Volume 10, No. 1, Spring 1995
Table of Contents

ICPAMM Reviews International Safety Efforts in Anesthesia
Sux "Contraindication" Reduced to "Warning"
Research Grant Applications Sought by APSF
Parenteral Medication Recommendations to be Distributed
Letter to the Editor
German Anesthesiologists Also Wrestle with Sux Indications
From the Literature: Safety-Related Papers Summarized
Anesthesia Workstation Standards Studied
Simulator Conference in May
What do Anesthesiologists Know About Medical Gas and Vacuum Systems?
APSF Will Conduct Nationwide Survey of Anesthesia Residents
Contributions to APSF In Memory of James B. Robinett, Jr., M.D. from the Texas Society of Anesthesiologists
Newsletter Editorial Policy Adopted

ICPAMM Reviews International Safety Efforts in Anesthesia

by Jeffrey B. Cooper, Ph.D.

For the sixth time in the past 10 years, the International Committee for Prevention of Anesthesia Mortality and Morbidity convened on October 2, 1994, to review studies of mortality and morbidity and generic topics related to patient safety. Dr. Jeffrey Cooper opened the day-long session with a brief review of seminal events in anesthesia safety since the group's founding in 1984 in Boston. The Anesthesia Patient Safety Foundation and later the Australian Patient Safety Foundation had their roots in that first gathering. Standards for monitoring, a topic of heated debate in 1984, are now widely accepted throughout the world. Many studies of mortality and morbidity have been discussed at these meetings and the information has been useful to many participants in conducting similar studies tailored to the investigators' home countries. Numerous collaborative efforts have arisen or derived energy or guidance from the supportive atmosphere of ICPAMM. This year's congenial, but critical, discussions seemed to provide more of the same. It was a small (20 participants) but diverse (10 countries represented) attendance, one day before the start of the European Congress of Anaesthesiology in Jerusalem, Israel. The small-group format provided greater opportunity for detailed discussions and exchanges; the participants later suggested that future meetings be restricted to similar numbers.

The U.S. Closed Claims Study

Dr. J. S. Gravenstein, standing in for Dr. E.C. Pierce, Jr., highlighted key findings from the ASA sponsored study of closed malpractice claims in the U.S. He noted that the majority of cases in the study involve healthy patients for non-emergency procedures; inadequate ventilation cases make up the largest category of events and instances of nerve injury the second largest. The mechanism of the majority of nerve injuries remains unknown, presenting a challenge for clinical research. Obstetrical claims are another category of great importance and for which new insights are needed.

One of the most interesting problems identified in the U.S. Closed Claims Study is sudden cardiac arrest during spinal anesthesia. After reviewing the data and the possible mechanisms for this sudden event and a personal anecdote, Dr. Gravenstein emphasized the dramatic and dangerous character of this specific event and the need for research leading to better understanding its etiology and appropriate courses of treatment.

The closed claims data may only represent the tip of the iceberg; there are data to suggest that approximately 4% of cases may lead to potentially compensable injuries, while claims against anesthesiologists are made only in approximately I in 200 cases for all causes.

Perhaps one of the most interesting findings from the closed-claims data is how outcome of a case affects the judgment of reviewers of that case, in the sense that a severe adverse outcome is more likely to lead to a conclusion that the care was substandard than the same circumstances with a less severe outcome. This raises serious concerns about how reviewers may be biased in judging culpability of clinicians.

The discussion that followed focused on differences between medical-legal characteristics of various countries and about how well the U.S. system did or did not do in meeting the objectives of compensating for injury and deterring preventable injuries. Dr. David Gaba of Stanford noted that the closed claims data suggests that it does not do very well at either. Dr. William Runciman (Australia) offered that, despite such problems, the tort system does do an effective job in 'getting the attention' of those who can effect changes for the better. The discussions also suggest that the litigation climate of the U.S. is now being experienced more and more in other countries as well and can be expected to continue to increase.


Dr. John Lunn reported on highlights of the latest National Confidential Enquiry on Perioperative Deaths (NCEPOD) in the U.K. The basis of this study is not epidemiologic investigation. Rather, it is aimed specifically toward the objective of improving quality of care. Dr. Lunn takes a definition of quality from the book 'Kaisen," which describes the Japanese concepts of continuous improvement of quality a 'characteristic of an activity that can be improved.' This contrasts with the emphasis of malpractice claims, which aim to assign fault and compensate victims. Dr. Lunn emphasized that one of the important attributes of the study is that it is not specific to anesthesia; both surgeons and anesthetists are involved in submitting reports, and aspects of both surgical and anesthesia care are scrutinized. After numerous attempts to seek agreement in assessments between reviewers, they have abandoned such notions because they have not been very successful

The NCEPOD has, in the past five years, examined numerous issues including pediatric deaths, a random selection of perioperative deaths, and deaths associated with specific operations. More recently, emphasis has been on different methods of eliciting increased cooperation from all surgeons and anesthetists. In 1995, it is planned that only the first death report by each surgical team will be examined.

The various NCEPOD reports have highlighted recommendations in many areas. The deployment of staff has been seen as an important issue. The anesthetists should be better matched to the patients clinical condition, and the supervision and appropriate skills of staff require improvement. As an example of how specific complications have been examined with data from the study, findings of cases involving thromboembolism were described in more detail. This has been identified as an area requiring further research, which will be funded by the Department of Health in the U.K. Also, guidelines are being published suggesting that each hospital prepare a protocol for treatment of Ns condition.

NCEPOD has extensively examined issues related to deaths occurring within 30 days of 15 specific procedures, whether of surgical or anesthetic origin. For instance, there is a collection of 100 reports of death following operation for strangulated hernia. Much larger samples are available for other operations, e.g., total hip replacement and CABG.

Dr. Lunn repeatedly emphasized the importance of NCEPOD being a collaboration between anesthetists and surgeons, which he believes has been vitally important for its success. He gave several examples of issues that have been identified specifically for surgeons: avoiding inappropriate surgery when death is imminent, increasing the frequency with which a specialist s opinion is sought prior to some operations, improving the preparation and 'resuscitation" of a patient prior to surgery, and increasing the involvement of consultant anesthetists in the operating room.

One major suggestion addresses an idiosyncrasy of anesthesia in the UK induction of anesthesia outside of the operating room and then transporting the anesthetized patient into the actual operating "theater." Findings of NCEPOD have resulted in the recommendation that induction of anesthesia be undertaken in the operating room itself.

There have been numerous general recommendations arising from the findings of NCEPOD. Cooperation of all anesthetists and surgeons continues to be encouraged and may be required by law. Efforts are being made to improve the access to essential medical services, to improve the supervision of trainees and to address specific issues such as the potential to improve the outcome from thromboembolism.

Dr. Ikuto Yoshiya from Japan inquired about the effect of studying perioperative deaths occurring within less than 30 days of operation. He noted that the ongoing Japanese study is based on a 7-day endpoint. Dr. Lunn commented that approximately 50% of perioperative deaths occur in the first 6 days so that many deaths potentially associated with operation and anesthesia may be lost from study with a 7-day cut off period.

Changing Physicians' Practice Patterns

Dr. Marsha Cohen of the University of Toronto described early results of a study aimed at changing practice patterns in a way that would effect an improvement in a specific outcome. The outcome chosen was post operative nausea and vomiting (PONV). 'Academic detailing' (an intense, targeted educational effort) and individualized feedback were used in an attempt to increase the use of specific interventions (use of droperidol, metoclopramide, other antiemetic premedications, and naso-gastric tubes) at one hospital with a second hospital serving as a control. The use of the promoted preventive measures and the rates of PONV were tracked at both hospitals, but academic detailing, feedback to anesthesiologists, and announcement of the group rates of PONV were only done at the study hospital. Of 3,328 high-risk patients in the study, 97.3% were interviewed by the study's research nurses. The results showed that, after the enhanced education, anesthesiologists at the study hospital significantly increased their use of 'any preventive measure' and specifically the use of high-dose droperidol. Individualized feedback to specific anesthesiologists as follow-up to the educational efforts at the study hospital even further increased the use of high-dose droperidol. Practice continued 'as usual' at the control hospital; during the study period, they used the promoted therapeutic measures significantly less frequently.

Did the increased use of promoted measures affect the rate of nausea and vomiting at the study hospital? Preliminary results (data are still being collected) indicated that the rate of PONV was not significantly changed at either the study or control hospitals as compared to baseline rates. However, during the two years of the study, the rate of PONV at the study hospital was lower.

There was no obvious explanation for the results. About 25% of patients were not receiving any preventive measures, and the promoted measures were not completely effective, only reducing the rate of PONV by 30%. The study shows that practices can be changed through various educational efforts, but studies designed to show improved patient outcomes are extremely difficult to execute.

Anesthesia Safety in Developing Countries

Dr. Sidney Gassner, President of the European Congress of Anaesthesiology, spoke to the group of his experiences of many years ago in providing anesthesia and other medical services in the area that is now Malawi. Several people in the audience having singular experiences agreed that the availability of anesthesia and related services hasn't improved much in most of the underdeveloped countries. There is a stark contrast between the predominantly physician-administered anesthesia with the availability of modern drugs and high technology of industrialized countries and the conditions found in Malawi, which was previously Niasaland. More striking are the differences in health of the populations, Dr. Gassner described the high prevalence of many serious diseases, e.g., malaria and schistosomiasis. In the face of such stark conditions, the delivery of basic medical care takes on a much more important role than anesthesia. Despite this, he provided anesthesia and performed surgery for a variety of ailments. He stressed that the underdeveloped countries are in great need of the most basic training in anesthesia, but that anesthesia can be delivered with relative safety using very basic techniques. Under such primitive conditions, he urged that prevention of critical events becomes even more important because so little is available to mount an effective response to serious problems. The efforts of many anesthetists from around the world who provide training and care in these conditions were noted and appreciated.

The Australian Incident Monitoring System

Dr. William Runciman reported on the status of this now six-year continuous effort, which is conducted under the auspices of the Australian Patient Safety Foundation. Thirty manuscripts have described analyses of various subsets of incidents and specific problems and attributes of the data (see Anesthesia Intensive Care, Vol. 21, No. 5, October, 1993). He emphasized how anonymity of reporting, which is protected by law in Australia, has been critical to the high rate of participation and the candor of reports. It is no longer necessary to recruit hospitals to participate since they volunteer on their own. The POS (person on the spot) is another critical feature. This is the person who organizes efforts at a hospital and to whom feedback is sent on pooled data; no individual reports are distributed. Feedback via newsletters and meetings has also been thought to be effective at increasing support for the study and spreading word of the findings.

There are now more than 4,000 incidents collected and available for direct access in the central database. Dr. Runciman described how this has been useful in addressing specific questions that are raised by individuals, companies, or the government. He described an example in which AIMS data was useful in preventing inappropriate government action to alter the design of vaporizers as a result of a publicized adverse event.

Currently, the AIMS leadership is working toward a Generic Occurrence Code that could be used by any medical specialty for this kind of event reporting. An international effort is also underway to broaden reporting to other countries using the AIMS system. Hospitals in about a dozen countries have expressed interest in being involved. Dr. Runciman believes that each country must collect data of its own to have the results accepted by the medical community.

Incident Reporting System in the U.S.

Dr. David Gaba described the concept of introducing an incident reporting and feedback system in the U.S. The Anesthesia Patient Safety Foundation (U.S.) Board of Directors examined this possibility at its retreat in 1992 and approved the idea of developing such a system, which would be similar in principle to that operated by NASA for American aviation. The objective is to improve safety, not necessarily to do scientific investigations. AU types of potentially adverse events would be reported. NASA experience is that getting information directed to plots is more important than reporting only to the leaders and managers in the aviation industry. Although the proposed system would be similar in some respects to AIMS, the expectation is that reporters would not be entirely anonymous Rather, additional information would be gathered after an initial report to provide more detail about the character of the events. Dr. Gaba noted the experience by NASA of the importance of a narrative from a reporter most involved with an event in helping to identify causes. Following the second phase of data gathering, all identifiers would be removed from the reports. The biggest impediment, which has hampered other attempts to create such a reporting mechanism, are the concerns about potential access to the information and its potential use against medical personnel making the report. It is much more difficult in the U.S. to acquire the kind of legal protection that has been afforded the AIMS and CEPOD studies. Progress toward establishing a system has been stalled by the lack of personnel to assist in the legal research and design of the system.

Prospective Study of Anesthesia Mortality and Morbidity in Holland

Dr. Anneke Meursing and her colleague, Dr. Sesmu Arbus, summarized key elements of a study of anesthesia mortality and morbidity that is intended to begin soon in the Netherlands. Dr. Meursing noted that standards for anesthesia equipment were promulgated in Holland in 1978. This followed from a controversy created by Dr. Smalhout, who had spoken out about unnecessary anesthesia deaths. Approval of the Mastricht Treaty for the European Community has created additional pressure to document current (presumed excellent) levels of anesthesia safety because of concern that high standards of care in Holland may be challenged.

The Dutch study will be a prospective, case-control design, examining mortality and morbidity within 24 hours of surgery in 63 hospitals in three provinces. This will include more than 500,000 procedures. There will be a 'correspondent" in each hospital and anonymity will be preserved.

Concern was expressed that the use of controls will prove difficult; this approach was abandoned in the CEPOD effort because of the difficulty of defining what characteristics should be matched. Drs. Meursing and Arbus will take the group's suggestions under advisement.

Safety Progress in Japan

Dr. Yoshiya presented a paper prepared by Dr. Yoshihro Shimada, who could not attend. Dr. Yoshiya described how deficiencies in the first survey of anesthesia outcomes, about which Dr. Shimada reported at the last ICPAMM meeting, have led to the design of a new study, with an expanded number of hospitals and a more rigorous statistical design. Japan has adopted standards for minimal monitoring that are almost identical to that of the American Society of Anesthesiologists (see APSF Newsletter, 9: 23, Fall 1994).

International Study of Prolonged Postoperative Cognitive Dysfunction in the Elderly

A pilot study recently reported in the British Journal of Anaesthesia has led to the design of an international study of prolonged postoperative cognitive dysfunction (PPOCD) in the elderly. Dr. Jakob Trier-Moller described the equivocal results from the first study (a subcomponent of the well known Danish pulse oximeter prospective study), in which no statistically significant correlation was found between the use of pulse oximetry and PPOCD. He explained how the deficiencies in testing in that study and deficiencies in the design of other studies have failed to verify a commonly held perception that anesthesia is sometimes associated with varying degrees of PPOCD. A potential key reason is that most psychometric testing is not designed to identify physiologic/pathophysiologic issues. In the earlier study that Dr. Moller led, for instance, it was learned after the fact that a key test, the Wechsler Memory Scale, was not well standardized, especially in translation to Danish. Problems with repetitive testing and subject drop-out also hampered the power of the statistics.

The new international study of PPOCD will focus on elderly patients since it is suspected that a larger effect will be seen in that population. A more sensitive battery of psychomotor tests has been devised and will be performed pre and post-operatively. There will be several control groups to separate the effects of anesthesia from confounders. Ten hospitals from ten countries will participate (including one in the U.S., funded from a grant awarded this year by the APSF). Pilot studies of data collection have been completed; data collection for the main study is planned to begin presently.

Patient Satisfaction

Dr. Fred Orkin spoke in favor of broadening the ICPAMM focus to include outcomes other than the most serious. He based his argument on several beliefs: because serious adverse events are now rare, studies cannot have sufficient statistical power to reach significance; anesthesia now contributes little to serious adverse outcomes; anesthetists are not sufficiently sensitive to quality measures; there are substantial opportunities to improve care to patients who are apparently not injured by anesthesia; patients have a different perspective than providers about what constitutes quality care.

Dr. Orkin asked, "What really concerns patients?; what do they want?" He described how the process of conjoint analysis is used to identify customer needs in the consumer market, e.g. hotel industry, and how this can be applied to anesthesia services. The basis of the measurement is that patients place a dollar value on different levels of services from which a ranking is created. Different lists of symptoms are presented to a subject, who then ranks them. One sample list included "wide-awake post-operatively, no dysphoria, no nausea, extra cost $50." Dr. Orkin has been conducting a sporadic, long-term study with this methodology to examine and demonstrate the concept. Preliminary data suggest, for instance, that patients place a high value on not having nausea and vomiting.

The book Through the Patient's Eyes by Gereis et al. was suggested as a reference for these kinds of ideas. There ensued a lively debate about adding this topic to future ICPAMM meetings. Some felt that there was a danger of diluting the message of the continued need to press for safety from adverse outcomes, especially in the increasing climate of economic pressures to cut costs. The issue was not resolved.

ICPAMM Will Meet Again

Participants at this meeting unanimously agreed to plan the next meeting in conjunction with the June 1996 World Congress of Anaesthesiology in Sydney. It is felt that the small group format should be retained since it is conducive to open, frank discussion.

Dr. Cooper is the Coordinator of the International Committee for Prevention of Anesthesia Mortality and Morbidity. Comments and requests for participation should be addressed to him at the Department of Anesthesia, Massachusetts General Hospital, Boston, MA 02114.

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Sux "Contraindication" Reduced to "Warning"

by Robert C. Morell, M.D.

The final chapter (for now, at least) in the great succinylcholine controversy has been written and is reported here. A 'warning' about the possible response to succinylcholine will replace the contraindication statement that sparked the controversy. The recent extensive discussion regarding the elective use of succinylcholine in the pediatric population has been the subject of a debate and editorial in the Spring 1994 issue of the APSF Newsletter.(1,2) The Fall 1994 issue of this publication carried a chronology of the events leading to the revision of the succinylcholine package insert and the subsequent reconsideration of that revision. (3) An editorial appeared in that same issue addressing the process of drug education. (4)

Burroughs Wellcome (the manufacturer of Anectine) has elected to follow the recommendations of the Anesthetic and Life Support Drug Advisory Committee (ALSAC). This committee recommended that the previously issued statement of contraindication of succinylcholine in children and adolescents be rescinded and replaced with a warning. As of November 1994, the Burroughs Wellcome package insert for Anectine brand succinylcholine has been revised to contain a "boxed" warning. This warning is located at the beginning of the insert (see WARNING box below).

Substitution of this warning has accomplished several goals recommended by the ALSAC committee. The contraindication has been downgraded to a (strong) warning. The population at greatest risk has been defined more accurately, e.g., children under the age of eight, particularly males. Most importantly, educational material has been supplied regarding the need for prompt recognition and proper treatment should a hyperkalemic response occur. The package insert also readdresses these issues in the 'Precautions' section and in the "Dosage and Administration' section.

This newly revised package insert was in effect as of November 1994. Before this issue of the APSF Newsletter reaches the readers, anesthesiologists should have received 'Dear Doctor" letters and the new package insert from Burroughs Wellcome. It is likely that other manufacturers will follow suit.

There will undoubtedly be anesthesiologists and nurse anesthetists who feel that the revised warning and insert is 'too strong." There will also be physicians and CRNAs who believe that it is 'not strong enough." All those interested should rest assured that this document is the result of a long and arduous process which occurred through the best efforts of the anesthesia community, the FDA, the ALSAC committee and the manufacturers of succinylcholine. The process has been educational for all anesthesia practitioners.

Dr. Morell of Bowman-Gray School of Medicine in Winston-Salem NC is a member of the APSF Newsletter Editorial Board.


1. Morell RC, Berman JM (Pro); Woelfel SK (Con). In My Opinion: a debate: is succinylcholine safe for children. Anesthesia Patient Safety Foundation Newsletter 1994; 9(l):1,3-5.

2. Eichhorn JH. Editorial: Are we becoming too afraid of complications?. Anesthesia Patient Safety Foundation Newsletter 1994,9(l):2-3.

3. Morell RC. FDA Group Urges Sux Label Wording Reduced to 'Warning'. Anesthesia Patient Safety Foundation Newsletter 1994; 9(3): 25,27-28.

4. Miller ED. Editorial: Sux debate shows process of drug education. Anesthesia Patient Safety Foundation Newsletter 1994; 9(3)26.

5. Package Insert. Anectine (Succinylcholine Chloride) Injection, USP. Burroughs Wellcome Company, November 1994.

WARNING: Risk of Cardiac Arrest from Hyperkalemic Rhabdomyolysis

There have been rare reports of acute rhabdomyolysis with hyperkalemia followed by ventricular dysrhythmias, cardiac arrest and death after the administration of succinylcholine to apparently healthy children who were subsequently found to have undiagnosed skeletal muscle myopathy, most frequently Duchenne's muscular dystrophy.

This syndrome often presents as peaked T-waves and sudden cardiac arrest within minutes after the administration of the drug in healthy appearing children (usually, but not exclusively, males, and most frequently 8 years of age or younger). There have also been reports in adolescents.

Therefore, when a healthy appearing infant or child develops cardiac arrest soon after administration of succinylcholine, not felt to be due to inadequate ventilation, oxygenation or anesthetic overdose, immediate treatment for hyperkalemia should be instituted. This should include administration of intravenous calcium, bicarbonate, and glucose with insulin, with hyperventilation. Due to the abrupt onset of this syndrome, routine resuscitative measures are likely to be unsuccessful. However, extraordinary and prolonged resuscitative efforts have resulted in successful resuscitation in some reported cases. In addition, in the presence of signs of malignant hyperthermia, appropriate treatment should be instituted concurrently.

Since there may be no signs or symptoms to alert the practitioner to which patients are at risk, it is recommended that the use of succinylcholine in children should be reserved for emergency intubation or instances where immediate securing of the airway is necessary, e.g., laryngospasm, difficult airway, full stomach, or for intramuscular use when a suitable vein is inaccessible (see PRECAUTIONS: PEDIATRIC USE and DOSAGE AND ADMINISTRATION).'

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Research Grant Applications Sought by APSF

The Anesthesia Patient Safety Foundation announces the deadline of June 15,1995, for receipt of applications for research grants to start January 1, 1996. Grants are limited to a total of $50,000, cannot include indirect costs, and must be completed within two years. Priority is given to studies that concern problems of anesthesia for relatively healthy patients, that use existing medical knowledge, and that promise improved methods of patient safety readily incorporated into clinical practice.

Areas of research interest include, but are not limited to: new clinical methods of prevention and/or early diagnosis of mishaps, evaluation of new and/or reevaluation of old technologies for prevention and diagnosis, identification of predictors of patients and anesthetists at increased risk for mishaps, development of innovative methods for measurement of cost-effectiveness of techniques designed to increase patient safety, and approaches to acquiring scientifically valid data about any complex problem related to patient safety. Innovative ideas are encouraged.

Guidelines describing the scope of the grant program and the application format may be obtained from the Anesthesia Patient Safety Foundation, Executive Office; 1400 Locust St., 9 Ermine; Pittsburgh, PA 15219. Awards will be announced at the annual meeting of the APSF on October 20,1995.

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Parenteral Medication Recommendations to be Distributed

In recent years, there has been a trend toward increased use of intravenous anesthetic agents in the operating room and for sedation of ventilated patients in the intensive care unit. Since outbreaks of infection have been associated with intravenous medications, an understanding of appropriate aseptic technique is necessary for their use.

A booklet entitled, 'Recommendations for Handling Parenteral Medications Used for Anesthesia or Sedation' and an accompanying poster have been prepared and will be distributed to members of the Anesthesia Patient Safety Foundation through a grant provided by Zeneca Pharmaceuticals. The recommendations are derived from current infection control guidelines and published studies.

As the medical community is faced with increasing production and economic pressures that could compromise safety, it is more crucial than ever that proper infection control practice be maintained.

For more information, contact Arnold Berry, M.D., Professor of Anesthesiology; Emory University School of Medicine; 1364 Clifton Road, N.E.; Atlanta, GA 30399; (404) 778-3937.

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Letter to the Editor

Succinylcholine Seen as Safest, Cheapest Relaxant, Much Better than IANDNMB's

To The Editor

The recommendation to limit intermediate-acting non-depolarizing neuromuscular blockers (IANDNMB's) to rapid sequence when succinylcholine is contraindicated, or cases of 60-90 minutes or less, reported in an ASA meeting session summary by Dr. Mark P. Fritz (APSF Newsletter, Winter 1994-95) goes in the right direction, but not far enough. It is actually quite easy to almost totally eliminate these costly drugs from anesthesia practice while enhancing safety.

I use the following guidelines:

1. Only intubate when necessary.

2. Unless contraindicated, use succinylcholine for all intubations.

3. Administer judicious incremental doses of relaxant to achieve the required surgical relaxation (you'd be surprised how little is needed for many procedures!). Do not base doses of NMB on the twitch ratio but on the surgical situation.

4. Do not paralyze a patient for personal convenience, and if feasible, assist rather than control respiration.

5. Use succinylcholine infusions for cases under 60 minutes and use pancuronium, curare, or metocurine for longer cases.

Using these common-sense guidelines for some 20 years, I have avoided or minimized:

1. The "can't intubate, can't ventilate" scenario.

2. Awake, paralyzed patients.

3. Ventilator induced hypotension.

Not only is this a safer, more reasonable practice than the ubiquitous exclusive use of IANDNMB's, but the average relaxant costs are under $5.00 per case versus the $20-50 (or more) range I frequently see now!

Steven S. Kron M.D. New Britain, CT

Question on Reading in OR Sparks Debate

APSF Newsletter Readers Give Record Response, Tend to Oppose Reading

To the Editor

In response to 'reading during OR cases,' I would not consider-any reading during any case, even M.A.C., except to check a particular item in my 'Handbook of Clinical Anesthesia." I haven't done it in 28 years and don't intend to start now. I couldn't come up with the name of a single CRNA that I know who reads during a case.

I would consider it a violation of the principles of good anesthesia practice to read or be doing anything else that would distract me from my patient and monitors.

Peter V. Goihl, CRNA Fort Atkinson, WI

Reading in OR Condemned but (?) Common

To the Editor

Having taught and practiced anesthesiology for over 40 years, I agree completely with Col. Carl Bostek regarding reading during a case.

Such a cavalier attitude as that to which he refers, such a breaking of the contract of care between anesthesiologist and patient, such a denigration of the profession of anesthesiology has led in large part to the anesthesiologist being considered as a second-class physician and anesthesiology as a 'minor specialty.'

All the warning bells and whistles in the world cannot replace the moment-by-moment care and observation than an anesthesiologist has promised to the patient. Dr. Beecher's 'educated hand' should still be alive and well.

I consider it shameful that the right or wrong of any such distraction from anesthesia duty should still be a question.

Franklin B. McKechnie, M.D. Winter Park, FL

[Past President, American Society of Anesthesiologists]

To the Editor:

Every patient being monitored during surgery deserves unflagging vigilance by the anesthesia provider. Does any anesthesia training program teach otherwise?

Cyrus B. Kapadia, M.D. Morristown, NJ

To the Editor

To read or not to read; that is the question! Several years ago, with a plethora of monitors to watch my patients for me during the longer and more predictable cases, I began to bring anesthesia related reading material into the OR. Then one day, I found a paperback left behind by one of my colleagues. Out of boredom, I picked it up and began perusing it and, before you know it, the case was over, the muscle relaxant was still at full blast, and the patient was still on the ventilator with a full load of surgical-depth anesthesia on board. Since that day, the only reading material that I bring 'into surgery with me is the patient chart.

Edwin Patt, CRNA Jackson, Michigan

Surgeon Sees Widespread OR Reading

Editor's Note: The following letter arrived via an unimpeachable source. The surgeon author requests anonymity out of concern for his relationships with his anesthesiology coworkers. After verification of the authenticity of the letter with its author, an exception to the usual policy on identification of letter writers is made and the letter appears here.

To the Editor

Through my anesthesia colleagues, I am familiar with your publication. I heard about the letter asking whether or not reading during surgical cases was appropriate behavior.

As a general surgeon in a medium-sized city who operates in six different facilities, I know and work with at least 40 anesthesia providers, both physicians who do their own cases and CRNA's supervised by anesthesiologists. It is my observation that virtually all the anesthesia providers who care for my patients read material not associated with the case during these anesthetics, specifically novels or the Wall Street journal. Some do crossword puzzles. At least half at some time or another work on a portable computer (often apparently related to personal financial matters). It seems that the first year in practice, new anesthesiologists and anesthetists are much less likely to do these things but then start, while the oldest providers are the most Rely to read or be otherwise occupied.

In truth, it did not occur to me that it might be any different or a debate question. This appears, at least to me, a universal practice. Am I correct or, for some reason, am I exposed to a skewed sample? Please advise. Thank you.

Name and location withheld by request.

OR Reading Provokes Varied Views: Some Reading Defended as Means to Stay Sharp

To the Editor

While I agree with Lt. Col. Bostek's observation that '[reading] results in a lack of vigilance that could (my emphasis) lead to problems,' I believe that reading and other activity actually may improve vigilance for some people and in some circumstances. These non-anesthesia activities reduce my susceptibility to boredom, fatigue and sensory extinction, probably averting the 'white line hypnosis' that I may get driving for long stretches on the freeway.

Of course, non-anesthesia activity and distractions must be timed judiciously in the maintenance phase of anesthesia. This allows adequate time for appropriate surveillance of surgical progress, anesthetic management and record keeping. My anesthetic duty today was caring for a healthy patient undergoing excision of a third ventricular colloid cyst. While my neurosurgical colleague worked along, I read the entire APSF

Newsletter, drafted this reply and one other letter, and worked on a draft of a QA project. Throughout, I felt that I was completely aware of my patient's status and the progress of the surgeon. Just as one can drive a car and carry on a conversation, it is not too difficult to choose the appropriate times and cases to use non-anesthesia activity to improve our awareness and alertness. When the surgeon started to close today, I ceased my non-anesthetic activity. Closure took a while and I found my attention wandering and I felt less alert than I had been earlier.

At ease, Lt. Colonel! You can pay attention without standing at attention.

Norman Hey, M.D., FRCPC

Sudbury, Ontario

Pilots, Drivers Should Not Read, Nor Should We

To the Editor

I am responding to the letter from Lt. Col. Bostek in the Winter APSF Newsletter regarding reading during cases. I would have to agree with most of his conclusions. In the past, I have tried to read anesthesiology-related material during cases and found that I could not concentrate well enough to comprehend what I was reading. Also, I felt that vigilance would be compromised if I did not give my full attention to the patient. Thus, I abandoned the practice early in my career.

Let me draw an analogy. We would not want our airline pilot, auto mechanic, taxi driver, or any other person providing a service for us in any area in which lack of attention to detail could result in harm to us not giving their full attention to the performance of their job. Our patients have the right to expect nothing less from us. The anesthesiologist, not an electronic box with alarms, is the most important monitor.

Joseph M. Saenz, M.D. V.A. Medical Center Jackson, MS

Vigilance, Not Reading, Prevents "Tube-Tech" Idea

To the Editor

In response to the Letter to the Editor ('Is It OK to Read During OR Cases?') from the Winter 1994-95 APSF Newsletter, my answer is an unqualified no! Unless I have missed the point, one of the guiding principles expressed on our society's coat of anus is vigilance. Nowhere on our society's coat of arms or in our training is there mention of distraction or inattention as a guiding principle.

I have made it my personal mission as an academic anesthesiologist to impress on our trainees the importance of vigilance, attention to detail, and attention to the surgical field while providing anesthesia. Yet, frequently I observe residents, CRNA's, and fellow staff anesthesiologists reading in the operating room. just as frequently, I observe surgeons and operating room nurses bringing a situation to the attention of the anesthesia provider that should have been noticed had the anesthetist been vigilant.

Needless to say, this has potential impact on patient safety, and it also affects how we are viewed by our surgical colleagues.

As a medical specialty, we have made great strides in the field of perioperative management and the provision of safe and effective anesthetics. Too often, our expert medical judgement is challenged by our surgical colleagues, and there is often evidence in those interactions of a credibility gap. I submit that the common practice of reading in the operating room encourages the impression among our surgical colleagues that anesthesiologists are simply 'tube techs" disinterested and inattentive. I do not encourage that impression by our surgical colleagues and I will not tolerate behavior that predisposes to it.

David K. Black, M.D.

Department of Anesthesiology

Naval Regional Medical Center, Oakland, CA

Moral Contract Outweighs Any Vigilance Debate

To the Editor

I read with interest Lieutenant Colonel Bostek's letter in the Winter 1994-95 issue of the APSF Newsletter.

I concur with his feelings about reading in the operating room. I also appreciate the feeling of his colleagues who believe that they can safely read in the OR. I've also heard claims that reading may serve to enhance vigilance (personally, Fm not sure how).

I feel that these arguments beg the issue. We, as anesthesia care providers, have entered into a moral contract with our patients. This contract implies that we will devote all of our efforts to their care when they have entrusted themselves to us in the operating room (or the delivery room, intensive care unit, emergency room, pain management clinic, or wherever). In good conscience, I don't believe that any of us could read and not breach our covenant. I've not the eloquence of a philosopher, nor the knowledge of the law like an attorney, but I can't help believe that it is wrong. I can't imagine that our patients would be too pleased to find that their anesthesiologist or anesthetist was reading (whether it be a journal or a novel) wife providing anesthesia care. As an analogy, how would you feel if you found out that the pilot on your commercial airliner was reading instead of monitoring the controls, instruments, and other members of the flight crew?

I offer these thoughts as a teacher and practitioner with seventeen years experience (yes, and I am also a pilot). I offer for your readers' consideration that if one cannot maintain the necessary vigilance in the operating room without reading, one should consider abandoning the practice of anesthesia. After all, I've heard concern that there is an overabundance of anesthesia care providers and this is one way to address that issue.

Maybe I'm just old-fashioned, but I am most respectfully yours,

Shepard B. Stone, M.P.S., P.A. Lecturer in Anesthesiology

Yale University School of Medicine

Physician, Associate Anesthesiologist Yale-New Haven Hospital

More "No's" to Reading: Reading During Case Can Lead to Sub-optimal Care

To the Editor

In response to the question, 'Is it OK to read during OR cases?" My answer is "No!'

Having worked in university hospitals, university-affiliated hospitals, small community hospitals, with only anesthesiologists, with anesthesiologists and nurse anesthetists, and with primarily nurse anesthetists under the supervision of anesthesiologists, I can recall only one instance where the majority of the department agreed to allow reading in the OR. This was with one surgeon who took 6-8 hours to perform an A-V graft on the arm using local anesthesia and monitored anesthesia care. And even in this rare instance, if the patient was not manifesting stable vital signs, the anesthesia care team member was not allowed to read.

Regardless of the type of reading material, any concentrated effort other than on the care of the patient is an unsafe practice that is a distraction and can result in sub-optimal patient care.

The practice of reading in the OR should strongly be discouraged and, in most instances, not permitted at all.

Please add my vote for 'No!' to your survey question.

Janet N. Siler, M.D. Staff Anesthesiologist

Cinnaminson, NJ

Reading Belittles Anesthesiologists' Efforts

To the Editor.

Regarding the letter in the Winter APSF Newsletter concerning reading in the OR, I feel that it is totally unacceptable for anesthesiologists to read in the OR during a case. This gives others in the OR the impression that what we do is not interesting or important. In other words, it tends to belittle our efforts to those around us.

It may be acceptable to read the package insert from a drug that you are about to administer with which you are unfamiliar, but I can think of no other circumstances under which this behavior is justified. Anesthesia is currently struggling for its economic W, and we don't need to give our detractors justification. One can not read and be vigilant at the same time. If people find anesthesia that boring, then maybe they should choose another more stimulating area of medicine and leave anesthesia to those who find it interesting and challenging.

Robert Feinstein, M.D., Ph.D. Department of Anesthesiology

Washington University School of Medicine St. Louis, MO

"Art" of Anesthesia Requires Vigilance

To the Editor

In response to the letter from C. Carl Bostek in the Winter APSF Newsletter, I must weigh in with an emphatic "NO!" to the practice of reading during cases. One of the very first lessons I learned as a resident was that reading in the OR was not permitted. The basis for this prohibition (which I have followed now for six years) was simple: patient safety may be jeopardized by an inattentive anesthesia provider. While we in anesthesia have embraced the impressive advances in monitoring technology, I believe we may well be on a slippery slope and should beware of over reliance on bells and whistles. Subtle changes in a patients condition, which may signify an actual or impending problem, can often fall well within the alarm parameters of our monitors. This is the essence of the 'art" of anesthesia.

Beyond this, however, is an issue which I feel is equally, if not more, important: that of the perception of us as anesthesiologists. I can think of no other medical specialty in which the practitioner can read while actually performing his or her job. Reading during cases implies to all those present in the operating room that anyone off the street should be capable of providing anesthesia. After all, what special training, expertise or technical skills are required to put your feet up on the anesthesia machine and read a novel, a newspaper or even a medical journal? As we try to educate our patients, our colleagues and the public at large about the important job we perform (particularly regarding patient safety), I strongly believe that reading in the OR does nothing to advance our cause. Vigilance, we must demonstrate, is a continuous phenomenon, not one that begins when the crossword puzzle ends.

David J. Cohen M.D.

North Oakland Medical Centers

Clinical Assistant Professor of Anesthesiology Wayne State University Pontiac, MI

APSF Author Clarifies: Spinal Narcotics OK in OB

To the Editor

It is the intent of this supplemental communication to clarify an issue raised in our previous Risk Management/QA program description that appeared in the Newsletter (Summer 1994, page 18) and commented upon by Dr. Abouleish (Winter Newsletter, page 50). Our guideline dealing with avoidance of intrathecal opioids applies to surgical patients only and is not intended to apply to obstetric or chronic pain patients. We hope that this information clarifies our position and we apologize for any confusion that may have been accidentally created.

Casey D. Blitt, M.D.

Old Pueblo Anesthesia Tucson, AZ

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German Anesthesiologists Also Wrestle with Sux Indications

By Robert C. Morell, M.D.

The recent controversy regarding succinylcholine and the remote possibility of hyperkalernia as a result of undiagnosed myopathy was fueled, in part, by German reports from Dr. Schulte-Sasse of succinylcholine-related cardiac arrest. German anesthesiologists are now faced with probable label revisions similar to those which occurred in the United States and Canada (see related article). The German equivalent of the Food and Drug Administration is the Bundesinstitut fur Arzneimittel und Medizinalproduckte, known as the BIAM. The BIAM intends to prescribe a change in the labeling of succinylcholine to the manufacturers of this drug who offer it for sale in Germany. A translation of the proposed label change is as follows:

"Because of the severity of the adverse effects (intractable cardiac arrests in children with myopathy) it is recommended that also in apparently

healthy children and adolescents, the use of succinylcholine be restricted to emergency situations, in which immediate intubation and securing of the airway is mandatory."

In this context the word "recommended" has a very similar meaning to the term 'contraindicated' as used in the U.S., according to Professor J. Link of the Freie Universitat Berlin.

The proposed label change has prompted responses from the German Society of Anesthesiology and Intensive Care Medicine (DGAI) and practicing German anesthesiologists. The BIAM also has an advisory committee similar to the U.S.'s Anesthetic and Life Support Drug Advisory Committee (ALSAC) which advised the FDA. This advisory committee is named Commission 'A' and advises the BIAM regarding the approval of new drugs and the reevaluation of approved drugs. The BIAM can reach decisions opposite that of Commission 'A' and Commission "A" has no veto power. Academic physicians and experts in various medical disciplines comprise the membership of this Commission. The BIAM itself answers to the Minister of Health. A new "Committee for Proprietary Medicinal Products' has recently been formed (by the Commission of the European Community) and may end up resolving any differences that may arise between the pharmaceutical manufacturers and the BIAM.

Obviously, the resolution of the succinylcholine controversy will be at least as complicated in Germany as it was in the United States. It will be interesting to follow the developments and to see if the German situation will result in package insert language similar to that adopted in Canada and the U.S.

Dr. Morell of Bowman-Gray School of Medicine in Winston-Salem, NC, is a member of the APSF Newsletter Editorial Board and author of several Newsletter articles on the succinylcholine controversy.

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From the Literature: Safety-Related Papers Summarized

by Fred Orkin, M.D.

A survey of the recent literature relevant to anesthesia safety yielded the following citations and brief descriptions:

1. Gerteis M. Edgman-Levitan S. Daley J, Delbanco TL (eds): Through the Patient's Eyes: Understanding and Promoting Patient-Centered Care. San Francisco, Jossey-Bass, 1993 Hardcover, 317 pp (US $29.95). What do patients experience when they go to the hospital? This text summarizes the patients perspective based on a national survey of more than 6,000 patients after treatment in 62 U.S. hospitals, field visits to 20 hospitals, and associated focus groups. Seven dimensions of patient-centered care are described, with recommendations for dealing more effectively with them. Highlighted is the undertreatment of postoperative pain.

2. Banks IC, Tackley RM: A standard set of terms for critical incident recording? Br J Anaesth 1994; 73: 703-708. Anesthetic-related critical incidents are studied in many countries, but 'many identical concepts, words and phrases ... fare] often expressed or spelt differently, Ieading to duplication or confusion of the underlying phenomena. As a remedy, a comprehensive thesaurus of clinical terms is being developed for use in Britain's Read Clinical Classifications to describe critical incidents more accurately and facilitate national registries. This is an activity within the British National Health Service to describe all aspects of clinical medicine within a computer-based data base.

3. Iezzoni LI (ed): Risk Adjustment for Measuring Health Outcomes. Ann Arbor (Ml): Health Administration Press, 1994 Softcover, 423 pp (US $41.00): This text summarizes the state-of-the-art in making adjustments for patient risk when making comparisons of patient outcomes across different treatment options and settings. Of note, ASA Physical Status Classification receives only passing mention as a 'global subjective" measure of co-morbidity.

4. Leape LL: Error in medicine JAMA 1994; 272: 1851-1857. This is a masterful synthesis of the managerial, statistical, and engineering sciences' perspectives on error and its prevention, as applied to health care. Leape leans heavily on psychological and human factors research, noting what has been learned about prevention in aviation and nuclear energy industries, how these concepts depart from the traditional approach in medicine, and what systems changes are needed in health care for error prevention. While misquoting temporal aspects, he attributes improvements in anesthesia care to the application of error prevention strategies.

5. Blumenthal D: Making medical errors in 'medical treasures.' JAMA 1994; 272: 1867-1968. A brief, but meaty editorial accompanying Leape's paper on error urges adoption of the new sciences of quality management and error prevention, which rely on systems sciences and statistical process control, among other non-medical fields and methods. Without using the term kaizen, he emphasizes that each error presents an opportunity to devise new ways to improve care.

6. Walker IS (ed): Quality and Safety in Anaesthesia. London: BMJ Publishing Group, 1994 Softcover, 212 pp 19.00.: A British risk manager hosts his colleagues in anesthesiology, psychology, and risk management to present current reviews of such mainstream topics as quality management, the National CEPOD Study, lessons from aviation, anesthetic critical incidents, and the roles of computers, equipment design, patient monitoring, and practice standards in maintaining and enhancing quality in anesthesia care.

7. Warden IC, Borton CL, Horan BF: Mortality associated with anaesthesia in New South Wales, 1984-1990. Med J Aust 1994; 161: 585-593. Ongoing surveillance of deaths associated with anesthesia in New South Wales reports that the estimated rate of anesthesia-related deaths in the period 1984-90 was half that for 1970 and about a quarter that for 1960. In 11% of the deaths, there were contributing factors under the control of the anesthetist. Three quarters of the deaths involved abdominal, cardiothoracic or vascular surgery, with 70% relating to emergency procedures.

Dr. Orkin is from the Dartmouth-Hitchcock Medical Center and has long been an observer of personnel issues and complications in anesthesiology practice.

Editor's note: Any other recent publications relevant to anesthesia patient safety not covered here deserve mention in this column Readers are invited to identify such publications in a note to the Editor (see Page 2, bottom right comer) and also, if desired, include a brief review (even up to 500 words) of the material.

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Anesthesia Workstation Standards Studied

With the obvious patient safety implications firmly in the minds of meeting participants, standards for the U.S. 'anesthesia workstation' were the subject of a Nov. 17-18 meeting of the ASTM Committee on Anesthesia Workstations. This work closely parallels the European Community Standards discussed in the APSF Newsletter in Fall of 1992 ("International Standards') and Summer of 1994 (Italy and Japan).

The Committee dealt with draft number 5, dated October 1994, and, also, written comments regarding the oxygen failure protection device clause and related test methods were presented. Clinicians on the committee expressed the opinion that the capability of medical air to flow should remain available on the machine when the oxygen failure protection (referred to as 'fag safe') device activates and cuts off gases from the machine.

In the section on pressure monitoring, requirements were added for a negative pressure alarm which will activate at -10 cm H20 within one second of the event occurring. In the section on protection against incorrect vaporizer output, lengthy discussion again ensued over the requirement for agent monitoring to be a mandatory component of the anesthesia workstation.

By majority vote, the committee left an amended requirement in the draft which will state that, "the anesthesia workstation shall have means for monitoring the vapor concentration of the agent either in the fresh gas or inspiratory gas."

The document section on electronic interface requirements was again revisited with the introduction of reformulated guidelines from the ad hoc group leader. Proposed wording was tabled, and both users and manufacturers stated their positions on the issue. Several changes were presented, and the modified text was put to a vote. By majority vote on sections of the text, it was voted that 'the manufacturer shall make available and offer as appropriate technical support related to the functioning of the communication protocol.' Wording on availability and services without cost was deleted, and complete wording of the clause will appear in the next draft.

In a separate discussion, the ad hoc committee of infusion pump manufacturers had provided wording describing a protocol specifically formulated for infusion pumps as a component of the anesthesia workstation whereby control of the pump may be turned over to the central control of the anesthesia workstation.

The group of Automated Anesthesia Record Keeper (AARK) systems manufacturers met concurrently to define and formulate the section on automated anesthesia record keeping with its particular requirements. This group will present its proposal to the committee at the next meeting.

Future meetings of the ASTM Committee on Anesthesia Workstations were scheduled for February and April of 1995.

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Simulator Conference in May

Signaling the significant growth of acceptance of anesthesia simulators as training and CME tools, a 'Conference on Simulators in Anesthesiology Education' is scheduled for May 12-14, 1995, in Rochester, NY, where it will be sponsored by the Department of Anesthesiology, University of Rochester School of Medicine.

Conference participants are urged to bring abstracts of research in progress and posters describing their educational programs for discussion with others engaged in working with the new full anesthesia simulators.

The conference will be held at the picturesque Woodcliff Lodge. For further information or to register, contact the Department of Anesthesiology at the University of Rochester, (716) 275-1385.

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What do Anesthesiologists Know About Medical Gas and Vacuum Systems?

by Todd G. Peterson, M.D.

Daily, anesthesiologists depend on their Medical Gas Vacuum System (or 'MGVS') to continuously deliver an adequate supply of 'medical grade" gases for patient care. Because these systems seldom appear to have problems and are hidden behind the walls, little thought is given to the complexity of the MGVS and its potential safety hazards.

To educate anesthesiologists regarding the potential problems in the design, construction, maintenance, and certification of the MGVS, the APSF Subcommittee on the MGVS was formed, and, at the 1994 ASA Annual Meeting in San Francisco, presented a scientific exhibit 'Beyond the Walls" which demonstrated many problems encountered in MGVS. As part of this exhibit, a survey was conducted to define what practitioners know about the MGVS they use and the problems that they have encountered.

One hundred and two visitors to the exhibit participated in the survey and their demographic makeup is summarized in Table 1.

Table 1: Survey Demographics


Anesthesiologists at Academic Institutions: 53

Anesthesiologists at Nonacademic Institutions: 32

Other: (CRNA, residents, engineers, technologists):17

Years of Experience

0 to 5 years 22

6 to 10 years 18

11 to 15 years 29

16 to 20 years 10

Greater than 20 years 23

Primary Site of Practice

Hospital with more than 500 beds 42

Hospital with 100 to 500 beds 41

Other (Small hospital, Outpatient Surgery center) 7

Anesthesiology Residency Training site 58

CRNA Training site 16

Knowledge of the MGVS was assessed in a series of seven questions which ranged from site specific questions such as "Do you know who is responsible for and maintains your MGVS?' and 'Is it certified?' to general questions of prior awareness of MGVS problems and education experience. Only 55% of those surveyed knew who was responsible at their institution for the MGVS; a mere 25% knew that their system had been certified. Of those having medical air in their facility (31 of 93), only 50% had checked that the compressor was medical grade, 35% the outside air purity, and 25% the locations of the intake for the compressor.

Most sites had bulk liquid oxygen supplies (87 of 97), but only 51% knew that the bulk site was the responsibility of the supplier. Though 73% of those responding knew the location of the zone cut-off valves (a question frequently asked on JCAHO surveys), only 27% knew where the bulk supply or main line cutoff valve was located. Of those responding, 40% were aware of the complexity of a MGVS shutdown, but only 25% knew of the requirements for piping and brazing in construction. Thirty percent of respondents knew of the potential contaminants to be found in medical gas systems, and this correlated significantly with those having experienced problems with their MGVS (p=.005). In addition, only 24 of 99 had received any teaching about the MGVS as part of their training, yet 83 of 92 felt that it should be covered as part of training. Overall knowledge of the MGVS correlated positively with three factors: being an academic anesthesiologist (p=.02), years of practice (p=.005), and having experienced a MG-VS problem (p=.017).

Five questions dealt with first hand experience with MGVS problems, failures and shutdowns. Sixty-one problems were reported by 39 of 102 respondents. The most common problems encountered were:

Contaminants (liquid, particulate, infectious, and gaseous) 28%

Components failures (valves, regulators, etc.) 18%

Bulk supply problems 18%

Pipeline leaks 15%

Design and construction problems 15%

Fifty-five respondents (54%) reported having had a shutdown of the MGVS at their institution; there were no significant differences between institutions either in size or whether they were a training site or not. Most shutdowns (58%) occurred to expand the MGVS, though 18% were to upgrade systems to meet standards and 9% were to clean systems of contaminants. For these shutdowns, less than half of the anesthesia departments represented actively participated in the planning process (45%); the rest (except for one case in which no warning was given) were only informed when the shutdown was to occur. Two patient deaths were reported that resulted from MGVS shutdowns or failures (one resulted from a crossed pipeline and no data were given on the second).

This survey shows that there is a significant knowledge deficit among anesthesiologists regarding the MGVS and its potential hazards. Nearly 30% of those surveyed acknowledged that they had little knowledge of their MGVS. Few (25%) were taught about the MGVS during their training (yet, over 90% of respondents felt that lectures about the MGVS should be included as part of the residency program). These survey results suggest that one way many anesthesiologists may learn about their MGVS is through experiencing problems or failures (a very strong correlation between problems experienced and knowledge of the MGVS). Extrapolating from the survey data, an anesthesiologist might expect a failure or shutdown of the MGVS (that would directly affect him/her and clinical care) about once every 10 years.

The APSF Subcommittee on the MGVS has been working to help educate the practitioner through a continuing series of articles in the APSF Newsletter and through presentation of the 'Beyond the Walls' scientific exhibit at the 1994 ASA and NYPGA conferences. Clearly though, there is a need for these topics to be covered as part of residency training. Strong support was expressed in the survey results for the development of training aids such as videotapes, reprints, exhibits, and a general outline of the issues. Efforts are underway to organize and fund a videotape that could be used in training programs. Further, the Subcommittee has proposed creation of a 'MGVS Hotline' to answer questions about the MGVS and assist with MGVS problems. When available, details will appear in the APSF Newsletter.

Dr. Peterson, an active member of the APSF subcommittee on MGVS, is Assistant Professor of Anesthesiology, University 0 Arizona, Phoenix

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APSF Will Conduct Nationwide Survey of Anesthesia Residents

The Anesthesia Patient Safety Foundation will conduct a survey of anesthesia residents concerning specific patient safety issues and residency training in patient safety. The survey will be directed by APSF Resident Representative James Healzer, M.D., and faculty members David Gaba, M.D., and Steven Howard, M.D., all of Stanford University and the Palo Alto V.A. Medical Center.

Within the next few months, survey forms will be sent to all anesthesia program directors for distribution to their program's residents. Residents are strongly encouraged to complete the survey form and return it in the envelope provided. Anesthesia residents will have this opportunity to report on their experiences with patient safety issues during residency.

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Contributions to APSF In Memory of James B. Robinett, Jr., M.D. from the Texas Society of Anesthesiologists

APSF Corporate Donors

Grand Patrons

American Society of Anesthesiologists

Burroughs Wellcome Co.

Cerenex, a Division of Glaxo, Inc.

The Dryden Fund

Ohmeda, Inc.

Preferred Physicians Mutual Risk Retention Group

Puritan-Bennett Corporation

Zeneca Pharmaceuticals Group (ICI)


Abbott Laboratories Nellcor, Inc.

Organon, Inc.

Sustaining Members

Baxter Healthcare Corporation

Becton Dickinson


Datex Medical Instrumentation, Inc.

Hewlett Packard Company

Mallinckrodt Medical, Inc.

Marquette Electronics, Inc.

Medical Inter-Insurance Exchange

North American Drager

Sponsoring Members

J. Jeffrey Andrews, M.D.

Anesthesiologists'' Professional Assurance Co.

Arkive Information Systems, Inc.

Aspect Medical Systems

Augustine Medical, Inc.

Beth Israel (MA) Anesthesia Foundation

Biennial Western Conference of Anesthesiology

CAE Link Corporation

Datascope Corporation

Grace Container Products Janssen Pharrnaceutica

King Systems Corporation Loral, Inc.

Medical Gas Management, Inc. Miles, Inc., Pharmaceuticals

Minneapolis Anesthesia Associates Pain Net, Inc.

Southeast Anesthesia Associates, P.A. Texas Medical Liability Trust

University of Texas Medical Center

Wisconsin Society of Anesthesiologists

Corporate Level Members

Anesoft, Inc.

Arizona Society of Anesthesiologists

Arrow International

Boeringer Laboratories, Inc.

Frederick W. Cheney, M.D.

Independence Anesthesia

Iowa Society of Anesthesiologists

Mississippi Society of Anesthesiologists

Pall Biomedical Products Company

Pennsylvania Medical Society Liability Ins. Co.

Texas Society of Anesthesiologists

Contributions to APSF received before March 15, 1995, will be acknowledged in the next four issues, beginning with Spring 1995. Contributions received after that date will be acknowledged in the four issues beginning with the Summer 1995 Newsletter.

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Newsletter Editorial Policy Adopted

The following is an editorial policy adopted by the APSF Board of Directors at its October 1994 meeting, as proposed by the Anesthesia Patient Safety Foundation Newsletter Editor, John H. Eichhorn, M.D.

At its meeting in October, the Executive Committee of the Anesthesia Patient Safety Foundation considered issues regarding the publication of articles in the APSF Newsletter which contain original research data not yet subjected to peer review. The Executive Committee makes the following statement:

Editorial decisions about the publication of submitted materials in the APSF Newsletter rest with the Editor, in consultation with the Newsletter Editorial Board.

The presence of original research data in an article submitted to the Newsletter does NOT in and of itself prevent that manuscript from being published in whole or in part in the APSF Newsletter. The decision on whether to publish any manuscript is based on content, quality of the writing, timeliness, and apparent interest to the readers of the Newsletter.

Articles containing original research data should be clearly identified as such in the Newsletter. For these articles (as well as others at the discretion of the Editor), there should be a special explanatory note reminding the reader that the material represents the statements of the named author(s) and that the article has NOT undergone peer review of its scientific content. Furthermore, the reader again should be reminded that the article does not necessarily represent the opinion of the Editor, the Editorial Board, or of the Anesthesia Patient Safety Foundation officers, directors, or members.

Recipients of the Newsletter are enthusiastically encouraged to submit letters or articles critiquing or affirming authors' statements contained in articles published in the Newsletter.

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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 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, 1995

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, Burton A. Dole, Jr., Vice-President; David M. Gaba, M.D., Secretary; Casey D. Blitt, M.D., Treasurer; E.S Siker, M.D.; Executive Director; Robert C. Black; Robert A. Caplan, M.D.; Jeffrey B. Cooper, Ph.D.; Joachim S. Gravenstein, M.D.

Newsletter Editorial Board:

John H. Eichhom, M.D., Editor; David E. Lees, M.D. and Gerald L. Zeitlin, M.D., Associate Editors; Stanley J. Aukburg, M.D., Jan Ehrenwerth, M.D., Ralph A. Epstein, M.D., Nancy Gondringer, C.R.N.A., Robert C. Morell, M.D. Jeffrey S. Vender, M. D.

Editorial Assistant Nola Gibson, Ph.D.

Address all general, membership, and subscription correspondence to:


Anesthesia Patient Safety Foundation

c/o Mercy Hospital

1400 Locust Street

Pittsburgh, PA 15219

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

John H. Eichhom, 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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