarized in Table 1) of periopera- measurement of core temperature may impair the ing spinal surgery, the patient is excessively tive hypothermia. The panel’s concerns included clinician’s ability to accurately determine a thermal exposed to the cold OR environment with little target. The appropriate sites for measuring core available area for attaching warming devices. Simi- The Unavoidable Chilling Effect temperature are the esophagus, nasopharynx, tym- lar problems occur in some major cardiac and vas- of General and Regional panic membrane (using an appropriately placed cular procedures where, in addition, active Anesthesia during Surgery thermocouple), and pulmonary artery. Many of warming of poorly perfused lower extremities these sites are unavailable during different types of (including during aortic cross-clamping) is pro- Physiologic temperature regulation in warm- cases. Of note, the bladder temperature may accu- scribed. Trauma patients undergoing multiple oper- blooded animals is intricately controlled by relying rately reflect other core temperatures, but in condi- ations by several surgical teams at the same time upon the autonomic and somatic nervous systems’ tions of low urine flow may be as unreliable as represent another such problem group. ability to sense changes in ambient temperature, rectal temperature. Relying on patient reports of Safety considerations include hyperthermia and within a narrow threshold, respond appropri- comfort during neuraxial anesthesia when they are and burns. Adult patients warmed by forced air are ately to maintain core body temperature in the nor- equally vulnerable to hypothermia is frustrated unlikely to become seriously hyperthermic because mothermic range between 36°C and 38°C. because patients’ sensation of hypothermia may be they can still sweat. In children and infants, this Induction of either general or regional anesthesia completely disrupted, and they may report comfort method is less effective due to a relatively larger impairs thermoregulation, allowing a redistribution when in fact they are becoming hypothermic. surface to absorb heat. Burns from forced air of heat from the central compartment of the body Lack of evidence-based guidelines on how devices have been reported when the delivery hose (consisting primarily of the major organs) to the best to warm patients results in practice guidelines has been used without an appropriate blanket. Cir- periphery. In addition, heat is lost to the cold OR (especially ASA standards), which are general and culating-water garments and pad devices have environment over time, furthering the heat deficit non-specific. Clinicians are given maximum clinical more effective heat transfer, and therefore are pro- that will ultimately be repaid postoperatively. flexibility, but little guidance about which tech- vided with a servo control to prevent hyperthermia. nique may prove successful in particular situations. The Consequences of Practice guidelines are in many cases more helpful Pre-Warming: An Important Perioperative Hypothermia than standards because they are specific enough to Component of Perioperative overcome institutional and personal practice based Very young, very old, and very sick patients are Temperature Management on tradition and convenience. more likely to become hypothermic during anesthe- One member of the panel suggested that 30 The benefits of warming may not be immedi- sia and surgery regardless of procedure. Addition- minutes of pre-warming would keep patients nor- ately apparent. Compared with using a drug or ally, certain procedures exacerbate perioperative mothermic during 2 subsequent hours of surgery hypothermia by their length or field exposure alone. performing surgery, the results of warming may be without further active measures being taken. Others The systemic changes indicated in the table have relatively delayed. Unlike giving a drug and noted that at least the initial drop in temperature is been noted to occur even as little as 0.5°C below the observing an immediate response, changes in core lessened in the pre-warmed patient so that intraop- normothermic range. Members of the panel believed body temperature occur very slowly because of the erative rewarming does not take so long. No inter- these effects are under-appreciated by the general energy flow to and from the body during heat vention can counteract the redistribution of heat medical and surgical community, believed the transfer. When core temperature falls early in a pro- from the core to the periphery during the initial severity of damage increased in tandem with the cedure, despite active warming, clinicians doubt the phase of hypothermia. Even forced air warming degree of hypothermia, and discussed some of the effectiveness of the intervention. Also, each patient during the first hour or so can only affect the reasons for this as well as some solutions. and procedure is different enough to be an “experi- peripheral compartment, having no effect on core ment of one” whereby the clinician does not know The General Lack of temperature. It is only after the periphery is warm whether a different modality would have a better that the total body heat content increases enough to Appreciation for the Incidence result in the particular patient. begin warming the core. Pre-warming as much as and Effects of Hypothermia The appropriate stakeholder may not make 30 minutes outside the OR or during pre-anesthesia decisions about what happens in the OR. Decisions procedures such as starting lines could preclude the Panelists noted that despite the importance of about adopting warming technology may be made need for intraoperative warming in short cases, and normothermia for surgical outcomes, there persists at an institutional level where the benefits of nor- could markedly improve the effectiveness of warm- an inter- and intra-institutional inconsistency. Some mothermia may not be the primary concern. Also, ing during longer ones. institutions uniformly strive for normothermia, and there may be unintentional “turf battles” about who consistently monitor core temperature, while others controls the treatment of certain complications (e.g., Passive vs. Active Warming may not even monitor as much as 40% of their wound infections) whose inception in the hypother- patients. Panelists spotlighted several reasons for Strategies mic intraoperative period may be hidden to this inconsistency, including the following: Passive warming by insulating to the maximum observers of the problem at a remote time. Education extent possible all exposed skin surfaces can reduce Staff turnover contributes to inconsistent prac- and closer cooperation is essential. Communication radiant and convective heat loss by approximately tice patterns because a trained constituency for and feedback from colleagues may be fragmented, 30%. All the common materials usually employed strict attention to practice patterns for maintaining such as the lack of reporting wound infections to the are equally effective, but the benefit drops off normothermia may dissolve as staff moves to new anesthesiology area, or the lack of communicating locations or even just new areas of interest. temperature information to surgery area. See “Hypothermia,” Next Page APSF NEWSLETTER Winter 2005-2006 PAGE 82 Hypothermia Has Multiple Effects

“Hypothermia,” From Preceding Page surement of core temperature and the use of could, in fact, go a long way toward the goal of active warming devices in all types of cases where normothermia for every patient, reducing the greatly after the first layer. Seventy percent of the anesthesia induced hypothermia occurs. This attendant consequences. heat loss and all of the heat redistribution must be dealt with actively. Possible Impact of Hypothermia Active warming involves the use of a device Organ System/Function Resulting Effect(s) that can both prevent heat loss (insulating the sur- Adrenergic System Stimulation of sympathetic nervous system face, but also warming the skin to reduce the gradi- ¥ ¥ Significant increase in norepinephrine ent for radiant heat loss) while also providing a net ¥ Minimal adrenomedullary/adrenocortical response positive thermal flux from the device to the patient, Coagulation Function ¥ Decreased platelet function thereby increasing the total heat content of the ¥ Impaired coagulation cascade body and warming the core. Active warming with ¥ Increased fibrinolysis forced air is inexpensive, safe, and far more effec- ¥ Potential for increased blood loss and need for transfusion tive in several studies than passive warming. Cardiovascular System ¥ Systemic and pulmonary vasoconstriction Although the heat capacity of air is low, forced air ¥ Increased blood pressure devices are effective because the air is dispersed ¥ Increased likelihood of ventricular dysrhythmia over a wide surface area. There is no demonstrated ¥ Increased risk of myocardial infarction difference in effectiveness between brands of Immune System ¥ Decreased neutrophil and macrophage function forced air systems. ¥ Decreased tissue oxygen levels ¥ Increased risk of wound infection Heat transfer from advanced technology circu- ¥ Potential for delayed wound healing lating-water devices can be up to 5 times greater Metabolic System ¥ Postoperative shivering, which increases total oxygen consumption than air per unit area. This accounts for their usage Pharmacokinetic Function ¥ Potentiation of neuromuscular blockers in surgical cases where body surface is at a pre- ¥ Decreased minimal alveolar concentration of inhaled agents mium and satisfactory results are difficult to Psychological/Emotional Effect Decreased patient satisfaction achieve with forced-air. ¥ Respiratory System ¥ Blunted ventilatory response to oxygen Summarizing, roundtable participants agreed ¥ Decreased tissue oxygen requirements that evidence-based practice guidelines could, ¥ Left shift in hemoglobin-oxygen dissociation curve where implemented, result in widespread mea-

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Anesthesia Patient Safety Foundation (APSF) APSF Education committee members Ken Abrams, Tricia Meyer, Susan Polk, Alan Harvey, and Richard Prielipp 520 N. Northwest Highway reviewed all 51 Scientific Exhibits and arrived at a consensus opinion for the Ellison C. “Jeep” Pierce, Jr., MD, Best Park Ridge, IL 60068-2573 Scientific Exhibit in Patient Safety Award. This year’s winner is “MacIntosh and IBM-compatible Laptop-based Vidoegraphy of Airway Management for Teaching Airway Management and Record Keeping” from Brett L. Arron, MD, Richard Gillerman, MD, and James E. Peacock, RN of Rhode Island Hospital, Providence, RI. Dr. Stoelting (left) pre- sents the award while Committee Members Richard Prielipp and Tricia Meyer look on. APSF NEWSLETTER Winter 2005-2006 PAGE 83

Difficult Intubation in the Obese Patient

by Craig Troop, MD haps an identifiable problem is the ever-increasing results. A pre-cut foam positioner designed to incidence of obesity with attendant comorbid dis- quickly achieve the HELP position is Reprinted with permission of ease processes. Five of the top 10 most “overweight commercially available. Texas Medical Liability Trust. cities” in the U.S. are in Texas. 2. Have airway management plans A, B, and C The following scenario is a synopsis of the anes- worked out, and all materials immediately thesiologist’s worst nightmare: can’t intubate/can’t As a broad classification, the morbidly obese available in the OR before the induction of ventilate. This ongoing concern in anesthesiology is patient is “apple-shaped” (tight fat) in appearance 4 anesthesia. If plan A is not achieving the desired being revisited in light of the personal observation or is “pear-shaped” (loose fat) in appearance. that as the prevalence of obesity increases, standard Based on my experience, the “tight fat” obese result, activate plan B, or C early. There is much oral intubation is becoming more difficult. The follow- patient tends to have a higher incidence of difficult wisdom in the phrase, “Don’t persist in the same ing summary is based on an actual closed claim case. airway issues. technique and expect a different result.” There There are several physical signs that can alert are numerous airway devices available for Case one to the possibility or probability of a patient hav- advanced airway management. In my opinion, it A 54-year-old man was scheduled for a total ing a difficult airway. The 6-Ds of airway assess- is important to master 3 or 4 different techniques, knee replacement. The patient was 5’6” and ment are 1 method used to evaluate for signs of and maintain a comfort level with each through weighed 250 pounds. His BMI was 40 kg/m2. In difficulty: constant practice. addition to obesity concerns, his medical history 1. Disproportion (tongue to pharyngeal size/ Again, the above suggestions are my opinions included hypertension, hypercholesterolemia, Mallampati classification) based on personal experience. For more informa- GERD, type II diabetes (diet controlled), and possi- tion, please review the ASA algorithm for manag- 2. Distortion (e.g., neck mass) ble sleep apnea. The patient agreed to the placement ing difficult airways, available at www.asahq.org/ of an epidural catheter for postoperative pain con- 3. Decreased thyromental distance (receding or publicationsAndServices/Difficult%20Airwaypdf. trol but demanded to “be asleep” for the surgery. weak chin) References Following the uneventful placement of an 4. Decreased interinscisor gap (reduced mouth 1. Cormack RS, Lehane J. Difficult tracheal intubation in epidural catheter, the patient was placed in a fully opening) obstetrics. Anaesthesia 1984;39:1105-11. supine position, monitors were connected, and a 2. Caplan RA, Benumof JL, Berry FA, et al. Practice guide- rapid sequence induction was performed. Oral 5. Decreased range of motion of the cervical spine, and lines for management of the difficult airway. A report laryngoscopy with a MAC 3 blade was attempted by the American Society of Anesthesiologists Task which revealed a grade 4 view (no identifiable 6. Dental overbite.5,6 Force on Management of the Difficult Airway. Anesthe- laryngeal anatomy).1 Mask ventilation with an oral siology 1993;78:597-602. Although all 6 points are important, in my opin- airway/bag and mask was attempted and noted to 3. Caplan RA, Benumof JL, Berry FA, et al. Practice guide- ion, “the jaw tells the story.” An over-looked and be difficult requiring high positive inspiratory pres- lines for management of the difficult airway: an simple clinical sign to assess the jaw is the upper lip sures. Oral laryngoscopy with a MAC 4 and then a updated report by the American Society of Anesthesiol- bite test.7 The patient is asked to touch their upper ogists Task Force on Management of the Difficult Air- Miller 2 blade was attempted. The difficult airway lip with their lower teeth, i.e., protrude the way. Anesthesiology 2003;98:1269-1277. cart, an intubating LMA, and additional anesthesia mandible. This simple test addresses D3 and D6. 4. American Society of Bariatric Surgery. Rationale for assistance were summoned. Between each attempt Concerning point D5, ask the patient to look up at the surgical treatment of morbid obesity. Available at to secure an airway, mask ventilation became the ceiling or tilt their head backward. Any launch- www.asbs.org/html/patients/rationale.html. increasingly difficult; peak airway pressures were Accessed August 22, 2005. reported to be “sky high.” After several minutes of ing forward of the patient’s shoulders confirms that the range of motion of the cervical spine is limited. 5. Mallampati S. Clinical Assessment of the Airway. Anes- unsuccessful airway management, a general sur- thesiology 1995;13:301-308. geon arrived. As the surgeon attempted a difficult Having clinically identified a potentially diffi- 6. Benumof JL. Airway Management: Principles and Prac- tracheotomy, the patient arrested and further resus- cult airway and especially for the “tight- tice. St. Louis: Mosby, 1996:126-42. citation efforts failed. fat”/“apple shaped” obese patient, here are some 7. Khan ZH, Kashfi A, Ebrahimkhani F. A comparison of personal, practical suggestions: the upper lip bite test (a simple new technique) with Discussion modified Mallampati classification in predicting diffi- 1. Start from a position of strength. The term culty in endotracheal intubation: a prospective blinded For every dramatic, worst-case scenario as HELP (head elevated laryngoscopy position) was study. Anesth Analg 2003;96:595-9. above, how many countless near misses occur? This coined by Dr. R. Levitan.8 Two articles on pre- 8. Levitan RM, Mechem CC, Ochroch EA, et al. Head-ele- article is not intended to be a lengthy review of the positioning the morbidly obese patient have vated laryngoscopy position: improving laryngeal difficult airway. There are many excellent resources shown that this position improves the exposure during laryngoscopy by increasing head ele- addressing this topic by notable national airway laryngoscopy view9 and that there is an increase vation. Ann Emerg Med 2003;41:322-30. educators. (Please see Caplan, et al.’s “Practice in the desaturation safety period.10 Rescue 9. Collins JS, Lemmons HJ, Brodsky JB, et al. Laryngoscopy Guidelines for Management of the Difficult Air- ventilation techniques, (oral airway/bag and and morbid obesity: a comparison of the “sniff” and 2,3 way.” The House of Delegates of the American mask) are facilitated by the HELP position. The “ramped” positions. Obes Surg 2004;14:1171-5. Society of Anesthesiologists spent more than 18 head and neck are elevated above the chest and 10. Dixon BJ, Dixon JB, Carden JR, et al. Preoxygenation is more effective in the 25 degrees head-up position than in months and more than $150,000 in approving these abdomen. The airway is therefore more isolated guidelines.) The intent of this article is to share the supine position in severely obese patients: a random- and easier to work with. Further, the weight of ized controlled study. Anesthesiology 2005;102:1110-5. some suggestions based on personal experience. the abdomen is falling away from the diaphragm As mentioned earlier, I have observed a trend of and less positive airway pressure is required. DISCLOSURE: Dr. Troop is the inventor of a an increase in the overall number of difficult airway Stacking with blankets can create the HELP commercially available pre-formed positioning aid patients. There are several reasons for this, but per- position, but may cause variable and/or unstable mentioned in this article. APSF NEWSLETTER Winter 2005-2006 PAGE 84

Letter to the Editor Letter to the Editor Reader Calls for Fair Monitoring and Risk-Benefit Analyses Vigilance Needed ™ To the Editor: This article, again well-researched and written, With DepoDur goes over the “benefit” of the drug avoiding the I would like to comment on 2 articles in the fall To the Editor: need for a “cumbersome epidural pump.” How- APSF Newsletter, “Complications of Cervical ever, the article states that 4% of patients receiving DepoDur™ will certainly find its niche in the Epidural Blocks Attract Insurance Company Atten- this drug required naloxone. A recent review of acute pain management arena; however, this for- tion” and “DepoDur™: A New Drug Formulation mulation should be used with extreme caution. Not with Unique Safety Consideration.” I believe the epidural opioids put the established incidence of respiratory depression at 0.09% to 0.4% from con- only did 75% of the patients need additional anal- articles have major problems and reflect poorly on gesia via an IV-PCA pump with all its associated tinuous infusion of epidural opioids.3 I was expect- how the APSF handles emerging safety issues. problems as described by Dr. Viscusi,1 the drug also ing to get an appropriate protocol for use of this had a higher side-effect profile. Whether it was 5% The article on cervical epidural blocks is actually drug that has at least a 10-fold greater incidence of of the patients or 12.5%2 needing an opioid antago- a nice mini-review; however, the entire focus of the respiratory depression then current therapy. In fact, article is on how to reduce insurance risk and it nist, these figures compare with 0% in the IV-PCA under the monitoring section of this article the only makes several recommendations. The article recom- group. The higher side-effect profile was in the conclusion is that “there are no universally mends the use of fluoroscopy, use of the prone elderly patients with comorbid conditions, the sub- accepted stands or published guidelines for respira- position, avoiding injections if pain is experienced, group who could potentially benefit most from this tory monitoring with opioid therapies by an accred- and limiting sedation if possible. However, it is not formulation. As the package insert highlights,3 itation body or society.” clear in reading the case reports presented that any extreme vigilance and close monitoring is needed of these measures do any good! Fluoroscopy with Again the APSF has missed the big picture of when DepoDur™ is used, a condition that is not epidurograms was used in the majority of cases, the putting patient safety first. A risk-benefit analysis achievable in the surgical wards of most hospitals. use of sedation was about 50%, and the article again might call into question the need for this drug Babak Roboubi, MD pointed out, it is not clear that needle contact with when its risk of respiratory depression is so much Director, Acute Pain Service the spinal cord is painful. greater than current therapy, and its benefit is so Washington Hospital Center Thus, given that cervical spinal cord trauma trivial. Because of these questions, perhaps contin- Washington, DC uous pulse oximetry should be used until more may be reduced but not eliminated, the correct References question is what is the risk versus benefit of cervical data establish this drug’s safety. Perhaps, if the arti- 1. Viscusi ER. DepoDur™: A new drug formulation with epidural injection? It is not a secret that there is a cle were written by someone else other than an unique safety considerations. APSF Newsletter 2005;20:50-1. controversy and a paucity of randomized controlled investigator involved in development of this drug, data to show that epidural steroids are of benefit;1 a more balanced view would be obtained. 2. Viscusi ER, Martin G, Hartrick CT, et al. Forty-eight hours of postoperative pain relief after total hip arthro- some do not use them in their practice at all. If there The field of anesthesiology is routinely lauded plasty with a novel, extended-release epidural mor- are any benefits, they seems to be short lived and of for the great strides in improving patient safety and 2 phine formulation. Anesthesiology 2005;102:1014-22. limited clinical usefulness. is held up as a model for other disciplines to follow. ™ The real story is not reducing the risks of cervi- We need to continue being ever vigilant and to 3. DepoDur Package Insert: Full Prescribing Information, Endo Pharmaceuticals, Chadds Ford, PA, 2005 cal epidural steroids, but whether they should be place our patients first, maximizing their safety and done at all. If a drug were released by a pharmaceu- minimizing their risks. But we cannot rest on our tical company that had an incidence of paralysis, laurels; we need to critically examine new medica- arachnoiditis, anoxic brain injury, and death, and tions and new procedures from an objective the company had difficulty showing that it had patient-oriented viewpoint. In the long run, this is clinical utility, it would never be released. If the what will keep our discipline strong and well APSF had properly reviewed the literature, I respected. believe a reasonable conclusion is to call for a mora- torium on cervical epidural outside of randomized Amir Tulchinsky, MD control studies, rather than to improve the Hartford, CT informed consent process. References 2006 APSF The second article, “DepoDur™: A New Drug 1. Butler, SH. Primum non nocere-first do no harm. Pain Formulation with Unique Safety Considerations,” 2005;116:175-176. Grant Application also missed the opportunity to improve patient 2. Koes BW, Scholten RJPM, Mens JMA, et al. Efficacy of safety. The headline on the second page of this arti- epidural steroid injection for low-back pain and sciatica: cle reads “Appropriate Protocols Needed for Depo- a systemic review of randomized clinical trials. Pain Guidelines Dur™.” I was excited to read this article as the 1995;279-288. manufacturer has been widely advertising this 3. Rathmell JP, Lair TR, Nauman B. The role of intrathecal See Page 74 medication, and drug representatives were making drugs in the treatment of acute pain. Anesth Analg the rounds selling this drug. 2005;101:S30-43. APSF NEWSLETTER Winter 2005-2006 PAGE 85

Letters to the Editor Postoperative Period Perceived As Most Likely Opportunity for Corneal Abrasions

To the Editor: To the Editor: To the Editor: I read with interest the letter in the Fall 2005 Please allow me to commend Celestive O. I share Dr. Okwuone's concern regarding the issue of the APSF Newsletter from Dr. Okwuone. Okwuone, MD, for his letter to the editor on “Anes- potential for corneal injury in the perioperative Corneal abrasions have been the most frequent thesia May Predispose Patients to Corneal Abra- period. I would add 2 more possible mechanisms of complication of anesthesia in my practice, and, if sions” in the fall 2005 issue of the APSF Newsletter. injury. During surgery involving the head or neck anything, the incidence seems to be rising, despite As he points out the exact mechanisms of the in which the eyes are draped, it is possible for the our best efforts to prevent them. injury to the cornea is unknown, but it is our duty surgeon or assistant to put continuous pressure on as anesthesiologists to use all precautions to pre- the cornea by inadvertently resting an arm on the It is difficult for me to imagine why patients, vent it. eye. Another period of vulnerability occurs before lying supine for short cases, with nothing (other or after transport to the PACU when the plastic than eyelid tapes) touching their eyes, who have In my opinion most corneal abrasions are oxygen mask is placed on the patient’s face and can not been ventilated with a mask, should suffer such caused by the rubbing of the eyes during emer- easily pull the eyelid up, scratching the cornea. gence from anesthesia. Certainly the pulse oximeter injuries. sensor in this situation is the most likely cause of Heidi Smith, MD My belief is that a large number of corneal abra- injury. To prevent that, I ask the PACU nurses to Seattle, WA sions are self-inflicted, either during or after emer- place the pulse oximeter sensor on one of the toes gence from general anesthesia. My experience is rather than the finger. that many, if not most patients will reach for their M. Saeed Dhamee, MD Improved APSF website: faces as they wake up in particular, in order to rub Milwaukee, WI their eyes. We spend a considerable amount of time www.apsf.org in the OR, during transport, and in the PACU ver- bally and physically restraining patients from touching their faces. Few things are more irritating, both to anesthe- siologists and their patients, than to have a corneal abrasion become manifest after an otherwise uncomplicated anesthetic. I personally have on sev- eral occasions received a call from the PACU nurse stating, “Mrs. Jones is ready to go home, but one of her eyes is red and hurting.” This an hour after see- ing her in PACU with both eyes open (not red), responding appropriately, and denying any dis- comfort. My guess is that this injury has occurred subsequent to that time, but I am somewhat mysti- fied as to how. I try to watch as the oxygen mask is applied in PACU, since I think that is a potential cause of eye injury, but failing that as the etiology, one must look to the patient. I don't have an easy solution to this seeming dilemma. Restraining patients for more than a few minutes is impractical for a variety of reasons, not the least of which is medicolegal. Eye ointment, as noted by Dr. Okuone, is usually of dubious value and involves some minor drawbacks of its own— blurry vision, risk of transmitting infection, and the occasional allergic reaction. I would be very inter- ested to hear the views of other anesthesiologists on ® this subject. Eric A. Wardrip, MD working for patient safety Encinitas, CA APSF NEWSLETTER Winter 2005-2006 PAGE 86

In My Opinion Labeling History Reviewed and Future Explored by Patrick Foster, MD Visiting anesthesiologists to the Tygerberg Hos- must now include four data fields: drug name, drug Placing a label on an otherwise unmarked pital took labels home to the United Kingdom, mass per unit volume, date and time of preparation, syringe containing a drug intended for intravenous many European countries, Canada, and the United and dispenser’s identity. The standard label now use would seem an uncontroversial contribution to States, thus leading to the development of several used in most OR’s has space for the extra details. patient safety. Yet 20 years after the original specifi- informal versions. Dr. Rendell Baker was one of the Third, these changes are brought about by the chal- cation was published, we still await universal first to introduce these ideas to the United States. lenge to the prime status of the syringe as drug acceptance of the idea. The original specifications were published in delivery container by the larger medication contain- 1985 by the South African Bureau of Standards as ers, which deliver more drug over a longer period at The Problem SABS 0207-1985, and placed in the catalog of the less cost in material and supervision. As our “drugs The need for such a marker has existed since those International Standards Organization, of which the for use in anesthesia” is revised to become “drugs for early days in anesthesia when intravenous barbiturates SABS is a member. Currently this standard is pub- use in anesthesia and intensive care,” so must our first challenged inhaled drugs at Pearl Harbor, and lished by the Standards South Africa division of the designs include new large containers labels with when Cecil Gray established the pivotal role of curare SABS as SANS 10207 (www.stansa.co.za). A second extra data fields relevant to the longer stay within an in general anesthesia. The speed of response to an revision is now under preparation to appear on this intensive care system. For this use present syringe intravenous (IV) injection may not allow time to man- 20th anniversary of the original. labels are too small. Will there be 24-48 hour labels, 7 age the consequences of an error, and use of the IV day specials, or Medicare monthly concessions? route in general anesthesia has become more wide- A Need for Change We approach an era when general anesthesia, spread. Many of us have devised systems for labeling After 20 years a revision is necessary, if only to once provided by the skilled hand, operating a gas our drugs. But now, the single anesthesiologist or incorporate the changes brought by new technology. dispenser to meter oxygen flows and narcotic anesthetist, once independently responsible for patient There were few applications for computers in a vapors, is to be replaced by a ventilator controlled well-being during surgical assault, is being integrated 1970s OR, but today, a syringe label can provide the by a dedicated computer that drives a series of gas into a surgical team, where responsibility for most interface between anesthesia machine and a com- and infusion meters. As a stranger among these aspects of a patient’s care is shared; others now expect puter that can “autopilot” a general anesthetic while binary controls, may there still be a handheld insight into the gasman’s codes. So our once simple recording the data. A revision also provides a syringe? Will some experience nostalgia for the labeling system, designed as a rapid recognition code chance to revisit some of the basic aims that shaped days of one provider responsible for the full care of for the anesthesiologist or anesthetist, now has to the first standard, which sometimes may have been one patient at a time? evolve into a nationally agreed code for the precise misunderstood. There were drug representatives recognition of pre-prepared injectable drugs for use by who believed the labels would replace the identify- On Basic Design other surgical team members. ing “house colors” of their products. (Today, some The widespread acceptance of the color coded makers wishing to support the color code concept, label system almost certainly depends on easy How it Started pack drugs of a similar class in boxes of the speci- recognition of a pattern that combines 3 simple ele- In the mid 1950s the University of Stellenbosch fied color. This is even more dangerous since drugs ments: the syringe size, label color, and printing. started planning a new medical school campus in such as ephedrine and epinephrine can be mixed up Most times a person will use several drugs, from Cape Town, South Africa, that would integrate med- in the same drawer of a drug cart stocked by a different classes, as identified by the color code, and ical, dental, and nursing schools with a major general junior aid). The main goal was to reduce the danger each in a syringe large enough for the dose. Often, hospital. All of this came into being in the early 1970s of the wrong IV injection during the process of anes- it is possible to pick out a drug from across the as the largest “school under one roof” in the Southern thesia. A design was proposed for a series of labels room by the syringe size and color, at a distance hemisphere, known as the Tygerberg Hospital. easily identifiable by color and print. These were to where printing would be illegible. Print confirms an Design ideas were sought throughout Britain, be applied to any syringe containing any drug, initial selection based on syringe size and color pat- Europe, and the United States, and major equipment intended for IV use, after it had been transferred tern. Critics of the system object that color blindness sources were expected to come from Britain. How- from its original pack into an anonymous syringe. must make the system unreliable. Years of full ever, 6,000-mile supply lines and misunderstandings Implied in the standard is observance of the safe acceptance and recently a well designed study1 of local circumstances meant that needs were often practice that only the ultimate user of an IV drug have shown this to be untrue. best met by local design and manufacture. Against should prepare the injection and affix the label. For Why aren’t our traffic signals red, amber, and this background, the incidental production of a optimum safety, it is essential to use one standard blue to suit our many red/green blind users? In syringe labeling system for a large anesthesia service design as variations may lead to confusion. fact, this use of color has proven valuable with the was a minor undertaking, supported by the local Originally the focus of the 1985 standard was on small label size imposed by the size of a 2-3 ml Anesthesia Society. After testing designs in the mid anesthesia practice; however, this need now syringe: a whole colored label stuck on a rounded 1970s Avery printed the original design and supplied extends to cover PACU or postoperative ICU care. surface is easier to interpret than the print. international color definitions in the national specifi- Recently, JCAHO regulations have addressed a cation. Rolls, each with 100 individual names on the wider range of drugs: Enlarging the Code code color, were mounted alongside each other on a “A new requirement for all types of accredited Should the color code be enlarged to include all dowel comprising a multiple dispenser. Some colors organizations that provide surgical or other drugs used in intensive care as some enthusiasts sug- were chosen to reflect the class characteristics: “dan- invasive services specifies that all medications, gest? I believe that the acceptance of the present sys- ger” red for muscle relaxants; blue to signify the medication containers, and other solutions tem has depended in large part on its simplicity; from cyanosis of opiate-induced respiratory depression; used in peri-operative settings be labeled.” the start it was never intended to include all classes in green for atropine-like drugs used in a syringe size This innovation, that includes syringes with the pharmacopoeia. It would be difficult to find more smaller than (red) relaxants. There were few specific than about 15 distinct colors and for most users to antidotes to the IV drugs used in anesthesia, but these other medication containers, seems eminently rea- sonable so long as one notes the following items: memorize all 15 (when they daily rely on only 5 or 6 were considered important enough to have some link classes in most patients). There are 1 or 2 colors still to the color code of the agonist. This was done by First, a single unlabeled syringe is an anathema; “available”. That should be enough. Meanwhile a using diagonal white stripes and color stripes in the unidentified content is presumed dangerous and to white label can be used for all other drugs while the color bar of the agonist. Thus nalorphine, atropine, be discarded. Creative solutions will be found to role for color coding remains safe with anesthesia. and flumazenil share the color of opiates, relaxants, or cover simple routine clinical procedures such as the benzodiazepines, respectively. With mixtures some “flu shot.” For example, “Provided that the syringe In passing, one notes that there are other accepted interesting stripe patterns emerged, such as never leaves the hand of the user from the time of its load- color codes for volatile anesthetics and for compressed red/green/white alternating for the usual standard ing from a manufacturer’s container until its discharge, gases that do not interact with the label code. relaxant reversal of neostigmine and anticholinergic. no label need be applied.” Second, the simplest label See “Labeling,” Next Page APSF NEWSLETTER Winter 2005-2006 PAGE 87

Letters to the Editor: Forced Air Warmer Hospital Pharmacy May Help in Meeting JCAHO Requirements Burn Can Occur With To the Editor: Similarly, a pharmacy can prepare 250 mL bags of vasoactive medications (e.g., phenylephrine 80 Poor Circulation Dr. Lambert clearly presents the need for com- mcg/mL, epinephrine 16 mcg/mL, and norepineph- mercially prepared appropriately diluted resuscita- rine 16 mcg/mL) that are kept immediately avail- 1 To the Editor: tion medications. In the absence of such, some of able in a conveniently located refrigerator for major the concerns that he identifies can be addressed by cases (e.g., liver transplants, cardiac surgery, and We recently had a child in the cardiac catheteri- a hospital (or OR satellite) pharmacy. zation lab experience extensive third-degree burns of significant trauma cases). Often there is time a leg due to the forced-air warmer. After analysis of A pharmacy can prepare batch sealed 10 mL urgency in starting these cases; having these drugs this case, it is apparent that the cause for the burn syringes of phenylephrine 80 mcg/mL and already prepared could save critical time. Bolus was poor circulation to the affected leg. Under nor- ephedrine 5 mg/mL. If kept refrigerated, these doses can be withdrawn from these bags. mal conditions, blood flow removes the heat locally syringes are good for 7 days after preparation. However, with the recently issued USP Chapter and redistributes it to the rest of the body. In condi- Advantages of this system include standardizing 797 standards, it is more difficult for hospital phar- tions of extremely poor blood flow, temperatures the dilution concentration in every location, a macies to prepare batch medications. For those hos- that would normally cause no consequences may reduced risk of infectious contamination, a pre- pitals that can, the above benefits can be accrued. lead to significant burns. In this patient as well as sumed reduced risk of dilution errors (especially if many others in the cardiac catheterization lab, causes anesthesia trainees are present), anesthesia provider Jonathan V. Roth, MD for diminished lower extremity perfusion include time saving, and appropriate labeling as required by Philadelphia, PA sheaths placed in the groin vessels, thrombosed the JCAHO and Department of Health. There is less Reference groin vessels from previous procedures, and low car- wastage of medications and diluent since a pharma- cist can produce 25 10mL syringes of 80 mcg/mL 1. Lambert DH. System fixes needed to prevent drug diac output. We urge anesthesia providers in the car- errors. APSF Newsletter 2005;20:54-5. diac catheterization lab to use extreme caution when phenylephrine from just two 10-mg phenylephrine applying forced air warmers to the lower extremities vials and one 250 mL IV solution bag. of children, including keeping an adequate amount of space between the warmer and the skin, not using higher temperature settings, and considering placing a blanket between the legs and warmer. Also, the Bar Coding, Computerization May Be Future for Labels warming sleeve can be placed from the cephalad “Labeling,” From Preceding Page user, seeing the familiar color and drug name, position toward the torso instead of around the might miss the small following figure. lower extremities first, if there is adequate room at Code could be extended by extra markings on a the head of the bed for the warming unit. syringe. Better than color coded syringe caps would (Was it thiopentone 2.5% or 5%? Did you be a form of coding, color or print, on the thumb dilute the sufentanil?). Samuel Golden, MD plate of the plunger. One could suggest a use to Cathy Bachman, MD indicate the refrigerated shelf life of pre-filled Chicago, IL syringes from a central pharmacy. Stacked syringes are then sorted by end colors. The Role for Barcodes Fatigue Must Be Two questions still await a good answer; what are you going to code, and who will be reading it? With Addressed the inclusion of critical care in our label code, there Until final decisions are made, new label designs might To the Editor: may now be a role for such a vehicle for rapid, accu- rate patient data transfer. JCAHO, in the document appear as shown. I appreciate the attention that your newsletter quoted above, places special emphasis on full, accu- has given to the threats to patient safety that arise rate data transfer at every patient “hand off” (transfer) The practical value of color codes on syringes from fatigued anesthesia providers. I agree with Dr. between caregivers. The syringe label even has lim- lies ultimately in ease of use. With a color printer Curry's letter (Fall 2005 issue) that more providers ited space for small barcodes, although the value sheets of labels can be printed and kept in a loose- are needed to enhance safety for our patients. Faced could be in routine anesthesia may be difficult to see. leaf cover. Simpler, but more costly, is to buy rolls of 100 preprinted labels and mount a series on a as we are with a shortage of anesthesiologists and Reading barcode requires a computerized scan- CRNAs, it is unlikely that bolstered staff ranks will dowel as dispenser. More elegant and versatile ner. Ultimately this can take the form of a peripheral might be an adaptation of a dedicated label printer soon alleviate this problem. A brief review of inter- syringe reader-driver that also detect drug and vol- disciplinary literature reveals that the impact of programmed to produce any selected drug, name, ume in the syringe by reading code, and, by, follow- color, and dose, with today’s date and preparer. It fatigue is being acknowledged in many practice ing plunger head movement, record dose and time. might even barcode patient name, age, sex, weight. specialties, even those that do not face the man- Printed Labels But for millions this last will remain a dream wher- power issues that we experience. I believe that it is ever basic drugs, syringes, even oxygen, are still on time for the anesthesia community to forge a posi- Do people realize that buying into a system of their wish list. tion paper that deals with the scheduling of pre-printed labels can lead to a problem? One Patrick Foster is a Professor Emeritus in the Depart- providers. Through this, health care administra- assumes that members of a department first agreed tions may be made more aware of the significant ment of Anesthesia, Penn State University, Milton S. to their label list of standard drug names and doses. Hershey Medical Center, Hershey, PA. threats that face patients due to overworked and This means that an unscheduled format must be sig- under-supported providers. Vigilance is the key to naled using a (non-color code) white label. Real Reference safer anesthesia. danger may arise when drug indicates an “almost 1. Cumberland P, Rahi JS, Peckham CS. Impact of congen- Brian K. Miller, CRNA, MS the same” drug, as when the name remains ital colour vision deficiency on education and uninten- unchanged but concentration is only changed on the Hudson, WI tional injuries: findings from the 1958 British birth label. If a standard label is used, flag it. Otherwise a cohort. BMJ 2004;329:1074-5. APSF NEWSLETTER Winter 2005-2006 PAGE 88 In the Next Issue: The focus of the Spring 2006 issue of the APSF Newsletter will be “What to Do After An Adverse Event” and will include • Immediate management • Communication • Disclosure

From left to right (front row): Sue Stratman, • More patient and family perspectives Dr. Julianne Chase, Linda Kenney, and (back row) Dr. Jeffrey Cooper and Dr. Frederick van Pelt • Effect on the provider shared stories of patient and family perspectives on adverse events at the 2005 APSF Board of Directors • Effect on the trainee Workshop (see this issue’s lead article).

NONPROFIT ORG. Anesthesia Patient Safety Foundation U.S. POSTAGE Building One, Suite Two PAID WILMINGTON, DE 8007 South Meridian Street PERMIT NO. 1387 Indianapolis, IN 46217-2922