Patient safety as a driving force for anesthesia research, innovation, and education again was featured prominently in both the Scientific and the Technical Exhibits at the ASA Annual Meeting in San Diego, October 16-20, 2010. There were significant patient safety concerns presented as well as proposed technical and educational improvement strategies.
In the Scientific Exhibits, safety-related topics varied widely, from some of the biggest to some others that might appear somewhat mundane but that still represent everyday hazards that persist as threats to patients.
Directly addressing one of the rare but potentially devastating threats to patients, wrong-site surgery, was an extensive exhibit from Seattle’s Virginia Mason Clinic. An analytic tool with a probability model to predict the risks (most often involving failures of communication) leading to potential wrong-site accidents was presented. It incorporates points from the recently introduced World Health Organization Surgical Safety Checklist. Application of the model at that institution led to procedural changes that emphasize “second source” separate independent verification of the correct surgery and site, such as imaging, test results, or an additional member of the surgical team. Dramatic success of the changes was shown when questions about the surgical site (not adverse incidents) were reduced from 6.9/10,000 in 2009 to only 0.2/10,000 in 2010.
A global perspective was featured by the Boston team that won the APSF’s E.C. Pierce Award for the best safety-themed Scientific Exhibit. The subject was the World-Health Organization “Global Oximetry (GO) Project” and its instructional video intended to help introduce pulse oximetry to anesthetizing locations in the developing and underdeveloped areas of the world where pulse oximeters currently do not exist. The value of pulse oximetry as the one electronic technology most likely to help improve anesthesia safety was a prominent component of the WHO “Safe Surgery Saves Lives” global initiative (lead article, APSF Newsletter, Summer 2008). The WHO is working with donors and equipment manufacturers to develop and introduce robust simple oximeters that can run on batteries if necessary and are suited to the most basic of anesthetizing locations.
On the other end of the spectrum were several technical innovations intensely focused on everyday issues that have major safety implications. Noting the danger involved if an O2 tank is emptied while transporting an O2-dependent patient, a team from the Mass General in Boston presented a new oxygen tank regulator that also “reads” in “minutes of O2 remaining” at the 3 common flow rates available on the regulator. This would allow simple “on the fly” assessment of O2 supply relative to the transport needs and decreased risk of running out. Also addressing a concern regarding supplemental O2, a team from Belgium displayed the “Baroprevent.” It is a relatively simple device that attaches to the bottom of a wall O2 outlet and functions as pressure relief valve that will “pop off” automatically when pressure in the distal O2 tubing exceeds 60 cm H2O, such as might occur with a T-piece obstruction or an incorrect connection. Likewise, the same booth showed the “Safety Frog” to prevent volutrauma from an anesthesia machine. It attaches between the absorber head and the inspiratory limb of the breathing circuit, measures pressure, and both “pops off” and alarms when there is dangerously high sustained pressure.
Airway management and safety issues did not necessarily dominate the exhibits as they have in some recent years, but were certainly well represented. As often stated in this report, the induction of deep unconsciousness and muscle relaxation before genuine confirmation that a patient’s airway can be comfortably managed and accessed is still (even with all the recent attention and device development) one of the least improved and most dangerous things anesthesia professionals do.
“Innovations in Airway Management” was the title of a wide-ranging multifaceted exhibit from the Cleveland Clinic. Provoked by the ideas that fiberoptic bronchoscopes may not be immediately available for an airway emergency because they are being cleaned and also the concern that the cleaning may not be completely effective, the team proposed an improvement to the sealed sheath covering with a lens at the end that covers scopes and keeps them clean during use. Previously available sheaths of this type covered the scope’s suction port, making it useless. Their new “Vaccu-safe” version incorporates a suction port in the sheath covering to restore that function (suction secretions or administer O2). Also, in the same booth were demonstrated a nasal airway with an inflatable cuff, an oral airway with a suction port, and an easily malleable video intubating stylet.
A new style of airway Bougie was in an exhibit from the University of Nebraska. With depth markings throughout its impressive length, it has one malleable end that is fairly firm (enough to pick up the epiglottis – especially helpful when a video scope is employed in an extremely challenging airway) and, conversely, a special flexible soft tip at the other end. Demonstrations with airway mannequins illustrated the applications.
A different level of airway safety concern was addressed by 2 exhibits. A team from Cook County Hospital in Chicago presented the value of and strategies for “early aggressive management” of difficult airways in unstable trauma patients. Further, a team from International TraumaCare presented an exhibit targeting dangers from airway compromise during non-OR sedation with a web-based training course entitled “SAFE” (Sedation and Airway for Everyone). While useful in any setting for anyone administering sedation, it particularly targets challenging environments, “austere or remote” locations, and education for paraprofessionals who previously had little training in sedation.
Rounding out the safety theme were a cardiac risk reduction checklist from the University of California (San Francisco); an online module to teach and assess ACLS skills from the University of Washington; a demonstration of a computerized PACU handoff report from St. Louis University; an informational and promotional update of the ASA Simulation Education Network; and an extensive exhibit from the Harvard-based Institute for Safety in Office-Based Surgery, including a checklist building on the WHO Surgical Safety Checklist. Finally, arguably the most visually appealing scientific exhibit, which came from the University of Florida, was a “mixed simulation” of central venous catheter placement that featured truly remarkable and very instructive 3-D video images of the relevant anatomy and insertion approaches.
In the Technical (commercial) Exhibits at the ASA meeting, both the expected and some new displays were presented. Interestingly, in general, the expansive exhibit extravaganza seemed at least to make a start towards recapturing some of its pre-recession grandeur. Also, prominently featured were several international exhibitors not previously seen at the ASA.
Video airway devices for the second year dominated the safety-oriented component of the Technical Exhibits. There were at least 15 exhibitors with all types and shapes of products. Small screens that clamp to an IV pole were popular. “Eye-catching,” as it were, described very small (3” diagonal) screens directly on a scope in place of the traditional eye-piece lens. The multitude of shapes and sizes of video scope blades reached a new high.
Likewise, competition in the ultrasound market continues to be strong. A variety of probes have various features but the result is similar. A new product, however, is the special needle for blocks or central line insertion that has an outer wall covered with tiny geometric shapes that more effectively reflect the ultra-sound signal (something like a prism) and, thus, are significantly more visible on the screen. Also for central line placement is a tiny disposable transducer that allows guide wire advancement when venous pressure is sensed with the intension of preventing accidental arterial cannulation.
Adoption of electronic anesthesia information management systems, endorsed by the APSF as a safety-promoting concept, has been slowed in recent years by the economic recession. Many versions were still exhibited, but not with the emphasis of a few years ago. One new type has the image of a traditional paper anesthesia record on the screen and the ability of the practitioner to “write” on the screen with a stylus, creating a record looking like the familiar hand-written paper version, which then can be printed. That particular one does not capture, for example, vital signs into a true digital record, but a companion version with touch screen entry (like texting) instead does create a storable digital record.
There were 3 new brain function devices intended to be used as monitors during general anesthesia. A potentially related but different new product was a special sensor placed above the bridge of the patient’s nose in the medial corner of the eye socket that is advertised as directly measuring brain temperature via an anatomic “tunnel” that conducts heat from the brain to the skin. Patient warming devices were widely featured, as always. There were new types of special central venous catheters that feature heating elements and were touted as enhancing normothermia in big invasive cases. More small printers for real-time medication labels generated on the anesthesia cart from an associated bar code reader were displayed, likely inspired by the initial one 2 years ago that received significant attention at the special APSF workshop on medication safety (lead article, APSF Newsletter, Spring 2010). Pre-op testing for sleep apnea dangers was not quite as prominent as last year, but still clearly evident. A new activated charcoal filter was displayed that goes on both limbs of the breathing circuit and is advertised as clearing an anesthesia machine of residual volatile agent so that it can be ready for an MH-susceptible patient in less than 1 minute. A new device for continuous cardiac output determination via sensors on the endotracheal tube cuff was displayed.
Several airway-related inventions were offered in the exhibits. An oral airway intended to help prepare for awake FOB intubation has 2 integral lumens, one for administering O2 and the other with an internal atomizer at the airway tip for the dispersion of local anesthetic to the airway in an easier fashion than previously available. A laryngeal mask type device with a pressure sensing gauge on the cuff pilot tube was advertised as promoting better fit and less risk to airway mucosa and underlying nerves. Another new offering was an acoustic sensor affixed to the neck to detect and record respiratory rate, which was offered as an improvement for “conscious sedation” cases.
Lastly, less of a patient safety commentary than an observation on the practice of anesthesia care in this country, the ASA commercial exhibits had a record number of business and practice management exhibitors, all with even bolder new claims of improved practice profitability via enhanced revenue and reduced costs. This likely is a reflection of the economic recession that appears to have affected aspects of the lives of most people, including anesthesia professionals.
Overall, patient safety persisted as a distinct focus among both types of exhibits at the 2010 ASA Annual Meeting. This emphasizes both continued success in improving patient safety and also the significant challenges yet remaining.
Dr. Eichhorn, Professor of Anesthesiology at the University of Kentucky, founded the APSF Newsletter in 1985 and was editor until 2002. He remains on the Editorial Board and serves as a senior consultant to the APSF Executive Committee.