A single consent for serial anesthetics in burn surgery.

Obtaining anesthesia informed consent for a series of repetitive debridements in burn-injured patients requires a significant time investment for anesthesiologists and patient families. A single consent form was introduced that covered multiple related anesthetics in burn patients. The number of consents per patient before and after implementation was analyzed using Welch ANOVA; Tukey-Kramer post hoc test, with 99% confidence intervals for mean differences was used to examine pairwise comparisons. The mean number of consents per patient was 4.5 ± 2.8 and 1.6 ± 0.51 (P < 0.001) before (2010) and after implementation (2013), respectively. The Multiple Related Anesthetics Consent Form in this population resulted in less time spent by anesthesia providers in obtaining consent for patients undergoing multiple related procedures while providing patient- and family-centric care.

Anesthesiology leadership rounding: identifying opportunities for improvement.

INTRODUCTION: Rounding that includes participation of individuals with authority to implement changes has been advocated as important to the transformation of an institution into a high-quality and safe organization. We describe a Department of Anesthesiology's experience with leadership rounding. METHODS: The Department Chair or other senior faculty designate, a quality coordinator, up to four residents, the ward charge nurse, and patient nurses participated in rounds at bedsides. RESULTS: During a 23-month period, 14 significant opportunities to improve care were identified. Nurses identified 5 of these opportunities, primary team physicians 2, the rounding team 4, and patients or their family members another 3. The anesthesiology service had sole or shared responsibility for 10 improvements. CONCLUSION: A variety of organizations track specific measures across all phases of the patient experience to gauge quality of care. Chart auditing tools for detecting threats to safety are often used. These measures and tools missed opportunities for improvement that were discovered only through rounding. We conclude that the introduction of leadership rounding by an anesthesiology service can identify opportunities for improving quality that are not captured by conventional efforts.

Automatic computerized endotracheal tube position verification: an animal model evaluation.

BACKGROUND: Improper endotracheal tube positioning carries a high risk for morbidity and mortality; verification and confirmation of correct placement is necessary. We propose a computer-automated identification of endotracheal tube positioning using image analysis. The end product will not retain a monitor; rather, the acquired image will be automatically analyzed by a mini electronic processor. METHODS: An algorithm that automatically analyzes images has been developed: it classifies images into esophagus, trachea, and carina. Image processing includes converting the image to grayscale and extracting and classifying into 1 class, on the basis of similarity to pretrained patterns. A prototypical video sensor mounted on an intubating stylet has also been assembled. This stylet was introduced into 10 bovine throats, and video images were gathered. Videos were analyzed and classified as carina, trachea, or esophagus. The videos were then introduced to the new algorithm. In each test cycle, 9 videos were used to train the algorithm, and the 10th was used as a benchmark. This procedure was repeated 10 times so that each video was used 9 times for teaching and 1 time for testing. RESULTS: Ten videos were recorded, of which 1600 images were extracted (trachea: 490 images; carina: 550 images; and esophagus: 560 images). Only 1 esophageal image was classified as trachea (false positive 0.001%). Two carinal images and 22 tracheal images were recognized as esophagus (false negative 0.041%), sensitivity 0.98 and specificity 0.99. Twenty images of the carina were identified as trachea, and 25 images of the trachea were identified as the carina (false positive 0.045%, false negative 0.041%, sensitivity 0.96 and specificity 0.95). CONCLUSION: A potential tube position verification system was assessed. High accuracy of the analysis algorithm was shown using nonperfused biological tissue, justifying further research.

Supplemental oxygen compromises the use of pulse oximetry for detection of apnea and hypoventilation during sedation in simulated pediatric patients.

OBJECTIVE: The goal was to assess the time to recognition of apnea in a simulated pediatric sedation scenario, with and without supplemental oxygen. METHODS: A pediatric human patient simulator mannequin was used to simulate apnea in a 6-year-old patient who received sedation for resetting of a fractured leg. Thirty pediatricians participating in a credentialing course for sedation were randomly assigned to 2 groups. Those in group 1 (N = 15) used supplemental oxygen, and those in group 2 (N = 15) did not use supplemental oxygen. A third group (N = 10), consisting of anesthesiology residents (postgraduate years 2 and 3 equivalent), performed the scenario with oxygen supplementation, to ensure validity and reliability of the simulation. The time interval from simulated apnea to bag-mask ventilation was recorded. Oxygen saturation and Paco(2) values were recorded. All recorded variables and measurements were compared between the groups. RESULTS: The time interval for bag-mask ventilation to occur in group 1 (oxygen supplementation) was significantly longer than that in group 2 (without oxygen supplementation) (173 +/- 130 and 83 +/- 42 seconds, respectively). The time interval for bag-mask ventilation to occur was shorter in group 3 (anesthesiology residents) (24 +/- 6 seconds). Paco(2) reached a higher level in group 1 (75 +/- 26 mmHg), compared with groups 2 and 3 (48 +/- 10 and 42 +/- 3 mmHg, respectively). There was no significant difference between the groups in oxygen saturation values at the time of clinical detection of apnea (93 +/- 5%, 88 +/- 5%, and 94 +/- 7%, respectively). CONCLUSIONS: Hypoventilation and apnea are detected more quickly when patients undergoing sedation breathe only air. Supplemental oxygen not only does not prevent oxygen desaturation but also delays the recognition of apnea.

Aestiva ventilation mode selector switch failures.

We describe three cases of previously unreported failures of the Bag-Ventilator Switch in Aestiva/5 anesthesia machines (GE Healthcare/Datex-Ohmeda, Madison, WI). Each failure mode produced a large breathing-circuit leak. Examination of the switches revealed a cracked toggle actuator, residue build-up, and a cracked selector switch housing as causes for the failures. When a leak with no visible cause develops, consider advancing the mode selector switch fully to its mechanical limit or consider that the toggle actuator or its anchoring mechanism may have failed. These cases demonstrate that it is imperative to always be prepared to immediately use an alternate method for ventilation. Cases describing failure to ventilate due to sudden equipment malfunction underscore the need to always have functioning backup ventilation equipment available.

Airway management of patient with Smith-Lemli-Opitz syndrome for gastric surgery: case report.

A case of term, 5-day-old boy, with low birth weight of 2.4 kg, with Smith-Lemli-Opitz syndrome (SLOS) who was first scheduled for gastrostomy tube placement and later for pylorotomy, is discussed. General appearance of face and small chin showed possible difficulties during intubation, which are well known from the literature. Anesthetic plan included possibility of fiberoptic intubation. Mask induction and ventilation had been successful but attempts to intubate patient using fiberoptic bronchoscope had not been feasible and both procedures had been performed using laryngeal mask airway (LMA#1) with spontaneous ventilation without complications. In this case, we are showing the ability to secure the airway in a small infant with SLOS using LMA and the possibility to perform successfully surgery on the gastrointestinal tract.

Reducing the incidence of surgical fires: supplying nasal cannulae with sub-100% O2 gas mixtures from anesthesia machines.

In June 2003, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) recommended: "As a general policy, use air or FiO2 at < or =30% for open delivery (consistent with patient needs)" to prevent surgical fires. One way to interpret JCAHO's recommendation is that 100% O2 should not be indiscriminately used, and anesthesia providers should have the ability, consistent with patient needs and their clinical judgment, to deliver sub-100% O2 with nasal cannulae. An auxiliary O2 flowmeter has a barbed outlet connector that offers a convenient means to connect a cannula to an anesthesia machine and is routinely used for open delivery of 100% O2. The auxiliary O2 flowmeter provides only 100% O2 and thus does not allow titration of the O2 concentration to patient needs and may increase the risk of surgical fires. This report clarifies the JCAHO recommendation and describes different means of addressing it that are based primarily on using the anesthesia machine to blend a sub-100% O2 gas mixture and delivering it via a nasal cannula. The options presented depend on the model and manufacturer of the anesthesia machine and allow delivery via nasal cannula of O2 concentrations that range from 21% to 100%.

The Stealth Station Image Guidance System may interfere with pulse oximetry.

PURPOSE: Interference on pulse oximetry can come from many sources. We found an additional source of interference from the Stealth Station. This article gives an overview of sources of pulse oximeter interference so that clinicians can better prevent them. Technical features: This article discusses the infrared disturbances caused by the Stealth Station. The Stealth Station is a frameless stereotactic positioning system that utilizes a three dimensional location system to measure the position of the patient and the surgical tools, and to relate those positions to previously recorded imaging. To understand the disturbance caused by the Stealth Station, we discuss its operation and that of pulse oximeter monitors. Pulse oximeter interference can come from volume artifacts, electrical and light noise, and can be caused by issues related to the patient. Because the passive Stealth Station contains a strong infrared light source, interference caused by light is a likely reason for the interference we noted. Pulse oximeters rely on the time-variant light signal modulated by arterial volume variations in the finger. Although relatively immune to static light sources, pulse oximeters are extremely sensitive to time-varying light sources. The light emitted by the passive Stealth Station is time-varying at 4 Hz and this is causing the pulse oximeter to provide invalid results. Shielding can generally be used to stop the light from the Stealth Station from being picked up by the pulse oximeter sensor. CONCLUSION: Infrared light interference can be very common, but is easily dealt with if one is aware of it.

The presence of working memory without explicit recall in a critically ill patient.

UNLABELLED: We describe an intubated patient sedated with propofol who interacted with caregivers, demonstrating intact "working memory." When neuromuscular blockade and bispectral index (BIS) monitoring were instituted, a greatly reduced amount of sedative achieved BIS values less than 60. Neither the sedation that allowed working memory nor the lighter sedation that produced BIS values less than 60 resulted in recall. This experience suggests that working memory demonstrated when BIS values are less than 60 is unlikely to lead to recall. IMPLICATIONS: The presence of intact working memory during sedation is a poor predictor of explicit recall when bispectral index values are maintained less than 60.

Alternative management techniques for the difficult airway: optical stylets.

PURPOSE OF REVIEW: We present the newest devices being promoted for difficult-airway management. Our focus is on optical stylets which offer a forward view from the stylet end positioned within the tip of the endotracheal tube. RECENT FINDINGS: Reports suggest that these devices are mastered quickly and offer effective airway management aid. Available in adult and pediatric sizes they are economically priced at approximately US$ 3000. SUMMARY: Generally favorable experience with use of optical stylets continues to be reported. Our survey of clinicians' opinions reflects our own experience; these devices are unique and are attractive adjuncts to standard- and difficult-airway carts.