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

Preventing Wrong Site Surgery – A Quarterly Update From The Pennsylvania Patient Safety Authority (PSA)

Of particular interest is that the number of reports for wrong site surgery in Pennsylvania appear to be declining.  However, wrong site placement of local anesthetic blocks is becoming an increasing percentage of the reports.  For example wrong site blocks constituted 20% of the wrong site events in the first six months of data reporting to the PSA, but they accounted for 44% of wrong site events in the most recent six months of reporting.  These are two of the four examples provided by the PSA: 1) a patient was scheduled for a surgical procedure on the left hand under axillary block. The anesthesiologist blocked the right arm. The correct arm, left, was marked appropriately. The error was discovered by the anesthesiologist after initiating the block.  2) A patient was admitted for surgery [on the right knee]. The patient was seen by the anesthesiologist who asked the patient which knee was to be operated on. The patient stated “left.” The anesthesiologist performed the nerve block on the left side. The patient was taken to the OR for the right-knee surgery where it was determined the nerve block was done on the wrong side.  Doing a formal time-out before an anesthetic block could potentially eliminate about 27% (92 of 337) of the wrong site errors reported in the surgical suite. However, based on the data from the Preventing Wrong-Site Surgery Project, a time-out before an anesthetic block does not eliminate the need to do a time-out just before the start of the surgical procedure, with the site marking visible in the prepped and draped surgical field.

In the opinion of the PSA, the 2010 revision of the Joint Commission’s Universal Protocol does not help the confusion about when to do the time-out.  The 2009 version states that the time-out should be done before the start of anesthesia; the 2010 version reverts to stating that the time-out should be done before the incision.  Based on multiple studies from the Preventing Wrong-Site Surgery Project, the Authority strongly advises that a formal time-out be done with the anesthesia provider just before any anesthetic block is placed and that another time-out be done with the surgeon just before the incision, unless the surgeon performs the anesthetic block and incision in continuity after the surgical field has been prepped and draped. 

Ref: Pennsylvania Patient Safety Advisory 2008;6:141-143

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

Wrong site surgery – the five year national experience

  From the August 2009 Newsletter of the Premier Safety Institute

  With 2,700 cases of wrong-site surgery continuing to occur annually, experts recommend more consistent adoption of the Universal Protocol (UP), or in this case, a defined alternative process when site-marking is impractical.

  A recent review of the National Practitioner Data Bank and additional closed claims databases for wrong-site procedures estimated that wrong-site surgery continues to occur approximately 1,300 to 2,700 times annually in the United States, despite the Joint Commission (TJC) requirement for a UP five years ago. In addition, up to 30 percent of all wrong-site and wrong-patient procedures have their genesis before patient admission to the hospital from scenarios such as inaccurate clinic note dictations or mislabeling of radiographs, reinforcing the need for the UP to prevent error.

  The UP was introduced by TJC in July 2004 as a National Patient Safety Goal and consists of three components: a pre-procedure verification process, surgical site marking, and a surgical "timeout" immediately prior to starting the procedure.

  Expansion of "timeout"
  The timeout was recently expanded to include the verification of correct patient positioning, availability of relevant documents, diagnostic images, instruments and implants, and the need for preoperative antibiotics and other essential medications, e.g., the use of beta-blockers. Some disagree with an expanded approach, believing that it dilutes the original intent. However, many hospitals have found it to be helpful to improve all the processes of care.

  Less widely publicized are wrong-site invasive procedures performed outside the operating room, highlighting the reason that this protocol should be applied equally to clinical settings outside the operating room for any invasive procedure that requires a patient's consent.

  Improper surgical site-marking a common risk factor
  Inadequate or inaccurate surgical site-marking represent a major risk factor for wrong-site surgery. Examples that have led to error include site-marking by a junior member of the surgical team who will not be present during the procedure, using an "X" that may be misunderstood as "not this side," the use of non-permanent markers that wash off during surgical prep, residual markings from previous surgery, or inability to mark the site (e.g., mucosal surfaces, teeth, visceral surgery).

  Challenges with adoption of UP
  Five years after the launch of the UP, an editorial in the July 2009 issue of Patient Safety in Surgery reviewed the obstacles that have limited the effectiveness of UP and need to be addressed to improve the process. These include:

• No consistent method for documenting correct procedure, patient, during pre-admission work-up.
• Lack of adoption of UP across all specialties, not just surgical specialties.
• Huge variation in site-marking methods.
• Lack of agreement to aborting process and starting over if any objections or inconsistencies.
• No repeated "timeout" for every additional procedure on same patient.
• Not involving patient in the site marking.
• Lack of an alternative site-marking process for sites unable or impractical to be marked.

(Link to original article: http://www.premierinc.com/quality-safety/tools-services/safety/safety-share/08-09-full.jsp#story-05 )

This article was reproduced with small modifications with permission from the Premier Safety Institute.  Any reference to this article should link back to their site.

 

DSS comment:  Reducing an event to zero is extraordinarily difficult as the medical profession is finding out.  However, institutions and practitioners are also finding out that being involved in a wrong site event creates enormous negative publicity, regulatory scrutiny, fines and even loss of practice privileges.  In addition to wrong sited surgery there exists examples of wrong sited nerve blocks, chest tube placement, and radiation therapy all of which place patients at risk.  In the case of wrong sited blocks at minimum the patient must endure the discomfort of an additional procedure.  On occasion there may be a complication from the wrongly placed block or the repeated block.  It seems to me that before any procedure some sort of time out should occur to confirm the following: 1) the correct patient is being treated, 2) the correct supplies and drugs are available, and the 3) correct site has been identified.

 

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

A patient unexpectedly does not “wake up” at the end of an anesthetic and is taken to the PACU

Dr. Falk discusses what needs to be done when a patient unexpectedly does not “wake up” at the end of a general anesthetic: An unresponsive patient in the recovery suite should be approached as if they have a life threatening condition.  Immediate evaluation and survey should include the basics of resuscitation.  Can the patient maintain an airway? Are they respiring effectively?  Are hemodynamic parameters adequate?  If this initial survey is satisfactory further investigation to determine the cause of unconsciousness should be performed.  Oxygenation should be immediately assessed with a pulse oximeter.  A blood gas should be sent to determine ventilatory adequacy and for a quick determination of metabolic abnormalities (pH, PaCO2, glucose, hyper/hyponatremia, hypo/hypercalcemia).  Other labwork should include a chemistry panel and a CBC.  A thorough neurologic exam should be performed checking basic reflexes (pupil response and size, corneal, cough/gag reflex).  In the absence of protective airway reflexes the patient should be intubated.  If there is no suspicion of metabolic abnormalities or residual anesthetic drug, neurologic imaging and testing should be the next diagnostic step including CT scan and EEG.

A Quick Differential Diagnosis includes:

Hypoxemia

Hypercarbia

Hypotension

Hypoglycemia

Narcotic Excess

Residual Neuromuscular Blocking Drug

Residual Volatile Anesthetic

Residual intravenous sedative drugs (midazolam, propofol, etomidate, ketamine, et al)

Central Cholinergic Syndrome (atropine, scopolamine, etc.)

Stroke
Seizure (non-convulsive status epilepticus)

Hypernatremia

Hyponatremia

Hypophosphatemia

Hypo/Hypercalcemia

Severe Anemia

Scott A Falk, M.D., is Assistant Professor of Anesthesiology and Critical Care, Department of Anesthesiology and Critical Care University of Pennsylvania, Philadelphia.  He is also Medical Director of the Post Anesthesia Care Unit at the Hospital of the University of Pennsylvania

“Can’t ventilate/can’t intubate”, needle cricothyrotomy and jet ventilation

Dr. Wei expands on his conference comments concerning needle cricothyrotomy and jet ventilation after needle cricothyrotomy -- The cannot ventilate/intubate emergency situation is responsible for a previously irreducible 1-28% of all deaths associated with anesthesia (Benumof and Scheller, Anesthesiology, 1989, 71:769-778). Needle cricothyrotomy followed by transtracheal jet ventilation (TTJV) or surgical cricothyrotomy are the recommended final life saving treatments in the “cannot ventilate/intubate” emergency by both the American Society of Anesthesiologists (ASA) and the Difficult Airway Society (Benumof et al., Anesthesiology 2003; 98: 1269-77, Henderson JJ et al., Anaesthesia 2004; 59: 675-94). Needle cricothyrotomy followed by TTJV is often an effective, quick, simple and inexpensive solution to the “cannot ventilate/intubate” problem, and should be available in every anesthetizing location (Benumof and Scheller, Anesthesiology, 1989, 71:769-778, attached). A commercial transtracheal jet catheter is recommended for needle cricothyrotomy as it will be less easily kinked compared to the regular #14 or #16 intravenous angiocatheter. A jet ventilator with high pressure oxygen source is recommended to perform effective TTJV after needle cricothyrotomy although the high flow but low pressure (15 liter/min) oxygen source from the anesthesia machine may provide partial oxygenation but not adequate ventilation. A needle cricothyrotomy connected to a conventional breathing circuit or Ambu bag may not be effective for adequate oxygenation and ventilation because of high resistance secondary to the small internal diameter (ID) of the needle (~ 2 mm) (Scrase and Woollard, Anaesthesia 2006, 61: 962-974). Complications of needle cricothyrotomy and TTJV include barotrauma (subcutaneous emphysema, pneumothorax and mediastinal emphysema), esophageal puncture, or bleeding (hematoma and hemoptysis). The barotrauma incidence during HFJV can be up to 10%. Strategies to prevent barotrauma during TTJV include following: 1) Obtain experience with TTJV by using it in elective cases or on a manikin before using it in the “cannot ventilate/intubate emergency” situation.  Similarly get experience in placing a needle cricothyrotomy using manikins. 2) Make sure there is adequate exit for the volume of air being injected into the lung by observing chest movement and listening to breath sounds.  In the situation of complete upper airway obstruction a second needle cricothyrotomy may be inserted as an expiration path. 3) Use low frequency (15-20 /min) and low driving pressure (starting at around 20 psi and increase gradually if needed). 4) A definite airway such as surgical airway should be established as soon as possible after successful needle cricothyrotomy.

 

Huafeng Wei, M.D., Ph.D. is Assistant Professor of Anesthesiology and Critical Care, University of Pennsylvania

Michael Duggan, M.D. discusses diabetic ketoacidosis

Use the following hypothetical case as a starting point.  A morbidly obese (BMI 48.8) woman in her early 20’s with no significant past medical history presented for relatively minor, superficial, elective surgery involving skin grafting.  In the pre operative holding area her vital signs were normal except for a pulse of 142.  An EKG showed sinus tachycardia.  The patient notes significant anxiety.  The patient is given 1 L crystalloid and 2 mg midazolam and her pulse came down to 128.  The decision was made to proceed to the operating room and an uneventful induction of general endotracheal anesthesia ensued.  After a second liter of fluid, the heart rate remained in the 130s and an intraoperative venous blood gas was sent.  The results were remarkable for a pH of 7.25; a calculated bicarbonate of 14, and a glucose of 486.  The pt was given a 10 unit IV insulin bolus and started on an insulin drip.  She received an additional liter of IV fluid and was admitted for further evaluation of her hyperglycemia and acidosis.

Diabetic ketoacidosis (DKA) can present with signs and symptoms of excessive thirst, urination, vomiting, abdominal pain, confusion, tachypnea and tachycardia.  However in some cases the symptoms can be minimal.  DKA can also present in type II diabetics but is more common with type I diabetes.  It is often precipitated by insulin omission or an underlying stress such as an infection or myocardial infarction.  The diagnosis of DKA includes hyperglycemia (though often less than 600 mg/dL), acidosis, and the presence of ketone bodies in the blood or urine.  DKA differs from hyperglycemic, hyperosmolar, nonketosis (HHNK) which more commonly presents in type II diabetics.  Ketone bodies are rarely seen in HHNK and patients often have a glucose > 600 mg/dL.

Treatment and anesthetic concerns of DKA are focused primarily on the underlying fluid deficit and electrolyte abnormalities as well as treatment of the hyperglycemia.  Patients in DKA can have a fluid deficit of 3-6 L and should be resuscitated with normal saline at a rate of at least 0.5 – 1 L/hr with the goal of replacing 1/3 of the deficit in the first 6-8 hrs and the remaining 2/3 over 24 hours.  Depletion of total body potassium (often 3-5 mEq/kg) is the primary electrolyte disturbance and serum levels reach a nadir 2-4 hours after IV insulin therapy is started.  Potassium repletion is necessary and should be monitored every 2-4 hours in the early treatment phase.  An intravenous insulin bolus of 10 units followed by a continuous infusion is a standard practice.  The degree of acidosis should be followed by an ABG or by following the anion gap.  After the glucose falls below 250 mg/dL, the IV fluids should include 5% dextrose.  Insulin should be continued until the ketosis resolves.

Ref: Miller R (ed): Miller’s Anesthesia, 2005

Dr. Duggan is a senior resident in the Department of Anesthesiology and Critical Care at the University of Pennsylvania

Pre operative angiotensin converting enzyme inhibitor therapy increases mortality after coronary artery bypass grafting

Dr. Savino calls our attention to this article by Miceli et al: This study evaluates the effect of pre-operative angiotensin-converting enzyme inhibitor (ACEI) therapy on early clinical outcomes after coronary artery bypass grafting (CABG).  Therapy with ACEIs has been shown to reduce the rate of mortality and prevent cardiovascular events in patients with coronary artery disease. However, their pre-operative use in patients undergoing CABG is still controversial.  A retrospective, observational, cohort study was undertaken of prospectively collected data on 10,023 consecutive patients undergoing isolated CABG between April 1996 and May 2008. Of these, 3,052 patients receiving pre-operative ACEI were matched to a control group by propensity score analysis.  Results:  The overall rate of mortality was 1%. Pre-operative ACEI therapy was associated with a doubling in the risk of death (1.3% vs. 0.7%; odds ratio [OR]: 2.00, 95% confidence interval [CI]: 1.17 to 3.42; p = 0.013). There was also a significant difference between the ACEI and control group in the risk of post-operative renal dysfunction (PRD) (7.1% vs. 5.4%; OR: 1.36, 95% CI: 1.1 to 1.67; p = 0.006), atrial fibrillation (AF) (25% vs. 20%; OR: 1.34, 95% CI: 1.18 to 1.51; p < 0.0001), and increased use of inotropic support (45.9% vs. 41.1%; OR: 1.22, 95% CI: 1.1 to 1.36; p < 0.0001). In a multivariate analysis, pre-operative ACEI treatment was an independent predictor of mortality (p = 0.04), PRD (p = 0.0002), use of inotropic drugs (p < 0.0001), and AF (p < 0.0001).  Conclusions: Pre-operative therapy with ACEI is associated with an increased risk of mortality, use of inotropic support, PRD, and new onset of post-operative AF. (Miceli A et al:  Effects of angiotensin converting enzyme inhibitor therapy on clinical outcome in patients undergoing coronary artery bypass grafting. J Am Coll Cardiol 2009;54:1778-84)

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

Dr. Arkoosh comments on health care reform

Philadelphia Inquirer January 26, 2010

Meaningful reform will require courage

By Valerie Arkoosh

Doctors can empathize with the president and Congress right now. Treating a relentless disease can be enormously frustrating, and sometimes we may feel tempted to give up and walk away. But just as doctors stay with their patients, Congress and the president must stay with their patient, the American public, by keeping their commitment to strong health-care reform.

Although the political world went topsy-turvy last week, the Massachusetts vote did not change a single thing for American patients. Close to 50 million remain uninsured, those with preexisting conditions still go uncovered, and many face delays and denials of care.

Over the past week, a number of prescriptions have been offered for the reform effort. Besides abandoning it entirely - which would be wrong for the reasons mentioned above - they include passage of only the least contentious reforms, in a compromise with Republicans; and House approval of the existing Senate bill, for which the support has been almost entirely Democratic.

Passing only the most popular parts of the bills would only create new problems. For example, if Congress requires insurance companies to cover all preexisting conditions but does not require that everyone purchase insurance, the commonsense response for most Americans would be to wait until they get sick to buy insurance. It would be like requiring car insurers to sell coverage at accident scenes; insurance premiums would skyrocket, and the insurance system would fail.

And if Congress does require everyone to purchase insurance, there must be provisions for those who can't afford it - pointing again to the need for a comprehensive bill.

The only sensible way forward is House approval of the Senate bill. The Senate and House bills have much in common: Both would eliminate the worst insurance-company abuses, create consumer-friendly insurance markets, help people afford insurance, change the way doctors and hospitals are paid to reward high-quality care, increase the number of primary-care doctors, and encourage preventative care.

The two bills differ in some important ways, including how we pay for reform and how much help low-income Americans will get. But these differences can be reconciled later through a process known as budget reconciliation, or in the three to four years before the legislation is fully implemented.

Despite all the talk during the past week of watered-down health-care reform, Americans will have to take a big step forward if they want to substantially improve the fairness and security of the system. It's up to the president and Congress to lead us in taking that step. Baby steps won't work.

At this critical moment, the president and Congress must not abandon the American people who elected them to solve this problem. They should move to pass the Senate bill and fix our failing health-care system.

Solving real problems, like curing tough diseases, is hard. Like doctors who muster the courage to prescribe a difficult but necessary treatment, our leaders must have the courage to put patients ahead of politics.

---

Dr. Valerie Arkoosh is a professor of clinical anesthesiology and critical care and of clinical obstetrics and gynecology at the University of Pennsylvania School of Medicine. She is also the president-elect of the National Physicians Alliance. She can be reached at [email protected]

This editorial appeared in the Philadelphia Inquirer January 26, 2010

Reprinted with permission

Link to original: http://www.philly.com/inquirer/opinion/82664417.html

Indwelling Urinary Catheter presence for more than 2 days post operatively is associated with a higher risk of urinary tract infections

Wald et al reported a retrospective cohort study of 35,904 Medicare patients from 2,965 United States acute care hospitals who underwent major surgery (coronary artery bypass and other open cardiac operations, vascular surgery, general abdominal colorectal surgery, hip or knee joint arthroplasty) during 2001.  Eighty six percent of patients undergoing these major operations had perioperative indwelling urinary catheters.  Of these, 50% had their catheters for longer than 2 days post operatively.  Those patients with catheters for more than 2 days were twice as likely to a develop urinary tract infection than patients with catheterization of 2 days or less.  In addition post operative catheterization greater than 2 days was also associated with increased 30 day mortality, and decreased likelihood to be discharged home.  In their introduction the authors note that the risk of urinary tract infection is 5 to 10% per catheter day beyond the first 48 hours.  In their discussion the authors note that “among patients with urinary tract infection an estimated 3.6% will develop bacteremia – a condition that adds significantly to length of stay, and is a risk factor for death among elderly patients.”  Wald HL et al: Indwelling urinary catheter use in the postoperative period.  Analysis of the National Surgical Infection Prevention Project Data.  Arch Surg 2008;143:551-557

 

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

Normothermia Attenuates Cerebral Metabolic Distress In Patients With Aneurysmal Subarachnoid Hemorrhage And Refractory Fever

A team of investigators from PENN MED (including WA Kofke, Department of Anesthesiology and Critical Care) recently investigated the effect of sustained fever (temperature greater than 38.3 deg C despite antipyretics) on the lactate/pyruvate ratio (LPR) of microdialisate samples obtained from brain tissue of patients who had acute subarachnoid hemorrhage (SAH).  An increase in the LPR is considered a marker for increased anaerobic glycolysis, a sign of metabolic stress in brain.  The authors defined an episode of metabolic crisis as an LPR greater than 40.  Reducing body temperature with ice packs and an external cooling device reduced the mean LPR and reduced the percentage of LPR values in the metabolic crisis range.  This was true whether or not ICP was elevated.  The authors concluded that fever control is associated with reduced cerebral metabolic distress in patients with SAH irrespective of ICP (Oddo M et al: Induced normothermia attenuates cerebral metabolic distress in patients with aneurismal subarachnoid hemorrhage and refractory fever.  Stroke 2009;40:1913-1916).

  Dr. Fleisher (Chair, Department of Anesthesiology and Critical Care) points out that this paper has some interesting correlates with several papers showing increased cognitive dysfunction after cardiopulmonary bypass when the body temperature is greater than 37 degrees C: 1) Sahu B et al: Neurocognitive function in patients undergoing coronary artery bypass graft surgery with cardiopulmonary bypass: The effect of two different rewarming strategies.  J Cardiovasc Vasc Anesth 2009;23:14-21. 2) Grigone AM et al: The rewarming rate and increased peak temperature alter neurocognitive outcome after cardiac surgery.  Anesth Analg 2002;94:4-10. 3) Grocon HP et al: Postoperative hyperthermia is associated with cognitive dysfunction after coronary artery bypass graft surgery.  Stroke 2002;33:537-541

 

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

Cardiac Arrest – Torsades de pointes – not just droperidol – not just theoretical

Many antipsychotics have been associated with prolongation of the QT interval.  The package insert for olanzapine (Zyprexa), a popular antipsychotic marketed by Eli Lilly and Company, notes that “in pooled studies of adults … there were no significant differences between olanzapine and placebo in the proportion of patients experiencing potentially important changes in ECG parameters, including QT.”  However recently Morissette P et al. showed that, at higher blood concentrations such as may be seen in patients with renal or hepatic insufficiency or very high daily drug dosing, olanzapine has direct cardiac electrophysiologic effects that might lead to QT prolongation in patients (olanzapine prolongs cardiac repolarization by blocking the rapid component of the delayed rectifier potassium current.  J Psychopharmacol 2007;21:735-741).  Also note the black box warning that this drug should not be used in elderly patients with dementia-related psychosis because there are reports of increased mortality.

 

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