Episode #19 Keeping Patients Safe: TXA Update and Transportation Ventilation

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.

To start the show off I want to let you know about the APSF response to Cybersecurity Threats. This is absolutely something that can impact patient safety and US Health Care Systems need to be ready.  On November 2, 2020, the APSF published the article, “The APSF Issues Preliminary Guidance on Cybersecurity Threats to US Health Care Systems.” I encourage you to check out the article on our website, on the main page under APSF news and updates. We will dive more into this topic in the future, but for now the APSF Committee on Technology recommends that all anesthesia professionals work to strengthen down-time procedures, increase vigilance, and review reporting on medical device and system performance. I will include a link to the article in the show notes as well.

And now back to our regularly scheduled program.

Today, we are going to highlight the recent alert regarding tranexamic acid administration from the National Alert Network before returning to the Rapid Response to Questions from our Readers to review some important patient safety concerns

Before we dive into today’s episode, we’d like to recognize Fresenius Kabi, a major corporate supporter of APSF. Fresenius Kabi has generously provided unrestricted support as well as research and educational grants to further our vision that “no one shall be harmed by anesthesia care”. Thank you, Fresenius Kabi – we wouldn’t be able to do all that we do without you!”

The National Alert Network includes members of the National Coordination Council for Medication Error Reporting and Prevention. This network works with the Institute for Safe Medication Practices or ISMP as well as the American Society of Health-System Pharmacists or ASHP to create warnings for healthcare providers about medication errors that have caused or may cause serious injury or death. These groups strive to disseminate this knowledge to help prevent these serious medication-related complications. This recent alert is related to tranexamic acid administration and includes 3 cases of accidental intrathecal administration of tranexamic acid instead of the intended local anesthetic medication leading to seizures. This drug error likely occurred since the top cap for tranexamic acid is blue and a similar shade of blue to many local anesthetics. For pictures of these top caps, please check out the APSF website under the Who We Are heading and click on News and Updates. On page 2 with a date of publication of September 9^th you will see the alert and the image.  From the top and at quick glance these medications can look very similar and it is vital to pay particular attention to avoid this complication.  These cases involved mixing up tranexamic acid for local anesthesia during placement of a spinal for the anesthesia for a case. The patients developed seizures following intrathecal tranexamic acid administration, but ultimately recovered. The Institute for Safe Medical Practices attributes these repeated errors to the similar or same color blue cap on vials of tranexamic acid and local anesthetics. In addition, these drug error events have occurred in places where use of a barcode scanner may not be used frequently such as out of OR environments in the preoperative holding area and labor and delivery.

Let’s take a minute to review tranexamic acid.  It is an antifibrinolytic medication used for patients with hemophilia to prevent hemorrhage during and after tooth extraction. It is also used off-label in the OR during cardiac surgery, trauma, obstetric hemorrhage, spine surgery and joint surgery to control bleeding. Unfortunately, tranexamic acid is a neurotoxin and spinal administration comes with a 50% mortality rate and serious complications have been seen in survivors including seizures, permanent neurological issue, ventricular fibrillation, and paraplegia.

So, now that we can see that this is a big patient safety problem, what are somethings that we can do to prevent this event from occurring. First, we can separate the storage of local anesthetics and tranexamic acid.  Consider keeping tranexamic acid in a separate location even. Next, you may want to consider storing these drugs so that the label is clearly visible instead of just the blue cap. Speaking of the blue cap, consider minimizing the drugs with the same caps by purchasing from different manufactures or placing labels on the drug caps that clearly state “contains tranexamic acid.” Don’t forget to the use the barcode scanner to generate a correct label for the medications as well and use this even when you are in the perioperative area or labor and delivery. There is a special connection available to help prevent misconnections for neuraxial drug administration called the NRFit and this may be something to consider to help prevent this event. Finally, another option is to use pharmacy-prepared syringes or infusions of tranexamic acid with proper labelling to help differentiate this medication from local anesthetics.  This is such an important topic. In fact, it is one of the APSF’s Patient Safety Priorities, Medication Safety. Please stay vigilant to help prevent this drug error and check out the show notes where I have included a link the article on the APSF website.

That was a lot of important information so I am going to give you a moment to stretch and get ready to review a rapid response to questions from our readers.

I hope you are ready because here we go. The Rapid Response today comes to us from the October 2019 APSF Newsletter. You can find it by clicking on the patient safety resources heading from the APSF homepage, 3^rd one down is Rapid Response to questions from our readers. Then, you will need to scroll down to page 2 to find the article, “PEA Arrest During Transport of a Ventilated Patient Due to Clogged Respiratory Filter on Ambu Bag.” And don’t worry because I will include a link in the show notes.  At the top of the article, the Editor includes a note that the clogged filter may happen in any device similar to the Ambu bag so definitely stay vigilant with any transport ventilation equipment.  So, what happened in this case submitted by Gerasimov and Toor?

The case involves a 65 year old intubated patient with sepsis and new end-stage renal disease on dialysis who presented to the interventional radiology suite for dialysis catheter insertion. At the end of the procedure, the patient remained intubated and was transported back to the ICU with a self-inflating Ambu bag and manual ventilation by the anesthesia team. On the way to the ICU, the patient became harder to ventilate and then become hypotensive, hypoxic and suffered a PEA arrest. CPR was started and during resuscitation, the anesthesia professional discovered that the Ambu bag expiratory valve filter was obstructed with secretions. The ETT was then disconnected from the Ambu bag with an audible escape of air and then the patient had return of circulation. Why did the patient suffer a cardiac arrest? The authors tells us that when there is not enough time for expiration and incomplete exhalation, auto-positive end-expiratory pressure (auto-PEEP) can occur in patients who require mechanical ventilation. PEEP is the positive pressure at the level of the alveoli at end exhalation. This scenario is more common in patients with intrinsic lung disease such as severe asthma or COPD, but we can see it in patients without lung disease. Auto-PEEP creates increased alveolar pressure that can lead to increased work of breathing, decreased ventilation, barotrauma, and hemodynamic instability. It is important to know how to prevent this, detect it, and treat auto-PEEP.  This was a case of cardiac arrest due to auto-PEEP from a clogged expiratory filter with return of spontaneous circulation after removal of the expiratory airflow obstruction. After this case, the filter was removed from all Ambu bags at the authors institution and replaced with a splash guard. Check out the article for pictures of these components of the Ambu bag as well.  The splash guard is useful to protect healthcare professionals and does not contain a filter that may be subsequently obstructed with secretions or blood. Thank you to Gerasimov and Toor for sharing this case to help prevent this from happening in the future.

This case also highlights a unique anesthesia patient care scenario – transportation within the hospital for patients who require mechanical ventilation. Just because we leave the ICU or OR does not mean that we can let down our guard. In fact, during transport we need to be even more vigilant. The next article is also from the October 2019 APSF Newsletter and you can find it in the Rapid Response to Questions from our readers section and scrolling down, it is on the first page. The article is “Considerations for Mechanical Support of Ventilation During Patient Transport” by Algarra and Gravenstein. The authors start out by highlighting the severity of the problem since there are reported complications ranging from 10-31% during transport for patients who require mechanical ventilation. There are definitely some unique considerations for ventilation during transport as well as special equipment to support ventilation outside of the operating room. We often have so many resources (including monitors, alarms, suction, and additional colleagues) available in the OR to ensure adequate oxygenation and ventilation in patients who require manual or mechanical ventilation. When we leave the OR, we may have reduced resources and now we have to maneuver the bed through hallways and elevators.

So, what can we do to make this process safer for our patients? We just talked about the case of the clogged expiratory filter in the Ambu Bag leading to cardiac arrest during patient transport. The purpose of the filter is to protect the environment, but these filters can cause an obstruction anytime they are connected to an endotracheal tube or anywhere in the expiratory path. So, this is definitely something that you will want to keep on your differential anytime you see increasing airway pressures and there is a filter in line. Don’t forget that the obstruction may occur within the endotracheal tube as well.  The solution in the rapid response case was to use a splash guard which certainly helps to avoid a clogged filter, but there is a risk for contamination of the environment and nearby healthcare workers. Another option is to transport patients with a transport ventilator and a respiratory therapist and as long as the oxygen supply to the transport ventilator is adequate, this is a very safe form of transport. The authors include a chart the looks at the advantages and disadvantages of ventilation transport devices. I will include that chart in the show notes, but let’s take a moment to review now.

First up is the self-inflating bag, like an Ambu Bag which has the advantages of ventilation even if there is no gas supply, it is light and easy to use and familiar to anesthesia professionals. The disadvantages include no visual indication of inspiration or exhalation, no standard monitoring for inspiration and expiration, decreased compliance of the self-inflating bag with variable tidal volume and respiratory rate.

Next up we have the Mapleson Circuit. The advantages of this device is that you can see the patient’s respiratory efforts by looking at the bag and inspiration and exhalation can be felt manually. The disadvantages include that it depends on a compressed gas supply and the tidal volumes depend on the gas flow and APL valve setting…and once again there is no standard for monitoring inspiration and expiration and tidal volume and respiratory rate are variable.

Last, but certainly not least is the transport ventilator. The advantages are significant since ventilation can be programed and it is stable and reliable as well as hands free and there is standard monitoring built into the device.  Unfortunately, there are some significant disadvantages since these devices require a significant amount of resources in terms of the device and a trained respiratory therapist and it requires a compressed gas supply.

So, what are the take aways from this case? Remember that anything added to the breathing circuit may become an obstruction thus preventing exhalation which could ultimately lead to cardiovascular collapse. It is really important to assess and monitor the patient’s respiratory status and ventilation closely during manual ventilation while transporting a patient. Many transport monitors have the option now for capnography during transport and this can help you keep an eye on inspiration and exhalation and monitoring the end-tidal CO2 concentration can help to ensure adequate ventilation during transport and improve patient safety!

Okay, that’s all the time we have for today! If you have any questions or comments from today’s show, please email us at [email protected].

Visit APSF.org for detailed information and check out the show notes for links to all the topics we discussed today.  We love hearing from you on Twitter. Don’t forget to tag us in any of your patient safety related tweets @APSForg and use the hashtag #APSFpodcast to let us know that you are listening to the show.

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

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