Episode #101 Thermal Injuries Revisited and LAST Case of the Day

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. Just like last week, today is another very special day for the podcast.

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It is our 101^st Episode! That’s right, we are starting the next century of podcast shows dedicated to improving anesthesia patient safety. We hope you will continue to listen to our interviews with patient safety experts, article reviews from the newest APSF newsletters, lots of rapid responses to questions from our readers, articles between issues, patient safety priorities, drug alerts, clinical safety concerns, and so much more.

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

Now, one of our favorites segments on this show is when authors of the article submit audio clips so that we can get even more insight related to the APSF article and patient safety threat. Today, we are kicking off the show with several author clips. Recently, we discussed an important patient safety threat in the operating room related to convection warmers and thermal injuries. This was a Rapid Response to questions from our readers article from the February 2022 APSF Newsletter. The article by Luke Janik and Ryan Lewandowski is called, “Thermal Injury After Use of a Convective Warming System.” We talked about it as a 2-part series on our podcast, so I hope you already listened to episodes #94 and #95. If not, as soon as you are done listening to this show, we hope that you will check them out for more information. We reached out to Janik with a couple of questions related to his article and he provides some great insight.

Let’s get started with this exciting question and answer show now. I will let our guest introduce himself now.

[Janik] “Hi, my name is Luke Janik, and I’m an anesthesiologist at Northshore University Health System in Evanston, IL as well as a clinical assistant professor at the Pritzker School of Medicine.”

First up, I asked Janik, “What was it like to discover the thermal injuries on the 2 consecutive patients?” Let’s take a listen to what he had to say.

[Janik] “I learned about these cases when they came through our department’s quality review process. We have a very large surgical volume and have used the same warming devices for many years without issues so when I heard that there were thermal injuries in back to back cases in the same operating room, it made me suspicious that there was either a malfunction of device or incorrect use of the device.”

[Bechtel] The rapid response column in the APSF Newsletter is such an important resource for anesthesia professionals interested in improving anesthesia patient safety especially when there is a question or concern about a medical device. So, next, Janik talks about the decision to submit these cases and discussion to the APSF.

[Janik] “I’m a big fan of the rapid response column. It’s one of the few places in the anesthesia literature where the everyday anesthesia professional can voice safety concerns about a device and actually get a response from the manufacturer. There really is no other platform like it. I have to say I was really impressed by the team at Smith’s Medical. They were very receptive to investigating these injuries with us and they wrote an excellent response discussing the safe use of convection warming devices.”

[Bechtel] If we are to continue our progress towards no patient harmed by anesthesia care, then we need to make changes to our practice after threats to patient safety have been identified. Take a listen as Janik describes the clinical practice changes made following the cases of thermal injury.

[Janik] “We made several changes to our practice as a result of these cases. most importantly, we educated our department members about the importance of the air manifold component. For those who don’t know, the air manifold is that hard plastic elbow shaped piece located on the end of the warming hose. The air manifold is the piece that actually plugs into the warming blanket and it promotes even distribution of air flow throughout the warming blanket. It’s critical for the proper functioning of the device. Surprisingly what we discovered in our investigation is that even though it’s a critical component it can be removed. In our opinion, this creates a set up for failure. For whatever reason in at least one of our cases, the air manifold was missing and the anesthesia professional inadvertently connected the end of the hose directly into the warming blanket. So, we are really focusing on making sure everyone verifies the presence of the air manifold before using the device. Another change we made is the recommendation to start the warming device on the medium temperature setting rather than the highest setting. In anesthesia practices around the world warming devices are routinely started on the high setting, but if you look at the operator’s manual, it actually recommends the medium setting to start. Finally, we encourage routine check of the patient and the warming blanket to ensure that no cables or cords from the surgical field are lying over the patient and restricting air flow.”

[Bechtel] While we are on the topic, I also asked Janik if there was anything else that he would like to discuss?” Here’s his reply.

[Janik] “One thing I’ve learned from the Rapid Response column is that if you suspect a device has malfunctioned, make sure to save the device in question. Typically, the manufacturer’s are receptive to inquiry but they usually want the device shipped back to them for inspection, so make sure that you don’t dispose of it before contacting the manufacturer. “

[Bechtel] Finally, Janik shares what he hopes to see going forward. His observations are important related to safe use and design of medical devices in general and the convection warming device, air manifold, and warming blanket specifically.

[Janik] “A well designed device should prevent the user from making an error. In human factors engineering, this is known as a forcing function. Let’s look at an example. A person cannot accidently fill their car with diesel gasoline because the diesel gas pumps don’t physically fit into the gas tank of regular cars. In the cases that we discuss here, even though the air manifold component was a critical piece the device was still able to be used without it. When the user plugged the end of the hose into the warming blanket, it fit just fine even though the air manifold component was missing. In my opinion, this is a design flaw. The hose should be incompatible to the blanket without the presence of the air manifold. Had the hose been a different size or different shape, the user would not have been able to make that connection and it would have prevented the improver use of the device. I hope that the manufacturer considers addressing this design in future models.”

[Bechtel] Thank you so much to Janik for his contributions to the show today. Have you submitted a rapid response to questions from our readers article yet? If not, what are you waiting for? The deadline for the October 2022 APSF Newsletter is fast approaching on July 10^th. Here are the guidelines for submission:

• The purpose of this column is to allow expeditious communication of technology-related safety concerns raised by our readers, with input and response from manufacturers and industry representatives.
• Please limit the word count to fewer than 1000 words.
• Please provide no more than 15 references.

To check out all of the past rapid response submissions and responses, head over to APSF.org and click on the Newsletter heading. Third one down is the Rapid Response section. Some of the most popular articles in this column are:

• How do flow sensors work?
• Humidity levels in the OR
• Potential Burn Hazard from General Electric MRIs
• Reusable Anesthesia Breathing Circuits Considered
• Not All Manifolds are the Same: Lessons in Intravenous Drug Administration

We have covered some of these on the podcast already and we will be covering more going forward, so stay tuned.

We have another interesting case to discuss today. This is one of our Articles between issues from May 10, 2022. The article is called “Change in Anesthesia Choice and the LAST Case of the Day: How COVID Policies Can Affect Outcomes in an Ambulatory Surgery Center” by Justin Benoit and Fred Shapiro. To follow along with us, head over to APSF.org and click on the Newsletter heading. Second one down in the Articles Between Issues heading. Then, scroll down until you get to our featured article. The article reviews the changes in clinical decision making that occurred during the COVID pandemic and the impact on patient outcomes. We will discuss the following: patient management, changes in decision making for general anesthesia vs. monitored anesthesia care (MAC), and the use of simulation to educate personnel. The authors start by reviewing the options for ophthalmic surgery at an ambulatory surgery center with Monitored Anesthesia Care and local anesthesia which may be preferred to decrease the need for performing an aerosol generating procedure related to general anesthesia and then benefit for general anesthesia is deceased requirement for local anesthesia. Now, let’s get into the case.

The authors report on a case of an 85-year old, 63kg patient with history of macular degeneration for right-sided vitrectomy. She had already had a vitrectomy performed under general anesthesia prior to the Covid pandemic given the duration of the procedure and the surgeon’s preferences. For this second procedure, the decision was made between the patient, surgical and anesthesia teams to proceed with monitored anesthesia care to minimize the risk of an aerosolizing procedure given that it was during the Covid pandemic. Routine ASA monitors were used and sedation was given with 1 mg midazolam and 50 mcg remifentanil. The surgeon performed a retrobulbar block with 6mls of 1% lidocaine 0.375% bupivacaine mixture with 5units hyaluronidase. There was inadequate akinesis following the initial block. The surgery performed an additional block with another 6mls of the mixture. There were no complications during the block placement since aspiration of blood or CSF was negative. Shortly after the patient became unresponsive with seizure-like activity and in cardiac arrest. CPR was started with intubation and administration of intralipid 1.5ml/kg bolus followed by infusion at 0.25ml/kg/min. The patient had return of spontaneous circulation with improved hemodynamics and was transported by ambulance to an ICU. She was extubated on POD #1 and did not have any further complications. Several weeks later, that patient underwent successful vitrectomy under general anesthesia. Have you taken care of a patient with LAST at an ambulatory surgery center? You need to be prepared whenever local anesthesia is administered and be ready to act quickly to keep patients safe. The good news is that LAST is not a common event and occurs with an incidence of about 0.03%. Administration of local anesthesia for nerve blocks during ophthalmological procedures is common with about 76% of ophthalmologists reporting using local anesthesia every day, but over 50% reported not receiving specific training on LAST. In addition, even if the majority of physicians know that 20% intravenous lipid emulsion is the treatment for LAST, may do not have experience administering it during a LAST event. This case highlights a unique threat to patient safety during the Covid Era since the decision was made to proceed with MAC rather than general anesthesia in order to avoid performing an aerosol generating procedure that would be required for general anesthesia. As a result, local anesthesia and monitored anesthesia care was used. It is critical that ambulatory surgery centers be prepared to treat patients who develop life-threatening complications related to surgery and anesthesia. This is includes having a detailed emergency policy procedure plan and the ability to transfer patients to a tertiary care setting if needed. For more information check out the institute for Safety in Office-Based Surgery for a safety checklist and emergency manual.  We have talked about this checklist before on the podcast and I will include a link in the show notes. This article raises the question of safe anesthesia care at an ambulatory surgery center one step further because of the additional consideration during the Covid era. The authors ask the question, “What is the safest anesthetic choice for patients and personnel?

These are some important considerations:

• Monitored anesthesia care decreases the risk for performing an aerosol generating procedure, but remember general anesthesia may still be needed.
• If conversion to general anesthesia is necessary, there may be additional steps required for PPE and equipment to help keep the patient and healthcare professionals safe.
• There may be significant time delays due to these additional steps leading to case delays for patients and increased resource utilization.
• Medical simulation programs at an ambulatory surgery center are critical for increasing education, communication and team work between OR staff, nursing, surgeons, and anesthesia professionals. Necessary skills include rapid communication, delegation of tasks, location of emergency materials, providers scope of practice, and logistic of transport to tertiary care centers.
• Finally, a clear emergency action plan with appropriate cognitive aids is vital for patient management during life-threatening emergencies.

Keep in mind that keeping patients safe during the Covid pandemic and keep patients safe during anesthesia care may include additional risks and new considerations especially if monitored anesthesia care with local anesthetic is preferred to general anesthesia to avoid aerosol-generating procedures during general anesthesia. You can be prepared with education through team-based clinical simulations as well as checklists, cognitive aids, and a clear emergency action plan.

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 101 shows. We have more interviews and articles to review as well as authors to hear from and so much more. We may be hearing from you 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