Letters to the Editor:

Transesophageal Pacing: Possible Solution to Excessive Beta Blockade

Future Possibilities in Central Venous Cannulation with Ultrasound Guidance

Checklists Cover Critical Details

Transesophageal Pacing: Possible Solution to Excessive Beta Blockade

To the Editor:

I have followed this exchange of opinions with great interest, aware that most likely those raising issues with beta blockade as a “standard of care” are influenced by similar strong statements about the early use of PA catheters. The letter from Dr. Royster omitted, I believe, an easy solution to the problem of a bit too much beta blockade: transesophageal atrial pacing. There is a TAPSCOPE in the OR where I work, and when it is employed, it solves the heart-rate-of-<50 problem with great predictability, unlike the variable results with atropine and friends. The initial cost is of course much higher but so is the probability of success. I have no connection with the company that makes the pacing device (CardioCommand, Inc. - www.cardiocommand.com) and receive no compensation from them.

C.F. Ward, MD
San Diego, CA

Future Possibilities in Central Venous Cannulation with Ultrasound Guidance

To the Editor:

We studied 462 CVC procedures; cannulation failure with UG was 2.1% vs. 13.8% with AL. Arterial puncture rates averaged 7.0% regardless of technique (p=0.45). The junior operator tended to be more at risk for arterial puncture during CVC with UG. This arterial puncture rate is higher than reported in the original efficacy studies of CVC with UG.³ We attribute this high rate in part to operator experience. We postulated that a clip-on needle guide might lower the arterial puncture rate in CVC with UG, in particular, among junior operators. We evaluated this hypothesis in a prospective, randomized trial that has just been completed. We plan to report our results in abstract format this year at the ASA.

Our preliminary analysis shows a sample size of 429 CVC procedures (needle-guide 47.6%, UG 52.4%) with an arteriotomy rate of 4.7%. The needle-guide appears to minimize the number of attempts required but does not lower the arteriotomy rate. We are currently analyzing our results to delineate the effects of operator experience.

CVC with UG clearly benefits the junior operator, especially in a patient with difficult anatomy or at high risk for bleeding; UG allows the junior operator to conduct CVC with a success rate of a more senior operator.⁵ The impact of UG on CVC by experienced operators only is a matter of debate. To our knowledge, there is no prospective, randomized trial that has examined the question; opinions depend on operator preference and experience.

Morbidity and mortality from CVC are a national concern. First, the Agency for Healthcare Research and Quality identified CVC with real time UG as one of the top 11 patient safety practices. Secondly, an analysis of the ASA Closed Claims Database reveals 41 claims due to CVC,⁶ including 14 carotid artery injuries with a 36% mortality (median payment of $60,000), and 9 pneumothoraces with an 11% mortality (median payment of $125,000). What are the next steps to address this national concern? We propose the following two investigations.

1) What is the prevalence of CVC with UG in anesthesia practices across the US? This could be approximated by means of a questionnaire-based study. We are currently designing such a survey to measure practice patterns of CVC with UG by anesthesia providers. A measured baseline national prevalence of UG in CVC would be essential in planning future strategies for improving outcome after CVC.

2) Does CVC with UG offer any benefit over CVC with AL by experienced operators in a non-teaching setting? A prospective, randomized trial of CVC by experienced operators with and without UG would provide the necessary data that would be applicable to the majority of anesthesia practices in the US. If CVC with UG by experienced operators in a non-teaching setting saves time, minimizes complications, and improves outcome, then it should be strongly considered for routine use in CVC practice.

John G. Augoustides, MD
Justin I. Weiner, BA
Philadelphia, PA

References

1. Webster TA, Blitt CD. Portable ultrasound facilitates central vascular access: a case for routine use. APSF Newsletter 2002;17:35.
2. Overdyk FJ. Ultrasound guidance should not be standard of care. APSF Newsletter 2003;17:55.
3. Troianos CA, Jobes DR, Ellison N. Ultrasound-guided cannulation of the internal jugular vein. Anesth Analg 1991;72:823-6.
4. Augoustides JG, Jobes DR, Diaz D, Weiner J. Safe internal jugular vein cannulation. J Cardiothorac Vasc Anesth 2002;16:262-3.
5. Augoustides JG, Diaz D, Weiner J, et al. Current practice of internal jugular venous cannulation in a university anesthesia department: influence of operator experience on success of cannulation and arterial injury. J Cardiothorac Vasc Anesth 2002;16:567-71.
6. Spitellie PH, Bowdle TA, Posner KL, et al. Injuries from central lines: a closed claims analysis. Anesthesiology 2002;96:A1124.

Checklists Cover Critical Details

To the Editor:

The practice of anesthesiology contains dynamics and complexity similar to that found in the aviation industry. Meticulous preparation, constant monitoring and frequent adjustments, temporally precise execution of critical maneuvers, and crisis management are important elements in both professions. Studies of decision-making and human error in airline disasters revealed the need for organized management of specific situations [http://anesthesia.stanford.edu/VASimulator/EMedicine.htm]. Checklists found in the aircraft’s procedure manuals are used to control the infinite variables that must be managed, particularly during emergencies. As a pilot of 38 years and an anesthesiologist of 15 years, I began using aviation style checklists early in my career for routine but critical maneuvers in the operating room to insure that I didn’t commit the anesthetic equivalent of taking off with my door open or landing with my landing gear up.

Designing and executing operation-specific anesthetics are common, nearly routine, elements of anesthesia practice. Critical errors can occur when patient-specific data are lost or forgotten during the hustle of daily practice. As a supervising, academic pediatric anesthesiologist, I am frequently called to induce a patient whom I evaluated 20-60 minutes earlier. During that interlude, I have reviewed other pre-ops of patients for similar operations, each containing modest variation in their histories. Critical details are easily lost in the noise of the constant data flow.

Just before I induce the patient, I use a checklist as a last-minute confirmation that I haven’t forgotten critical detail. I advocate a quick re-check for those issues that are not part of the operation-specific anesthetic but require a deviation, variation, or alternation in that plan.

CABINS: Cardiac, Airway, Bleeding, Intolerances, NPO, Steroids (Table 1). I have taken to listing a CABINS score on the top of the anesthesia record, the score reflecting the number of positives in the acronym. This does not replace the anesthetic pre-op, but it quickly refocuses my attention to issues outside the procedure-specific aesthetic, and I hope, prevents me from using barbiturate in a patient with porphyria or non-depolarizating muscle relaxants in a patient with prior history of anaphylaxis. The jingle takes all of 10 seconds to recite and focuses my attention away from the considerable details of the pre-op to those issues that alter the operation-specific anesthetic.

Acronyms are a means to help us remember critically important and commonly bulky information. CABINS is helpful to me because it forces me to ritualistically recall important data prior to the induction. CABINS is my checklist, based on my practice population, practice style, and operating routines. The real value to any checklist is to invent or modify one for your own practice, giving consideration to your anesthetic routines, patient population, and operating room demands. The process of developing the checklist is at least as helpful as its ritualistic use.

Loren A. Bauman, MD
Winston-Salem, NC