Dept Of Anesthesiology & Critical Care, University Of Pennsylvania School Of Medicine

Retained objects -- anesthesia related

The Agency for Healthcare Research and Quality has a section called case and commentary some of which are of interest to anesthesiologists.  In October 2009 they presented  a case that I briefly summarize as follows:

One day after a vascular bypass procedure on the right upper extremity that started under MAC but was converted to general endotracheal anesthesia, this 70 year old man complained that whenever “he tried to drink any liquid it would come right out his nose.”  He promptly demonstrated this phenomenon when the surgical team expressed their skepticism.  The patient took a gulp of orange juice with the physicians present and they witnessed that most of the juice came out of his nose and spilled onto his hospital gown;  he demonstrated this a number of times showing its repeatability.  Concerned about a pharyngeal fistula or some other anatomic abnormality the surgical team consulted an Otorhinolaryngologist who discovered a nasopharyngeal airway lodged within the nasal cavity (not visible externally) which apparently acted as a retrograde conduit of fluid.  Chart review revealed that a nasopharyngeal airway had been used during the MAC portion of the patient’s surgery the previous day.  The article notes that aspirated nasal airways have been associated with a number of complications including airway obstruction and that symptom may not present immediately.  They noted one case in which an aspirated nasal airway was not discovered for weeks and was only discovered after investigation for persistent cough and recurrent chest infections (the device was lodged within the trachea near the right mainstem bronchus).  The typical nasopharyngeal airway has no radio-opaque strip, RFID tag, or suture tail.  Anesthesia devices are not typically “counted” so the only person who may know that a nasopharyngeal airway was used is the person who placed it.  It would seem prudent to make sure that insertion and removal of nasopharyngeal airways are clearly noted on the anesthesia record, that the presence of nasopharyngeal airways are part of any “handoffs", and that changes in anesthetic plan are accompanied by a reevaluation of the need for any nasopharyngeal airways or other support devices that may have been placed.

The entire presentation can be found at http://webmm.ahrq.gov/case.aspx?caseID=208 along with a very nice discussion by Christopher R. Lee M.D. from the Department of Anesthesiology and Pain Medicine, University of Washington Medical Center.  The home page for the most recent case is at http://webmm.ahrq.gov/index.aspx.  There is also a link to their case archive http://webmm.ahrq.gov/caseArchive.aspx

 

David S. Smith, M.D., Ph.D.

 

Protecting patients from unknown hazards

Peter Pronovost’s very productive group examines a process by which previously unknown hazards that may be associated with the introduction of new health care services can be anticipated.  The authors note that “One of the greatest challenges facing practitioners and risk managers is the identification of previously unknown hazards.  These threats to patient safety often lie at the apex of available knowledge and are rarely – if ever – obvious.  With the rapid proliferation of new health care services, unknown hazards may propagate as new therapies are integrated into the existing health care system.”  They note that at present “a comprehensive approach by which to safely integrate new therapies into the existing clinical environment has yet to be clearly articulated.”  The authors emphasize the need to engage in this process before the new therapy or process is instituted.  They describe the use of a multidisciplinary team of the key stake holders involved with a given project.  The framework they propose is “composed of five process phases: 1) identify existing knowledge of hazards and defenses (literature review, communication with other institutions), 2) anticipate what can go wrong (brainstorm concerns, failure mode analysis), 3) simulate the process, 4) analyze hazards and defects, and 5) design the system to defend against such hazards (develop an operational protocol and check list to standardize the management of patient cases and to serve as a safety check for use prior to every case, monitor any patient safety events).”  Details of these steps are provided and three clinical examples of this process are given in the article.  Ref: Herzer KR: A practical framework for patient care teams to prospectively identify and mitigate clinical hazards.  Jt Comm J Qual Patient Saf 2009;35:72-81

 

David S. Smith, M.D., Ph.D.

Separating analgesic from respiratory effects of narcotics

In a rodent study published in the June 2009 issue of Anesthesiology, Ren et al begins to separate the analgesic from the respiratory effects of narcotics.  They found that administration of Ampakine CX717 attenuated (when given before) or reversed (when given after) an intraperiotoneal dose of fentanyl that would produce apnea.  The authors note that the compound used is considered safe for primate studies and clinical trials for cognitive disorders.  It also crosses the blood brain barrier.  The effect of CX717 does not directly reverse the effect of the narcotic on the respiratory center but rather it accentuates a pathway that is important to generating the respiratory rhythm within the preBotzinger complex.  Ren J et al: Ampakine CX717 protects against fentanyl-induced respiratory depression and lethal apnea in rats.  Anesthesiology 2009;110:1364-70.

 

David S. Smith, M.D., Ph.D.