Episode #170 Anesthesia Patient Safety Threats: Hypoxemia in the GI Suite and Wrong Drug in the Pyxis Drawer

October 3, 2023

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Welcome to the next installment of the Anesthesia Patient Safety podcast hosted by Alli Bechtel.  This podcast will be an exciting journey towards improved anesthesia patient safety.

Our first article today is an article between issues that was published on July 16, 2023, called “Sudden Hypoxemia in GI Procedure Relieved by a New Distal Pharyngeal Airway: Case Report” by James DuCanto.

Here are some suggestions to decrease the risk for hypoxemia during upper endoscopy procedures:

  • Upper pharyngeal topicalization to reduce the amount of sedation needed.
  • Slow and careful titration of sedative agents
  • In high-risk patients, consider assisted face mask ventilation with a bag-mask ventilation prior to placement of the endoscope to improve lung recruitment and decrease hypoventilation.
  • Once upper airway obstruction has occurred, placement of a DPA may help to decrease the risk for apnea, hypoxemia, and other adverse events.

Keep in mind that there are risks associated with the use of a DPA. Risks may include potential injuries to the lips, tongue, teeth, and palate which are similar to traditional oropharyngeal airways.

We are striving for the goal that no patient is harmed by hypoxemia during upper endoscopies. If you get a chance, check out the 2019 APSF article, “Hypoxia During Upper GI Endoscopy: There is Still Room for Improvement.

Our next featured article is “Wrong Medication in the Anesthesia Pyxis Machine” by Anthony Kong published on May 17, 2023.

Here is the citation that we talked about on the show today. This is a prospective observational study of 3,671 perioperative medication administration events. Of these events, 5.3% involved a medical error or resulted in an adverse drug event.

  • Karen, CN, Patel, A et al. Evaluation of Perioperative Medication Errors and Adverse Drug Events. Anesthesiology. 2016; 124:25-34.

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© 2023, The Anesthesia Patient Safety Foundation

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. Last week, we talked about some newly published articles between issues about endotracheal tube cuff inflation failure and medication safety issues with drug dilution in the operating room. Today, we have a couple more articles to discuss to help keep patients safe especially in the GI Suite and when using an automated drug dispensing cabinet.

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

Our first article today is an article between issues that was published on July 16, 2023, called “Sudden Hypoxemia in GI Procedure Relieved by a New Distal Pharyngeal Airway: Case Report” by James DuCanto. To follow along with us, head over to APSF.org and click on the Newsletter heading. Second one down is Articles Between Issues. Then scroll down until you get to July 2023 and our featured article today. I will include a link in the show notes as well.

We have talked about some of the patient safety challenges that anesthesia professionals may face when providing anesthesia care for gastrointestinal endoscopy cases including upper airway obstruction and hypoxemia. Closed claims analysis has shown that GI endoscopy cases are associated with the highest number of malpractice claims for anesthesia professionals. There is a need for improvement in upper airway patency and oxygenation beyond the supplemental oxygen administration from oxygen masks. Have you used a Distal Pharyngeal Airway or DPA? This is a narrow tube-shaped oral airway that can be placed next to an Upper GI endoscope to help treat distal pharyngeal airway obstruction during endoscopy. Using a DPA may be an important tool in the airway management toolbox during monitored anesthesia care and sedation.

Upper endoscopy procedures are shared airway cases with the endoscopist which may lead to difficulties with airway management. Hypoxemia during upper endoscopy occurs when oxygen saturations are less than 90% for 15 or more seconds. A prospective study in ASA 1 and 2 patients undergoing endoscopy revealed that the rate of hypoxemia may be as high has 51%. This is especially concerning because if left untreated, apnea, bradycardia, and cardiac arrest may occur. The anesthetic plan for GI procedures often involves deep sedation, defined by the author as sedation that is greater than moderate sedation while maintaining spontaneous ventilation. Benefits from monitored anesthesia care or MAC for GI procedures includes increased patient comfort, improved quality of examination, rapid recovery, and savings of time and money. The challenge for providing sedation involves the balance between blunting the gag reflux during placement of the endoscope and maintaining spontaneous ventilation while managing the patients’ comorbidities and sharing the airway with the endoscopist.  An EGD bite block is often placed which may interfere with airway support as well.

Now that we have some background information. Let’s check out a case report of a 60-year-old, 137 kg man with a BMI of 53 and a past medical history of hypertension, type 2 diabetes, obstructive sleep apnea, and hepatic steatosis who presented for an upper endoscopy procedure or EGD at an ambulatory surgery center. Routine monitors were placed and 8L of oxygen were administered through an endoscopy mask. The patient was positioned in a left lateral position with 30 degrees elevation of the head of the bed. IV sedation with propofol was administered until the patient became unresponsive to verbal or gentle physical stimuli. The EGD endoscope was inserted with a jaw thrust assist. Apnea occurred at the beginning of the procedure leading to hypoxemia with oxygen saturation decreasing from 99% to 60%. A jaw thrust was performed without improvement in oxygenation. At this point, the endoscopy mask was lifted briefly by the chin to quickly place the distal pharyngeal airway next to the EGD bite block. Check out Figure 1 and 2 in the article for an image of the DPA and the use of a DPA in a mannequin next to a bite block. Following placement of the DPA, the patient’s hypoxemia resolved quickly with the reversal of airway obstruction. The procedure was able to be completed and there were no further complications.

This case helps to highlight a common problem during upper endoscopy procedures. Monitoring is critical for early recognition and treatment. Risk factors for airway obstruction from redundant distal pharyngeal tissue leading to hypoxemia include the following:

OSA

Obesity

Age greater than 60 years old.

It is also important to be on the lookout for patient comorbidities that may lead to decreased respiratory reserve volumes.

Patients may become apneic during the produce due to oversedation, upper airway obstruction by the large EGD endoscope, anesthesia-induced myorelaxation of the distal pharynx and tongue, and respiratory depression. Apnea may be quickly followed by hypoxemia.

So how can we decrease the risk for hypoxemia during upper endoscopy procedures? Here are some suggestions:

Upper pharyngeal topicalization to reduce the amount of sedation needed.

Slow and careful titration of sedative agents

In high-risk patients, consider assisted face mask ventilation with a bag-mask ventilation prior to placement of the endoscope to improve lung recruitment and decrease hypoventilation.

Once upper airway obstruction has occurred, placement of a DPA may help to decrease the risk for apnea, hypoxemia, and other adverse events. Placement of a DPA can be done with the endoscope in place. If the airway obstruction is relieved by the DPA and the patient is able to maintain adequate oxygenation and ventilation, the procedure may continue without removing the endoscope to provide rescue ventilation and possibly aborting the procedure.

Risk associated with the use of a DPA include potential injuries to the lips, tongue, teeth, and palate which are similar to traditional oropharyngeal airways. We are striving for the goal that no patient is harmed by hypoxemia during upper endoscopies. If you get a chance, check out the 2019 APSF article,

“Hypoxia During Upper GI Endoscopy: There is Still Room for Improvement.” I will include a link in the show notes as well. Use of a distal pharyngeal airway may be a simple, cost-effective tool to help with basic airway management during upper endoscopy procedures when jaw thrust, and head and neck repositioning maneuvers are unable to relieve the airway obstruction. Going forward, further clinical studies are needed to confirm the role for DPAs in improving patient safety during upper endoscopy.

We have time to review one more article today. It’s another article between issues. Our next featured article is “Wrong Medication in the Anesthesia Pyxis Machine” by Anthony Kong published on May 17, 2023. To follow along with us, head back over to APSF.org and click on the Newsletter heading. Second one down is Articles Between Issues and then scroll down until you get to May 2023 and our featured article today.

The author describes the following case:

“One morning, as I prepared for my first carotid case, I retrieved a 2 ml vial of lidocaine 2% from my Anesthesia Pyxis (an automatic medication dispenser) and administered it without incident. However, while getting ready for my second carotid case, I discovered a 1 ml vial of phenylephrine (10 mg) in container #22 amongst other 2 ml vials of lidocaine 2 %. Upon closer examination, I noticed three more vials of phenylephrine mixed with approximately 12 vials of 2 ml lidocaine 2% in the same container, all of which looked identical. I immediately contacted the in-house pharmacist, insisting that she come down to “document and retrieve” the misplaced vials of phenylephrine. I also notified the charge nurse and asked her to verify and ensure that every Pyxis was checked, confirming that container #22 did not contain phenylephrine.”

Whew, what a crucial discovery and recognition of the misplaced vials. This is another example of a threat to medication safety during anesthesia care. The stakes are quite high since administering 10mg undiluted phenylephrine can have disastrous consequences. Anesthesia professionals are responsible for checking and confirming medications including ensuring the correct medication, dose, route of administration, and timing as well as monitoring for drug effect and adverse effects. Medication errors may happen due to muscle memory, just reaching into the correct drawer of the automated dispensing cabinet and expecting to pull out the correct medication or due to the poor lighting in the operating room.

Let’s check out the literature. In a prospective observational study of 3,671 perioperative medication administration events, 5.3% involved a medical error or resulted in an adverse drug event. The author’s case of an incorrectly stocked Pyxis machine due to look-alike drug vials could have resulted in a serious medical error. We are left with a call to action that there continue to be challenges in the perioperative environment and anesthesia professionals must remain vigilant to prevent medication errors and keep patients safe.

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.

Do you have case report related to anesthesia care and patient safety? Have you thought about contributing a case report to the ASPF Newsletter. Case reports should focus on novel perioperative patient safety cases, be less than 750 words, with no more than 10 references. Authors should follow the CARE guidelines and the CARE checklist needs to be provided as well. The ASPF Newsletter is published three times a year in February, June, and October and submission deadlines are November 10th, March 10th and July 10th, but you can feel free to submit a manuscript at any time for review. Who knows you might be the next author of an article between issues or featured in a future APSF Newsletter.

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

© 2023, The Anesthesia Patient Safety Foundation