Circulation 60,475 • Volume 15, No. 3 • Fall 2000

Safety Topics Permeate WFSA World Congress: June Montreal Meeting Adds 2 New Perspectives

John H. Eichhorn, MD

Patient safety issues and concerns permeated the multitude of presentations at the 12th World Congress of Anesthesiologists of the World Federated Societies of Anesthesiologists held in Montréal, Canada in June of this year.

The subjects addressed and the presentations given certainly included many now-traditional considerations of classic anesthesia patient safety issues. However, in addition, there were a significant number of presentations from representatives of countries around the world that likely both surprised and stimulated Congress attendees from the United States and Canada, in two ways particularly. First, anesthesia care in developing and economically disadvantaged (“third-world”) countries routinely faces enormous obstacles that are functionally unknown in the highly developed economically advantaged countries such as the U.S. Second (in one way quite interesting but in another potentially troubling), clinical research studies and anecdotal reports from countries that do not have the rigid governmental and institutional control mechanisms such as that in the U.S. may present investigations or observations that would not be possible in the U.S., thus stimulating thinking and perspectives that might otherwise be overlooked.

Issues from developing countries again included the fundamental idea of the often low status of anesthesia providers and the limitation of resources that almost by definition accompanies a lack of respect or desirable status for anesthesiology as a medical profession and the administration of anesthesia as a key component of medical care. This idea was partly covered in the article “International Anesthesia Safety Group Hears Worldwide Perspective at World Congress” in the Summer 2000 APSF Newsletter . A main point made by Dr. Amr Montasser of Egypt was: “…as important as anesthesia patient safety is, in developing countries, efforts to identify and address safety issues very often must, by definition, assume a secondary role in a profession where basic survival is still a fundamental goal.” Even in practice situations where the value of anesthesia care is recognized, whether government-sponsored or private, the stark lack of resources not only can severely limit the breadth and depth of available anesthesia care, but also can itself cause dangerous anesthesia safety problems. Throughout the World Congress meetings, there was an underlying current of desire for the meeting itself to generate ideas and proposals that anesthesiologists could take back to the ministry of health (or equivalent) in their countries (since a great deal of medical care originates with or is controlled by the government in developing countries) both to help upgrade the status of anesthesia and its providers within the medical establishment and also to enhance resource allocation to anesthesia care.

New Perspectives

Epidemiologic observations from new reporting sources were presented. Malaysia has a national Perioperative Mortality Review which compiles statistics on and conducts analyses of deaths of any patient who had any anesthetic on that terminal admission. The perioperative death rate (all causes) from two studies in 1998 was between 6 and 7 per 1000 patients. The presenting authors concluded “that further improvement can be made.” The same type of conclusion was presented by Dr. Y Kawashima of Japan in his report that the rate of anesthesia-related cardiac arrest in 2.3 million patients was 1 per 10,000.

An example of interesting clinical research was the presentation of Dr. WD Mi from Bejing, China, who conducted multi-hour anesthetics using only a combination TIVA infusion of ketamine, propofol, and fentanyl. In adults (ages 20-50), cardiac output decreased by more than 30%, but in the elderly (>age 65), there was no statistically significant decrease. There was no significant change in stroke volume or ejection fraction in either group. Emergence and extubation were “quick” in all patients and it was concluded that this technique is safe and effective, particularly for geriatric anesthesia.

As is the case with all considerations of anesthesia patient safety, airway manipulations and issues were prominent in the discussions. Tools and techniques, some widely familiar, some not, were the subject of several new studies. The utility of the laryngeal mask airway with low-flow gas anesthesia was demonstrated by Dr. J Sukro of Malaysia. Blind intubation of patients with known difficult airways using a new type of tube-changer catheter inserted through an LMA with subsequent tracheal placement confirmation using a self-inflating bulb was reported by Dr. Y Wafai of Chicago. Dr. S Nimmaanrat of Thailand reported a case of an unexpected huge vallecular cyst completely obscuring attempted direct laryngoscopy and preventing intubation; it was noted that the “anesthesiologist should anticipate laryngeal abnormalities when the patient presents with underwater voice…” A study by Dr. J Schreiberova of the Czech Republic on predicting difficult intubation compared detailed preop airway exam with awake “first look assessment.” Both correlated with correct predictions. The “first look” was less reliable with inexperienced practitioners but more effective, and eventually preferable, with increasing years of practice. The value of using Mallimpati class and thyro-mental distance in predicting difficult intubation was confirmed by Dr. NA Merah of West Africa. A similar type of study with matching results was presented by Dr. V Hassani of Tehran, Iran.

Other topics each covered in multiple poster presentations included safety questions surrounding, for example, isovolemic hemodilution for procedures with anticipated large blood losses. With procedural caveats, the conclusions favored the use of these types of protocols. Availability of safe and secure medical gas supplies and the obvious patient safety implications was also a topic considered. Degrees of needed monitoring for patients receiving low-flow gas general anesthesia was discussed in a presentation from Belarus. An extensive study from Norway concluded that color-coding syringe labels did not reduce “syringe-swap” errors in which incorrect drugs were administered (which happened with surprisingly great frequency and most often involved awake patients incorrectly receiving muscle relaxants); greater vigilance was called for.

Another tack was taken in several presentations regarding safety issues involving anesthesia and OR personnel OR gas pollution was considered a significant problem by presenters from several countries and there were also discussions of potentially infectious patients, including one by Dr. S Blanot from France about transmission of Creutzfeldt-Jacob disease.

Practitioners as Threats

Interestingly, the safety risk to patients of anesthesiologists whose skills are suboptimal was discussed. Dr. M Tessler of Montréal, Canada, extended the comparison of anesthesiologists to commercial airliner pilots to include questions about consideration of age and physical abilities in governmental granting of licenses. In Canada, there are no age or physical ability considerations or limitations for licenses to practice medicine, in contrast to the strict guidelines for physical abilities required for a pilot’s license. It was recommended that regulations for minimum standards for anesthesiologists be instituted. Further, Dr. A Merry of Auckland, New Zealand, gave a talk entitled “The Physician Who Is a Risk to Patients.” He posited a thesis questioning if there is “a minority of high-risk doctors, namely ‘the ill,’ ‘the bad,’ and ‘the incompetent…'” that requires scrutiny. An outline of these “problem doctors” was provided. It included transmission of infectious disease from anesthesiologist to patient, doctors with physical and mental illnesses (especially dementia) that impair clinical function, aging doctors with slowed reflexes and very junior doctors with inadequate supervision, severe fatigue among doctors of all ages leading to decreased vigilance and slowed reactions in a crisis, and, expectedly, doctors impaired from substance abuse. However, it was stressed that this subset of doctors “classically thought to pose a risk to patients” is extremely small compared to vast majority of practitioners who are “good doctors” but: “the evidence suggests that, as in any activity, most doctors make mistakes.” Reference was made to the 1991 Harvard study of New York State errors in care of hospitalized patients, the 1995 Quality in Australian Health Care Study, and, indirectly to the U.S. Institute of Medicine 1999 study of medical errors. The essence of the presentation was in a quote from Dr. Atul Gawande in his well-known 1999 article, “When Doctors Make Mistakes,” in the New Yorker magazine: “The real problem isn’t how to stop bad doctors from harming, even killing their patients. It’s how to prevent good doctors from doing so.” Dr. Merry acknowledges that solutions will not be easy. Better systems based on clinical governance and risk management will be needed to generate effective, realistic action. He cites Canada and New Zealand as examples where there are new and innovative approaches allowing informal registering of concern about the competency or impairment of a doctor and the subsequent construction of a competency program and review for the practitioner in question.

Info Implications

Another talk entitled “Safety – What’s New” by Dr. R Webb of Queensland, Australia opened with the idea, “Advances in safety in anesthesia have traditionally been made in areas such as training, maintenance of standards, re-accreditation, monitoring, newer and better drugs, newer and better equipment, newer and better techniques, audit and outcome analysis, crisis management training and the use of sophisticated simulators.” Information management is the next big area that will have an impact on anesthesia patient safety, the presenter maintained. First is the idea that widespread use of the Internet will significantly speed up dissemination of all types of relevant information to practitioners who can then much more quickly incorporate it into their anesthesia care. Another aspect is the electronic archiving and retrieval of patient information so that anesthesia personnel about to begin an anesthetic can have instant complete access to all available data, whether from an outpatient preop screen (and a myriad of associated test results) two days prior or an adverse anesthesia event years before. Studies were cited showing that nearly 10% of anesthesia incidents had a failure of information communication as a contributory factor and dramatic reduction of that statistic as well as general improvement in patient outcomes were the stated goal of the new application of information technology to anesthesia patient safety.

Dr. Eichhorn, Professor and Chairman of Anesthesiology at the University of Mississippi, Jackson, MS, is Editor of the APSF Newsletter and was a member of the American delegation to the World Congress.