Welcome to the APSF SafetyNet. This group of experts discusses the safety questions that are most commonly sent to the APSF website. The purpose of the APSF Network of Safety Experts is to provide expert opinions and recommendations to questions received from the anesthesia community about patient safety issues and topics.

If you have a safety question, just mail it to, then check this page to see if the SafetyNet experts have discussed it. Please note that answers to questions should not be considered to be advice about the care of specific patients.

“How does your anesthesia group/department assure its anesthesiologists and nurse anesthetists maintain proficiency in management of difficult airways?”

Expert 1: In our institution we do a wide range of difficult cases. Anesthesiologists, residents, CRNA’s, and if necessary, ENT surgeons and others work together in concert in the approach to the difficult airway. No one is alone in a difficult scenario.

Expert 2: Our institution has several large volume ENT practices as well as a spinal cord center, therefore, we see a large number of difficult airways each year. We approach patient safety from two fronts. First, we have 1-2 departmental conferences each year dedicated to the discussion of difficult airway management. During these conferences we review the ASA guidelines for difficult airway management and the different techniques available to secure a difficult airway. Second, we have six difficult airway carts available within our operating rooms that are stocked with a wide variety of difficult airway management equipment including intubating LMAs, lightwands and Combitubes. We encourage our staff to use this equipment electively to gain experience with it in non-emergent situations.

Expert 3: As part of our resident’s training we spend a considerable amount of time on recognizing and managing difficult airways. This training has didactic and academic components. Academically, we have workshops twice a year (which are mandatory for residents and attendings) on recognizing and managing difficult airways; we cover the use of LMAs and intubating LMAs, esophageal-tracheal combitubes, Flex-guide and Eschman stylets, using the Cook Airway Exchange Catheter via the LMA to intubate the trachea, FOB, cricothyrotomy with and without retrograde intubation and jet ventilation. Of course, we also stress familiarity with the ASA algorithm for difficult airways. We also require the residents to view the ASA videotapes on recognition and management of the difficult airway.

Clinically, we practice the techniques taught in the Workshops, with the exception of cricothyrotomy (which we have never had to resort to in the last 13 1/2 years). We also have a rotation in FFOB during which the residents have the opportunity to perform several fiberoptic intubations daily. And we have 2 difficult airway carts available in the OR.

Expert 4: We have at least two departmental conferences per year specifically addressing difficulty airways management. We also have a miniworkshop in July each year to demonstrate some of the equipment to our staff and residents. Each July all of our new CA 1 residents participate in a core lecture series; one of the lectures is dedicated to airway management. Finally, we have a rotation for senior residents in Advanced Airways, designed to help them perfect their skills in LMA, light wand , fiberoptic intubation, etc. during routine OR cases.

We also have a dedicated difficult airway cart in the OR workroom which has all of the same type of equipment that you describe. We have a difficult intubation cart in the recovery room also; this is of more use to the team who respondsto codes in the hospital.

For cases outside the OR, we take a prepared cart for “Special Procedures”, which is kept in our workroom. It contains almost everything one would need to give anesthesia outside the OR. We have two anesthesia machines, dedicated to non OR use, and maintained by us. They are stored in our radiology department, which is centrally located to ct, mri, angio, endoscopy, etc.

“How does your anesthesia group/department assure patient safety when anesthesia is administered in a non-operating room setting?”

Expert 1: Anesthesia outside the OR is done with the same anesthesia machines, carts, and technicians as in the OR. Once again, no one is left deserted in a distant location alone for any extended period of time and someone is kept available if help is needed (resident and staff).

Expert 2: We have a very active “outpost” anesthesia service that cares for patients in radiology, the cardiac catheterization lab, GI endoscopy suite, and the bronchoscopy suite. We adhere to the same standards in these locations as we do in the operating rooms. An anesthesia machine will be brought to an anesthetizing location if general anesthesia is used and seperate adult and pediatric anesthesia carts are available for use in these areas. Our staffing ratios will vary depending on the age of the patient and the planned anesthetic. Backup personnel are always identified and readily available during the critical portions of the anesthetics.

Expert 3: We provide anesthesia services in several locations outside of the main OR (radiology, endoscopy, cardiac catheterization, etc.) With rare exceptions, these are performed during regular working hours (Monday through Friday) so that additional help is always readily available. A resident and attending are assigned to each procedure, and both will stay until the procedure is safely completed. (The patient is then accompanied, with the appropriate monitoring, to the appropriate post-anesthesia care area to recover). They bring an anesthesia machine and cart with them wherever they are going, and whatever special equipment is needed for that procedure. If any additional help is needed, a call to the main OR is all that’s needed.

“Is it safe to leave an anesthetized patient alone for brief periods of time?”

Expert 1: There is no question that an ASA member would have been violating the ASA code of conduct under the circumstances described in this message. I am not aware whether the AANA has a code of conduct similar to that of the ASA. There is probably no violation of laws, except perhaps HCFA’s regulations.

Expert 2: The answer to this question is quite clear and obvious. No patient should be left alone (without trained anesthesia personnel present) during any anesthetic. This IS patient abandonment, it is dangerous and should not under any circumstances be tolerated.

“Could you please provide information on the current standards for line isolation?”

Expert 1: Line isolation monitors are only required where there are isolated power systems, as identified by section 3- of NFPA 99 Health Care Facilities. Isolated power systems are not required in operating rooms, but may be installed in “wet locations” such as cystoscopy; definition of a “wet location” is up to the individual hospital. “Wet locations” may be addressed by either isolated power systems (such as in an OR) or by ground fault protection devices, where power interruption can be tolerated.

“What are the risks and benefits of using induction rooms, adjacent to operating rooms?”

Expert 1: We use what we call block rooms to initiate regional anesthetics for our orthopedic patients. In these rooms we currently perform spinals, combined spinal/epidurals, and a variety of nerve blocks. Although these rooms are fully equipped to perform a general anesthetic, we do not use these rooms to induce general anesthesia.

“What could cause numbness of the right lip and facial numbness after an anesthetic?”

Safety Expert: This is usually caused by pressure on the mandibular branch of the facial nerve when masking and gripping the face (lower lip or upper?). It might alsoalso be caused by pressure from the mask strap, etc. The nerve is very superficial and can be compressed easily against the mandible, which would explain these symptoms.

“Can a PAC be inserted safely in patients with pre-existing left bundle branch block (LBBB)?”

Yes, but additional measures to insure a stable cardiac rhythm are necessary. During passage of the PAC, a temporary right bundle branch block is often induced as the catheter impacts the interventricular septum. Thus, in a patient with a pre-existing LBBB, cardiac asystole may occur. The risk of asystole in this setting is probably in the range of 1 – 2%. Therefore, during insertion of the PAC in these patients, an alternative mechanism to pace the heart must be immediately available. This could include an internal temporary endocardial pacing wire, epicardial pacing wires, or placement of transcutaneous pacing patches (Zollo transcutaneous pacemakers). Author: Richard C. Prielipp, M.D., FCCM; Wake Forest University

“Are there any standards for installation of gas pipelines in the operating room?”

The installation of the medical gas/vacuum system should have been done in compliance with NFPA 99 (1999), which is available from the National Fire Protection Association. Consult their web page for info on ordering the booklet, if your department or hospital engineering does not have a copy.

The installer is required to do certain tests with regard to cross connections, hydrocarbons and particulate matter. The hospital should have insisted on an independent verifier as part of the contract who will come in and check the entire system prior to the hospital accepting the finished project. It is as President Reagan once said, “Trust, but verify!”

“Is it safe to reuse multidose vials after they have been entered by contaminated needles?”

Any contaminent, for example, bacteria, a virus such as hepatitis B or C or HIV, could be transmitted this way. Studies have shown that red blood cells are present in IV tubing in IVs that are attached to patients. The mechanism that they travel retrograde is called axial diffusion. Smaller particles probably travel farther than the cells. Any way you look at it, there is no guarantee that there is no contaminent in the IV.

“Should tongue studs be removed prior to elective surgery?”

Tongue studs can only be removed with a special tool. This is probably not easily done in a preop setting and usually requires an official consult from the burly tattoo parlor operator that inserted the stud. Since they are extremely difficult to remove, they are probably no more or less dangerous than other attached mouth appliances (fixed bridges or braces). They are not like earrings, which are meant to be changed. Most patients will not take kindly to having the stud removed as they are difficult to replace.

We make the same statements to patients/parents as with dental appliances: there is a risk of damage to the stud although we will do our best to be careful; if broken, there is a risk of the stud being swallowed or being lodged in the airway although we will also do our best to avoid these complications. As with all anesthetic risks for elective procedures, the patient/parent has to agree to accept these risks (or thay can elect to have the stud removed prior to surgery).

“How many family members can safely observe a caesarian section?”

Why is it necessary to have more than the significant other person in the C-Section OR? Does it improve the outcome of the baby or the mother? How many people are needed to prevent a person from being alone? I think the answer is 1. This is personal and private event for the mother and father and privacy should be respected by friends and family. There might be rare exceptions when another person (parent’s parent or some figure of authority or religious leader) actually helps calm an otherwise distraught or hysterical patient. That might be a justification for another person.

There should be a justification of the potential risk that is added. The patient and the spouse should want to minimize risks. C-section is surgery. In my opinion, additional people add to risk of infection, equipment malfunction by running into or tripping over something, touching instruments, getting in the way. The significant other is quite enough distraction. As it is they often video everything anyway. Everyone else can see the videos and pictures.