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"How does your anesthesia group/department assure
its anesthesiologists and nurse anesthetists maintain proficiency
in management of difficult airways?"
Expert 1: In our institution we do a wide range
of difficult cases. Anesthesiologists, residents, CRNA's, and if
necessary, ENT surgeons and others work together in concert in the
approach to the difficult airway. No one is alone in a difficult
scenario.
Expert 2: Our institution has several large volume
ENT practices as well as a spinal cord center, therefore, we see
a large number of difficult airways each year. We approach patient
safety from two fronts. First, we have 1-2 departmental conferences
each year dedicated to the discussion of difficult airway management.
During these conferences we review the ASA guidelines for difficult
airway management and the different techniques available to secure
a difficult airway. Second, we have six difficult airway carts available
within our operating rooms that are stocked with a wide variety
of difficult airway management equipment including intubating LMAs,
lightwands and Combitubes. We encourage our staff to use this equipment
electively to gain experience with it in non-emergent situations.
Expert 3: As part of our resident's training we
spend a considerable amount of time on recognizing and managing
difficult airways. This training has didactic and academic components.
Academically, we have workshops twice a year (which are mandatory
for residents and attendings) on recognizing and managing difficult
airways; we cover the use of LMAs and intubating LMAs, esophageal-tracheal
combitubes, Flex-guide and Eschman stylets, using the Cook Airway
Exchange Catheter via the LMA to intubate the trachea, FOB, cricothyrotomy
with and without retrograde intubation and jet ventilation. Of course,
we also stress familiarity with the ASA algorithm for difficult
airways. We also require the residents to view the ASA videotapes
on recognition and management of the difficult airway.
Clinically, we practice the techniques taught in
the Workshops, with the exception of cricothyrotomy (which we have
never had to resort to in the last 13 1/2 years). We also have a
rotation in FFOB during which the residents have the opportunity
to perform several fiberoptic intubations daily. And we have 2 difficult
airway carts available in the OR.
Expert 4: We have at least two departmental conferences
per year specifically addressing difficulty airways management.
We also have a miniworkshop in July each year to demonstrate some
of the equipment to our staff and residents. Each July all of our
new CA 1 residents participate in a core lecture series; one of
the lectures is dedicated to airway management. Finally, we have
a rotation for senior residents in Advanced Airways, designed to
help them perfect their skills in LMA, light wand , fiberoptic intubation,
etc. during routine OR cases.
We also have a dedicated difficult airway cart in
the OR workroom which has all of the same type of equipment that
you describe. We have a difficult intubation cart in the recovery
room also; this is of more use to the team who respondsto codes
in the hospital.
For cases outside the OR, we take a prepared cart
for "Special Procedures", which is kept in our workroom. It contains
almost everything one would need to give anesthesia outside the
OR. We have two anesthesia machines, dedicated to non OR use, and
maintained by us. They are stored in our radiology department, which
is centrally located to ct, mri, angio, endoscopy, etc.
"How does your anesthesia group/department assure
patient safety when anesthesia is administered in a non-operating
room setting?"
Expert 1: Anesthesia outside the OR is done with
the same anesthesia machines, carts, and technicians as in the OR.
Once again, no one is left deserted in a distant location alone
for any extended period of time and someone is kept available if
help is needed (resident and staff).
Expert 2: We have a very active "outpost" anesthesia
service that cares for patients in radiology, the cardiac catheterization
lab, GI endoscopy suite, and the bronchoscopy suite. We adhere to
the same standards in these locations as we do in the operating
rooms. An anesthesia machine will be brought to an anesthetizing
location if general anesthesia is used and seperate adult and pediatric
anesthesia carts are available for use in these areas. Our staffing
ratios will vary depending on the age of the patient and the planned
anesthetic. Backup personnel are always identified and readily available
during the critical portions of the anesthetics.
Expert 3: We provide anesthesia services in several
locations outside of the main OR (radiology, endoscopy, cardiac
catheterization, etc.) With rare exceptions, these are performed
during regular working hours (Monday through Friday) so that additional
help is always readily available. A resident and attending are assigned
to each procedure, and both will stay until the procedure is safely
completed. (The patient is then accompanied, with the appropriate
monitoring, to the appropriate post-anesthesia care area to recover).
They bring an anesthesia machine and cart with them wherever they
are going, and whatever special equipment is needed for that procedure.
If any additional help is needed, a call to the main OR is all that's
needed.
"Is it safe to leave an anesthetized patient alone
for brief periods of time?"
Expert 1: There is no question that an ASA member
would have been violating the ASA code of conduct under the circumstances
described in this message. I am not aware whether the AANA has a
code of conduct similar to that of the ASA. There is probably no
violation of laws, except perhaps HCFA's regulations.
Expert 2: The answer to this question is quite clear
and obvious. No patient should be left alone (without trained anesthesia
personnel present) during any anesthetic. This IS patient abandonment,
it is dangerous and should not under any circumstances be tolerated.
"Could you please provide information on the current
standards for line isolation?"
Expert 1: Line isolation monitors are only required
where there are isolated power systems, as identified by section
3-3.2.2.1 of NFPA 99 Health Care Facilities. Isolated power systems
are not required in operating rooms, but may be installed in "wet
locations" such as cystoscopy; definition of a "wet location" is
up to the individual hospital. "Wet locations" may be addressed
by either isolated power systems (such as in an OR) or by ground
fault protection devices, where power interruption can be tolerated.
"What are the risks and benefits of using induction
rooms, adjacent to operating rooms?"
Expert 1: We use what we call block rooms to initiate
regional anesthetics for our orthopedic patients. In these rooms
we currently perform spinals, combined spinal/epidurals, and a variety
of nerve blocks. Although these rooms are fully equipped to perform
a general anesthetic, we do not use these rooms to induce general
anesthesia.
"What could cause numbness of the right lip and
facial numbness after an anesthetic?"
Safety Expert: This is usually caused by pressure
on the mandibular branch of the facial nerve when masking and gripping
the face (lower lip or upper?). It might alsoalso be caused by pressure
from the mask strap, etc. The nerve is very superficial and can
be compressed easily against the mandible, which would explain these
symptoms.
"Can a PAC be inserted safely in patients with
pre-existing left bundle branch block (LBBB)?"
Yes, but additional measures to insure a stable
cardiac rhythm are necessary. During passage of the PAC, a temporary
right bundle branch block is often induced as the catheter impacts
the interventricular septum. Thus, in a patient with a pre-existing
LBBB, cardiac asystole may occur. The risk of asystole in this setting
is probably in the range of 1 - 2%. Therefore, during insertion
of the PAC in these patients, an alternative mechanism to pace the
heart must be immediately available. This could include an internal
temporary endocardial pacing wire, epicardial pacing wires, or placement
of transcutaneous pacing patches (Zollo transcutaneous pacemakers).
Author: Richard C. Prielipp, M.D., FCCM; Wake Forest University
"Are there any standards for installation of gas
pipelines in the operating room?"
The installation of the medical gas/vacuum system
should have been done in compliance with NFPA 99 (1999), which is
available from the National Fire Protection Association. Consult
their web page for info on ordering the booklet, if your department
or hospital engineering does not have a copy.
The installer is required to do certain tests with
regard to cross connections, hydrocarbons and particulate matter.
The hospital should have insisted on an independent verifier as
part of the contract who will come in and check the entire system
prior to the hospital accepting the finished project. It is as President
Reagan once said, "Trust, but verify!"
"Is it safe to reuse multidose vials after they
have been entered by contaminated needles?"
Any contaminent, for example, bacteria, a virus
such as hepatitis B or C or HIV, could be transmitted this way.
Studies have shown that red blood cells are present in IV tubing
in IVs that are attached to patients. The mechanism that they travel
retrograde is called axial diffusion. Smaller particles probably
travel farther than the cells. Any way you look at it, there is
no guarantee that there is no contaminent in the IV.
"Should tongue studs be removed prior to elective
surgery?"
Tongue studs can only be removed with a special
tool. This is probably not easily done in a preop setting and usually
requires an official consult from the burly tattoo parlor operator
that inserted the stud. Since they are extremely difficult to remove,
they are probably no more or less dangerous than other attached
mouth appliances (fixed bridges or braces). They are not like earrings,
which are meant to be changed. Most patients will not take kindly
to having the stud removed as they are difficult to replace.
We make the same statements to patients/parents
as with dental appliances: there is a risk of damage to the stud
although we will do our best to be careful; if broken, there is
a risk of the stud being swallowed or being lodged in the airway
although we will also do our best to avoid these complications.
As with all anesthetic risks for elective procedures, the patient/parent
has to agree to accept these risks (or thay can elect to have the
stud removed prior to surgery).
"How many family members can safely observe a
caesarian section?"
Why is it necessary to have more than the significant
other person in the C-Section OR? Does it improve the outcome of
the baby or the mother? How many people are needed to prevent a
person from being alone? I think the answer is 1. This is personal
and private event for the mother and father and privacy should be
respected by friends and family. There might be rare exceptions
when another person (parent's parent or some figure of authority
or religious leader) actually helps calm an otherwise distraught
or hysterical patient. That might be a justification for another
person.
There should be a justification of the potential
risk that is added. The patient and the spouse should want to minimize
risks. C-section is surgery. In my opinion, additional people add
to risk of infection, equipment malfunction by running into or tripping
over something, touching instruments, getting in the way. The significant
other is quite enough distraction. As it is they of tne video everything
anyway. Everyone else can see the videos and pictures.
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