Both the Scientific and the Technical Exhibits at the ASA annual meeting in Orlando in October had significant patient safety elements that demonstrated ongoing and new patient safety concerns as well as safety improvement strategies.
In the Scientific Exhibits, airway concerns did not dominate as much as in recent years, but there were several relevant entries. A protocol developed at the University of Pennsylvania identifies and labels, both at the bedside and throughout all hospital care, patients with known difficulty airways (including historical details and tips about both prior unsuccessful and successful airway management techniques for that patient). Teaching laryngoscopy and intubation to students, particularly stressing non-OR settings, using video-assisted laryngoscopes of various brand and types was the topic of presentations from the Universities of Oregon and Nebraska. Predictably, both learning and performance were improved after video-assisted teaching. An exhibit from Belgium showed a new specially shaped inflatable pillow for optimizing patient position for airway management, catheter insertions, or even surgical procedures. Beneficial application in morbidly obese patients was stressed in the demonstration. An exhibit from a Chicago group outlined complex multidisciplinary management of obstructive sleep apnea patients, especially for corrective airway surgery.
Again this year several exhibits involved the safety of regional anesthesia and nerve blocks with particular emphasis on ultrasound needle guidance as a way to avoid complications and untoward outcomes.
Exhibits Stress Education
A series of exhibits from various sources focused on educational issues, always with the implication that better educated practitioners are safer practitioners. Following up on the APSF “technology training initiative,” an exhibit from Milwaukee outlined a program for a computerized anesthesia machine training protocol while the well-known team from the University of Florida introduced a new technical approach called “mixed reality,” in which computerized virtual anesthesia machines are shown side-by-side with real machines that students can (and do) manipulate to learn practical concrete skills. On a more comprehensive level, a combined team from Ohio and Texas demonstrated a “core” anesthesia patient safety curriculum for new anesthesia trainees, with special emphasis on critical incidents and crisis management. Also, a program from Harvard based on a 2006 ASA Panel Discussion focused on ensuring maximum safety of office-based anesthetics was exhibited and featured many ASA publications, including the key 2008 update on a “safe office anesthesia environment.” Further, a multimodal training protocol to enhance compliance by anesthesia personnel with infection-control measures was exhibited by a team from Milwaukee.
From a large New Jersey group, an updated and more elaborate version of a “technically simple and effective” face tent fashioned essentially from a plastic bag was presented demonstrating the transformation of basic nasal cannula administration of oxygen into a much higher concentration (40-60%) delivery device. This also facilitates CO2 sampling for ventilation monitoring and is intended for use during MAC or TIVA cases in virtually any patient position.
The Mass General in Boston provided 2 comparatively elaborate exhibits. In keeping with the APSF 2008 theme stressing the prevention of OR medication errors and their potentially lethal consequences, there was an impressive exhibit of their proprietary “smart label” system for syringes of medications drawn up by anesthesia personnel into syringes marked with a specific unique patient label printed right on the anesthesia machine. Finally, the importance of medical device free interoperability that facilitates the assemblage and coordinated function—essentially “plug and play”—of equipment in the OR (e.g., the ability to take an OR table x-ray without turning off the ventilator because the anesthesia machine and the x-ray tube are compatible and can “talk to each other”) provoked an exhibit featuring ideas that promote this “Integrated Clinical Environment.”
Airway management issues remained prominent. 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 one of the least improved and most dangerous things anesthesia professionals do. Accordingly, new variants of “laryngeal mask” devices were exhibited, some of which are intended specifically to help facilitate placement of an oral endotracheal tube into the larynx, including with special extra channels and novel shapes all to help direct blind passage of a tube. Other new laryngeal devices were without an inflatable cuff or with a built-in insertion handle. An “intra-oral mask” with an attached oropharyngeal airway was advertised as a “solution for ventilatory emergencies.” Many versions of optical and video laryngoscopes were displayed, one in particular with an internal fiberoptic system for illumination and viewing the larynx on a 1-inch screen (that will also accept a video camera to project the image) in a basic handle onto which can be affixed 1 of 7 different disposable plastic blades for different sizes and purposes. Again featured this year was the video teaching system consisting of a camera on a head band worn by a resident attempting airway manipulation and aimed so that others, particularly the supervising faculty, see on the monitor exactly what the resident is seeing down the airway.
Other airway-related devices featured in exhibits included an intubating stylet to facilitate passage of a regular endotracheal tube that, on the stylet itself, has a soft inflatable dilating balloon and a flexible tapered tip, all intended to guide an endotracheal tube smoothly into a larynx “when anatomical challenges are encountered.” To help prepare for an awake fiberoptic approach to the larynx, another device was displayed that sprays atomized local anesthetic into the airway. It consists of a curved rigid blade that at the proximal handle end holds a syringe of local that connects via internal tubing to an atomizer at the distal end, which is started over the tongue and slowly advanced down to the vallecula, spraying local all the way.
Another type of airway-related device that seemed to attract significant attention on the exhibit floor was a plastic head-rest device that administers and holds a “jaw-thrust” maneuver for the practitioner. Intended for patients breathing spontaneously under sedation or general anesthesia, getting positive pressure mask ventilation, fiber optic intubation, or even during post-op transport, the “jaw elevation device” has a plastic support pillow that creates the “sniffing position” and a plastic cradle-like support on either side that is adjustable. These supports are positioned to hold and elevate the angles of the patient’s jaw and then are locked in place, maintaining that “jaw-thrust” position hands-free. It is advertised to be applicable in any circumstance where a jaw thrust is beneficial.
One other positioning issue addressed in various similar ways by different manufacturers involved pillow systems, foam or inflatable, of varying shapes and sizes all intended to optimize patient upper body and head position for direct airway access, particularly in morbidly obese patients. Somewhat related were the several various systems and services prominently displayed and touted that are intended to screen outpatients preoperatively at home for obstructive sleep apnea in a manner that will prospectively alert the involved anesthesia (and surgery) professionals to be prepared to deal with a patient’s airway obstruction at the time of surgery and after.
A device potentially useful for an emerging or sedated patient at risk for airway obstruction is a small non-rebreathing bag with tubing for connection to an oxygen flowmeter (and also with a side port for connection of capnograph tubing if desired) that is part of a plastic mask-shaped device that can either be connected directly to an LMA or unfolded to make a small face mask with an elastic head strap. The visible excursion of the small non-rebreathing bag with each breath is intended to function as a surrogate ventilation monitor for the observant anesthesia professional presiding over the sedation, emergence, or transport. Another “sedation mask” intended for monitored anesthesia care appeared to be a fairly standard plastic anesthesia mask with an inflatable cuff and a rubber head strap and connected to a anesthesia machine breathing circuit, but also with a new “CO2 monitoring port” in the mask to sample gas from the patient’s mouth/nose area.
Ultrasound guidance devices, both for vascular access and placement of nerve blocks, were again very prominently displayed and heavily advertised in the exhibit hall. One quite different approach to situations of difficult intravascular access at the time of an acute need for fluid and/or medication infusion was the device that very quickly and easily establishes inter-osseous access via a surprisingly simple insertion of a cannula into the tibia or proximal humerus that is then connected to IV tubing and a bag of fluid. Often now used on ambulances or in emergency departments, the device, according to the manufacturer, facilitates administration of medication and fluid (even large volumes) essentially as fast as an IV. Until now it has not been widely used in ORs, and it is being offered as an alternative to establish necessary primary or supplemental “vascular access” when IV puncture (peripheral or central) would be time-consuming, difficult, or even impossible.
Continuous cardiac output measurements were advanced as enhanced patient safety features in unstable patients. One manufacturer offers a device for continuous output measurements determined from only a “standard central venous catheter” that is advertised as “less invasive” than a pulmonary artery catheter. Another device billed as “non-invasive” is a continuous cardiac output device incorporated into an endotracheal tube that would be used in a standard manner for general anesthesia. It measures changes in electrical impedance resulting from pulsatile blood flow in the aorta.
Normothermia Remains Hot Topic
Patient warming in the OR received renewed attention due to the federal performance measure involving a requirement for normothermia at the end of extensive colorectal surgery. The usual array of devices had this new specific purpose added to their advertising. One new device was a “forced air warming gown” intended for the patient to wear preoperatively in order to enter the OR with a maximal reservoir of body heat. Application of this heat preoperatively was shown in an abstract from Northwestern to be more effective in achieving normothermia at PACU admission than without, and this pre-op warmed group had fewer infections and a shorter average hospital stay. Possibly more to the direct point was a new device for “intravascular temperature management.” A variety of central venous catheters have been crafted incorporating small bore tubing carrying circulating saline, creating functionally an internal heat exchanger when connected to the external pump on which the temperature of the circulating fluid can be varied to add or remove patient heat “from the inside out.” The device is advocated for active warming of surgical patients to treat or prevent hypothermia or active cooling of surgical or ICU patients for any appropriate indication.
Last but far from least was a new device intended to address the issue of bacterial contamination of the anesthesia work space and the specific risk of spread of infection by anesthesia personnel through manipulation of IV lines, injection ports, and stopcocks during administration of anesthesia. The “personal sanitizer dispenser” delivers metered doses of alcohol-based hand antiseptic with a gentle squeeze, fits in the palm of the hand, and is intended to be clipped to the scrub suit (usually at the beltline on the side of the dominant hand) of an anesthesia professional in the OR. A study at Dartmouth documented a 27-fold increase in hand decontamination events and a more than 80% reduction in bacteria cultured from IV tubing in the cases where the device was used correctly. Further study to correlate with postoperative nosocomial infections was intended.
Overall, patient safety persisted as a focus among both types of exhibits at the ASA annual meeting. This emphasizes both the current success in improving patient safety and also the significant challenges yet remaining.
Dr. John 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.