Figure 1: Axial view of MR image showing “enhanced” nerve roots which
are edematous and have a star-like appearance.
Letters to the Editor:
Reporting Adverse Events is a Double-Edged Sword
Power Interruption Still a Major Safety Disruption
Alpha-2 Agonists May Also Impact Outcome
Reader Questions Safety of Spinal Anesthesia
How May Oral-Tracheal Intubation Be Improved?
Reporting Adverse Events is a Double-Edged Sword
To the Editor:
As David Hunt mentioned in the Summer 2003 issue of the APSF Newsletter, his group suffered by following APSF and medical insurance companies’ recommendations to report any untoward event. We have had a similar experience. Our insurance company gave us about 40 days notice that they were going to terminate our coverage, based on claims history. We reported several untoward events to them as we had been instructed to do in our insurance-sponsored classes to reduce litigation exposure.
Based on several nuisance suits (everyone named even though there was no anesthesia mishap) and those self-reported untoward events, we were considered too risky.
We appealed the decision and won, but had to apply to other carriers in the meantime. We decided to drop our insurance carrier because of a 250% increase in our premium quote with them and because of the way they handled the situation which imposed great stress on our group.
We have a new carrier. They were glad we reported any untoward events because once reported, the carrier is liable for coverage and damages. Now our premium is much less, and our benefits much greater. Our new carrier provides unlimited legal defense for HIPAA and Medicare investigations, and they also pay government/ HIPAA fines up to the limits of the policy. Our previous insurer only paid $25,000 of legal fees in these circumstances, and our current insurer pays up to $50,000 in legal defense. Neither picks up the fines.
In the end, we are glad it happened. We have a better and cheaper product. Reporting untoward events is a double-edged sword and may not be as benign as the insurance companies would have one believe. We have heard of horror stories of Medicare investigations and feel safer now that we are with a new carrier.
Stacy Tait, MD, FACC
Fort Smith, AR
Power Interruption Still a Major Safety Disruption
To the Editor:
For decades anesthesia has been compared to aviation. The reasons are numerous and widely known, or at least widely repeated. Consistent with this comparison, the cockpit of modern commercial airplane is a delight to every anesthesia practitioner, filled with integrated electronic displays that reveal the raw navigation/aircraft systems data and the refined “big picture” distilled from that information. Current generation anesthesia machines seem, at first glance, to follow this exact philosophy. However, there is a significant difference that only becomes evident with daily use. Modern aircraft have multi-function displays, which allow critical information to be rerouted and displayed as required when the primary display fails—as it sometimes does. The anesthesia machines do not currently have this luxury. A power supply disruption of the sole display of all vital signs and/or critical flow/concentration/ventilation parameters, leaves the practitioner in the dark, with no raw data. Further, programmed for this event, the machine then abruptly becomes the world’s largest oxygen flow meter, eliminating the possibility of anesthetic overdose, or in fact any dose. The experience is terrifying. There is a significant design flaw at work here—a final common pathway, the disruption of which creates an immediate patient care crisis. Thirty years in the operating room, never having experienced such events, and a so-called improved technology created the longest 15 seconds in my professional career, as I struggled to reanimate an ECG/pulse oximeter display, frozen on a screen, using the last ditch sophistication of cycling the ON-OFF switch.
Everyone must evaluate new equipment from the view of just one question: what happens if it hiccups? Rest assured, from the greatest lesson of the computer age, it will, and at the moment when it is least acceptable. No single malfunction should deprive the practitioner of information required to verify satisfactory vital signs and provide basic anesthetic requirements—a voltage variation or circuit board failure is not a legitimate medical indication to change anesthetic technique. Nevertheless, it has occurred, and will again, until this flaw is addressed and eliminated.
C.F. Ward, MD
San Diego, CA
Alpha-2 Agonists May Also Impact Outcome
To the Editor:
Meiler et al. are to be commended for reviewing the effect of beta-blockers, statins, and “depth” of anesthesia on long-term morbidity following surgery.1 In addition to these interventions, following the introduction of alpha-2 agonists in human anesthesia,2 several large-scale trials or meta-analyses suggested that alpha-2 agonists decrease myocardial ischemia/infarction or mortality following cardiovascular surgery.3-5 A recent editorial6 stated that the “53% reduction in overall mortality [is] actually. . . more impressive than what has been found in the pooled beta-blocker studies.” Given the simplicity of oral administration of clonidine 2-6 µg/kg, clinicians should consider this intervention, with appropriate reduction in anesthetic doses and volume loading in coronary/ hypertensive patients presenting for major cardiovascular surgery.2 The above-mentioned editorial added that investigators should add alpha-2 agonists to the array of drugs under trial to further reduce mortality following surgery.6
Luc Quintin, MD, PhD
Lyon, France
Marco Ghignone, MD, FRCPC
West Palm Beach, FL
Reader Questions Safety of Spinal Anesthesia
To the Editor:
Lambert1 made a recent call for further examination of the transient radicular irritation syndrome (TRIS) that may occur after spinal anesthesia. This certainly deserves investigation. Although Schneider2 pointed out the incidence and possible seriousness of this apparent complication in 1993, one may think that its appearance may have been precipitated by a change in the local anesthetic composition or the technique of injection. However, Vandam and Dripps3 described this precise syndrome in one of their classic series of 3 publications on neurological complications noted in 10,098 patients receiving spinal anesthesia. Moreover, Pizzolato4 in 1959 and Gentili et al.5 in 1980, using different laboratory techniques, showed that all local anesthetics at high concentrations produce neurotoxicity.
It is not surprising that diagnostic electrophysiological studies do not reveal abnormalities in these cases, as they usually are only contributory after 15 or more days after nerve root injury.6 However, experienced radiologists can recognize the early stages of radicular inflammation when MRI images of nerve roots are enhanced with intravenous gadolinium, as shown in Figure 1.7-10 These findings can be seen in CAT scans, only when preceded by myelography, which is hardly justifiable under such circumstances, since it can exacerbate radicular injury.11
Figure 1: Axial view of MR image showing “enhanced” nerve roots which |
I echo Lambert’s suggestion for further investigation on TRIS and other neurological complications that may follow neuroaxial anesthesia; this is a challenge for all of us, and specifically the APSF.
The evidence against lidocaine in concentrations equal to or greater than 2% continues to mount.12,13 A lower incidence has been reported with prilocaine,13 mepivacaine and bupivacaine,14 and tetracaine,15 thus confirming the axiom proposed by Pizzolato: “All local anesthetics are potentially neurotoxic.”4 Since even a plain spinal tap results in inflammatory changes in the CSF, the $60,000 question raised by Gaiser,16 “Should intrathecal lidocaine be used in the 21st century?” can be expanded to the next logical question, one that we do not want to hear, “Should spinal anesthesia be used at all?”
J. Antonio Aldrete, MD, MS
Birmingham, AL
How May Oral-Tracheal Intubation Be Improved?
To the Editor:
A forum on “Airway Management Continues to Raise Safety Concerns” regularly includes current recommendations on ways to secure a jeopardized airway after attempts at endotracheal tube placement during “difficult intubation” fail.1 At this stage an effective rescue technique, without question, becomes the only available option to avoid patient injury.
In retrospect many questions must always be asked, including—why did conventional intubation fail, and what technical changes are necessary to improve outcome? To date, the answers have ranged from developing scoring systems in the attempt to pre-emptively identify patients at risk, bettering laryngoscopic view via, for example, altering head position, and assigning cause for difficult intubation to patients’ physical characteristics such as obesity.2
The focus on modifying selective aspects of the intubating procedure, however, is based on unproven assumptions about the intubating process itself. Current opinion accepts the principle that oral tracheal intubation, as presently practiced, is the correct way to intubate, since historically it has proven reliable for most intubations and problematic only in a small percentage of cases, the latter constituting “difficult intubations.” Longevity, along with absence of a reliable alternative, has, by default, made the current method the standard—to be refined, but never questioned. However, is this reasoning correct, and would using an alternate approach that combines uncomplicated intubation of normal patients with a seamless transition to intubate successfully during “difficult intubations” be desirable? Any such technique would enhance safety by significantly reducing the number of patients requiring emergency airway management, many under adverse circumstances.
The need for a new technique that improves outcome during difficult laryngoscopy, should therefore, at the very least, be recognized and discussed. Only then can the strengths and weaknesses of conventional intubation be debated, and the fundamental factors governing successful tracheal intubation recognized. Failure to do so only propagates the status quo without significantly improving management of unanticipated “difficult intubations.”
In practice, does a viable alternative exist, and on what concepts is it based? A complete system for intubation that requires mandatory use of a styleted endotracheal tube and follows obligatory rules has been used successfully for many years in a variety of clinical conditions.3 I submit that this technique used routinely in the hands of trained operators is a major advance in oral tracheal intubation.
Many experienced anaesthesiologists will not accept the suggestion that their personal method of intubation may be improved, while others search for answers to problems they have encountered. However, the issue of how best to perform oral tracheal intubation should be accepted for what it is, an unresolved clinical problem, with solutions that must meet the criteria of evidence-based medicine. Only then will fact be separated from bias.
Russell B. P. Stasiuk, MD
Vancouver, British Columbia
References