Episode #207 Patient Safety During Prone Positioning, Loss of Resistance Syringe Concerns, and Lidocaine versus Fentanyl for Induction

June 19, 2024

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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 featured article today is an Article Between Issues. It is “The Underappreciated Dangers of the Prone Position” published on 30th April 2024 and written by Taizoon Q. Dhoon MD; Shermeen Vakharia MD; Evan Villaluz MD; and Debra E. Morrison MD.

Thank you to Taizoon Dhoon for contributing to the show today.

We reviewed clinical recommendations today. Preoperative considerations include a thorough and focused preoperative exam for all patients who will require prone positioning with patient history, airway examination, preexisting neurological deficits, anticipated duration of the procedure, and proposed positioning with evaluation of the patient’s capacity for prone positioning depending on co-morbidities and risk factors. Intraoperative considerations include the following: securing the endotracheal tube, obtaining appropriate access and monitoring, proper padding and frequent pressure-point checks, teamwork to position safely, neutral neck positioning, safe arm movement.

Once the patient is in the prone position, additional considerations include the following:

  • First, check on the vital signs. Is the patient hemodynamically stable? Are your monitors working? The bed should remain in the room until hemodynamic stability is confirmed. For patients who become unstable once in the prone position, quickly re-position supine and resuscitate, evaluate and treat the cause of the hemodynamic changes without delay.
  • Next, make sure that appropriate padding is used to help keep your patient safe. Throughout the case, you will need to check pressure points as well as the eyes, mouth, and neck for proper positioning to help prevent any pressure-related injuries.

Our next featured article is from April 16, 2024, and it is “Loss of Resistance Epidural Syringes with a Retraction Stop and the Risk of Accidental Dural Puncture” by Tatsumi Yakushiji, Keisuke Yoshida, Takayuki Hasegawa, and Satoki Inoue. This is a letter to the editor about the Perifix LOR syringe by B-Braun that is designed to be used for the loss of resistance technique during epidural placement to detect the epidural space.

Finally, we head over to the In the Literature section. Our next featured article is a summary of the study, “Comparison of the hemodynamic effects of opioid-based versus lidocaine-based induction of anesthesia with propofol in older adults: a randomized controlled trial.” This summary was completed by Sood and Panday and published on the APSF website on April 29, 2024.

Here is the citation for the study:

Anaesthesia Critical Care & Pain Medicine | April 2023
Amin SM, Hasanin A, ElSayed OS, Mostafa M, Khaled D, Arafa AS, Hassan A. Comparison of the hemodynamic effects of opioid-based versus lidocaine-based induction of anesthesia with propofol in older adults: a randomized controlled trial. Anaesth Crit Care Pain Med. 2023 Aug;42(4):101225. doi: 10.1016/j.accpm.2023.101225. Epub 2023 Apr 6. PMID: 37030397.

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© 2024, 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. For the past two weeks we have discussed the underappreciated dangers of the prone position for patients during anesthesia care. This is an important time to remain vigilant since patients are at risk for positioning injuries as well as significant physiologic changes while in the prone position. Today, we are going to hear from one of the authors of the APSF Newsletter article. Then, it’s time to catch up on a couple more articles between issues, so stay tuned.

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

We are returning to the Article Between Issues, “The Underappreciated Dangers of the Prone Position” published on 30th April 2024 and written by Taizoon Dhoon and colleagues. To follow along with us, head over to APSF.org and click on the Newsletter heading. The second one down is Articles Between Issues and from here scroll down until you get to our featured article today. I will include a link in the show notes as well. To help kick off the show today, we are going to hear from one of the authors. Here he is now.

[Dhoon] “Hi, my name is Taizoon Dhoon. I’m an associate professor at the University of California, Irvine and serve as a vice chair for quality and patient safety for the Department of Anesthesiology and Perioperative Care.”

[Bechtel] I asked Dhoon why he wrote this article. Let’s take a listen to what he had to say.

[Dhoon] The goal of our article is to review the potential injuries associated with the prone position, but also focus on the physiologic changes that occur with it. In our article, we really wanted to focus on the physiologic changes that can occur with the prone position. This type of understanding is crucial in high-risk patients, even those undergoing a low-risk procedure.  For example, a patient with cardiopulmonary disease may not be able to tolerate an ERCP in the prone position due to the potential changes that can occur.”

[Bechtel] I also asked Dhoon what he hopes to see going forward. Here is his response.

[Dhoon] “The goal of our article was to raise awareness and understanding among anesthesia professionals about the potential pressure related injuries and physiologic changes that can occur when the prone position is used.  We hope that this knowledge will improve communication and collaboration between anesthesia professionals with our surgical and procedural colleagues and in turn enhance patient care.”

[Bechtel] Thank you so much to Dhoon for contributing to the show today and for your excellent article. Before we move on to our next article between issues, let’s do a quick review of the recommendations for keeping patients safe during anesthesia care in the prone position.

Let’s start with preoperative considerations which include the following:

  • Complete a thorough and focused preoperative exam for all patients who will require prone positioning with consideration for patient history, airway examination, and preexisting neurological deficits.
  • Discuss the anticipated duration of the procedure and proposed positioning.
  • Evaluate the patient’s capacity for prone positioning depending on co-morbidities and risk factors.
  • If needed, attempt positioning in the desired position with the patient in an empty operating room before the day of surgery to demonstrate that it is possible to safely obtain prone positioning.
  • Document with photographs, important details, and extra equipment that may be needed for safe positioning on the day of surgery.
  • Complete a preoperative cardiac evaluation with consideration for functional status and exercise capacity. It is important to have a low threshold for further testing in high-risk patients. Stress echocardiography can help to determine the risk of ischemic heart disease as well as provide vital information about right ventricular function, pulmonary hypertension, and valvular heart disease.
  • Plan for additional monitoring and appropriate access with availability of inotropes, vasopressors, and pulmonary vasodilators if needed.

It’s time to move into the operating room. Intraoperative considerations include the following:

  • Secure the endotracheal tube carefully to prevent dislodgement or malposition.
  • Obtain appropriate peripheral and central access as well as intra-arterial catheter placement while supine prior to positioning prone.
  • Teamwork during prone positioning with about 5-6 team members including the anesthesia professional and surgeon to ensure careful and safe positioning for the surgery or procedure.
  • Careful arm positioning with movement of the arms independent of the other arm to prevent shoulder joint injury especially during the initial prone positioning and during the re-positioning supine at the end of the case.
  • Keep the axilla free from tension
  • Additional padding around the ulnar nerve
  • Positioning arms slightly anterior to the shoulders in the coronal plane with the arms less than the patient’s full extension at the elbow joint to protect the brachial plexus and biceps tendon.

Once the patient is in the prone position, you have more work to do.

  • First, check on the vital signs. Is the patient hemodynamically stable? Are your monitors working? The bed should remain in the room until hemodynamic stability is confirmed. For patients who become unstable once in the prone position, it is possible to quickly re-position supine and resuscitate, evaluate and treat the cause of the hemodynamic changes without delay.
  • Next, make sure that appropriate padding is used to help keep your patient safe. Throughout the case, you will need to check pressure points as well as the eyes, mouth, and neck for proper positioning to help prevent any pressure-related injuries.

Postoperative considerations once the patient has been re-positioned supine include determining the safe time to extubate depending on the presence of any facial, lingual, and glottic edema. Patients with significant edema may need to remain intubated and monitored in the intensive care unit until the edema has resolved and it is safe to extubate. Patients who can be extubated at the end of the case may require higher level of care postoperatively in the intensive care unit depending on the patient’s comorbidities, the surgical procedure, and any significant hemodynamic changes. Anesthesia professionals are charged with understanding the patterns of pressure-related injuries and physiologic changes that may occur during a procedure in the prone position and remain vigilant to help keep patients safe.

And now it’s time to move on to another Article Between Issues. Here we go!

Our next article is from April 16, 2024, and it is “Loss of Resistance Epidural Syringes with a Retraction Stop and the Risk of Accidental Dural Puncture” by Tatsumi Yakushiji and colleagues. To follow along with us, head 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 our featured article today. I will include a link in the show notes as well.

This is a letter to the editor about the Perifix LOR syringe by B-Braun that is designed to be used for the loss of resistance technique during epidural placement to detect the epidural space. This syringe is designed to slide easily with minimal contact area between the barrel and the plunger. There is a stop built into the syringe at the back of the barrel to prevent the plunger from being pulled out of the barrel during retraction. Check out Figure 1 in the article which is a photograph of the syringe with the plunger pulled back to the built-in stop. This is marked by the black arrow. At this point, the plunger tip should stop at the number 8 on the syringe, which is the white arrow. The authors describe being able to retract the plunger past the stop by applying a bit more force. Once the plunger is pulled back past the stop, then it is not possible to re-engage the plunger back into the barrel easily. This makes sense because the syringe is not designed for the plunger to be able to be pulled beyond the built-in stop in the first place. As a result, if the syringe was inadvertently pulled past the stop during epidural placement, then there is a risk for accidental dural puncture because the loss of resistance will not occur even though the needle tip reaches the epidural space.

Now, it’s time to head over to the In the Literature Section. Our next featured article is a summary of the study, “Comparison of the hemodynamic effects of opioid-based versus lidocaine-based induction of anesthesia with propofol in older adults: a randomized controlled trial.” This summary was completed by Sood and Panday and published on the APSF website on April 29, 2024.  This summary is of the April 2023 article in Anaesthesia Critical Care and Pain Medicine by Amin and colleagues. Check out the show notes for the full citation and link to the APSF article. Here’s the summary:

  • This was a randomized, controlled trial conducted in Cairo University to compare the hemodynamic profiles of lidocaine versus opioid based induction with propofol.
  • 100 patients were included in the study and met the criteria of over 60 years old, ASA 1-3, and undergoing non-cardiac surgery.
  • Induction of anesthesia involved patients receiving 1mg/kg of lidocaine in the lidocaine group or 1 mcg/kg of fentanyl in the fentanyl group with propofol induction.
  • Hypotension was defined as mean arterial blood pressure less than 65mmHg or a greater than 30% reduction from the patient’s baseline.

Results revealed the following:

    • 0% or 0/47 patients in the lidocaine group developed hypotension.
    • 61% or 28 out of 46 patients developed hypotension in the Fentanyl group and 13% developed severe hypotension.
    • The mean blood pressure dropped in both groups from pre-induction level with a more pronounced decrease in the fentanyl group. One patient in the fentanyl group experienced bradycardia as well.
    • Intubation conditions were similar between the two groups.
  • In conclusion, lidocaine-based regimen reduced post induction hypotension in older patients than the fentanyl-based induction.

Are you using lidocaine or fentanyl for induction for older patients? Will this article change the way you practice? The In the Literature section is a great way for you to stay up to date on the latest in perioperative patient safety.

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.

The June 2024 APSF Newsletter has been released! We are so excited to feature many of these excellent articles here on the podcast. In the meantime, you can check out the articles online over at APSF.org and click on the Newsletter heading. The first one down is the current issue which is now the June 2024 APSF Newsletter. Stay tuned for all new podcast episodes on these articles soon.

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

© 2024, The Anesthesia Patient Safety Foundation