Episode #56 Good News About Anesthesia Patient Safety and Rapid Response Round-up

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. Today we are going to share some good news about patient safety and then head into the OR to review a couple recent rapid response articles.

Before we dive into today’s episode, we’d like to recognize Merck, a major corporate supporter of APSF. Merck 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, Merck- we wouldn’t be able to do all that we do without you!”

Let’s start the show with our good news that comes to us from a recent article published to APSF.org on June 8, 2021 and it is really good news because Anesthesiology continues to improve patient safety and the APSF is a big part of that. You can find the article by heading over to APSF.org and clicking on the Patient Safety Resources heading 4^th one down is News and Updates. Then, scroll down to June 8^th. This announcement highlights a recent report from Anesthesiology News called “A Decade of Anesthesiology Data: Continuing the Journey Towards the Goal of Zero Harm.” This report reveals that the rate of claims per 100 anesthesiologists in the US decreased from 4.9 to 3.2% from 2010 to 2019 and the specialty of anesthesiology had the largest decrease in rate of claims. Another indication that anesthesiology is making progress towards improved patient safety is the percentage of closed malpractice claims involving an anesthesiologist within the total number of closed claims for all specialties decreased from 11.7% to 8% in the same time period. In addition, the rate of improved patient safety may be faster in anesthesiology than all other specialties. For more information, check out the full report by Icenhower and Small that was published in the May 2021 issue of Anesthesiology News and I will include a link to the large report by Burke and colleagues, “A Call for Action – Insights from a Decade of Malpractice Claims” in the show notes.

Go ahead and freshen up your cup of coffee because we are going to move on to a June Articles Between the Issues Rapid Response.

[Race Track Noise]

That’s right we are talking about the article “Fire Extinguisher in the Operating Room” that was published online on June 1^st, 2021. To follow along with us, head over to APSF.org and click on the Newsletter heading, 3^rd one down is Rapid Response to Questions from our readers. Then scroll down until you see our featured article.  This Rapid Response was submitted by Jefri Williams and he writes,

“Dear Rapid Response:

I am writing to inquire about requirements for fire extinguishers in the operating room. Is it a requirement that each operating room have its own fire extinguisher located in the room? If it is not a regulatory requirement, what is the APSF recommendation?

Thank you.”

And thank you, Williams for submitting these questions. The rapid response was written by Jeffrey Feldman, the Chair of the APSF Committee on Technology and Jan Ehrenwerth who served as the former ASA liaison to NFPA. The authors start by establishing the priority in the OR to first avoid OR fires to begin with and if we are able to completely avoid OR fires than we can keep patients safe and fire extinguishers will not be necessary in the OR. An OR fire should be a “never event” and there are published protocols and safety guidelines to help accomplish this goal. In addition, the APSF has resources for OR fire prevention on the website. After you are done listening to the podcast today, I hope that you will check out the OR Fire Safety Video and I will include a link in the show notes.

Fire safety in the OR falls under the domain of the National Fire Protection Association or NFPA. Let’s look into some of the regulations. The NFPA-99 is the Healthcare Facilities Code which states that a fire extinguisher is required within 75 feet of every working location. The Joint Commission is involved in the accreditation process and adheres to the NFPA guidelines so this requirement is vital for accreditation as well. Another requirement from the NFPA-99 published in 2021 states that “Clean agent or water mist type fire extinguishers shall be provided in the operating room.” In order to follow this requirement, there must be a clean agent or water mist type of fire extinguisher within 75 feet of each operating room.

These regulations are only the first step towards keep patients safe from OR fires. The ASA, APSF, and the ECRI acknowledge that additional steps are necessary to protect patients and staff if an operating room fire occurs. The additional step is to have a CO2 fire extinguisher available. The ECRI recommends that a 5lb CO2 extinguisher by placed inside each OR and mounted near the entrance. The APSF agrees. This is not part of the NFPA-99 document, but there is an Annex document which states that a CO2 extinguisher may be used instead of a clean air agent. This comment is important because it provides support for maintaining CO2 extinguishers in each operating room. Check out the article for the location of the comment in the annex in case you need to provide support for maintaining a supply of CO2 extinguishers in the operating rooms at your institution.

That provided some great answers to the submitted questions, but the authors continue to provide additional important information about what to do if there is an OR fire. Remember, the first priority is the protect the patient and the staff. If the fire is on the patient, then your first option is NOT to use a fire extinguisher. Surgical procedures that take place above the xiphoid process, utilize a heat source, and have an open oxygen source have a high risk for a fire. In this case, a basin of water or saline must be immediately available on the OR table and this can be used to put out the fire quickly. For a fire on the drapes, it is imperative to remove the drapes from the patient and pull them to the floor of the OR. Then, a fire extinguisher can be used on the drapes once they are on the floor. So, keep in mind that water or saline should be used to extinguish a fire that occurs on a patient while a fire extinguisher is necessary to put out a fire on the OR drapes since the surgical drapes are impervious to water. The entire OR team will need to work together to keep patients and staff safe and quickly extinguish the fire so if one of the team members needs to leave the OR to find a fire extinguisher then this is not an ideal situation. Instead, if the CO2 fire extinguisher is mounted on the wall in a clearly visible and known location, it can save time and improve safety. Thank you so much to Williams for your questions and your interest in anesthesia patient safety.

We have time to talk about another Rapid Response article today. This one is from the June 2021 Newsletter, and it is called, “Cardiopulmonary Arrest Precipitated by Supraglottic Kinking of Polyvinyl Endotracheal Tube” by Seelhammer and colleagues. Let’s get started with a summary. This is the case of a 55 year-old man who was intubated with a polyvinyl endotracheal tube that developed an intraoral kink in the tube leading to a cardiac arrest. The cardiac arrest likely occurred due to acute, rapidly increased intrathoracic pressure from the kinked tube which likely led to significantly increased vagal activity combined with pre-existing bifasicular block with the resultant complete AV block. The authors start off with a call to action that in this situation, it is vital to recognize the kinked endotracheal tube and take action to restore a patent airway and prevent hemodynamic collapse.

Now, that I have piqued your interest, we are going to hear more about this case. The authors write that a 55 year old man with a past medical history of a bifasicular heart block was brought to the OR for elective endoscopic sinus surgery. Intubation was straightforward with a 7.5mm Shiley polyvinyl endotracheal tube. The endotracheal tube was secured with a cloth tube tie as well as an endotracheal tube holder. During the case, the patient received sevoflurane as well as continuous propofol and remifentanil infusions for maintenance of anesthesia. Controlled ventilation was accomplished with volume control mode with 450ml tidal volumes with 5cm H2O water positive end-expiratory pressure and a respiratory rate of 12 breaths per minute. The inspiratory to expiratory ratio was set at 1:2 with a pressure limit of 40cm H2O. About 120 minutes into the case, the patient developed an acute increased in peak airway pressures from 33cm H2O up to 62cm H2O. This abrupt change was followed by third degree AV block and then cardiac arrest. The patient received CPR with return of spontaneous circulation and was maintained on an Epinephrine infusion. Manual ventilation revealed significantly decreased respiratory compliance. The anesthesia team attempted the following to address the pulmonary compliance: Increased pressure limit on the ventilator, decreased tidal volume to 4ml/kg, confirmed of adequate muscle relaxation, prolonged inspiratory time and finally bronchoscopy. The bronchoscope was unable to be passed through the endotracheal tube due to a significant kink and near total occlusion of the tube. Video laryngoscopy revealed that the endotracheal tube was kinked at the 19cm marking. A tube exchanger was also unable to be passed through the tube so the decision was made to extubate followed by emergent re-intubation with return of normal pulmonary compliance. There are pictures of the kinked endotracheal tube that accompany this article so I encourage you to check it out. Further evaluation of the patient after the arrest revealed arterial partial pressure of carbon dioxide increased to 64 which improved following re-intubation. The ECG revealed sinus rhythm with the pre-existing bifasicular block. A rescue transesophageal echo was performed which revealed generalized left ventricular hypokinesis and an LV EF of about 40% and mild to moderately reduced right ventricular systolic function. Chest Xray results were normal. Repeated measurements of cardiac troponins remained below the institutional cutoff for myocardial ischemia. Serum electrolytes were normal except for a low ionized calcium at 3.75mg per deciliter.

Thank you to the authors for sharing this case. Have you ever seen a kinked endotracheal tube in your patients? Let’s discuss the important points from this case so that we can recognize a kinked tube and act quickly to restore a patent airway as well as be able to prevent this from occurring in the first place whenever possible.

The authors describe the hemodynamic changes for the patient which started with an acute increase in intrathoracic pressure followed by increased vagal activity with decreased conduction through the AV node which then led to progression from the patient’s bifasicular block to complete third-degree AV block. Another cause may have been air trapping from the acute expiratory flow obstruction in the endotracheal tube. Additional factors that may have contributed include decreased cardiac output, hypercarbia, hypocalcemia, surgical stress, coronary ischemia, arrhythmia, and volatile anesthetic administration.

So, how often does endotracheal tube kinking occur? Not very often, thankfully and most of the time, the anesthesia professionals are able to see the kink in the tube outside of the patient’s mouth and quickly reposition the tube so that occlusion of the tube does not occur. Endotracheal tube kinks are more likely to occur at higher temperatures such as body temperature compared to room temperature and with bending in the direction of the convexity of the tube. Kinking in the Mallinckrodt and Rusch endotracheal tubes has been reported at the location of the cuff air inflation line.

What do we need to be on the look-out for in the OR after intubation and placement of an endotracheal tube? Signs may include elevated peak airway pressures or changes on the capnography waveform at first followed by hypercarbia and hypoxia. If endotracheal tube kinking or obstruction is suspected, an attempt may be made to pass  a flexible suction catheter through the tube. If the suction catheter, bronchoscope, or airway exchange catheter are unable to pass through the kinked tube, it is important to gather back-up airway equipment and even supplies for a surgical airway depending on the surgery and the patient prior to removing the kinked tube and performing an emergent re-intubation with a new and patent endotracheal tube.

Importantly, there are steps that we can take to ensure that this does not happen in the operating room. Careful non-traumatic intubation and adequately securing the endotracheal tube  during patient positioning and oropharyngeal surgery is necessary. Remember, this is the time to act quickly because if you are able to restore the lumen of the endotracheal tube, it may help to prevent not only changes in respiratory or cardiovascular parameters, but also cardiovascular collapse. Another way to prevent kinking of the endotracheal tube when the tube must be positioned at an acute angle, such as for oropharyngeal surgery, is to use a ring-Adair-Elwyn or RAE tube or a wire-reinformed spiral endotracheal tube. However, the wire spiral endotracheal tubes may become permanently occluded if there is a significant kink in the tube. The authors also remind us that the event of a kinked endotracheal tube should be reported by way of an established institutional incident reporting protocol with manufacturer review of the equipment if necessary.

If you have any questions or comments from today’s show, please email us at [email protected] or connect with us on Twitter, Instagram, Facebook, or LinkedIn.

Visit APSF.org for detailed information and check out the show notes for links to all the topics we discussed today.  Whether you are listening to the podcast on our website or have subscribed on iTunes or Spotify or where ever you get your podcasts, thanks for listening!! Stay tuned for more great shows especially since the June 2021 APSF newsletter is out! That’s right, the newest APSF newsletter is available on line and you do not want to miss it. I will include a link in the show notes and I am so excited to talk about more of these articles and introduce some of the authors on future shows!

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

© 2021, The Anesthesia Patient Safety Foundation