Volume 6, no. 4 pp 37-48
Table of Contents

Safety Persists as ASA Meeting Theme
ASA Exhibits Feature Safety Technology, Ideas
Editorial: APSF President Assesses 1991 Safety Developments
APSF Awards 3 More Research Grants for $175K
From the Literature: URIs and General Anesthesia in Children
From the Literature: ECRI Review Explains, Warns of OR Fires
Anesthesia Techs Hold Annual Meeting in SF

Safety Persists as ASA Meeting Theme

by Robert S. Holzman, M.D.; Susan L. Polk, M.D.; Donald R. Webre, M.D.; and Gerald L. Zeitlin, M.D.

Anesthesia patient safety and related topics were featured in 59 scientific presentations in four sessions at the October American Society of Anesthesiologists' Annual Meeting in San Francisco. In the Patient Safety and Education Section of the meeting, there mere two half-* oral paper presentations, one poster session, and one session of the new poster-discussion format, which was moderated by Ellison C. Pierce, Jr., M.D., President of the APSF, with discussion by Frederick Cheney, M.D., Chairman of the ASA Committee on Professional Liability and principal investigator of the ASA closed claims study.

Summarized here are selected papers from these four sessions. Several other presentations, including some from other sessions, also were relevant to patient safety. In all, patient safety persists as one of the major themes of the submitted presentations at this meeting.

Prospective Pulse Oximeter Study

Dr. J. Moller and associates from Denmark reported further findings from what will probably be the only prospective outcome study comparing patients given anesthesia with or without monitoring of oxygen saturation. This study is supported by the Anesthesia Patient Safety Foundation and included as co-authors Drs. J. Cooper and J. Gravenstein of the APSF Executive Committee This was a randomized study involving more than 20,802 patients, observed in both the operating room and in the PACU. As might be expected, there was a 19-fold increase in diagnosed hypoxemia in the group in which oximeters were used as opposed to the group in which they were not supporting Comroe's observations many years ago that observation of 'cyanosis' is a virtually useless method of trying to estimate hypoxemia. In the OR, cardiovascular events-were observed in 7. 8 percent of both groups, but myocardial ischemia defined as angina or ST depression was noted in 12 of the patients with oximetry and 26 of those without. This unexpected observation suggests an association between pulse oximetry, diagnosis of hypoxemia, and related myocardial ischemia that requires more study. In all, 15 predefined complications in the period from the day of surgery until the seventh postoperative day were studied. One or more postoperative complications were found in 5.2 percent of the population. Pneumonia, pulmonary edema and atelectasis were seen in 1.3 percent, 0.2 want and 0.7 percent of patients respectively. Cardiac failure and myocardial infarction were seen in 0.5 percent and 0.1 percent respectively. Cerebral stroke and pulmonary embolism were seen in 0.1 percent of patients. Most of the cardiac and pulmonary complications occurred in the first three days, peaking on the second postoperative day.

In a second paper, also presented by Dr. Moller, early postanesthesia outcome was examined in the same patient population, continuing the random assignment to pulse oximetry or nonpulse oximetry monitoring groups. Specially trained individuals recorded the presence of predefined complications from the first to the seventh postoperative day without knowledge of pulse oximetry use during anesthetic care. One or more postoperative complications were found in 10 percent of the pulse oximetry and 9.4 percent of the nonpulse oximetry patients. There was no statistically significant difference between respiratory, cardiovascular, neurologic, or infectious complications between groups. This finding of no difference in postoperative complications and perioperative outcome stands in interesting contrast to pulse oximetry's contribution to increased speed of intervention in adverse intraoperative events.

Choice of Technique

Dr. R. Sorensen and colleagues from the University of Utah used the technique of meta-analysis to try to decide an old but important question in anesthesia whether regional or general anesthesia affects morbidity and mortality. Meta-analysis uses statistical methods to systematically combine evidence from existing studies. They searched Medline for all the relevant studies since 1966 and only included randomized controlled clinical trials. The effect of the method of anesthesia used was summarized as the risk difference, which is the absolute difference in frequency of outcome between control and treatment groups. The authors found little difference in outcome when they compared death rates, cardiovascular, pulmonary and neurological complications, pulmonary embolus and nausea and vomiting. However there was a 2 3 percent greater incidence of deep vein thrombosis in patients who received general anesthesia.

The authors stated that this study was only intended to give a provisional answer to the question until a similar prospective study can be done.

Dr. N. Sharrock from the Hospital for Special Surgery in New York reviewed a ten-year experience in changing over from general to regional anesthesia for total joint arthroplasties. From 1981-1985, during which all total joint arthroplasties underwent general anesthesia, 28 of 5,394 patients (0.52 percent) died. From 1987-1990, the era of increased regional techniques 10 of 6,635 (0.15 percent) died. While it is possible that anesthetic technique made a contribution to the decrease in mortality, the author acknowledged that concurrent improvements in patient monitoring technology, increased use of invasive monitoring, the introduction of postoperative epidural analgesia, and changes in perioperative care acuity (postoperative intensive care, staffing changes and an enhanced quality assurance program) may have also contributed.

Modifiers and Outcome

Dr. D. Cullen from the Massachusetts General Hospital and Harvard Medical School presented a paper on the relationship of the physical status (ASAPS) and/or patient age to length of hospital stay, postoperative complications, and post discharge physician visits following total hip replacement, transurethral prostate resection, and cholecystectomy in 1,099 patients. For total hip replacement, both age and ASA-PS correlated with increasing length of stay, postoperative complications, and post discharge physician visits, with age the most important factor. For transurethral prostate resection, length of stay increased with age, but even more so with physical status. Postoperative complications and physician visits increased significantly with physical status, but not with age. For cholecystectomy, length of stay increased with both age and physical status, while complications and physician visits increased significantly only with physical status. It was suggested by Dr. Cullen that surveillance of this type of data is of particular importance when the Resource-Based Relative Value Scale will be implemented, as care for sicker and older patients may be under compensated through the averaging system, and that age and physical status are pragmatic means of stratifying patients for more equitable reimbursement.

Outcomes of Clinical Practice

In another installment of the ASA Closed Claim Project database, patterns of eye injury associated with anesthesia were reported by Dr. W. Gild of the University of Washington and his collaborators. Seventy-one claims for eye injury (three percent of the total database) consisted of eye injuries, with most of these cases (61 percent) resulting in blindness. Half of these claims were for anterior chamber injuries, and half for posterior chamber. Patient movement during anesthesia was the mechanism of injury in 30 percent of the cases, with 16 of the claims occurring during general anesthesia, and five during monitored anesthesia cam AU of the movement claims resulted in permanent injury, and payments were made to the plaintiff in 88 percent. The median payment for movement-related claims was $108,000 (compared to $9,000 for nonmovement claims). It is of particular interest for anesthetic plan formulation that muscle relaxants were not used in more than half of the claims for movement under anesthesia, and peripheral nerve stimulators were not used in any. It was concluded that patient movement during general anesthesia for ophthalmic surgery is a significant source of eye injury claims, that these claims incorporate a high severity of injury, are generally determined to follow substandard anesthetic care (by peer review), and are characterized by high payments. It was suggested that complication-related movements could be prevented through the use of muscle relaxants and monitoring of neuromuscular blockade.

With increasing success in medical and surgical interventions for children with complex congenital heart disease, many are surviving to develop normal childhood diseases requiring ordinarily "routine" surgical care. Dr. M. Strafford of the Children's Hospital and Harvard Medical School, Boston, presented her work with Dr. K. Henderson on anesthetic morbidity in congenital heart disease patients undergoing outpatient surgery. In one year, they identified 25 consecutive patients with congenital heart disease who underwent 27 anesthetics. Multiple diagnoses were found, and physical status category was two to three. All patients had preoperative room air saturations 90 percent by pulse oximetry. Two patients were noted to have an adverse event during the 2 7 procedures: one patient with unrepaired Tetralogy of Fallot had severe nausea and vomiting in the post anesthesia care unit, and one patient with Down's Syndrome and an unrepaired ventricular septal defect had airway obstruction and bradycardia on induction, releived with an oropharyngeal airway and atropine. They concluded that patients with congenital heart disease can be successful candidates for day surgery, but suggest that patients with moderate cyanosis and uncompensated congestive head failure should be excluded.

In another study, Drs. Strafford and Henderson studied anesthetic morbidity in patients with congenital heart disease undergoing noncardiac surgery. They gathered data from 110 consecutive patients undergoing 135 anesthetics in one recent year. Sixty of these patients had previously undergone either definitive or palliative surgery. Twenty-four suffered congestive heart failure, 17 of whom were compensated at the time of this additional surgery. The median age was 2.9 years. Remarkably, 47 percent of the group suffered a perioperative event. The majority of these perioperative events were described as airway emergencies, dysrhythmias, or incidents involving circulatory instability. The authors pointed out that what might be considered a minor adverse event in a healthy patient is potentially much more serious in these children.

Special Anesthetic Problems

Dr. C. Haberkern of the Children's Hospital Medical Center and University of Washington in Seattle presented a preliminary report of the National Preoperative Transfusion Study Group on preparation of sickle cell anemia patients for surgery. Preoperative transfusion is routinely carried out to suppress sickle cell production, dilute circulating sickle erythrocytes, and improve blood viscosity, although no prospective studies support this therapy, 565 patients have been enrolled from 35 institutions so far. They were randomized to two treatment arms: aggressive treatment to lower Hb S 30 percent and correct anemia to 10 gm/dl or simple treatment to correct anemia to 10 gm/dl only. Those patients who did not meet entry criteria were studied prospectively according to two further groups: no preoperative treatment, or nonrandomized treatment. Although the patient groupings have not yet been identified, data from the first 319 patients have been examined, including 169 in the randomized treatment groups. Initial results indicate an intraoperative complication rate of ten percent (hypothermia, hypoxia, hypertension, hypotension, airway obstruction and acidosis). Significant perioperative complications were acute chest syndrome or pain crisis (I 2 percent each), fever or infection in ten percent, new red blood cell antibody formation in nine percent, transfusion reactions in five percent, neurological events in two percent, death in two percent, and renal failure in one percent. The preliminary results outline an intra and perioperative care and complication profile for sickle cell anemia patients, and may suggest preferable methods of treatment once the study is completed.

Two abstracts addressed safety issues about malignant hyperthermia. The first, by Drs. C. Greenberg and H. Rosenberg of the Departments of Anesthesiology at Columbia University and Hahnemann University, reported the "hotline" experience of the Malignant Hyperthermia Association of the United States (MHAUS) in 1990, when over 534 calls were handled by 21 MH consultants. Seventy-three percent of the calls were from anesthesiologists or CRNA's. Three hundred and thirty-five calls were to request information about MH; 60 percent concerned preoperative evaluation or perioperative management of known susceptibles or those with a suspicious family history. Ninety-six were requests for assistance with case management, 71 of which concerned masseter muscle rigidity (MMR) after succinylcholine, and 65 were inquiries about acute or suspected MH. Sixty-two percent of MMR cases were associated with otolaryngology procedures, and 12 cases of MMR progressed to clinical MH. Four cardiac arrests were reported, but no deaths.

A related study was reported by Dr. S. Yentis of the Hospital for Sick Children in Toronto. Many patients are labeled as "malignant hyperthermia susceptible" (MHS) because of positive family history or a previous MH reaction, without confirmation by a muscle biopsy. He reported a review of 268 patients (ages one day to 19 years) labeled as MHS who underwent 365 trigger-free general anesthetics during a ten-year period. Twenty patients (5.5 percent) were biopsy positive, 103 (28.2 percent) received prophylactic dantrolene (which was routinely administered prior to 1986), and 12 (3.3 percent) were pyrexial (38.5 degrees C) postoperatively, most episodes of which were explained by other causes. The authors concluded that intra and postoperative pyrexia and complications related to MH are rare in children labeled as MHS undergoing trigger-free anesthesia.

Do Not Resuscitate Orders and the Anesthesiologist

Three reports of surveys addressed a most interesting evolution in patient safety concerns the care of the patient with "do not resuscitate" (DNR) orders coming to the operating room for surgical procedures. Dr. M. Clemency of Emory University reported on a survey of 187 anesthesiologists, 59 percent of whom assumed that a DNR order is suspended when a patient is scheduled for surgery. Half of this group discussed with the patient/family this assumption or their intention to intubate and resuscitate during a cardiopulmonary arrest. Responses differed for palliative or elective procedures, elective procedures eliciting a greater tendency to provide resuscitative efforts than palliative procedures, but did not differ according to type of anesthetic technique (MAC, regional, or general anesthesia). While the respondents agreed that after discussions with the patient about DNR status and anesthetic risk, patients would retain DNR status, they nevertheless acknowledged that if the patient sustained a cardiopulmonary arrest, they would institute positive pressure ventilation with a mask or endotrachial tube, and use vasoactive drugs or defibrillation in a large number of cases.

The ambiguity of this dilemma continued in the report of Dr. G. Boyd from the University of Alabama at Birmingham, who surveyed the anesthesiology faculty as well as participants at an Annual Review course. Seventy-two percent of 125 respondents felt that DNR patients should never or rarely be candidates for surgical procedures. Fifty-nine percent felt that such orders should be routinely discontinued for the perianesthetic period and 68 percent would perform a full resuscitation for an iatrogenically induced arrest, while 66 percent would oblige the DNR order if the patient died from their intrinsic disease in the operating room. Eighty-seven percent felt the surgeon should inform the anesthesiologist in a timely fashion preoperatively. The point was further made that patients should be informed of the differences in causes and outcome for resuscitation in the operating room rather than elsewhere in the hospital..

The third poster, presented by Dr. D. M. Rothenberg of Rush Presbyterian-St. Luke's Medical Center, Chicago, reported a survey of 106 hospitals. Fifty-four percent haw an existing DNR policy for surgical patients; 79 percent of those with a policy suspend it at the time of surgery. In addition, 31 percent still administered CPR to a patient despite maintaining DNR status. Only one out of three hospitals without a DNR policy were planning to formulate one.

Internal inconsistencies and ambiguities ran through all three of these reports. As was pointed out in the presentations, the Patient Self Determination Act just now taking effect will provide strong impetus for anesthesiologists to become informed and involved with their institutional ethics committees in the clarification of their response to DNR status and the administration of anesthesia.

Anesthesia Machine Safety Issues

Dr. J. Brooks of the Ohio State University revisited microbial contamination of anesthesia machines since general replacement of reusable equipment with disposable endotracheal tubes, masks, breathing tubes, and rebreathing bags over the past 20 years. Twenty sets of anesthesia machine cultures were obtained at the inspiratory valve, the expiratory valve, and the C02 canister. Anesthesia ventilators were cultured at the bellows and/or ventilator expiratory valve. Five of 20 sets of circle system cultures were positive for bacterial growth (Staphylococcus and Pseudomonas-like organisms). Anesthesia ventilators were 44 percent (8/1 8) contaminated with K. pneumoniae, Ps. aeruginosa, Xanthomonas maltophilia, Comomonas acidovorans, and Aspergillus sp. It is of particular interest that some of the most common surgical wound infections are from the same organisms identified in the contaminated anesthesia machines. This is an area that deserves attention because of the potential for safer care through lowering of surgical infection rates and also avoiding patient cross contamination.

Carbon monoxide (CO) may be generated in C02 absorbent following exposure to fluorinated anesthetics, according to an abstract presented by Dr. R. Moon from Duke University in collaboration with colleagues at Emory University and Northwestern University. Several cases of carbon monoxide poisoning have been reported previously, uncovered during routine co-oximetry, when either Baralyme® and Sodasorb® were used as the absorbent. The investigators measured CO levels inside Sodasorb cannisters in idle anesthesia machines 3 20 times. Two hundred seventy-one of the 3 20 samples (84.7 percent) showed CO concentration less than 20 ppm. Sixteen of the 320 samples (5 percent) showed CO concentrations greater than 100 ppm, with six of the 320 samples (1.9 percent) exceeding 1,000 ppm. (EPA standards are 9 ppm/8 hrs., or 35 ppm/1 hr. exposure). Cannisters which have been in place for longer periods of time were more likely to contain high CO concentrations, but one cannister which had been used for only nine anesthetics over four days also had a concentration greater than 1,000 ppm. The used Sodasorb contained formate, which, when gently heated, may have produced CO. The authors provided convincing evidence that formate may be an intermediate that may contribute to CO poisoning in C02 absorbent following exposure to fluorinated anesthetics.

Vaporizer Contamination

Dr. P. Popic and associates from the University of Wisconsin studied the incidence of contamination of vaporizers with an incorrect volatile agent. Fifteen ml aliquots from a total of 926 vaporizers at 32 institutions were obtained and examined for contamination with a gas chromatograph. Results showed that 29 of the 926 vaporizers (3 percent) were contaminated. Both high(50 percent halothane in an isoflurane vaporizer) and low degree contamination existed. There were few differences among various anesthesia practice settings (private practice vs. teaching) and the incidence of contamination.

Contamination increased significantly with: 1) more personnel available to fill vaporizers; 2) larger hospitals; and 3) more variety of type of vaporizers requiring filling. Agent specific monitoring did not decrease the incidence of contamination. Pin indexing decreased but did not prevent contamination (one vaporizer with pin indexing was contaminated).

Misfiring Vaporizers With Desflurane

Dr. J. Andrews and colleagues at the University of Texas, Galveston developed a computer model to demonstrate the effects of misfilling contemporary vaporizers currently in common use with desflurane. Desflurane has a vapor pressure of 743 mmHg at 22 degrees C.

At a one percent setting, desflurane output would be 40 percent from halothane and isoflurane vaporizers and a dramatic 58 percent from an enflurane vaporizer. MAC of desflurane is approximately six percent, indicating that a massive overdose is possible from this type of accidental misfilling. Further, a hypoxic mixture occurs with all misfillings at dial settings exceeding four percent even if the vaporizer is supplied with 100 percent oxygen.

Vaporizer Output During Patient Transport

In contrast to the misfilling issue, bouncing a vaporizer around appears less dangerous to the patient. The steady state output from vaporizers attached to transport carts encountering obstacles and jostling was studied by Drs. R. Friedhoff and J. Abenstein from the Mayo Clinic. A Fluotec vaporizer was welded to the frame of a gurney stretcher. While traveling down hallways, over floor/carpet strips, over electrical cords, accelerating, decelerating, shaking, and running into walls, output of halothane from the vaporizer was measured using an anesthetic analyzer.

Results showed the Fluotec vaporizer can he expected to deliver accurate and predictable concentrations of halothane under these conditions. There was never a change of more than 0. I percent anesthetic concentration during any of these potentially disruptive events.

Methodology for Incident Analysis

Dr. R. Cook of the Cognitive Systems Engineering Laboratory and the Department of Anesthesiology of Ohio State University presented a preliminary but fascinating abstract on the application of cognitive science techniques for analyzing anesthesia critical incidents, a study partly supported by a grant from the Anesthesia Patient Safety Foundation. While a reader new to these concepts presented in the printed abstract may be confused by the broad and nonspecific references to cognitive strategies, a handbook ("Human Performance in Anesthesia: A Corpus of Cases") published by his laboratory was distributed by Dr. Cook at the session. Much of the effort and principles of cognitive science involve attempts to distinguish between bad outcomes and flawed performance and then focus on the causes of performance error. Human cognitive performance research is a dynamically evolving field that has already proven valuable in other event-driven professions often cited in analogies to the practice of anesthesiology such as nuclear power plant operation and commercial aviation, and is of fundamental interest in anesthesia patient safety.

OR Safety Behavior

In directly related work, Dr. D. Gaba and his group from Stanford presented two abstracts from their continuing studies of the behavior of anesthesiologists in critical situations in the operating room. In the first, they studied novice residents all within the first eight weeks of training. During each case, an observer noted which tasks the resident was performing; every five minutes the resident was asked to rate his or her workload on a numerical scale and the observer also noted whether the resident was noticing a red light placed near the EKG monitor and illuminated at random times during the procedure. The activities associated with preparation, induction, and emergence account for a large portion of the workload but occupy only a small fraction of the residents total time. Manual tasks diverted the residents attention from visual stimuli but it remained uncertain whether they would have been able to detect patient abnormalities appearing on monitors under the same circumstances. Comfortingly, Gaba did not find that interaction with the attending impaired visual vigilance.

In their second paper Gaba and colleagues describe how, using the principles developed in the aviation industry for Cockpit Resource Management, they have developed a course for anesthesiologists entitled Anesthesia Crisis Resource Management (ACRM). After an elaborate didactic course, trainees spend time in a very realistic simulator in which they have to manage crises of varying intensity without the possibility of harm to a patient. Although Gaba states that this training will not necessarily improve the outcome of patients of the physicians who participated, the attendees believed that it would. In these days when serious adverse outcomes are declining in frequency and residents will complete their training having very little experience with critical incidents, the use of such simulators seems to merit serious attention and support from the specialty.

Quality of Care and Peer Review

Dr. K. Posner and her colleagues who administer the ASA Closed Claims Study have extended their investigations into the scientific reliability of peer review. In this newly reported study they asked pairs of independently practicing anesthesiologists to review anesthesia malpractice claim files and judge the appropriateness of anesthesia cam "Standard of Care" judgments were based on the implicit criterion of Treasonable and prudent" practice. In a prior study this group has demonstrated that severity of injury influences the judgment of reviewers as to the appropriateness of cam So, in this study they measured levels of agreement in two subsets of claims of differing severity (namely, temporary and permanent injuries) as well as for the entire group of claims. Using sophisticated statistical methods of analysis for peer-reviewer agreement they found fair to good agreement for the whole group of claims, fair to good agreement for the permanent injuries but no agreement greater than chance for the temporary injuries.

Their results suggest that in a malpractice proceeding it may not be difficult for an attorney to find conflicting opinions among experts and that this may be the result of the absence of explicit guidelines in judging the quality of anesthesia care

Algorithms Ignored

In a study from the mountains of Utah and Switzerland, Dr. I East and associates asked why physicians taking care of mechanically ventilated patients in an ICU did not always follow the treatment instructions given them by a computerized protocol. The computer software also asked the physicians to give a reason why they did not feel that a particular treatment was valid and then the investigators looked at the antecedents when the reason given was 'hemodynamic instability'. In a retrospective analysis, the authors found that there was no central tendency among the clinicians in any of the variables that would indicate they were following rules that defined 'instability'. In fact, such variables as mixed venous oxygen saturation and wedge pressures were not even measured most of the time. The authors concluded that the decision making process used by most physicians has great variation, both internally one physician at different times, and externally among different physicians. Therefore, they now have protocols developed by a consensus group which they state are associated with a significant increase in patient survival perhaps due to better application and consequent reduction in the number of mistakes.

Picking Safe Residents

Two papers addressed the process of resident selection, adding credence to the almost universal impression that personality characteristics are most important in the eventual success and safety of an anesthesiologist. Dc 1. S. McDonald and colleagues from Ohio State University reported a five-institution study which attempted to develop a predictive profile for screening resident candidates to determine them fitness for anesthesiology. Ninety-five residents were tested using the California Psychological Inventory (CPI) before beginning their clinical training, and the results were compared with faculty evaluations at & end of the first and second years of residency. Four personality facets were positively correlated with performance: Empathy, Socialization, Achievement via Conformance (in structured situations), and Achievement via Independence (in unstructured situations). In two of the programs picked at random, the CPI was able to identify the weakest residents, and the authors concluded that the CPI could be used to screen candidates for their ability to succeed in anesthesiology.

Drs. D. Frankville and J. Benumof from the University of California at San Diego reported results of a national survey of factors used in selection of residents. They found that, by far, the inter-view was the most important component of the resident file, followed distantly by the Dean's letter, the transcript, letters of recommendation, NBME scores and the CV. Little weight was afforded to the medical school or the personal statement.

Teaching Safe Residents

Three papers addressed how residents learn. Drs. S. Polk and S. Wirtes from the University of Chicago reported the correlation between conference attendance and examination scores to he weak but present in a group of first year residents. Dr. D. Reinhart from Southwestern Medical Center in Dallas found that resident participation in an independent study program with quizzes correlated positively with improvement in entraining examination scores, but that the residents were nonetheless poorly motivated to continue to participate in the program. Drs. 1. Downs and M. R. Hodges from the University of South Florida found that residents' behavior (such as moderating the pressure in endotracheal tube cuffs) was positively, but not optimally, influenced by the presence of an independent observer in the operating room checking cuff pressure over a period of time. A lecture by the chairman specifically addressing appropriate inflation pressure did nothing to further optimize resident behavior in this respect. Dr. Downs is continuing this field of research, examining whether operant conditioning techniques can be used to bring about appropriate attention to details by residents.

Safety Issues for Anesthesiologists

It is now generally acknowledged and supported by data in the literature that anesthesiologists are at increased risk for chemical dependency, and two ASA abstracts addressed substance abuse. Dr. P. Frasco and associates from the Duke University Medical Center examined substance abuse problems in anesthesia residency training programs through the use of surveys obtained at the 1989 and 1990 Annual Symposia for anesthesiology chief residents m the United States and Canada. Survey results were analyzed according to four regions in the United States (Northeast, Southeast, Central, and West) and Canada. From 47 percent to 89 percent of training programs, depending on regional distribution, have a substance abuse rectum and from 0 percent to a maximum of 33 percent have a substance abuse committee.

Seventy clinicians (residents, fellows, faculty and CRNAs) were identified as substance dependent in 1989, and 73 in 1990, with at least nine deaths, but no attempt was made to correlate the presence of educational programs with the incidence of the disease. In discussion of this paper, Dr. B. Arnold presented some preliminary findings of the longitudinal study being conducted by the ASA Committee on Occupational Health of Operating Room Personnel, which indicate that training programs which address the issue of chemical dependency in anesthesia personnel do have a higher incidence of identification of affected colleagues. It seems possible that educational programs do not prevent the disease, but rather heighten awareness of it so that it may be more readily identified.

In a second paper on substance abuse, Dr. R. Klein and associates of the Oregon Health Sciences University attempted to look at the relationship between controlled substance accountability and controlled substance abuse. They received responses from 102 anesthesiology residency program directors, representing 137 hospitals. Ninety-five of the 137 hospitals (69 percent) reported at least one controlled substance dependent individual between 1985 and 1989. Seventy-six of the 102 training programs has at least one such individual. It was not possible to establish a correlation between the controlled substance accounting method and the occurrence of controlled substance abuse due to the low frequency of occurrence at an individual institution, with many additional variables. However, 45 percent to 48 percent of the responders indicated that they used the anesthetic record on a daily or random basis to audit the amount of controlled substance administered, and 31 percent performed random audits of individual anesthesia providers' controlled substance usage pattern. Seventy-one of the 102 hospitals made changes in their accountability systems over the five years of the survey. Most program directors felt that their accountability programs were not aiding in the detection of dependent individuals.

Finally, in a further evaluation of anesthesiologist safety, Dr. K. Henderson and colleagues of Children's Hospital and Harvard Medical School compared the radiation exposure of pediatric anesthesia fellows in the operating room and the cardiac catheterization laboratory (CL). The typical day in the CL would consist of two to three catheterizations, with fluoroscopy time ranging from 14-85 minutes, with an average of 30 minutes. The badge readings ranged from 20-180 mrem/month. Operating room fellows received undetectable ( 10 mrem/month) levels. AD fellows wore lead aprons, 50 percent wore a thyroid shield, and one stepped at least ten feet away from the source during every exposure (resulting in a reading of 30 mrem/month, despite spending 26 hours in the CL!). As the maximum permissible dose for non-radiation workers (including anesthesiologists) is 42 mrem/month, many of the anesthesiologists in the CL were exceeding the levels for many of the fluoroscopy technicians (40-150 mrem/month). Anesthesiologists, for their own well-being, should be aware of the principles of radiation safety (including duration of exposure) and the inverse square law (which governs the density of the dose per distance from the source), and should incorporate these principles, as patient safety permits, in their care of patients.

Dr. Holzman, Children's Hospital, Boston is Chairman of the Harvard Department of Anesthesia Risk Management Committee; Dr. Folk moderated the ASA session on education and is from the University of Chicago; Dr. Webre is in charge of didactic education in the Department of Anesthesiology at the University of Mississippi; and Dr. Zeitlin of the Brigham and Women's Hospital in Boston, is an Associate Editor of the APSF Newsletter.

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ASA Exhibits Feature Safety Technology, Ideas

by John H. Eichhorn, M.D.

Technology and concepts intended to promote anesthesia patient safety were widely shown in the technical and scientific exhibits at the October, 1991, Annual Meeting of the American Society of Anesthesiologists.

For the fourth straight year, there were no fundamental technologic breakthroughs shown. Several variations on existing themes and modified/improved technical aspects of various pieces of equipment were exhibited. Permutations and combinations of a diverse array of monitors were prominently featured. Essentially any conceivable configuration that could be desired by an anesthesia provider could be found. Also, ECG ST segment analysis with related analysis and interpretation algorithms seemed to be widely available in routine OR ECG monitors.

One new feature in a monitor is contained in a new spirometer that, in addition to the usual features (including capnography and agent analysis), displays a continuous flow-volume or pressure-volume loop on the screen. It is advertised as an aid in the care of patients with abnormal ventilation patterns.

A new noninvasive real-time waveform blood pressure monitor was shown. It uses continuous radial artery oscillotonometry with a sensor over the wrist that generate an electrical signal proportional to blood pressure. The sensor is held against the artery by a pneumatic bladder that inflates and deflates automatically to achieve the optimum arterial signal.

Intra-arterial blood gas measurements continue to be featured with each new variation in the sensor technology toured as finally solving the problem of dampened signals from arterial wall distortion and clot, thrombin, and protein deposition on the sensor.

Airways Big

Management of the difficult airway was a popular topic in the exhibits. Two new products are intended to facilitate difficult intubations. One plastic intubation "guide" for blind orotracheal intubation slides through the mouth down to the superior aspect of the Larynx. Its shape is specific to &de the special introducer stylet that comes with the kit directly into the trachea so that the endotracheal tube can then be pushed off the introducer into the trachea. The introducer stylet has distal aspiration holes and a proximal syringe, the combination of which is reportedly intended to facilitate identification of correct tracheal placement or accidental incorrect esophageal placement.

The other device intended for difficult airways is designed for blind oro or nasotracheal intubation, although it can also be fitted with a laryngeal mirror to facilitate direct visualization of the larynx. This mechanical stylet has a port for the connection of an ear-piece stethoscope to amplify breath sounds from the advancing stylet tip and make location of the trachea easier. The stylet is connected to a handle with an adjusting lever that flexes and extends the tip of the stylet so, guided by the loudness of the breath sounds, it can be blindly directed into the trachea. In essence, this device is intended to accomplish the same goal as a fiberoptic intubating laryngoscope bid without the fiberoptics (and, thus, at a small fraction of the cost).

"Safe 'Scope"

Another interesting laryngoscopy product is intended for use with conventional laryngoscope blades. Functioning in much the same manner as a condom, plastic disposable laryngoscope blade sheaths or sleeves cover the blade during use so that cross contamination of oral secretions between patients can be avoided while simultaneously reducing the need for cumbersome blade cleaning and sterilization after each use. The manufacturer states that the fight from the end of the blade is only slightly diminished and this does not impair intubation. The concept of "safe 'scope" may be aesthetically attractive to patients, but it remains to be seen whether anesthesia providers purchase these protective sleeves for laryngoscope blades.

Pulse oximeters, of course, were shown in many types, styles, shapes, sizes, and colors. A new oximeter was presented as being capable of noninvasive brain oximetry. It is intended to measure intracerebral oxygenation and the product literature correctly states that the large majority of blood in the brain is venous so a saturation reading of 73 percent is normal. While noting that, "ideally, the monitoring system should measure the organ directly" (the sensor placed directly on the brain during craniotomy), it is intended also for external placement and use in a wide variety of settings in which patients may be at risk for cerebral hypoxemia. Again, the potential value of this monitor will be seen as it is tested more extensively in actual clinical situations.

The scientific exhibits contained several additional presentations with safety implications. The phenomenon of latex-allergic patients was noted. Apparently, certain patients with chronic exposure to latex catheters and gloves (e.g. cases of neurologic dysfuction) develop potent antibody responses and may exhibit anaphylaxis in the OR when exposed to latex goods. Strategies to avoid and treat this syndrome were suggested. Safe sedation of children for MRI scanning was featured in an exhibit. Another exhibit involved a questionnaire about anesthesia machine infection control policies (cleaning of machines between patients) and beliefs (whether machines can be the source of nosocomial infections). The response to this questionnaire undoubtedly will form the basis for a subsequent presentation on this topic. Finally, the Federal Food and Drug Administration had an exhibit on the details of the Safe Medical Devices Act of 1990 and the device user facility reporting requirements which mandate filing a report if a medical device is involved in causing a death or serious illness/ injury (see APSF Newsletter, Summer, 199 1).

In all, the ASA exhibits at this annual meeting reflected some maturation of the patient safety "movement" in anesthesiology. Emphasis appeared to be on specific applications and "fine-tuning" rather than block buster-type dramatic advances, which may again be on the drawing boards for subsequent years' exhibits.

Dr. Eichhom, Professor and Chairman of Anesthesiology at the University of Mississippi, is Editor of the APSF Newsletter.

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Editorial: APSF President Assesses 1991 Safety Developments

The Anesthesia Patient Safety Foundation completed its sixth year in October. Among its interests, funding safety research and providing the only publication dedicated to disseminating knowledge of anesthesia patient safety continue to be primary.

Another major undertaking for the Foundation during the year was joint sponsorship with the Food and Drug Administration of an international, multidisciplinary conference targeting human error in anesthesia. Out of the meeting came a set of broad research goals examining methods of improving performance in anesthesia practitioners and a decision to hold an open scientific meeting in 1993 to discuss these issues further.

Anesthesia Simulators

Also important among the APSF goals is hastening the development of anesthesia simulators for education and training. The reasons for this are several. One primary concern is the new opportunity for teaching technical skills and crisis management in a realistic simulation environment rather than with a live patient. In addition, such an approach allows familiarity with numerous difficult anesthesia crises rather than the select few that occur for any single individual during a three-year residency training program. Jeffrey R Cooper, Ph.D., has recently reviewed the role of realistic anesthesia simulators. (1)

One of the most rapidly expanding safety areas in American medicine, about which all anesthesia personnel should be aware, is the development of practice parameters guidelines. A widespread consensus among professional and lay groups knowledgeable about current medical management sees these parameters as vehicles for improving over-all patient care (reducing inappropriate care), making more effective use of resources, and advancing methodologies in clinical decision making. It is estimated that some 1,800 practice parameters have been published in recent years by a number of organizations, including specialty societies, managed care plans, academic medical centers, medical insurance companies and the Federal Government. Of special note was the establishment by Congress two years ago of the Agency for Health Care Policy and Research (AHCPR), with funding for 1990 of some $126,000,000 and for 1992, some $221,000,000. A major undertaking for this agency is the writing of practice guidelines.

It has been my view for many years that the primary developers of such parameters should be physician groups. The American Medical Association (AMA) fortunately has taken the lead, among medical organizations, in attempting to analyze, coordinate and direct the enormous amount of activity in this arena by providing thoughtful guidance to the many interested parties. To do this, the AMA has established a Practice Parameters Forum, to which I am the American Society of Anesthesiologists (ASA) representatives, and a Practice Parameters Partnership, to which James F. Arens, M.D., is ASA representative. Clearly, if physicians do not take the responsibility for developing guidelines, government agencies and other third parties will do it for us.

ASA Practice Parameters

With this reasoning, the ASA has recently appointed an Ad Hoc Committee on Practice Parameters that has now met several times and established a consultative relationship with Steven H. Woolf, M.D., M.P.H., a well known authority on the subject of practice guidelines. The Committee has appointed two Task Forces, one dealing with the parameters involved in pulmonary artery monitoring, chaired by Michael F. Roizen, M.D., and one with the difficult airway, chaired by Robert A. Caplan, M.D. Both Task Form hope to complete their undertakings in time for consideration by the ASA Board of Directors in August, 1992, and approval or disapproval by the ASA House of Delegates in October, 1992. Dr. Woolf has provided an excellent review of the subject that I urge all anesthesia practitioners to stud V.2

Lastly all of us on the APSF Executive Committee and Board are pleased to see the Foundation growing in membership among all anesthesia practitioners as well as diverse individuals in many allied fields. The other medical specialty areas in American medicine continue to admire the anesthesia patient safety movement.

Ellison C. Pierce, Jr., M.D. APSF President


1. Cooper JB: Realistic anesthesia simulators. ASA Newsletter 1991; 55:12-15.

2. Woolf SH: Practice guidelines: A new reality in Medicine Arch Intern Med 1990; 150:1811-1818.

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APSF Awards 3 More Research Grants for $175K

by Jeffrey B. Cooper, Ph.D.

Three research grants were chosen for funding from among twenty-seven applications reviewed by the APSF Committee on Scientific Evaluation. The total amount of the awards was $175,507. The Committee also decided on several modifications to the guidelines and conditions of awards for grants to begin in 1993.

Safety of Pediatric Postoperative Analgesia to be Studied

Dr. Charles Berde, Director of the Pain Treatment Service of the Children's Hospital in Boston, will lead a multi-center study of the safety and risk factors associated with postoperative regional analgesia for pediatric patients. The study group collected pilot data retrospectively from approximately 9,000 regional anesthesia administrations and examined convulsions, cardiovascular instability, and severe respiratory depression among patients receiving postoperative analgesia. They will further analyze their existing database and expand it with prospective reports of adverse events reported from the 13 participating institutions. The study group was assembled with approval of the Society for Pediatric Anesthesia and the American Academy of Pediatrics Section on Anesthesiology. Using the pooled data, the group hopes to reach a consensus on guidelines for dosing schedules for epidural infusions of bupivicaine, fentanyl, morphine and hydromorphone.

Effect of Long Work Hours on Performance and Learning Will be Examined

Dr. Lance Lichtor and colleagues of the Department of Anesthesia and Critical Care at the University of Chicago will study the effects of long work hours on the ability of anesthesia and surgical providers to monitor multiple sources of information and to learn and retain information after 24-hour (anesthesiologists) and 36-hour (surgeons and pediatricians) work shifts. ICU nurses will be used as control subjects. Learning and recall will be tested via several standard psychological testing methods. Performance on monitoring tasks will be measured in a realistic simulation environment set up to mimic the operating room or ICU setting. This aspect of testing will use the simulation environment developed at the University of Florida, Gainesville. By using a simulation environment for testing, offering monetary incentives to volunteers and documenting alcohol, caffeine and other drug usage, the investigators hope to provide more objective information that has been available from previous studies on this controversial topic. Further, and, by comparing both younger and older subjects, the effects of age on task performance of medical providers may also be revealed.

Systems Engineering Applied to Anesthesia Tasks in Interdisciplinary Study

Dr. M. Elisabeth Pate-Cornell, Associate Professor of Industrial Engineering at Stanford University, will apply the technique of probabilistic risk assessment PRA) to develop a quantitative risk analysis model )r anesthesia and assess the effects of organizational actors on the risk of accidents. She has previously ad success in using PRA to study such situations s off-shore oil platform and space orbiters. Along with her colleagues in the Industrial Engineering Department and anesthesia consultants, she will apply the same general accident models they have sod m industrial domains and develop intermediate models, creating "fault trees" and applying stochastic principles to estimate the risk of various outcomes caused by system failures. The concept requires knowledge of probabilities of various possible events, which will be estimated from published studies or expert opinion. This research represents another venture into interdisciplinary risk analysis research via the APSF grants program.

Changes in the APSF Grant Program

There have been a few modifications to the grants program that will apply to applications for funding beginning January, 1993 (due by June 15, 1992 see announcement on page 3 7). The total amount of each award will be limited to S 50, 000, but projects will be permitted to extend for up to two years. Although the top applications represented interesting approaches to patient safety, the entire set of 27 applications was felt by the committee to be lacking in overall quality and innovation. The new guidelines include additional suggestions to applicants, urging that expert advice be sought for proposal preparation and experimental design. Once again, applicants are encouraged to refer to previous articles in the APSF Newsletter, which have described the type of ideas given priority and the problems which lead to lack of success (Volume 4, No. 4, December, 1989 and Volume 5, No. 4, 1990).

Dr. Jeffrey B. Cooper, Massachusetts General Hospital, Boston, is the Chairman of the APSF Committee on Scientific Evaluation. Other members of the committee are listed on page 47.

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From the Literature: URIs and General Anesthesia in Children

Cohen MM, Cameron CB. Should you cancel the operation when a child has an upper respiratory tract infection? Anesth Analg 199 1; 72:282-8.

The title of this paper by Drs. Cohen and Cameron asks an important question that affects anesthetic practice and patient safety. In recent years, several publications have been aimed at seeking an answer to this question. The Cohen and Cameron paper increases our understanding of the risks involved when administration general anesthesia to children with infected upper airway tracts.

The authors prospectively studied 1,283 children with URIs who had been identified in a large pediatric anesthesia data base of 29,220 children. Their findings indicate a two to seven-fold increase in respiratory-related adverse events during the perioperative period. In addition, when endotracheal intubation was performed in their URI population, them was a striking eleven-fold increase in respiratory complications.

Of interest was the observation of no age-related variation in respiratory risk in this study. Both intraoperatively and in the recovery room, airway obstruction was identified as the most common adverse respiratory event. Of note is the high incidence of post-intubation croup in children less than one year of age who underwent endotracheal intubation in the presence of a URI.

These authors are to be commended for taking on such a challenging and important investigation. It is unfortunate that they did not quantify the degree or severity of preoperative respiratory disease by symptomatology (e.g. cough, clear vs. purulent rhinitis, sore throat, etc.). In addition, the use of pulse oximetry data would have likely driven home their conclusions even more strongly. Despite this criticism, the authors have contributed significantly to our understanding of the safe clinical practice of pediatric anesthesia.

When discussing general anesthesia risk during URI's, several other studies deserve mention. Dueck et al.(1) demonstrated that acute viral respiratory infection m their sheep model significantly worsened the pulmonary effects of anesthesia. DeSoto et al. (2) demonstrated a significantly increased risk for postoperative oxygen desaturation after general anesthesia in children with URI's. While both of these studies she-d important understanding on the risk factors associated with general anesthesia during URI's, they still leave unanswered the issue of exactly what type of URI symptom complex leads to a worse outcome.

This author believes the answer lies in distinguishing rhinitis from the more significant pharyngitis/laryngitis/tracheobronchitis/pneumonitis Complex. (3) In the face of a URI, following symptomatology should help distinguish these entities when a child presents with acute upper respiratory illness:

1 Cough (especially during your exam or if the parent states the child coughs while sleeping)

2. Sore throat

3. Hoarseness

4. Fever (temperature>38 degrees C rectally with an associated URI symptom)

5. Malaise, lethargy or increased irritability

6. Vomiting, diarrhea or generalized rashes

Points four through six above appear to be indicative of systemic infection and likely indicate a virulent viral pathogen with associated illness. Symptomatology points one through three above are observations from clinical practice. The isolated "runny nose" without any of the associated symptoms mentioned above seems to be a different risk entity for general anesthesia. The difficulty comes in developing the clinical acumen to distinguish between these two clinical entities.

Once surgery and anesthesia have been cancelled, the next question pertains to rescheduling. Past investigations that examine pulmonary function parameters have noted residual dysfunction up to eight weeks after a URI. However, Wald et al. (4) recently concluded that the duration of a "URI effect" in children is two to three weeks based on the time to resolution of all symptoms and return to normal premorbid activity. It is reasonable to suggest that " guideline is suitable for rescheduling elective surgery after postponement.

With more clinical studies W that of Cohen and Cameron, we may someday be able to more accurately answer the question, When should you cancel the anesthetic when a child has an upper respiratory tract infection? Placing the patient's safety first, the anesthesiologist should be the decision-maker on the operating room team on this issue

Abstracted by: Allen J. Hinkle, M.D., Associate Professor of Anesthesiology and Pediatrics, Director, Pediatric Anesthesia Services, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire.


1. Dueck R, Prutow R, Richman D: Effect of parainfluenza infection on gas exchange and FRC response to anesthesia in sheep. Anesthesiology 199 1; 74: 1044-105 1.

2. DeSoto H, Paid R, Soliman IE, Hannallah RS: Changes in oxygen saturation following general anesthesia in children with upper respiratory infection: signs and symptoms undergoing otolaryngological procedures. Anesthesiology 1988; 68:276-279.

3. Hinkle, AJ: What wisdom is there in administering elective general anesthesia to children with active upper respiratory tract infection? Anesth Analg 1989; 68:414-415.

4. Wald ER, Guerra N, Byers C: Upper respiratory tract infections in young children: duration of and frequency of complications. Pediatrics 1991; 87:129-133.

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From the Literature: ECRI Review Explains, Warns of OR Fires

"The Patient Is On Fire!" is an article published by the ECRI in its journal Health Devices (Vol. 21, No. 1, January, 1992, p. 3). Fires on the actual operating table almost always corm as a complete surprise to the OR team. In one described case, an operating laser used during brain tumor surgery mistakenly activated by the surgeon ignited the surgical drapes. The smoke was heavy enough to form evacuation of the OR while the drapes and patient burned. Such incidents are comparatively rare but very dramatic and do occur often enough to cause significant concern.

ECRI (previously known as the "Emergency Care Research Institute") is the world's largest independent, nonprofit evaluator of medical devices and has been in existence for more than 20 years. In some senses, it might be considered analogous to a "Consumers Union" type organization for the medical equipment field. ECRI is also involved in accident investigation for hospitals and risk management consultation. Health Devices is the ECRI journal covering its equipment evaluation work as well as relevant general news.

ECRI authors Albert L. de Richemond and Mark Bruley describe in detail the components and implications of OR fires. They point out in "The Patient Is On Fire" that in each operating room, the basic elements of a fire are ever present, creating a constant danger.

For a fire to occur, three components of the "fire triangle" must be present:

1 ) The heat source e.g. laser, electrocautery, or fiberoptic light cord. (The most common scenario involves unintentional activation of the electrosurgical unit foot or hand switch and a consequent spark.)

2) An oxidizer 02 or N20 How to support and accelerate combustion.

3) Fuel surgical drapes, sponges, egg crate foam mattresses, alcohol or acetone-based solutions, GI tract gas, shoe covers, or anything else that will bum readily.

The products of combustion of the fuel component include oxides, carbon dioxide, nitrogen dioxide, carbon monoxide, and unburned carbon. Plastics, always present in the OR environment, will usually not bum in room air but bum vigorously in an oxidizer-rich (usually oxygen enriched) environment and produce the most toxic products of combustion. Burning plastic emits hydrogen chloride, hydrogen fluoride, cyanide, mustard gas, phenol, and poisonous complex hydrocarbons.

Fire prevention begins by understanding the fire triangle and how to keep its component parts from coming together in the operating room. The anesthesia provider must be aware of the danger of creating an oxygen-rich environment near a he-at source. This could easily happen, for example, during a case involving MAC including supplemental oxygen insufflation for surgery on the head or neck. This is a set-up for a fire and the use of an electrosurgical unit or laser in such a situation must be given extraordinarily careful thought prior to the case. If such instruments must be used, it is advisable to put saline-soaked sponges all around the surgical field to minimize the potential source of fuel for combustion (dry drapes or sponges).

A specific plan to deal with a fire emergency, especially one involving a patient, and regular practice of that plan are critical adjuncts to good prevention efforts. In-service educational sessions on fire safety for all involved, especially anesthesia providers, are essential.

Stopping a fire in the operating room requires a sequence of steps, starting with the disruption of the fire triangle.

1) Stop the flow of oxygen and/or anesthetic gases to the patient. If this does not put out the fire, cool the fire with nonflammable liquid (e.g. saline from a basin on the scrub table) or, from an extinguisher, carbon dioxide. Halon from a fire extinguisher cools and chemically disrupts the combustion reaction. (It may be wise to have a small two or five pounds halon extinguisher in each OR at all times.) A small flame on a drape may be simply patted out with a gloved hand. Smothering a small flame with a wet towel is also very effective.

2) Remove the burning/burned material.

3) Support the patient appropriately.

Information and guidance from local fire departments concerning fire drills and the proper techniques and equipment for extinguishing operating room fire can aid hospitals in establishing a protocol for controlling such occurrences and mines any injuries. Relevant literature from the National Fire Protection Association and the American Society for Testing and Materials should be provided to OR personnel.

Vigilance, knowledge of fire, and quick action will aid in the prevention of fire and fire-related injuries. If a fire occurs, educated operating room personnel should be able to keep damage to a minimum. Fire extinguisher location, type, and proper use must be covered repeatedly in the drills. All personnel must know where the oxygen shutoff for the whole room is and how to use it because in a large fire, this may be life-saving for both patient and personnel. Drills should include explicit information about immediate notification of hospital and fire officials and how to get help quickly.

Publication of this thorough discussion in Health Devices (Circulation Department, ECRI, 5200 Butler Pike, Plymouth Meeting, PA 19462; 215-825-6000) of the unusual but severe hazard of OR fires should prompt all anesthesia providers to take the necessary steps in the prevention and management of OR fires, and, thus, help insure a maximally safe experience for our patients.

Abstracted by: Chester H. Lake, Jr., M.D., Assistant Professor, Department of Anesthesiology, University of Mississippi, Jackson

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Anesthesia Techs Hold Annual Meeting in SF

by Dennis McMahon

The American Society of Anesthesia Technologists and Technicians (ASATT) held its second annual meeting on October 27 and 28, concurrently with the ASA Annual Meeting in San Francisco. Attendance at the ASATT conference exceeded the capacity of the facilities at the Hilton and reflected the growth of & Society from its charter membership of about I 00 one year ago to the present roster of almost 500. Lectures were given on technical subjects such as autotransfusion, pharmacology, blood pressure measurement techniques, and the prevention of anesthesia mishaps, as well as reports on the evolving role of the anesthesia technologist.

The ASATT was formed two years ago as an educational organization whose goal is the standardization of the training and skills of anesthesia technical personnel i.e. those who support, but do not perform, anesthesia patient cam The Society is governed by four elected officers, an executive director, and a Board of Directors representing each of seven regions of the country. It is intended as a national network for individual technicians, as well as for the many state and regional societies of anesthesia technologists that have formed within the past decade. There are currently active societies in eight areas, with interest in other regions.

A quarterly newsletter, The Sensor, provides news of technician activities in various regions, cites recent articles in the anesthesia and biomedical literature that are pertinent to anesthesia technologists, and reports progress toward the standardized training and certification of these personnel. Currently, comprehensive training for anesthesia technologists is almost entirely in-house, and there is no nationally recognized certification.

Both safety and efficiency in anesthesia care are enhanced by knowledgeable support personnel. Well trained technicians who understand the theory and practical application of the technology that they deal with will provide an added line of defense against critical incidents in the OR. In addition to indirect support functions, proficient technologists can expedite the logistics of patient care by setting up equipment and accessories before procedures, as well as assisting with specific intra-operative functions. Toward that end, the focus of the leadership this coming year will be to reinforce the activity of regional societies, increase membership, and develop the training guidelines written by the Society last summer. The guidelines, in a modular format, are currently bang reviewed by the ASA Anesthesia Care Team Committee and a committee of the AANA, and will be refined by next June. They are intended as a reference for clinicians responsible for the in-service education of their department technical staff, as well as for those proposing to offer a formal training program for anesthesia technologists. As another educational approach, the ASATT now has a complete set of the APSF/ASA Patient Safety videotapes, for loan to members for use in departmental in-services, or at regional technician society meetings.

Anesthesia clinicians who would like to foster education for their technical support personnel are invited to contact the ASATT: 9805 N.E. 116th Street, #A183, Kirkland, WA 98034; (800) 352-3575.

Mr. McMahon of the Virginia Mason Medical Center, Seattle, is the current president of the ASATT.

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In the conclusion of the article on the new FDA preanesthetic equipment checklist in the Summer issue on page 2 7 an incorrect telephone number appeared. The end of the article correctly reads:

Those interested in contributing to the revision efforts for the FDA Checkout should contact either their ASA or AANA representatives. Alternatively, the FDA may be contacted directly by writing or calling:

Mr. Jay Crowley

Center for Devices and Radiological Health HFZ-240

Food and Drug Administration

1901 Chapman Drive

Rockville, Maryland 20857

(301) 443-2436


The Anesthesia Patient Safety Foundation Newsletter is the official publication of the nonprofit Anesthesia Patient Safety Foundation and is published quarterly at Overland Park, Kansas. Annual membership: Individual $25.00, Corporate $500.00. This and any additional contributions to the Foundation are tax deductible Copyright, Anesthesia Patient Safety Foundation, 1991.

The opinions expressed in this newsletter are not necessarily those of the Anesthesia Patient Safety Foundation or its members or board of directors. Validity of opinions presented, drug dosages, accuracy and completeness of content are not guaranteed by the APSF.

APSF Executive Committee: Ellison C. Pierce, Jr., M.D., President; W Dekle Rountree Jr., Vice-President; David M. Gaba, M.D., Secretary; Burton A. Dole, Jr., Treasurer; Casey D. Blitt, M.D.; Jeffrey B Cooper, Ph.D.; Joachim S. Gravenstein, M.D.; E.& Siker, M.D.

Newsletter Editorial Board John H. Eichhorn, M.D., Editor; David E. Lees, M.D. and Gerald L. Zeitlin, M.D., Associate Editors; Stanley J. Aukburg M.D., Nancy Gondringer, C.R.N.A.; Jeffrey S. Vender, M.D., Ralph A. Epstein, M.D., Bernard V. Wetchler, M.D., Mr. Mark D. Wood.

Address all general, membership, and subscription correspondence to:

Administrator 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

Department of Anesthesiology

University of Mississippi Medical Center

2500 North State Street

Jackson, MS 39216-4505

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