Patient safety, as always, was a prominent theme of both the Scientific and the Technical Exhibits at the ASA Annual Meeting in New Orleans, October 17-21, 2009. There were significant ongoing and new patient safety concerns as well as safety improvement strategies.
In the Scientific Exhibits, airway concerns were not as prominent as in recent years, but there were airway entries. One extensive exhibit from the University of North Carolina reflected a larger common theme of the overall meeting because it presented support for the idea that optical laryngoscopes are superior to conventional laryngoscopes in negotiating endotracheal tube placement in typical difficult airway situations. Illustrations documented anatomical circumstances in which traditional alignment of larynx, pharynx, and mouth opening is nearly or completely impossible and how an optical device that functionally “sees around the corner” can facilitate relatively easy intubation in such patients. Various innovative devices were featured in other exhibits, several intended to help with spontaneously breathing patients during MAC and TIVA, including a return of the demonstration of a face tent fashioned essentially from a plastic bag demonstrating the transformation of basic nasal cannula administration of oxygen into a much higher concentration (40-60%) delivery device—while also facilitating CO2 sampling for ventilation monitoring.
3-D imaging was prominent, especially in an exhibit from the University of Rochester illustrating the creation of models of a patient’s airway, neck, or brachial plexus using a scanner, an ultrasound image, and a new computer program. Likewise, an exhibit from the Harvard’s Brigham and Women’s Hospital showed 3-D imaging of thoracic epidural catheter placement, both for real time clinical care and for a teaching video to present and illustrate access/placement techniques.
Safety concerns about anesthesia providers manipulating and using large-bore temporary dialysis catheters filled with high-concentration heparin have existed for many years, and an exhibit from the Medical College of Wisconsin presented a safety protocol and a plan for accrediting anesthesia caregivers to handle and manage these catheters.
Also related to intravenous access were demonstrations of 2 (St. Luke’s Roosevelt, New York, and Utrecht, Netherlands) new “vein finders” utilizing infrared-based technologies that can “see” veins underneath the skin, either with “night-vision-like” goggles or transillumination of an extremity into an IR camera feeding an image on an adjacent screen. Both are particularly intended to help place peripheral IV cannulae in pediatric patients.
An exhibit from the Advocate Illinois Masonic Medical Center correlated perfectly with the APSF Directors Workshop on cerebral perfusion pressure (“How Low Can you Go?”) when it featured “the evolution and safety” of deliberate intraoperative hypotension with specific suggestions on its safe and successful use.
A perennially controversial topic was featured in an exhibit from the University of Florida. The concept that supplemental oxygen administration to a spontaneously breathing patient can prevent pulse oximetry monitoring from detecting hypoventilation was highlighted, along with the complementary recommendation to limit whenever possible patients (with postop pain medication, sedation, etc.) to room air, thus enabling the pulse oximeter to enhance safety by showing the early fall in hemoglobin saturation resulting from impaired respiration.
Several exhibits indirectly promoted patient safety by outlining educational efforts and programs to improve practitioners’ skills (such as with ultrasound guidance for regional anesthesia), leading to safer care. One remarkable exhibit from the University of British Columbia featured caregiver education in real time. Computer scientists have developed “The Intelligent Anesthesia Navigator,” which is an integrated expert system that could take the input from physiologic monitors, combine it with basic patient information, and then compute situation analysis, differential diagnoses, and (drawing from a preprogrammed library) expert advisories for action (including web link references for more details)—all in real time, in the OR, or at the bedside. When questioned, the exhibitors did not embrace the term “ultimate smart alarm,” suggesting that was overly simplistic. Of all the exhibits, this was the most futuristic and also provocative because it offered a hint of where technology may take us in the decades to come.
The APSF Pierce Award for the best safety themed scientific exhibit went to the “CommunicatOR,” from Thomas Jefferson University for the exhibition of a computer software based communications program that can be used in real time, including in the OR, to facilitate clinical communication with patients who do not speak English.
In the Technical Exhibits at the meeting, newer themes assumed some of the lead roles.
It was abundantly clear that this is the year of the video laryngoscope. In a variety of permutations and combinations (small screen on a laryngoscope handle or malleable stylet, fiberoptic camera connection of various direct and indirect scopes to small, medium, or large external viewing screens, or even some new wireless connections), electronic imaging of the airway was one of the two “biggest” product categories as far as number of devices, number of companies, and wide variations on the theme. Not to be completely outdone, various manufacturers of supraglottic airway devices (LMA and others) displayed a host of new variants with differing details and claims for utility and even superiority in relevant clinical situations.
The other “big” theme was ultrasound applications. A great many manufacturers displayed devices for vascular access (including one that sends the ultrasound signal through the catheter being inserted) and for facilitating regional anesthesia. Another approach to emergency vascular access was featured in an expanded display of tools for rapid access and high flow intraosseous delivery of crystalloid, colloid, and blood.
An interesting product display featuring a wireless continuous temperature probe provoked more than a few discussions of the question of when all patient monitors, particularly in the OR, might become wireless and how cumbersome and even dangerous the usual tangle of monitoring wires (often 10 or more) can be at the “head of the table” during an anesthetic or, often even more so, during emergence at the end of an anesthetic.
Patient warming devices of various types (including imbedded in the OR table) seemed to stage something of a resurgence in the seemingly vast exhibit hall in New Orleans (and there appeared to be 2 new provider warming devices on display). One manufacturer suggested that the impending implementation of the SCIP guidelines on hypothermia at the time of admission to PACU and the use of that metric in part to determine reimbursement for anesthesia professional services contributed to the renewed emphasis on warming technologies and strategies.
Other observations: Real time monitoring of cardiac output and intravascular volume status, most often from endotracheal tube or esophageal probes was again touted as a patient safety advantage. Commercial displays of IR facilitated “vein finders” increased in number. Finally, with all the emphasis in the anesthesia patient safety literature and campaigns on OR medication safety and avoidance of medication errors by anesthesia professionals, there was only one exhibit featuring prepackaged anesthesia medication and one featuring an automated syringe label printer for OR use.
Overall, patient safety persisted as a focus among both types of exhibits at the ASA Annual Meeting. This emphasizes some of the innovative thinking that has contributed to improving anesthesia patient safety but also the significant safety challenges yet remaining.
Dr. John Eichhorn, Professor of Anesthesiology at the University of Kentucky, founded the APSF Newsletter in 1985 and was its Editor until 2002. He remains on the Editorial Board and serves as a senior consultant to the APSF Executive Committee.