who launches “safe surgery saves lives” - anesthesia patient safety … · 2018-04-05 ·...

NEWSLETTERVolume 23, No. 2, 21-36 Circulation 84,122 Summer 2008

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

®

www.apsf.org

Inside: Q&A ................................................................................................................................Page 24-27

Dear SIRS: Flow Sensors ................................................................................................Page 28

Israeli Exchange Program ..............................................................................................Page 30

Mock Debate on Syringe Reuse Dangers ....................................................................Page 34

Letters to the Editor ..................................................................................................Pages 32-35

With the Anesthesia Patient Safety Foundationas one of the 160 endorsing professional organiza-tions from literally all around the globe, The WorldHealth Organization (WHO), through WHO’s WorldAlliance for Patient Safety, launched its SecondGlobal Patient Safety Challenge: “Safe Surgery SavesLives,” June 25 in Washington, DC.

This world-wide patient safety initiativeacknowledges that surgery often is, in fact, not atherapeutic benefit, but rather a public health hazardfor much of the world’s population and addressesimproving the safety of surgical care everywhere.The previous First Global Patient Safety Challenge,"Clean Care is Safer Care," focusing on “HandHygiene in Health Care” and clean water waslaunched in October 2005, and has been widely cred-ited with promoting significant advances in thesafety of basic health care in the developing world.

APSF ConnectionThe new Safe Surgery Saves Lives program cen-

ters on a single-page safety checklist, but is pre-sented in a 170-page document that has 4 mainsections: Surgical Site Infection Prevention, SafeAnaesthesia, Safe Surgical Teams, and Measurementof Surgical Care and Quality Assurance Mecha-nisms. The 6-member “Working Group” that pro-duced the Safe Anaesthesia section includes John H.Eichhorn, MD, professor of anesthesiology at theUniversity of Kentucky, who was founding editor ofthe APSF Newsletter and now serves as consultant tothe APSF Executive Committee, and also Jeffrey B.Cooper, PhD, director of biomedical engineering atPartners Healthcare/Massachusetts General Hospi-tal and executive vice president of APSF. The other4 anesthesiologists are from New Zealand, India,

dards that can be applied universally across bordersand settings, the Safe Surgery Saves Lives Challengehopes to create an environment of safety that willhelp improve both access for and care of surgicalpatients.

Dr. Gawande stated, "Surgical care has been anessential component of public health systems world-wide for a century. The quality and safety of that carehas been dismayingly variable in every part of theworld. The Safe Surgery Saves Lives campaign aimsto change that by raising the standard that peopleeverywhere can expect."

Universal ApplicationPrimarily targeting underdeveloped, resource-

challenged parts of the world, but applicable univer-sally wherever surgery is performed, the Safe SurgerySaves Lives program focuses on providing simpleand practical checklists, practice standards, and pro-tocols specifically intended to help make surgeryand anesthesia safer. Quality improvement pro-grams, perceived as a need in a majority of theworld, are specifically targeted by the “measure-ment and QA” section.

The main tangible product of the program is the“Surgical Safety Checklist” (see Figure 1) that willbe used to promote safety and improve quality ofsurgical services. The checklist is designed to besimple and widely applicable. It aims to reinforceestablished safety practices, and many of the stepsare already accepted as routine in facilities in manylocations. It also aims to foster better communicationand teamwork among clinical disciplines (note therequirement for team members to introduce them-selves by name and role to open the Time Out). Thechecklist is intended as a tool for clinicians toimprove safety by reducing unnecessary surgicaldeaths and complications. The individual safetychecks have been included based on clinical evi-dence or expert opinion that their inclusion willreduce the likelihood of serious, avoidable surgicalor anesthesia harm and that adherence to them isunlikely to introduce injury or unmanageable cost.

At the time of the June launch, the SurgicalSafety Checklist was being field tested in real cases

See “WHO,” Page 23

Nigeria, and England. Dr. Eichhorn attended thelaunch event as the APSF representative.

The Safe Surgery Saves Lives June launch eventwas hosted by the WHO Regional Director for theAmericas and attended by Ministers of Health,world leaders in surgery, anesthesiology, and nurs-ing, and also Dr. Atul Gawande, a Harvard facultymember in both Health Policy/Management andSurgery, the organizational leader for this WHO ini-tiative intended to reduce deaths and complicationsin surgery globally. During the launch there werevideo links to numerous sites around the world test-ing the new "WHO Surgical Safety Checklist" andendorsements of this approach to safety from healthcare associations—anesthesia, medical, surgical,nursing, patient safety, as well as ministries ofhealth—worldwide. The World Alliance for PatientSafety was honored that Senator Edward M.Kennedy had accepted its invitation to deliver wel-coming remarks for this global launch. SenatorKennedy affirmed his strong support for this initia-tive, but his recent health concerns prevented his per-sonal attendance at the expansive event that tookplace at the Pan American Health Organizationheadquarters building.

MissionThere are more major surgeries than births

worldwide, yet surgery is much more dangerous andhas a much higher mortality rate. The incidence ofconditions requiring surgery is rising as a proportionof the total global burden of disease, and surgicalintervention is expected to increase around theworld. Surgical care and its safe delivery can poten-tially affect the lives of many millions of peopleworldwide. By defining a core set of minimum stan-

WHO Launches “Safe Surgery Saves Lives”

APSF NEWSLETTER Summer 2008 PAGE 22

NEWSLETTERThe Official Journal of the Anesthesia Patient Safety Foundation

The Anesthesia Patient Safety FoundationNewsletter is the official publication of the nonprofitAnesthesia Patient Safety Foundation and is pub-lished quarterly at Wilmington, Delaware. Annualcontributor cost: Individual–$100, Corporate–$500.This and any additional contributions to the Founda-tion are tax deductible. © Copyright, AnesthesiaPatient Safety Foundation, 2008.

The opinions expressed in this Newsletter are notnecessarily those of the Anesthesia Patient SafetyFoundation. The APSF neither writes nor promulgatesstandards, and the opinions expressed herein shouldnot be construed to constitute practice standards orpractice parameters. Validity of opinions presented,drug dosages, accuracy, and completeness of contentare not guaranteed by the APSF.

APSF Executive Committee:Robert K. Stoelting, MD, President; Nassib G.

Chamoun, Vice President; Jeffrey B. Cooper, PhD,Executive Vice President; George A. Schapiro,Executive Vice President; Matthew B. Weinger, MD,Secretary; Casey D. Blitt, MD, Treasurer; Sorin J. Brull,MD; Robert A. Caplan, MD; David M. Gaba, MD;Lorri A. Lee, MD; Robert C. Morell, MD; Michael A.Olympio, MD; Richard C. Prielipp, MD. Consultant tothe Executive Committee: John H. Eichhorn, MD.Newsletter Editorial Board:

Robert C. Morell, MD, Editor; Lorri A. Lee, MD,Associate Editor; Sorin J. Brull, MD; Joan Christie, MD;Jan Ehrenwerth, MD; John H. Eichhorn, MD; RodneyC. Lester, PhD, CRNA; Glenn S. Murphy, MD; DeniseO’Brien, MSN, RN; Karen Posner, PhD; Andrew F.Smith, MRCP FRCA; Wilson Somerville, PhD; JefferyVender, MD.

Address all general, contributor, and subscriptioncorrespondence to:Administrator, Deanna WalkerAnesthesia Patient Safety FoundationBuilding One, Suite Two8007 South Meridian StreetIndianapolis, IN 46217-2922e-mail address: [email protected]: (317) 888-1482

Address Newsletter editorial comments, questions, letters, and suggestions to:Robert C. Morell, MDEditor, APSF Newsletterc/o Addie Larimore, Editorial AssistantDepartment of AnesthesiologyWake Forest University School of Medicine9th Floor CSBMedical Center BoulevardWinston-Salem, NC 27157-1009e-mail: [email protected]

www.apsf.org

®

Announcing

The Doctors CompanyFoundation Ann S. Lofsky, MD,

Research Award

The APSF is pleased to announce the

establishment of The Doctors Company

Foundation Ann S. Lofsky, MD,

Research Award. This award is made possible by

a grant from The Doctors Company Foundation.

A $5,000 grant will be awarded annually for the

next 5 years, beginning in 2008, to a research pro-

ject deemed worthy of the ideals and dedication

exemplified by Dr. Ann S. Lofsky. Dr. Lofsky was

a regular contributor to the APSF Newsletter, a

special consultant to the APSF Executive Com-

mittee, and a member of the APSF Board of

Directors. Her untimely passing cut short a

much-valued and meaningful career as an anes-

thesiologist and as a dedicated contributor to

anesthesia patient safety. It is the hope of the

APSF that this award will inspire others toward

her ideals and honor her memory.


“WHO,” From Page 21 Expansive BackgroundSupporting the Surgical Safety Checklist is a com-

prehensive “technical document” focusing on 10 spe-cific objectives to improve the safety of surgical care. Itdetails the rationale for and explains the application ofthe checklist items though an “implementationmanual” for the checklist. It also stands as an exten-sive additional resource in the 4 areas in which dra-matic improvements are targeted in the safety of

anesthesia care: surgical site infection prevention, safeanaesthesia, safe surgical teams, and measurement ofsurgical services. The goal of the Challenge is toimprove surgical safety around the world by defininga core set of safety and basic practice standards thatcan be applied in all WHO Member States regardlessof circumstance or environment. The working groups

WHO Develops New Surgical Safety Checklistin operating rooms in each of the 6 WHO regionsaround the world. Included are surgical settingswith widely variable economic and resource-avail-ability conditions. The current checklist is labeled“First Edition” to indicate that the checklist may beenhanced over time based on experience andresearch on its application.

Figure 1: The new WHO Surgical Safety Checklist is intended to help improve quality of care and enhance the safety of surgery, especially in developing and resource-challenged parts of theworld. It is universally applicable, however, and its rigorous adoption clearly could be of significant benefit, particularly in promoting communication and cooperation in the OR, in everysurgical suite in the US.

PATIENT HAS CONFIRMED

• IDENTITY

• SITE

• PROCEDURE

• CONSENT

SITE MARKED/NOT APPLICABLE

ANAESTHESIA SAFETY CHECK COMPLETED

PULSE OXIMETER ON PATIENT AND FUNCTIONING

DOES PATIENT HAVE A:

KNOWN ALLERGY?

NO

YES

DIFFICULT AIRWAY/ASPIRATION RISK?

NO

YES, AND EQUIPMENT/ASSISTANCE AVAILABLE

RISK OF >500ML BLOOD LOSS (7ML/KG IN CHILDREN)?

NO

YES, AND ADEQUATE INTRAVENOUS ACCESS AND FLUIDS PLANNED

SIGN IN

CONFIRM ALL TEAM MEMBERS HAVEINTRODUCED THEMSELVES BY NAME AND ROLE

SURGEON, ANAESTHESIA PROFESSIONALAND NURSE VERBALLY CONFIRM• PATIENT• SITE• PROCEDURE

ANTICIPATED CRITICAL EVENTS

SURGEON REVIEWS: WHAT ARE THECRITICAL OR UNEXPECTED STEPS,OPERATIVE DURATION, ANTICIPATEDBLOOD LOSS?

ANAESTHESIA TEAM REVIEWS: ARE THEREANY PATIENT-SPECIFIC CONCERNS?

NURSING TEAM REVIEWS: HAS STERILITY(INCLUDING INDICATOR RESULTS) BEENCONFIRMED? ARE THERE EQUIPMENTISSUES OR ANY CONCERNS?

HAS ANTIBIOTIC PROPHYLAXIS BEEN GIVEN WITHIN THE LAST 60 MINUTES?

YES

NOT APPLICABLE

IS ESSENTIAL IMAGING DISPLAYED?

YES

NOT APPLICABLE

TIME OUT

Before induction of anaesthesia Before skin incision Before patient leaves operating room

SURGICAL SAFETY CHECKLIST (FIRST EDITION)

NURSE VERBALLY CONFIRMS WITH THETEAM:

THE NAME OF THE PROCEDURE RECORDED

THAT INSTRUMENT, SPONGE AND NEEDLE COUNTS ARE CORRECT (OR NOT APPLICABLE)

HOW THE SPECIMEN IS LABELLED(INCLUDING PATIENT NAME)

WHETHER THERE ARE ANY EQUIPMENT PROBLEMS TO BE ADDRESSED

SURGEON, ANAESTHESIA PROFESSIONAL AND NURSE REVIEW THE KEY CONCERNS FOR RECOVERY AND MANAGEMENT OF THIS PATIENT

SIGN OUT

THIS CHECKLIST IS NOT INTENDED TO BE COMPREHENSIVE. ADDITIONS AND MODIFICATIONS TO FIT LOCAL PRACTICE ARE ENCOURAGED.

See “WHO,” Page 26


Numerous questions to the Committee on Technology are individually and quickly answered each quarter by knowledgeable committee members. Many ofthose responses would be of value to the general readership, but are not suitable for the Dear SIRS column. Therefore, we have created this simple column toaddress the needs of our readership.

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

Why Don’t All Vaporizers Have an “Empty” Alarm?Dear Q&A,

Since anesthesia awareness is now in the publicforum, I was wondering why the non-desflu-rane vaporizers don’t have an “empty” alarm.Seems like an easy fix to prevent the vaporizerfrom running out during a case that goes unno-ticed. Perhaps it has already been done and weare waiting for the upgrades to occur, butthought I would pass it along.

The above would prevent empty vaporizers,but it would not prevent failure to turn thevaporizer on during a case. With electroniccharting being a future reality, is the APSFgoing to require all electronic charting to flagend-tidal anesthetic gas concentrations thatapproach awareness MAC values? While theprograms are being written it would be of greatvalue if the APSF came out with a list of require-ments for electronic charting to preventmishaps rather than leaving the algorithms tothe programmers who usually know nothingabout anesthesia.

Terry W. Bejot, MDLincoln, NE

Dear Dr. Bejot,

The consensus is that low agent alarms wouldbe useful on all vaporizers. However, the sug-gestion of minimizing the risk of patient aware-ness through the use of a low agent alarmwould not be as efficacious as properly mea-sured exhaled agent concentration, whichyields an estimate of Minimum Alveolar Con-centration (MAC) of the agent. It has been sug-gested that an exhaled agent concentrationgreater than 0.8 MAC will minimize the risk ofawareness.1 See “Q&A,” Next Page

The low agent alarm would be a very usefuladjunct to monitoring the exhaled agent con-centration to indicate the need to refill thevaporizer before it’s operation is compromisedby having too little agent in the vaporizer. Con-cern was expressed about retrofitting currentvaporizers with reliable low level alarms,because most of the currently available vaporiz-ers are purely mechanical and the alarm systemwould add complexities of a sensor, potentialleak of agent, electronic circuitry, and batterypower and maintenance to name a few issues.Add to that the complexities of a sensor/alarmsystem that must be immune from extraneousradio frequencies (cautery, cell phones, andother devices), and must alarm when the bat-tery is low and when the agent is low or whenthe device is not working properly.

Some non-desflurane electronic vaporizersalready provide a low-level alarm, while somemanufacturers have indicated they do plan formonitoring the amount of liquid in all vaporiz-ers on future anesthesia machines. Most likely,the market place will drive all manufacturers inthis direction. Meanwhile, the use of exhaledend-tidal agent concentration should beemployed and properly monitored to minimizethe likelihood of patient awareness.

With regard to electronic charting, the Commit-tee on Technology is not a standards-settingcommittee and will not be promulgating stan-dards or requirements for medical records ofany kind including computerized anesthesiarecords. Thank you for bringing this importanttopic to us for discussion.

The Committee on Technology

Reference1. Hardman J G, Aitkenhead AR. Awareness during anes-

thesia. Continuing Education in Anaesthesia, Critical Care& Pain. 2005 5(6):183-186.

Dear Q&A,

I have been asked to come up with an emergencyresponse plan if someone should drop a bottle ofisoflurane liquid for inhalation anesthesia. Arethere any published guidelines that address howto handle this situation if it occurs? Would this bethe same procedure for sevoflurane?

Amanda Wilsey, CVTAbbott Park, IL

Dear Ms. Wilsey,

The answer to your question can be found in theOccupational Safety and Health Administration’sAnesthestic Gases: Guidelines for Workplace Exposuresavailable at http://www.osha.gov/dts /osta/anestheticgases/index.html/anestheticgases/index.html#G. These guidelines, published in 1999and revised in 2000, apply to all liquid inhalationalanesthetic agents and are excerpted as follows:

Anesthetic Gases: Guidelines for WorkplaceExposures

These guidelines are not a new standard or regu-lation, and they create no new legal obligations.The guidelines are advisory in nature, informa-tional in content, and are intended to assistemployers in providing a safe and healthfulworkplace through effective prevention pro-grams adapted to the needs of each place of


“Q&A,” From Preceding Page

How Do I Handle an Isoflurane Spill?

employment. These guidelines are notintended to address issues to patient care. . . .

Section G. CLEAN-UP AND DISPOSAL OFLIQUID ANESTHETIC AGENT SPILLS

Small volumes of liquid anesthetic agents suchas halothane, enflurane, isoflurane, desflurane,and sevoflurane evaporate readily at normalroom temperatures, and may dissipate beforeany attempts to clean up or collect the liquidare initiated. However, when large spills occur,such as when one or more bottles of a liquidagent break, specific cleaning and containmentprocedures are necessary and appropriate dis-posal is required (AANA 1992).1 The recom-mendations of the chemical manufacturer’smaterial safety data sheet (MSDS) that identifyexposure reduction techniques for spills andemergencies should be followed.

In addition, OSHA Standard for HazardousWaste Operations and Emergency Response (29CFR 1910.120) would apply if emergencyresponse efforts are performed by employees.The employer must determine the potential foran emergency in a reasonably predictableworst-case scenario, and plan response proce-dures accordingly. Only adequately trained andequipped workers may respond to spills. Whenthe situation is unclear or data are lacking onthe exposure level, the response needs to be thesame as for high levels of exposure. Responsesto incidental releases of liquid anesthetic agentswhere the substance can be absorbed, neutral-ized, or otherwise controlled at the time ofrelease by employees in the immediate releasearea, or by maintenance personnel do not fallwithin the scope of this standard.

Because of the volatility of liquid anesthetics,rapid removal by suctioning in the OR is thepreferred method for cleaning up spills. Spillsof large volumes in poorly ventilated areas orin storage areas should be absorbed using anabsorbent material, sometimes called a sorbent,which is designed for clean-up of organicchemicals. "Spill pillows" commonly used in

hospital laboratories, vermiculite, and carbon-based sorbents are some of the materials com-mercially available and regularly used for thispurpose. Caution should be exercised if brokenglass bottles pose a hazard.

Both enflurane and desflurane are consideredhazardous wastes under the EPA regulationsbecause these chemicals contain trace amountsof chloroform (a hazardous substance), a by-product of the manufacturing process. Conse-quently, sorbents that have been saturated withenflurane or desflurane should be managed asan EPA hazardous waste material due to thetrace concentrations of chloroform present.Isoflurane and halothane do not contain traceamounts of chloroform or any other regulatedsubstance and are therefore not considered haz-ardous wastes by EPA.

To minimize exposure to all liquid anestheticagents during clean-up and to limit exposureduring disposal procedures, the following gen-eral guidelines are recommended. The wastematerial should be placed in a container, tightlysealed, properly labeled, and disposed of withother chemical wastes sent to a facility’s inciner-ator or removed by a chemical waste contractor.After a large spill has occurred and the appro-priate response action taken, airborne monitor-ing should be conducted to determine if the spillwas effectively contained and cleaned up.

Determination of appropriate disposal proce-dures for each facility is the sole responsibility ofthat facility. Empty anesthetic bottles are notconsidered regulated waste and may be dis-carded with ordinary trash or recycled. Further-more, the facility as well as the waste handlingcontractor must comply with all applicable fed-eral, state, and local regulations.

To minimize exposure to waste liquid anestheticagents during clean-up and disposal, the follow-ing general guidelines are recommended by themanufacturers of liquid anesthetic agents:• Wear appropriate personal protective

equipment. (Refer to section E4 on personalprotective equipment).

• Where possible, ventilate area of spill orleak. Appropriate respirators should beworn.

• Restrict persons not wearing protectiveequipment from areas of spills or leaksuntil clean-up is complete.

• Collect the liquid spilled and the absorbentmaterials used to contain a spill in a glass orplastic container. Tightly cap and seal thecontainer and remove it from theanesthetizing location. Label the containerclearly to indicate its contents.

• Transfer the sealed containers to the wastedisposal company that handles and haulswaste materials.

• Health-care facilities that own or operatemedical waste incinerators may dispose ofwaste anesthetics by using an appropriateincineration method after verifying thatindividual incineration operating permitsallow burning of anesthetic agents ateach site.

Reference1. American Association of Nurse Anesthetists

(AANA). Management of waste anesthetic gases. ParkRidge, IL: 1992. Pp. 16-17.

APSF ExecutiveCommittee

InvitesCollaboration

From time to time the Anesthesia Patient SafetyFoundation reconfirms its commitment ofworking with all who devote their energies tomaking anesthesia as safe as humanly possible.Thus, the Foundation invites collaboration fromall who administer anesthesia, and all whoprovide the settings in which anesthesia ispracticed, all individuals and all organizationswho, through their work, affect the safety ofpatients receiving anesthesia. All will find useager to listen to their suggestions and to workwith them toward the common goal of safeanesthesia for all patients.


To the Editor:

Residual muscle weakness in the Post-Anesthe-sia Care Unit (PACU) secondary to intraoperativelyadministered nondepolarizing relaxants is muchmore common than most clinicians appreciate, andrepresents a potentially significant public health andpatient safety issue. Recent surveys of clinical prac-tices in Europe suggest that muscle relaxants areoften administered without proper monitoring, andrecent US publications continue to report significantmorbidity associated with under-appreciated resid-ual neuromuscular weakness.

If the incidence of postoperative residual weak-ness is to be reduced significantly, we need a betterunderstanding of the current practices with nonde-polarizing relaxants among clinicians. Surveys inDenmark, Germany, the United Kingdom, andMexico have suggested that only 43%, 28%, 10%, and2% of clinicians, respectively, routinely use neuro-muscular monitors of any kind. No comparablestudy of clinical practice in North America has everbeen undertaken.

Repeated editorials suggesting proper drug man-agement and intraoperative monitoring have beenlargely ignored. The standard of care suggested byexperts in the field regarding relaxant administrationand the need for monitoring thus appear to be atvariance with actual clinical practice. The extent to

Letter to the Editor:Newsletter Readers Invited to Participatein Survey on Residual Weakness in PACU

which this is true in the United States is currentlyunknown.

It is our objective to survey and compare clinicalpractices associated with the use of neuromuscularblocking drugs and neuromuscular monitoringamong anesthesia practitioners in the United Statesand the European Union. At a time when majorchanges appear imminent in the way we think aboutand administer neuromuscular blocking drugs, webelieve that a better understanding of actual clinicalattitudes and practices is timely.

Thus, we kindly request your help in examiningthis matter, and invite all readers of the Newsletter toanonymously answer a brief series of questions on awebsite:

http://www.nmjuncture.com/usasurvey/usasurvey.html.

This study is not sponsored by a society, nor doesit have any commercial affiliation. We have alsosecured our institutional approvals for this survey.

Many thanks for your time and help.

Mohamed Naguib

Aaron Kopman

Cynthia Lien

Jennifer M. Hunter

Sorin J. Brull

of international experts were convened to review theliterature and the experiences of clinicians around theworld and achieve the consensus contained in thetechnical document.

Anesthesia AntecedentsThe Safe Anaesthesia Working Group was first

convened in early 2007. Its initial deliberationsinvolved reviewing the International Standards for aSafe Practice of Anaesthesia, a comprehensive prac-tice protocol document that recognized the wide dis-parity in medical care resources around the worldand recommended solutions, which had beenadopted as world standards by the World FederatedSocieties of Anesthesiologists (WFSA) at the WorldCongress in June 1992. That document had been cre-ated by the independently funded International TaskForce on Anaesthesia Safety comprised of expertsfrom 9 countries and chaired by Dr. Eichhorn andalso Dr. J.S. Gravenstein, who was then from theUniversity of Florida. The WHO Working Groupused the WFSA model as the stimulus for the subjectareas and the anesthesia practice standards in thetechnical document, included in the detailed tabular“Guide to infrastructure, supplies, and anaesthesiastandards at three levels of health-care facilities.”

In addition to the essential practice standards,the “Safe Anaesthesia” section of 30 pages in thetechnical document includes highly referenced pre-sentations on the value of pulse oximetry andcapnography monitoring; preanesthetic preparationand check-out; anesthetic infrastructure, facilities,and equipment; airway management; and medica-tions and their safe administration. The subsequentsection on anticipating and treating hypovolemiaand hemorrhage combines anesthesia and surgicalconsiderations. Again, while the first intended targetfor these patient safety efforts is the underdevelopedand emerging areas of the world, the principles, pro-tocols, and standards are universally applicable inevery operating room in the world, including themost advanced and sophisticated. Improvement ofanesthesia and surgical patient safety is possibleeverywhere and is the goal of this initiative.

Links to the WHO appear on the APSF websitehome page and more specific information about theWHO Safe Surgery Saves Lives Global Patient SafetyChallenge can be accessed at: http://www.who.int/patientsafety/safesurgery/en/.

“WHO,” From Page 23

International Standardsfor the Safe Practice ofAnesthesia Reviewed

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——————————— P R E S S R E L E A S E ———————————

Anesthesia Patient Safety Foundation Awards aGrant to the Society for Pediatric Anesthesia

The Anesthesia Patient Safety Foundationis pleased to announce the

BOARD OF DIRECTORS WORKSHOP

Innovations in Medication Safety in the Operating Room

Friday, October 17, 2008

1300-1700 (Salons 11-12)Rosen Centre Hotel

Orlando, FL

Registration is not required for attendance.

George A. Schapiro, ChairAPSF Executive Vice PresidentDan Brennan . . . . . . . . . . Abbott LaboratoriesSean Lynch . . . . . . . . . . . Anesthesia Healthcare

PartnersCliff Rapp. . . . . . . . . . . . . Anesthesiologists

Professional InsuranceCompany

Nassib G. Chamoun . . . . Aspect Medical SystemCharles H. McLeskey, MD . . . . . . . . Baxter HealthcareMichael S. Garrison . . . . Becton DickinsonTimothy W. Vanderveen, PharmD . . Cardinal HealthcareRoger S. Mecca, MD . . . . CovidienThomas W. Barford . . . . Datascope CorporationRobert Clark . . . . . . . . . . Dräger MedicalKevin L. Zacharoff, MD. . . . . . . . . EKR TherapeuticsMike Gustafson. . . . . . . . Ethicon Endo-SurgeryCarolyne Coyle . . . . . . . . GE HealthcareTim Hagerty . . . . . . . . . . HospiraSteven R. Block . . . . . . . . LMA of North AmericaJoe Kiana . . . . . . . . . . . . . MasimoNancy Stahulak. . . . . . . . Medical ProtectiveDeborah Lange-Kuitse, PhD . . . . . . . . . . . McKesson Provider

TechnologiesBrian Eckley. . . . . . . . . . . MGI Pharma, Inc.Dominic Corsale . . . . . . . OridionWalter Huehn . . . . . . . . . Philips Medical

SystemsSteve Sanford . . . . . . . . . Preferred Physicians

Medical Risk RetentionGroup

Keith Serzen . . . . . . . . . . ResMedMichael Stabile, MD . . . . Safer SleepShane Varughese, MD . . Schering-PloughAndrew Rose. . . . . . . . . . Smiths MedicalDominic Spadafore. . . . . SomaneticsJoseph Davin . . . . . . . . . . SpacelabsPeter McGregor. . . . . . . . Teleflex MedicalChristopher M. Jones . . . Tensys MedicalSusan K. Palmer, MD . . . The Doctors CompanyTerry Wall . . . . . . . . . . . . Vital SignsAbe AbramovichCasey D. Blitt, MDRobert K. Stoelting, MD

A N E S T H E S I A P A T I E N TS A F E T Y F O U N D A T I O N

CORPORATEADVISORY COUNCIL

®

The Anesthesia Patient Safety Foundation hasawarded a grant to the Society for Pediatric Anes-thesia (SPA) to assist in the development of “Wakeup Safe,” a quality improvement initiative to collectand analyze causes of adverse outcomes that occurduring anesthesia in children in the United States.

The beginning phase involves representativesfrom 10 major pediatric institutions. Among theseare Children’s Hospital Boston, the Children’s Hos-pital of New York, Children’s Hospital and RegionalMedical Center (Seattle, WA), John Hopkins Chil-dren’s Center, Texas Children’s Hospital, and Van-derbilt Children’s Hospital, in association with theSPA. The group is developing a standard method forEvent Analysis to assess serious perioperativeadverse events, which can be used as part of the peerreview process in each hospital. Analysis of the datafrom these events will permit the SPA “Wake upSafe” steering group to make recommendations forpractice changes designed to reduce the frequency ofthese untoward events and improve patient safety.

Although great strides have been made in safetysince the discovery of anesthesia 160 years ago,patients continue to experience harm related to anes-thesia and surgical care. Despite the millions of anes-thetics delivered each year to children and the manyyears that anesthesia has been used in children, theincidence and etiology of these serious eventsremain uncertain and not well studied, in large part

because these events are relatively rare today and anintegrated system to report and analyze them doesnot exist. The SPA Wake up Safe Initiative shouldallow us to learn from the adverse events to improvecare. After the initial phase, the goal is to make theEvent Analysis and the related learning opportunityavailable to all children’s hospitals and pediatricanesthesia programs around the country.

Initially the events to be studied include death,cardiac arrest, serious bodily injury, unanticipatedmajor escalation of care, surgery on the wrongpatient or body part, fire, awareness under anesthe-sia, and the medication error resulting in seriousinjury. As the participating institutions and the Wakeup Safe steering committee gather experience, addi-tional events and other expected and unexpected out-comes will be added.

The Society for Pediatric Anesthesia is the largestprofessional group for Pediatric Anesthesiologists inthe United States. The mission of the SPA is to “fosterquality anesthesia and perioperative care, and to alle-viate pain in children.” The Society has approxi-mately 1700 active members in the United States,including most pediatric anesthesiologists in thecountry, as well as members from other countries.


Dear SIRS

The information in this column is provided forsafety-related educational purposes only, and doesnot constitute medical or legal advice. Individual orgroup responses are only commentary, provided forpurposes of education or discussion, and are neitherstatements of advice nor the opinions of APSF. It isnot the intention of APSF to provide specific medicalor legal advice or to endorse any specific views or rec-ommendations in response to the inquiries posted. Inno event shall APSF be responsible or liable, directlyor indirectly, for any damage or loss caused or allegedto be caused by or in connection with the reliance onany such information.

Dear SIRS refers to the Safety Infor-mation Response System. The purposeof this column is to allow expeditiouscommunication of technology-relatedsafety concerns raised by our readers,with input and responses from manufac-turers and industry representatives. Thisprocess was developed by Drs. MichaelOlympio, Chair of the Committee onTechnology, and Robert Morell, Editor ofthis newsletter. Dr. Olympio is oversee-ing the column and coordinating thereaders’ inquiries and the responsesfrom industry. Dear SIRS made itsdebut in the Spring 2004 issue.

S AFETY

I NFORMATION

R ESPONSE

S YSTEM

Reader Ponders Relative Risksof Retrograde Arterial Flow

Dear SIRS:

Several staff members are concerned that ourinvasive arterial monitoring kit (HospiraTRANSPAC IV), if flushed rapidly, can produce ret-rograde flow. An article by Murphy et al.,1 “Retro-grade blood flow in the brachial and axillary arteriesduring routine radial arterial catheter flushing” isrelevant. I have looked at other similar sets withinline syringes. Any comments on Hospira or otherproducts? Thank you.

Linda Boan, CRNAWest Columbia, SC

Dear Ms. Boan:

I appreciate your question to APSF regarding ret-rograde flow. If I understood correctly, are youasking whether syringe-type arterial line flush sys-tems, as opposed to pressurized valve mechanisms,might cause retrograde emboli when injected tooforcefully? The risk in pressurized valve systemsdepends upon the pressure in the infusion bag rela-tive to the patient's arterial blood pressure, and theduration of the flush, I suppose, as well as theamount of distal resistance to forward flow. I wouldnot think it unique to any vendor, but your cited arti-cle describes the relative risks when using thesyringe-type flush mechanism. Retrograde flow isthe reason why in-line air bubbles or clot are poten-tially dangerous, since they might flow retrograde tothe aortic arch and then anterograde into the cerebralcirculation with a risk of stroke. I will forward yourquestion to Hospira for comment on your specificsystem.

Sincerely,Dr. Michael A. OlympioCo-Editor, Dear SIRS

Dear SIRS:

Thank you for responding to my question. Somestaff members feel that the kit’s syringe design andthe needleless ports, to some extent, are very prone toair entrapment. More importantly, the inline syringe(size 10+ ml) allows flushing (clearing the tubing fol-lowing withdrawal of blood from the needleless port)at a rate which could result in retrograde flow. Whilethe inline system insures sterility, does it increase thepossibility of catastrophe? I appreciate your time andinput.

Linda Boan

Dear Ms. Boan:

Thank you for your question about SAFESET,Hospira’s closed needle-less blood sampling system.As you noted in your letter, SAFESET can help pro-tect against exposure to blood-borne pathogens andIV line contamination. It also reduces blood waste. Itis important to be diligent when priming the SAFE-SET as it is with any pressure monitoring kit. We tryto train clinicians on the most effective means forpriming kits with SAFESET. Some key points:

• Prime the reservoir with the tip pointed up (oneway stopcock on top).

• Aspirate and re-infuse slowly, no faster than 1mL per second.

• Prime the reservoir utilizing gravity instead ofpressure from the infusion cuff.

• Additionally, some users find it beneficial to tapthe transducer, reservoir and sampling portsduring the priming process to dislodge anymicrobubbles.

This and related information is contained in theproduct’s Instructions for Use. Should you needadditional copies of our product’s Instructions forUse, please do not hesitate to contact our MedicalCommunications Group at 1.800.615.0187.

If used according to the Instructions for Useincluded with the product, there should be minimalrisk of retrograde flow in the patient’s arterial systemwith a Transpac IV kit with SAFESET, and the Anes-thesiology journal article you referenced would tendto support that belief. The conclusions section of thearticle states that manual flushing of radial arterialcatheters at rates faster than 1 mL/s produces retro-grade flow in the proximal axillary artery. It furtherstates in the body of the article that retrograde flowwas noted in none of the patients when the 10 mLflush volume used in the study was infused over aperiod of 9 seconds or greater. Our instructions foruse state in section VI to “turn the one-way stopcockintegral to the in-line reservoir on and return the fluidcontained in the SAFESET in-line reservoir to thepatient by pressing the plunger down slowly. Returnthe reservoir volume to the patient at a rate of 1 cc persecond (10 seconds for 10 mL), until the plungerreaches its locked position.”

If the Instructions for Use are not followed, ofcourse the risk of retrograde flow would beincreased. I would remind the individual who

See “Dear SIRS,” Next Page


A panel on the perioperative management ofpatients with cardiac stents was held a the Inter-national Anesthesia Research Society 82nd Con-gress held on March 29, 2008, in San Francisco,CA. Dr. Richard Prielipp was moderator andpanelists included Dr. Diane Head, Dr. LisaNewsome, and Dr. Hans Priebe. Topicsincluded perioperative management ofantiplatelet therapy, the biology and pathophys-iology of coronary endothelium, and differencesbetween bare metal stents and drug elutingstents.

Editor's Note: Please see previous issues of thisnewsletter as well as the comprehensive 2-partreview article on Coronary Artery Stents by Dr.Newsome and colleagues that was recently pub-lished in the August 2008 issue of Anesthesia andAnalgesia within the Patient Safety section of thatpublication.

Manufacturer Instructions Minimize A-line Risks

raised this concern that at the end of the referencedarticle this statement appears: “However, adverseclinical outcomes related to radial arterial catheterflushing are rare, and our previous investigation wasunable to document the passage of microbubbles intothe central circulation during the flushing process.”2

Finally, I researched our company’s complaintdatabase going back 5 years and found no complaintsrelated to your concern of retrograde emboli whenaspirating or re-infusing rapidly.

Steven Pregulman, MDGlobal Medical Director - Device DevelopmentHospira, Inc.

References

1. Murphy GS, Szokol JW, Marymont JH, Avram MJ, VenderJS, Kubasiak J. Retrograde blood flow in the brachial andaxillary arteries during routine radial arterial catheterflushing. Anesthesiology. 2006; 105:492–7.

2. Murphy GS, Szokol JW, Marymont JH, Avram MJ, VenderJS. Retrograde air embolization during routine radialartery catheter flushing in adult cardiac surgical patients:An ultrasound study. Anesthesiology. 2004; 101:614–9.

“Dear SIRS,” From Preceding Page

Left to right are Dr. Hans Priebe, Dr. Lisa Newsome, Dr. Diane Head, and moderator, Dr. Richard Prielipp, at the recentIARS panel on the perioperative management of patients with cardiac stents.

Panel on the Perioperative Managementof Patients With Cardiac Stents

Transpac IV Kit with SAFESET.


by Al Rothstein

Michael Lewis knows the advantages of physi-cian visit programs. The associate professor of clini-cal anesthesiology and program director ofanesthesiology at the University of Miami’s MillerSchool of Medicine is a prestigious Fulbright Scholar.

“I taught Israeli anesthesiology residents andspent 3 days a week building a website dealing withperioperative care of the elderly,” Lewis says.

The results of his physician visit allowed Dr.Lewis to develop a well-defined syllabus in geriatricanesthesiology. Once this body of knowledge wasorganized, he created a website for it and submittedit for peer review. It was submitted to the Associationof American Medical Colleges (AAMC), has beenapproved, and is waiting to be posted on their web-site. From his experience, the entire anesthesia com-munity has a new, widely available learning tool.

“From a patient safety standpoint, I have createdan educational product for caregivers to the elderlyduring the perioperative period,” he says. For exam-ple, if an elderly citizen emerges from surgery in aconfused state, the anesthesiologist can access thewebsite to reference treatment options.

Dr. Lewis is even more proud of his accomplish-ment given the rigorous review process he wentthrough to earn the Fulbright Scholarship, including:

• Seeking a sponsor in Israel

• Submitting a detailed written proposal of hisanticipated activities

• Waiting for the proposal to be reviewed in theUSA, then in Israel.

This careful, painstaking procedure took about 6months. “Well worth the process, making it evenmore of an honor,” says Dr. Lewis.

He points out that his Fulbright experience wasfrom an academic standpoint. It reinforced his thirstfor even more educational visits for himself, and hasprompted him to encourage fellow anesthesiologiststo do the same. It also ignited his passion to help tostart a US chapter of the Israeli Medical AssociationWorld Fellowship (IMA-WF), which is knownworldwide for its physician exchange visits. In fact,thanks to Dr. Lewis, Dr. Abe Berger, and others, theIMA-WF US chapter (http://www.ima-wf-usa.org)has just become a reality. Dr. Lewis would like to seehis fellow anesthesiologists take full advantage of itas the exchange visits through the US chapterdevelop.

“The IMA programs will allow physicians inprivate practice as well as in academia to work inIsrael,” he says.

Dr. Tzaki Siev-Ner, chair of IMA-WF’s head-quarters in Israel, says the application process forIMA physician visits takes about 2 months. He addsthat the American physicians who participate in theIMA’s programs will be giving as well as receiving.

“Israel is becoming short on physicians in allspecialties, and there is a huge demand for anesthe-siologists,” Siev-Ner points out.

For example, in one emergency program, visit-ing Americans would substitute for Israeli anesthe-siologists who are recruited to the army.

Another benefit for American anesthesiologistsis learning from the experience of Israeli physicianswho have dealt with mass casualty situations, Siev-Ner says.

However, he emphasizes that Israel is interestedin welcoming these physicians in peace time as well,benefiting from each other’s experience, exchangingideas and knowledge, and initiating joint projects.Nevertheless, he is not asking American anesthesi-ologists to move to Israel permanently. He says theexchange program allows them to choose to workthere for 1 week or longer.

Dr. Lewis says not only does the visiting physi-cians relieve a physical shortage, but it eases anemotional stress of health care professionals as well:“My Fulbright sabbatical took place during theLebanon war and I, along with the Israeli physi-cians, felt the pain of a people under attack.”

“You take back to America the ability to providehigh quality anesthesia in the presence of limitedresources,” he says. Because of budget restraints,not all of the medications or equipment readilyavailable to the anesthesiologist in the US is alwaysimmediately accessible to a colleague practicing inIsrael.

“Because of my single visit with the Fulbrightprogram, I have become a better physician and havebeen able to contribute to my profession, particu-larly in the field of geriatric anesthesiology,” Lewisadds. “Now that we have more choices for organi-zations offering physician visits, the potential forcontributions that my fellow anesthesiologists canmake to their patients has no limit.”

Al Rothstein is responsible for public relations for theIsraeli Medical Association, United States ChapterAtlanta, GA and Tallahassee, FL. For more informationon the Israeli Medical Association's programs, pleasevisit www.ima-wf-usaorg.

Israeli Exchange ProgramFacilitates Information Exchange

Letter to the Editor

Reader DisappointedWith APSF NewsletterTo the Editor:

I would like to update you on events that haveunfolded since the initial publication of the APSFNewsletter article by Dr. Evan Kharasch regardinggeneric sevoflurane.

This article rang a bell that cannot be un-rung. Ibelieve the article only presented partial data, andshould have concentrated on the manufacturingprocess of the Penlon Sigma Delta vaporizer, whichdegrades all brands of sevoflurane, rather than on theimplied "unsafe" formulations of generic sevoflurane.Unfortunately, it is my perception from questions thatI continue to receive regarding the safety of genericsevoflurane, that the manufacturers' responses to thearticle have not been well read.

As a safety organization, the APSF has a responsi-bility to put forth accurate and objective data. I am verydisappointed with the disservice that the APSF and theNewsletter have done in this circumstance, which couldhave been avoided by closer editorial scrutiny. Bypotentially limiting effective and economical choicesand by creating a risk-management issue where noneexists, the APSF has, in this case, decreased patientsafety and made our jobs more difficult.

George Mychaskiw II, DO, FAAP, FACOPJackson, MS

APSF COT SelectsPhilip for NewLeadership Role

Dr. Michael A. Olympio, chair of the Committeeon Technology (COT), is pleased to announce theappointment of Dr. James E. Philip, ME (E), MD,CCE, as the first media relations director of COT, fora 2-year term. Dr. Philip is a recent addition to COTbut has been peripherally involved with the APSFsince its inception. Philip co-authored one of themany critical incident manuscripts from Dr. JeffreyCooper’s laboratory in the 1970s and 1980s, and hewas a colleague of Dr. Jeep Pierce, founder of theAPSF. He served as a member of the APSF ScientificEvaluation Committee from1995-1999, and was oneof several designated speakers for an early APSF pro-ject, the Grand Anesthesia Safety Symposium(GASS). Philip continues his safety efforts today, andlectures extensively on “Anesthesia is a Safe Spe-cialty.” More recently, Philip served as president ofthe Society for Technology in Anesthesia. His newposition with COT as Media Relations Director is pri-marily concerned with the timely and accurate com-munications of COT administrative details and safetyefforts through the on-line APSF website. Welcome toDr. Philip.


Anesthesia Patient Safety FoundationCorporate Donors Founding Patron ($500,000 and higher) American Society of Anesthesiologists (asahq.org)

Community Donors (includes Anesthesia Groups, Individuals, SpecialtyOrganizations, and State Societies)Grand Sponsor ($5,000 and higher)Alabama State Society of AnesthesiologistsAmerican Academy of Anesthesiologists Assistants American Association of Nurse AnesthetistsAsheville Anesthesia AssociatesFlorida Society of AnesthesiologistsDr. and Mrs. Thomas R. HillIndiana Society of AnesthesiologistsIowa Society of AnesthesiologistsFrank B. Moya, MD Charitable FoundationNorth American Partners in AnesthesiaRobert K. Stoelting, MDValley Anesthesiology FoundationVance Wall FoundationWilmington Anesthesiologists, PLLC, Wilmington, NC

Sustaining Sponsor ($2,000 to $4,999)Anaesthesia Associates of MassachusettsAnesthesia Consultants Medical GroupAnesthesia Resources ManagementArizona Society of AnesthesiologistsCritical Health Systems, IncNassib G. ChamounGeorgia Society of AnesthesiologistsMadison Anesthesiology ConsultantsMassachusetts Society of AnesthesiologistsMichigan Society of AnesthesiologistsMinnesota Society of AnesthesiologistsOhio Society of AnesthesiologistsOld Pueblo Anesthesia GroupPennsylvania Society of AnesthesiologistsPhysician Specialists in AnesthesiaProvidence Anchorage Anesthesia Medical GroupSociety of Cardiovascular AnesthesiologistsTennessee Society of AnesthesiologistsDrs. Mary Ellen and Mark Warner

Contributing Sponsor ($750 to $1,999)Affiliated Anesthesiologists of Oklahoma City, OKAmerican Association of Oral and Maxillofacial SurgeonsAmerican Society of Critical Care AnesthesiologistsAmerican Society of PeriAnesthesia Nurses Associated Anesthesiologists (St Paul, MN)J. Jeffrey Andrews, MDAnesthesia Associates of Northwest Dayton, Inc.Anesthesia Services of Birmingham

Associated Anesthesiologists of St. Paul, MNAssociation of Anesthesia Program DirectorsSorin J. Brull, MDRobert A. Caplan, MDFrederick W. Cheney, MDCalifornia Society of AnesthesiologistsConnecticut State Society of AnesthesiologistsJeffrey B. Cooper, PhDDr. Robert and Mrs. Jeanne CordesSteven F. Croy, MDDistrict of Columbia Society of AnesthesiologistsDavid M. Gaba, MDJohn H. Eichhorn, MDGreater Atlanta Society of AnesthesiologistsWilliam L. Greer, MDIllinois Society of AnesthesiologistsRobert. H. Intress, MDKansas City Society of AnesthesiologistsKentucky Society of AnesthesiologistsJohn W. Kinsinger, MDKunkel-Shaker FamilyLorri A. Lee, MDRodney C. Lester, CRNAEdward R. Molina-Lamas, MDMaryland Society of AnesthesiologistsMichiana Anesthesia CareMissouri Society of AnesthesiologistsRobert C. Morell, MDNebraska Society of AnesthesiologistsJohn B. Neeld, MD, in honor of Eugene P. Sinclair, MDNevada State Society of AnesthesiologistsNurse Anesthesia of MaineOhio Academy of Anesthesiologist AssistantsOklahoma Society of AnesthesiologistsOregon Society of AnesthesiologistsOregon Anesthesiology GroupPhysician Anesthesia ServicePittsburgh Anesthesia AssociatesLaura M. Roland, MDSanta Fe Anesthesia Specialists Society of Academic Anesthesia ChairsSociety for Ambulatory Anesthesia Society of Neurosurgical Anesthesia and Critical CareSociety for Pediatric AnesthesiaStockham-Hill FoundationTexas Association of Nurse AnesthetistsTexas Society of AnesthesiologistsDr. and Mrs. Donald C. TylerWashington State Society of AnesthesiologistsWisconsin Association of Nurse AnesthetistsWisconsin Society of Anesthesiologists

Sponsor ($200 to $749)Alaska Association of Nurse AnesthetistsEllen Allinger, AA-C, and James Allinger, MDKristy Z. Baker, MDRobert L. Barth, MDE. Jane Brock, DOLillian K. Chen, MDColorado Society of AnesthesiologistsKathleen A. Connor, MDGlenn DeBoer, MDSteven R. Dryden, MDJames E. Duckett, MDJan Ehrenwerth, MDJames Ellwood, MDJane C. K. Fitch, MD/Carol E. Rose, MDRichard Gnaedinger, MDJames D. Grant, MDJoel G. Greenspan, MDGriffin Anesthesia AssociatesJohn A. Hamel V, MDAlexander A. Hannenberg, MDDaniel E. Headrick, MDWilliam D. Heady, CRNAPeter L. Hendricks, MDJames S. Hicks, MDDavid P. Holder, MD Victor J. Hough, MDHoward E. Hudson, Jr., MDJay C. Horrow, MDKaiser Permanente Nurse Anesthetist AssociationTamos Kallos, MDScott D. Kelley, MDDaniel J. Klemmedson, DDS, MDKansas Society of AnesthesiologistsBettyLou Koffel, MDMichael G, Kral, MDGeorge Lederhaas, MDDavid P. Maguire, MDMaine Society of AnesthesiologistsAlan P. Marco, MDMaryland Association of Nurse AnesthetistsGregory B. McComas, MDE. Kay McDivitt, MDMedical Anesthesiology Consultants CorporationTricia A. Meyer, Pharm DRoger A. Moore, MDNew Hampshire Society of AnesthesiologistsNew Jersey State Society of AnesthesiologistsNew Mexico Society of AnesthesiologistsL. Charles Novak, MDDenise O’Brien, RNRobert H. Odell, Jr., MD, PhD

Michael A. Olympio, MDCarmelita S. Pablo, MDSrikanth S. Patankar, MDPennsylvania Association of Nurse AnesthetistsMukesh K. Patel, MDGaylon K. Peterson, MDDrs. Beverly and James PhilipPhysician Specialists in AnesthesiaRichard C. Prielipp, MDRhode Island Society of AnesthesiologistsJo Ann and George Schapiro Philanthropic FundLarry D. Shirley, MDLiberacion L. Soriano, MDSociety for Obstetric Anesthesia and PerinatologySociety for Technology in AnesthesiaSouth County Anesthesia AssociationSouth Carolina Society of AnesthesiologistsStudents, American Academy of Anesthesiologist AssistantsUniversity of Maryland Department of AnesthesiologyVermont Society of AnesthesiologistsVirginia Society of AnesthesiologistsMartin D. Wagner, MDMatthew B. Weinger, MDDr. and Mrs. Donald L. WeningerWest Virginia State Society of AnesthesiologistsDr. and Mrs. WetchlerWichita Anesthesiology, CharteredG. Edwin Wilson, MDWisconsin Academy of Anesthesiologist AssistantsJohn M. Zerwas, MD

In MemoriamIn memory of Richard J. Bjerke, MD (Mary Ann Graves)In memory of Louis S. Blancato, MD (Dr. and Mrs.

Bernard V. Wetcheler, MD)In memory of Bertram Watts Coffer, MD (American Soci-

ety of Anesthesiologists)In memory of Margie Frola, CRNA (Sharon Rose Johnson,

MD)In memory of Stephen D. Graham, MD (Texas Society of

Anesthesiologists)In memory of Particia A. Hawkins, CRNA (Douglas B.

Coursin, MD)In memory of Patricia A. Hawkins, CRNA (Michael and

Catherine Murray)In memory of Joseph A. Lee, MD

(Department of Anesthesia, University of Manitoba,and Robert K. Stoelting, MD)

In memory of Dr. Richard Strausbaugh (Anesthesia Asso-ciates of York, PA)

In memory of Leroy D. Vandam, MD (Dr. and Mrs.George Carter Bell)

Note: Donations are always welcome. Send to APSF; c/o 520 N. Northwest Highway, Park Ridge, IL 60068-2573 (Donor list current through July 17, 2008)

Philips Medical Systems(medical.philips.com)

Grand Patron ($150,000 to $199,999)Anesthesia Healthcare Partners, Inc.

(AHP) (ahphealthcare.com)Sponsoring Patron

($75,000 to $149,999)GE Healthcare (gemedical.com)

Benefactor Patron ($25,000 to $49,999)Abbott Laboratories

(abbott.com)Aspect Medical Systems

(aspectms.com)Covidien

(covidien.com)

Supporting Patron ($15,000 to $24,999)Cardinal Health, Alaris Products (alarismed.com)Dräger Medical (draeger.com)Preferred Physicians Medical (ppmrrg.com)Schering-Plough (Schering-plough.com)Patron ($10,000 to $14,999)DocuSys (docusys.net)Ethicon Endo-Surgery (ethiconendo.com)Hospira (hospira.com)iMDsoft (imd-soft.com) Oridion Capnography (oridion.com)Somanetics Corporation (somanetics.com)Spacelabs Medical (spacelabs.com)

Sustaining Donor ($5,000 to $9,999)Anesthesiologists Professional Assurance Company

(apacinsurance.com)Baxter Anesthesia and Critical Care (baxter.com)Becton Dickinson (bd.com)Datascope Corporation (datascope.com)EKR Therapeutics (ekrtx.com)LMA of North America (lmana.com)McKesson Provider Technologies (mckesson.com)Medical Protective (medpro.com)Minrad, Inc. (minrad.com)ProAssurance (proassurance.com)ResMed (resmed.com)Safer Sleep LLC (safersleep.com)Smiths Medical (smiths-medical.com)

Teleflex Medical (teleflexmedical.com)Tensys Medical (tensysmedical.com)The Doctors Company (thedoctors.com)Vital Signs (vital-signs.com)Sponsoring Donor ($1,000 to $4,999)Anesthesia Business Consultants (anesthesiallc.com)Allied Healthcare (alliedhpi.com)Armstrong Medical (armstrongmedical.net)B. Braun Medical, Inc. (bbraunusa.com)Cook Critical Care (cookgroup.com)Intersurgical, Inc. (intersurgical.com)King Systems (kingsystems.com)Medical Education Technologies, Inc. (meti.com)Micropore, Inc. (extendair.com)

TRIFID Medical Group LLC (trifidmedical.com)W.R. Grace (wrgrace.com)Corporate Level Donor ($500 to $999)Belmont Instrument Corporation

(belmontinstrument.com)ProMed Strategies, LLCSharn Anesthesia, Inc.Wolters KluwerParticipating AssociationsAmerican Association of Nurse Anesthetists

(aana.com)Subscribing SocietiesAmerican Society of Anesthesia Technologists and Techni-

cians (asatt.org)

MGI Pharma, Inc.(mgipharma.com)

Cardinal Health Foundation(cardinal.com)

Masimo Corporation(masimo.com)


in both jugular veins was observed in 2/23 healthyvolunteers at 15° and in 9/23 at 90° head-up tilt.7

Pressure in jugular veins may become negativedue to subtraction of the hydrostatic gradient ρghfrom CVP. Therefore CPP = MAP – Patm (0), when-ever CVP – ρgh < 0 and ICP < 0. Global brain ischemiaduring controlled hypotension in a beach chair posi-tion is a particular case of the “cerebral venous steal.”8

Cerebral ischemia develops because of exhaustedcerebral autoregulation (beta blockade) and is exacer-bated by the jugular venous collapse in the sittingposition, which leads to a further reduction of CBF(cardiac output diversion or “steal” from the brainsimilar to the blood flow diversion toward dependentportions of pulmonary circulation). This phenomenonoccurs in the sitting position during craniotomy,when CVP – ρgh < 0 (Patm = ICP = 0 with open cra-nium) and can be accompanied by a venous airembolism if the non-collapsible venous sinus isinjured. Cerebral venous steal due to jugular collapsecan also occur in patients with intact cranium, whenICP ≤ 0 and CVP - ρgh << 0. Although the vertebralvenous plexus becomes the predominant outflowpathway during jugular compression in the sittingposition,7 flow through it is impeded during headrotation/tilt, especially in patients with cervical steno-sis. Thus the practice of CPP measurement site adjust-ment to the skull base level, whenever patientposition is changed and CVP - ρgh < 0, is justified. Ifjugular bulb pressure can be measured directly, pres-sure transducer level adjustments do not affect CPPcalculation, as long as both the arterial and venoustransducers stay at the same level.9

Given the above considerations, we propose gen-eralizing the CPP formula to account for the effect ofatmospheric pressure on the jugular veins. In a sittingposition the atmospheric pressure (Patm = 0) willbecome an effective outflow pressure whenever itexceeds venous pressure.

Thus,

CPP = MAP – ICP, if ICP>CVP and ICP>Patm (1)

CPP = MAP – CVP, if CVP>ICP and CVP>Patm (2)

CPP = MAP – Patm, if Patm>CVP and Patm>ICP (3)

(whichever results in the smallest difference).

If measurements are done at a different level thanthe skull base or the head position is changed, thehydrostatic pressure gradient (ρgh) has to be sub-tracted from all the terms of the CPP equation except

To the Editor:

Recent case reports described permanent injuryfrom global cerebral ischemia in a beach chair posi-tion.1,2 Follow-up discussion in the APSF Newsletterdid not result in consensus on safe limits of arterialblood pressure during anesthesia in the sitting posi-tion, how the blood pressure should be measuredduring head-up tilt, and the beta-blocker’s role inthese complications.3,4

Cases of cerebral ischemia in a beach chair posi-tion mandate the revision of postural cerebral perfu-sion management. Perfusion pressure is thedifference between the inflow Pi and outflow pres-sure Po, measured at the organ level: CPP=MAP-CVPor CPP=MAP-ICP if ICP>CVP. While measuringpressure in the intercommunicating vessels, we haveto account for the hydrostatic pressure difference(ρgh), where h is the difference in height between 2measurement points and ρ is the density of blood.Because of the energy conservation law, heart workagainst gravity is zero (blood flows in a circular fash-ion as described by Harvey and potential energyremains the same upon completion of the circle).5

Therefore the site of CPP measurement could be any-where, as long as the hydrostatic gradient from themeasurement site to the organ level ρ remains thesame for inflow and outflow pressures and there is nosignificant flow related pressure drop between themeasurement site and the organ level.4 Simple addi-tion of hydrostatic column from the measurementlevel to the organ level does not change CPP value:(MAP + ρgh) – (CVP + ρgh) = MAP – CVP. And yetso many neuroanesthesiologists continue to zero thearterial pressure transducer at the level of the exter-nal acoustic meatus.3

Several considerations come here into play:

1) Measuring arterial pressure alone does not defineCPP. In the sitting position arterial pressure is dif-ferent if measured at the head, torso, or calf level,while CPP is a pressure difference and remains thesame. When the arterial pressure transducer dropson the floor, arterial hypertension can be falselydiagnosed. CPP = MAP – CVP would stay thesame whether measured at the head, torso, or thefloor level.

2) The hydrostatic indifference level (HIL) is a pointwhere pressure does not change during body tilt.Measuring MAP or (MAP – CVP) at this levelshould be indifferent to the body tilt. The onlyproblem with this approach is that HIL has to be

individually determined and HIL for venous andarterial systems was found to be different due tothe difference in regional compliances.

3) Even if we measure MAP and CVP simultane-ously and eliminate the self-negating effect ofhydrostatic column ρgh (25 cm water = 18 mmHg)from the brain to the measurement site, we cannot reliably estimate CPP. Negative transmuralpressure leads to jugular collapse with the head-up tilt. Directly measured jugular pressure abovethe thoracic inlet in the upright position stayedaround 0 mmHg despite negative CVP in 8healthy subjects with a gradient reaching 20 cm ofwater. No such gradient was observed in 2patients with chronic cardiac tamponade.6

4) Arterial pressure measured at the zero venouspressure level is arithmetically equivalent to cere-bral perfusion pressure (CPP = MAP – 0). Skullbase approximates zero venous pressure levelwhen CVP – ρgh < 0, because jugular veins areexposed to the atmospheric pressure upon exitingthe scull. This is the reason why we should adjustthe site of arterial pressure measurement whensitting. That is why the skull base can be referredas zero venous pressure level for the cerebral per-fusion pressure estimation, unless venous pres-sure is measured in the jugular bulb directly.

5) Assessing CPP and adjusting the BP measurementlevel from the heart to the skull (about 20 mmHg)may not be important if MAP is maintained >70-100 mmHg (CPP >50-80), but it is critical if MAPis maintained at 50 mmHg (CPP 30 mmHg).

Venous outflow depends not only on the outflowpressure, but also on the venous resistance. Veins tendto collapse when external pressure exceeds intralumi-nal pressure, and venous resistance correspondinglyincreases. Venous resistance becomes infinitely highduring occlusion. This phenomenon can interchange-ably be described by the nonlinear venous outflowresistance or the change in effective venous outflowpressure (Starling resistor). Starling resistor is impliedin the classic definition of cerebral perfusion pressure(mean arterial pressure minus intracranial or venouspressure, whichever comes higher): CPP = MAP –ICP, when ICP > CVP, and CPP = MAP – CVP whenCVP > ICP.4 Jugular veins are exposed to atmosphericpressure and collapse with the head-up position.6 Thiscollapse can be directly observed when jugular veindistention (JVD - external jugular vein collapse point)moves with the body tilt. Complete cessation of flow


Modified Calculation of the Cerebral PerfusionPressure in a Sitting Position: Jugular StarlingResistor and Related Clinical Implications

See “Calculation,” Next Page


from the atmospheric pressure, as atmospheric pres-sure does not change when adjusting the measure-ment level.

If CVP is maintained above 18 mmHg (ρgh), theclassical CPP definition1,2 is valid and measurementlevel adjustments are not mandatory.

To minimize risk of unrecognized global cerebralischemia in the sitting position we propose severalsimple considerations:

1) Obtain baseline BP measurement in the sittingposition and use it as a guide (measurement site isnot critical as long as it does not change during thecase and central blood pressure pulse wave prop-agation/reflection remains similar).

2) Evaluate for signs of cervical stenosis; avoid cer-vical malpositioning which could impede bloodoutflow through the vertebral venous plexus.

3) Document any patient position changes andchanges in BP measurement site or technique.

4) If patient position or BP monitoring site ischanged, reassess the new CPP to account for theStarling resistor in the cervical veins (CPP =(MAP – ρgh) – max ((ICP – ρgh), (CVP – ρgh),Patm), whereas h is the height from skull base toBP measurement site, Patm=0.

5) Visual assessment of the jugular vein column pre-dicts if jugular veins will collapse in the sittingposition.10

6) Volume loading will counteract the effect of Patmon the jugular veins and will prevent their col-lapse once CVP > ρgh (about 18 mmHg).

7) If the controlled hypotension is prolonged andexceeds diurnal minimum in the upright bloodpressure, consider neuromonitoring (regional tech-nique, maintaining verbal contact, near infraredcerebral oximetry, MCA Doppler, EEG, etc.).

Mindaugas Pranevicius, MDOsvaldas Pranevicius, MD, PhDBronx, NY

References

1. Cullen DJ, Kirby RR. Beach chair position may decreasecerebral perfusion; catastrophic outcomes have occurred.APSF Newsletter. 2007;22(2):25,27.

2. Pohl A, Cullen DJ. Cerebral ischemia during shouldersurgery in the upright position: a case series. J ClinAnesth. 2005;17:463-9

3. Cucchiara RF. Hazards of beach chair position explored.APSF Newsletter. 2008;22(4):81.

4. Munis J. The problems of posture, pressure, and perfu-sion: cerebral perfusion pressure defined. APSF Newslet-ter. .2008; 22(4):82-3.

5. Harvey W. On the motion of the heart and blood in ani-mals. London: George Bell and Sons; 1889.

6. Avasthey P. Venous pressure changes during orthostasis.Cardiovasc Res. 1972;6:657-63.

7. Valdueza JM, von Munster T, Hoffman O, et al. Posturaldependency of the cerebral venous outflow. Lancet.2000;355:200-1.

8. Pranevicius M, Pranevicius O. Cerebral venous steal:blood flow diversion with increased tissue pressure. Neu-rosurgery. 2002;51(5):1267,73; discussion 1273-4.

9. Eckenhof JE, Enderby GE, Larson A, et al. Human cere-bral circulation during deliberate hypotension and head-up tilt. J Appl Physiol. 1963;18:1130-8.

10. Sinisalo J, Rapola J, Rossinen J, et al. Simplifying the esti-mation of jugular venous pressure. Am J Cardiol.2007;100:1779-81.

“Calculation,” From Preceding Page

Simple Considerations ProfferedTo Minimize Sitting Position Risks


Reader RecommendsZero ToleranceTo the Editor:

First I would like to confer my support for theAPSF. An open forum is the best way to discuss andsolve safety issues.

Second, it is good to see the APSF fund safetyresearch initiatives. One hopes, the $1.092 millionrecently divided among a number of proposals willmake a difference.

I have to take umbrage with Dr. AsokumarBuvanendran's proposal “Patients after MinorSurgery with MAC: Is It Safe to Drive?”

Is this research necessary, and does it pass acommon sense test? Have we as a society minimizedthe attention we pay to driving safety well beyondwhat is reasonable? Would MADD (MothersAgainst Drunk Driving) approve of this research?

National Highway Traffic Safety Administrationstatistics for 2006 show that 42,642 people werekilled and 2,575,000 people were injured in motorvehicle accidents for the previous 1-year period.Over 17,000 of the deaths were alcohol related.

Blood alcohol content (BAC) research originallylooked at BAC from .02% to 0.1% and found impair-ment was commonly seen at the .02% levels, but wehave rather arbitrarily fixated on .08% as the “safe”BAC. Many other countries have set lower limits.

Cell phones, GPS screens, eating, even in-dashvideo screens are the norm. Drunk driving andspeeding is rampant. I jog, cycle, and motorcycle andam commonly a victim of driver inattention and dis-traction. Now I might have to worry about a driving,hungry, sleep deprived colonoscopy patient callingahead his take-out food order on his cell phone!

Dr. Buvanendran's proposal contends if we canreturn to a baseline level of weaving, reaction times,and collisions on a driving simulator we can drivehome. Would he also contend that we are able toreturn to work safely as well? Should your surgeon,anesthesia provider, and nursing staff go back towork after sedation or a glass of wine at lunch?

There should be NO double standard for drivingperformance and everything else. We as health careprofessionals should champion a zero tolerance ofintoxicants while driving.

William Higgins, CRNAKaneohe, HI

Check out the Reader’s Poll onthe APSF Website at

www.apsf.orgGive your opinion on timely issues.

www.apsf.org

®


The APSF Committee on Technology held amock debate on syringe reuse on May 6, 2008, inChicago, IL. The vision of the committee was todevelop material which could be used to discouragethe unsafe clinical practice of reusing infusionsyringes during anesthetic care. This effort was adirect corollary of the final paragraph in the Spring2008 issue of the APSF Newsletter Q&A column,which stated that it is insufficient to condemnsyringe reuse practices without acknowledging thefactors that lead to these behaviors.

Addressing the symptoms without trying to curethe underlying “disease” would be but a short-termsolution. Thus, we must investigate, understand, andeliminate the factors that predispose one to the prac-tice of unsafe medicine. As clinicians, we face severeproduction pressure and take “shortcuts” in theprocess of safe preparation of medication; we maygive in to the financial importance that others, or weourselves, place on speed and efficiency; or we maysincerely believe that we are preventing waste,thereby reducing the cost of medicine. An under-standing of this complex environment may help toeliminate the root cause of such behaviors, whichcould then facilitate safer practices. At this session,members of the COT reviewed several of the sum-mary points from the CDC presentation on syringereuse and multiple publicized episodes of viral trans-mission related to syringe reuse. It was noted that asmany as 27% of clinicians could be reusing propofolinfusion syringes (while changing the microboretubing) based on 220 respondents to an APSF Poll.Subsequent to this discussion, 2 teams were randomlyorganized to conduct an impromptu mock debate onthe proposition, “Syringe reuse should be our recom-mended practice, when using a syringe pump withextended length microbore tubing.”

The proponents of this mock proposition arguedthat there are no data to show that this practice isunsafe; therefore, in the absence of such data it is anacceptable practice. Currently this practice is accept-able and common on medical missions whereresources are severely limited. The practice is eco-nomically sound and results in less waste; it is alsoconvenient and saves time. Connections are limited,therefore lessening the risk of misconnections andassociated hazards. The group argued that it couldbe considered “financial malpractice” to not reuseinfusion syringes in this manner. Furthermore, it isenvironmentally sound, using fewer resources, withless plastic and storage needed. The group pointedout the lack of intellectual arguments or scientificevidence for the reflux of potentially infectious mate-rial up the exchangeable tubing, and into thereusable syringe. Conversely, the group opposingthis practice argued that going against single-uselabeling required safety data to prove that the prac-tice is safe and acceptable. The lack of evidence is

neither compelling nor sufficient to alter a potentiallysafer practice. The burden of proof must be on prov-ing that this practice is safe. For example, concernswere raised that reflux into a syringe could occurduring syringe decompression for refilling, or,during the pressurized injection of another, andpotentially contaminated, syringe of bolus drug dis-tally in the IV line. Concerns exist that the plunger ofthe infusion syringe is in fact contaminated, and maycontaminate the internal wall of the syringe, onceinjected. Alternative practices, such as using prefilledsyringes could address convenience issues. On rebut-tal, this group further believed that economic, storage,and environmental concerns could be addressed byusing “just in time” delivery methods and imple-menting recycling for disposables. The “learned handrule” was recommended to justify economics; what isthe likelihood of an adverse event multiplied by thecost of such an event?

On rebuttal, the affirmative first group arguedthat we don’t throw away anesthesia machinesbetween cases, and breathing circuit components arealways reused. Broad cross contamination issuespersist with potentially greater risks from dirtygloves, lack of hand washing, pulse oximeter probes,ECG leads, and blood pressure cuffs that may trans-mit infectious material between patients.

The COT found this to be a useful and excitingexercise to objectively examine the basis for beliefsand resultant behaviors, particularly when partici-pants were “given permission” to take the uncon-ventional position.

Mock Debate Held onSyringe Reuse Dangers

Letter to the EditorAnesthesia ProviderDoesn’t Share Pilot’sRiskTo the Editor:

Regarding the use of the metaphor of the anes-thesia provider as a pilot and the notion that takeoffsand landings are like induction and emergence:

In addition to the “. . . system formed by thepatient, the anesthesiologist and/or the CRNA, andthe surrounding environment of the operating room(including personnel and equipment) being morecomplex than that which characterizes commercialaviation . . .," there is another glaring difference. Thepilot is on board and suffers the same fate as his pas-sengers as a consequence of his/her actions—not sowith the anesthesia provider.

John Danner, CRNASheboygan, Wisconsin

® working forpatient safety

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working for patient safety

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first in patient safety

AnesthesiaPatient Safety

Foundationis pleased to announce the

APSF/AmericanSociety of

Anesthesiologists(ASA)

President’s Endowed Research Award

In full support ($150,000) of a grant to be awarded in

October 2008.

This represents the secondnamed APSF/ASA named

grant. The funds ($300,000)for both named grants willbe provided from the APSFEndowment Fund, whichwas made possible by thegenerous contributions ofASA to APSF over the last

several years.

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Letters to the Editor

Drug Labeling Error is Reported72,000 deaths annually. Further, of the 900,000 med-ical mistakes made annually, less than a third arebeing reported.1

The literature suggests 2 schools of thought onproduct identification. One is that the drug should bedistinguishable by appearance.2 With many similarsized and shaped suppositories on the market thismay be difficult, and therefore current opinioninforms us that the only way to be sure of content isto read the label.3

Our case demonstrates the worst possible sce-nario: a wrongly labelled and ambiguous drug. Theauthors therefore recommend that mistakes can bereduced by careful reading of product labels andreporting any anomalies found. Further, while thesetechniques may help to reduce human error, theyneed to work hand-in-hand with anesthetic drugawareness, a term recently coined as pharmacovigi-lence. Only then can we safely clarify drug productsand avoid drug error confusion.

S. J. Law M. DavisonStoke Mandeville Hospital, UK

To the Editor:

Drug errors are common. We would like to reporta drug labeling error that occurred in our department.

A pediatric patient was scheduled for an electiveplastics operation for which rectal paracetamol wasto be part of the analgesic regime. On being handedthis product by the operating department practi-tioner, we discovered from its labeling (Figure 1) thatit was out-of-date.

The labeling firstly showed that it was out-of-date. Also more importantly, the actual drug dosagecontained in the suppositories was ambiguous. Wasit 60 mg or 1 g? Subsequent correspondence with themanufacturers revealed that this product may con-tain chloral hydrate and not, in fact, paracetamol. Thedrug was immediately withheld and the errorreported. We are subsequently awaiting the results ofanalysis by the company.

We would like to raise awareness among our col-leagues of the potential problems of drug labeling. Inthe UK, 1 in 10 patients is on the receiving end of acci-dents or errors, which are estimated to contribute to

Figure 1. Drug labeling on the reverse.

To the Editor:We read with great interest several letters, edito-

rials, and reports on airway management thatappeared in the APFS Newsletters earlier this year.1,2

We think that some critical points were notaddressed in these reports and that further consider-ation of this topic is warranted.

It seems that there has been considerable confu-sion and inconsistencies in interpretations of theAirway Management recommendations that origi-nally appeared in 1993 and were revised more recentlyby the ASA,3 or by other international organizationslike the Society for Airway Management (SAM) or bysome expert collegue.4 These inconsistencies are pre-sent in literature and in our daily practice.

Although a clear message was sent by an excel-lent publication by Pressman,5 “Can’t ventilate? Soplease recover spontaneous ventilation,” it should bestated that this publication ignored other availableresources and options for airway management.

As everyone knows, difficult ventilation is a sce-nario not so uncommon in the obese patient (whenit is really obesity, not as proposed by a BMI26 kg/m2),6 and a valuable resource has beenrecently re-outlined.7,8

References1. Troop C. Difficult intubation in the obese patient. APSF

Newsletter. 2005-06;20:83.

2. Stasiuk R. Lessons from “can’t intubate/can’t ventilate”report. APSF Newsletter. 2006;21:58.

3. American Society of Anesthesiologists Task Force onManagement of the Difficult Airway. Practice guidelinesfor management of the difficult airway: an updated reportby the American Society of Anesthesiologists Task Forceon Management of the Difficult Airway. Anesthesiology.2003;98:1269-77.

4. Rosenblatt WH. The airway approach algorithm: a deci-sion tree for organizing preoperative airway information.J Clin Anesth. 2004;16:312-6.

5. Pressman MA. Return to spontaneous ventilation can belife-saving. APSF Newsletter. 2006;21:58.

6. Langeron O, Masso E, Huraux C, et al. Prediction of diffi-cult mask ventilation. Anesthesiology. 2000;92:1229-36.

7. Combes X, Le Roux B, Suen P, et al. Unanticipated diffi-cult airway in anesthetized patients: prospective valida-tion of a management algorithm. Anesthesiology.2004;100:1146-50.

8. Brodsky JB, Lemmens HJ, Brock-Utne JG, et al. Morbidobesity and tracheal intubation. Anesth Analg.2002;94:732-6.

The point is those resources and protocols tomanage unpredictable difficult airway are right inour hands, or well, in our bags ( bag “mask” ventila-tion, or better, bag laryngeal mask ventilation),whenever you decide to put your patient to sleep.The laryngeal mask airway is a valuable device,often underutilized by anesthesiologists. However,in centers with a significant prevalence of obesepatients, the value of this device is fully recognized.

The real question is why do many anesthesiolo-gists forget to rely on a laryngeal mask airway as ahelpful tool in the difficult ventilation scenario? Thedevice is an excellent emergency backup airway.

Moreover, in obese patients, it provides temporaryairway management and allows for valuable timeneeded for preparation for a fiberoptic intubation.4,8

In addition, for some of us, it is actually thedefinitive airway used to deliver anesthesia safelyand reasonably (with the ProSeal you can really evenachieve high peak pressure).

Davide Cattano, MDIvan Kangrga, MD, PhDSt. Louis, MO

References

1. Harrop P. Opportunities in Pharmaceutical RFID.IDTechEx, 2006-Aug-03.

2. Ferner R. Misleading drug packaging. BMJ. 1992;248:361-3.

3. Nunn D. Avoiding drug errors. BMJ. 1995;311:514.

Don’t Forget the LMA!


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• World Health Organization Launches“Safe Surgery Saves Lives”

• Q&A– Why Don’t All Vaporizers Have an “Empty” Alarm?

– What to Do in Case of a Spill.

• Mock Debate Held on Syringe Reuse

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