Episode #100 New Monitoring Recommendations for Safe Anesthesia Care

Hello and welcome back to the Anesthesia Patient Safety Podcast.  My name is Alli Bechtel, and I am your host. Thank you for joining us for another show. Today is a very special day for the podcast.

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It is our 100^th Episode! Whether you are a century listener, or this is your first show, welcome! We are so glad you are here. We started this podcast series by reviewing the APSF mission statement and Priorities in 2020.

100 shows later, let’s review the 2022 APSF priorities. To find the priorities, head over to APSF.org and click on the APSF Priorities heading. Here you can also find a list of APSF activates related to these priorities. The 10 priorities include: Culture of Safety, Teamwork, Clinical Deterioration, Non-operating room anesthesia, Perioperative brain health, opioid-related harm, medication safety, infectious disease, clinician safety, and airway management. We hope you will tune in for our next 100 shows too as we tackle threats to anesthesia patient safety and continue to work towards our mission.

Before we dive into the episode today, we’d like to recognize Preferred Physicians Medical Risk Retention Group, a major corporate supporter of APSF. Preferred Physicians Medical Risk Retention Group has generously provided unrestricted support to further our vision that “no one shall be harmed by anesthesia care”. Thank you, Preferred Physicians Medical Risk Retention Group – we wouldn’t be able to do all that we do without you!”

To kick off the show today, we would like to recognize Jaime Hyman and Jessica Miranda for their recent award from the APSF and Society for Ambulatory Anesthesia for their project, “How to ‘unlearn’ in the face of new evidence: A quality improvement initiative to remove gabapentinoids from Enhanced Recover After Surgery pathways within a Health System.” Congratulations and thank you for your work to help keep patient safe.

For our 100^th episode, we are discussing something that is fundamental to anesthesia patient safety, monitoring. Appropriate monitoring is vital to keeping patient safe during anesthesia care. You can also find the theme of monitoring in the APSF Priorities. Check out the third priority, Clinical Deterioration, which involves preventing, detecting, determining pathogenesis, and mitigating clinical deterioration in the perioperative environment.

Our featured article today is, “APSF-Endorsed Statement on Revising Recommendations for Patient Monitoring During Anesthesia” by the APSF Committee on Technology with approval from the APSF Board of Directors. To follow along with us, head over to APSF.org and click on the Newsletter heading. Fifth one down is Newsletter Archives. Then, scroll down and click on the February 2022 APSF Newsletter. From here, scroll down until you see our featured article today.

This statement is an important step towards improved patient safety. So, lace up your shoes because here we go!

The article starts off with by addressing the need for this statement. The appendix for this article includes the Standards for Monitoring published by different professional societies that were reviewed by the APSF Committee on Technology. These are the monitoring standards from around the world, but patient safety during anesthesia care should not depend on the patient’s location. The differences in these standards around the world need to be addressed to help make keep patients safe with appropriate monitoring. Next, the authors tell us the goals of this statement:

1. Identify monitoring practices that are important for improved patient safety that are missing from existing statements
2. Build collaboration between professional organizations to unify monitoring standard guidelines across all anesthesia professional organizations

Keep in mind that this statement is NOT designed to set a monitoring standard, but rather to build upon expert consensus. Expert consensus is critical to set guidelines that improve clinical practices and patient safety. Another consideration is the availability of resources. Clinical practice locations in resource-limited areas may not be able to follow all the recommendations, but the statement may be able to provide support for anesthesia professionals to advocate for resources to follow these recommendations when resources are available or become available.

Let’s continue into the article. The authors start off with some background. Keeping patient safe during anesthesia care requires ensuring adequate end-organ perfusion and oxygenation. This forms the basis for the monitoring standards related to hemodynamics, ventilation, and oxygenation. The good news is that the current standards for monitoring already include this. Another critical part of keeping patients safe during anesthesia care is administering anesthetic drugs so that patients are unconscious and immobile, depending on the surgery. We have the technology available to monitor this as well which is so important since underdoing puts patients at risk for awareness or moving during the surgery while overdosing may lead to hypotension, delayed awakening, or residual neuromuscular weakness. There is a threat to patient safety due to this gap in the monitoring standard related to monitoring drug effectiveness and residual effects. Updating these monitoring standards is an important step towards improved patient safety. So, with that, let’s talk about the specific updated recommendations from the APSF-Committee on Technology.

First up, awareness prevention during inhaled anesthesia. How can our monitors help us to decrease awareness and recall during general anesthesia and the associated increased patient morbidity? When volatile anesthetics are used, maintaining MAC greater than or equal to 0.7 can help to decrease the risk of awareness and recall anytime a neuromuscular blocking agent has been used. The good news here is that the International Organization for Standardization already states that anesthesia workstations that deliver inhaled agents must measure the end-expired concentration of the inhaled anesthetic. The next step is to include the requirement for monitoring end-expired concentration of volatile anesthetics anytime they are used to provide anesthesia care. The addition of this as an international monitoring standard appears to be straightforward, inexpensive, and addresses a significant patient safety issue. What about patients who do not tolerate 0.7 MAC or greater with inhaled anesthetics from hemodynamic instability. In order to keep these patients safe, the use of an EEG-based monitor for anesthetic depth should be used to make sure that patients are at an adequate depth of anesthesia and less likely to have awareness or recall.

I’m going to read the proposed monitoring practice now:

• “Whenever an inhaled agent is administered, its end-expired concentration shall be measured and a low concentration alarm be activated if available.
• Whenever a neuromuscular blocking agent is administered during inhalational anesthesia, if 0.7 MAC cannot be maintained, an EEG-based monitor of anesthetic depth should be used and an inadequate anesthetic depth alarm limit set if available.
• Exceptions would include procedures (e.g., Neurosurgery) where the technology for EEG-based monitoring cannot be placed or used effectively.”

Next up, let’s talk about awareness prevention related to intravenous anesthesia. This is an important consideration since the risk of awareness and recall under anesthesia is higher when intravenous agents are used compared to inhaled agents. Underdosing during total intravenous anesthesia may be due to technical error or the pharmacokinetic and pharmacodynamic variability of the drug or drug combinations as well as the lack of continuous monitoring and measuring of drug concentrations.  An EEG-based monitor of unconsciousness is a critical monitor to help decrease the risk for awareness during total intravenous anesthesia combined with neuromuscular blocking agents. These devices are available and have been studied with regard for measuring IV anesthetic effect and the potential for awareness. EEG-based devices use parameters such as spectral edge calculation, density, and compressed spectral array display to generate the bispectral and patient state indices which provides a straightforward monitor to use during clinical care. Once again, this is an important step to keep patients safe and align international monitoring standards. Here is the proposed monitoring practice:

• “Whenever a neuromuscular blocking agent is administered during total intravenous anesthesia, an EEG-based monitor of drug effect is recommended, and alarm limits activated when available.
• Exceptions would include procedures (e.g., Neurosurgery) where the technology for EEG-based monitoring cannot be placed or used effectively.”

We are really on a roll now. The next consideration is something that we have talked about before on this podcast because it is a threat to patient safety, postoperative residual muscle weakness which increases the risk for airway obstruction, aspiration, and respiratory complications. Quantitative neuromuscular function monitoring is the preferred monitor anytime neuromuscular blocking agents are used. Other common monitors include qualitative twitch monitors or subjective monitors include 5 sec head lift which are unable to reliably prevent residual muscle weakness, but any type of neuromuscular blockade monitor compared to no monitor at all can help to improve anesthesia patient safety whenever neuromuscular blocking drugs are administered. Here is the proposed monitoring practice:

• “Whenever a neuromuscular blocking agent is administered, a neuromuscular block monitor shall be applied and used. Quantitative is preferable to qualitative neuromuscular blockade monitoring.”

The fourth consideration for update monitoring standards is airway pressure monitoring. Anesthesia professionals are the airway experts. Failure to monitor airway pressures puts patients at risk for lung barotrauma. In addition, lung protective ventilation is an important consideration during anesthesia care, yet there is no consistent monitoring standard for airway pressures. The good news is that the technology for monitoring already exists since monitoring standards already require airway pressure monitoring for ventilators. We are already monitoring this, but we need to go one step further by including it as a monitoring standard such as the one proposed by the APSF:

• “When ventilation is controlled by a mechanical ventilator, there shall be in continuous use a device that is capable of measuring airway pressure. Alarms for detecting disconnection of components of the breathing system and dangerously high pressure shall be available and enabled. The device must give an audible signal when its alarm threshold is exceeded.”

Are you using these monitors in your clinical practice already? Do you have the EEG-based monitor for drug effect or quantitative neuromuscular function monitor available to use in your operating theatres? This statement is so important because it moves beyond individual clinical practice to working towards unified monitoring standards during anesthesia care around the world.

If you have any questions or comments from today’s show, please email us at [email protected]. Please keep in mind that the information in this show is provided for informational purposes only and does not constitute medical or legal advice. We hope that you will visit APSF.org for detailed information and check out the show notes for links to all the topics we discussed today.

To all our listeners and the APSF family, thank you for listening and your work towards improving anesthesia patient safety. We are excited to reach this big milestone with the podcast and even more excited about the next 100 shows. We have more interviews with anesthesia patient safety experts as well as Newsletter articles, rapid responses, and articles between issues to discuss. We may be hearing from your on the podcast! If you are interested in contributing content to the APSF head over to APSF.org and click on the Newsletter heading and scroll down to the guide for authors. We would love to hear from you on one of our 100+ shows!

Until next time, stay vigilant so that no one shall be harmed by anesthesia care.

© 2022, The Anesthesia Patient Safety Foundation