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

Volume 30, No.1, 1-16 Circulation 118,032 June 2015

What is Your MH IQ ? by Charles B, Watson, MD, FCCM, and Barbara W. Brandom, MD

Question Your Understanding remain unreported, they do provide a profile of metabolic monitors are important in the immedi- 14 of MH: events that take place, and there is no evidence to ate postoperative period as well. suggest a decrease in MH-related death or compli- The anesthesia community has the best under- cations. The most recent review of MH Registry 3. MH is very rare—there is one standing of Malignant Hyperthermia [MH] data shows an increased, rather than decreased, causative genetic mutation because it is a genetically determined illness that is number of deaths reported.3 most often recognized during or immediately after associated with MH anesthesia with the potent inhalational agents In addition, there has been skepticism that suc- susceptibility. and/or administration of succinylcholine. More- cinylcholine, alone, causes MH crisis in susceptible 4,5 FALSE—Depending on the population over, a specific antidote for the MH crisis has been individuals. Older data from the MH registry and newer data from the Canadian MH experience in reviewed, MH crisis has been reported with an available since the late 1970s, dantrolene sodium. incidence ranging from 1:8,000 to 1:30,000 anes- recent years clearly show that MH crisis can be Now dantrolene and other necessary elements thetics. Quarterly reviews of calls to the MH Hot- induced by succinylcholine administration, needed for emergency treatment of an MH epi- line [800-MH-HYPER] made when a caller alone.4,6-8 Succinylcholine induced muscle contrac- sode are immediately available to anesthesia staff suspects MH show that around 30% are MH crisis at most hospital and outpatient anesthetizing ture of patients and swine shown susceptible to MH while most represent other acute processes. Early areas where triggering agents are employed. by halothane caffeine contracture testing have been work focused the problems associated with MH 9,10 Death during an MH crisis has undoubtedly demonstrated. While the actual magnitude of the crisis on skeletal muscle abnormalities because of decreased since the entity was first identified in risk associated with succinylcholine, alone, is the marked increase in muscle tone seen in many the middle of the last century because of anesthe- unknown, it is evident that organizations where suc- MH events.15 In recent years there has been a dra- sia care givers’ increased awareness and ability to cinylcholine may be used with or without triggering matic growth in understanding the genetics treat the crisis. inhalational agents should have both the MH anti- underlying MH susceptibility. Susceptible indi- dote, dantrolene, and an approach for management viduals have demonstrated one or more mutations Your MH “IQ” ? of MH crisis.11 in the calcium release channel [Ca2+] RYR1 gene16 and in genes for 2 other proteins that interact with Test yourself with the following statements. RYR1.17,18 Criteria for establishing a causative Are they true or false? 2. Fever is a late finding in MH crisis. If we take measures to See “MH IQ,” Page 3 1. MH is better understood now, keep patients warm, after more than 40 years of temperature monitoring is anesthesia education, research, unimportant. Methylene Blue and the and clinical experience, so it is FALSE—Fever was one of the 3 early signs of Risk of Serotonin Toxicity no longer lethal. MH crisis reported in a majority of patients by Adair Locke, MD FALSE— There may be an improvement in our reported to the MH registry in recent reviews. understanding of MH susceptibility and the MH Indeed it was the first sign of MH in approxi- Methylene blue is administered intravenously crisis since it was first identified as a fatal perioper- mately one-third and one of the 3 initial signs of by anesthesia providers for a variety of clinical ative event with high fever.1 Indeed, one review of MH crisis in approximately two-thirds of patients uses and may be used with increasing frequency MH in New Zealand reported no deaths from MH recently reported from the MH registry. Tempera- as an intraoperative urologic marker dye due to an crisis from a series of more than 120 crises.2 Unfor- ture monitoring is important and review of data indefinite nationwide shortage of indigo carmine. tunately there are still patients dying of MH every from the MH registry showed that survival after It is a potent monoamine oxidase (MAO) inhibitor, year. MH episodes, individuals with positive MH MH crisis was related to core temperature moni- and in combination with other serotonergic agents biopsies, and MH-like events have been reported to toring. It is likely that, when temperature is not such as selective serotonin reuptake inhibitors the North American MH Registry (NAMHR) since monitored and rising temperature is missed, rec- (SSRIs), MB can produce serotonin toxicity in the 1,2 1988. While data resources in a registry do not pro- ognition of MH crisis is delayed in a significant perioperative period. vide an accurate event baseline and many events number of cases.3,12,13 Also, temperature and other See “Methylene Blue,” Page 5

TABLE OF CONTENTS, PAGE 2 APSF NEWSLETTER June 2015 PAGE 2

Table of Contents Articles: What is Your MH IQ ?...... Cover www.apsf.org Methylene Blue and Risk of Serotonin Toxicity...... Cover NEWSLETTER AIMS: Should We AIM Higher?...... Page 10 The Official Journal of the Anesthesia Patient Safety Foundation

Improving Post Anesthesia Care Unit (PACU) The Anesthesia Patient Safety Foundation Newsletter Handoff by Implementing a Succinct Checklist...... Page 13 is the official publication of the nonprofit Anesthesia An Unusual Cause of Hypoxia With Closed Endotracheal Suction System...... Page 15 Patient Safety Foundation and is published three times per year in Wilmington, Delaware. Individual Letters and Q&A subscription–$100, Cor­por­ate–$500. Contri­butions to the Foundation are tax deduct­ible. ©Copy­right, Letter to the Editor: Drug Shortages...... Page 12 Anesthesia Patient Safety Foundation, 2015. The opinions expressed in this Newsletter are not APSF Announcements necessarily those of the Anesthesia Patient Safety Safety Editor, Patient Safety Position Announcement...... Page 3 Foundation. The APSF neither writes nor promulgates standards, and the opinions expressed herein should Merck Educational Grant to APSF...... Page 7 not be construed to constitute practice standards or 2015 Corporate Advisory Council...... Page 7 practice parameters. Validity of opinions presented, drug dosages, accuracy, and completeness of content APSF Corporate Supporter Page...... Page 8 are not guaranteed by the APSF. APSF Donor Page...... Page 9 APSF Executive Committee: APSF Educational DVDs...... Page 12 Robert K. Stoelting, MD, President; Jeffrey B. Cooper, PhD, Executive Vice President; George A. Schapiro, Executive Vice President; Robert J. White, Vice President; Matthew B. Weinger, MD, Secretary; Casey D. Blitt, MD, Treasurer; Sorin J. Brull, MD; Robert A. Caplan, MD; Support Your APSF David M. Gaba, MD; Steven K. Howard, MD; Lorri A. Lee, MD; Robert C. Morell, MD; A. William Paulsen, —Your Voice in Patient Safety— PhD; Richard C. Prielipp, MD; Steven R. Sanford, JD; Maria A. van Pelt, CRNA; Mark A. Warner, MD. Please donate online or make checks payable to the APSF and mail donations to Consultants to the Executive Committee: John H. Anesthesia Patient Safety Foundation (APSF) Eichhorn, MD; Bruce P. Hallbert, PhD. 1061 American Lane, Schaumburg, IL 60167-4973 Newsletter Editorial Board: Robert C. Morell, MD, Co-Editor; Lorri A. Lee, MD, Co-Editor; Steven B. Greenberg, MD, Assistant Editor; Sorin J. Brull, MD; Joan Christie, MD; Jan Ehrenwerth, MD; John H. Eichhorn, MD; Glenn S. Murphy, MD; APSF Newsletter John O’Donnell, DrPH, CRNA; Wilson Somerville, PhD; Jeffery Vender, MD. Address all general, contributor, and sub­scription guide for authors correspondence to: Administrator, Deanna Walker may also be directed to the editors. Commercial Anesthesia Patient Safety Foundation The APSF Newsletter is the official journal of the Building One, Suite Two Anesthesia Patient Safety Foundation. It is products are not advertised or endorsed by the 8007 South Meridian Street published 3 times per year, in June, October, and APSF Newsletter; however, upon occasion, articles Indianapolis, IN 46217-2922 February. The APSF Newsletter is not a peer- about certain novel and important technological e-mail address: [email protected] reviewed publication, and decisions regarding advances may be submitted. In such instances the FAX: (317) 888-1482 content and acceptance of submissions for authors should have no commercial ties to, or Address Newsletter editorial comments, questions, letters, publication are the responsibility of the editors. financial interest in, the technology or commercial and suggestions to: Individuals and/or entities interested in product. The editors will make decisions regarding Robert C. Morell, MD submitting material for publication should contact publication on a case-by-case basis. Senior Co-Editor, APSF Newsletter the editors directly at [email protected] and/or If accepted for publication, copyright for the c/o Addie Larimore, Editorial Assistant [email protected]. Full-length original manuscripts accepted article is transferred to the Anesthesia Department of Anesthesiology such as those that would normally be submitted to Patient Safety Foundation. Except for copyright, all Wake Forest University School of Medicine peer review journals such as Anesthesiology or 9th Floor CSB other rights such as for patents, procedures, or Anesthesia & Analgesia are generally not appropriate Medical Center Boulevard processes are retained by the author. Permission to for publication in the Newsletter due to space Winston-Salem, NC 27157-1009 reproduce articles, figures, tables, or content from the e-mail: [email protected] limitations and the need for a peer-review process. APSF Newsletter must be obtained from the APSF. Letters to the editor and occasional brief case Send contributions to: reports are welcome and should be limited to 1,500 All submissions should include author affili- Anesthesia Patient Safety Foundation words. Special invited articles, regarding patient ations including institution, city, and state, and a Building One, Suite Two safety issues and newsworthy articles, are often statement regarding disclosure of financial inter- 8007 South Meridian Street solicited by the editors. These articles should be ests, particularly in relation to the content of the Indianapolis, IN 46217-2922 limited to 2,000 words. Ideas for such contributions article. Or please donate online at www.apsf.org. APSF NEWSLETTER June 2015 PAGE 3

Malignant Hyperthermia Misconceptions Revealed “MH IQ,” From Cover Page genetic marker are quite rigorous. In the past link- age to MH susceptibility in one or more families, was demonstrated to loci on chromosomes 1, 3, 5, 7, 17 & 19, but the only genes shown to be associ- ated with MH susceptibility are RYR1 on chromo- some 19, CACNA1S on chromosome 1, and STAC3 on chromosome 12. Thus, clinical genetic testing of MH risk has moved beyond the Hot Spots in RYR1 to include ALL of RYR1 and 2 other genes, CAC- NA1S and STAC3.19,20 Of the >450 MH-associated mutations identified in RYR1, only fewer than 40 have been shown to be functionally causative as reported by the European MH group (www.emhg. org). Interestingly, characterization of the genetics of families with MH susceptibility shows that more individuals in a family carry the genetic marker than have demonstrated MH crisis.21 This suggests that a larger group of individuals is at risk for development of MH than the number reported to have had a crisis, whatever the actual incidence of MH crisis may be. About one in 2,000 people has a genetic trait that could support the development of an MH crisis when their muscle is stressed. MH Uncontrolled myoplasmic Ca2+ release is the key to malignant hyperthermia. The most prominent cytosolic is neither very rare nor the result of a simple genetic Ca2+ elevation results from the freeing of stored sarcoplasmic Ca2+ mediated by ryanodine receptor type 1 defect. Genetic testing is valuable, as it is very spe- (RyR1). While volatile anesthetics stimulate Ca2+ release via RyR1, succinylcholine acts indirectly by activat- cific, and can help identify many individuals sus- ing the nicotinergic acetylcholine receptor (nAChR), a nonspecific cation channel, resulting in continuous ceptible to MH. However, the gold standard for local depolarisation. The depolarization can trigger propagated action potentials and will further activate the diagnosing MH susceptibility remains in vitro test- dihydropyridine receptors (DHPR, CaV1.1) leading to the gating of both Ca2+ release from the SR via RyR1 ing of viable muscle, with the caffeine-halothane and L-type Ca2+ current from the extracellular space. contracture test [CHCT], because genetic testing is only 30-50% sensitive at this time. Figure 1. Effects of MH triggers on Ca2+ release. Source: http://www.ojrd.com/content/9/1/8 4. MH crisis is only seen when susceptible individuals are exposed to one of the potent volatile anesthetic agents.

FALSE—MH crisis is most commonly www.apsf.org observed during administration of potent inhala- tional anesthetics after administration of succinyl- choline. Halothane, enflurane, isoflurane, SECTION EDITOR, PATIENT SAFETY desflurane, and sevoflurane have all triggered MH The Anesthesia Patient Safety Foundation (APSF) is pleased to invite applications for when used alone. MH following exposure to suc- Section Editor, Patient Safety, Anesthesia & Analgesia, to begin January 1, 2016. Anesthesia cinylcholine, alone, is more rare but does occur.7,8 & Analgesia is the official scientific journal of APSF. Thus, an office or surgery center that does not Candidates should be leaders in anesthesiology with specific expertise and experience in administer volatile anesthetics but keeps succinyl- patient safety, including a national and/or international reputation for research and choline available for emergency use must be pre- contributions to patient safety within anesthesiology. Candidates should also have pared to treat MH. Fatal MH has even occurred experience in medical editing, and proven administrative and organizational skills. without exposure to any anesthetic.22 The duties of the Section Editor for Patient Safety included (1) handling of 125 to 150 manuscripts annually, (2) providing an annual report, (3) attending the Anesthesia & 5. MH crisis is an anesthesia- Analgesia Editorial Board Meeting, and (4) commissioning review articles, updates, related syndrome and only editorials, annual meeting reports, and other articles related to patient safety in occurs in the perioperative Anesthesia & Analgesia. The Safety Section Editor is also a member of the APSF Executive period. Committee that meets three times annually. FALSE—A small number of patients who are Candidates should send a letter expressing their interest and curriculum vitae to MH susceptible have symptoms during day-to-day Robert K. Stoelting, MD, APSF President, at [email protected]. life. In fact, some patients who are known to be MH Deadline for receipt of application materials in September 1, 2015. See “MH IQ,” Next Page APSF NEWSLETTER June 2015 PAGE 4

New Formulation of Dantrolene Much Easier to Prepare

“MH IQ,” From Preceding Page the drug for injection. In addition, 600 ml of fluid will of the Malignant Hyperthermia Association of the be administered with the full dose. United States. Anesthesiology 2008;108:603-11. susceptible have such severe symptoms that they 13. Larach MG, Gronert GA, Allen GC, et al. Clinical pre- 23 There is a newer formulation, Ryanodex®, have needed to take oral dantrolene. Recently, it sentation, treatment, and complications of malignant has become apparent that MH susceptibles may recently available from Eagle Pharmaceuticals hyperthermia in North America from 1987 to 2006. experience sudden death under stressful circum- that allows a small volume diluent [5 ml] to mix Anesth Analg 2010;110:498-507. 22 stances. This suggests that MH is a stress-related a vial of 250 mg for immediate injection. This 14. Litman RS, Flood CD, Kaplan RF, et al. Postoperative syndrome independent of anesthesia. formulation can be mixed more rapidly than malignant hyperthermia: an analysis of cases from the other lyophilized preparations on the market. North American Malignant HyperthermiaRegistry. Anesthesiology 2008;109:825-9. 6. MH crisis isn’t possible if Five to ten ml of solution of solution from 2 vials of Ryanodex provides a more than ample load- 15. Nelson TE, Flewellen EH. Malignant hyperthermia: someone has had a number of ing dose of 2-3 mg/kg dantrolene for large diagnosis, treatment and investigations of a skeletal event free anesthetics. adults. Manufacturer’s information can be muscle lesion. Tex Rep Biol Med 1979;38:105-20. FALSE—MH has been reported after multiple obtained from http://www.ryanodex.com. 16. Brandom BW, Bina S, Wong CA, et al. Ryanodine recep- tor type 1 gene variants in the malignant hyperthermia- event-free anesthetics. The largest number of anes- Charles B. Watson, MD, FCCM, Department of susceptible population of the United States. Anesth thetics reported to the MH Hotline before a patient Anesthesia, Bridgeport Hospital, Yale-New Haven Analg 2013;116:1078-86. has experienced an MH crisis is now 20, while Health, Bridgeport, CT 17. Horstick EJ, Linsley JW, Dowling JJ, et al. Stac3 is a com- Adverse Metabolic or Muscular Reaction to Anes- ponent of the excitation-contraction coupling machin- thesia (AMRA) reports in the NAMHR document Barbara W. Brandom, MD, MH Hotline Consultant ery and mutated in Native American myopathy. Nat the median number of anesthetics experienced (1991-2011); Director, North American MH Registry of Commun 2013;4:1952. 13 prior to a MH crisis is 2 and the maximum is 30. Malignant Hyperthermia Association of the United 18. Kim JH, Jarvik GP, Browning BL, et al. Exome sequenc- States (2000-present); Professor of Anesthesiology, ing reveals novel rare variants in the ryanodine receptor 7. It is more difficult to remove University of Pittsburgh, Pittsburgh, PA. and calcium channel genes in malignant hyperthermia families. Anesthesiology 2013;119:1054-65. “triggering” volatile anesthetics References 19. Sambuughin N, Sei Y, Gallagher KL, et al. North Ameri- from newer anesthetic machines can malignant hyperthermia population: screening of 1. Britt BA, Gordon RA. Three cases of malignant hyper- with high fresh gas flow. thermia with special consideration of management. Can the ryanodine receptor gene and identification of novel Therefore, anesthesia depart- Anaesth Soc J 1969;16:99-105. mutations. Anesthesiology 2001;95:594-9. ments should always have a 2. Pollock AN, Langton EE, Couchman K, et al. Suspected 20. Sei Y, Sambuughin NN, Davis EJ, et al. Malignant malignant hyperthermia reactions in New Zealand. hyperthermia in North America: genetic screening of Anaesth Intensive Care 2002;30:453-61. “clean” machine available. the three hot spots in the type I ryanodine receptor 3. Larach MG, Brandom BW, Allen GC, et al. Malignant gene. Anesthesiology 2004;101:824-30. TRUE & FALSE—Some of the newer anesthe- hyperthermia deaths related to inadequate temperature sia machines may take an hour or more to "wash monitoring, 2007-2012: a report from the North Ameri- 21. Matos AR, Sambuughin N, Rumjanek FD, et al. Multi- can Malignant Hyperthermia Registry of the Malignant out" inhaled agents, even when the vaporizers are generational Brazilian family with malignant hyper- Hyperthermia Association of the United States. Anesth thermia and a novel mutation in the RYR1 gene. Braz J Analg 2014;119:1359-66. off, before the machine would be safe to provide Med Biol Res 2009;42:1218-24. anesthesia for an MH susceptible patient. Also, 4. Iaizzo PA, Wedel DJ. Response to succinylcholine in there are commercially available, cylindrical char- porcine malignant hyperthermia. Anesth Analg 22. Brandom BW, Muldoon SM. Unexpected MH deaths 1994;79:143-51. coal filters that can be fitted to both ports of a con- without exposure to inhalation anesthetics in pediat- 5. Hopkins PM. Malignant hyperthermia: pharmacology ric patients. Paediatr Anaesth 2013;23:851-4. ventional circle system so that agent concentrations of triggering. Br J Anaesth 2011;107:48-56. are reduced to less than 5 ppm within a few min- 6. Almeida da Silva HC, dos Santos Almeida C, Mendes 23. Gronert GA. Dantrolene in malignant hyperthermia utes. While these may need to be changed periodi- Brandão JC, et al. Malignant hyperthermia in Brazil: (MH)-susceptible patients with exaggerated exercise analysis of hotline activity in 2009. Rev Bras Anestesiol stress. Anesthesiology 2000;93:905 cally, they can ensure an agent "free," safe machine 2013;63:13-9. for the MHS patient who needs anesthesia without 7. Riazi S, Larach MG, Hu C, et al. Malignant hyperther- triggering agents. Keeping an expensive or out- mia in Canada: characteristics of index anesthetics in dated “clean machine” in reserve is not necessary. 129 malignant hyperthermia susceptible probands. Anesth Analg 2014;118:381-7. SUPPORT YOUR APSF 8. Visoiu M, Young MC, Wieland K, et al. Anesthetic drugs 8. Dantrolene comes in large vials and onset of malignant hyperthermia. Anesth Analg Your Donation: 2014;118:388-96. and is difficult to draw up. 9. Fletcher JE, Rosenberg H, Lizzo FH. Effects of droperi- • Funds Research Grants TRUE & FALSE—Dantrium® (www.dantrium. dol, haloperidol and ketamine on halothane, succinyl- • Supports Your APSF Newsletter ® choline and caffeine contractures: implications for com) or Revonto (www.revonto.com) dissolves in malignant hyperthermia. Acta Anaesthesiol Scand • Promotes Important Safety 60 ml of sterile water in under 20 seconds. Dantrolene 1989;33:187-92. sodium is not in suspension until it is mixed as it is in 10. Gronert GA, Theye RA. Suxamethonium-induced Initiatives porcine malignant hyperthermia. Br J Anaesth a lyophilized powder form. However, the additional 1976;48:513-7. • Facilitates Clinician- time of drawing up 60 ml, injecting it into the vial, 11. Dexter F, Epstein RH, Wachtel RE, et al. Estimate of the Manufacturer Interactions and then drawing it up again will take about one relative risk of succinylcholine for triggering malignant minute. Depending on how many personnel are hyperthermia. Anesth Analg 2013;116:118-22. • Supports the Website tasked with preparing the full dose of 2.5mg/kg of 12. Larach MG, Brandom BW, Allen GC, et al. Cardiac arrests and deaths associated with malignant hyperther- Donate online at apsf.org. dantrolene sodium for injection for an average adult, mia in North America from 1987 to 2006: a report from about 10 vials, it may take many minutes to prepare the North American Malignant Hyperthermia Registry APSF NEWSLETTER June 2015 PAGE 5

Indigo Carmine Shortage Leads to Increased Use of Methylene Blue and Its Associated Risks “Methylene Blue,” From Cover Administration of methylene blue in isolation is raw material.4 At the author’s institution, methy- Methylene blue (methylthioninium chloride) is not thought to confer any significant risk of sero- lene blue has become the most common choice as 3 an alternative indicator dye. Methylene blue, structurally related to tricyclic antidepressants tonin toxicity. unlike indigo carmine, is a potent MAO inhibitor and acts on monoamine oxidase (MAO), espe- Marker dyes such as indigo carmine are com- and when combined with a variety of medications cially MAO-A, as well as on the nitric oxide (NO)- monly used in surgical procedures to confirm with serotonergic activity, may contribute to seri- cyclic GMP pathway. In addition to its use as a ureteral patency and to localize ureteral orifices, ous sequelae secondary to serotonin toxicity. Spe- marker dye, it is used in clinical practice for the for lymph node and vessel delineation, and for cific commonly encountered serotonergic treatment of hypotensive shock/vasoplegic syn- tumor localization. Beyond an occasional idio- medications include SSRIs like fluoxetine, parox- drome, ifosfamide-induced encephalopathy, and syncratic drug reaction or mild pressor effect, the etine, and escitalopram, serotonin-norepinephrine 2 methemoglobinemia. Methylene blue has also intravenous administration of indigo carmine is reuptake inhibitors (SNRIs) like venlafaxine and been used as an infusion to localize parathyroid generally well tolerated. Unfortunately, indigo duloxetine, and tricyclic antidepressants (TCAs) tissue during parathyroidectomy. In fact, the earli- carmine is not currently available from either of (e.g.,amitriptyline and clomipramine).5 Even weak est reports of postoperative neurologic complica- its 2 manufacturers, producing a nationwide serotonin reuptake inhibitors such as intravenous tions associated with the administration of shortage. American Regent, Inc., (Shirley, New fentanyl, transdermal fentanyl patch, meperidine, methylene blue were during the perioperative York) has placed indigo carmine on back order tramadol, and methadone have been associated period of elective parathyroidectomies. It is rap- due to manufacturing delays, and Akorn Phar- with serotonin toxicity in combination with either idly absorbed in nervous tissue and reaches high maceuticals (Lake Forest, IL) has discontinued methylene blue and / or other serotonergic medi- concentrations in brain tissue in rat models.2 its production indefinitely due to shortage of cations.7, 8 A more complete list of serotonergic medications can be found on the FDA website.5 Careful consideration of the concurrent use of these medications in the perioperative period is The “Serotonin Toxicity Triangle.” warranted. Interactions among the classes of serotonergic drugs that can produce Serotonin toxicity is a result of inappropriately serious serotonin toxicity with examples. high levels of synaptic serotonin and its severity directly relates to the concentration of serotonin (5-HT) in the synaptic spaces in nervous tissue. MAOIs Both serotonin releasers like methamphetamine E.g., tranylcypromine, and serotonin reuptake inhibitors (SRIs) have the moclobemide, methylene blue, potential to induce severe serotonin toxicity when selegiline, furazolidone administered with MAO inhibitors. Selective and non-selective serotonin reuptake inhibitors increase serotonin by preventing its clearance from the intraneuronal synaptic space. MAO inhibitors prevent intraneuronal metabolism of Serotonin Serotonin serotonin, leading to increased release of serotonin Toxicity Toxicity from neurons. SRIs by themselves, even if taken in overdose, do not usually precipitate the severe form of serotonin toxicity. However, normal thera- peutic SRI doses along with even a single dose of an MAOI like methylene blue may lead to sero- tonin toxicity as a result of the combination of increased 5-HT release and reduced synaptic 5-HT SRIs Serotonin clearance.9 E.g., SSRIs, SNRIs, TCAs, No Releasers Methylene blue has been used clinically for over clomipramine, tramadol, Serotonin E.g., MDMA, a century, but its association with serotonin toxicity chlorpheniramine Toxicity methamphetamine, has just been elucidated in the last decade. Two sur- phentermine gical case series from 2006 and 2007 describe meth- ylene-blue associated CNS toxicity in patients receiving intraoperative methylene blue. While all patients taking an SRI did not develop CNS toxicity, all of the cases of toxicity involved patients that Figure 1. Classes of serotonergic drugs that can produce severe serotonin toxicity with examples (not an exhaustive list). were taking SRIs. Additionally, there are now at SRI, serotonin reuptake inhibitor; SSRI, selective serotonin reuptake inhibitor; TCA, tricyclic antidepressants. Source: Modified from Stanford et al.5,6,9 See “Methylene Blue,” Next Page APSF NEWSLETTER June 2015 PAGE 6

Serotonin Toxicity is Potentially Lethal

“Methylene Blue,” From Preceding Page Table 1. Hunter Serotonin Toxicity Criteria procedure. There are reports of indocyanine green being used to identify ureters using near infrared In the presence of a serotonergic agent, serotonin least 14 individual published case reports of prob- light.4 Oral phenazopyridine and vitamin B com- able or definite serotonin toxicity involving the toxicity is established at a high confidence level if any one of the 5 conditions below are present: plex may also be considered for preoperative concurrent use of serotonin reuptake inhibitors administration. If methylene blue use is being con- and methylene blue, 1 of which was fatal.1 A pat- 1) Spontaneous clonus sidered, it is advisable to discontinue the SRI to tern in several early case reports of the serotonin allow clearance of the active ingredient and its toxidrome occurring with methylene blue admin- 2) Tremor AND hyperreflexia active metabolites, with a recommended washout istration prompted in vitro studies by Gillman and 3) Inducible clonus AND agitation OR period of approximately 2 weeks for most seroto- Ramsay in 2006, which were the first to demon- diaphoresis nergic psychiatric drugs. Fluoxetine (Prozac) and strate MB’s highly potent reversible MAO-A its major active metabolite have exceptionally long inhibitor activity at nanomolar concentrations. 4) Ocular clonus AND agitation OR half-lives and should be discontinued at least 5 Further study has revealed that due to its high diaphoresis weeks prior to the administration of methylene potency, even low doses (less than 1 mg/kg) are blue. Individual package inserts can provide guid- likely to produce clinically significant MAO inhi- 5) Hypertonicity AND temperature > 38° C ance for discontinuation of these medications in bition.2 In July 2011, after receiving reports of seri- AND Inducible clonus OR ocular clonus this setting.11 Many serotonergic medications are ous perioperative adverse events, the FDA issued 3 extensively metabolized by the liver, so prolonged a safety announcement highlighting the risk of From Ng et al. clearance should be expected in the case of impair- central nervous system dysfunction when admin- Serotonin toxicity is a potentially lethal condi- ment of hepatic metabolism.12 Methylene blue istering methylene blue to patients taking seroto- tion that manifests with mental status changes, nergic psychiatric medications.5 administration, in the setting of concomitant SRI autonomic hyperactivity, and neuromuscular use, may be considered for life-threatening indica- Because serotonin toxicity represents a spectrum abnormalities. Clinical signs may include tremor, tions such as vasoplegia with cardiopulmonary of severity depending on the ability of a drug or nervousness, agitation, mydriasis, mood dyspho- bypass, methemoglobinemia, ifosfamide-induced combination of drugs to raise serotonin levels, differ- ria, hyperreflexia, and inducible clonus. In its most encephalopathy and cyanide poisoning. If the ben- severe form, confusion, muscle rigidity, sustained ent medications may have more risk of producing efit is deemed to outweigh the risk and methylene clonus, and hyperthermia with temperatures greater serotonin toxicity than others depending on the blue is given, the patient should be monitored for than 38.5°C may be present. Signs of serotonin toxic- degree of serotonin augmentation that they produce. symptoms of CNS toxicity for 24 hours after the last ity can be mistaken for other conditions in the setting Drugs within the same class may have varying dose of methylene blue.4 effects on serotonin. For example, tricyclic antide- of a recent anesthetic. Benzodiazepines and muscle pressants (TCAs) cause serotonin reuptake inhibi- relaxants may also mask symptoms. Agitation and In summary, the administration of methylene tion as well as norepinephrine reuptake inhibition. mood disturbance may be interpreted as postopera- blue in patients taking serotonergic medications, The degree and selectivity of inhibition of the sero- tive delirium and elevated temperature may raise especially SSRIs and SNRIs, may produce sero- tonin versus norepinephrine transport differs among the suspicion of malignant hyperthermia. Other con- tonin toxicity. With a shortage of indigo carmine, TCAs with clomipramine being most potent at sero- ditions with overlapping symptoms include anticho- methylene blue may be administered with more tonin reuptake while desipramine has little serotonin linergic crisis, neuroleptic malignant syndrome, frequency especially for urologic procedures. activity.10 Other antidepressants such as mirtazapine acute alcohol withdrawal, and metabolite-mediated Anesthesia providers should be cognizant of this and trazodone also have low serotonergic activity.1 opiate toxicity. The combination of a SRI or other drug-drug interaction and associated sequelae. serotonergic agent with methylene blue should Nevertheless, the FDA has extended the warning to Dr. Locke is an Assistant Professor of Anesthesi- all serotonergic drugs and suggests that they be dis- prompt a high degree of suspicion for serotonin tox- ology at Wake Forest Baptist Health in Winston continued with anticipated methylene blue dosing icity. The Hunter serotonin toxicity scale is useful to Salem, NC. until further information is available. confirm a diagnosis so that immediate treatment References may be initiated (Table 1). 1. Gillman PK. CNS toxicity involving methylene blue: the exemplar for understanding and predicting drug Treatment consists of discontinuation of interactions that precipitate serotonin toxicity. J Psy- serotonergic drugs, normalizing vital signs chopharmacol 2011;25:429-36. with supportive therapy, sedation with 2. Top WM, Gillman PK, de Langen CJ, Kooy A. Fatal benzodiazepines, and cooling therapy for methylene blue associated serotonin toxicity. Neth J hyperthermia if necessary. Moderate and Med 2014;72:179-81. severe toxicity may benefit from serotonin 3. Ng BK, Cameron AJ, Liang R, Rahman H. [Serotonin receptor antagonists such as cyproheptadine, syndrome following methylene blue infusion during parathyroidectomy: a case report and literature chlorpromazine, or the more potent olanzapine review]. Can J Anaesth 2008;55:36-41. 2 and ketanserin. 4. American Society of Health-System Pharmacists. Indigo carmine injection. Available at: http://www. Discontinuing a psychiatric medication may not ashp.org/menu/DrugShortages/CurrentShortages/ be feasible for some patients, so deciding on an alter- Bulletin.aspx?id=861. Updated March 18, 2015. Last native intraoperative marker agent may be war- accessed April 9, 2015. ranted, if there are any available for a given surgical See “Methylene Blue,” Next Page APSF NEWSLETTER June 2015 PAGE 7

References Provide More Information on ANESTHESIA PATIENT Serotonin Syndrome and Methylene Blue SAFETY FOUNDATION “Methylene Blue,” From Preceding Page tions and precipitating medications. Neurocrit Care. CORPORATE 2014;21:108-137. 5. Food and Drug Administration. FDA drug safety 9. Stanford SC, Stanford BJ, Gillman PK. Risk of ADVISORY COUNCIL communication: Serious CNS reactions possible when methylene blue is given to patients taking cer- severe serotonin toxicity following co-administra- tain psychiatric medications. Available at: http:// tion of methylene blue and serotonin reuptake www.fda.gov/Drugs/DrugSaswfety/ucm263190. inhibitors: an update on a case report of post-oper- George A. Schapiro, Chair htm. Accessed January 27, 2015. ative delirium. J Psychopharmacol 2010;24:1433-8. APSF Executive Vice President 6. Boyer EW, Shannon M. Serotonin syndrome. NEJM 10. Yildiz A, Gönül A, Tamam L. Mechanism of actions 2005; 352: 1112-1120. of antidepressants: beyond the receptors. Bull Clin Gerald Eichhorn...... AbbVie 7. Fentanyl and serotonin syndrome. Canadian Adverse Psychopharmacol 2002;12:194-200. Brian E. Tufts...... Baxter Healthcare Reaction Newsletter 2012;22(2):2. Available at 11. Prozac (fluoxetine) [package insert]. Indianapolis, http://www.hc-sc.gc.ca/dhp-mps/alt_formats/ Indiana: Eli Lily and Company; Revised 10/2014. pdf/medeff/bulletin/carn-bcei_v22n2-eng.pdf. Michael S. Garrison...... Becton Dickinson Accessed April 10, 2015. 12. Van Harten, J. Clinical pharmacokinetics of selec- Mike Connelly...... B. Braun 8. Pedavally S1, Fugate JE, Rabinstein AA. Serotonin tive serotonin reuptake inhibitors. Clinical Pharma- syndrome in the intensive care unit: clinical presenta- cokinetics 1993; 24: 203-20. Rizwan Faroqui...... CareFusion Michael Grabel...... Codonics The APSF continues to accept and Dan J. Sirota...... Cook Medical appreciate contributions. Patty Reilly, CRNA...... Covidien Please donate online at apsf.org David Karchner...... Dräger Medical or make checks payable to the APSF and mail donations to Peter Clayton...... Edwards Lifesciences Matti E. Lehtonen...... GE Healthcare Anesthesia Patient Safety Foundation (APSF) Joseph A. Gillis...... 3M Infection 1061 American Lane Prevention Division Schaumburg, IL 60167-4973 Chris Dax...... Masimo Rachel A. Hollingshead, RN...... Merck Jeffrey M. Corliss...... Mindray Kathy Hart...... Nihon Kohden www.apsf.org America The Anesthesia Patient Safety Foundation Daniel R. Mueller...... Pall Corporation Mark Wagner...... PharMEDium gratefully acknowledges an educational grant from Services Heidi Hughes, RN...... Philips Healthcare Steven R. Sanford, JD ...... Preferred Physicians Medical Risk Retention Group Andrew Greenfield, MD...... Sheridan Healthcorp Tom Ulseth...... Smiths Medical www.merck.com Andrew Levi...... Spacelabs Cary G. Vance...... Teleflex to support the June 2015 issue of the Abe Abramovich APSF Newsletter Casey D. Blitt, MD Robert K. Stoelting, MD APSF NEWSLETTER June 2015 PAGE 8

Anesthesia Patient Safety Foundation

CORPORATE SUPPORTER PAGE

APSF is pleased to recognize the following corporate supporters for their exceptional level of support of APSF

Covidien is committed to creating innovative medical solutions for better patient outcomes and delivering value through clinical leadership and excellence in everything we do. www.covidien.com

Today’s Merck is a global health care leader working to help the world be well. Through our prescription medicines, vaccines and biologic therapies, we operate in more than 140 countries to deliver innovative health solutions. www.merck.com

CareFusion combines technology and intelligence to measurably Preferred Physicians Medical providing malpractice protection improve patient care. Our clinically proven products are designed exclusively to anesthesiologists nationwide, PPM is to help improve the safety and cost of health care for generations anesthesiologist founded, owned and governed. PPM is a leader to come. www.carefusion.com in anesthesia specific risk management and patient safety initiatives. www.ppmrrg.com

Baxter’s Global Anesthesia and Critical Care Business is a GE Healthcare leading manufacturer in anesthesia and preoperative (gemedical.com) medicine, providing all three of the modern inhaled anesthetics for general anesthesia, as well as products for PONV and hemodynamic control. www.baxter.com

Masimo is dedicated to helping anesthesia professionals provide PharMEDium is the leading national provider of outsourced, optimal anesthesia care with immediate access to detailed compounded sterile preparations. Our broad portfolio of prefilled clinical intelligence and physiological data that helps to improve O.R. anesthesia syringes, solutions for nerve block pumps, anesthesia, blood, and fluid management decisions. epidurals and ICU medications are prepared using only the www.masimofoundation.org highest standards. www.pharmedium.com APSF NEWSLETTER June 2015 PAGE 9

Online donations accepted at Anesthesia Patient Safety Foundation www.apsf.org Corporate Donors Founding Patron ($425,000) American Society of Anesthesiologists (asahq.org) Sustaining Professional Organization Grand Patron Supporting Patron ($125,000 and higher) ($100,000 and higher) ($50,000 to $99,999) American Association of Nurse Anesthetists Covidien Merck and Company (aana.com) (covidien.com) (merck.com)

Sponsoring Patron ($30,000 to $49,999) Benefactor Patron ($20,000 to $29,999) CareFusion (carefusion.com) Preferred Physicians Medical Risk Retention Group (ppmrmg.com) Baxter Anesthesia and Critical GE Healthcare Masimo Foundation PharmMEDium Services Care (baxter.com) (gemedical.com) (masimo.com) (pharmedium.com) Patron ($10,000 to $19,999) Sustaining Donor ($5,000 to $9,999) Sponsoring Donor ($1,000 to $4,999) Corporate Level Donor ($500 to $999) AbbVie (abbvie.com) Becton Dickinson (bd.com) AMBU, Inc (ambu.com) Paragon Service (paragonservice.com) Cook Medical (cookgroup.com) B. Braun Medical, Inc. (bbraun.com) Anesthesia Business Consultants (anesthesiallc.com) ProMed Strategies Dräger Medical (draeger.com) Codonics (codonics.com) Anesthesia Check (anesthesiacheck.com) Wolters Kluwer (lww.com) Belmont Instrument Corporation Edwards Lifesciences (edwards.com) Mindray North America (mindray.com) Nihon Kohden America, Inc. (belmontinstrument.com) Subscribing Societies Philips Healthcare (medical.philips.com) (nihonkohden.com) Hospira, Inc. American Society of Anesthesia Technologists and Spacelabs Medical (spacelabs.com) Pall Corporation (pall.com) Intersurgical, Inc. (intersurgical.com) Technicians (asatt.org) Teleflex Incorporated (teleflex.com) Respiratory Motion (respiratorymotion.com) Micropore, Inc. (microporeinc.com) American Society of Dentist Anesthesiologists 3M Infection Prevention Division Sheridan Healthcorp, Inc. (shcr.com) W.R. Grace (wrgrace.com) (3m.com/infectionprevention) Smiths Medical (smiths-medical.com)

Community Donors (includes Individuals, Anesthesia Groups, Specialty Organizations, and State Societies) Grand Sponsor Anesthesia Associates of Columbus, GA Society for Pediatric Anesthesia Patient Safety Glen E. Holley, MD Kenneth R. Stone, MD ($15,000 and higher) American Society of PeriAnesthesia Nurses and Education Fund Shelly Ikdea, CRNA Sam (John) T. Sum-Ping, MB, ChB US Anesthesia Partners (GHA-Houston, JLR- Anesthesia Consultants Medical Group South Dakota Society of Anesthesiologists Janice J. Izlar, CRNA James F. Szocik, MD Robert E. Johnstone, MD Orlando, Pinnacle-Dallas) Casey D. Blitt, MD South Denver Anesthesiologists Bijo Thomas, MD Dr. and Mrs. Robert A. Caplan Spectrum Medical Group of Portland, ME Kansas State Society of Anesthesiologists Dr. and Mrs. Stephen J. Thomas Benefactor Sponsor Frederick W. Cheney, MD Stockham-Hill Foundation Marshal B. Kaplan, MD Twin Cities Anesthesia Associates (MN) (5,000 to $14,999) California Society of Anesthesiologists TEAMHealth Michael G, Kral, MD University of Maryland Anesthesiology Catherine M. Kuhn, MD Alabama State Society of Anesthesiologists Connecticut State Society of Anesthesiologists Tejas Anesthesia Associates James Lamberg, DO American Academy of Anesthesiologist Jeffrey B. Cooper, PhD Texas Association of Nurse Anesthetists Susan A Vassallo, MD (in honor of Rodney C. Lester, PhD, CRNA Assistants Texas Society of Anesthesiologists Neelakantan Sunder, MD) Dr. and Mrs. Robert A. Cordes Kathleen A. Levitt, MD. and Johan P. Anaesthesia Associates of Massachusetts District of Columbia Society of Twin Cities Anesthesia Associates (MN) J. Clark Venable, MD American Dental Society of Anesthesiology Suyderhoud, MD Vermont Society of Anesthesiologists Anesthesiologists Donald C. Tyler, MD Kevin P. Lodge, MD Timothy J. Dowd, MD Virginia Society of Anesthesiologists John H. Eichhorn, MD Mary Ellen and Mark A. Warner Michael J. Loushin, MD Indiana Society of Anesthesiologists Gerald Feldman Washington State Society of Anesthesiologists Thomas L. Warren, MD Philip B. Lumb, MB, BS Matthew B. Weinger, MD Minnesota Society of Anesthesiologists Georgia Society of Anesthesiologists Wisconsin Society of Anesthesiologists Maine Society of Anesthesiologists Andrew Weisinger, MD Frank B. Moya, MD, Continuing Education Goldilocks Anesthesia Foundation Christina M. Martin, AA-C Sponsor ($200 to $749) West Florida Anesthesia Consultants Programs International Anesthesia Research Society (in Edwin Mathews, MD North American Partners in Anesthesia AllCare Clinical Associates (Asheville, NC) Wichita Anesthesiology, Chartered recognition of Sorin J. Brull, MD) Anesthesia Associates of Kansas City Russell K. McAllister, MD Phymed Management, LLC Illinois Society of Anesthesiologists Anesthesia Associates of Northwest Gregory B. McComas, MD In Memoriam Robert K. Stoelting, MD Iowa Society of Anesthesiologists Dayton, Inc. E. Kay McDivitt, MD In memory of Max Berenbom, PhD Tennessee Society of Anesthesiologists Kaiser Permanente Nurse Anesthetists Donald E. Arnold, MD Missouri Academy of Anesthesiologist (David A. Gaba, MD) Valley Anesthesiology Foundation Association (KPNNA) Balboa Anesthesia Group Assistants In memory of Harold C. Boehning, MD Sustaining Sponsor Kansas City Society of Anesthesiologists Robert L. Barth, MD Mississippi Society of Anesthesiologists (Texas Society of Anesthesiologists) Roger A. Moore, MD ($2,000 to $4,999) Kentucky Society of Anesthesiologists William C. Berger, MD In memory of Raymond Boylan, MD Robert C. Morell, MD Academy of Anesthesiology Lorri A. Lee, MD Vincent C. Bogan, CRNA (Raymond J. Boylan, Jr., MD) Soe Myint, MD Anesthesia Resources Management Anne Marie Lynn, MD Amanda Burden, MD In memory of W. Darrell Burnham, MD Lillian K. Chen, MD Joseph J. Naples, MD Arizona Society of Anesthesiologists Maryland Society of Anesthesiologists (Mississippi Society of Anesthesiologists) Madison Anesthesiology Consultants Joan M. Christie, MD John B. Neeld, MD In memory of Raymond W. Cohen Joseph L. Meltzer, MD New Jersey State Society of Anesthesiologists Massachusetts Society of Anesthesiologists Eirene H. Choroser, CRNA (in honor of Drs. (Jerry A. Cohen, MD) Missouri Society of Anesthesiologists New Mexico Society of Anesthesiologists Patricia A. Meyer, PharmD Chris Heard and Ramiro Mireles) In memory of Sanjay Datta, MD Northwest Anesthesia Physicians Mark C. Norris, MD Marlene V. Chua, MD (Mark C. Norris, MD) Michiana Anesthesia Care Nurse Anesthesia of Maine Ducu Onisei, MD Daniel J. Cole, MD In memory of Hank Davis, MD Michigan Society of Anesthesiologists Ohio Academy of Anesthesiologist Assistants Michael A. Olympio, MD Melvin A. Cohen, MD (Sharon Rose Johnson, MD) Michael D. Miller, MD Ohio Society of Anesthesiologists Frank J. Overdyk, MSEE, MD Colorado Society of Anesthesiologists In memory of Katie Donahue, DO North Carolina Society of Anesthesiologists Oklahoma Society of Anesthesiologists John K. Desmarteau, MD Mukesh K. Patel, MD (James Lamberg, DO) Old Pueblo Anesthesia Group Andrew E. Dick, MD Lee S. Perrin, MD Oregon Society of Anesthesiologists In memory of Eugene H. Flewellen, III, MD Pennsylvania Society of Anesthesiologists Richard P. Dutton, MD, MBA Gregory B. Petersen, MD Pamela P. Palmer, MD (Texas Society of Anesthesiologists) Society of Academic Anesthesiology Srikanth S. Patankar, MD Stephen B. Edelstein, MD Drs. Beverly and James Philip Associations In memory of Margie Frola, CRNA A. William Paulsen, PhD, AA-C Michael R. England, MD Tian Hoe Poh, MD Springfield Anesthesia Service at Baystate (Sharon Rose Johnson, MD) James M. Pepple, MD Gary B. Friedman, MD Matthew W. Ragland, MD Medical Center Maunak E Rana, MD In memory of Andrew Glickman, MD Physician Anesthesia Service Georgia Association of Nurse Anesthetists Ian J. Gilmour, MD Christopher Reinhart, CRNA (Sharon Rose Johnson, MD) Contributing Sponsor Physician Specialists in Anesthesia (Atlanta, Richard Gnaedinger, MD Yashesh R. Savani, MD In memory of Donna M. Holder, MD ($750 to $1,999) GA) James D. Grant, MD Howard Schapiro and Jan Carroll (Karen P. Branam, MD) Affiliated Anesthesiologists of Oklahoma Rhode Island Society of Anesthesiologists Joel G. Greenspan, MD Sanford H. Schaps, MD In memory of Russell Morrison, CRNA City, OK Laura M. Roland, MD Allen N. Gustin, MD Society for Neuroscience in Anesthesiology (Jeanne M. Kachnij, CRNA) Alaska Association of Nurse Anesthetists Carol E. Rose, MD Alexander Hannenberg, MD (Pierce Research and Critical Care In memory of Jack D. Stringham, MD Alaska Society of Anesthesiologists Society for Ambulatory Anesthesia Fund) Stephen J. Skahen, MD (Gregory Peterson, MD) American Association of Oral and Society for Obstetric Anesthesia and Gary R. Haynes, MD South Carolina Society of Anesthesiologists In memory of Alon P. Winnie, MD (Frank Maxillofacial Surgeons Perinatology John F. Heath, MD Shepard B. Stone, PA Moya Continuing Education Programs) Note: Donations are always welcome. Donate online ( http://www.apsf.org/donate_form.php)or mail to APSF, 1061 American Lane, Schaumburg, IL 60167-4973. (Donor list current through May 1, 2015.) APSF NEWSLETTER June 2015 PAGE 10

AIMS: Should We AIM Higher? by Mark A. Deshur, MD, MBA, and Wilton C. Levine, MD

Adoption of Anesthesia Information Manage- Legibility records after AIMS implementation. The study eval- ment Systems (AIMS) continues to accelerate. It is uated 17 data elements, finding that completion of 7 AIMS have matured anesthesia care documenta- estimated that 75% of US academic anesthesiology tion from illegible scribble to organized data with elements declined and only 1 improved with AIMS departments are using an AIMS and that this will clear graphics (Figure 1). It is no longer necessary to implementation. A subsequent evaluation was com- rise to 84% by 2020.1 Within a few short years, it is decipher another clinician’s handwriting when pleted at 7 and 15 months, finding improvement in likely that residents finishing training will have no reviewing an anesthetic record or to squeeze com- all deficiencies, yet at levels still inferior to paper significant experience charting on paper. AIMS are ments sideways into the margin to ensure one’s charting.3 This improvement was related to the addi- well poised to become the standard of care for anes- thoughts are completely documented. tion of customized hard stops before record closure, thesia documentation. This advance is not without tradeoffs. A typical and it emphasizes the opportunity for human factor Adoption has been facilitated by numerous 3-hour paper anesthetic record contains 264 data engineers to further optimize AIMS. promises, many of which have been discussed in points.3 In contrast, the same record documented 2 Nevertheless, there is promise. Sandberg et al., previous APSF Newsletters. These include, but are on an AIMS may contain more than 10 times as looked at allergy documentation in the electronic not limited to improved legibility, more accurate many data points. Not only do AIMS automatically data capture, improved chart completion, real-time capture the patient’s physiologic and respiratory anesthesia record. At baseline, he found that 30% of decision support, more complete charge capture, data with greater fidelity, they frequently require charts were missing basic allergy documentation. A new opportunities for clinical research, better quality clinicians to manually document substantially more customized system was developed to page the anes- improvement data, and participation in quality out- information as well. thesia provider if allergies were not documented comes registries. within 15 minutes of the anesthesia start time. Fol- Thus, a typical anesthetic no longer fits concisely Multiple studies in the literature support these on a single sheet of paper. It is now necessary to lowing implementation, the missing allergy docu- 5 benefits, though many of these advantages have also review multiple printed pages or scroll through mentation rate fell to 8%. Similarly, a recent review been dependent on significant customization or dozens of screens to view a record in its entirety. of AIMS data by McCarty et al. demonstrated the homegrown systems. Customization is necessary These new records are perfectly legible, but often dif- ability to improve chart completion. In their study, because the standard out-of-the-box functionality for ficult to follow. complete airway documentation improved from many of the popular systems fail to achieve even the 13.2% to 91.6% by using an AIMS in conjunction most basic of benefits. The literature also suggests Chart completion with deliberate process improvement tools and inte- the need for substantial financial resources and dedi- There are many studies on chart completion with grated decision support.6 cated staff to support both the implementation and AIMS. Despite the belief that AIMS automatically maintenance of an AIMS. As health care dollars improve chart completion, these studies show mixed While there is tremendous potential, most become more scarce, this promises to become results. Edwards et al. demonstrated a significant chart completion benefits to date have required a increasingly challenging. What follows is a review of improvement in 6 data elements with the implemen- homegrown IT solution, locally focused process some of the claims outlined above and a discussion tation of an AIMS.4 Shear et al. reviewed 200 paper improvement efforts, and significant financial and of the current state of AIMS. records prior to AIMS implementation and 200 clinical resources.

A B C Figure 1: a) The original Harvey Cushing Ether Chart from 1895 courtesy of Massachusetts General Hospital Archives and Special Collections b) Modern paper anesthesia record See “AIMS,” Next Page c) Electronic anesthesia record APSF NEWSLETTER June 2015 PAGE 11

AIMS Offers Benefits But Improvements Needed

“AIMS,” From Preceding Page workload increases, reaction time slows, brain func- References tion is compromised, drivers scan the road less and 1. Stol IS, Ehrenfeld JM, Epstein RH. Technology diffu- Better Quality Data often miss otherwise obvious visual cues.10 Though sion of anesthesia information management systems not well studied in the anesthesia literature, it must in to academic anesthesia departments in the United AIMS promise to supply us with more accurate States. Anesth Analg 2014;118:644-50. and more plentiful quality data. Peterfreund et al. be assumed that our providers are equally suscepti- developed a secure electronic system to capture ble to these effects. 2. Thys DM. The role of information systems in anesthe- sia. APSF Newsletter 2001;16:3 quality assurance information linked to an auto- mated anesthesia record.7 They nearly doubled the Discussion 3. Shear TS, Mitchell JS, Deshur MA. The effect of anes- number of quality assurance events captured by thesia charting modalities on the rate of charting defi- Many of the benefits achieved with AIMS require ciencies: A comparison of paper and electronic instituting a hard stop in their AIMS. In addition, additional custom programming to bring to fruition. anesthesia records. ASA Abstract, 2013. the ease of reporting was improved by seamlessly Moving forward, we will need to continue to push linking the process of quality reporting with case 4. Edwards KE, Hagen SM, Hannam J, Kruger C, Yu R, the AIMS vendors to incorporate user friendly and Merry AF. A randomized comparison between documentation. meaningful decision support capabilities into their records made with an anesthesia information man- In contrast to the improvement shown by Peter- systems. agement system and by hand, and evaluation of the feund et al., the results reported by Pruitt et al. at Chil- Hawthorne effect. Can J Anaesth 2013;60:990-7. As you embark on your AIMS journey, we dren’s Hospital of Philadelphia show continued 5. Sandberg WS, Sandberg EH, Seim AR, Anupama S, encourage you to follow the path outlined in the lit- cause for concern. They retrospectively reviewed Ehrenfeld JM, Spring SF, Walsh JL. Real-time check- AIMS and Continuous Quality Improvement (CQI) erature. You will need a clinical champion who ing of electronic anesthesia records for documenta- tion errors and automatically text messaging reports of 995 pediatric patients.8 Observers recorded understands your institution’s anesthesia workflow and the inner workings of your AIMS functionality. clinicians improves quality of documentation. Anesth 8 cases of emesis during induction and all were con- Analg 2008;106:192-201. firmed with the attending anesthesiologist. How- You should seek non-clinical support to help manage, maintain, and troubleshoot any issues as 6. Mccarty LK, Saddawi-Konefka D, Gargan LM, ever, only 3 were recorded in AIMS records and only Driscoll WD, Walsh JL, Peterfreund, RA. Application 1 was documented in the CQI. While no comparison they arise. In many ways, the biomedical team has of process improvement principles to increase fre- was made to paper records in this study, it highlights become equally important as the anesthesia provid- quency of complete airway management documenta- the ongoing challenge to capture manually docu- ers in the world of the AIMS.11,12 tion. Anesthesiology 2014;121:1166-74. mented events, even with an AIMS.6 There is no doubt that AIMS are here to stay. 7. Peterfreund RA, Driscoll WD, Walsh JL, Subrama- Another significant promise is the use of registry They offer a powerful set of tools that promise to nian A, Anupama S, et al. Evaluation of a mandatory quality assurance data capture in anesthesia: A secure data to provide an evidence-based foundation for improve the care we provide. However, these sys- electronic system to capture quality assurance infor- guiding treatment. By compiling large quantities of tems are far from mature and they continue to have mation linked to an automated anesthesia record. data from a diverse group of institutions, it may be significant limitations. We need to be cognizant of Anesth Analg 2011; 112(5):1218-25. possible to identify hidden trends and draw their shortcomings, and redouble our efforts to 8. Pruitt EY, Simpao A, Cook-Sather S, Rehman M. Reli- conclusions in new and unique ways. However, it is remain vigilant. After all, next to every AIMS lies some- ability of critical event reporting in an Anesthesia necessary to remain cognizant of the concept that one’s loved one. Information Management System (AIMS). Society for “garbage in = garbage out.” There is often a Technology in Anesthesia (STA) Annual Meeting misguided belief that conclusions drawn from Mark A. Deshur, MD, MBA Abstract #54. 2012. database mining are more accurate. In fact, the Director of Anesthesia Information Technology 9. Monk TG, Hurrell M, Norton A. Anesthesia Informa- quality of this data is poorly understood. In order to Director of Pediatric Anesthesia tion Management Systems: Toward standardization truly have comparable quality data, standard data NorthShore University HealthSystem of terminology in Anesthesia Information Manage- definitions are needed. Groups like the Multicenter ment Systems. APSF Newsletter. http://www.apsf. Clinical Assistant Professor org/initiatives_systems.php. Accessed May 1, 2015. Perioperative Outcomes Group (MPOG), the University of Chicago, Pritzker School of Medicine Anesthesia Quality Institute (AQI) and the APSF are 10. Strayer et al. Cognitive distraction in the vehicle, currently working to define those terminologies.9 Wilton C. Levine, MD AAA Foundation for Traffic Safety, 2013.Human Fac- tors Summer 2006;48(2):381–391. Until their work is complete, one must read any Associate Medical Director conclusions with a cautious eye. Perioperative Services 11. Sandberg WS. Anesthesia Information Management Systems: Almost There. Anesth Analg 2008;107:1100-02. Massachusetts General Hospital Distraction Assistant Professor 12. Ehrenfeld JM. Anesthesia Information Management Systems: A guide to their successful installation and AIMS have added new complexities to our Harvard Medical School use. Anesthesiology News, September, 2009. already chaotic work environments. What used to fit on one side of an 8 ½” x 11” sheet of paper is now buried beneath dozens of screens. Depending on A Statement by the Executive Committee of the APSF comfort with computers and experience with these From time to time, the Anesthesia Patient Safety Foundation reconfirms its­commitment systems, there is a very significant potential for dis- tracting a clinician from our primary mission: vigi- of working with all who devote their energies to making anesthesia as safe as humanly lant patient care. possible. Thus, the Foundation invites collaboration from all who administer anesthesia, all The distraction risk has been well studied, dem- who supply the tools of anesthesia, and all who provide the settings in which anesthesia is onstrating that those who are distracted perform at a practiced, all individuals and all organizations who, through their work, affect the safety of level similar to being sleep deprived or intoxicated. One need only observe a car swerving in front of patients receiving anesthesia. All will find us eager to listen to their suggestions and to them to realize the dangerous effects of distraction work with them toward the common goal of safe anesthesia for all patients. on performance. Indeed, AAA found that as mental APSF NEWSLETTER June 2015 PAGE 12

www.apsf.org APSF Announces Availability of Recently Released Educational DVDs

Visit the APSF website (www.apsf.org) to view the following DVDs and request a complimentary copy

• Opioid-Induced Ventilatory Impair- • Perioperative Visual Loss (POVL): • APSF Presents Simulated Informed ment (OIVI): Time for a Change in Risk Factors and Evolving Man- Consent Scenarios for Patients at the Monitoring Strategy for Postop- agement Strategies (10 minutes) Risk for Perioperative Visual Loss erative PCA Patients (7 minutes) Ischemic Optic Neuropathy (18 minutes)

FDA Authority Clarified

To the Editor: Dear Dr. Baum: The APSF Newsletter in February 2015 carried a We recognize and agree that the FDA has piece on drug shortages (“Drug Shortages in the authority to regulate drug manufacturing quality. U.S. – A Balanced Perspective”). It seems there In our article, we referenced the ISPE’s definition may have been an error. The authors indicate that of a "quality system" that, in part, is defined as a the FDA “has no authority to regulate the quality “system that complies with the regulations of manufacturing." The statutory responsibility of enforced by the FDA.” In addition, we list factors the FDA in regulating manufacturing quality goes that may prevent drug shortages such as “Strong back many decades. Did the authors mean to write Quality Systems that lead to compliance with manufacturing quantity? manufacturing regulations.” The FDA indeed has Sincerely, authority to regulate the quality of drugs manu- Victor C. Baum, M.D. factured and mandate reporting of drug shortages U.S. FDA but, to date, has not been granted authority to Siler Spring, MD regulate the quantity and hence the supply of Email: [email protected] drugs manufactured. We apologize for the typo- graphical error. Daniel S Orlovich, PharmD Richard J Kelly, MD, JD, MPH APSF NEWSLETTER June 2015 PAGE 13

Improving Post Anesthesia Care Unit (PACU) Handoff by Implementing a Succinct Checklist by Christopher Potestio, MD; Jay Mottla, GT-2; Emily Kelley, RN; and Kerry DeGroot, MD INTRODUCTION institutions have adopted standardized handoffs, METHODS such as SBAR (situation, background, assessment, Anesthesia providers participate in patient Institutional Review Board approval was recommendation) to try to ensure a quality handoffs several times for each patient under their obtained prior to this study. To create our checklist, exchange of information. However, no large scale care. Each handoff has the potential for poor com- we first used the information published in prior munication that may jeopardize patient safety. In studies have indicated the best structured approach studies and anesthesia textbooks to create an all- fact, a recent study suggested that more operating and no widely accepted guidelines exist for PACU inclusive 42 itemized list in a PACU handoff.5 We 4 room (OR) anesthesia handoffs are associated with handoff. modified our checklist to include only data relevant increased adverse events.1 With this potential for Prior efforts to standardize the PACU handoff to our institution's PACU handoff process. For adverse events in mind, the Joint Commissions have been viewed as a burdensome addition to example, during casual conversation with our 2006 National Patient Safety Goal requires "a stan- the handoff process. Therefore, our aim was to PACU nurses, residents, CRNAs, and attending 2 dardized approach" for handoffs. create a succinct checklist to help expedite the anesthesiologists, we found that “failed punctures” and “inspection of all lines and catheters” were As a quality improvement initiative, our institu- handoff process while increasing meaningful addressed during a separate nursing assessment so tion has focused on the anesthesia team-to-PACU communication between anesthesia provider and they were excluded from the checklist. This feed- nurse handoff. The ASA defines the standard for OR- PACU nurse.5 We hypothesized that we would back helped reduce our checklist down to 17 items. to-PACU handoff: "Upon arrival in the PACU, the still observe a significant increase in information patient shall be re-evaluated and a verbal report to the exchanged despite fewer checklist items. In addi- The third step of preparing the PACU Handoff responsible PACU nurse by a member of the anesthe- tion, a more succinct checklist would allow for an Checklist was to measure its effectiveness during sia care team who accompanies the patient.” 3 In spite easier transition into everyday practice and actual PACU handoffs. We randomly observed 10 of these guidelines, the quality and quantity of would avoid the negative response that similar PACU handoffs and screened for additional items information exchanged can still be variable. Some checklists have received in the past. exchanged that should be included in our handoff checklist. We found that “preoperative vital signs” and “other medications (antihypertensives and Figure 1. PACU Handoff Checklist steroids)” were an integral part of the handoffs process but were not included in previous lists. Patient Identification (Nameband check) Our final checklist (Figure 1) included a unique Time In checklist item, "closed loop communication," in Allergies order to address two-way communication between Surgical Procedure and Reason for Surgery PACU nurse and anesthesia provider. Both the ASA and the Joint Commission describe two-way Type of Anesthesia (GA, TIVA, regional) communication as an integral part of any transition Surgical or anesthetic complications of care. Patient PMH and ASA Scoring An item was counted as successfully exchanged Preoperative Cognitive Function between anesthesia resident and PACU nurse if the Preoperative Activity Level (METs) item was mentioned in any capacity. Data collec- tors were volunteer medical students who were Limb Restriction independent from the care team and study team. Preop Vitals They observed the handoff without intervention Positioning of Patient (if other than supine) and made no assessment of the quality of the infor- mation exchanged. A stopwatch was used to record Intubation conditions (grade of view, airway, quality of bag the time from the start to finish of the sign out. All mask ventilation, bite block?) times were rounded to the nearest second. Lines/catheters (IVs, a-lines, CVSs, foley chest tubes, surgi- We observed PACU handoffs completed by resi- cal drains, VP shunt) dents of all years of training during the months of Procedure Fluid Management Fluids= April to June, so that all residents had at least 6 EBL= months of clinical training before participating in our UO= study. We collected baseline data (Group A) by observing residents complete the PACU handoff Analgesia Plan - During Case, Postop Orders without the aid of a checklist. We observed 50 hand- Antiemetics Administered offs in this group. The data collectors used the PACU Handoff Data Collection sheet to record the items Medications due during PACU (antibiotics, etc.) that were exchanged during handoff as well as the

Medications Other Intra-Op Medications (steroids, antihypertensives) time it took to complete the handoff. The data for these 50 handoffs made up our control group. "Do you have any questions or concerns?" See “PACU Checklist,” Next Page APSF NEWSLETTER June 2015 PAGE 14

Checklists May Reduce Morbidity and Mortality “PACU Checklist,” From Preceding Page While they included significantly more items for 2 reasons. The resident may have deemed a Once baseline data was collected, the checklist in their handoff, residents who used the PACU particular item non-essential to the transition of was introduced to our residents. Prior to the start Handoff Checklist spent a significantly longer care or may have missed the item due to general of one of our daily academic conferences, each amount of time completing their handoff com- unfamiliarity with the new tool. In the latter case, item on the checklist was reviewed with the resi- pared to those that did not use a checklist (Group further use of the checklist would likely lead to an dents so that they were able to appreciate a suc- B: 126.4 +/- 52.25 seconds; Group A: 100.86 +/- additional increase in amount of information cessful handoff of information. After this 36.00 seconds, p = 0.011). included in the PACU handoff. introduction to the checklist, Group B data were The six residents that participated in handoffs Failure in communication has been shown to collected as residents completed the PACU handoff in both groups (4 CA-1s, 2 CA-2s) accounted for risk patient safety in several studies across differ- by using the PACU Handoff Checklist as a guide 28 handoffs in Group A and 20 handoffs in Group ent specialties.6-9 When checklists were introduced for exchange of information. The same PACU B. In a subgroup analysis, percentage of overall to preoperative and intraoperative care, there has Handoff Data Collection Sheet was used to record items exchanged by this crossover resident sub- been an association with a significant reduction in items exchanged and the time it took to complete group was very similar to the total (Group B morbidity and mortality.10,11 Agarwal and col- the handoff. [crossover residents]: average, 69.96% +/- 12.62%; leagues introduced a standardized handoff tool Group A [crossover residents]: average 52.23% for transition of care from the operating room to RESULTS +/- 8.96%, p = 0.014). They also spent a signifi- pediatric cardiac ICU. This effort led to a decrease A total of 14 residents (6 CA-1 residents, 4 CA-2 cantly longer amount of time completing their in postoperative complications and an improve- residents, 4 CA-3 residents) were observed for handoffs with the checklist (Group B: 131.5 +/- ment in 24 hour patient outcomes.12 56.43 seconds; Group A: 106.61 +/- 40.44 seconds, patient handovers in Group A (control group). A In the only randomized clinical trial to date on p = 0.002). total of 8 residents (4 CA-1s, 3 CA-2s, 1 CA-3s) PACU handoffs, Salzwedel and colleagues sur- were observed for patient handoffs in Group B The more time spent on the handoff, the more veyed senior anesthesiologists at their institution (experimental group). Six residents participated in items were addressed. Handoffs with the use of and constructed a checklist consisting of 37 items handoffs in both groups (4 CA-1s, 2 CA-2s). Each the checklist (Group B) spent less time discussing integral to their PACU handoff.5 They found that resident participated in 1-8 handovers. The per- each item than handoffs that did not use the the use of a checklist for PACU handoff improved centage of overall items handed off increased sig- checklist (Group A), although this difference did exchange of information, but took significantly nificantly with the use of the PACU Checklist not approach statistical significance (Group B: longer (35 seconds) when compared to handoffs (Group B: average, 69.5% +/- 16.5%, Group A: 7.71 +/- 3.17 seconds per item, Group A: 8.23 +/- that did not use a checklist. Our study yielded average, 51.50% +/-8.28% p = 0.018) (Figure 2). 2.70 seconds per item, p = 0.366). similar results; handoffs in Group B were 26 sec- Residents who used a checklist (Group B) onds longer. It appears that the extra time invested handed off 8 items on the checklist with a signifi- DISCUSSION in an organized PACU sign out results in more cantly higher frequency compared to residents With the use of a checklist, the percentage of information exchanged. However, the increased who did not use a checklist (Group A). These items exchanged during PACU handoff increased burden it places on the anesthesia provider may items were: Antibiotics (p = 0.016), Standing Medi- significantly (Figure 2). The checklist clearly deter organizations from implementing similar cations (p <0.001), Preoperative Cognitive Func- increased the amount of information exchanged strategies. We quantified this difference by mea- tion (p < 0.001), Complications (p < 0.001), Patient during our handoffs; but only 4 out of 50 handoffs suring the “velocity” of the handoffs. Group B, Positioning (p < 0.001), Limb Restriction (p < included 100% of the information listed. Items with the use of the checklist, exchanged 7.7 items/ 0.001), and Preoperative Activity Level(p < 0.001). most commonly missed include Preoperative second which is an improvement over Group A, They also completed the task of Closed Loop Com- Cognitive Function, Lines/catheters, and Anti- which exchanged 8.2 items/second without the munication more often (p < 0.001) emetics. Missed items may have been excluded checklist. Our study is the first study to target handoffs * by residents. At this early juncture in training, an 100% organized PACU handoff may have increased ben- 90% efit. Without the polished clinical skills and judg- ment of a seasoned anesthesia provider, residents 80% may be more likely to miss an important piece of 70% information in their sign out. 60% There were several inherent limitations to our study. Because our data collectors did not record 50% any qualitative data about the information 40% exchanged, we are unable to tell if any errors were made during these handoffs; in fact, we are not 30% able to comment on the quality of handoffs at all, 20% but simply report the percent of items addressed. Any effort to create a comprehensive sign out Percent of Items Exchanged Percent 10% tool will invariably increase the length of the sign 0 Group A Group B out while an effort to create an efficient sign out tool will streamline the sign out while possibly Figure 2. Percent of items exchanged during PACU handoff. Data were compared using chi squared test. Group B excluding vital information. The information that (Checklist) exchanged a significantly higher percentage of important information when compared to Group A (No should be included in a complete, thorough PACU Checklist). *A significant difference with p = 0.018. See “PACU Checklist,” Next Page APSF NEWSLETTER June 2015 PAGE 15

An Unusual Cause of Hypoxia with Multidisciplinary Process Needed Closed Endotracheal Suction System “PACU Checklist,” From Preceding Page sign out varies greatly from patient to patient; by Harihar V. Hegde, MD, and Vinayak B. Nayak, MBBS therefore, any standardization tool is often going To the Editor: the CSS and the catheter mount was drained of fluid. to be too comprehensive or too efficient. Airway suctioning is usually performed by intro- Oxygen saturation improved steadily over the next The anesthesia provider is not the only person ducing a suction catheter into the endotracheal tube hour and the patient was subsequently discharged providing sign out information to the PACU nurse; after disconnecting the patient from the ventilator. It from the ICU after recovery. our surgical colleagues provide information that is can also be accomplished with a closed suctioning In an apparent attempt to reduce the overall also integral to patient care. Future endeavors will aim to incorporate the surgical handoff in an effort to system (CSS) included in the ventilator circuit, which time and number of tasks required to perform create a comprehensive, multidisciplinary sign out allows the introduction of suction catheter into the endotracheal suctioning, the nursing staff had kept process. In addition, a larger study will allow us to airway without disconnecting the patient from the the NS connected to the saline port of the CSS. The ventilator. Closed suctioning technique facilitates con- measure the effect that a standardized sign out pro- one-way valve in the saline port is designed to pre- tinuous mechanical ventilation and oxygenation cess will have on patient outcome. vent inadvertent saline aerosolization.2 By attach- during the suctioning event. CSS has some advan- ing the intravenous infusion set firmly to the Dr. Potestio is a CA-2 and Dr. DeGroot is an Associate tages compared to the conventional, open-suction irrigation port, the one-way valve was in "open" Professor in the Department of Anesthesiology, Medstar technique. It can be helpful in limiting environmental, Georgetown University Hospital, Washington, DC. personnel, and patient contamination and in prevent- position allowing sustained irrigation of saline ing the loss of lung volume and the alveolar derecruit- leading to flooding of the airway as the infusion set Mr. Mottla is a 2nd year medical student and Ms. ment associated with standard suctioning in severely was also kept "on." Kelley is an RN in the Post Anesthesia Care Unit, at Med- hypoxemic patients. The use of closed suction is sug- Even if it is slightly labor-intensive and time star Georgetown University Hospital, Washington, DC. gested for adults requiring high FiO2, or PEEP, or at consuming to irrigate saline using a saline filled References risk for lung derecruitment, and for neonates.1 syringe, saline should not be kept connected to the 1. Saager L., Hesler B. D., You J., Turan A., Mascha E. J., Ses- A patient on mechanical ventilation in our inten- CSS through an intravenous infusion set. There is sler D. I., Kurz A. Intraoperative transitions of anesthesia sive care unit with CSS (Portex® SuctionPro 72™, no instruction in the product insert regarding how care and postoperative adverse outcomes. Anesthesiology 2014;121:695-706. Dual Lumen Closed ventilation suction catheter with to irrigate or a warning regarding the possibility of inadvertent aerosolization of saline if fluid is kept 2. Arora V., Johnson J. A model for building a standardized T connector) developed gradual (over a period of half hand-off protocol. Joint Commission Journal on Quality and an hour) desaturation while being ventilated in syn- connected to the irrigation port. This incident is Patient Safety 2006; 32: 646-655. chronized intermittent mandatory ventilation mode. reported to alert the caregivers, especially the inten- 3. American Society of Anesthesiologists Committee on Surgi- Common causes for hypoxia in a patient on mechani- sive care specialists and nursing staff working in cal Anesthesia. Guidelines for patient care in anesthesiology. ASA website. https://www.asahq.org/For-Members/Stan- cal ventilation related to endotracheal tube and intensive care units, about this potential complica- dards-Guidelines-and-Statements.aspx. Last amended Octo- breathing circuits like kinking, displacement, discon- tion associated with CSS. ber 19, 2011. Accessed October 19, 2014. nections, leaks and obstruction, pneumothorax were Harihar V. Hegde, MD 4. Hoefner-Notz R., Wintz M., Sammons J., & Markowitw S. Using evidence-based practice to implement standardized ruled out by bedside clinical examination. A small Vinayak B. Nayak, MBBS quantity of clear aspirate was observed on endotra- anesthesia-to-PACU handoff tool and improve PACU staff Dept. of Anaesthesiology, SDM College of Medical satisfaction. Journal of PeriAnesthesia Nursing 2013;28:e3. cheal suction. While the cause for desaturation was Sciences and Hospital, Sattur, Dharwad, India. 5. Salzwedel C., Bartz H. J., Kühnelt I., Appel D., Haupt O., being actively searched for, we noticed the catheter Maisch S., & Schmidt G. N. The effect of a checklist on the mount filled with fluid. Upon examination of the CSS Conflicts of interest and financial support: There quality of post-anaesthesia patient handover: a random- it was noticed that the nursing staff had kept con- are no conflicts of interest involved in this report. ized controlled trial. International journal for quality in health care nected a 500 ml Normal Saline (NS) bottle to the saline 2013;25:176-181. References 6. Wilson RM, Runciman WB, Gibberd RW, Harrison BT, port of CSS (Figure 1) with the intravenous infusion 1. Restrepo RD, Brown JM 2nd, Hughes JM. AARC Newby L, Hamilton JD. The Quality in Australian Health set "on", suction port kept connected to the central Clinical Practice Guidelines. Endotracheal suctioning Care Study. Medical Journal of Australia 1995; 63:458-71. suction and thumb control valve in "off" position. NS of mechanically ventilated patients with artificial air- 7. Hart E. M., & Owen, H. Errors and omissions in anesthesia: drops were seen being slowly infused into the breath- ways 2010. Respir Care 2010;55:758-64. a pilot study using a pilot’s checklist. Anesthesia & Analge- ing circuit. NS was immediately disconnected from 2. http://bcove.me/noraas7w Accessed May 5, 2015. sia 2005;101:246-250. 8. Sutcliffe K. M., Lewton E., & Rosenthal M. M. Communica- Thumb control tion failures: an insidious contributor to medical mishaps. valve Academic Medicine 2004;79:186-194. 9. Patterson ES, Roth EM, Woods DD, Chow R, Gomes JO. Handoff strategies in settings with high consequences for failure: lessons for health care operations. Int J Qual Health Suction port Care 2004;16:125-132. 10. Haynes A. B., Weiser T. G., Berry W. R., Lipsitz S. R., Breizat A. H. S., Dellinger E. P., Herbosa T., Joseph S., Kibatala P.L. Lapitan M.C., Merry A.F., Moorthy K., Reznick, R.K., Saline port Taylor B., Gawande A. A. A surgical safety checklist to reduce morbidity and mortality in a global population. New England Journal of Medicine 2009;360:491-499. 11. Wolff A. M., Taylor S. A., & McCabe J. F. Using checklists and reminders in clinical pathways to improve hospital inpatient "T" connector care. Medical Journal of Australia 2004;181:428-431. 12. Agarwal H. S., Saville B. R., Slayton J. M., Donahue B. S., Daves S., Christian K. G., Bichell D.P., Harris Z. L. Stan- dardized postoperative handover process improves out- comes in the intensive care unit: a model for operational sustainability and improved team performance. Critical Closed suction catheter that was misused resulting in oxygen desaturation. Care Medicine 2012;40:2109-2115. Anesthesia Patient Safety Foundation NONPROFIT ORG. Building One, Suite Two U.S. POSTAGE 8007 South Meridian Street PAID WILMINGTON, DE Indianapolis, IN 46217-2922 PERMIT NO. 1858

APSF NEWSLETTER June 2015

In This Issue: What is Your MH IQ? ------Methylene Blue and Risk of Serotonin Toxicity ------AIMS: Should We AIM Higher? ------PACU Checklist ------An Unusual Cause of Hypoxia with Closed Endotracheal Suction System ------Safety Section Editor Position