Episode #3 Highlights from the June 2020 APSF Newsletter

July 21, 2020

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

During this episode, I introduce the famous APSF Newsletter.  If you are interest in patient safety, make sure that subscribe to the newsletter so that you can get early access to our newsletter by email: https://www.apsf.org/subscribe/

Interested in contributing content to the APSF Newsletter?! Publication occurs three times each year in February, June, and October.  Mark your calendars because the deadlines for submission are at the following times: 1) February Issue: November 15th, 2) June Issue: March 15th, 3) October Issue: July 15th. Check out our website here for more details: https://www.apsf.org/apsf-newsletter/guide-for-authors/

Are you active on social media and want to join our team of APSF Ambassadors?  You can email Emily Methangkool, our APSF Ambassador Program Director, for more information at [email protected]

The first APSF Newsletter was released in the spring of 1986. I review a Current Question at that time in the Patient Safety Section and the question was “Is Monitoring for Hypoxemia More Important than for Hypercarbia?” written by David Cullen, MD.

Next, we dive into the June 2020 Newsletter and the 3 featured articles.Next, we dive into the June 2020 Newsletter and the 3 featured articles.

  1. An Update on the Perioperative Considerations for COVID-19 Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2)
  2. COVID-19 Pandemic—Decontamination of Respirators and Masks for the General Public, Health Care Workers, and Hospital Environments
  3. Postoperative Recurarization After Sugammadex Administration Due to the Lack of Appropriate Neuromuscular Monitoring: The Japanese Experience

I end the show today by reviewing the Letter to the Editor and the case of the misfilled vaporizer. Make sure that you stay vigilant in the OR and investigate any abnormal monitor readings.


Be sure to check out the APSF website at https://www.apsf.org/

Make sure that you subscribe to our newsletter at https://www.apsf.org/subscribe/

Follow us on Twitter @APSForg. #APSFpodcast.

Questions or Comments? Email me at [email protected].

© 2020, The Anesthesia Patient Safety Foundation

Hello and welcome back to the Anesthesia Patient Safety Podcast.  I’m your host, Alli Bechtel. Thank you for joining me for another show.

Okay, raise your hands if you have ever received an APSF Newsletter!  One of the limitations of podcasting is that you cannot see that I am raising my hand and I hope that many of you are raising your hands now!   If you are not raising your hand right now, don’t worry I have great news for you.  Just click on the link in the show notes so that you can subscribe to our newsletter.  This is a must read for everyone with an interest in perioperative safety which I am guessing is everyone listening to the show right now, so go sign up!!

I know that as soon as I get the email for the APSF Newsletter, I like to get a nice cup of coffee and dive right into all of the great articles and information so that I can stay up to date on all things patient safety. I also know that every once in a while, you might miss a Newsletter or maybe you were planning on returning to a past Newsletter article that really piqued your interest.  Well, I have great news for you, just click over to the APSF Newsletter archives page on our website and you can find all the great newsletters from June 2020 all the way back to 1986.

In case you were wondering, it was in the spring of 1986 that APSF release the First Newsletter.  Let’s take a look at it.  One of articles in the Newsletter was a Current Questions in Patient Safety Section and the question was “Is Monitoring for Hypoxemia More Important than for Hypercarbia?” written by David Cullen, MD.  The short answer that Cullen reveals is YES given the resultant respiratory and cardiac arrest that follow if hypoxia is not immediately recognized and treated to reverse the course. Hypercarbia is a serious concern for patient safety as well especially if it is due to hypoventilation. The combination of hypoxemia plus hypercarbia is particular dangerous for patients because it can lead to respiratory acidosis, myocardial depression, bradycardia, and cardiac arrest.  Monitoring and staying vigilant is so important to diagnose and treat patients quickly to prevent significant morbidity and mortality. If you get a chance, I highly recommend looking back through the archives!

The other things that you will see on the Newsletter page is that the APSF Newsletter has been translated into Japanese, Spanish, Chinese, French, and Portuguese.

Now, let’s say you don’t just want to read the Newsletter, but you want to become a contributor.  That’s great.  The APSF Newsletter is the official journal of the Anesthesia Patient Safety Foundation and has a large readership since it is distributed to anesthesia professionals, perioperative providers, key industry representatives, and risk managers.  And the content that we are looking for is anesthesia related perioperative patient safety! Publication occurs three times each year in February, June, and October.  Mark your calendars because the deadlines for submission are at the following times: 1) February Issue: November 15th, 2) June Issue: March 15th, 3) October Issue: July 15th and I will make a note of these in the show notes. Our team of newsletter editors will make the decision about content for the newsletter and submissions may be accepted for future newsletters as well as for the APSF website and social media pages and some of you will be lucky enough that I will talk about your submission on a future podcast. I will include the submission guidelines in the show notes and you can also find them on our website.   We are looking for invited review articles, Pro-Con debates, Question and Answer articles, Letters to the Editor, and Conference reports. We also have a rapid response to questions from the readers of our newsletter column and I will feature some of these rapid responses on future episodes.  It is sure to be exciting and filled with lots of great information. If you or your organization is interested in submitting content for an upcoming newsletter publication, please contact our Newsletter Editor-In-Chief and you can find the email address in the show notes.

Before we dive into the June 2020 APSF Newsletter, here are a few quick announcements first! By the way, if you do not already receive the Newsletter, you can subscribe for free on our website. I’ll link to this in the show notes.

Are you on social media?  If so, then we hope you will connect with us. You can follow us on Facebook, Twitter, and Linked In and I will have the links in the show notes. Not only do we want you to follow us, but we want to hear from you too.  Make sure that you tag us when you share your patient safety-related work including academic articles, presentations, and projects and we will spread the word with our growing community. If you have the social media bug combined with a passion for anesthesia patient safety, then please consider joining our team of APSF Ambassadors.  You can send an email to Emily Methangkool, our APSF Ambassador Program Director. I will have her email in the show notes – she can’t wait to hear from you!! Okay, we are going to take a quick break so I can tweet about this podcast…

And I’m back…there are 3 featured articles in our June edition. The Covid-19 Pandemic has impacted every area of healthcare and that is why you will see lots of information about the impact on anesthesia patient care and safety in our June Newsletter.  And of course, as we discussed in the last show, we have an extensive resource library on the website, so don’t forget to check that out for the latest news and recommendations, a s well as valuable information about PPE, ventilators, perioperative protocols, drug-drug interactions, and more.

Ok, back to the featured articles in the June 2020 Newsletter. The first one is “An Update on the Perioperative Considerations for COVID-19 Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2).” Definitely go check out that article and that is something that I would like to cover in a future episode.

The next featured article is “COVID-19 Pandemic—Decontamination of Respirators and Masks for the General Public, Health Care Workers, and Hospital Environments.” There has been a large media focus on mask and respirator shortages for healthcare workers and the general public and this article provides excellent information about the scientific data on the use of three decontamination methods including uultraviolet germicidal irradiation, steam heat and oven heating. Let’s take a closer look. The ultraviolet germicidal irradiation method involves suspending the masks or respirators in the middle of 2 UV systems that are placed 1 meter away from the front and back of the respirators or masks within a small decontamination room. The light used for decontamination was UV-C light applied to the masks for 5 minutes.

The next method was the oven cleaning method with a mask or respiratory placed on a stack of coffee filters in an oven preheated to 77 degrees Celcius or 170 degrees Farhenheit for 30 miutes. This temp was chosensince it is the lowest temp setting on many household ovens and the COVID-19 virus is deactivated at 70 degrees Celcius. The masks did not touch any metal inside the oven in order to avoid thermal damage.  The final method tested was steam heat treatment. Masks or respirators were placed on a rack in a steamer with boiling water for 30 minutes. The investigators measured filtration efficiency and breathing resistance of an N95 respiratory, a procedure mask and a surgical mask before and after decontamination.  The results included >95% efficiency for the N95 mask for the entire size range including a >98% efficiency for the Covid-19 virus size.  The surgical and procedure masks had lower filtration efficiency, but for the Covid-19 virus size, these masks were 85% and 80% efficient, respectively. The decontamination methods did not lead to changes in mask shape or degradation of the material and filtration efficiency and breathing resistance was maintained for up to 10 treatments.   Fit-testing is important with N95 respiratory use and the investigators reported the fit testing was maintained after oven decontamination, but steam heat treatment may affect the respirator fit. The authors conclude that respirators and masks that are not visibly contaminated or have signs of deterioration may be decontaminated with the studied methods that are available in the hospital setting or in most home environments for up to 10 times while maintaining adequate filtration efficiency and breathability.

The third featured article is “Postoperative Recurarization After Sugammadex Administration Due to the Lack of Appropriate Neuromuscular Monitoring: The Japanese Experience. If you are using Sugammadex at your institution, make sure that you check out this article. Sugammadex has been used in Japan for approximately 12.32 million patients over 8 years so that has provided a wealth of information about the safety of its use and what to look out for in terms of dosing, administration, and monitoring.

Stay with me as we move over to the letters to the editor.  Bond, Barry, and Hollis submitted, the case of “Misfilling the Exhausted Vaporizer” and the case starts with a 61year old patient who was taken urgently to the OR for removal of pelvic hardware. After induction, the anesthesia machine gas analyzer displayed co-administration of Isoflurane and Sevoflurane even though only one vaporizer was in use.  After this abnormal monitor finding, maintenance of anesthesia was performed with a TIVA and the patient did not have any complications from the anesthetics. The anesthesia team collaborated with biomedical engineers and realized that the sevoflurane vaporizer had been filled with Isoflurane incorrectly and that this had been the case for the 6 prior anesthetics performed in that OR that had gone unnoticed.  Remember, it is important to investigate display monitor abnormalities. So, how was this discovery made. The vaporizer was connected to different anesthesia machines in different operating rooms and each device revealed the same display finding including levels of Isoflurane and Sevoflurane. When a different Sevoflurane vaporizer was connected to the original anesthesia machine, the monitor displayed only Sevoflurane in the corresponding amount.  The combination of these results led to the conclusion that the original Sevoflurane vaporizer was filled with Isoflurane.  Electronic anesthesia records reveal so much information and it was discovered that there was mixed Isoflurane and Sevoflurane documented for the 6 cases in that operating room.  The alarms were functioning throughout the day with the initial alarm signaling the mixed gas administration of the volatile agents. The team thought that this alarm was due to malfunction of the gas analyzer rather than actual administration of Isoflurane since an Isoflurane vaporizer was not in the room at the time. A really important point from this letter highlights alarm fatigue which may occur due to frequent and sometimes even constant audible alarms in the OR. It may be easy to quickly dismiss alerts for non-life threatening events, but this can lead to harm if not addressed.   You might be asking yourself, how did the isoflurane get into the Sevoflurane vaporizer.  Further evaluation revealed that the Sevoflurane-specific vaporizer key can be forced onto an Isoflurane bottle. Another component of this case is the importance of intraoperative handoffs since a personnel change occurred during the day and the first team failed to point out the mixed gas monitor alarm that they had encountered earlier in the day. The key takeaway from this case is the misfiling a vaporizer may still occur despite the safety mechanisms that are in place including device specific keys for each volatile agent and vaporizer. The misfiling may occur by forcing the wrong vaporizer key onto the inappropriate vaporizer bottle or directly pouring the contents from one bottle into another.  Make sure that you stay vigilant when you see abnormal readings on your gas analyzer.

If you find that the APSF website has become your go-to for up-to-date information about how to keep your patients safe, please consider donating to the APSF. Remember that this is a volunteer organization and our volunteers have been on a mission to continue our commitment to patient safety and healthcare professionals throughout this very difficult time and we will continue to do so! You can make a difference with your contribution no matter the size. I am wrapping up this podcast so just check out the show notes, click on the link and donate!!  We are keeping it simple for you.  And for those of you who like hashtags, there is something really special for you because you can join the #APSFCrowd by donating just $15 a year as part of the APSF’s first-ever crowd-funding initiative.

Well, that is all the time we have for today.  Thank you so much for joining me on this journey towards improved patient safety.If you have any questions or comments from today’s show, please email me at [email protected].

Don’t forget to subscribe to the podcast through iTunes or your favorite podcast app and we would love it if you could share this podcast with all of your work colleagues, friends, and family and don’t forget to leave us a review.

Visit APSF.org for detailed information and check out the show notes for links to all the topics we discussed today.  Plus, you can find us on twitter @APSForg, that’s APSF – org.  Follow along with us for additional patient safety information. And you can be part of this conversation too by tagging us on twitter and using the hashtag #APSFpodcast.

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

© 2020, The Anesthesia Patient Safety Foundation