Volume 3, No. 2, pp9-16 June, 1988
Table of Contents

Children Face Extra Safety Problems
Post-Op Mortality Studied in APSF Sponsored Research
Letters to the Editor: 'Aggressive' QA at Cook County Hospital
Volatile Agent Overdose Is Potential Cause of Catastrophe
Current Questions in Patient Safety: Leaving Patients Unattended
Survey On Fatigue And Work Practices Of Anesthesia Practitioners
Letters to the Editor: Medical Decisions Asked of PACU Nurses?

Children Face Extra Safety Problems

Pediatric Anesthesia The Practical and the Practicable

by Robert S. Holzman, M.D.

Anesthesia clinicians who work with children are at an interesting point in history-the junction of the practical and the practicable. Practices that are realistically based in our experience have to be blended with our current knowledge of the biological responses of children to surgery and an evolving body of research.

Pediatric cases can be the most fun and the most frightening for an anesthesia caregiver. The rewards for a case well done are great-personal satisfaction, a good outcome for a child, and relieved and thankful parents. The narrower margin for error due to great differences in oxygen consumption, carbon dioxide production, fluid requirements, as well as risks of hypothermia, laryngospasm, and rapid desaturation combine to demand a heightened awareness on the part of the anesthesia clinicians "telescoping" of vigilance-in an effort to prevent anesthesia accidents.

Ever since the first recorded anesthetic death, a healthy 15-year-old girl named Hannah Greener undergoing toenail excision under chloroform anesthesia in 1848, there has been consistent recognition of age-related risks in anesthesia. Studies in pediatric anesthetic mortality over a 30 year period from 1948 to 1979 reveal a mortality range of 3.3: 10,000 to 0 in 35,000 in a variety of surgical populations. Most studies consistently reflect a greater mortality for children. Keenan and Boynan in 1985 reported a threefold greater risk of cardiac arrest due to anesthesia (4.7: 1 0,000) in children less than 12 years old. Despite these studies, there is nevertheless a paucity of data on the "near-misses," the close calls that clinicians have in daily practice when working with children. Beginning in 1954 at The Children's Hospital of Boston, statistics reflecting more than 150,000 patients from 0-20 years of age reveals an anesthetic mortality of 1.8:10,000 in the 0-10-year-old group from 1954-1966, decreasing to 0.8: 10,000 in this same group from 1966-1978, and 0. 6: 1 0,000 in the 10-20-year-old group.

Through the 1960s, aspiration was a leading cause of morbidity and mortality. Changing attitudes toward routine tracheal intubation and respiratory care of children contributed to decreasing this risk. Hemorrhage was revealed as a major source of morbidity over the following decade, and again, changing attitudes in favor of more aggressive fluid therapy for children affected this statistic. Over the last decade, there has been a steady growth in the number and complexity of pediatric surgical patients, and our attention is focused more than ever on fundamental concepts of pediatric anesthesia, critical care, and specific monitoring needs, concepts which inevitably impact on quality, outcome, and safety.

Heat Loss Threat

It has been long-recognized that infants and children are at two distinct disadvantages when it comes to defense against heat loss. First, they cannot sustain body temperatures as well as adults can in cold environments, and second, their high ratio of surface area to body weight results in greater heat loss through the skin. Premature infants are even more vulnerable, requiring higher environmental temperatures to maintain normothermia. "Core" temperature monitoring (esophageal, rectal) may be lm sensitive to hypothermia than axillary or skin temperature, where a temperature change will register earliest. Early detection provides the opportunity to make a therapeutic intervention, preventing further heat loss.

For procedures involving limited surgical exposure, such as plastic surgery of the face and neck or single extremity procedures, conservative means of addressing heat loss may be employed-a warming blanket, wrapping of extremities, and increasing the room temperature to a tolerable limit. For major procedures involving body cavity exposure for long periods of time, heated humidification systems supply both humidity and heat to the breathing circuit, and to the blood traversing the pulmonary circulation. Low flows in a semi-closed circle absorption system (I liter or less total fresh gas flaw) or closed circuit techniques achieve a higher temperature in the airway and minimize the amount of cold dry gas delivered to the humidifier. Confidence with low-flow anesthesia is bolstered by the routine use of a mass spectrometer as well as an oxygen analyzer.

NICU Veterans

As younger babies and veterans of the Newborn Intensive Care Unit are presenting themselves for anesthesia and surgery, maturation of ventilatory control has become a very important issue. Consensus is that abnormal postoperative ventilatory control in conception should be anticipated following anesthesia. Such patients are not good candidates for day-surgery. Alternative anesthetic techniques such as regional anesthesia exist, and investigations in several centers are underway in follow-up initial reports of a dramatic decrease in postoperative mechanical ventilation following the use of spinal anesthesia in ex-premature-s.

A better understanding of the dynamics of the pulmonary circulation has evolved over the last decade. In addition to knowledge of the transitional circulation in the term newborn, an understanding of the pulmonary circulation is particularly important when caring for the critically ill baby who may revert to a few circulatory pattern when pulmonary vascular resistance increases, in the setting of acidosis, hypercarbia, and hypoxemia. Anesthesiologists play a vital role in influencing the adequacy of pulmonary blood flow through their intraoperative choice of anesthetic agents, regulation of the depth of anesthesia, fluid management, and ventilatory volume, rate, and pattern.

Stress Cited

Depth of anesthesia, choice of agents, and the role of stress attenuation is receiving increased attention. The well-known inverse relation between MAC and age has been expanded to include additional pharmacologic considerations such as significantly reduced MAC requirements in the premature and age-dependent differences in blood and tissue solubility of potent inhalation agents. Very recent studies examining hormonal, metabolic, and hemodynamic aspects of newborn surgical stress suggest a relationship between intraoperative anesthetic management and perioperative outcome. Clinical studies over the last several years examining the pharmacodynamics of fentanyl and sufentanyl in children form the basis for rational alternatives to pure inhalation techniques, for both cardiac as well as routine surgical procedures. The attenuation of postoperative pain in children following the intraoperative use of methadone has been enthusiastically accepted by patients and parents.

Airway Concerns

More than half of anesthetic deaths are attributed to airway related mishaps such as failure to ventilate, esophageal intubation, ventilator disconnects, or accidental extubations. In several studies, perhaps 75% of such accidents are avoidable. There are few routine airway considerations in the care of children, because care needs to be directed to age-specific concerns. First, the tongue is relatively large, and occupies the majority of the mouth and oropharynx. The large head of the infant and small child eliminates the desirability of a pillow or blanket to bring the head and neck into a I 'sniffing" position, but this often makes manipulation more difficult. The larynx of the infant and small child is high and anterior, with the narrowest portion of the airway in the cricoid region, which is non-expansile. Lastly, the distance between the bifurcation of the trachea and the vocal cords in the infant is no more than 4-5 cm. Confirmation of tracheal tube placement needs to be accomplished not only by auscultation (breath sounds can be heard in the head of a newborn) but by direct examination of chest expansion, a persistent humidified "flash" in the tracheal tube, an "anesthesia" vital capacity maneuver (chest wall compression and simultaneous auscultation of breath sounds through the tracheal tube) and capnography when in doubt.

Mask ventilation in children needs to be accomplished with minimal encroachment of the fingers on the soft tissue of the submental area; pressure here only displaces the soft tissues of the oral cavity closer to the palate, worsening intra-oral obstruction.

Straight blade laryngoscopes are preferable in children up to school age because of the relatively large head size and the higher and more anterior position of the larynx. In school age children, curved blade-s can be employed as effectively as in adults. Once passed through the vocal cords, the tracheal tube may "hang up" at the cricoid or may impact on the anterior tracheal wall, requiring release of exposure by the laryn8oscope in order to allow the tube to advance. Finally, again, once the tube is passed, care should be taken to confirm the position of the tube in mid-trachea, as moderate amounts of flexion or extension may result in endobronchial or supraglottic placement of the tube with surgical positioning. Flex and then extend the patient's head while listening to breath sounds, then tape the tube to the most immobile portion of the face (the maxilla and zygoma) unless other considerations are present.

Very Rapid Changes

All anesthesiologists during training and in practice develop a feeling for the different tempo that characterizes care for children. The rapidity of changes in oxygenation, adequacy of the airway and heart rate are traditionally monitored in real-time by "the experienced eye, ear, and hand" through stethoscopy and palpation, in addition to the usual non-invasive monitors. Direct observation through the senses of the clinician has, in the past, often been faster that available monitors, allowing rapid correction of recognized problems. Pulse oximetry and capnography now allow confirmation and quantification of real-time clinical senses, and augment the anesthesiologist's ability to make fine adjustments or potentially life-saving interventions. Routine use of capnography has enabled early detection and intervention for malignant hyperthermia crises and venous air embolism. invasive vascular monitoring, particularly in the sick newborn, provides guidance on volume and metabolic status, and is part of the increasingly aggressive attitude toward early diagnosis and intervention in pediatric anesthesia and critical care.

The nature of pediatric practice is changing in very fundamental ways due to economic influences. Particularly in pediatrics, this impacts on the amount of time available to establish rapport with the child and family in the face of 60% day-surgery or day-admissions in many institutions. The patient and family have often been seen by another member of the department, on a different day in the Pre-Op Clinic, or may not have been seen at all until the day of surgery. When anesthesia care can be so de-centralized and out of control of the clinician with primary responsibility, a great deal of reliance is placed upon consistency and completeness of a colleague's preoperative evaluation. Clear communication is essential under such circumstances, in addition to a investment of time for the sake of rapport with the parents and patient, lest we slip back to the image of the "faceless" practice of anesthesia.

Pediatric surgeons and pediatric anesthesiologists in tertiary care institutions are continuing to accept the challenges of caring for ever-younger, increasingly fragile patients, as well as & survivors of early medical and surgical interventions who present with subsequent "routine" surgical problems. With the combination of the "practical" approaches developed through experience and the "practicable" approaches based on current research and technical advances, and increased awareness of causes of anesthesia accidents, we hope to continue to tailor care to each patient's needs, establishing parity with all of the other anesthesia subspecialties, against the backdrop of in increasing ability to provide for quality and safety when anesthetizing children.

Dr. Holzman is Clinical Director, Department of Anesthesiology, Children's Hospital, Boston.

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Post-Op Mortality Studied in APSF Sponsored Research

by J. Lance Lichtor, M.D.

Editors note: Dr. Lichton was a recipient of an APSF Research Grant for 1987. He reports here on a portion of his work,

Anesthesia is generally thought to be associated with minimal risk. Nonetheless, certain cases in which anesthesia is thought to be a key factor in the demise of the patient make the headlines because of multimillion dollar settlements. We felt that current impartial data on death after anesthesia and surgery would be useful to assess risk in a variety of settings.

Data tapes representing the National Hospital discharge Survey (NHOS) between the years 1979 and 1984 were examined. The National Master Facility Inventory of Hospitals and Institutions constitutes the basis for hospital selection in this survey. The National Center for Health Statistics has published guidelines for the maintenance of this inventory as well as procedures for insuring completeness of its coverage. Hospitals with fewer than 1,000 beds were stratified according to size and geographical region. Allocation of hospitals in the survey were then made in a controlled fashion so that hospitals were property distributed by type of ownership and geographic division. AU hospitals with 1,000 beds or more were included with certainty in the sample. Smaller hospitals were included by probabilities ranging from certainty for the largest hospitals to I in 40 for the smallest hospitals.

Within hospitals, the smallest fraction of discharged patients were evaluated in the largest hospitals, and the largest fraction was examined in the smallest hospitals. The discharges were selected by a random technique, usually by the last digit in the patient's medical record number. A weight was assigned for each record which was based on the reciprocals of the probability of sample selection, adjustment for non-responses, and ratio adjustment for fixed totals. The weight allows for extrapolation to national or regional estimates.

Each record includes information on patient age, date of admission and discharge, discharge status, diagnoses (at most seven), procedures performed (at most four), age, bed size of hospital, source of payment, hospital ownership, and region of country. This information was used in our analysis. We selected only those patients who we felt had a high likelihood of requiring general or regional anesthesia for their procedure, whose "discharge status" was "dead", and who died within six days of their surgical procedure. Ratios were calculated by determining those patients who died who fit a certain criterion and dividing this number by the total number of patients who fit that category. For example, the relative ratio for patients who died and had Medicare was calculated by finding those Medicare patients who died and then dividing this number by the total number of Medicare patients who had surgery.

Between 1979 and 1984, a total of 745 patients from the sample population of hospitals who had surgery were determined to have died within one day of their surgery; using the weighting factors, this represents 135,570 patients in the United States. A total of 1,798 patients, representing 330,499 patients nationwide died within six days of their surgery. In all, 343,800 patients, representing a nationally projected 67 million patients underwent surgery during the six-year period. The incidence of death within one day of surgery was 2.21 per thousand, while the incidence of death was 5.33 per thousand within six days of surgery. The table lists the death rates per thousand for each year during the study. Both crude and standardized rates are listed. Because the average age of patients undergoing surgery has increased between the year 1979 and 1984, the death rates have be-en standardized; we arbitra6y chose to standardize the death rates to the age distribution present in 1979.

Young, Old at Risk

Death rates are highest in the young and old; the figure illustrates death rates according to age of the patient. Hospitals over 300 beds have higher death rates following surgery than do smaller hospitals. Government and church hospitals, both of which have socio-economically disadvantaged, have higher death rates than proprietary hospitals. Patients with Medicare insurance, and those without insurance have greater mortality rates following surgery than do patients with commercial insurance. Patients undergoing thoracic, cardiac, vascular and neurosurgical procedures also have a higher incidence of death following surgery than do patients undergoing other types of procedures.

The results of our study are interesting in several respects. The standardized death rates are relatively constant for patients who died within one and six days of surgery. Anesthesia residency programs tend to emphasize teaching for cardiac, vascular and neurosurgical cases; this practice seems confirmed by the relatively high incidence of patients who died after surgical procedures.

Death rates are relatively higher in government or church-owned hospitals than in proprietary hospitals; the mason for this is not totally clear. Patients with Medicare show the highest ratio of death after surgery. This undoubtedly correlates with advanced age; these patients tend to have a high incidence of organ failure than do their younger counterparts. Patients with self payment or no charge show a high ratio of death, particularly within one day of surgery; this may be artifactual, however, due to the relatively small size of this population (the variance of the measurement is relatively high).

Our results are similar to those obtained in similar current studies of mortality in Europe, and in older studies from the United States. In 1982, the Association of Anaesthetists of Great Britain and Ireland reported an overall mortality rate of 0.53% within six days of operation. The data in our study provides a means for us in the future to quantify changes in our quality of care and patient outcome caused by measures forced on us by cost containment measures, legal influences, or our own beliefs.

Dr. Lichtor is Assistant Professor, Department of Anesthesia and Critical Care, University of Chicago.

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Letters to the Editor: 'Aggressive' QA at Cook County Hospital

To the Editor:

The concerns with liability, along with the usual tendency to let complications go without immediate discussion to an undeterminate date, leads to unfavorable trends.

At Chicago's Cook County Hospital, we have developed an aggressive approach in assessing the quality of care that is available to our patients. Our aim is towards achieving the safest possible atmosphere for administration of anesthetics to indigent, frequently critically ill patients. This is achieved by information obtained from various quality assurance/risk management activities, structured into a coordinated program along with the other hospital departments.

First, we have a consistent reporting mechanism wherein all residents and CRNAs along with faculty report on a monthly basis their professional activities related to quality assurance in the operating room and critical care areas along with the mishaps and "near misses" they had during that month. AN this information is compiled together reflecting an in-depth search for any trend or pattern focusing towards a particular type of anesthetic mishap and/or towards particular CRNA, resident, or faculty.

There is also a mortality/morbidity reporting system wherein the following problems are automatically reported.

1. Difficult intubation

2. Reintubation

3. Aspiration pneumonia

4. Dental complications

5. Nerve damage

6. Adverse drug reaction

7. Blood/component transfusion reaction

8. Iatrogenic patient injuries

9. Wide swings in hemodynarnic and respiratory parameters

10. Unplanned patient transfer to ICU

11. Complications in PACU needing intervention

12. Cardiac arrest in operating room and recovery room

These reports are submitted to the department chairman or his designee within 24 hours of the occurrence and are discussed in the general departmental meeting, every week, wherein (apart from discussion of the case) corrective action and recommendations are made immediately. Depending on the severity of the mishap, these recommendations may be formalized in the form of a protocol which is subsequently followed and monitored for compliance.

A formal report is made on all deaths that occur within the first 48 hours of surgery or regardless of the time, if anesthesia is implicated in the demise to the patient. AD death reports are discussed immediately with the department chairman and faculty members.

A pre-operative checklist for verification of readiness of the anesthesia apparatus has been developed and is attached to the anesthesia machine. It is rigorously followed by the anesthesia personnel. This has resulted in minimizing equipment-related mishaps. Similarly, a protocol for the treatment of malignant hyperthermia is also attached to every anesthesia machine, along with an adequate supply of dantrolene sodium and cold saline solution in the refrigerator, with an MH tray available in each operating room suite.

The Departmental Quality Assurance Committee has produced guidelines for invasive monitoring in high-risk patients. The committee has also been instrumental in developing specific protocols for various situations which have been helpful in reducing mortality and morbidity in high-risk patients.

The department adheres to the guidelines set up by the Blood Bank Committee while administering blood to patients. Moreover, anesthesia equipment and monitoring devices have been included in risk management programs according to ICAH spe6fications. This has resulted in periodic testing, documentation and reporting of problems related to equipment and repair by professional technicians or by the manufacturer when needed.

In the PACU, justification for the presence of an endotracheal tube in place as well as therapy of hypertensive episodes are currently under surveillance.

There is an on-going medical record review wherein certain aspects of pre-operative evaluation, anesthetic records, and post-operative visits are reviewed monthly and compliance is compared with the expected norms. This medical record review has improved charting and record keeping, which is an important element in anesthesia practice.

The Anesthesiology Department is represented in the hospital-wide Quality Assurance Committee where problems related to patient care from all departments are discussed on a monthly basis. There is also a quality assurance hotline, set up by this committee, intending to deal with problems needing immediate attention.

With the help of these Quality Assurance activities, the department has been able to identify, evaluate, and respond appropriately in a timely fashion to problems related to patient cam

Lata Sabnis, M.D. Attending Physician and J. Antonio Aldrete, M.D. Chairman, Department of Anesthesiology and Critical Care, Cook County Hospital.

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Volatile Agent Overdose Is Potential Cause of Catastrophe

by Richard L. Keenan, M.D,

Recent advances in anesthesia equipment design and the availability of clinical gas monitoring methods have raised two important safety questions. First, should "kettle" type vaporizers (Copper Kettle, Venitrol, etc.), which require calculation and the setting of two flowmeters (vaporizer and diluent flows) be abandoned in favor of the "tec" type vaporizer, in which concentrations are dialed directly, with automatic flow and temperature compensation? Second, should the concentration of respired volatile agents be monitored routinely?

A recent review of the literature reveals that absolute overdose of volatile anesthetics is, after hypoxemia, the second cammonest cause of anesthesia mortality and serious morbidity (1). Mishaps specifically due to misapplication of kettle type vaporizers have been identified m at least two published studies. (2,3) Typically, "kettle" control errors result from miscalculation, misunderstanding, or incorrect flowmeter settings leading to the delivery of excessively high concentrations which are unintended and, more importantly, unrecognized at the time.

The human errors of miscalculation and misunderstanding are eliminated with "tec" vaporizers. Calibration errors, while possible, are typically not greater than the expected variability of patient response. Although "tec" vaporizers can accidentally deliver lethal concentrations when overturned, bolting the vaporizer to the machine has eliminated this hazard. No published case collection or epidemiologic study of anesthetic death mentions a mishap due to a "tec" vaporizer. On this evidence it may be concluded that the "tec" vaporizer has a demonstrated safety advantage over the "kettle".

However, it is important to note that the evidence for the safety of the "tec" vaporizer comes from an era in which inhaled concentrations of volatile agent were not routinely measured, but instead were estimated from flowmeter and vaporizer settings. Furthermore, traditional high flow circle and non-rebreathing systems allowed the assumption that the inhaled concentration was the same as that in the fresh gas flow.

From the evidence, therefore, it is reasonable to conclude that "tec" vaporizers, but not "kettle" vaporizers, may be used safely in high flow system when respired anesthetic gas concentrations are not measured.

It can be argued that the "kettle" is worth preserving as a valuable teaching tool which allows the demonstration of the vaporizing properties of agent any agent for that matter, since the "kettle"' unlike the "tec", is not agent specific. Moreover, the "kettle" is arguably more versatile in low flow systems. Since reported mishaps with the "kettle" have typically involved the delivery of unexpected and unknown high concentrations of agent, then the routine measurement of these concentrations should obviate this problem. It is reasonable to recommend, therefore, that when respired anesthetic gas concentrations are monitored, any vaporizer, including the "kettle', can be used with reasonable safety.

In summary, volatile anesthetic gases may be administered safely in the absence of anesthetic gas monitoring only when "tec" vaporizers are used in high flow circle or non-rebreathing systems. With anesthetic gas monitoring, any vaporizer and any degree of re-breathing may be employed without danger of delivering unknown lethal concentrations of agent.


1. Keenan RL: Anesthesia Disasters. Seminars in Anesthesia 5:175-179, 1986.

2. Keenan RL, Boyan CP: Cardiac Arrest due to anesthesia. A study of incidence and causes. JAMA 253:2373-2377, 1985.

3. Cooper IB, Newbower RS, Long CD, McPeek B: Preventable anesthesia mishaps: A study of human factors. Anesthesiology 49:399-406, 1978.

Dr. Keenan is Professor and Chairman, Department of Anesthesiology, Medical College of Virginia, Richmond.

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Current Questions in Patient Safety: Leaving Patients Unattended

Question: When, if ever, is it appropriate for an anesthesiologist to step outside the OR door for brief periods, such as during x-ray or fluoroscopy? How should this situation be managed regarding observation and monitoring of the patient?

Dr. Zauder replies: It is never appropriate for the anesthesiologist to leave an anesthetized patient, for any reason, or for even the briefest period unless replaced by an appropriate substitute. Appropriate shielding provides adequate protection against radiation to allay any concerns the anesthesiologist may have in that regard. Though the number of monitors employed by anesthesiologists have proliferated in recent years, they do not and cannot substitute for the personal attention of a skilled anesthesiologist. Vigilance - the byword of the specialty must be constant. There is no acceptable alternative.

Answer by Howard L. Zauder, M.D., Ph.D., Professor and Chairman, Department of Anesthesiology. SUNY Health Science Center at Syracuse; Immediate Past President, American Society of Anesthesiologists.


Dr. Jene replies:

It is not appropriate for the anesthesiologist or member of the anesthesia care team to leave a patient unattended during surgery or a procedure while under his/her anesthesia care.

If the need arises for a "break" or "absence" from the patient, appropriate measures should be taken by the responsible member of the anesthesia care team to provide continuity of care for the patient.

This may be arranged in many ways, e.g., have another member of the anesthesia care team come into the OR to cover time away. This should be brief and the surgeon should be aware of the change.

During x-ray and fluoroscopy procedures, proper shielding protection should be available from the Radiology Department to provide the needed safety for those who must stay with the patient. In some OR's or x-ray rooms, there will be a lead shield or protected area a few feet from the patient which can be used for the brief period of exposure needed. There must be careful coordination between the anesthesia and radiology personnel so that the anesthetist can duck behind the shield for a moment. When this is not available, lead aprons should he worn and some anesthesia practitioners also squat down at the head of the table so the metal table top is between them and the x-ray beam.

When the anesthesiologist or member of the anesthesia care team agrees to provide anesthesia for a patient undergoing a surgical procedure, this is in effect an agreement/contract between two parties for a service. The patient should have Discussed this with the anesthesia care provider prior to the procedure. This conference (which covers Procedure, Alternatives, Risks PAR) should be documented on the chart prior to an elective procedure. This is part of the standard of rare all patients should receive. This agreement between physician and patient is clearly outlined in the ASA Peer Review Manual as well as by most hospitals and should be in the anesthesiology department/service guidelines for all members to follow. There is a clear understanding that this agreement with the patient includes the continuous presence of anesthesia personnel throughout the procedure.

When the ASA adopted the Standards for Basic Intra-Operative Monitoring in 1986, the homework from which EVERY anesthesia provider should function was established. Likewise, each patient and surgeon can expect no less from the member of the anesthesia care team at the head of the table. These standards have been widely publicized and should be observed routinely in ALL anesthesiology departments. The first standard states: "Qualified anesthesia personnel shall be present in the room throughout the conduct of all general anesthetics, regional anesthetics and monitored anesthesia care."

The anesthesia which is provided within a medical setting, (hospital, x-ray office, ambulatory surgical facility, or other) should have the same standard of care available to ALL patients. This should be a written part of departmental policy and procedure. If not the case, then the chairman of anesthesia is responsible for undertaking the proper means to establish this uniformity. It may he necessary for an ad hoc committee of anesthesiology representatives as well as members of the surgery, obstetrics, x-ray, risk management, and quality assurance departments to work toward this goal. Documentation of the standard of care, department policy and guidelines must be available, reviewed regularly, and be acknowledged by signature by each anesthesia care provider. If the standard of care is not followed, then this breach of the acknowledged policy will provide a rationale for the department chairman to confront those involved regarding the issue(s). A good example would be a practitioner leaving a patient unattended while taking a break. The written policy will provide a platform from which to address the question and then take actions or recommend solutions, which may call for limitation of privileges, monitoring of behavior, additional training, letters of reprimand, etc.

Finally a continent regarding monitors: with the advent of the current invasive and noninvasive monitors, it is even more important for the anesthesiologist or member of the anesthesia care team to understand, use, and document the information. However, just because there are numbers flashing and cardiac and respiratory tracings evident, this does not constitute permission to leave the patient unattended or delegate monitor watching to a member of the OR staff. The patient is the obligation of the anesthesia care provider and this must never be forgotten.

Answer by Joanne Jene, M.D., Portland, Oregon, who is a member of the ASA Pea Review Committee.

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Survey On Fatigue And Work Practices Of Anesthesia Practitioners

Without sufficient sleep and rest, the attention and vigilance of even the most stalwart worker is likely to fail. But, we don't know at what point safety is actually compromised. How long do most of us believe we can work without a rest period or without a good night's sleep? Do older practitioners require more or less rest than younger practitioners? Do most of us need periodic, short breaks? How long should those rest periods be?

Because anesthetic mishaps have been blamed on fatigue, it behooves the profession to determine what it believes to be reasonable work practices. To this end, we have developed a questionnaire to correct information and solicit opinions about work practices in anesthesia.

You will find a survey form facing this page. It is brief and anonymous. The results will be made available to all. If you practice anesthesia, we urge you to fill out the questionnaire and return it. It is preaddressed and requires no stamp. Simply detach, fold, and seal with the gummed edge.

Thank you for contributing in such an important way to the anesthesia profession.

For The Anesthesia Patient Safety Foundation

J.S. Gravenstein, M.D., J.B. Cooper, Ph.D., E Orkin, M.D., and R. Montoya

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Letters to the Editor: Medical Decisions Asked of PACU Nurses?

To the Editor:

I write to the APSF Newsletter regarding a situation that has been recurrently discussed in the risk management circles of Massachusetts.

Concern has been raised as to whether the practice of allowing registered nurses in the Post Anesthesia Care Unit (Recovery Room) to educate patients should be continued in light of our increasing litigious society.

In conversations with various Risk Managers from a variety of different-sized hospitals, it is becoming increasingly apparent that supervision of the Recovery Room staff by the responsible anesthesiologists is varied depending upon the type of hospitals surveyed.

For example, large teaching hospitals with residency programs in anesthesia tend to have available anesthesiologists in the recovery room at all times. However, mid to small-sized hospitals who practice with two to three staff anesthesiologists at best, rarely have an anesthesiologist immediately available to the recovery room. In most cases, the anesthesiologist transfers the intubated patient to the PACU and then begins another case. This leaves the extubation of patients to the discretion of the nursing staff based upon criteria taught to them usually on the job by the department anesthesiologist.

At a recent symposium sponsored by The Society for Post Anesthesia Care Nurses, a key note speaker felt that extubation by registered nurses was a duty above and beyond what is allowable under the Nurse Practice Act and in fact places the registered nurse, the anesthesiologist, and the hospital at risk if complications were to ensue. She further stated that if registered nurses practice extubation, it places them at the same level of duty of an anesthesiologist in that they should have the ability to handle complications and reintubation.

Again, in the informal survey conducted of various hospitals regarding this topic, it is dear that most Post Anesthesia Care Nurses cannot readily intubate nor have they been trained or educated to do so.

I would appreciate the thoughts of involved anesthesia providers concerning this matter. The position taken to date by some hospitals in Massachusetts are to:

1. Not allow recovery room staff to extubate, requiring increased anesthesia staff or increased time for the patient to be discharged from the operating room suite; or

2. To continue to allow recovery room staff to extubate after having been through an educational process developed and implemented by usually the Chief of Anesthesia for the involved hospital.

Clark A. Fenn Risk Manager Holyoke Hospital, Inc. (MA)

Editors note: Replies are welcome, either directly to Mr. Fenn or to the APSF Newsletter for publication.

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(Approved by House of Delegates on October 14, 1987)

These standards apply to all patients who receive anesthesia or monitored anesthesia cam Under unusual circumstances, e.g. extreme emergencies, these standards may be modified. When this is the case, the circumstances shall he documented in the patient's record.

Standard 1: An anesthesiologist shall be responsible for determining the medical status of the patient,. developing a plan of anesthesia care, and acquainting that patient or the responsible adult with the proposed plan.

The development of an appropriate plan of anesthesia care is based upon:

1 . Reviewing the medical record.

2 . Interviewing and examining the patient to:

a. Discuss the medical history, previous anesthetic experiences and drug therapy.

b. Assess those aspects of the physical condition that might affect decisions regarding perioperative risk and management.

3. Obtaining and/or reviewing tests and consultations necessary to the conduct of anesthesia. 4. Determining the appropriate prescription of preoperative medications as necessary to the conduct of anesthesia.

The responsible anesthesiologist shall verify that the above has been properly performed and documented in the patient's record.

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(Approved by House of Delegates on October 14, 1987)

Preanesthetic laboratory and diagnostic testing is often essential; however, no routine* laboratory or diagnostic screenings** test is necessary for the preanesthetic evaluation of patients. Appropriate indications for ordering tests include the identification of specific clinical indicators or risk factors (e.g. age, pre-existing disease, magnitude of the surgical procedure). Anesthesiologists, anesthesiology departments or health care facilities should develop appropriate guidelines for preanesthetic screening tests in selected populations after considering the probable contribution of each test to patient outcome. Individual anesthesiologists should order test(s) when, in their judgement, the results may influence decisions regarding risks and management of the anesthesia and surgery. Legal requirements for laboratory testing where they exist should be observed.

*Routine refers to a policy of performing a test or tests without regard to clinical indications in an individual patient.

** Screening means efforts to detect disease in unselected populations of asymptomatic patients.

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The Anesthesia Patient Safety Foundation Newsletter is the official publication of the nonprofit Anesthesia Patient Safety Foundation and is published quarterly in March, June, September, and December at Overland Park, Kansas. Annual membership: Individual $25.00, Corporate $500.00. This and any additional contributions to the Foundation are tax deductible

The opinions expressed in this newsletter are not necessarily those of the Anesthesia Patient Safety Foundation or its members or board of directors.

APSF Executive Committee:

Ellison C. Pierce, Jr., M.D., President; W Dekle Rountree, Jr., Vice-President; E.S. Siker, M.D., Secretary; Burton A. Dole, Jr., Treasurer; Jeffrey B. Cooper, Ph.D.; Joachim S. Gavenstein, M.D.; James E Holzer, J.D.

Newsletter Editorial Board:

John H. Eichhorn, M.D., Stanley 1. Aukburg, M.D., Jeffrey M. Beutler, C.R.N.A., M.S., Ralph A. Epstein, M.D., David E. Lees, M.D., E.S. Siker, M.D., Benard V. Wetchler, M.D., Mr. Mark D. Wood

Address all general, membership, and subscription correspondence to:


Anesthesia Patient Safety Foundation

515 Busse Highway

Park Ridge, IL 60068

Address Newsletter editorial comments, questions, letters, and suggestions to:

John H. Eichhorn, M.D.

Editor, APSF Newsletter; Dept. Anesthesia Beth Israel Hospital, DA-717 Boston, MA 02215