no patient harmed from post-op opoids

NEWSLETTERThe Official Journal of the Anesthesia Patient Safety Foundation

Volume 26, No. 2, 21-40 Circulation 94,429 Fall 2011

www.apsf.org

®

Inside: Tribute to Jeep Pierce ......................................................................................................Page 23Methadone Article References .......................................................................................Page 28Dear SIRS: Reusable Anesthesia Breathing Circuits Considered .........................Page 30Threshold Monitoring, Alarm Fatigue, Patterns of Death .......................................Page 32Donors .......................................................................................................................... Pages 36-37Dr. John Walsh Receives Cooper Patient Safety Award ...........................................Page 38Monitor Displays: Non-Moving vs. Moving Waveforms...................................................... 39Letters to the Editor ...............................................................................Pages 25, 27, 29, 38, 39

See “Monitoring,” Page 26

2) If “Yes” to electronic monitoring, who should be mon-itored (inclusively or selectively) and what monitors/technology should be utilized?

Dr.Stoeltingopenedtheconferencebyassertingthatcontinuouselectronicmonitoringofoxygenationand/orventilationmayallowformorerapiddiagno-sisandpreventionofdrug-induced,postoperativerespiratorydepression.Hecommentedthatwecannotwaitfortheperfecttechnologybeforeweintervene,andthat“maintainingthestatusquoinhopesthatadifferentresultwilloccurisunrealistic.”Henotedthatthegoaloftheconferencewastoutilizetheavailableevidencetodiscernthebestmonitoringstrategiesforprovidingeffectiveearlywarningofpostoperativerespiratorydepression.

Dr.Overdykfollowedandnotedthatthiscompli-cationoccursmorefrequentlyandismucheasiertodetectthanawarenessundergeneralanesthesiawheresignificantresourceshavebeeninvestedinresearchandmonitoring.Hebelievesthatthisinitia-tiveshouldbecomea“nationalpatientsafetyprior-i ty.” Dr. Overdyk discussed research thatdemonstratedthatapproximatelyone-thirdofcodebluearrestsinhospitalsarefromrespiratorydepres-sion,2andthatnaloxoneisadministeredinabout0.2-0.7%ofpatientsreceivingpostoperativeopioids.3,4

Followingtheseintroductoryremarks,familymembersofpatientswhodiedfromdrug-inducedrespiratorydepressionrecountedtheirlovedones’medicaltragedies.Theyallnotedthelackofmonitor-ingfortheirlovedonesduringtheirlastdaysinthehospitalafterundergoingelectiveroutinesurgery.

Matthew B. Weinger, MD, and Lorri A. Lee, MD, for the Anesthesia Patient Safety Foundation

TheAPSFbelievesthatclinicallysignificant,drug-inducedrespiratorydepressioninthepostop-erativeperiodremainsaseriouspatientsafetyriskthatcontinuestobeassociatedwithsignificantmor-bidityandmortalitysinceitwasfirstaddressedbytheAPSFin2006.1TheAPSFenvisionsthat“no patient shall be harmed by opioid-induced respiratory depression in the postoperative period,”andconvenedthesecondmultidisciplinaryconferenceonthisseriouspatientsafetyissueinJuneofthisyearinPhoenix,AZ,with136stakeholdersinattendance.Theconferenceaddressed“EssentialMonitoringStrategiestoDetectClinicallySignificantDrug-InducedRespiratoryDepressioninthePostoperativePeriod.”

Attendeesincludedcliniciansandresearchersfromnursing,anesthesia,andsurgery(morethanhalfofconferenceattendees),withrepresentationfromtheVeteransHealthAdministration,theAmericanSocietyofAnesthesiologists,theAmericanAssociationofNurse Anesthet is ts , American Academy ofAnesthesiologistsAssistants,AmericanHospitalAssociation,AmericanCollegeofSurgeons,AmericanSociety of PeriAnesthesia Nurses, the JointCommission,AssociationfortheAdvancementofMedical Instrumentation,American Society ofHealthcareRiskManagement, Institute forSafeMedicationPractices,andothersocietiesandnon-profitagencies.Additionally,malpracticeinsurersandfamilymembersofpatientswhohavediedfromthiscomplica-tionprovidedinputonthescopeandimpactoftheproblem,andrepresentativesfromthemonitoringtech-nologyindustry(aboutone-fourthofattendees)dis-cussedthepotentialforimprovedmonitoringofpatients’respiratorystatusinthepostoperativeperiod.

Drs.RobertK.Stoelting,APSFpresident,andF r a n k J . O v e r d y k , a d j u n c t p r o f e s s o r o fAnesthesiologyattheMedicalUniversityofSouthCarolina,co-moderatedtheconferenceconsistingof24briefpresentations,6smallbreakoutgroups,andadiscussionsession.Twoquestionswerepostedtoallspeakersandaudiencemembers:

1) Should electronic monitoring be utilized to facilitate detection of drug-induced postoperative respiratory depression?

Theyimploredthegrouptoenactchangesimmedi-atelythatwouldpreventsuchfuturetragedies.

D r. M a t t h e w B . We i n g e r, p ro f e s s o r o fAnesthesiologyatVanderbiltUniversity,showedmultiplestudiesthatprovideevidenceforfrequentuseofnaloxoneforpostoperativeopioid-inducedrespiratorydepression.HestatedthattheliteraturesuggeststhatintheU.S.about0.3%ofpostoperativepatientsreceivenaloxonerescueaccountingforupto20,000patientsannually.Hefurtherestimatedthatone-tenthofthesepatientssuffersignificantsequelae.Dr.Weingeralsoprovidedevidencedemonstratingthatalltypesofparenteralopioidsandroutesareinvolvedintheseevents.Hethendiscussedthereli-ability,sensitivity,specificity,andresponsetimeforthevarioustypesofmonitorsforoxygenationandventilationtodetectrespiratorydepression.Forpatientswhoarenotintubated,pulseoximetrywasthebestmonitorwhensupplementaloxygenwasnotbeingutilized.Inthepresenceofsupplementaloxygen,capnographyfaredbest(seeTable1).1

Afterthispresentation,Dr.NikolausGravenstein,aprofessorattheUniversityofFlorida,highlightedtheremarkableobservationthatpatientshavingvitalsignscheckedevery4hoursareleftunmonitored96%ofthetime.Henoted,asdidmanyspeakers,thatsupplementaloxygenmaymaskhypoventilation,andthatunderthesecircumstancespulseoximetryisaverylatedetectorofrespiratorydepression.Lethalhypercarbia ispossibledespitenormaloxygen

“No Patient Shall Be Harmed By Opioid-Induced Respiratory Depression”[Proceedings of “Essential Monitoring Strategies to Detect Clinically Significant Drug-Induced Respiratory Depression in the Postoperative Period” Conference]

APSF NEWSLETTER Fall 2011 PAGE 22

NEWSLETTERThe Official Journal of the Anesthesia Patient Safety Foundation

TheAnesthesia Patient Safety Foundation NewsletteristheofficialpublicationofthenonprofitAnesthesiaPatientSafetyFoundationandispub-lishedquarterlyinWilmington,Delaware.Annualcontributorcost:Individual–$100,Corporate–$500.This and any additional contributions to theFoundation are tax deductible. © Copyright,AnesthesiaPatientSafetyFoundation,2011.

TheopinionsexpressedinthisNewsletterarenotnecessarilythoseoftheAnesthesiaPatientSafetyFoundation.TheAPSFneitherwritesnorpromulgatesstandards,andtheopinionsexpressedhereinshouldnotbeconstruedtoconstitutepracticestandardsorpracticeparameters.Validityofopinionspresented,drugdosages,accuracy,andcompletenessofcontentarenotguaranteedbytheAPSF.APSF Executive Committee:

RobertK.Stoelting,MD,President;NassibG.Chamoun,VicePresident;JeffreyB.Cooper,PhD,Executive Vice President; GeorgeA. Schapiro,ExecutiveVicePresident;MatthewB.Weinger,MD,Secretary;CaseyD.Blitt,MD,Treasurer;SorinJ.Brull,MD;RobertA.Caplan,MD;DavidM.Gaba,MD;PatriciaA.Kapur,MD;LorriA.Lee,MD;RobertC.Morell,MD;A.WilliamPaulsen,PhD;RichardC.Prielipp,MD;StevenR.Sanford,JD;MarkA.Warner,MD.ConsultantstotheExecutiveCommittee:JohnH.Eichhorn,MD;MariaA.Magro,CRNA,MS,MSN.Newsletter Editorial Board:

RobertC.Morell,MD,Co-Editor;LorriA.Lee,MD,Co-Editor;SorinJ.Brull,MD;JoanChristie,MD;JanEhrenwerth,MD;JohnH.Eichhorn,MD;SusanR.Fossum,RN;StevenB.Greenberg,MD;RodneyC.Lester,PhD,CRNA;GlennS.Murphy,MD;JohnO'Donnell;KarenPosner,PhD;AndrewF.Smith,MRCP,FRCA;WilsonSomerville,PhD;JefferyVender,MD.

Address all general, contributor, and sub scription cor-respondence to:Administrator,DeannaWalkerAnesthesiaPatientSafetyFoundationBuildingOne,SuiteTwo8007SouthMeridianStreetIndianapolis,IN46217-2922e-mailaddress:[email protected]:(317)888-1482

Address Newsletter editorial comments, questions, letters, and suggestions to:RobertC.Morell,MDEditor,APSF Newsletterc/oAddieLarimore,EditorialAssistantDepartmentofAnesthesiologyWakeForestUniversitySchoolofMedicine9thFloorCSBMedicalCenterBoulevardWinston-Salem,NC27157-1009e-mail:[email protected]

www.apsf.org

®

APSF gratefully acknowledges

the generous support of

Anaesthesia Associates ofMassachusetts

in memory of Ellison C. Pierce, Jr., MD

Supports APSF Research

APSF gratefully acknowledges the

generous contribution of $150,000 from

Covidien in full support of a

2012 APSF Research Grant that will

be designated the

APSF/Covidien Research Awardwww.covidien.com

New Scientific Evaluation Committee MembersAnnually,theAPSFScientificEvaluationCommittee(SEC)considerstheaddition

ofnewmemberstoparticipateinthereviewofclinicalandeducationalpatientsafetygrants.ApplicantsforSECmembershipshouldbeexperiencedpatientsafetyresearcherswithatrackrecordoffundingandpeer-reviewedpublication.TheSECisparticularlyinterestedinapplicantswithsafetyrelatedexpertiseininformatics,simu-lation,ortheresponsibleconductofresearch.InterestedapplicantsshouldsubmittheircurriculumvitaeandacoverletterexplaininginterestandqualificationstoDr.SorinBrullatbrull@apsf.org.


See “Pierce,” Next Page

by John H. Eichhorn, MD, and Jeffrey B. Cooper, PhD

EllisonC.Pierce,Jr.,MD,affectionatelyknowntosomanyas“Jeep,”wasthecornerstoneoftheconcep-tionandevolutionofanesthesiapatientsafety.HispassingonApril3,2011,atage82wasatremendouslosstoeveryoneinvolvedwithanesthesiainparticu-larandheathcareingeneral.Patientsaswellaspro-vidersperpetuallyoweDr.Pierceagreatdebtofgratitude,forJeepPiercewasthepioneeringpatientsafetyleader.Hemadeahugedifferenceinthesafetyof health care for everyone.A truevisionary,hesawwhatneededtobeseenandsaidwhatneededtobesaid.Hewason a perpetual mission to preventpatientsfrombeinginjuredorkilledbyanesthesiacare.Whenheembarkedonthatmission,hedidnotknowthattheimpactwouldextendfarbeyondthespe-cialtytowhichhedevotedhislife.

WhilehehadexperiencedclosecallsintheORlikeallanesthesiologists,Dr.Piercedidnotdescribebeingdirectlyinvolvedinaseriousanesthesiaacci-dent.However,wehaveaninterestingrevelationononesourceofDr.Pierce’spassionforsafetyfromarecollectionofRobertH.Bode,MD.Dr.Bode,along-time,closeassociateofDr.PierceandformervicechairmantoDr.PierceattheNewEnglandDeaconessHospitalinBoston(andcurrentlyaffiliatedwithNewEnglandBaptistHospitalandasso-ciateprofessorofAnesthesiaatBostonUniversitySchoolofMedicine)spokeatthememorialserviceheldatthehistoricTrinityChurchindowntownBoston.Hetoldofhow,duringthetimescoveredbyDr.Pierce’searlyandmiddlecareer,themostgrievousanesthesiaerrorscausingcatastrophicoutcomesincludedunrec-ognizedesophagealintubationsanddis-connec t ions f rom the brea th ingapparatus.Dr.Piercewitnessed theimpactofsuchanoccurrencefirsthand.Itinvolvedthe18-yearolddaughterofoneofhisfriends.Shearrestedanddiedduringanesthesiafordentalsurgeryafteranaccidentalesophagealintuba-tion,whichwasnotrecognizeduntilitwastoolate.FromthewayJeeptoldthatstoryonafewoccasions,itsurelywasoneofseveralstimulithatprovokedhimtoworktowardpreventingallsuchtragicanestheticaccidents.Andbecausehewassodedicatedtoanes-thesiology,hepursuedthisquestwithallofhisvigoranddoggedpersistencebecauseheknewitwasthemostimportantthingthathecoulddoforourspe-cialty.Fortunatelyforallofus,healsohadthe

wisdomandsignificantpoliticalsavvytoachievegreatprogress.

Early “Primitive” DaysRaised in North Carolina, educated at the

UniversityofVirginiaandDukeUniversitySchoolofMedicine,Dr.PierceretainedpartofasouthernaccentinspiteofhisdecadesinBoston.ThiswasclearlyaudibleasDr.Pierceelegantlyoutlinedhispersonalhis-toryinhismemorable1995RovenstineLectureatthe

abdominalprocedures.Intubationwasrelativelyuncommon,andmaskanesthesiawasevenusedforthyroidectomy.Controversyragedaboutthenewlyintroducedclassofdrugs,musclerelaxants,andpro-longedblocksrequiringpostoperativehandventila-tioninthenewlycreatedentitycalledthe“recoveryroom”werenotuncommon.Intraoperativemonitor-ingwasabloodpressurecuffandperhapsaprecor-dial stethoscope.An ECG monitor was rarelyavailable.Therewerenobloodgasmeasurements.

Introductionofthebrandnewcopperkettlevaporizerledtoanepidemicofetheroverdoses.Intraoperativecardiacarrestsfromavarietyofcauseswerenotunusual.Whenapatientdiedonthetable,thefamilywassimplytoldthatthepatientjustcouldnottoleratetheanes-thesia—“toobad.”Estimatesofmortal-itycausedsolelybyanesthesiacarerangedfrom1to12per10,000cases.ItwasthisenvironmentthatfirstinspiredDr.Pierce’sawarenessthatanesthesiacarecouldactuallybemorethreateningtopatientsthantheirunderlyingsurgi-calpathology.Henotedthatheagreedwithhislongtimefriend,Dr.WilliamK.HamiltonofUCSanFrancisco, that“anestheticdeaths”weremostlikely90%duetohumanerror.

D r. P i e rc e re c o u n t e d i n t h eRovenstinelecture1hisearlyinterestinanesthesiaaccidents:“In1962,Ibecameinterestedinanesthesiapatientsafety.IhadjoinedLeroyVandamatthePeterBentBrighamHospitalasdefactovicechairman.Inhisinimitableway,onedayheassignedmethesubject,‘anes-thesiaaccidents,’tobegivenasaresi-dent'slecture.Istillhavenotesinmyfilesfromthattalk,whichbeganasacollectionofanesthesiamishapsthatIknew about personally.” He oftenrepeatedhissaddisbeliefregardinghowmanypatientsheheardaboutfromalloverthecountrywhowereinjured or killed by unrecognizedesophagealintubations.Inthe1970s,whenhewaschairofAnesthesiaatthe

NewEnglandDeaconessHospital,Dr.Pierce’sinter-estinsafetydeepenedfurtherwhenhisdepartmentwas1of4recruitedfortheinitiallandmarkstudiesbyJeffreyB.Cooper,PhD,oftheMassachusettsGeneralHospitalandHarvardontheanalysisofanesthesia“criticalincidents.”Thus,thestagewassetforakeycoincidencethathelpedstartDr.Pierce

A Tribute to Ellison C. (Jeep) Pierce, Jr., MD, the Beloved Founding Leader of the APSF

American Society ofAnesthesiologistsAnnualMeeting.1HerecountedhowhefirstgaveanesthesiaasaresidentinJuly1954,whentheequipmentandprac-ticeswereprimitivebytoday’sstandards.CyclopropanewasoftenusedwithanIVstartedonlyafterinduction,althoughthiopentalwascommonandsometimesalsousedasamaintenanceinfusion.Tonsillectomywasdonewithopendropetherandnoendotrachealtube.Rectaldrugadministrationwasemployedand,also,spinalswereverycommon—includingforupper


Dr. Pierce Proclaims “Protect Patients First”InhisRovenstinelecture,1Dr.Pierceemphasized

howextremelyproudhewasofthefactthatatthe1995ASAmeeting,therewere139scientificpaperspresentedinthesectionfeaturingpatientsafety,andthatamere10yearspreviously,thetopicexistednowhereontheprogram.Buildingtoaconclusion,hecharacteristicallyexhorted,“Patientsafetyisnotafad.Itisnotapreoccupationofthepast.Itisnotanobjectivethathasbeenfulfilledorareflectionofaproblemthathasbeensolved.Patientsafetyisanongoingnecessity.Itmustbesustainedbyresearch,training,anddailyapplicationintheworkplace.”Hewasveryconcernedthatproductionpressuresandcostconcerns“couldeasilyundomanyofthegainsthatwecherishsohighly,”butheconcludedhisepicandrivetingpresentationwith,“Patientsafetyistrulytheframeworkofmodernanestheticpractice,andwemustredoubleeffortstokeepitstrongandgrowing.”

Well-Deserved RecognitionAmongthenumeroushonorsDr.Piercereceived,

perhapsthemostmeaningfulwashisinductionasanAmericanintotheprestigiousRoyalCollegeofAnaesthetistsintheUK.Also,hereceivedaspecialcitationfromtheFoodandDrugAdministrationforhiswork,andreceivedawardsfromtheRoyalSocietyofMedicine(UK),theAmericanMedicalAssociation,andtheRussianSocietyofAnesthesiology.Dr.PiercespokeonthetopicofanesthesiasafetyacrosstheUS,aswellasinJapan,Russia,andalsovariouscitiesinEurope,SouthAmerica,andAustralia.Heisknowntoanesthesiapractitionerstheworldoverforhisappearancesinsafetyandtrainingfilms(manyofwhichhehelpedproduce)sponsoredbytheFDA,theASA,andtheAPSF.

Dr.RobertK.Stoelting,MD,currentpresidentoftheAPSF,atDr.Pierce’smemorialservice,summa-rizedseveraltributeshehadreceivedhonoringDr.Pierce,includingonefromE.S.“Rick”Siker,MD,thefirstAPSFsecretaryandthenexecutivedirectorwhocommented,“IamcomfortedbytheknowledgethathemadeanindeliblemarkonAmericanmedicineandthathiscontributionswillneverbeforgotten.”Also,Mr.MichaelScott,thelong-timeASAlegalcounseladded,“ItwasaprivilegetoworkwithDr.PierceontheformationoftheAPSF.AsASAcounselformanyyearsIworkedcloselywithasuccessionofdedicated,ableleadersofthespecialty,butnonedisplayedtheintensesenseofsingularmissionatallhoursofthedayandnightthandidDr.Piercewithrespecttoimprov-ingpatientsafety.Hewastrulyanuncommonman.”

JamesF.English,MD,whosucceededDr.Piercea s p re s i d e n t o f A n e s t h e s i a A s s o c i a t e s o fMassachusettsin1998,spokeofhisclosefriendandmentorat thememorialservice.He laudedDr.Pierce’sremarkablesuccessesandcontinued,“Jeepdidn'taccomplishallthisbybeingashrinkingviolet.Hehadaverystronganddistinctpersonality.He

forwardtobecomewhatisnowaglobalmovementtopreventneedlessinjuriesanddeathsfromerrorsbothhumanandsystem-induced.Hewasanattractor,someoneweallwantedtohelptoaccomplishhisgoals.WhenheassembledthenimbleindependentteamthatwouldbuildtheAPSF,hewasinclusiveandstrategic.Beyondanesthesiologists,theoriginalBoardofDirectorsincludedlawyers,pharmaceuticalanddevicemanufacturers,abiomedicalengineer,riskmanagers,nurseanesthetists,malpracticeinsurers,and representatives from the Food and DrugAdministration,theJointCommission,theAmericanCollegeofSurgeons,andtheAmericanMedicalAssociation.AsDr.Piercenoted,suchdiversityofstakeholderscertainlywasnotpossibleinthestruc-turedenvironmentoftheASAatthattime.Heknewjusthowfarhecouldgo,justwhatkindsofpeopletogetherwereneededtodothejob.

Dr.Piercewasn’ttheonewithallthedetailedideas.Yet,heinstantlycouldspotagoodone.And,hemadethepersonwhohaditfeellikeagenius.Hewasgenerousandsincerewithhispraise;yethewasn’tlookingforithimself(buthereceivedalotofit,includingmanyrecognitionsofhispioneeringefforts).Hewashappyandsatisfiedinhimselftoseethegoodworkbeingdone—theAPSF Newsletter informingandeducatingtheentirecommunityofanesthesiaprofessionals,theresearchgrantsprogramsupportingpatientsafetyresearchforthefirsttimeeverandyieldingsometrulygroundbreakinginsightandinnovation,thecatalysisofnewtechnologies,thedevelopmentofhigh-fidelitymannequin-basedsimu-lationandteamworktraining(focusedbothonhumanerroranalysisandcrisisresourcemanage-ment),andtheinnumerablespecialprojectsthatcamefromAPSFduringthesepast26years—alltheresultofanorganizationthatwasbuiltfromDr.Pierce’sastutesenseofpeople,diplomacy,andtiming.Further,asimmediatepastpresidentoftheASAin1985,Dr.PierceparticipatedinthecreationoftheASAClosedClaimsProjectthatpersuadedseveralmal-practiceinsurancecompaniestoopentheirfilesforanalysisofwhatcausedanesthesiaaccidents.Insub-sequentyears,thatprojectyieldedseveralimportantstudiescontributingdirectlytosafetyimprovements.

Visionary SuccessWhiletheexactstatisticscanbe(andare)debated,

thereiswidespreadrecognitionthatanesthesiacare,particularlyintheUSAbutalsothroughoutthedevel-opedworld,hasbecomemuchsaferforthepatientoverthelast26years.Contributingtothisdramaticimprovementhavebeenmanyfactors,includingespeciallythepracticestandardsandprotocolsstartedatHarvardandexpandedbytheASAthatDr.Piercesupportedsostrongly,butallofthefactorstogetherrelatebacktotheoriginaldrivebyDr.Piercetoimple-mentthesimpleideathatistheAPSF’svision:“thatnopatientshallbeharmedbyanesthesia.”

onapathwhichultimatelybirthedamovementper-manentlychanginganesthesiapracticeand,infact,allofhealthcare.

“Reality” TV Hits HomeTheABCtelevisionprogram20/20airedonApril

22,1982,asegmentcalled"TheDeepSleep:6,000WillDieorSufferBrainDamage."Theannounceropenedwith"Ifyouaregoingtogointoanesthesia,youaregoingonalongtripandyoushouldnotdoit,ifyoucanavoiditinanyway.Generalanesthesiaissafemostofthetime,buttherearedangersfromhumanerror,carelessness,andacriticalshortageofanesthe-siologists.Thisyear,6,000patientswilldieorsufferbraindamage."Afterscenesofpatientswhohadexperiencedanesthesiamishaps,theprogramstated,"Thepeopleyouhavejustseenaretragicvictimsofadangertheyneverknewexisted—mistakesinadmin-isteringanesthesia."Theyshowedapatientwhowasleftinacomaaftertheanesthesiologistmistakenlyturnedofftheoxygenratherthanthenitrousoxideattheendofananesthetic.Later,oneofthehostswastoldthat,"ThereisahospitalinNewYorkCitywherethereare2anesthesiapeoplecovering5operatingrooms."Heappearedincredulousandasked,"Howdotheydoit?"Thereply:"Well,theyrunquicklyandprayalot."Publicattentionandreactionweresignifi-cant,justcompoundingthealreadyextant“malprac-ticecrisis”inanesthesiapractice.Dr.Piercethoughtaboutprotectingpatientsfirst,doctorssecond.Thatwasapotentiallyriskypoliticalmovebuthedidn'thesitate.Hejustdidtherightthing.

Dr.Piercerelated,“The20/20programwasawatershedforanesthesiapatientsafetyendeavors.Atthetime,IwasfirstvicepresidentoftheAmericanSocietyofAnesthesiologists(ASA)anddecidedtoestablishanewASAcommittee,theCommitteeonPatientSafetyandRiskManagement....neverbeforehadtheconceptofpatientsafetybeensospecificallyaddressedbyourspecialtysociety.”1Thisappearstohavebeenthefirstuseinthiscontextofthenowubiq-uitousterm“patientsafety.”

ISPAMM and APSFSoonafter,Dr.Piercehelpedorganizeandhostan

unprecedented and important gathering—theInternationalSymposiumonPreventableAnesthesiaMortalityandMorbidityinBoston.Stronglystimu-latedbythatenergeticassemblage,Dr.Piercecon-ceivedoftheideaoftheAnesthesiaPatientSafetyFoundation(APSF).Throughhischarisma,politicalknow-how,patience,andpersistence,hecreatedandwasthefirstpresidentoftheorganizationthathasbeenthebeaconforpatientsafetyinanesthesiaandfarbeyond.

ThroughAPSFandhismanyconnectionsintheworldofmedicine,Dr.Pierce’svisionwasmoved

“Pierce,” From Preceding Page

See “Pierce,” Next Page


knewhowtogetwhathewanted,andoneofhismaintoolswashisskillincommunicating.Jeepwasveryeruditeandarticulateandhereveledinbeingdescrip-tive.Forexample,oneofhispetpeeveswasfalsepiety.Whenheencounteredit,herelishedusingthewordsanctimonious....itwouldrolloffhistongue,oftenprecededbyaninterestingadjectiveandalwaysfollowedbyacolorfulnoun.”Dr.EnglishrecountedoneofhisfavoritestoriesofJeep:“AyoungdoctorjoineduswhohadallkindsofideasabouthowJeep'sbelovedgroupandhospitalcouldbeimproved.Jeepdisagreedwitheverysuggestion,atfirstpolitelybutwithincreasingvehemenceasthisdoctorpersisted.Afewtimesheevenhadtoresorttohispatentedrebuke:‘YOUCAIN'TDOTHAYAT!’”

Dr.PiercewasalsoeulogizedbyDr.BobBode,whosharedilluminatingpersonalinsights:“Briefly,IwouldliketodescribetheJeepPierceIgrewtoloveandrespect.Jeepwasimpeccablyhonest,hadagreatsenseofhumor,andwasawonderfulmentortomeandtomanyothers.Hetreatedeveryonewithdignityandrespect,whetheryouwereaseniorphysician,nurseanesthetist,anesthesiatechnician,orderly,orreceptionistatthePrudentialTowers.Jeepwasalso

aniconoclast,arebelofsorts,whobasicallydidnotcarehowothersfeltabouthimaslongasheknewinhisheartthathewasdoingtherightthing....Jeepwasagreatleaderwhosestylewasalwaysdeliberateandheoftenraisedhisvoiceforeffect.Hewasahighlyrespectedman,butmanynursesattheDeaconessthoughtthathecouldbeintimidatingattimes.Jeepwoulddenythis."

Dimensional DiversityDespitehisintensityaboutpatientsafety,Dr.

Piercewasfarfromunidimensional.Hehadotherlovesaswell—surelythemostforhislatewife,Elizabeth,andhischildrenChipandWendy,andhis3grandchildren.Also,inasocialmoment,he’drevealhispassionforlargepipeorgansandtheirmagicalmusic,includingtheoneatBoston’sTrinityChurchwherehismemorialservicewasheld.Hetraveled the world to see the special ones.Functionallya“renaissanceman,”helovedoperaandarchitecture,too,butespeciallyhistory.WinstonChurchillwashishero;hereadallhecouldaboutthegreatleaderandstatesman(anddisplayedaChurchillbustinthevestibuleofhisapartment,agiftfromtheAPSFonhisretirementaspresident).Dr.Piercealwayshadadelightfulsenseofhumor

“Pierce,” From Preceding Page

Pierce Labeled Transcendent Visionary

To the Editor:

Iamwritinginresponsetotherecentarticle“RisksofAnesthesiaCareinRemoteLocations"inthespring-summer2011issue.Ifeeltheauthorsdrawthewrongconclusionsfromthedescribedtragedy.Thepatientwasgiven3drugsthatarerespiratorydepres-sants.Thedosewasadjusteduntilthepatientwasasleep,feltnodiscomfort,andtoleratedaforeignbodyinhisthroat.Thatstatewasformerlydescribedasanesthetized,butthetermMACnowseemstohavereplacedit.Itnowseemsthatgeneral anesthesia isatermonlyusedifavolatileagentisalsoused.

Onecouldarguethatthesemanticsarenotimpor-tant,butthewholeissueofsedationversusanesthe-sianeedstobefurtherexamined.

Withageneralanestheticitiscustomarytoguar-anteeanairway,nottoassumethatitisprobablyOK.Itiscustomarytouseacapnogram,notjustwhenitisprobablyneeded,butinallcases.Itisalsocustomarynottotakechancesandhopethattheoutcomewillbegood.Puttinganunconsciouspatientfacedowninthedarkwouldbeatriumphofoptimismoverpru-dence.TodoitwithoutaPlanBforinstantaccesstotheairwayishardtounderstand.

Letters to the Editor

Reader Questions Conclusions on Remote Locations

andcontagiouslaughter,andhewasquicktohelpothers,evenwhenhehimselfmighthavebeeninneed.

Passionate,persistent,patient,jovial,charming,anddedicatedcompletelytoacausehebelievedin,hewasaninspirationtoallofus.Dr.Englishright-fully labeledhim“transcendent”(“surpassing;extendingorlyingbeyondthelimitsofnormalexpe-rience”).EllisonC.Pierce,Jr.,MD,wastrulya“greatman.”Hehasleftanesthesiapracticeanorderofmagnitudesaferandtheworldgenerallyabetterplace.Wedoandwillmisshimenormously.

Dr. John Eichhorn, Professor of Anesthesiology at the University of Kentucky, was the founding editor of the APSFNewsletter and remains on the Editorial Board and serves as a senior consultant to the APSF Executive Com-mittee. Dr. Jeffrey B Cooper, Director, Center for Medical Simulation and Professor of Anaesthesia, Harvard Medical School, Boston, MA, is Executive Vice President of the APSF and one of the founding members of the Executive Committee.

Reference

1. Pierce,EC.The34thRovenstineLecture:40YearsbehindtheMask:SafetyRevisited.Anesthesiology1996;84:965-975.

Allof thishasnothingtodowith“RemoteLocations.”Whatisremoteistheobservanceoftradi-tionalanesthesiapractices.

Theauthorsdescribethedifficultiesofprovidingsafecareanddescribedarkrooms,inadequateanes-thesiasupport,variabilityofmonitoring,andsoforth.ToquoteNancyReagan,“Justsayno.”Ifonefeelsthattheenvironmentisnotsafe,thenonemustrefusetoparticipate.

Ithinkmanyanesthetistsworrythattheywillberegardedastroublesomeanduncooperativeiftheyholdoutforsafetyissues,butinfact,theoppositeistrue.Mostsurgeons,endoscopists,andthelikehavelittletrainingorknowledgeofairwaymanagement.Theywantustotakechargeofthesafetyissues,settheguidelines,organizetheequipment,andmakeitsafe.Ibelievetheyrespectourexpertise;thelastthingtheywantisananestheticcrisis,especiallywhenpreventable.

Kenneth Green, MB, BS, FFARCSWaterville, ME

In Reply:

WethankDr.Greenforhisinterestinournews-letterarticleandweagreethatanesthesialeadershipinpatientsafetyforout-of-operatingroomsedation

isimportant.Theintentoftheanesthesiaproviderinthecasepresentedwastoadministermoderateseda-tion.Thiscaseillustratesthatwiththecontinuumofsedation,moderatesedationmayquicklyprogresstogeneralanesthesiaandbeunrecognized,particularlywhenmultipledrugsareadministeredduringashortperiodandrespiratorymonitoringisinadequate.Thetransitionfrommoderatesedationtogeneralanesthe-siaalsovariesfrompatient-patient,aswellaswithchangingdegreesofproceduralstimulationandpain.

Baseduponthecasesweanalyzed,wehopedtodeliveraclearmessage:vigilanceandrespiratorymoni-toringshouldbesimilarforsedationasforgeneralanes-thesia,independentoftheplacewhereanesthesiacareisprovided.Aspointedoutinyourletter,continuousmonitoringofexhaledCO2constitutesthekeypreventa-tivemeasuretorespiratorymishapsinpatientsunder-goingproceduralsedation.TheAmericanSocietyofAnesthesiologists(ASA)StandardsofMonitoringnowrequirescapnographyformonitoringventilationduringmonitoredanesthesiacare,unlessprecludedorinvali-datedbythenatureofthepatient,procedure,orequip-ment(effectiveJuly1,2011).

Sincerely,

Julia Metzner, MD

Karen B. Domino, MD, MPH


saturation.Healsopredictedthattheincreasedemphasisonpostoperativepainmanagementbycen-tersthatgovernreimbursementwillundoubtedlyresultinahigherincidenceofopioid-inducedrespira-torydepression.

Therewasnotuniformagreement initiallyregardingselectiveversusuniversalmonitoring,orriskstratification,forpatientsreceivingpostoperativeopioids.Severalspeakersdiscussedcoexistingcondi-tionsanddiseasesassociatedwithpostoperativedrug-inducedrespiratorydepressionincludingobe-sity,sleepapneasyndromes,advancedage,organsystemdysfunction,concurrentCNSdepressantuse,andpreoperativechronicopioidtolerance.Manyoftheseriskfactors(especiallyobesity)havebeenincreasinginthegeneralpopulation.Yet,someoftheseconditionsthatpredisposetoopioid-inducedrespiratorydepressionmaybeundiagnosedinthesurgicalpatient.Inparticular,Dr.FrancesE.Chung,professorofAnesthesiologyattheUniversityofTorontopresenteddatashowingthatoverthree-quar-tersofmenandwomenwithmoderatetoseveresleepapneaareundiagnosed,witha7-22%prevalence.5

Therefore,riskstratificationforincreasedpostopera-tiveelectronicmonitoringwouldpotentiallymissa

largepopulationofpatientsthatisatincreasedriskforopioid-inducedrespiratorydepression.

RayR.Maddox,PharmD,fromSt.Joseph’s/CandlerHealthSysteminSavannah,GA,sharedhisexperienceduringthegeneralaudiencediscussionses-sion.Hishospitalinstitutedcapnographywithorwithoutpulseoximetrymonitoringover5yearsagoforallpatientsreceivingparenteralorneuraxialopi-oidspostoperativelyaftersomehigh-severityadverseeventsinvolvingopioids.Theyfoundearlyintheirbetatestingthatitwasnotpossibletoreliablypredictopioidresponsivenessbasedonriskstratificationandelectedtomonitorallpatientsreceivingpostoperativeopioids.Todate,theyhavenothadanyrespiratoryarrestsrelatedtotheadministrationofpostoperativeopioids since they insti tuted the increasedmonitoring.6

FurtherdatafromDr.Chungdemonstratedthatmonitoringpatientspostoperativelyforrespiratorydepressionmayentailmorethanoneortwonightsaftersurgery.Herdatashowedthattheapnea-hypop-neaindex(AHI)insleepapneapatientsishighestonthethirdnightaftersurgeryandremainsabovethepreoperativebaselineouttotheseventhpostopera-tivenight.7Furtherresearchisneededtodetermineifthetypeanddurationofsurgeryandanesthesiaimpactthesefindings.Itremainsunclearhowtobest

Table 1. Comparison of Available Monitoring Modalities for Detection of Opioid-Induced Respiratory Depression in the Postoperative Period

Monitoring Modality Sensitivity * Specificity Reliability Response Time

PetCO2 (intubated) High High High Fast

SpO2 (no O2 supplement) High Moderate-High High Fast

PetCO2 (unintubated) High Moderate-High§ Moderate Fast

PaCO2 High High High Slow

PvCO2 High Moderate High Slow

PtcCO2 Moderate High Low-Moderate‡ Medium

SpO2 (with O2 supplement) Moderate Moderate High Slow

Clinical assessment (skilled clini-cian)

Moderate Moderate-High Moderate Slow

Respiratory rate (newer technol-ogy)

Moderate Moderate† Moderate Medium

Tidal volume (unintubated) Moderate Moderate Low Medium

C h e s t w a l l i m p e d a n c e (for respir. rate)

Low-Moderate Low† Low Medium

Clinical assessment (less skilled clinician)

Low-Moderate Low-Moderate Low-Moderate Slow

* Definitions: Sensitivity = positive in the presence of respiratory depression (low false negative rate); Specificity = negative in the absence of respiratory depression (low false positive rate); Reliability = accuracy and availability (likelihood of an available and accurate reading at the time of respiratory depression); Response time = average time from the onset of respiratory depression until the variable reads abnormally if it is going to do so.

§ If PetCO2 is high, this is highly specific for respiratory depression. However, if is low, because of unknown dead space, it can only be used as a measure of respiratory rate.

‡ New PtcCO2 technologies may be more reliable. † In some patients, respiratory rate alone may not be a good measure of opioid-induced respiratory depression.

monitorseveresleepapneapatientsafterproceduresthatwouldbeconsideredoutpatientsurgery.

Dr.ScottF.Gallagher,associateprofessorofSurgeryfromtheUniversityofFloridainTampa,FLprovideddatashowingthatbariatricsleepapneapatientswillhavesevereprolongedhypoxemiaevenwiththeircontinuouspositiveairwaypressure(CPAP)inplace.8Consequently,monitoringofoxy-genationandventilationisstillneededinthesepatientspostoperatively,evenwhentheyareusingCPAP.

Dr. J . Paul Curry, c l in ica l professor o fAnesthesiologyattheUniversityofCaliforniainLosAngelesDavidGeffenSchoolofMedicine,andstaffanesthesiologist at Hoag Memorial HospitalPresbyterianinNewportBeach,CA,andDr.LarryA.Lynn,apulmonaryintensivistandtheexecutivedirectoroftheSleepandBreathingResearchInstituteinColumbus,OH,presenteduniquedatadescribing3differentpatternsofunexpectedhospitaldeaths.Thesepatternsincludedprogressivemetabolicacido-sis(e.g.,sepsis),opioid-inducedcarbondioxidenar-cosis,anddrug-inducedarousalfailurewithsleepapnea(seearticleonpage32).Theyshoweddifferenttrendsinpulseoximetryvalues,minuteventilation,respiratoryrate,andarterialcarbondioxidelevelsassociatedwitheachofthese3patternsofdeath.9Theynotedthathealthcareprovidersarenotwelleducatedaboutthesepatternsandmaymissearlywarningsigns.Further,theybelievethatmonitorswiththresholdalarms(i.e.,alarmuponreachingaspecificvalue)arenotusefulbecauseoftheirinabilitytodistinguishmeaningfulfromnuisancealarms,dependingonthedeathmechanism.Theyalsodis-cussedthatearlydetectionofdeterioratingpatientconditionswillbepoorwhenthresholdalarmssuchaspulseoximetryaresettolowervaluestoreducetheincidenceof“false”alarms.Drs.CurryandLynnencouragedindustrytodevelopsmarttechnologiesthatcoulddetectthespecificpatternsofvitalsignspreceding these types of death and alert careproviders.

Inagreementwiththeuseofsmarttechnologiesfor pattern recognition, Dr. Richard E. Moon,ProfessorofAnesthesiologyandMedicineatDukeUniversity,suggestedthatmultimodalmonitoringwasnecessarytodetectpostoperative,drug-inducedrespiratorydepression.Hebelievedwecouldincor-poratethetechnologyusedwithautomatedimplant-ablecardioverter-defibrillators(AICD)thatutilizecomplextime-dependentpatternrecognitionalgo-rithmsbasedonreferencewaveforms.Dr.MarkR.Montoney,MD,MBA,ExecutiveVPandCMO,VanguardHealthSystems,Nashville,TN,concurredthatsmarttechnologiesmustbedevelopedthatcanreliablydetectearlyprogressionofclinicalinstabilityandtriggerpromptcaregiverresponses.Dr.ElizabethA.Hunt,apediatricintensivistfromJohnHopkinsUniversitySchoolofMedicinealsoobservedthatpro-gressivetypesofmultimodalmonitoringforvitalsignsthatcouldbeincorporatedtoidentifypatternsandpercentdeviationfrombaselinevitalsignswould

From “Monitoring,” Page 21

Leaders and Experts Share Perspectives

See “Monitoring,” Next Page


From “Monitoring,” Preceding Page

Small Groups Agree on Electronic Monitoring

See “Monitoring,” Next Page

beusefultoprovideearlydetectionofdeteriorationinthepediatricsetting.

DavidA.Scott,MB,BS,PhD,AssociateProfessorofAnaesthesiaatSt.Vincent’sHospitalinMelbourne,Australia,presenteddatashowingtheimportanceoftheassessmentofsedationlevelinpreventingventila-toryimpairmentfromopioids.Henotedthatopioidsaffectconsciousness(sedation),airwaytone,andcen-tralrespiratorydriveandthatmonitoringstrategiesshouldaddressalloftheseparameters.Heagainespoused the importance of assessing trends.ConsistentwithDr.Scott’spresentation,ChrisPasero,RN-BC,apainspecialistfromElDoradoHills,CA,alsocommentedontheimportanceofnursesbeingabletoassessanddocumentsedationlevelsaspartofamultimodalmonitoringstrategytodetectdrug-inducedrespiratorydepression.Someaudiencemem-berssuggestedthatsedationshouldbethesixthvitalsign.Ms.Paseroalsoadvocatedforindividualizedpaintreatmentstrategieswithanemphasisonmulti-modalanalgesia.

Other speakers provided evidence that allpatientscouldbenefitfromincreasedpostoperativemonitoring,andthattheincreasedcostsofmonitor-ingwouldbeoffsetfinanciallybyimprovedout-comes.Withcontinuousmonitoring,patientshadfewertransferstotheintensivecareunitandbettersurvivalifin-hospitalarrestsoccurred,comparedtopatientswithtraditionalmonitoringevery2-4hours.Supportiveofthissupposition,expertsintheimple-mentationofrapidresponseteamsincludingDr.MichaelA.DeVita,anintensivistfromSt.Vincent’sHospitalinBridgeport,CT,providedevidencethatwhileincreasedmonitoringimprovedsurvivalforin-hospitalarrests,thepatients’associatedmedicalcon-ditions only predicted about 50% of arrest ornear-arrestevents.10Inotherwords,riskstratificationofpatientsusingaspecificsetofpredictorscouldmissuptohalfofthosewhowillhaveseriousinpa-tientevents.Dr.GeorgeT.Blike,aprofessorofAnesthesiaatDartmouthUniversity,observedthatoneoftheessentialdifferencesseparatingthebestandworstqualityhospitalswasnottheirnumberofcomplications,buttheirmanagementofcomplica-tionsoncetheyoccur.Hesummarizedhisresearchinwhichpatientswhowereundercontinuouspostop-erativepulseoximetrysurveillancewithalarmsthatalertednursesofabnormalvitalsignshadsignifi-cantlyfewerrescuesandunanticipatedtransferstotheintensivecareunit.11

StevenR.Sanford,JD,presidentandCOOofPreferredPhysiciansMedical,discussedthatone-thirdoftheir96malpracticeinsuranceclaimsinvolv-ingpostoperativerespiratoryarrestsfocusedonallegationsofdrug-inducedrespiratoryarrestresult-ingindeathorbraindamage.Anotherthirdofthissubsetofclaimsinvolvedpatientswithobstructivesleepapneawithinadequatemonitoringallegedbyexpertwitnessesorreviewers.

Dr.RobertA.WisefromtheJointCommission(JC)discussedtherigorousprocessfortranslatingapatientsafetyissueintoaNationalPatientSafety

GoalorStandard.TheJCfocusesononetotwosafetyissueseachyearsothattheimportanceofeachissueishighlighted.Henotedthateducationalpublicationsbyaccreditingorstandards-makingbodiescanbeaccomplishedmorequickly.

TimothyW.Vanderveen,PharmD,MS,fromCareFusion,RogerS.MeccaMD,fromCovidien,Catherine W. Parham, MD, MBA, from GEHealthcare,MichaelO’Reilly,MD,MS,fromMasimo(andaprofessorofAnesthesiologyandPerioperativeCare,UniversityofCalifornia,Irvine),DavidLain,PhD,JD,FCCP,RRTfromOridionCapnography,andAndreasBindszusfromPhilipsHealthcareallpro-videdtheirthoughtsoncontinuouselectronicmoni-toring to prevent drug-induced respiratorydepressioninthepostoperativeperiod.Theseindus-tryleadersupdatedtheaudienceonthecurrentlyavailablemonitorsofoxygenationandventilation.Pulseoximetrymonitorswiredtoacentrallocationwithalarms,nasalcapnographymonitorsthatalertproviders,pulseoximetryand/orcapnographymon-itorsintegratedintoPCApumpsthatcanalarmandhaltthedeliveryoffurtheropioid,andacousticmoni-torsofrespiratoryratecoupledwithpulseoximetrythatalertprovidersofabnormalsituationswerealldiscussed.

Oneoftherecurringconcernsnotedbymultiplespeakerswastheissueof“alarmfatigue”innursesduetofrequentfalsepositivealarms,oftencausedbydisplacedmonitoringsensorsorartifact,butalsofromthresholdalarmssetatlevelstominimizefalsenegativeoutcomes(i.e.,noorlatealarminadeterio-ratingpatient).Frequentlyunreliablemonitorscanresultindelayedornoresponsefromrescuers(e.g.,nurses)whenrealeventsoccur.Manyspeakersandaudiencemembersimploredindustrytodevelopmultimodalmonitorsthatwouldbeabletodetectpatternsfrommultiplevitalsigns,andtheoretically,provemorereliable.

Followingtheformallectures,audiencememberswereassignedtobreakoutgroupstoreachconsensusonthetwoquestionsposedattheopeningofthecon-ference.Summariesoftheirgroupsessionswerepro-videdby thegroup leaders to thereassembledparticipants.Therewasexcellentagreementacrossallgroupsthatelectronicmonitoringshouldbeutilizedtofacilitatedetectionofdrug-inducedpostoperativerespiratorydepression.Similarly,mostgroupsbelievedallpatientsreceivingpostoperativeopioidsshouldbemonitoredcontinuously,butthatthispro-cessmayneedtobeimplementedinagradedfashionbecauseofresourcelimitations.Thedurationofmon-itoringrecommended,particularlyinlightofDr.Chung’spresentation,wasnotclear.Additionally,managementofoutpatientspostoperativelywasnotadequatelyaddressedatthismeeting.

Therewasverygoodagreementbetweengroupsthatpulseoximetryshouldbeutilizedformonitoringasmanypatientsaspossiblebecauseofitsexistingwideavailability,easeofuse,andproviderfamiliar-ity.However,ifsupplementaloxygenwasbeingusedforpatients,thenmostgroupsbelievedcapnographyshouldalsobeappliedtopatientstodetecthypoven-tilation.Somegroupsbelievedthatanelectronic

centralobservationareaforthemonitorsandalarmswouldbeuseful.Improvededucationandassess-mentofsedationlevelbynursingwasalsonotedbymanygroupsasdesirable.

Afewaudiencemembersbelievedthattakingactiononthispatientsafetyissuewasprematurebecausetherewassparseevidence-basedmedicinedemonstratingthatincreasedmonitoringimprovedoutcomes.Theybelievedthatmoreresearchwasneededtodevisemorereliablemonitorswithout-comesstudiesbeforerecommendingthesecostlyinterventions.Mostconferenceparticipantsacknowl-edgedthelegitimacyofthisconcern,butbelievedthecontinuedlossoflivesfromthispreventablecompli-cationwarrantedimmediateinterventionwiththebestavailablemonitorsuntilsuperiormonitorsweredeveloped.

Letter to the Editor

UVA Launches Difficult Intubation LabelTo the Editor:

IwouldliketoshareapracticerecentlyadoptedbytheUniversityofVirginiatoassisthealthcarepro-viderstoidentifyintubatedpatientswhoexperiencedadifficultintubation.Whenadifficultintubationisencountered,abrightorangestickerlabeled"difficultintubation"isplacedcircumferentiallyaroundtheendotrachealtube,belowtheconnector—aliteral"redflag."Thisalertsthecaregiversinvolvedinextubationofthepatientthatreintubation,ifnecessary,wouldpossiblyrequirespecialequipmentinordertobesuc-cessful.Thisavoidsanymiscommunicationamonghealthcareprovidersregardingtheairwaymanage-menthistory.

Geraldine Syverud, CRNACharlottesville, VA


14.RegenthalR,KruegerM,KoeppelC,PreissR.Druglevels:therapeuticandtoxicserum/plasmaconcentra-t ions of common drugs. J Cl in Monit Comput 1999;15:529-44.

15.KrantzMJ,RowanSB,SchmittnerJ,etal.Physicianaware-nessofthecardiaceffectsofmethadone:resultsofanationalsurvey. J Addict Dis2007;26:79-85.

16.TrescotAM,HelmS,HansenH,etal.Opioidsintheman-agementofchronicnon-cancerpain:anupdateofAmeri-canSocietyoftheInterventionalPainPhysicians'(ASIPP)Guidelines.Pain Physician2008;11(2Suppl):S5-S62.

17.Opioidproductschart:opioidproductsthatmayberequiredtohaveriskevaluationandmitigationstrategies(REMS).FDAUSFoodandDrugAdministration.Avail-ableat:http://www.fda.gov/Drugs/DrugSafety/Infor-mationbyDrugClass/ucm163654.htm.AccessedAugust10,2011.

18.OfficeofNationalDrugControlPolicy.Newsrelease:newdatareveal400%increaseinsubstanceabusetreatmentadmissionsforpeopleabusingprescriptiondrugs.July15,2010.Availableat:http://www.whitehousedrugpolicy.gov/news/press10/071510.html.AccessedAugust10,2011.

19.Interagencyguidelineonopioiddosingforchronicnon-cancerpain.AgencyMedicalDirectorsGroup,Washing-tonState.2010Update.Availableat:http://www.agencymeddirectors.wa.gov/Files/OpioidGdline.pdf.AccessedAugust10,2011.

Duringthequestionandanswersession,Dr.StevenF.Shafer,editor-in-chiefofAnesthesia & Analgesia,urgedeveryonetostudytheoutcomesofanynewmonitoringinitiatives.Dr.MarkA.Warner,ASAPresident,offeredtofacilitateimplementationoftheserecommendationsbyhavingASAworkwithkeynursingandsurgicalgroups.

Insummary,theconsensusofconferenceattend-eeswasthatcontinualelectronicmonitoringshouldbeutilizedforinpatientsreceivingpostoperativeopi-oids.Whensupplementaloxygenisnotbeingused,pulseoximetrywasthoughttobethemostreliableandpracticalmonitorcurrentlyavailable.Ifsupple-mentaloxygenisadded,thenmonitorsofventilation(e.g.,capnography)werethoughttobenecessarytodetecthypoventilation.Improvededucationofallcareprovidersonthedangersofpostoperativeopi-oids,andbetterassessmentofsedationlevelwerethoughttobecriticalstepsinthepreventionofpost-operativedrug-inducedrespiratorydepression.Itwasacknowledgedthatlimitedresourcesmayresultinastagedimplementationofcontinualmonitoringstrategieswiththehighestriskgroupsbeingmoni-toredfirst,butwiththegoalofmonitoringallinpa-tients receiving postoperative opioids. Riskstratificationwasshowntobeinsufficienttoeradicatepos topera t ive opio id- induced resp i ra torydepression.

Preventabledeathsandanoxicbraininjuryfromunrecognizedopioidrelatedsedationandrespiratorydepressionremainaseriousandgrowingpatientsafetyconcern.Theissuesidentifiedandtheactions

From “Monitoring,” Preceding Page

Consensus Supports Continual Monitoringrecommendedbythisgroupshouldmitigatetheseriskswiththegoaltoeventuallyeradicatethiscauseofpreventablepatientharm.

A summary of the conclusions and recommen-dations from this conference can be found at the APSF website at http://apsf.org/announcements.php?id=7 or by clicking on the link under Announcements at www.apsf.org, and a brief Meeting Report of the proceedings of the confer-ence will be published in Anesthesia and Analgesia (in press).

Dr. Weinger is the Norman Ty Smith Chair in Patient Safety and Medical Simulation, and Professor of Anesthe-siology, Biomedical Informatics, and Medical Education at Vanderbilt University School of Medicine and a Senior Staff Physician Scientist in the Geriatric Research Educa-tion and Clinical Center (GRECC) in the VA Tennessee Valley Healthcare System. Dr. Lee is an Associate Professor in the Department of Anesthesiology and Pain Medicine at the University of Washington and Co-editor of the APSFNewsletter.

References

1. WeingerMB.Dangersofpostoperativeopioids.APSF Newsletter2006-2007;21:61-7.

2. FechoK,FreemanJ,SmithFR,etal.In-hospitalresuscita-tion:opioidsandotherfactorsinfluencingsurvival.Thera-peutics and Clinical Risk Management 2009;5:961-8.

3. Looi-LyonsLC,ChungFF,ChanVW,etal.Respiratorydepression:anadverseoutcomeduringpatientcontrolledanalgesiatherapy.J Clin Anesth1996;8:151-6.

4. ShapiroA,ZoharE,ZaslanskyR,etal.Thefrequencyandtimingofrespiratorydepressionin1524postoperative

patientstreatedwithsystemicorneuraxialmorphine.J Clin Anesth2005;17:537-42.

5. AnkichettyS,ChungF.Considerationsforpatientswithobstructivesleepapneaundergoingambulatorysurgery.Curr Opin Anaesthesiol2011Jul13.[Epubaheadofprint]

6. MaddoxRR,OglesbyH,WilliamsCK,FieldsM,DanelloS.Continuousrespiratorymonitoringanda“smart”infusionsystemimprovesafetyofpatient-controlledanalgesiainthepostoperativeperiod.In:HenriksenK,BattlesJB,KeyesMA,GradyML,editors.AdvancesinPatientSafety:NewDirectionsandAlternativeApproaches(Vol.4:TechnologyandMedicationSafety).Rockville(MD):AgencyforHealthcareResearchandQuality(US);2008Aug.

7. ChungF,LiaoP,YegneswaranB,etal.Theeffectofsur-geryonthesleeparchitectureofpatientsatriskofOSA–apilotstudy.#A1732.AmericanSocietyofAnesthesiolo-gists2008AnnualMeeting.

8. GallagherSF,HainesKL,OsterlundLG,etal.Postopera-tivehypoxemia:common,undetected,andunsuspectedafterbariatricsurgery.J Surg Res2010;159:622-6.

9. LynnLA,CurryJP.Patternsofunexpectedin-hospitaldeaths:Arootcauseanalysis.Patient Safety in Surgery2011;5:3.

10.GalhotraS,DeVitaMA,SimmonsRL,etal.Maturerapidresponsesystemandpotentiallyavoidablecardiopulmo-naryarrestsinhospital.Qual Saf Health Care2007;16:260-5.

11. TaenzerAH,PykeJB,McGrathSP,BlikeGT.Impactofpulseoximetrysurveillanceonrescueeventsandinten-sivecareunittransfers:Abefore-and-afterconcurrencestudy.Anesthesiology2010;112:284-9.

6. KrantzMJ,MartinJ,StimmelB,etal.QTcintervalscreen-ing in methadone treatment . Ann Intern Med 2009;150:387-95.

7. TotahRA,SheffelsP,RobertsT,etal.RoleofCYP2B6instereoselectivehumanmethadonemetabolism.Anesthesi-ology2008;108:363-74.

8. CrettolS,DéglonJJ,BessonJ,etal.Methadoneenantiomerplasmalevels,CYP2B6,CYP2C19,andCYP2C9geno-types,andresponsetotreatment.Clin Pharmacol Ther2005;78:593-604.

9. AdelsonM,PelesE,BodnerG,KreekMJ.Correlationbetweenhighmethadonedosesandmethadoneserumlevelsinmethadonemaintenancetreatment(MMT)patients.J Addict Dis2007;26:15-26.

10.LiY,KantelipJP,Gerritsen-vanSchieveenP,DavaniS.Interindividualvariabilityofmethadoneresponse:impactofgeneticpolymorphism.Mol Diagn Ther 2008;12:109-24.

11. Methadone:DrugInformation.UpToDate®.Lexi-Comp,Inc.1978-2010.Availableat:http://www.uptodate.com/contents/methadone-drug-information.AccessedAugust10,2011.

12.Publichealthadvisory:methadoneuseforpaincontrolmayresultindeathandlifethreateningchangesinbreath-ingandheartrate.FDAUSFoodandDrugAdministra-tion.November27,2006.Availableat:http://www.fda.gov/ForConsumers/ConsumerUpdates/ucm124346.htm.AccessedAugust10,2011.

13.AnsermotN,AlbayrakO,SchläpferJ,etal.Substitutionof(R,S)-methadoneby(R)-methadone:ImpactonQTcinter-val.Arch Intern Med2010;170:529-36.

InthelastissueofthisNewsletter(Volume26,No.1),Dr.JoanChristieauthoredanimportantarticleaddressingtherisksofmethadoneandmeanstomiti-gatesuchrisk.BothDr.Christieandtheeditorshavereceivedcorrespondencerequestingreferencesforthisarticle.Thesereferenceswereomittedfromtheoriginalarticleduetospacelimitationsasaneditorialdecision.Inlightoftherecentrequests,wearepro-vidingthesegeneralpertinentreferencesasfollows:1. LembergK,KontinenVK,ViljakkaK,etal.Morphine,

oxycodone,methadoneanditsenantiomersindifferentmodels of nociception in the rat. Anesth Analg 2006;102:1768-74.

2. OkieS.Afloodofopioids,arisingtideofdeaths.N Engl J Med2010;363:1981-5.

3. ClarkJD.Understandingmethadonemetabolism:afoun-dationforsaferuse.Anesthesiology2008;108:351-2.

4. WellsC.Deadlypills’tollmounting.Sarasota-ManateeHerald-TribuneDecember4,2010.Availableat:http://www.heraldtribune.com/article/20101204/ARTI-CLE/12041028.AccessedAugust10,2011.

5. WarnerM,ChenLH,MakucDM.Increaseinfatalpoison-ingsinvolvingopioidanalgesicsintheUnitedStates,1999-2006.NCHSDataBrief2009;(22):1-8.Availableat:http://www.cdc.gov/nchs/data/databriefs/db22.pdf.

Methadone References Supplied by Request


To the Editor:

A2-hour-old,1400gmneonatewasbroughttotheORforgastrochisisrepair.Afteranuneventful,intra-venousinductionwithpropofolandrocuroniumandeasymaskventilation,weintubatedtheneonatewitha3.0uncuffedendotrachealtubestyletedwitha6FRuschFlexi-Slip™stylet(TeleflexMedical,ResearchTrianglePark,NC,USA)withoutanydifficulties.Whiletheresidentheldontotheendotrachealtube,thestyletwasremovedwithsomedifficulty.Ataglanceuponremoval,thestyletlookedintact.Theendotrachealtubeplacementwasconfirmedbyend-tidalCO2andauscultationofbilateralbreathsounds.Whiletapingtheendotrachealtubeinplace,wenoticedaforeignobjectinthetube.Weremovedthetubeandreturnedtomaskventilatingthepatient.Theforeignobjectwasfoundtobethedistalendoftheplasticcoveringofthestylet.Theneonatewasreintubatedwithoutastyletandthevitalsignsremainedstablethroughout.Aftersecuringthesecondendotrachealtube,wereinspectedthestyletandnoticedthattheplasticcoveringhadretractedexposingthemetalinternalrod.Theanestheticpro-ceededuneventfully.

Thefollowingday,wewereabletoreproducetheshearing-offofthedistalendoftheplasticcoveringofthe6FFlexi-Slip™styletbyagainusinga3.0endo-trachealtubeandholdingontightlytothetubeduringremovalofthestylet.

Indiscussingthiseventwithcolleagues,someofthemmentionedthattheyroutinelylubricatethestyletbeforeinsertingitinsuchasmallendotrachealtube.Others,though,neverusealubricantbecauseofconcernsofresidualdriedlubricantinanalreadysmallendotrachealtubelumen.Ididtrytoreproducetheshearingoffoftheplasticcoveringwithalubri-catedstyletandwasnotabletodoso.


Plastic Covering of Stylet Can Shear Off During Intubation

Ihaveintubatedagoodnumberofnewbornswithstyletedendotrachealtubeswithoutlubricationandhaveneverexperiencedanyshearing-offofplas-ticpriortothisevent.Thestyletslidesintothe3.0endotrachealtubeeasilyandonlyifthetubeisheldtightlyisitdifficulttoremove.Asmallertubesizemayincreasethechanceofdifficultiesinremovingthestylet.Thisstyletisrecommendedforuseinendo-trachealtubesizesof2.0-3.5.

Wehavereportedthiseventtothedistributorandsentthestyletandshearedofftiptothemforaninvestigation.Additionally,wedidinformtheFDA/MedWatchAlertsandsentoutasafetyalerttoallpediatricanesthesiologistworkingatourinstitution.

Figure 1: From top to bottom: Intact stylet; stylet immediately after distal end sheared off; sheared off tip in endotracheal tube.

Figure 2: Stylet after plastic covering retracted.

Theshearing-offoftheplasticcoveringwithinanendotrachealtubecanpotentiallyleadtoaseriousadverseevent.Inourcaseitwasrecognizedearlyandnegativeconsequenceswereavoided.Nevertheless,weshouldallbeawareofthispotentialcomplication.

Rose Campise Luther, MDAssistant Professor of Clinical AnesthesiaMedical College of WisconsinChildren's Hospital of WisconsinMilwaukee, WI

Christina D. Diaz, MDAssistant Professor of Clinical AnesthesiaMedical College of Wisconsin Milwaukee, WI

Check out the APSF Monthly Poll at www.apsf.org

Give your opinion on timely issues.

www.apsf.org

®


Dear SIRS:Iambeingaskedtoconsiderreusableanesthesia

breathingcircuitswithPallfilters.SearchingtheAPSF Newsletter,IfoundseveralquestionsregardingthistopicintheSpring09issue.Someofthosequestionswereprintedunderthe"OntheHorizon"title.Ihaven'tfoundanyfollow-upsince.Whatisthestatusofthisdebate?

R. Mauricio Gonzalez MDClinical Assistant Professor of AnesthesiologyBoston University School of MedicineVice Chairman of Clinical AffairsDepartment of AnesthesiologyBoston Medical Center

Response

DearDr.Gonzalez:

Ithasbecomeincreasinglycommontouseanesthe-siabreathingcircuitfiltersinanefforttodecreaseinfec-tiousriskfromdiseasessuchasHIV,hepatitisC,tuberculosis,SARS,vCJD,andH1N1influenza.1Thistrendmayalsobefueled,inpart,byliabilityconcernsregardingthepossibilityoftransmittingsuchdanger-ousinfectionsinhealthcare.1WhentheSARSpan-demichitinCanada,50%ofthedeathswerehealthcareworkers,including3anesthesiologists.2Onceitwasbetterunderstoodhowtheinfectionwasbeingspread,theOntarioMinistryofHealthmandatedtheuseofpleatedhydrophobicsubmicronfilters.2

Thereareseveralreportsintheliteratureofcon-taminationpotentiallyspreadingthroughanesthesiamachines.In2instances,aseeminglyunlikelypatho-gen,HCV,(HepatitisCVirus)spreadfrompatienttopatientviatheanesthesiabreathingcirclesystem.3Studieshaveshownthatanesthesiamachinescanbecomecontaminated,andventilatorshavebeenshowntospreadinfectionsfrompatienttopatient.4,5Ifananesthesiamachineisusedincaringforapatientwhoisrecognizedasbeingcolonizedorinfected,itshouldbedecontaminated.Toooften,however,decon-taminationconsistsofmerelywipingthemachinewithadisinfectant.Thisdoeslittleornothingtoprotectsub-sequentpatientsfromorganismsthatmayberesidinginthemachineorsodalimecanister.

Theanesthesiaenvironmentpresentsadifficultchallengeforafilteroraheatandmoistureexchangefilter(HMEF).Highlevelsofmoisturemaynegativelyaffectfiltrationefficiency.Filtersthattestwellinadryenvironmentmaybelesseffectiveintherelativelymoistenvironmentfoundintheanesthesiasetting.6

Vulnerablepatientsmaybesufferingfrompreexistinginfections,maybeimmunocompromised,intubated,andplacedinanenvironmentthatiswarmandmoist,resultinginconsiderableriskforinfection.

Thereare2basictypesoffilters,mechanical(pleatedhydrophobic)andelectrostatic.Electrostatic

filtershaveanappliedchargeonthemedia.Thisappliedchargewillattractaerosolizedparticlesoftheopposite charge, andhold themon themedia.Mechanicalfiltershavenoappliedcharge.Instead,theyfilterprimarilybyhavingsmallerintersticesinthemedia,andtheyareoftenpleatedtoincreasethesur-faceareainordertokeepresistancetoaminimum.7

Electrostaticfiltersmayperformwellinthedryenvironmentduringtesting,butnotaswellinthemorehumidenvironmentassociatedwithanesthesiadelivery.8Itisimportanttokeeppatientrespiratorysecretionsfromenteringthemedia,whichmayfacili-tateinfectiouscontamination.Severalstudieshaveshownthatmanyfiltersarepenetratedbyfluidevenwhenlowpressuresareapplied.6,9,10Thepressureneededtodrivethefluidthroughthefiltermediaisoftenbelowthosepressurescommonlyusedtodeliveranestheticgasestopatients.IthasbeenshownthatpleatedhydrophobicHMEFrequiresubstantiallyhigherpressurestoforcefluidintothemedia.11Theentryoffluidintofiltermediaisparticularlyproblem-aticforelectrostaticfiltersthatmaylosemuchoftheirefficacywhentheybecomewet.10ShouldtheHMEFsorfiltersbebreached,theanesthesiacircuitmaybecomecontaminated.12

TheInternationalOrganizationforStandardization(ISO)hasaddressedbreathingsystemfiltersforanes-theticandrespiratoryuseandpromulgatedastan-dard, ISO 23328-1.13 A key point is that thisinternationalstandardrequiresfiltervalidationbymeansofastandardizedtestusinga0.3micronparti-clechallenge.Italsomandatesspecifictidalvolumesandflowratestobeusedtoinsureconsistencyandaccuracyoftesting.Thistypeofstandardizationpro-videsamoreconsistentandscientificallyobjectivemethodforjudgingtheeffectivenessofafilterandshouldbeusedalongwithstudiesthatevaluatefiltra-tionperformanceinamoistenvironment.

Wehaveknownforalongtimethatanesthesiamachinesandcircuitsmaybecomecontaminated.14,15Thediscussionoffiltrationusehas,however,gradu-allymovedfromansweringthequestion:“Canfilterscontributetodecreasingmachineandcircuitcontami-nation?”to“Arefiltersasafealternativetotheindi-vidualreplacementofbreathingcircuitsandcanweextendcircuitlife?”16

Fromthestandpointofinfectioncontrolandcir-cuitreuseitisimportanttothinkofthecircuitsasapartofthemachine,ratherthanaseparateentity.Theentirecirclesystemmaybecomecontaminated,including the soda lime, and the machine.17,18Bernardsetal.foundinfectiouscontaminationbyAcinetobacter baumanniiincriticalcareunitventila-tors.Criticalcareventilatorsaresimilarenoughtoanesthesiamachinestoraiseconcernthatthelattermayserveasvehiclesforinfectionaswell.19

Reusable Anesthesia Breathing Circuits Considered

The information provided is for safety-related educational purposes only, and does not constitute medical or legal advice. Individual or group responses are only commentary, provided for pur-poses of education or discussion, and are neither statements of advice nor the opinions of APSF. It is not the intention of APSF to provide specific medi-cal or legal advice or to endorse any specific views or recommendations in response to the inquiries posted. In no event shall APSF be responsible or liable, directly or indirectly, for any damage or loss caused or alleged to be caused by or in connection with the reliance on any such information.

Dear SIRS refers to the SafetyInformation Response System. Thepurpose of this column is to allowexpeditiouscommunicationoftechnology-relatedsafetyconcernsraisedbyourreaders,withinputandresponsesfromm a n u f a c t u r e r s a n d i n d u s t r yrepresentatives. This process wasdeveloped by Dr. Michael Olympio,former chair of the Committee onTechnology, and Dr. Robert Morell,co-editorofthisnewsletter. Dear SIRS madeitsdebutintheSpring2004issue.Dr.AWilliamPaulsen,currentchairoftheCommitteeonTechnology,isoverseeingthecolumnandcoordinatingthereaders'inquiriesandtheresponsesfromindustry.

SAFETY

I NFORMATION

RESPONSE

SYSTEM

DearSIRS

See “Dear SIRS,” Next Page


IntheUnitedStatesitisbecomingmorecommonforcircuitstobereusedbetweenpatients,whenanHMEFisbeingusedatthepatientwye.ThispracticeismuchmorewidespreadinEurope,whereanesthesiacaregiversareespeciallyawareoftheissuesassociatedwithdisposableplasticsandtheenvironment.TheAssociationofAnaesthetistsofGreatBritainandIrelandsupportscircuitreuseformultiplepatientswhenusinganeffectiveHMEF.20ArecentGermanAnesthesiaand InfectionControlAssociations(DGKH/DGAI) statementallowsforanesthesiacir-cuitstobereusedformultiplepatientsaccordingtothecircuitlabeling,whenemployinganHMEFwithanefficiencyof>99%measuredaccordingtoISO23328-1,withanimportantcaveatrelatingtoliquidpenetrationvalues.21

AnearlierDear SIRScolumnposedaquestionaboutacompany(PallCorporation)thathashada510(k)forcircuitreusesince2002.22Thiscompany’sHMEF(PallUltipor™25filter)usesapleatedceramic,hydrophobicsub-micronmedia,whichhasperformedatthehighestlevels,irrespectiveoftestingmethodol-ogy.Thesefiltersworkequallywellinadryormoistenvironmentandhavebeenshowntopreventcon-taminationofthecircuitinclinicalusefor24hours.23,24ThisparticularHMEFhasalsobeenused,in vivo,onastandardanesthesiabreathingcircuitovera72-hourperiodwithanewfilterbeingutilizedforeachpatient.Nopatientcontaminationofthecircuitoccurred.25

Ifahospitalchoosestoreuseitscircuitsformulti-plepatients,intheinterestsofcostsavingsandtheenvironment,itisextremelyimportanttobecertainthattheHMEFshavebeenproperlyvalidatedagainstorganisms,resistance,andfluidpenetrationandthatthecircuitislabeledspecificallytopermitreusefor

multiplepatients.Ifahospitalchoosestogo“offlabel,”usingacircuitthatislabeled“SinglePatientUse,”effectivefiltrationmaynotbeassuredandrisksofcrosscontaminationandinfectionmayexist.Therefore,itisimportantthatproductsbeselectedwhichareintendedforandsupportmultiplepatientuse.

James M. Maguire, PhD, RCP, FCCPSenior Scientist/Lecturer, Pall Life SciencesSenior Consultant, Respiratory Care Veterans Administration

References

1. KammingD,GardamM,ChungF.AnaesthesiaandSARS.Br J Anaesth2003;90:715-8.

2. Directive03-06(R).SARSProvincialOperationsCentre.DirectivestoallOntarioacutecarehospitalsforhigh-riskproceduresinvolvingSARSpatientscriticalcareareas.Availableat:http://sars.medtau.org/revisedhighrisk.pdf.AccessedJuly22,2010

3. HeinsenA,BendtsenF,FomsgaardA.Aphylogeneticanalysiselucidatingacaseofpatient-to-patienttransmis-sionofhepatitisCvirusduringsurgery.J Hosp Infect 2000;46:309-13.

4. LangevinPB,RandKH,LayonAJ.Thepotentialfordis-seminationofMycobacteriumtuberculosisthroughtheanesthesiabreathingcircuit.Chest1999;115:1107-14.

5. CentersforDiseaseControlandPrevention(CDC).Tuber-culosisoutbreakinacommunityhospital—DistrictofColumbia, 2002. MMWR Morb Mortal Wkly Rep 2004;53:214-6.

6. HedleyRM,Allt-GrahamJ.Acomparisonofthefiltrationpropertiesofheatandmoistureexchangers.Anaesthesia 1992;47:414-20.

7. TurnbullD,FisherPC,MillsGH,Morgan-HughesNJ.Per-formanceofbreathingfiltersunderwetconditions:alabo-ratoryevaluation.Br J Anaesth2005;94:675-82.

8. WilkesAR.Heatandmoistureexchangersandbreathingsystemfilters:theiruseinanaesthesiaandintensivecare.Part1—history,principlesandefficiency.Anaesthesia 2011;66:31-9.

9. VezinaDP,TrépanierCA,LessardMR,etal.Aninvivoevaluationofthemycobacterialfiltrationefficacyofthreebreathingfiltersusedinanesthesia.Anesthesiology 2004;101:104-9.

10.LeeMG,FordJL,HuntPB,etal.Bacterialretentionprop-ertiesofheatandmoistureexchangefilters.Br J Anaesth1992;69:522-5.

11. VijayakumarM,MortonW,ZuchnerK,etal..Pressurerequiredtoforcewaterthroughbreathingsystemfilters—alaboratorystudy.Eur J Anaesthesiol2010;27:237(Abstract17AP3-10)

12.CannC,HampsonMA,WilkesAR,etal.Thepressurerequiredtoforceliquidthroughbreathingsystemfilters.Anaesthesia2006;61:492-7.

13.InternationalOrganizationforStandardization.Anaes-theticandrespiratoryequipment(ISO23328).Availableat:http://www.iso.org/iso/iso_catalogue/catalogue_tc/catalogue_detail.htm?csnumber=35330.AccessedJuly22,2011.

14.MagathTB.Methodforpreventingcross-infectionwithgasmachines.Anaesth Analg1938;17:215-7.

15.GrossGL.Decontaminationofanesthesiaapparatus.Anesthesiology1955;16:903-9.

16.EggerHalbeisCB,MacarioA,Brock-UtneJG.Thereuseofanesthesiabreathingsystems:anotherdifferenceofopin-ionandpracticebetweentheUnitedStatesandEurope. J Clin Anesth2008;20:81-3.

17.BodySC,PhilipJH.Gram-negativerodcontaminationofan Ohmeda anesthesia machine. Anesthesiology 2000;92:911.

18.BrooksJHJ,GuptaB,BakerD.Anesthesiamachinecon-tamination(abstract).Anesthesiology1991;75(3A):A874.

19.BernardsAT,HarinckHI,DijkshoornL,etal.PersistentAcinetobacterbaumannii?Lookinsideyourmedicalequipment.Infect Control Hosp Epidemiol2004;25:1002-4.

20.AssociationofAnaesthetistsofGreatBritainandIre-land. Infectioncontrol inanaesthesia.Anaesthesia2008;63:1027-36.

21.KramerA,KranabetterR,RathgeberJ,etal.Infectionpre-ventionduringanaesthesiaventilationbytheuseofbreathingsystemfilters(BSF):JointrecommendationbyGermanSocietyofHospitalHygiene(DGKH)andGermanSocietyforAnaesthesiologyandIntensiveCare(DGAI).GMS Krankenhhyg Interdiszip2010;5(2).

22.510(k)Summary.PallMedical,EastHills,NY.Availableat:http://www.accessdata.fda.gov/cdrh_docs/pdf/k013093.pdf.AccessedJuly22,2011.

23.TischlerJM,etal.DeterminingtheeffectivenessofthePallBB25AHMEfilterasabidirectionalbarriertothetrans-missionofbacteriaduringinhalationalanesthesia.(abstract)AANA J 1997;65(5):507.

24.ImaiN,NishimuraC,IkenoS,etal.Clinicalutilityofabreathingcircuitfilterduringgeneralanesthesiaoflongduration.Availableat:http://www.asaabstracts.com/strands/asaabstracts/searchArticle.htm;jsessionid=FE0AE09C5AF55430E497A03033907711?index=0&highlight=true&highlightcolor=0&bold=true&italic=false.AccessedJuly22,2011.

25.HanoverJJetal.TheeffectivenessofthePallBB25AHMEfilterduringextendeduseofananesthesiacircuit.(abstract)AANA J1999;67(5):448.

Products Should Be Chosen That Support Multiple Patient Use

Pall Ultipor™ 25 Filter and Multiple-Patient-Use Breathing Circuits.

“Dear SIRS,” From Preceding Page


J. Paul Curry, MD, and Lawrence A. Lynn, MD

IntroductionFollowingthegreatfireofLondonin1666,the

firstautomateddetectorandthresholdfirealarmwasinvented.Thisalarmwascomprisedofastringthatstretchedthrougheachroomofahouse,andthenextendedtothebasementwhereitwasconnectedtoaweightsuspendedoveragong.Intheory,afireinthis“thresholdmonitored”homewouldburnthroughthestringandtriggerthealarm,resultingina“betterlatethannever”arousalofitsoccupants.Today,hospitalcare-giversandtheirpatientsstillrelyonthissimplethresholdalarmmodel,substitutingthresholdvaluesofSPO2,RR,heartrate,andetCO2asclinicalsurro-gatesforthestring.Unfortunately,clinicaltrials1,2andarecentcomprehensiveresearchreview3suggestthatthesethresholdmonitors,likethestring,arenotaseffectiveastheirdesignersfirstbelieved.

Withourevolvingrecognitionoftheweaknesssinglethresholdsprovide,variationsonthethresholdalarmmethod,suchasthemodifiedearlywarningscore(MEWS),havebeenintroduced.TheMEWSsystemgeneratesnumericscoresfromarangeofthresholdbreachesandthenaddsthesescorestopro-duceasuper“fusion”threshold.WhileMEWSmaybeanimprovement,aswewillsee,itsuffersfromsig-nificantriskinducinganomaliesinevitablewheneversimpleadditionisusedtoquantifycomplexpatho-physiologicprocesses.

OnereasonthresholdmonitorsandMEWSmaynotbeaseffectiveasexpectedonhospitalgeneralcarefloorsisthatpatientsoftendieunexpectedlybyprogressionthrougharangeof3common,butdis-tinctlydifferentdynamicpatternsofinstability.Wecallthese"PatternsofUnexpectedHospitalDeath"(PUHD)(Table1).Whilethesedeathpatternsarenotoverlycomplex,theycannotbedetectedearlybyanysingleormulti-parameterthresholdbreach.

Threshold Monitoring, Alarm Fatigue, and the Patterns of Unexpected Hospital Death

Table 1—The 3 Clinical Pattern Types of Unexpected Hospital Death (PUHD)

TYPE I

Hyperventilation Compensated Respiratory Distress (e.g., Sepsis, PE, CHF)

StableSPO2withprogressivelyfallingPaCO2eventuallyyieldstoslowSPO2decline(mitigatedbyrespiratoryalkalosis),whichisfollowedbyprecipitousSPO2declinewhenmetabolicacidosisdominates.

TYPE II

Progressive Unidirectional Hypoventilation (CO2 Narcosis)

ProgressiveriseinPaCO2(andetCO2)andfallinSPO2over15minutestomanyhours.(Oftenduetooverdosingofnarcoticsorsedatives)

TYPE III

Sentinel Rapid Airflow/SPO2 Reductions Followed by Precipitous SPO2 Fall

Astateof“arousaldependentsurvival”thatoccursonlyduringsleep.Arousalfailureallowsprecipitoushypoxemiaduringapneacausingterminalarousalarrest.

The Common Patterns of Unexpected Hospital Death

(PUHD)Type I Pattern of Unexpected Hospital Death (e.g., Sepsis, CHF, PE)

ThispatternreflectsaclinicallyevolvingprocessassociatedwithmicrocirculatoryfailureinducedbysuchcommonconditionsasCHF,sepsis,andpulmo-naryembolism.Thepatterngenerallybeginswithsubtlehyperventilationandapersistentrespiratory

alkalosis (RA)despite subsequentprogressiveincreasesinaniongapandlacticacidlevels.Thisstageoccurswellbeforethedevelopmentofdomi-natemetabolicacidosis(MA),whichisusuallyassoci-ated with its late and terminal stages. Theseprogressivepatternphases(initialisolatedRAfol-lowedbymixedRAandMA,followedbydominateMA)comprisethetypicalprogressionofTypeIPUHD,andareshowninFigure1.

Unfortunately,theveryhighrespiratoryratethresholds(above30/min)commonlyusedtotriggerrapidresponseteamactivations,5,6occurmostofteninnon-survivors7withnoevidenceshowingtheyarebreachedearlyinsepsisorotherconditionsproduc-ingtheTypeIPUHD.Veryhighrespiratoryrates(above30/min),likehighlactatelevels,8arelikelytoassistdetectionwhenseveremetabolicacidosis,alateTypeIPUHDmanifestation,entersthepicture.Thesearebestconsideredmarkersofseverityanddiagnosticdelay9ratherthanusefulwarningsforearlydisease.

EventuallymicrocirculatoryfailureinthelungscausesafallinPaO2,10buthyperventilationcanper-petuateSPO2valueswellabove90%regardlessofa

SpO2: oxygen saturation; PaCO2: Arterial carbon dioxide tension; P-50: Oxygen tension where hemoglobin is 50% saturated; Ve: minute ventilation, RR: respiratory rate

Fig4 Fig3

Fig2

60

70

80

90

100

40

30

20

10

0

50

60

70

80

90

100

40

30

20

10

0

50

60

70

80

90

100

40

30

20

10

0

50

60

70

80

90

100

50

SpO2

SpO2 with 02 supplementation

SpO2 (room air)

PaCO2

Ve

PaCO2

RRVe

SpO2

PaCO2

Ve

Terminal rise of RR due to severe metabolic (lactic) acidosis

Apnea Apnea Apnea Apnea Terminal Apnea (Arousal Failure)

Onset Potentially Mortal Event(e.g., Sepsis, CHF, PE)

Divergence Pattern of SpO2 and RR

First SPO2 Threshold Warning (breach - 85)

15 minutes

Alarm Threshold = 90

ArousalFailure

RecoveryFailure

Potentially Fatal False Sense of Security (may exceed 12 hours)

Figure 1. Type I Pattern of Unexpected Hospital Death (e.g., Sepsis, CHF).

See “Threshold,” Next Page


Three Patterns are Associated With Unexpected Arrest

Fig4 Fig3

Fig2

60

70

80

90

100

40

30

20

10

0

50

60

70

80

90

100

40

30

20

10

0

50

60

70

80

90

100

40

30

20

10

0

50

60

70

80

90

100

50

SpO2


SpO2 (room air)

PaCO2

Ve

PaCO2

RRVe

SpO2

PaCO2

Ve






15 minutes


ArousalFailure

RecoveryFailure

Fig4 Fig3

Fig2

60

70

80

90

100

40

30

20

10

0

50

60

70

80

90

100

40

30

20

10

0

50

60

70

80

90

100

40

30

20

10

0

50

60

70

80

90

100

50

SpO2


SpO2 (room air)

PaCO2

Ve

PaCO2

RRVe

SpO2

PaCO2

Ve






15 minutes


ArousalFailure

RecoveryFailure

Figure 2. Type II Pattern of Unexpected Hospital Death (CO2 Narcosis).

Figure 3. Type III Pattern of Unexpected Hospital Death (Sleep Apnea with Arousal Failure).

“Lights out Saturation” (Time of “Arousal Arrest”) Resuscitation required after this time

From “Threshold,” Preceding Page


fallingPaO2becauseofrespiratoryalkalosis.11It'spreciselytheseearly,compensatoryphysiologicchanges,andtheoximetrypatternsfromTypeIPUHD,whichcanfoolcliniciansintomistakenlybelievingthesepatientsaren'tintrouble.

ThefailureofsinglethresholdshasledtothedevelopmentofrelianceonmultipleperturbedparameterscombinedtogenerateaModifiedEarlyWarningScore(MEWS).However,relianceonthesumofthresholdperturbationsofmultipleparame-terspresentsuniqueproblems.Injustoneexample,aheartpatientreceivingabetablockermayrequireahigherrespiratoryratetoachieveathresholdMEWSscorethanapatientwithoutheartdisease.ThesetypesofanomaliesillustratetheweaknessofoversimplifiedandarbitraryscoringlikeMEWS.

Tosummarize,thisuniqueTypeIprocessstartswitharisingminuteventilationandafallingPaCO2,thenalateslowfallinSPO2andamorerapidriseinminuteventilation(andatthispointasevereriseinrespiratoryrateandmarkedadditional fall inPaCO2),followedthenbyarapiddropinSPO2(oftenonlynowpassingthroughtheSPO2alarmthreshold).Ifsupplementaloxygenisprovided,theSPO2canremainstableevenclosertothedeathpoint, prolonging the false sense of security.ThresholdbreachesofRR,SPO2,ortheMEWSaregenerallylateandunpredictablemarkersoftheTypeIpattern.

Type II Pattern of Unexpected Hospital Death (CO2 Narcosis)

Sincethe1950s,12nursesandphysiciansintrain-inghave learnedthatnarcoticsproducedeaththroughasingularpath involvingprogressivehypoventilation.Perceivedasadeteriorating,self-propagatingprocess,boththenarcoticsandarisingPaCO2contributetothecentraldepressionofventila-torydrive,ultimatelyleadingto"CO2Narcosis"severeenoughtobringonrespiratoryarrest.Ashypoventilationprogresses,supplementallowflowoxygencanhideitentirelyfromthepulseoximeteruntilverylate,13-15justasitdoeswithTypeIPUHD.

Classiccasesofthisareseeninaccidentalnar-coticoverdose,andthosepatientswithhypoventila-tion syndromes, such as adult patients withcongenitalcentralhypoventilationsyndrome,e.g.,PHO2XBmutations.16

Insummary,(asillustratedinFigure2)theTypeIIPUHDcomprisesfirstaprogressivefallinminuteventilationduetodeclinesintidalvolumeand/orrespiratoryrate,bothunpredictablyvariable.ThisinducesaprogressiveriseinPaCO2withthepatientexhibitingprogressivelyhighersedationscorestothepointofstuporanddeath.PatientsprovidedwithsupplementaloxygencanmaintainSPO2valuesinthe90-100%rangeuntilverylate.

Type III Pattern of Unexpected Hospital Death (Sleep Apnea)

Havingjustdiscussedtheprevailingbeliefheldfordecades(andstillbeingtaughtinMedicalSchools)onthecauseofrespiratoryfailureanddeathinducedbynarcoticsandsedatives,we'renowreadytounsettleanycertaintyandcomfortthissimplisticbeliefmightpro-vide.A"standalone"TypeIIconcepthasfomentedthewidelyheldperceptionthatsedationscorescombinedwiththresholdalarmsfrompulseoximetersand/orcapnometrycanreliablyprovideearlydetection.

Backin2002,Lofsky17describedaclusterofunex-pectedhospitaldeathsinvolvingpatientswithriskfactorsforobstructivesleepapnea.Thesepatients

diedinbedinspiteofacceptabledosingofnarcotics.Surprisingly,theyallsharedauniqueclinicalcoursethatstartedwithbeingalert,thensleeping,andthendyingwithinbrieftimelines.Wenowknowthatsleepapneawitharousalfailureproducesadistinctpatternduringsleep,whichwe'venamedtheTypeIIIPUHD.ItdiffersfromourclassicTypeIICO2narcosisprocess,inthatitoccursonlyduringsleepandmaynotbeassociatedwithpriorelevatedsedationscores.Whenawake,patientswithprofoundTypeIIIarousalfailuremayexhibitnopathognomonicsymptomsorsigns,orshowevidenceofany"awake"sedation.Inotherwords,patientswitharousalfailureareorphaned,


Major Focus and Clinical Trials Are Needed


remainingcompletelyconcealedwithinourtypicalpreandpostoperativepopulations.AsshowninFigure3,thesentinelinstabilitycomponentofTypeIIIPUHDisinducedbysleepapneainthepresenceofarousalfailure.

ThisTypeIIIpatternarchitectureiscomprisedofrepetitivereductionsinairflowandSPO2fromsleeprelatedcyclingcollapsesoftheupperairway.18,19ThiscyclingshowninFigure4,withinitialcollapsingandthenreopeningoftheupperairway,producesatypicalandverydistinctivepatternofsignalclustersthatisreli-ablyacquiredthroughhighresolutionpulseoximetry.

Obstructivesleepapneacanbebestunderstoodasaconditionwhereduringsleep,one'supperairwaycollapsesandisheldclosedbyvigorousbutineffectiverespiratoryeffort(muchliketryingtosuckonacollapsedcellophanestraw).Eachapneainarepetitivesequenceofcyclicapneasisgenerallyter-minatedbyamicro-arousal.Thearousalthencausesbrief"overshoot"hyperventilationthatdrivesthePaCO2belownormal.ThisdropinPaCO2triggersafallincentralventilationdriveandupperairwaytone.Sincetheupperairwayisalreadyunstableitcollapsesagain,causingthecycletoreenterandself-propagate,producingitssentinelpatternofrepetitivereductionsinairflowandSPO2.18Narcotics,20-22spinalanesthesia,23sedatives,24andcyclinghypoxemia25canincreasethearousalthreshold(causearousaldelay),andthenrespiratoryarrestcanoccurfromcompletearousalfailure(arousalarrest).26,27Oncethisoccurs,ifnointerventionisprovidedimmedi-ately,aTypeIIIdeathwillfollowsuddenlyduringsleepwithoutwarningduetoprecipitoushypox-emia,andmostoftenwithoutmuchprogressivePaCO2elevationbecauseofinsufficienttimeforhypercarbiatodevelop.

Ithasbeenpostulatedthatchronicarousalfailuremaydevelopasafunctionofneuralplasticityinresponsetorepetitiveexposurestorapiddeclinesinoxygensaturationovermanyyears.Asthecentralarousalsystemadjustsitsresponse,thearousalitselfcanbecomeprogressivelymoredelayed(muchasitwouldtointermittentloudsoundsafteryearsofsleepexposuretothepassingofnearbytrains).Bythetimethepatient,exposedtomanyyearsofrepeti-tivedesaturationseverynight,arrivesforsurgery,thearousalfailuremayhaveunknowinglyprogressedtoprofoundlylowpre-oplevels.

OnereasonarousaldelaybecomessocriticalisthatSPO2isabletofallatveryrapidratesduringapnea.Manyphysiciansaccustomedtowitnessingpreoxygenatedapnealackafullappreciationfortheextremelyearlyandverysteepdesaturationslopesseeninrecumbent,obesepatientswithapnea.Infact,sincepostoperativefunctionalresidualcapacitydoesnothavedefinablelowerlimits,oxygendesaturationratesmayinsomecasesexceed1.5%persecondwithSPO2fallingtocriticalvalueswithnotimeforcon-t e m p o r a n e o u s h y p e rc a r b i a t o d e v e l o p . 2 8Occasionallyapatient'sarterialoxygensaturationfallstoapointwherethebrainnolongerreceives

sufficientoxygenforcentralarousaltooccur.21,26,27Thisiscalledthe"LightsOutSaturation"(LOS)andhappensbecausethehumanbrainisincapableofgen-eratingsufficientanaerobicmetabolismanddependsonacontinuoussupplyofoxygentosupportarousal.Ifarterialoxygensaturationsfallbelowthiscriticalvaluewherethehemoglobinmoleculesimplycannotreleasesufficientoxygentothebrain,EEGslowingoccurspromptlyandarousalbecomestotallysup-pressed:the"lightsgoout."

OncetheLOSisbreached,airwayreopeningwithoutresuscitationisn'ttobeexpected.Thebodyremainsaliveandcontinuestoburnglucoseandfat,andtheheartpumpsevermountingCO2storesthroughananoxicbody.Ifthepatientisdiscoverednowandresuscitationinitiated,theimmediatelydrawnbloodgaswillshowthePaCO2tobequitehigh,disguisingthisincidentasaTypeIIevent.

Insummary,ifunrecognizedsleepapneawithitsuniquestateofarousaldependentsurvivalexists,thecyclingSPO2signalscanprovidesentinelmarkersforbothcyclicalapneaandarousalfailure.Unknowingadministrationofnarcoticsand/orsedativestopatientswithpreexistingarousalfailurecandelayanalreadyfailingarousaltothepointofarousalarrest.

DiscussionLiketheLondonstring,theprimarylimitationsof

thresholdmonitorsareduetotheiroversimplifieddesign.Iftherewasonlyonepatternofahousefire,oronepatternofunexpectedrespiratoryinstability,itmightbepossibletofinda“best”stringpositioninthehouse,andabestclinicalthresholdinthehospital.However,thereare3commonpatternsofunexpectedhospitaldeath,allatcounterpurposetooneanotherregardingtheirdetection,effectsonphysiology,andpotentialforalarmfatigue.Optimizeathresholdtoreducealarmfatigueforonepatternandyouinadver-tentlyplacepatientssufferingfromtheotherpatternsatriskforgreaterdelays.Thresholdswhichappeareffectiveinonepopulationwithahighgroupingofonepatternmayfailinanotherpopulationwithadifferentdistribution.Forthisreason,alarmresearchstudiesmustidentifythedistributionofpatternsrenderingthealarmsbeforeanyconclusionscanbedrawn.Finally,“beeps”and/orMEWSthatdonottellthehealthcareworkerwhichdeathpatternisevolving,andhowfar

advancedthedeathpatternis,areeasytoignoreandprovidetoolittleinformationforaction.

Howeverold,thresholddevicesstilldohaveben-efits,andthesearetheonlydevicespresentlyavailabletoprotectourpatients.Changetomoreadvancedalarmprocessingtechnologywilltaketime.Oneimmediatesolutionistoexpeditethedevelopmentofatrainingcourse(analogoustotheadvancecardiaclifesupportcourse)tocertifyallhealthcareworkersusingpatientmonitors.Thistrainingwouldincludemod-ulesdesignedtoteachthePUHDs,thetechnicalandpathophysiologiccausesofalarmfatigue,andtheben-efits/limitationsofmonitoringandsedationscoringinrelationtoeachdistinctdeathpattern.

Formaltrainingwouldalsohelppreventdelayanddeathduetothresholdbased“technicaltriviali-ties”suchasapatient’sMEWSchangingtoolatefromascoreof3to4,orthegenerationofalarmfatiguebyadeathpatternwhichproducesmanyearly“thresh-oldbreaches”beforeanactualdeatheventoccurs,orafailuretoalarmatallfromthethresholdmonitoringofanunappreciated,compensatedparameter.

Anunderstandingoftherelationalandconforma-tionalcomplexityofthePUHDsalsoarguesstronglyforcomputationaltransparencyofallalarmproces-sors,whichsimplymeansthattheoriginalclinicaldataset,theprocesseddataset,andthebasisforout-putsasafunctionoftheprocessingareexposed(orreadilyexposable)inrealtimeatthebedsidebytheclinicalcare-giversmanagingpatients.Physiciansshouldtakechargeofthisprocess.

Finally,amajorfocusonimprovingpatientmoni-torsandclinicaltrialsisrequired.Patientsaredyinginhospitalswithsmartphonesintheirpocketsthatcanidentifyasongjustby“listening”toit,whilethemonitorstheyareconnectedtoarenotsmartenoughtoidentifyevenonepatternofunexpecteddeath.

ConclusionThereare3commonfundamentalpathophysio-

logicpatternsofunexpectedhospitaldeath.Thesepatternsaretoocomplexforearlydetectionbyanyunifyingnumericthresholdorsummationscore.Furthermore,alarmsresponsivetosimplefragments

Fig4 Fig3

Fig2

60

70

80

90

100

40

30

20

10

0

50

60

70

80

90

100

40

30

20

10

0

50

60

70

80

90

100

40

30

20

10

0

50

60

70

80

90

100

50

SpO2


SpO2 (room air)

PaCO2

Ve

PaCO2

RRVe

SpO2

PaCO2

Ve






15 minutes


ArousalFailure

RecoveryFailure

Figure 4. Type III Pattern: Note the Potential for Alarm Fatigue Preceding Arousal Failure.

From “Threshold,” Preceding Page


ofpatterns(e.g.,thresholdsortrends)ratherthanthepatternsthemselveshavethepotentialtoinducealarminflation.Thoseusingordesigningpatientmonitorsshouldreceiveformaltrainingrelevanttothepatternsofunexpectedhospitaldeath.Clinicaltrialsonalarmsshouldidentifythedistributionofthepatternsthatgeneratedthem.Inaddition,newmethodsandtech-nologieswhichdetect,identify,quantifyandtracktheactualpatternsofunexpectedhospitaldeathshouldbeinvestigated.It’stimetocutthestring.

Department of Anesthesiology and Perioperative Care, Newport Beach, CA. and a Clinical Professor, Department of Anesthesiology, David Geffen School of Medicine, UCLA.

Dr. Lynn is a pulmonary and critical care physician and serves as executive director of the Sleep and Breathing Research Institute in Columbus Ohio. He also serves on the FDA standards committee for pulse oximetry monitoring.

Disclosure: Dr. Curry has nothing to disclose. Dr. Lynn holds patents and receives royalties relating to inventions in the field of patient monitoring and pattern detection.

References1. ChanPS,KhalidA,LongmoreLS,etal.Hospital-wide

coderatesandmortalitybeforeandafterimplementationofarapidresponseteam.JAMA2008;300:2506-13.

2. RothschildJM,WoolfS,FinnKM,etal.Acontrolledtrialofarapidresponsesysteminanacademicmedicalcenter.Jt Comm J Qual Patient Saf2008;34:417-25,365.

3. ChanPS,JainR,NallmothuBK,etal.Rapidresponseteams:Asystematicreviewandmeta-analysis.Arch Intern Med2010;170:18-26.

4. Ghanem-ZoubiNO,VardiM,LaorA,etal.Assessmentofdisease-severityscoringsystemsforpatientswithsepsisingeneralinternalmedicinedepartments.Crit Care 2011;15:R95.

5. HravnakM,EdwardsL,ClontzA,etal.Definingtheinci-denceofcardiorespiratoryinstabilityinpatientsinstep-downunitsusinganelectronicintegratedmonitoringsystem.Arch Intern Med2008;168:1300-8.

6. AlianAA,RaffertyT.Evaluationofrapidresponseteamflag-alertparameters.Availableat:http://www.cardio-pulmonarycorp.com/pdf/RapidResponseAlertParame-ters.pdf.AccessedAugust11,2011.

7. BossinkAW,GroeneveldJ,HackCE,etal.Predictionofmortalityinfebrilemedicalpatients:Howusefularesys-temicinflammatoryresponsesyndromeandsepsiscrite-ria?Chest 1998;113:1533-41.

8. MikkelsenME,MiltiadesAN,GaieskiDF,etal.Serumlac-tateisassociatedwithmortalityinseveresepsisindepen-dent of organ failure and shock. Crit Care Med 2009;37:1670-7.

9. MariniC,DiRiccoG,FormichiB,etal.Arterialbasedeficitinpulmonaryembolismisanindexofseverityanddiag-nosticdelay. Intern Emerg Med2010;5:235-43.

10.GreerR.Thetemporalevolutionofacuterespiratorydis-tresssyndromefollowingshock.Eur J Anaesthesiol 2010;27:226-32.

11. Siggaard-AndersenO,GarbyL.TheBohreffectandtheHaldaneeffect. Scand J Clin Lab Invest1973;31:1-8.

12.SeikerHO,HickamJB.Carbondioxideintoxication:theclinicalsyndrome,itsetiologyandmanagementwithpar-ticularreferencetotheuseofmechanicalrespirators.Medicine(Baltimore)1956;35:389-423.

13.AyasN,BergstromLR,SchwabTR,etal.Unrecognizedseverepostoperativehypercapnia:acaseofapneicoxy-genation.MayoClinProc1998;73:51-4.

14.FuES,DownsJB,SchweigerJW,etal.Supplementaloxygenimpairsdetectionofhypoventilationbypulseoximetry.Chest 2004;126:1552-8.

15.ऀDownsJB.Hasoxygenadministrationdelayedappropri-aterespiratorycare?Fallaciesregardingoxygentherapy.Respir Care2003;48:611-20.

16.AnticNA,MalowBA,LangeN,etal.PHOX2Bmutation-confirmedcongenitalcentralhypoventilationsyndrome:presentationinadulthood.Am J Respir Crit Care Med 2006;174:923-7.

17.LofskyA.Sleepapneaandnarcoticpostoperativepainmedication:Amorbidityandmortalityrisk.APSF News-letter2002;17:24-5.

18.LynnLA.Interpretiveoximetry:futuredirectionsfordiag-nosticapplicationsoftheSpO2time-series.Anesth Analg2002;94(1Suppl):S84-8.

19.DempseyJA,VeaseySC,MorganBJ,etal.Pathophysiol-ogyofsleepapnea.Physiol Rev2010;90:47-112.

20.HajihaM,DuBordMA,LiuH,etal.Opioidreceptormechanismsatthehypoglossalmotorpoolandeffectson tongue muscle act ivi ty in vivo. J Physio l 2009;587:2677-92.

21.WhiteDP.Opioid-inducedsuppressionofgenioglossalmuscleactivity: is itclinicallyimportant?J Physiol 2009;587:3421-2.

22.VanDercarDH,MartinezAP,DeLisserEA.Sleepapneasyndromes:apotentialcontraindicationforpatient-con-trolledanalgesia.Anesthesiology1991;74:623-4.

23.WieczorekPM,CarliF.Obstructivesleepapneauncov-eredafterhighspinalanesthesia:acasereport.Can J Anaesth2005;52:761-4.

24.BerryRB,KouchiK,BowerJ,etal.Triazolaminpatientswithobstructivesleepapnea.Am J Respir Crit Care Med 1995;151:450-4.

25.JohnstonRV,GrantDA,WilkinsonMH,etal.Repetitivehypoxiarapidlydepressescardio-respiratoryresponsesduringactivesleepbutnotquietsleepinthenewbornlamb.J Physiol1999;519:571-9.

26.KhooSM,MukherjeeJJ,PhuaJ,etal.Obstructivesleepapneapresentingasrecurrentcardiopulmonaryarrest.Sleep Breath2009;13:89-92.

27.DykenME,YamadaT,GlennCL,etal.Obstructivesleepapneaassociatedwithcerebralhypoxemiaanddeath.Neurology2004;62:491-3.

28.WilkinsonMH,BergerPJ,BlanchN,etal.Effectofvenousoxygenationonarterialdesaturationrateduringrepeti-tiveapneasinlambs.Respir Physiol 1995;101:321-31.

Patterns and Training Are ImportantFrom “Threshold,” Preceding Page

GeorgeA.Schapiro, ChairAPSF Executive Vice President

GeraldEichhorn................. Abbott Laboratories

CliffRapp ............................ Anesthesiologists Professional Insurance Company

DennisI.Schneider............ Baxa

TomHarrison..................... Baxter Healthcare

MichaelS.Garrison........... Becton Dickinson

TimothyW.

Vanderveen,PharmD........ CareFusion

ThomasM.Patton.............. CAS Medical Systems

RobertJ.White................... Covidien

DavidKarchner.................. Dräger Medical

DouglasM.Hansell,MD.. GE Healthcare

MichaelJ.Stabile,MD....... Linde Therapeutic Solutions

StevenR.Block................... LMA of North America

MichaelO’Reilly,MD........ Masimo

TrishCrescitelli ................... McKesson Provider Technologies

ThomasW.Barford............ Mindray

KathyHart.......................... Nihon Kohden America

DominicCorsale................ Oridion

DanielR.Mueller............... Pall Corporation

MarkWagner...................... PharMEDium

WalterHuehn..................... Philips Medical System

StevenR.Sanford,JD....... Preferred Physicians Medical Risk Retention Group

J.C.Kyrillos........................ ResMed

Dr.RainerVogt .................. SenTec AG

CindyBaptiste..................... Sheridan Healthcorp, Inc.

TomUlseth.......................... Smiths Medical

JosephDavin...................... Spacelabs

CaryG.Vance..................... Teleflex

SusanK.Palmer,MD......... The Doctors Company

WilliamFox......................... WelchAllyn

AbeAbramovich

CaseyD.Blitt,MD

RobertK.Stoelting,MD

A N E S T H E S I A P A T I E N T S A F E T Y F O U N D A T I O N

CORPORATE ADVISORY COUNCIL

SUPPORT YOUR APSFPlease make checks payable to the APSF and mail donations to

Anesthesia Patient Safety Foundation (APSF)520 N. Northwest Highway, Park Ridge, IL 60068-2573

or make your donation online at www.APSF.org


Anesthesia Patient Safety FoundationC O R P O R AT E S U P P O R T E R PA G E

APSF is pleased to recognize the following corporate supporters for their exceptional level of support of APSF in 2011

Founding Patron

Founded in 1905, the American Society of Anesthesiologists is an educational, research, and scientific association with 46,000 members organized to raise and maintain the standards of anesthesiology and dedicated to the care and safety of

patients. http://www.asahq.org

Grand Patron

Covidien is committed to creating innovative medical solutions for better patient outcomes and delivering value through clinical leadership and excellence in everything we do. http://www.covidien.com

Sponsoring Patron

Baxter’s Global Anesthesia and Critical Care business is a leading manufacturer in anesthesia and peri-operative medicine, providing all three of the modern inhaled anesthetics for general anesthesia, as well products for PONV and

hemodynamic control. http://www.baxter.com

Benefactor Patrons

Abbott is a broad-based health care company devoted to bringing better medicines, trusted nutritional products, innovative medical devices and advanced diagnostics to patients and health care professionals around the world. www.abbott.com

Masimo is dedicated to helping anesthesiologists provide optimal anesthesia care with immediate access to detailed clinical intelligence and physiological data that helps to improve anesthesia, blood, and fluid management decisions. www.masimo.com

Oridion offers all patients and clinical environments the benefits of capnography. . . the only indication of the adequacy of ventilation and the earliest indication of airway compromise. www.oridion.com

PharMEDium is the leading national provider of outsourced, compounded sterile preparations. Our broad portfolio of prefilled O.R. anesthesia syringes, solutions for nerve block pumps, epidurals, and ICU medications are prepared using only the highest standards. www.pharmedium.com

Supporting PatronPreferred Physicians Medical: Providing malpractice protection exclusively to anesthesiologists nationwide. PPM is anesthesiologist founded, owned, and governed. PPM is a leader in anesthesia specific-risk management and patient safety initiatives. www.ppmrrg.com


Anesthesia Patient Safety Foundation

Supporting Patron ($15,000 to $24,999)Linde Healthcare (lifegas.com) Preferred Physicians Medical (ppmrrg.com)Patron ($10,000 to $14,999)CareFusion (carefusion.com)Spacelabs Medical (spacelabs.com)Sustaining Donor ($5,000 to $9,999)Anesthesiologists Professional Assurance Company

(apacinsurance.com)Baxa Corporation (baxa.com)Becton Dickinson (bd.com)

CAS Medical Systems (casmed.com)Dräger Medical (draeger.com)LMA of North America (lmana.com)McKesson Provider Technologies (mckesson.com)Mindray, Inc. (mindray.com)Nihon Kohden America, Inc. (nihonkohden.com)Pall Corporation (pall.com)ResMed (resmed.com)SenTec AG (sentec.com)Sheridan Healthcorp, Inc. (shcr.com)Smiths Medical (smiths-medical.com)Teleflex Medical (teleflex.com)

The Doctors Company Foundation (thedoctors.com)WelchAllyn (welchallyn.com)Sponsoring Donor ($1,000 to $4,999)Anesthesia Business Consultants (anesthesiallc.com)Allied Healthcare (alliedhpi.com)Armstrong Medical (armstrongmedical.net)Belmont Instrument Corporation

(belmontinstrument.com)Codonics (codonics.com)Cook Critical Care (cookgroup.com)iMDsoft (imd-soft.com)

King Systems (kingsystems.com)METI Learning (meti.com)TRIFID Medical Group LLC (trifidmedical.com)W.R. Grace (wrgrace.com)

Corporate Level Donor ($500 to $999)Promed StrategiesWolters Kluwer

Subscribing SocietiesAmerican Society of Anesthesia Technologists and

Technicians (asatt.org)

Note: Donations are always welcome. Donate online (www.apsf.org) or send to APSF, 520 N. Northwest Highway, Park Ridge, IL 60068-2573.(Donor list current through September 1, 2011.)

Corporate Donors Founding Patron ($500,000 and higher) American Society of Anesthesiologists (asahq.org)

Community Donors

(includes Anesthesia Groups, Individuals, Specialty Organizations, and State Societies)

Grand Sponsor ($5,000 and higher)

AlabamaStateSocietyofAnesthesiologistsAmericanAcademyofAnesthesiologist

AssistantsAnaesthesiaAssociatesofMassachusettsAnesthesiaMedicalGroup(Nashville,TN)GreaterHoustonAnesthesiologyIndianaSocietyofAnesthesiologistsMinnesotaSocietyofAnesthesiologistsFrankB.Moya,MD,CharitableFoundationNorthAmericanPartnersinAnesthesiaRobertK.Stoelting,MDTennesseeSocietyofAnesthesiologistsValleyAnesthesiologyFoundation

Sustaining Sponsor ($2,000 to $4,999)

AnesthesiaConsultantsMedicalGroupAnesthesiaResourcesManagementArizonaSocietyofAnesthesiologistsAshevilleAnesthesiaAssociatesNassibandMaureenChamounGeorgiaSocietyofAnesthesiologistsMadisonAnesthesiologyConsultantsMassachusettsSocietyofAnesthesiologistsRobertMcIvor,MDMichianaAnesthesiaCareMichiganSocietyofAnesthesiologistsOldPuebloAnesthesiaGroupPennsylvaniaSocietyofAnesthesiologistsPhysicianSpecialistsinAnesthesia(Atlanta,GA)ProvidenceAnchorageAnesthesiaMedical

GroupSocietyofAcademicAnesthesiology

AssociationsSocietyofCardiovascularAnesthesiologistsDrs.MaryEllenandMarkWarner

Contributing Sponsor ($750 to $1,999)

AcademyofAnesthesiologyAffiliatedAnesthesiologistsofOklahoma

City,OKAlaskaAssociationofNurseAnesthetists

AmericanAssociationofOralandMaxillofacialSurgeons

AmericanSocietyofPeriAnesthesiaNursesAnesthesiaAssociatesofNorthwestDayton,Inc.AnesthesiologyConsultantsofVirginia

(Roanoke,VA)AnesthesiaServicesofBirminghamJ.JeffreyAndrews,MDAssociatedAnesthesiologistsofSt.Paul,MNDr.andMrs.RobertA.CaplanFrederickW.Cheney,MDCaliforniaSocietyofAnesthesiologistsConnecticutStateSocietyof

AnesthesiologistsJeffreyB.Cooper,PhDJeanneandRobertCordes,MDStevenF.Croy,MDJohnH.Eichhorn,MDIllinoisSocietyofAnesthesiologistsIowaSocietyofAnesthesiologistsKansasCitySocietyofAnesthesiologistsKentuckySocietyofAnesthesiologistsJohnW.Kinsinger,MDLorriA.Lee,MDPaulG.Lee,MDAnneMarieLynn,MDMarylandSocietyofAnesthesiologistsJosephMeltzer,MDMichaelD.Miller,MDMissouriSocietyofAnesthesiologistsRobertC.Morell,MDNorthwestAnesthesiaPhysiciansNurseAnesthesiaofMaineOhioAcademyofAnesthesiologist

AssistantsOhioSocietyofAnesthesiologistsOklahomaSocietyofAnesthesiologistsOregonSocietyofAnesthesiologistsFrankJ.Overdyk,MDPhysicianAnesthesiaServiceLauraM.Roland,MDSantaFeAnesthesiaSpecialistsJoAnnandGeorgeSchapiroPhilanthropic

Fund

Drs.XimenaandDanielSesslerSocietyforAmbulatoryAnesthesiaSocietyofCriticalCareAnesthesiologistsSocietyforAirwayManagementSocietyforPediatricAnesthesiaSouthDakotaSocietyofAnesthesiologistsSpectrumMedicalGroupStockham-HillFoundationTejasAnesthesiaTexasAssociationofNurseAnesthetistsTexasSocietyofAnesthesiologistsTheSaintPaulFoundationDr.andMrs.DonaldC.TylerWashingtonStateSocietyof

AnesthesiologistsWisconsinAssociationofNurseAnesthetistsWisconsinSocietyofAnesthesiologistsJohnM.Zerwas,MD

Sponsor ($200 to $749)Sean S. Adams, MDLeslie Andes, MDAnesthesia Associates of Columbus, GADonald E. Arnold, MDBalboa Anesthesia GroupRobert L. Barth, MDWilliam C. Berger, MDBerkshire Medical Center (National Nurse

Anesthetists Week)Vincent C. Bogan, CRNAAmanda Burden, MDJohn Busch (Engineering Controls for

Medicine)Michael Caldwell, MDLillian K. Chen, MDJoan M. Christie, MDMarlene V. Chua, MDMelvin Cohen, MDColorado Society of AnesthesiologistsR. Lebron Cooper, MDDavid S. Currier, MDGlenn E. DeBoer, MDJan Ehrenwerth, MDBruce W. Evans, MDCynthia A. Ferris, MDJane C. K. Fitch, MD/Carol E. Rose, MDMark P. Fritz, MDWayne Fuller, MDGeorgia Association of Nurse AnesthetistsJames J. Gibbons

Ian J. Gilmour, MDRichard Gnaedinger, MDGoldilocks Anesthesia FoundationJames D. Grant, MDJoel G. Greenspan, MDWilliam L. Greer, MDGriffin Anesthesia AssociatesAlexander A. Hannenberg, MD (in honor

of Kansas City Society of Anesthesiologists)

Daniel E. Headrick, MDJ ohn F. Heath, MDSimon C. Hillier, MDVictor J. Hough, MDEric M. HumphreysPaul M. Jaklitsch, MDRobert E. Johnstone, MDKansas Society of AnesthesiologistsCeleste Kir schnerMichael G, Kral, MDRodney C. Lester, CRNAKevin P. Lodge, MDMaine Society of AnesthesiologistsAsif Malik, MDGregory B. McComas, MDE. Kay McDivitt, MDTricia A. Meyer, PharmDMississippi Society of AnesthesiologistsRoger A. Moore, MDNew Jersey State Society of

AnesthesiologistsNew Mexico Society of AnesthesiologistsSara M. Norvell, MDL. Charles Novak, MDDucu Onisei, MDMichael A. Olympio, MDSrikanth S. Patankar, MDMukesh K. Patel, MDPennsylvania Association of Nurse

AnesthetistsGaylon K. Peterson, MDDrs. Beverly and James PhilipRichard C. Prielipp, MDJohn Rask, MDRhode Island Society of AnesthesiologistsJanet and Howard SchapiroSanford Schaps, MDSociety for Neuroscience in

Anesthesiology and Critical Car eSociety for Obstetric Anesthesia and

PerinatologySouth County Anesthesia Association

South Carolina Society of Anesthesiologists

Shepard B. Stone, PASteven J. Thomas, MDUniversity of Maryland Anesthesiology

AssociatesVail Valley AnesthesiaVermont Society of AnesthesiologistsVirginia Society of AnesthesiologistsThomas L. War r en, MDJimmie Watkins, MD, DDS, PhDMatthew B. Weinger, MDDonald L. Weninger, MD (in honor of

Willard Albrecht, MD)Andrew Weisinger, MDWest Virginia State Society of

AnesthesiologistsWichita Anesthesiology, CharteredG. Edwin Wilson, MDWisconsin Academy of Anesthesiologist

AssistantsGerald L. Zeitlin, MD

In MemoriamIn memory of William J. Beightler, MD

(Texas Society of Anesthesiologists)In memory of E. H. Boyle, MD

(Philip F. Boyle, MD)In memory of Jose M. Brito-Suarez, MD

(Texas Society of Anesthesiologists) In memory of Hank Davis, MD

(Sharon Rose Johnson, MD)In memory of Steve Edstrom, MD

(Larry D. Shirley, MD)In memory of Margie Frola, CRNA

(Sharon Rose Johnson, MD)In memory of Andrew Glickman, MD

(Sharon Rose Johnson, MD)In memor y of Roy C. Kang, MD (Texas

Society of Anesthesiologists)In memory of Stevon S. Kebabjian, DO

(Texas Society of Anesthesiologists)In memory of Max K. Mendenhall, MD

(Texas Society of Anesthesiologists) In memory of Ellison C. Pierce, Jr., MD

(founding president of APSF) (multiple donors)

In memory of Robert Romero, MD (Texas Society of Anesthesiologists)

In memory of Sylvan E. Stool, MD (Lawrence M. Borland, MD)

In memory of Leroy D. Vandam, MD (Dr. and Mrs. George Carter Bell)

Grand Patron ($150,000 to $199,999)

Sponsoring Patron ($50,000 to $99,000)

Benefactor Patron ($25,000 to $49,999)

Masimo Foundation(masimo.com)

Sustaining Professional Organization ($25,000 and higher)

PharMEDium Services (pharmedium.com)

Oridion Capnography (oridion.com)

Online donations accepted at www.apsf.org

Covidien (covidien.com)

Baxter Anesthesia and Critical Care (baxter.com)

American Association of Nurse Anesthetists (aana.com)

Philips Healthcare (medical.philips.com)

Abbott Laboratories (abbott.com)

GE Healthcare (gemedical.com)


To The Editor:

I'mwritingtoinformyouofanearmissatourinstitution,alargecommunityhospital.Duringmymorningroomset-up,Inoticedamedicationvialcon-tainingawhitesubstancefoundonmyanesthesiaPyxis®machinetabletop.Thissubstancecouldhaveeasilybeenmistakenforpropofolasitwasidenticaltoourcurrentpropofolsupplyinvialshape,size,capcolor,labelcolor,solutioncolor,andconsistency,asevidencedinFigure1.ThesubstancewasaproductcalledRotaglide®lubricant.Itisusedasamedicallubricantforguidewires.

Aswithanynearmissordrugerror,therewereaseriesofunusualcircumstancesthatledtothisprod-uctbeingplacedonananesthesiatabletop.Followingourinstitution'sinvestigation,itisknownthatwecarrythisproductinaverylimitedquantityinourcatheterlabandinterventionalradiologysuites.Theproductisnotstockedbyourhospitalpharmacybut

safety,theirrecognitionofasignificantpatientsafetyproblem,theirproposaland/orimplementationofasolutiontoapatientsafetyissue,andothercontribu-tionstopatientsafety.

CongratulationstoDr.Walshforthehonorofreceivingthisawardforhiscontributionstoanesthe-siapatientsafety.

At itsgraduationceremonyonJune16, theDepartmentofAnesthesia,CriticalCareandPainMedicine(DACCPM)oftheMassachusettsGeneralHospitalawardeditsthirdannualJeffreyB.CooperPatientSafetyAward,whichisnamedinhonoroftheAPSFexecutivevicepresident.ThisyeartheawardwasgiventoDr.JohnWalshforhismanyenhance-mentsandapplicationsofthedepartment’sanesthe-siainformationsystem,whichhehasspearheadedsinceitsinceptionover10yearsago,andforhisdedi-cationtotheteachingofsafemedicationadministra-tionpracticeswithinthedepartment.Theentiredepartmentvotesonthisawardeachyear,basedonthefollowingsolicitationemail:

“Thisawardhonorsthededicationandcontribu-tionsofDr.JeffreyB.Coopertopatientsafety.Dr.CooperisaProfessorofAnaesthesia,HarvardMedicalSchool,andtheExecutiveDirectoroftheCenterforMedicalSimulation.Theintentistoannuallyrecognizetheexemplarycontributionsofanindividualmemberofthedepartmenttotheprovisionofsafepatientcare.Anothergoaloftheawardistofosteracultureofsafetyamongthemembersofthedepartment:What can you do to promote safe patient care?”

Eligible persons included members of theDACCPMattendingstaff,clinicalfellows,residents,nurseanesthetists,criticalcare/monitoringnurses,anesthesiatechnicians,andbiomedicalengineers.CandidateswerenominatedbaseduponhowtheirpracticeexemplifiesDr.Cooper’sidealsforpatient

Dr. John Walsh Receives MGH Annual Cooper Patient Safety Award

Dr. Robert Peterfreund (right), Department Quality Assurance Committee Chair, presents the award to Dr. John Walsh.

Editor’s note:

If your department or organization recognizes patient safety efforts with an award of any kind, please let the APSFNewsletterknow.

Dr. Robert Peterfreund (right), Department Quality Assurance Committee chair, presents the award to Dr. John Walsh.

throughaseparatesupplier.Itwasbroughttoouroperatingroomsuitestoshowasurgeonwhowaslookingforanewmedicallubricant.Thevialwasleftintheroomforthesurgeontolookatafterhecom-pletedhiscase.DuringorafterthecaseitremainedintheORandwasevidentlymistakenforananesthesiamedication,asevidencedbyitsplacementonouranesthesiaPyxis®machine.OurhospitalhassincetakenstepstomakesureRotaglide®lubricantremainssecureduntilwefindasuitablereplacementthatisnotidenticaltopropofol.

Itwasnotallthatlongagothatwedidn'tlabelsyringesofpropofolbecauseitwastheonly"whitestuff."Ihopethisletterservesasaremindertoalwaysreadmedicationlabelspriortodrawingitup,asthingsarenotalwaysastheyseem.

Susan Duerr-Trebilcock, CRNA, MS


All That's White Isn’t Necessarily Propofol

Figure 1. Top panel is the front view of a vial of propofol (left) next to a vial of Rotaglide (right). Bottom panel is the back side of these vials.


Request for Applications (RFA) for the

Patient Safety Investigator Career Development Award Program

(DEADLINE DECEMBER 31, 2011)

APSF is soliciting applications for training grants to develop the next generation of patient safety scientists.

In this initial, proof-of-concept RFA, we intend to fund one ($150,000 over 2 years) Patient Safety Career Development Award (PSCDA) to the sponsoring institution of a highly prom-ising new patient safety scientist. Please see the APSF website

(www.apsf.org) to download the application.

by Jonathan V. Roth, MD

Optimizing At-A-Glance Monitoring

Fordetal.reportedthatanesthesiologistsfre-quentlylookatmonitorsforveryshortperiodsoftimesandhavecalledfordesignsthattakethisbehaviorintoconsideration.1Inthisspirit,monitorsthatdisplaytracesthatdonotmove(i.e.,thestaticwaveformsthatareover-writtenwitheachnewsweep),asopposedtowaveformsthatmoveacrossthescreen,mayhaveadvantagesthatshouldbecon-sideredinfuturedesigns.

As an example, the Datascope “Expert”(DatascopeCorporation,Paramus,NJ)haswave-formsthatdonotmoveacrossthescreen;thestaticwaveformsgetreplacedaseachnewsweepcomesby.Ittakesabout6secondsforeachsweepacrossthescreenoftheECG,pulseoximeter,andpressurewaveforms.Ittakesabout15secondsforthesweepofthecapnograph.IfonequicklycountstheECG,pres-sure,orpulseoximeterdisplayedwaveformsandmultipliesthatnumberby10,ormultipliesthenumberofcapnographwaveformsby4,onecancloselyestimatetherateperminute.Sometimesthereareartifactsthatcausethenumericaldisplaytobe

incorrect.Knowledgeofthesemonitorspecificrela-tionshipsallowsonetoquicklydeterminetheactualstateofaffairs.

Asexamples,theECGandpulseoximeterratesdisplayedmayeitherbeunobtainableorinerrorasaresultofadoublecountorartifact.Ifthisisnotrecog-nized,ithasthepotentialtoleadtowrongtreatment.Thisauthorhaswitnessedasituationwheretheactualheartratewas55beatsperminute,boththepulseoxandECGweredoublecountinganddisplay-ingarateof110,andabetablockerwasadministered.Withmovingwaveforms,itwouldseemthatitwouldmoredifficultforpractitionerstolearnthatagivendistancebetweenmovingcomplexesequatestoagivenrateoverarangeofrates.Therespiratoryratedisplayedontheventilatorsystemmaybefalselyelevatediftheventilatorysystemisrecognizingcar-diacoscillationsasbreaths.Thisauthorhaswit-nessedapatientwithanactualrespiratoryrateof12breathsperminute,theventilatordisplayingarateof34becauseitwascountingcardiacoscillations,andanopioidnarcoticwasadministered.

Anotheradvantageisthatifoneneedsadisplaytobestaticinordertocloselyexaminesomefeatureofawaveform,itmaybeeasierandfastertolookatanon-movingdisplaythanonethatismoving.Monitorswithamovingdisplayrequireatleastoneextrastepin

Monitor Displays: Non-Moving Waveforms May Be Superior to Moving Waveforms


Disposing of MedsTo the Editor:

IreadDr.Terman'sarticle"OpioidPrescribing:REMSSleep,NeedReawakening"fromthespring/summerissuewithkeeninterest.Iamanon-medicalpersonmarriedtoananesthesiologistwhoisactiveintheASA.Withthesupportofourstatemedicalsoci-ety,ourallianceofphysician'sspousesstartedaSafeDisposalofMedicineprojectoverayearago.Wehavebeenprovidinginformationalmaterialtoourphysi-ciansandtheirpatientsabouthow,where,andwhytosafelydisposeofunneededmedication.Wearealsostressingtheimportanceofsecurestorageofmedi-cineandnevergivingsomeonemedicinenotpre-scribedforthem.Wehavefoundthatalargeportionofdrugabusecanbeattributedtoteenagerstakingmedicinetheyfindintheirhomesandsellingitorsharingitwiththeirfriends.Iapplaudyoureffortstoworkonthisimportantsafetyissue.Pleaseletmeknowifourorganizationcanbeofanyhelpwithyourefforts.

Michele KalishImmediate Past President, Alliance to MedChi The Maryland State Medical SocietySafe Disposal of Medicine Project, Chair

ordertofreezethemovingdisplay.Whetherornotapractitionerismorelikelytorecognizeanabnormalityonastaticdisplaythanonamovingwaveformisaquestionthatwillrequirefurtherstudy.

Insummary,itseemspossibleorlikelythatitiseasierandfasterwithastaticwaveformsystemtorecognizeanabnormalwaveform,orthatthenumeri-caldisplayisincorrect,andobtainamoreaccuraterate.AswiththeExpertsystem,sweepspeedsshouldbesetsothataminuteratecanbeobtainedbyawholenumbermultipleofthenumberofwaveformsdisplayed.Futurestudieswillberequiredtosupporttheaboveopinion.

Reference

1. FordS,BirminghamE,KingA,LimJ,AneserminoM.At-a-glancemonitoring:covertobservationsofanesthesiolo-gistsintheoperatingroom.AnesthAnalg2010;111:653-8.

Jonathan V. Roth, MDAssociate Professor of AnesthesiologyDepartment of AnesthesiologyAlbert Einstein Medical CenterThomas Jefferson School of MedicinePhiladelphia, PA

®

APSF NEWSLETTER Fall 2011

Anesthesia Patient Safety FoundationBuilding One, Suite Two8007 South Meridian StreetIndianapolis, IN 46217-2922

NONPROFIT ORG.U.S. POSTAGE

PAIDWILMINGTON, DEPERMIT NO. 674

In this issue:

Featured Article:

“No Patient Shall Be Harmed By Opioid-Induced Respiratory Depression”

Also:

Tribute to Jeep Pierce Dear SIRS: Reusable Anesthesia Breathing Circuits Considered

Threshold Monitoring, Alarm Fatigue, and the

Patterns of Hospital Death

no patient harmed from post-op opoids

Documents

cooper patient safety

druginducedr patient

threshold monitoring

electronic monitoring

alarm fatigue

dear sirs

monitor displays

john walsh