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NEWSLETTERwww.apsf.org The Official Journal of the Anesthesia Patient Safety Foundation

®

Ioanna Apostilidou, MD, and Richard C. Prielipp, MD

Hyperglycemia and glucose intolerance arecommon manifestations of perioperative stress inmany hospitalized patients. Diabetic patients havemore frequent, more prolonged, and more expen-sive hospital admissions that result in increasedmorbidity and mortality than nondiabetics. Diabeticpatients also require more frequent surgical inter-ventions and are more often admitted to the inten-sive care unit (ICU). Moreover, it is common foreven nondiabetic surgical and ICU patients todevelop acute hyperglycemia during stress. Thishyperglycemia is mediated by the release of proin-flammatory cytokines (e.g., TNF-alpha and IL-6)and elevated concentrations of catecholamines,growth hormone, glucagon, and glucocorticoids.1

These mediators induce metabolic alterations incarbohydrate balance that alter peripheral glucoseuptake and utilization, increase gluconeogenesis,depress glycogenesis, and induce glucose intoler-ance and insulin resistance.

Hyperglycemia produces deleterious effects onthe immune system, neutrophil function, and on theresponse to endotoxin. As a consequence, acutehyperglycemia adversely affects patient outcomes.Diabetic patients undergoing cardiac surgery man-aged with tight perioperative glycemic control havea lower rate of sternal wound infection and hospitalmortality.2-4 In a large nonrandomized study, 2,467diabetic cardiac surgical patients were classified in2 sequential groups, the control group with“usual” sliding scale insulin glucose control and thestudy group with continuous intravenous insulininfusion to maintain blood glucose <200 mg/dL.2

Continuous insulin infusion resulted in lower glucose levels and was associated with significantly

lower incidence of sternal wound infection (0.8 vs.2%) and lower postoperative mortality (2.5 vs.5.3%). In a subsequent analysis of 4,864 diabeticpatients who underwent open-heart procedures,the investigators reported that a 3-day continuousinsulin infusion that kept glucose levels <150 mg/dLwas a key factor in improved outcomes.4 Modulationof the metabolic state during cardiac ischemiaand inhibition of lipolysis by insulin stimulatesnitric oxide production and may confer cardiac pro-tection. For instance, in a prospective randomizedstudy of 141 coronary artery bypass graft (CABG)patients, Lazar and colleagues found that tightglycemic control (serum glucose, 125-200 mg/dL)decreased the incidence of recurrent wound infec-tions, episodes of recurrent ischemia, atrial fibrilla-tion, and postoperative length of stay.5 Outcome inpatients without diabetes undergoing cardiacsurgery also improve with tight glycemic control.6-9

An increase of only 20 mg/dL in the mean intraoper-ative glucose was linked to an increase of more than30% in adverse outcomes.8

ICU and Similar Patient GroupsNumerous prospective, randomized trials con-

firm that maintenance of normoglycemia in criticallyill patients (plasma glucose between 80-110 mg/dL)improves ICU outcomes.6-14 Euglycemia can beachieved in ICU patients with insulin infusionprotocols and reduces

• ICU mortality (-32%)• in-hospital mortality (-34%)• serious infections rate• onset of acute renal failure• neuropathy • duration of ventilatory dependence.10,11

While these benefits are more difficult to docu-ment in medical ICU patients,12 it is clear that appro-priate use of insulin decreases complications fromhyperglycemia associated with the response to acutedisease, with or without a direct impact on the pri-mary disease process itself.12-14

Other patients with acute illness and hyper-glycemia are also at risk. The Diabetes and Insulin-Glucose Infusion in Acute Myocardial Infarction(DIGAMI 1) study revealed that intensive glycemiccontrol during the peri-infarction period reducedlong-term mortality rate (1 year, -28%; 3.4 years, -25%).15 That benefit was evident regardless of theantidiabetic regimen used (DIGAMI 2) emphasizingthe importance of maintaining euglycemia.16 Acutestroke patients have higher mortality rates and poorerrecovery when blood glucose exceeds 110 mg/dL.17

Thus, evidence supports the use of aggressiveinsulin protocols to manage hyperglycemia inpatients admitted to acute care hospitals formyocardial infarction, stroke, those with a previousdiagnosis of diabetes, and those patients undergoingsurgery.18, 19

Management CaveatsTight glucose control demands frequent measure-

ment (at least hourly initially) of glucose concentrationand a consistent approach to management. Ideally, a glucose control protocol must fulfill these criteria:

1. Ability to make rapid, precise, consistent modi-fications in blood sugar

2. Ability to maintain, increase, or decrease bloodsugar depending on clinical situation

3. Ability to monitor glucose levels quickly, closeto real time with trend detection to allow pre-emptive glucose management. (See the appen-dix on page 26 for a protocol example from theUniversity of Minnesota.)

The risk of hypoglycemia and difficulty ofattaining normoglycemia with a tight glycemic con-trol protocol is an important safety concern in bothcardiac and other ICU patients.20 In 2 recent studies,a novel approach, the hyperinsulinemic normoglycemicclamp technique, achieved normoglycemia even during

See “Hyperglycemia,” Page 23

Inside:Team Training in Obstetrics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Page 24Line Isolation – Dear SIRS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Page 28Malignant Hyperthermia Death . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Page 32Letters to the Editor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Pages 35 – 37Oxygen Regulator Fires . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Page 38

Volume 21, No. 1, 21-40 Circulation 80,350 Summer 2006

Perioperative Hyperglycemia Raises RisksInflammation/Hormones Increase Adverse Outcomes

APSF NEWSLETTER Summer 2006 PAGE 22

by Robert C. Morell, MD

The American Society of Anesthesiologists haspublished a recent Practice Advisory pertaining topostoperative visual loss associated with spinalsurgery. The purpose of the advisory is to increaseawareness of permanent impairment and/or totalloss of sight associated with spinal surgery per-formed under general anesthesia. Anteriorischemic optic neuropathy, posterior ischemic opticneuropathy, and central retinal artery occlusion areall discussed in this practice advisory, which isavailable on-line at www.asahq.org and has also beenpublished in the June 2006 issue of Anesthesiology. Theadvisory is a report produced by the American Soci-ety of Anesthesiologists Task Force on PerioperativeBlindness and was approved by the ASA House ofDelegates on October 25, 2005. Primary findings of thetask force are summarized as follows:

“There is a subset of patients who undergo spineprocedures while they are positioned prone andreceiving general anesthesia that has an increased riskfor developing perioperative visual loss. This subsetincludes patients who are anticipated preoperativelyto undergo procedures that are prolonged, have sub-stantial blood loss, or both (high risk patients).”

“Consider informing high-risk patients thatthere is a small, unpredictable risk of perioperativevisual loss.”

“The use of deliberate hypotensive techniquesduring spine surgery has not been shown to be

associated with the development of perioperativevisual loss.”

“Colloids should be used along with crystal-loids to maintain intravascular volume in patientswho have substantial blood loss.”

“At this time there is no apparent transfusionthreshold that would eliminate the risk of periopera-tive visual loss related to anemia.”

“High-risk patients should be positioned so thattheir heads are level with or higher than the heartwhen possible. In addition, their heads should bemaintained in a neutral forward position (e.g., with-out significant neck flexion, extension, lateral flex-ion, or rotation) when possible.”

“Consideration should be given to the use ofstaged spine procedures in high-risk patients.”

Readers are encouraged to read the full docu-ment for detailed information on this importantadvisory, which includes specific information regardingthe methodology, application, sources and strength ofevidence, and limitations of this practice advisory.

Dr. Morell is the editor of this newsletter, ClinicalAssociate Professor of Anesthesiology, Wake ForestUniversity Health Sciences, Winston-Salem, NC, andAdjunct Clinical Associate Professor of Anesthesiology,University of Florida School of Medicine, Gainesville, FL.Dr. Morell is in the private practice of anesthesiology andresides in Niceville, FL.

NEWSLETTERThe Official Journal of the Anesthesia Patient Safety Foundation

The Anesthesia Patient Safety FoundationNewsletter is the official publication of the nonprofitAnesthesia Patient Safety Foundation and is publishedquarterly at Wilmington, Delaware. Annual contributorstatus: Individual – $100.00, Corporate – $500.00. Thisand any additional contributions to the Foundation aretax deductible. © Copyright, Anesthesia Patient SafetyFoundation, 2006.

The opinions expressed in this Newsletter are notnecessarily those of the Anesthesia Patient SafetyFoundation or its members or board of directors.Validity of opinions presented, drug dosages,accuracy, and completeness of content are notguaranteed by the APSF.

APSF Executive Committee:Robert K. Stoelting, MD, President; Jeffrey B.

Cooper, PhD, Executive Vice President; George A.Schapiro, Executive Vice President; David M. Gaba,MD, Secretary; Casey D. Blitt, MD, Treasurer; Sorin J.Brull, MD; Robert A. Caplan, MD; Nassib G.Chamoun; Robert C. Morell, MD; Michael A.Olympio, MD; Richard C. Prielipp, MD.Newsletter Editorial Board:

Robert C. Morell, MD, Editor; Sorin J. Brull, MD;Joan Christie, MD; Jan Ehrenwerth, MD; John H.Eichhorn, MD; Lorri A. Lee, MD ; Rodney C. Lester,PhD, CRNA; Glenn S. Murphy, MD; Denise O’Brien,BSN, RN; Karen Posner, PhD; Keith Ruskin, MD;Wilson Somerville, PhD; Jeffery Vender, MD.

Address all general, contributor, and subscriptioncorrespondence to:Administrator, Deanna WalkerAnesthesia Patient Safety FoundationBuilding One, Suite Two8007 South Meridian StreetIndianapolis, IN 46217-2922e-mail address: [email protected]: (317) 888-1482

Address Newsletter editorial comments, questions, letters, and suggestions to:Robert C. Morell, MDEditor, APSF Newsletterc/o Addie Larimore, Editorial AssistantDepartment of AnesthesiologyWake Forest University School of Medicine9th Floor CSBMedical Center BoulevardWinston-Salem, NC 27157-1009e-mail: [email protected]

www.apsf.org

®

A Statement by the ExecutiveCommittee of the APSF

From time to time, the Anesthesia Patient Safety Foundation reconfirmsits commitment of working with all who devote their energies to makinganesthesia as safe as humanly possible. Thus, the Foundation invites col-laboration from all who administer anesthesia, all who supply the tools ofanesthesia, and all who provide the settings in which anesthesia is prac-ticed, all individuals and all organizations who, through their work, affectthe safety of patients receiving anesthesia. All will find us eager to listento their suggestions and to work with them toward the common goal ofsafe anesthesia for all patients.

ASA Publishes Practice Advisoryfor Perioperative Visual LossAssociated with Spine Surgery


periods of especially high stress such as cardiacsurgery. This technique involves a fixed, relativelyhigh-dose infusion of insulin and then uses a variablerate of glucose infusion to “clamp” the blood glucoseconcentration at an appropriate level.21-23 However, thismethodology is incredibly labor and time intensive too.

Although the methodology for administeringinsulin and glucose may be debated, the clinical end-point is not. The American College of Endocrinologyposition statement recommends maintaining bloodglucose ≤110 mg/dL (<6.1 mM) in intensive carepatients to decrease perioperative complications andin-hospital morbidity and mortality.24 Most insulinprotocols for ICU patients target glucose levels in thephysiologic range of 80-110 mg/dL.10-12 However, westill need to elucidate the exact biochemical mecha-nisms by which the benefit of normoglycemia isactually conferred.6 Indeed, although insulin is theprimary agent available to lower blood sugar,recently available pharmacologic agents, such as theincretin mimetics, amylin and exenatide, which canactually lower glucagon release, may confer meta-bolic advantages distinct from insulin treatmentalone. Other strategies to ameliorate the periopera-tive “stress response” in surgical patients includeinterventions like epidural or spinal blockade toreduce catecholamine secretion and improve insulinresponsiveness.

In summary, we believe that whenever hyper-glycemia and/or insulin resistance occur, earlydetection and effective insulin therapy is indicated.Clearly, the potential of hypoglycemia remains themost serious safety issue. Recent clinical reportssuggest hypoglycemia may be associated wtih mul-tiple factors, including misunderstanding of theinsulin administration protocol, rebound responsefrom concomitant intravenous bolus of corticos-teroids, and other complex insulin and drug-patientinteractions. Therefore, there is intense interest incontinuous glucose level monitoring technology,which promises a means of avoiding, undiagnosedand untreated hypoglycemia. We also await thefindings of additional important clinical studiesregarding these issues.25

Dr. Apostolidou is Associate Professor of Anesthesiologyat the University of Minnesota in Minneapolis, MN. Dr. Prielipp is Professor and Chair of the Department ofAnesthesiology at that institution, and is also Chair of theAPSF Committee on Education and Training and amember of the APSF Executive Committee.

References1. Van den Berghe G. Dynamic neuroendocrine responses

to critical illness. Front Neuroendocrinol 2002;23:370–91.

2. Furnary AP, Zerr KJ, Grunkemeier GL, Starr A. Contin-uous intravenous insulin infusion reduces the incidenceof deep sternal wound infection in diabetic patients aftercardiac surgical procedures. Ann Thorac Surg1999;67:352–60.

3. Furnary AP, Gao G, Grunkemeier GL, et al. Continuousinsulin infusion reduces mortality in patients with dia-

betes undergoing coronary artery bypass grafting. J Thorac Cardiovasc Surg 2003;125:1007–21.

4. Furnary AP, Wu Y, Bookin SO. Effect of hyperglycemiaand continuous intravenous insulin infusions on out-comes of cardiac surgical procedures: the Portland Dia-betic Project. Endocr Pract 2004;10(Suppl 2):21–33.

5. Lazar HL, Chipkin SR, Fitzgerald CA, et al. Tightglycemic control in diabetic coronary artery bypass graftpatients improves perioperative outcomes and decreasesrecurrent ischemic events. Circulation 2004;109:1497–502.

6. Van den Berghe G. How does blood glucose control withinsulin save lives in intensive care? J Clin Invest2004;114:1187–95.

7. Latham R, Lancaster AD, Covington JF, et al. The associ-ation of diabetes and glucose control with surgical-siteinfections among cardiothoracic surgery patients. InfectControl Hosp Epidemiol 2001;22:607–12.

8. Gandhi GY, Nuttall GA, Abel MD, et al. Intraoperativehyperglycemia and perioperative outcomes in cardiacsurgery patients. Mayo Clin Proc 2005;80:862–6.

9. Doenst T, Wijeysundera D, Karkouti K, et al. Hyper-glycemia during cardiopulmonary bypass is an indepen-dent risk factor for mortality in patients undergoingcardiac surgery. J Thorac Cardiovasc Surg 2005;130:1144.

10. Pittas AG, Siegel RD, Lau J. Insulin therapy for criticallyill hospitalized patients: a meta-analysis of randomizedcontrolled trials. Arch Intern Med 2004;164:2005–11.

11. van den Berghe G, Wouters P, Weekers F, et al. Intensiveinsulin therapy in the critically ill patients. N Engl J Med2001;345:1359–67.

12. Van den Berghe G, Wilmer A, Hermans G, et al. Inten-sive insulin therapy in the medical ICU. N Engl J Med2006;354:449–61.

13. Krinsley JS. Association between hyperglycemiaand increased hospital mortality in a heterogeneous pop-ulation of critically ill patients. Mayo Clin Proc2003;78:1471–8.

14. Krinsley JS. Effect of an intensive glucose managementprotocol on the mortality of critically ill adult patients.Mayo Clin Proc 2004;79:992–1000. Aug;80(8):1101.

15. Malmberg K, Norhammar A, Wedel H, Ryden L.Glycometabolic state at admission: important riskmarker of mortality in conventionally treated patientswith diabetes mellitus and acute myocardial infarction:

long-term results from the Diabetes and Insulin-GlucoseInfusion in Acute Myocardial Infarction (DIGAMI)study. Circulation 1999;99:2626–32.

16. Malmberg K, Ryden L, Wedel H, et al.; DIGAMI 2 Inves-tigators. Intense metabolic control by means of insulin inpatients with diabetes mellitus and acute myocardialinfarction (DIGAMI 2): effects on mortality and morbid-ity. Eur Heart J 2005;26:650–61.

17. Capes SE, Hunt D, Malmberg K, et al. Stress hyper-glycemia and prognosis of stroke in nondiabetic and dia-betic patients: a systematic overview. Stroke2001;32:2426–32.

18. Umpierrez GE, Isaacs SD, Bazargan N, et al. Hyper-glycemia: an independent marker of in-hospital mortal-ity in patients with undiagnosed diabetes. J ClinEndocrinol Metab 2002;87:978–82.

19. Clement S, Braithwaite SS, Magee MF, et al; AmericanDiabetes Association Diabetes in Hospitals Writing Com-mittee. Management of diabetes and hyperglycemia inhospitals. Diabetes Care 2004;27:553–91.

20. Chaney MA, Nikolov MP, Blakeman BP, Bakhos M.Attempting to maintain normoglycemia during car-diopulmonary bypass with insulin may initiate postop-erative hypoglycemia. Anesth Analg 1999;89:1091–5.

21. Smith CE, Styn NR, Kalhan S, et al. Intraoperative glu-cose control in diabetic and nondiabetic patients duringcardiac surgery. J Cardiothorac Vasc Anesth 2005;19:201–8.

22. Carvalho G, Moore A, Qizilbash B, et al. Maintenance ofnormoglycemia during cardiac surgery. Anesth Analg2004;99:319–24

23. Coursin DB, Prielipp RC. The new anesthesia diet plan:keeping perioperative carbs in check. Anesth Analg2004;99:316–8.

24. Garber AJ, Moghissi ES, Bransome ED Jr, et al.; AmericanCollege of Endocrinology Task Force on Inpatient Dia-betes Metabolic Control. American College ofEndocrinology position statement on inpatient diabetesand metabolic control. Endocr Pract 2004;10:77–82.

25. Bellomo R, Egi M. Glycemic control in the intensive careunit: why we should wait for NICE-SUGAR. May ClinProc 2005;80:1546-1548.

Supports APSF ResearchAPSF gratefully acknowledges

the support of Cardinal Health Foundation in the full funding of a 2007 APSF Research Grant

that will be designated the APSF/Cardinal Health Foundation Research Award

“Hyperglycemia,” From Page 21

Methodology Might Be Debated, Clinical Endpoint Is Not

www.cardinal.com

See “Hyperglycemia,” Page 26


by Stephen D. Pratt, MD

The idea that medical errors and the adverseevents they cause are major public health concerns isnot likely to be news to readers of this Newsletter. Ithas been seven years since the Institute of Medicine(IOM) highlighted the fact that up to 98,000 Ameri-cans die every year due to medical errors.1 This placesmedical error as the leading cause of accidental deathin the United States, surpassing the combined totals ofmotor vehicle accidents, fire, and drowning. Sincethen, similar data have been found in the Canadianhealth care system, with in-hospital adverse eventsaccounting for between 9,200 and 24,000 deaths.2 Arecent report went so far as to suggest that limitinghealth care to the Medicare population may actuallyimprove mortality rates by decreasing the number ofmedical errors to which the elderly will be exposed.3

Many potential solutions to the problem of medicalerror have been proposed, including computerizedprovider-order-entry,4 site/side documentation forinvasive procedures,5 banning ambiguous abbrevia-tions,5 and many others. Teamwork, however, is per-haps the most recommended solution. Again, the ideathat teamwork has the potential to improve patientsafety is not news. The follow-up report from the IOMpublished in 2001, Crossing the Quality Chasm, recom-mended that health care teams better use the conceptsof Crew Resource Management (CRM) to improvecare.6 There have been small steps in the right directionover the ensuing 5 years. Team training has been asso-ciated with improved attitudes, behaviors, and out-comes. Grogan demonstrated that an 8-hour course onteamwork and CRM concepts can improve staff atti-tudes toward safety and teamwork,7 and the samegroup has found that team training has improvedpatient safety in the operating room (Seddon, personalcommunication). Morey et al. found that classroom-based team training effectively increased teamworkbehaviors and improved outcomes.8

Unfortunately, successfully implementing a team-work structure and changing the culture in which wepractice is still the exception rather than the rule.Many forces are impeding the shift to a new, team-based, medical paradigm, including the logistical andfinancial requirements of such a change, fears thatworking as a team might increase malpractice expo-sure, and even intransigence to change itself. How-ever, I believe there is a more fundamental factor atwork. I believe that most clinicians simply do notunderstand what “teamwork” would mean in themedical environment. They do not understand how amedical team would act differently from the waymedicine is currently practiced. Worse, since they donot know what the final product should look like,

they have no idea how to start to makes the changesthat would be necessary to get there. Although someliterature does exist,9,10 little has been publisheddescribing what teams do or what steps to take toimplement teamwork. As a result, even those whomight embrace the concepts of teamwork are oftenleft unable even start the process.

In an attempt to help to fill this gap in under-standing, the Society for Obstetric Anesthesia andPerinatology (SOAP) hosted a patient safety panel atits annual meeting in Hollywood, Florida, this year.Three national experts in medical teamwork trainingpresented the training methods the use to train theirstaff to be a team on their labor and delivery units.

Dr. Benjamin Sachs, Chairman of the Departmentof Obstetric and Gynecology at Beth Israel DeaconessMedical Center (BIDMC) and Professor at HarvardMedical School presented first. Dr. Sachs indicatedthat his department began a strong commitment topatient safety after a major adverse event in 2000.11

The training program used at BIDMC was developedin conjunction with the Department of Defense, Tri-care, and the American Institute for Research, andwith the help of such teamwork experts as EduardoSalas. Originally developed as part of a multi-centerprospective randomized trial on the effects of teamtraining on obstetric outcome, the training course hasgone through modifications based on the lessonslearned from the study and the most recent under-standing of what makes teams work well. The train-ing includes a 4-hour classroom-based trainingsession to teach the basic concepts of teamwork. Theseconcepts include Leadership, Situation Monitoring,Mutual Support, and Communication. The didactictraining is supported by the creation of 3 separatetypes of multidisciplinary teams. The first is the coreteam, those who administer direct patient care. Thesecond team is the coordinating team, a group thathelps to balance work loads and staffing, and isresponsible for ensuring that teamwork behaviorssuch as team meetings and briefings occur. The thirdteam is a pre-determined set of clinicians designatedto respond to emergencies, the contingency team.Well-defined tools and behaviors, including teammeetings and briefings, communication techniques,check lists, and feedback and conflict resolutionstrategies are used to remind staff how to act“teamly.” Finally, a structured implementationprocess helps to bring these concepts, behaviors, andpractices into the clinical environment. This imple-mentation process includes a deliberate schedule foradopting each new behavior, a strong coaching effort,strategies for dealing with resistance, and periodicreinforcement of the behaviors to sustain the changes.

Dr. Sachs presented data demonstrating a 25%decrease in major adverse outcomes in their obstetricpatients, with the best improvements coming in thehigh-risk preterm deliveries. In addition, his groupfound a nearly 50% reduction in malpractice casessince they implemented their teamwork system.

Dr. David Birnbach, Vice Chairman of the Depart-ment of Anesthesia and Director of the Center forPatient Safety at the University of Miami presentednext. His group uses a high-fidelity simulator at Jack-son Memorial Hospital to teach teamwork concepts.The simulation center at Jackson Memorial is state-of-the-art, costing more than $3 million annually inequipment and staffing. It includes an operating roomenvironment, complete with surgical and anesthesiaequipment, actors to play the obstetric and nursingstaff, and a “dummy” patient that can be manipulatedfrom a control room to simulate nearly any physio-logic perturbation. This realistic environment allowsstaff to be immersed in “real life” obstetric scenariosand requires that they use and practice their team-work skills. Dr. Birnbach showed multiple videotapesof actual cases from the simulator. These videos areused to debrief the sessions after the staff goesthrough the training. While clinical skills can betaught and honed in this environment, Dr. Birnbachindicated that the emphasis is on teamwork concepts,especially communication and resource management.Several of the scenarios depicted anesthesia staff get-ting into trouble and not even telling the rest of theteam about the problem or much less asking for help.The hope is that by seeing themselves make theseteamwork errors, staff will be able to change theirbehaviors and better use teamwork skills.

In a novel use of their simulator, Dr. Birnbach iscreating “best practice” scenarios. He has takenpatient complaints and re-enacted them in the simu-lator. Actors re-enact both the medical and interper-sonal problems as they were described by the patient.A second version of the scenario is then created thatdemonstrates a better way that the situation couldhave been handled.

Dr. Paul Preston was the third panelist. Dr. Preston is a staff anesthesiologist at the University ofCalifornia, San Francisco. He is a leader in developingteam training educational programs in the Kaiser Permanente system. After working with Dr. DavidGaba in the use of simulators to teach AnesthesiaCrisis Resource Management and Dr. MichaelLeonard in Humans Factors analysis and training, Dr.Preston has become an expert in teaching staff towork as a team. Dr. Preston presented a team-trainingmodel that incorporates both a classroom-based

SOAP Panel Advocates Team Training in Obstetrics

See “Team,” Next Page


education and simulated crisis management scenar-ios. The training is a 4-hour course. He starts with aquick review of human factors and CRM concepts.These include briefings, communications skills, asser-tion for safety, situation awareness, leadership, andresource management. He then brings staff throughsimulated emergencies. He has a relatively “low-tech”simulator that he is able to bring to the hospital beingtrained. Thus, staff are able to practice the crisis man-agement scenarios in their usual environment withtheir colleagues. The simulated cases are based on realcases that focus on potential or identified weaknessesin the system. He has more than 2 dozen obstetric andgeneral medical or surgical emergencies. He video-tapes these sessions and then debriefs the staff. Again,these debriefings focus on systems issues, communi-cation, and teamwork, and not clinical skills.

Based on the experience bringing this simulatedenvironment into many hospitals, Dr. Preston wasable to present some important lessons learned. Theseinclude some not-so-surprising facts (obstetricians areoften overloaded and do not communicate well),important leadership facts (nursing leaders areinvaluable in getting a “big picture” of the unit andhelping the obstetric providers maintain situationawareness), and even rather mundane practical facts(moving to the OR in a stat situation works best if thepiggybacked IVs are all unplugged, the epidural isplaced on the bed, and one person is in charge oftelling people when to go). Dr. Preston stated thatperhaps the most powerful effect of the team trainingis the consistent way that it encourages the cliniciansto come together to communicate and to fix problems.

A lively discussion and question and answerperiod followed the panelists’ presentations. In addi-tion, the Board of SOAP decided to create a patientsafety committee in order to ensure that future meet-ings include similar educational activities.

The 3 presenters on this panel have successfullybrought teamwork into their work environments.More importantly, they have created educational sys-tems that help clinicians to understand what team-work means in the medical environment and how togain the skills necessary to become a good teammember. The 3 systems are quite different, but eachincorporates the necessary components of CRM andhas been used successfully. One hopes that those inattendance returned to their practices with a betterunderstanding of what teamwork and CRM mean inmedicine and how they can be taught and imple-mented. With this important step, perhaps many

more units can make the necessary changes to a saferteam-based practice.

Dr. Pratt is an Instructor at the Beth Israel DeaconessMedical Center in Boston, MA.

References

1. Committee on Quality of Health Care in America, Instituteof Medicine. In Corrigan, Kohn, Donaldson (eds). To ErrIs Human: Building a Safer Health System. WashingtonDC: National Academy Press; 1999:26.

2. Baker GR, Norton PG, Flintoft V, et al. The CanadianAdverse Events Study: the incidence of adverse eventsamong hospital patients in Canada. CMAJ 2004;170:1678–86.

3. Dartmouth Medical School Center for the EvaluativeClinical Sciences. The Care of Patients with SevereChronic Illness. Dartmouth, NH: The Trustees of Dart-mouth College, 2006. Available online at:http://www.dartmouthatlas.org/atlases/2006_Chronic_Care_Atlas.pdf. Accessed June 5, 2006.

4. The Leapfrog Group. National Quality Forum EndorsedSafe Practices. Available online at: http://www.leapfrog-group.org/for_hospitals/leapfrog_safety_practices/nqf-safe_practices. Accessed June 5, 2006.

5. Staten PA. Patient safety: new goals set for 2003. NursManage 2003;34:14.

6. Committee on Quality of Health Care in America. Chap-ter 5 - Building Organizational Supports for Change.Crossing the Quality Chasm: A New Health System forthe 21st Century. Washington, D.C.: National Academy ofSciences, 2001:111-144.

7. Grogan EL, Stiles RA, France DJ, et al. The impact of avia-tion-based teamwork training on the attitudes of health-care professionals. J Am Coll Surg 2004;199:843-8.

8. Morey JC, Simon R, Jay GD, et al. Error reduction and per-formance improvement in the emergency departmentthrough formal teamwork training: evaluation results ofthe MedTeams project. Health Serv Res 2002;37:1553-81.

9. Curtis JR, Cook DJ, Wall RJ, et al. Intensive care unit qual-ity improvement: a "how-to" guide for the interdiscipli-nary team. Crit Care Med 2006;34:211-8.

10. Thompson D, Holzmueller C, Hunt D, et al. A morningbriefing: setting the stage for a clinically and operationallygood day. Jt Comm J Qual Patient Saf 2005;31:476-9.

11. Sachs BP. A 38-year-old woman with fetal loss and hys-terectomy. JAMA 2005;294:833-40.

Crew Resource Management Integral to Training“Team,” From Preceding Page

A birth in the Kaiser Simulator.

A snapshot of the control panel and “O.R.” in the simulator at Jackson Memorial Hospital.


GENERAL

Discontinue all currently active insulin orders.

Insulin infusions will be provided as 1 unit of regular insulin/mL in0.9% Sodium Chloride, in 30 mL syringes, unless otherwise requested.

If patients are on Parenteral Nutrition/Enteral Feeding, and they are held orcycled, contact MD for specific instructions regarding the insulin infusion.

If subcutaneous insulin (correction scale or scheduled) is ordered, discontinue the insulin infusion 2 hr after the 1st dose of Sub-Q insulin.

Discontinue this protocol when the patient has achieved glycemiccontrol, and is being transitioned to subcutaneous insulin or no longerrequires insulin therapy. See Transition Insulin Orders.

GLUCOSE MONITORING

Bedside glucose monitor (whole blood glucose) Q1H until glucose isstable within 80-110 mg/dL x 4, then Q2H until insulin infusion is dis-continued. If subsequent glucose values are outside the 80-110 mg/dLrange, measure whole blood glucose Q1H.

Obtain a STAT plasma glucose for changes in mental status,diaphoresis, or unexplained tachycardia.

INITIATION OF CONTINUOUS INSULIN INFUSION PROTOCOL

STEP ONE. For initial glucose value, start insulin infusion according toscale below:

Initial glucose value Action taken

111–140 mg/dL Start insulin infusion @ 1 unit/hour.

141–175 mg/dL Start insulin infusion @ 2 units/hour.

176 – 220 mg/dL Give 2 units IV bolus of regular insulin and startinsulin infusion @ 2 units/hour.

221– 300 mg/dL Give 4 units IV bolus of regular insulin and startinsulin infusion @ 3 units/hour.

301 – 400 mg/dL Give 10 units IV bolus of regular insulin and startinsulin infusion @ 4 units/hour.

INITIATION OF CONTINUOUS INSULIN INFUSION PROTOCOL, continued

STEP TWO. For 2nd blood glucose value, adjust insulin infusion according toscale below:

Second glucose value Action taken

<80 mg/dL Follow instructions for blood glucose value inStep Three.

80 – 110 mg/dL No changes. Continue current infusion rate.

111 – 400 mg/dL Increase insulin infusion BY 2 units / hour.

>400 mg/dL Notify MD.

STEP THREE. For all blood glucose values after the 2nd reading, adjust insulininfusion according to scale below:

Blood glucose value Action taken

<40 mg/dL Hold insulin infusion. Notify MD. Give 50 mL IVof Dextrose 50%. Recheck blood glucose in 15min. If <80 mg/dL, repeat 50 ml Dextrose 50%.If recheck glucose > 80 mg/dL, then restart insulininfusion at half previous rate.

40 – 59 mg/dL Hold insulin infusion. Give 25 mL IV of Dextrose50%. Recheck blood glucose in 15 minutes. If<80 mg/dL, repeat 25 mL of Dextrose 50%. Ifrecheck glucose >80 mg/dL, then restart insulininfusion at half previous rate.

60 –79 mg/dL Hold insulin infusion. Recheck blood glucose in1 hour. If <80 mg/dL, follow STEP 3 protocol. Ifrecheck glucose >80 mg/dL, then restart infusionat half previous rate.

80 – 110 mg/dL No changes if blood glucose stable within range.If blood glucose is fluctuating within range, titratein 0.5 unit increments based on patient responseto keep within range.

111 – 175 mg/dL Increase insulin infusion BY 0.5 – 1 unit/hour.

176 – 220 mg/dL Increase insulin infusion BY 1 – 2 units/hour.

221 –260 mg/dL Increase insulin infusion BY 2 – 3 units/hour.

261 – 300 mg/dL Increase insulin infusion BY 4 units/hour.



>400 mg/dL Notify MD

✔

✔

✔

✔

✔

✔

✔

“Hyperglycemia,” From Page 23

UMMC Continuous Intravenous INSULIN Infusion Orders; ADULT (>45 kg)

GOAL: Maintain glucose level between 80–100 mg/dL. Start protocol only if glucose >110 mg/dL x 2. This protocol is not to be used for patients in Diabetic Ketoacidosis (DKA).

MD SIGNATURE: ___________________________________________________________________ PAGER #:________________________ DATE: ____________________________

University of Minnesota Provides Protocol

Appendix 1: A continuous intravenous insulin infusion protocol from the University of Minnesota Medical Center.


Anesthesia Patient Safety FoundationCorporate DonorsFounding Patron ($500,000 and higher)American Society of Anesthesiologists (asahq.org)Sustaining Patron ($100,000 to $199,999)Anesthesia Healthcare Partners, Inc. (AHP) (ahphealthcare.com)

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Corporate Level Donors ($500 to $999)Belmont Instrument Corporation (belmontinstrument.com)Lippincott Williams and Wilkins

Participating AssociationsAmerican Association of Nurse Anesthetists (aana.com)

Subscribing SocietiesAmerican Society of Anesthesia Technologists and Technicians (asatt.org)

Community Donors (includes Anesthesia Groups, Individuals,

Specialty Organizations, and State Societies)

Grand Sponsor ($5,000 and higher)American Association of Nurse AnesthetistsAsheville Anesthesia AssociatesFlorida Society of AnesthesiologistsDr. and Mrs. Thomas R. HillIndiana Society of AnesthesiologistsIowa Society of AnesthesiologistsKrishnarao V. R. Pinnamaneni, MDRobert K. Stoelting, MD

Sustaining Sponsor ($2,000 to $4,999)Alabama State Society of AnesthesiologistsAmerican Academy of Anesthesiologist Assistants Anesthesia Associates of MassachusettsAnesthesia Consultants Medical GroupAnesthesia Resources ManagementArizona Society of AnesthesiologistsNassib G. ChamounGeorgia Society of AnesthesiologistsMadison Anesthesiology ConsultantsMassachusetts Society of AnesthesiologistsMichigan Society of AnesthesiologistsMinnesota Society of AnesthesiologistsFrank Moya Charitable FoundationOhio Society of AnesthesiologistsOld Pueblo Anesthesia GroupPennsylvania Society of AnesthesiologistSociety of Cardiovascular AnesthesiologistsTennessee Society of Anesthesiologists

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SurgeonsAmerican Society of Critical Care

AnesthesiologistsJ. Jeffrey Andrews, MDAnesthesia Associates of Northwest Dayton, Inc.Arkansas Society of Anesthesiologists

Association of Anesthesia Program DirectorsSorin J. Brull, MDCapital Anesthesiology AssociationFrederick W. Cheney, MDConnecticut State Society of AnesthesiologistsJeffrey B. Cooper, PhDSteve F. Croy, MDDavid M. Gaba, MDJohn H. Eichhorn, MDGreater Atlanta Society of AnesthesiologistsIllinois Society of AnesthesiologistsKentucky Society of AnesthesiologistsJohn W. Kinsinger, MDThomas J. Kunkel, MDRodney C, Lester, CRNAEdward R. Molina-Lamas, MDMadison Anesthesiology ConsultantsMaine Society of AnesthesiologistsMaryland Society of AnesthesiologistsMichiana Anesthesia CareMissouri Society of AnesthesiologistsRobert C. Morell, MDNebraska Society of AnesthesiologistsJohn B. Neeld, MDNorthwest Anesthesia PhysiciansNeshan Ohanian, MDNurse Anesthesia of MaineOklahoma Society of AnesthesiologistsOregon Society of AnesthesiologistsOregon Anesthesiology GroupPhysician Anesthesia ServicePittsburgh Anesthesia AssociatesSanta Fe Anesthesia Specialists Society of Academic Anesthesia ChairsSociety for Ambulatory Anesthesia Society of Neurosurgical Anesthesia and

Critical CareSociety for Pediatric AnesthesiaStockham-Hill FoundationTexas Society of AnesthesiologistsDrs. Mary Ellen and Mark WarnerWashington State Society of AnesthesiologistsWisconsin Society of Anesthesiologists

Sponsor ($100 to $749)Sean S. Adams, MD Robert Barth, MDManuel E. BonillaCalifornia Society of AnesthesiologistsRobert A. Caplan, MDCardiothoracic Anesthesia AssociatesCardiovascular Anesthesia, LLCMelvin A. Cohen, MDStuart M. Cohen, MDColorado Society of AnesthesiologistsDr. David ClementPaula A. Craigo, MDGlenn E. DeBoerJohn DesMarteau, MDNorig Ellison, MDJan Ehrenwerth, MDBasim I. Elhabashy, MDAnthony Frasca, MDB.L. Friedberg, MDThomas R. Farrell, MDGeorgia Anesthesia AssociatesIan Gilmour, MDBarry M. Glazer, MDGriffin Anesthesia AssociatesWilliam D. Heady, CRNAJames S. Hicks, MDDr. and Mrs. Glen E. HolleyVictor J. Hough, MDHoward E. Hudson, Jr., MDIndependence Anesthesia, Inc.Indianapolis Society of AnesthesiologistsRobert E. Johnstone, MDDaniel J. Klemmedson, DDS, MDKansas Society of AnesthesiologistsBettylou KoffelScott D. Kelley, MDAlan P. Marco, MDMaryland Association of Nurse AnesthetistsJohn P. McGee, MDMedical Anesthesiology Consultants CorporationMississippi Society of AnesthesiologistsRoger A. Moore, MD

Ervin Moss, MDNew Hampshire Society of AnesthesiologistsNew Jersey State Society of AnesthesiologistsNew Mexico Society of AnesthesiologistsL. Charles Novak, MDMark S. Noguchi, CRNADenise O’Brien, RNMichael A. Olympio, MDPennsylvania Association of Nurse AnesthetistsPhysician’s Accounts ReceivableMukesh K. Patel, MDGaylon K. Peterson, MDPhysician Specialists in AnesthesiaRichard C. Prielipp, MDRhode Island Society of AnesthesiologistsHenry Safford, CRNADrs. Chris and David SantamoreMuthia Shanmugham, MDSociety for Obstetric Anesthesia and PerinatologySouth County Anesthesia AssociationThe Woodlands Anesthesia AssociationUniversity of Maryland Anesthesiology

AssociatesUtah Society of AnesthesiologistsVermont Society of AnesthesiologistsVirginia Society of AnesthesiologistsMatthew B. Weinger, MDWest Virginia Association of Nurse AnesthetistsWest Virginia State Society of AnesthesiologistsDr. and Mrs. WetchlerLawrence Wobbrock, JDWest River Anesthesiology Consultants

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Note: Donations are always welcome. Send to APSF; c/o 520 N. Northwest Highway, Park Ridge, IL 60068-2573 (Donor list current through June 29, 2006)


Dear SIRS:Has there been a change in the recommended

use of line isolation monitors? We had an alarmtoday and we were told by our engineering depart-ment to essentially ignore it, as they are not evenbeing placed in new ORs. They say the equipmentmaintenance and use of ground fault circuit inter-rupters (GFCIs) has virtually eliminated any chanceof patient harm.

Could you update me on this, or point me to alink on how we should be approaching this issue in2006? Thanks so much.

Patrick Noud, MD

In Reply:

Dear SIRS:1) We are a Federal (VA) Hospital. About 11 years

ago we designed a new building that openedabout 9 years ago. We were told that isolatedpower was no longer required by code, but wecould choose it if we wanted to.

2) I chose isolated power in the OR because:

A) It is a passive safety system that does notdepend on an active component (GFCI) onevery circuit. It is built into the isolation fromground.

B) If a medical device has a first-fault, the circuitremains ON and all items on that circuit havethe same level of safety as with standard 3-wire circuitry AND you are alerted to a prob-lem; this is useful as other devices might stillbe on the same circuit. With a GFCI, the circuit“pops” to off so that all devices on it are with-out power. Further, you may not be immedi-ately aware as to whether the failure was dueto a ground fault or some other problem.

C) I myself would consider the OR a “wet loca-tion.” Most big cases have lots of blood andsaline squirted around, not to mention thepossibility of patient sweating, and rare cir-cumstances that are not usually wet couldbecome so in unusual situations. I think thatICUs could also fall into this category, butthey may not traditionally use isolated power.

3) My guess is that the cost differential is smallWHEN AMORTIZED over the lifetime of the ORsuite. I’m not sure that there isn’t more expensewith a building full of GFCIs in trouble-shootingthem and the like vs. an isolated line system.

4) I believe that in such matters knowledgeableclinicians should essentially have the final say, inconsultation with the engineers, not the otherway around. Building only to code may NOTnecessarily be the optimal thing for patient safety.

5) Even with an isolated power system, you doSTILL need to ensure that all devices have aground wire. This will handle (at least formacroshock protection) a double fault, as well asany leakage currents.

David Gaba, MDProfessor of AnesthesiaAssociate Dean for Immersive and Simulation-basedLearningStanford UniversityVA Palo Alto Healthcare System

Dear SIRS:First, the national requirements for isolated

power, and for ground fault interruption, come, tothe best of my knowledge, from the NFPA. Theapplicable standard is NFPA 99 - Standard for HealthCare Facilities 2005 edition, Chapter 4 - ElectricalSystems. The particular sections that are relevantto this discussion are 4.3.2.2.8 (Wet Locations),4.3.2.2.9 (Isolated Power Systems), and 4.3.2.6.3 (LineIsolation Monitors).

These standards are available on the NFPA website www.nfpa.org in "read only,” copyrightedformat. However, as I understand them for wet loca-tions, they require either isolated power systems, orground fault circuit interruption (GFCI); and it quali-fies GFCI to situations where power interruption istolerable (in the case of a short circuit).

Obviously, as you know, local and state stan-dards may vary from the NFPA. Finally, the ASAitself does not get more specific than to say, in its“Guidelines for Non-operating Room AnesthetizingLocations,” that “In any anesthetizing location deter-mined by the health care facility to be a ‘wet location’(e.g., for cystoscopy, arthroscopy, or birthing room in

Michael Olympio, MD, Chair of the APSF Committee on Technologyand Co-Founder of the Dear SIRS Initiative.

Dear SIRS refers to the Safety InformationResponse System. The purpose of this column is

to allow expeditious communication of technology-

related safety concerns raised by our readers, with

input and responses from manufacturers and

industry representatives. This process was devel-

oped by Drs. Michael Olympio, Chair of the Com-

mittee on Technology, and Robert Morell, Editor of

this newsletter. Dr. Olympio is overseeing the

column and coordinating the readers’ inquiries and

the responses from industry. Dear SIRS made its

debut in the Spring 2003 issue.

S AFETY

I NFORMATION

R ESPONSE

S YSTEM

Line Isolation Still ImportantDear SIRS

The information in this column is provided for safety-related educational purposes only, and does not constitute medical or legal advice. Individual or group responses areonly commentary, provided for purposes of education or discussion, and are neither statements of advice nor the opinions of APSF. It is not the intention of APSF to providespecific medical 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, directlyor indirectly, for any damage or loss caused or alleged to be caused by or in connection with the reliance on any such information.

See “Line Isolation,” Next Page


labor and delivery), either isolated power or electriccircuits with ground fault circuit interrupters shouldbe provided.”

I’ll copy this email to Dr. Jan Ehrenwerth, ourrepresentative to NFPA, for his additions or correc-tions. Thanks, and good luck with your OR con-struction!

Don Martin, MDChair, Committee on Equipment and FacilitiesAmerican Society of Anesthesiologists

Dear SIRS:I am happy to provide you with information about

isolated power and line isolation monitors (LIMs). Iam the ASA representative to NFPA, and have writ-ten and lectured on the subject many times. For refer-ence, please see my chapter (#8) on "Electrical Safety"in Barash's Clinical Anesthesia. In 1983, the NFPA(which sets most fire standards) removed the require-ment for isolated power and LIMs from ORs that donot use flammable anesthetic agents. This rule wasoriginally developed as a fire safety standard. There-fore, no explosion risk, no need to keep the rule. Itmade sense to them. What they did not account for,was the huge increase in electrical equipment, oftenwith very wet floors.

Note, however, that NFPA did not say, "Do notuse isolated power," but rather, "‘It is not required, butoptional."

Since isolated power is somewhat more expensive(the incremental cost is about $3000-5000 per OR),many hospitals have taken the shortsighted view toleave it out. Therefore, most ORs have no more elec-trical safety protection than your dining room. Evenyour kitchen and bath have GFCIs, which are betterthan nothing. I feel strongly that isolated powershould be retained. Hospital engineers are often mis-informed or wrong, and use made-up facts to supporttheir argument. As an example, at Yale University inthe past 10 years, we have built or remodeled 24 ORsand ALL HAVE ISOLATED POWER AND LIMs.

There are 2 ways to proceed, if you feel as I do,that this is an important safety feature. One is to say,"This is what we want, and we have to have it!" I feelthe better approach is for the Anesthesia and SurgeryDepartments to jointly declare that the ORs are WETLOCATIONS (the same as your kitchen or bathroom).This is easy to do: Think of cystoscopy, irrigationfluids, trauma blood loss, etc.). I am not sure what

code they are using that says ORs are not wet loca-tions. However, local practice can always overrule anational code, especially if one is going to a safersystem. I think that you have to be insistent on the ORbeing a wet location. Once that is accepted then theCODE states that they MUST use isolated power(LIMs) or GFCIs. GFCIs are generally felt not to beacceptable in ORs, because they cause interruption ofpower. This is fine in a bathroom, but in the OR it canbe hazardous. If the GFCI trips, the faulty piece ofequipment must first be identified and thenunplugged, before the circuit breaker can be reset.This is complicated by the fact that most new ORshave the circuit breaker panel located outside the OR,and it can be difficult to identify which panel controlsa given OR. The only safe way to use GFCIs in the ORis to make every electrical outlet its own branch cir-cuit. This is probably more expensive than isolatedpower.

In response to the question of responding to a LIMalarm – the answer is absolutely! The person who saidto ignore it should be sent back to school, or not beworking in an OR. The alarm is almost always signif-icant, if the LIM is a newer generation that alarms at 5milliamps. The very old LIM, which alarms at 2 mil-liamps, may give a false alarm. Obviously if you haveisolated power in the OR, you would not have a GFCIat the time.

It is important to fight this battle early in thedesign process, since once the walls are up, it is toolate and too expensive to change. I am happy to speakwith anyone about this at any time.

Jan Ehrenwerth, MDProfessor of AnesthesiologyYale University

Dear SIRS:The advantage of isolated power systems for crit-

ical locations in hospitals is that they provide safedependable power that is not interrupted by trips.Instead, the LIM gives an indication that there is aleakage problem before there is any loss of power. Theleakage is cumulative. When looking for the cause ofan alarm it's generally the last item plugged in! Thealarm threshold was increased from 2 Ma to 5 Ma in1978. If a system is experiencing a high number ofalarms it should be checked to assure that it is notusing the pre-1978 threshold. Mike Mahan, PE North Carolina Baptist HospitalWinston-Salem, NC

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“Line Isolation,” From Preceding Page

New ORs Should Have Isolated Power


Numerous questions to the Committee on Technology are individually and quickly answered each quarter by knowledgeablecommittee members. Many of those responses would be of value to the general readership, but are not suitable for the Dear SIRScolumn. Therefore, we have created this simple column to address the needs of our readership.

Dear Q&A:

In our operating rooms, we are exclusively usingDatex-Ohmeda vaporizers: isoflurane in Isotec 4 and5, sevoflurane in Sevotec 5, and desflurane in Tec 6.

Obviously, the agent in the vaporizer should bein date, but our question concerns the draining ofvaporizers at various intervals. The Datex-OhmedaTec 5 manual suggests draining the agent every 2weeks or an unspecified interval for agents withoutadditives. The Tec 6 apparently cannot be drained atall. We have never before drained our vaporizersand don't know of any other anesthesia departmentfollowing these guidelines. The effort, waste, andenvironmental issues are of concern to us, par-ticularly in regards to the recommended high fre-quency of drainage.

Any help regarding this issue is greatly appreci-ated, as we are now required to create a policy forour vaporizer maintenance.

Jay Jordan, MSN, CRNARowan Regional Medical CenterSalisbury, North Carolina

Dear Mr. Jordan:

We’ve discussed the issue of draining vaporiz-ers with people here in Madison. While the desflu-rane vaporizers are not meant to be drained in thefield, the other vaporizers may be drained. The UserReference Manual for Tec 5 and Tec 7 vaporizersstates:

Maintenance intervals:

Prior to performing any maintenance proce-dures or returning to a service center for repairs,clean and disinfect the vaporizer.

Every 2 weeks:

When the agent is low, drain the contents of thevaporizer into an appropriately marked containerand discard the agent. For halothane vaporizerscheck the output of anesthetic agent periodicallywith an agent monitor. See note below.

Note:

The decomposition of halothane causes therelease of halides, which may corrode metalcomponents particularly in the presence ofmoisture. Also, a preservative added tohalothane by its manufacturers to impededecomposition can leave a residue, which maycause vaporizer components to stick. Ifhalothane is used infrequently the vaporizershould be drained after use.

I’ve asked around and no one knows why therecommendation is the same for isoflurane,sevoflurane, and enflurane vaporizers as it shouldbe for halothane, except the common practice someyears back was to share vaporizers among manydifferent machines and all the user reference man-uals stem from one master manual addressingworst-case scenarios. With sharing vaporizers com-mon and with the possibility than any given vapor-izer may be sitting on a shelf someplace and notroutinely used, draining remained recommended;the user would not know how long a vaporizer wasstanding idle so the recommendation was asstated above. Most departments today have suffi-cient vaporizers to supply 1 for each machine.The issue remains, however, what is the quality ofthe agent in the vaporizer? Draining them periodi-cally and refilling them assures a more uniformproduct in the vaporizer. Of course the thymol issuewith halothane makes draining these vapor-izers advisable.

Thank you for your question.

The Committee on Technology

Dear Q&A:

How would you dispose of waste anesthesiaagent? I am a biomedical technician working for athird party company. I was asked this question by anadministrative officer in one of our client accounts.

Richard Shreve

Dear Mr. Shreve,

My answer would be to obtain advice from theengineering department of the hospital first, sug-gesting that you would like to use the hospitalevacuation system to "suction" the liquid (vapor)from the waste container. I would make this sugges-tion based upon the current method of scaveng-ing waste anesthetic gas, via suction and expulsionout the roof of the building, as I was told by our ownengineers. Would suction of the liquid itself be feasible and allowable by engineering?

• In the past we had built an evaporator for thispurpose that was connected to the hospitalscavenging system. The evaporator was anErlenmeyer flask into which the liquid agentwas poured. The rubber stopper for the flaskhad 2 glass tubes, one short one that barely wentthrough the rubber stopper that was connectedto hospital suction (suction and scavenging werethe same system in our hospital). The other glasstube was about 1/4 inch from the bottom of theflask and ran up through the rubber stopper andstuck up in the air, and sucked room air into theflask. This prevented liquid from entering thesuction system and in the case of halothane leftthe thymol in the flask (very low vapor pressure)as the halothane evaporated (keeping thymol outof the suction system is important). We were alsolocated at the end of the suction system so therewas flow from many sources to dilute theanesthetic gas from our evaporator. Thedifficulty is that some anesthetic agents,although not considered flammable, will burn ifmixed in correct proportions with oxygen ornitrous oxide – these are outside of the anestheticconcentrations of these agents. For example,sevoflurane is at the lower flammability level at11 volumes-percent in oxygen and 10 volumes-percent in nitrous oxide,1 far outside of the anes-thetic concentrations we use, but with a vaporpressure of approximately 200 mmHg at 25°Cand an efficient evaporator we can achieve maxi-mum concentrations of 26.3% at sea level. Typi-cally these concentrations from the evaporatorwill be diluted in the vacuum piping system such

NEW

The information provided in this column is for safety-related educational purposes only, and does not constitute medical nor legal advice. Individual or groupresponses are only commentary, provided for purposes of education or discussion, and are neither statements of advice nor the opinions of APSF. It is not the intentionof APSF to provide specific medical or legal advice or to endorse any specific views or recommendations in response to the inquiries posted. In no event shall APSF beresponsible 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.

See “Q&A,” Next Page

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

President: Robert K. Stoelting, MDAdministrator: Deanna M. Walker

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that very, very low levels of sevoflurane wouldreach the vacuum pump. Smaller hospitals mayhave difficulty with limited suction flow dilutiondepending upon the time of day that theevaporation was occurring.

• The other issue that has been receiving muchattention lately is the high oxygen concentrationsreaching oil-lubricated suction pumps andcausing flash fires and explosions that completelydestroyed the pumps.2 The addition of com-bustible concentrations of anesthetic agents mayrepresent serious hazards if attention is not paidto the physical characteristics of the suctionsystem. Some hospitals use separate high flowlow pressure scavenging systems that are not partof the suction system and may represent very littlehazard. My advice is to learn about yourscavenging system before your use a device likethe evaporator described above. The evaporatorhas the advantage that it uses air rather thanoxygen or nitrous oxide, but it will depend upondilution with other gases downstream that mayincrease the oxygen concentration butadditionally may further decrease the agentconcentration. The evaporator can be used safelyunder almost all circumstances.

• Pharmacy hoods are usually not evacuated butare pressurized to prevent contamination. Theyare similar to the positive pressure orthopedicrooms. I would also suggest that not all suction isevacuated in a safe fashion outside the buildingwith respect to inhalation agents. Some hospitals

have special evacuation paths to present theanesthesia waste where no one can breathe it.Regular suction may, or may not, be expelled in asimilar fashion. The NFPA has standards for theappropriate evacuation of waste anesthesiagases. Some appropriate waste gas systems maynot be able to handle liquid agent; rather theycan handle vapor. So that really leaves disposalof the agent by vaporizing into something that isevacuated according to the NFPA standards.

• Depending on where the waste agent resides I seea couple of possibilities.

1) Quick and dirty method: put it in a negativepressure vent – if available in the hospital.

2) Ask the manufacturer. In Germany and EUcountries, they have to provide guidelines fordisposal in the safety datasheets of the agents.Often it says there: Carry it to your next localcollection point for harmful substances.

Thank you.The Committee on Technology

References

1. Wallin RF, Regan BM, Napoli MD, Stern IJ. Sevoflurane:a new inhalational anesthetic agent. Anesth Analg1975;54:758-66.

2. Allen M, Lees DE. Fires in medical vacuum pumps: doyou need to be concerned? ASA Newsletter 2004;68(10).Available online at: http://www.asahq.org/Newslet-ters/2004/10_04/allen.html. Accessed June 19, 2006.

“Q&A”, From Preceding Page

NEW


by Henry Rosenberg, MD and Al Rothstein

The death of a young, vigorous, healthyindividual during routine surgery is an emotionallydevastating event. The family and friends of theperson are shocked, angry, depressed, beset by guilt,frustration, and thousands of questions. Was theresomething they could have done to prevent thedeath? Should the surgery have occurred? Didthe physicians and nurses miss something or act inappropriately?

These were the feelings and emotions experi-enced by the family and friends of Steven Nook,a 20-year-old athletic, affable, young man whodied following surgery to repair an injury to hisshoulder experienced during a skiing accident onJanuary 5, 2005.

Steven had so much to live for. He was a popularsophomore at University of Wisconsin-LaCrosse andaspired to be a physical education teacher and foot-ball coach. He made friends easily and was outgoing.

What happened and why did it happen? Stevendied as a result of malignant hyperthermia (MH) syn-drome, a rare reaction to commonly used anestheticagents. This syndrome, first recognized in1960, results from alterations to a specific gene.Unlike many other inherited (genetic) disordersthough, these rarely produce symptoms or signsuntil the patient receives a general anesthetic agent.It is like a viper lying in wait for the right circum-stances to strike.

In the 1960s and ‘70s the diagnosis of MH duringsurgery was a virtual death sentence; 80% of patientsdied after experiencing MH. However, thanks to theefforts of many anesthesiologists and other physiciansand scientists around the world, deaths from this dis-order now occur infrequently during or following the30 million or so anesthetics administered in the USevery year. Anesthesiologists and nurse anesthetistshave so many sensitive devices to monitor vital func-tions—respiration, oxygenation, cardiac function,temperature, and kidney function—that deathsrelated to anesthesia have become very uncommon,perhaps 1 in 250,000 healthy patients. Therefore,when a death occurs it is a shock and trauma to theentire anesthesia, operating room, and surgical teams.This story focuses on the short- and long-term reac-tions of the caregivers when a healthy patient suc-cumbs despite the best treatments available.

Where did the term MH come from? When thedisorder was first formally described, the dramaticand unusual feature of the reaction was an eleva-tion of body temperature to levels incompatiblewith survival—107-109°F or higher—in medicalterms, hyperthermia. Since 80% of patients diag-nosed with the disorder died, it was a malignantdisorder, hence the name. The reaction was especially

impressive because, as a rule, a patient’s body tem-perature has a tendency to drop during anesthesia.

The basic problem in MH is an increase in meta-bolic rate in response to most gas anesthetic agents,such as sevoflurane and desflurane, and a particu-lar paralyzing drug called succinylcholine. Furtherdetails concerning the mechanism of the increase inmetabolism may be found on the website of theMalignant Hyperthermia Association of the UnitedStates (MHAUS), a not-for-profit patient advocacygroup formed by a relative of a young man whodied from MH in 1981 (www.mhaus.org).

What has made death from MH a rarity at thistime? Three main factors: education of the anesthe-sia community to screen patients for family historiesof MH susceptibility and to recognize the earlysigns of MH, the routine measurement of exhaledcarbon dioxide (CO2 rises rapidly when metabolismincreases) and body temperature, and the US FDAapproval of dantrolene sodium IV for the treatmentof MH in 1979.

Dantrolene was indeed present in the OR whenSteven developed MH, and it was administered tohim rapidly and in sufficient doses; however, his casewas one of those very unusual circumstances becausethe development of full-blown MH occurred verylate, more than 3 hours into the surgery. Carbon diox-ide levels rose very slowly initially, and then racedahead explosively when the syndrome took hold. Ele-vation of body temperature, always a later sign ofMH, was especially late in his case. So, by the time theanesthesia team determined that MH was occurringand dantrolene should be given, the train had left thestation and was racing down the tracks. In fact, theantidote drug did retard the metabolic changes, butunfortunately damage to vital body functions hadtaken place and over the ensuing 2 days, and despiteheroic efforts, Steven’s coagulation system went awryand led to massive, uncontrolled hemorrhage.

Steven was not the stereotypical physical educa-tion major. He was not afraid to express himself inpoetry. For example,

People say, “I’m sorry” when I say I wasborn on 9/11. . .

But today is a day to be proud of. . .

Today, my birthday, America united

—“9/11” by Steven Nook

“The most shocking things were the subtle cluesthat this might be malignant hyperthermia (MH),”says Tami Ulatowski, MD, an anesthesiologist withSummit Anesthesiology group who was quickly

called in when the staff began to suspect that Stevenwas displaying signs of MH.

“The younger nurses thought of him as a peer, theolder nurses as their son,” remembers KathyDelleman, Intensive Care Unit Manager for AuroraSinai Medical Center in Milwaukee, WI. Dellemansays that it is unusual to identify so closely with apatient, but because of his age, personality, and skiingaccident, Steven had qualities that the staff couldidentify with.

One of the first steps that was taken once thediagnosis was made was to call a special “hotline”established in 1982 by MHAUS in order to helpanesthesia caregivers deal with the emergencymanagement of this complex disorder. This freeservice is staffed by approximately 30 anesthesiolo-gists expert in the management of MH. Three areavailable at any one time on a 24/7 basis.

Andrew Herlich, DMD, MD, was the MH Hot-line consultant at the time. Herlich is Professor ofAnesthesiology, Otolaryngology, and Pediatrics,and Medical Director of the Human SimulationCenter at the Temple University School of Medicine.Herlich was reassuring to Steven’s medical team andwas on the phone with them several times a day,having given them his personal home number andbeeper number. Dr. Herlich’s message was one ofsupport, advice, and reality.

“He told us not to be discouraged even thoughSteven’s temperature reached 109°,” says Dr. WilfridoCastillo, chief of the anesthesiology department atAurora Sinai. “We knew what we were up against,but because of Dr. Herlich’s guidance we knew thatwe were doing everything we could, and this pre-pared us in case of a bad outcome.”

“I tried to be strong and reassure Steven eachtime I was with him that he would get through this,”recalls Steven’s mother, Jacque Nook. “I believe heheard my voice and it gave him some comfort. Hemust have been so scared. It helped me to know thatthe monitor on his forehead (that measures the levelof consciousness) indicated that Steven was mostlikely aware of my voice. I rejoiced each time thenumbers on the monitor suggested that Steven washearing me. He knows his mother's voice! So I held ittogether as best I could, but I was screaming inside.”

The hospital staff was still hopeful that Stevenwould survive, but he wasn’t showing signs ofimprovement. “We felt helpless,” says Delleman. “Wewanted our interventions to work and they weren’t.”

A Devastated Medical StaffAs the situation worsened for Steven, it did the

same for the medical staff. Despite their professional-ism and disciplined approach from years of medical

Malignant Hyperthermia Death Holds Many Lessons

See “MH,” Next Page


training, an unfortunate MH death can have a devas-tating, personal effect. An effect that takes time tosurmount—one that motivates staff to recheck everymove, and in the end, look for new ways to preparefor another MH case.

Stephanie Kassulke was the anesthesia recoveryroom nurse and because she could identify so wellwith Steven, she was starting to have a difficult per-sonal time when she saw that Steven was notimproving. “When I went home that night, whenSteven was still alive, I was crying so hard in the carthat I almost had an accident. My kids are that age.They are young healthy kids. You put all of youreffort into it to help him make it, and you hope youwill get a miracle.”

Two days after Steven entered the hospital, hepassed away.

Dr. Herlich summarizes, “When Steven’s tem-perature precipitously rose in the OR, the anesthesi-ologist immediately called for help. He proceededto treat him by discontinuing the volatile anesthetic,cooling him by all means possible, administeringintravenous dantrolene, and correcting the meta-bolic abnormalities revealed by blood tests. However,over the ensuing hours after transfer to the intensivecare unit, Steven developed a severe bleeding prob-lem as well as a problem with heart function.”

“As a result of the stress of the MH, Stevendeveloped severe heart and kidney failure over thecourse of the next 2 days. The bleeding disorder wors-ened and was unresponsive to even the mostadvanced of therapies, including dialysis and theadministration of many medications and bloodproducts that stabilize blood clotting. During thisperiod, dantrolene was continuously administeredto maintain Steven’s temperature and bloodchemistries as close to normal as possible, whichwas obviously impossible.”

“They (the hospital staff) made every effort totell us what they were doing, how he was respond-ing, and give us any little hope they could muster,”remembers Mrs. Nook, herself a nurse. “However, Icould see the frustration in their eyes, when Stevenkept getting worse despite their efforts. Theywanted to see improvement as much as we did, andit didn't come.”

“When they called the code on Friday I knew itwas him,” says Kassulke. “When he died, I felt a lot ofanger.”

“This came out of nowhere,” says Delleman.“No warning.”

Before the procedure, his anesthesiologist hadquestioned Steven about whether there had beenany family history of adverse reactions to anesthesia.This question is part of the screening process for

MH and should be asked of all patients about toreceive a general anesthetic. In Steven’s case, theanswer to the question was no known family history.Many MH susceptibles have a benign family historyfor the disorder because MH does not manifest withevery exposure to anesthesia. This fact made the med-ical staff feel even more shocked, because they hadfollowed the proper screening procedure with Steven.

“The day he passed, there were a lot of tears,”says Delleman. “I don’t think there were a lot ofwords. There were more hugs and putting armsaround shoulders. Not everybody recovered in thesame way. Some were able to move on immedi-ately. For others, it was foremost in their mind.Some are still dealing with it several months later.”

“That following Sunday I went to church andcried through the sermon. I would be in the grocerystore and the thoughts would infiltrate. It happenedduring routine things.”

Delleman and Kassulke say that the medical staffwho have children close to Steven’s age had thetoughest time recovering. Delleman added, “I myselfhave a son a couple of years older. When I go home, Ilook at him in a different light. He had surgery a yearago and could have responded that way.”

Kassulke remembers, “I went home that night andI hugged both of my kids and told them I loved them.There were about 2 weeks when you sit down and cryright away just by thinking about it. What I have hadto deal with is the lack of control, watching this youngman slip through our fingers.

“I’m still having a hard time getting over it. Youknow in certain circumstances that there is nothingyou can do, but this wasn’t cancer or hemorrhaging.There was no previously known disease process tohelp you prepare for what might happen. I went backto work on Monday, but people were asking me whatwas wrong because I was down, subdued for awhile.”

In Remembrance, a child does not age

And so they never leave,

They’re in your heart at every stage

Of their life they weave.

—“Remembrance” by Steven Nook, December 2004

Dr. Castillo says that his main concern was withSteven’s anesthesiologist: “It was obvious he washaving a hard time. There is a decompression time,just like for a policeman or fireman involved in a crisisin the line of duty. He took some time off to be withhis family.”

Dr. Ulatowski says, “It’s the one thing anesthesi-ologists fear, the MH episode. I think it is everyanesthesiologist’s worst nightmare. To lose a

young, healthy patient in the OR in this day and age is virtually unimaginable, but that is what canhappen with MH.”

Dr. Herlich says that it can be much more shock-ing to a medical staff when a young, healthy manwalks into a hospital and does not walk out, than if a90-year-old with pre-existing conditions succumbs.Although saddened by that death as well, hesays medical professionals are not as emotionallyburdened because the patient has lived a full life, Her-lich states.

Dr. Castillo believes that most doctors feel theycan carry on after a situation like this, “but we need toadmit to ourselves that we are human, and we need torealize that we may not respond in the normal way inthe immediate future. We need to give ourselves timeto recover. Physicians should be honest with them-selves.” The same may be said for all those who carefor such patients.

Dr. Castillo initially had to push his own emo-tions aside, and let part of his recovery processinclude preparing for the next time this might hap-pen. “There are a lot of technical questions: Why didthis happen? What did we do? What could we havedone? Although I was not emotionally involvedbecause Steven was not my patient, I becameinvolved emotionally with the family later. I shed alot of tears when I sat down with the family, butone way I dealt with this was to be super prepared forsuch an event the next time.”

The close-knit Nook family itself was a source ofsupport for the hospital staff. Dr. Castillo remembersthat the staff and the family supported each other alot, the first time he had ever seen a family support astaff so strongly. The Nook family even e-mailedpoetry and anecdotes to the staff. “My strength comesfrom inside me and my love for my sons, from mystrong faith, and from my wonderful family andfriends,” Mrs. Nook says. “I attribute my ability tohelp the staff afterwards, to the fact that we sharedthis awful, gut-wrenching experience with them, andbonded with them,” says Mrs. Nook. “I felt a cama-raderie with them I can't explain. They had all thebest critical care skills, but saving Steven was out ofeveryone's reach. We were all in this horrible paintogether. I KNEW they were doing the best they could.They used all the best resources available to them.”

So when you’re lost, or don’t know what to do,

Remember. . .

Life brings with it, what you want it to.

—Untitled poem by Steven Nook

For the family and hospital staff, there was dis-course about sadness, support from the hospitalchaplain, psychologists, and the Crisis Intervention

Emotional Effects of Loss Are Extensive

See “MH,” Next Page

“MH,” From Preceding Page


Department. The medical staff found that going toSteven’s funeral and giving a creative memorial gifthelped them recover. “There were several of us whowent,” says Delleman. “Steven’s favorite colorwas blue, so we purchased a blue candle a foot highin a hurricane glass, with a ring of blue flowers. Asurgery nurse and I drove to Steven’s aunt’s houseto present it.”

“When we talk about crisis events, for some of themedical staff the sharp professional edge is dulleduntil the recovery is over,” says Marcia Williams, LPC(Licensed Professional Counselor) and Clinical NurseSpecialist in Crisis Intervention and Traumatic Grief atAurora St. Luke’s Medical Center. “One measure of therecovery process is how much the crisis continues tointrude into their daily lives. The disruption is real. Sowith most traumatic events the recovery time may be4–6 weeks, but for some it can actually get betterwithin a week.”

Ed Foster, the Chaplain Supervisor at Aurora-Sinai,points out that even when a medical professionalthinks they have recovered, the sad feelings can be trig-gered again. “It could be that another person resem-bling Steven comes in and it brings up all of thosefeelings again. The trouble is that folks want to judgethemselves harshly and think that there is somethingwrong with them. In that case they may really need totalk about it with another medical professional or evenconsider therapy. They don’t want to take the approachthat they have talked about it enough.”

Preparing for Next TimePart of the recovery process involves preparation

for another possible MH episode. For example, the staffis planning to have a mock MH drill at least once peryear, reinforcing all of the proper steps needed torespond to an MH crisis. These mock drills are empha-sized and covered thoroughly in the MH proceduremanuals for hospitals, ambulatory surgery centers, andsurgical offices produced by MHAUS.

Steps include

• assign specific tasks to staff

• provide checklists and worksheets

• emphasize frequent mock drills.

A slide show called “Managing MalignantHyperthermia Risk in Today's Surgical Environment”is also available through MHAUS. The slide showassists in developing standard of care practice guide-lines and algorithms to ensure that patients will haveaccess to appropriate interventions for treating MH.

Dr. Herlich suggests that MH drills should includefailure to control the syndrome with the first lines oftherapy. “For instance you are giving your first orsecond dose of dantrolene and the temperature is still

rising, the calcium values are decreasing, the potas-sium values are rising, and the patient’s coagulationis starting to deteriorate. Don’t go through a drill as ifgiving 1 or 2 doses of dantrolene means everything ishunky-dory and the patient walks out the door 1 or 2days later.”

Recovery room nurse Kassulke advises hospi-tals to increase awareness within all of the inpatientunits. For example, if a pregnant woman is about toundergo general anesthesia, ask the father aboutMH as well to see whether it might affect the baby.She also emphasizes the importance of the immedi-ate availability of an adequate supply of dantrolene.In Steven’s case, 90 bottles (450 milligrams) wereused in the initial 2 hours of the crisis. “We arefortunate at Sinai because we could pull dantrolenefrom 5 different hospitals. One of the reasons Stevenmade it out of OR and into critical care for 2 days isbecause we were able to get all of that dantrolene. Wewiped out just about all of the supply in the Milwau-kee region.”

Dr. Ulatowski’s message from Steven’s death isthat, “The work of educating and understanding thepresentation and optimal treatment of MH is notyet done. Not until there are no more deaths fromthe disorder.”

Dr. Herlich advises the OR team to call the MHHotline as early as possible. “It is analogous tomany other emergency situations. If you think it,you call. Don’t wait. If in your mind you have a sit-uation that you can’t explain and MH might beoccurring, even though the likelihood is low, youshould call the MH Hotline.”

Mrs. Nook advises patients who are unfamiliarwith anesthetics to be aware of any family historyof anesthesia problems, and not to take the experi-ence of undergoing general anesthesia lightly. “Littledid Steven or anyone else know that this would be anissue. But, just maybe, knowing MH could happenwould make the OR team feel the patient's skin a littlemore often, or maybe, just maybe, catch somethinggoing wrong a little sooner.”

ConclusionOver the past 3 decades, the mortality rate for MH

has dropped dramatically. However, as we see fromSteven’s case, death from MH can still occur, even inthe best of hands. When it does, it can have a dra-matic, traumatic effect on the entire medical staff, onethat can bring with it a long recovery time. However,something positive can result. For example a scholar-ship in Steven's name has been established at his highschool, Wauwatosa West, which already has garneredmore than $10,000 of community support. Also, theNook family is participating in the newly availablemolecular genetics testing procedure to help deter-mine MH susceptibility in other family members.

Information as to the diagnosis of MH by laboratorytesting may be found at

http://www.mhaus.org/index.cfm/fuseaction/Content.Display/PagePK/MolecularGenetics.cfm.

If the experience of Aurora-Sinai results in moreawareness of and preparation for other medical facil-ities, the MH mortality rate should continue to drop.It is hoped that the experience of the Nook familyand the Aurora Sinai staff will perhaps save othersfrom experiencing the same emotional devastation.

So do children, seem to grow

Pretty soon they’re on their way

And so you see them pack and go

It may seem a most lonesome day.

But know this is not the case

For they really never leave

Because memories have their place

And leave no room to grieve.

--“Remembrance” by Steven Nook, December 2004

Henry Rosenberg is the President of the MalignantHyperthermia Association of the United States andDirector of Medical Education and Clinical Research atSaint Barnabas Medical Center, Livingston, NJ. Al Rothstein is the public relations consultant for theMalignant Hyperthermia Association of the UnitedStates.

“MH,” From Preceding Page

Steven Nook —A victim of MH

Malignant Hyperthermia Education Must Continue


To the Editor:

I read with interest the unfortunate circum-stances surrounding the anesthetic mishapsrecounted in a recent issue of the APSF Newsletter(20(4):61–68), and the equally disastrous ways thehospitals and internal legal advisors handled themishaps. However, I do disagree with the impliedsuggestions that the physicians and hospitals failedsomehow to ensure that “incompetent” practitionersare weeded out and not allowed to practice. Inmy opinion, this is an unjustified criticism.

One only needs to compare the 2 systems of jus-tice meted out for an attorney accused of incompe-tence, and the physician accused of incompetence. Ihave been involved as a witness in both types ofcases. At least in Florida, the system for the attorneyis much simpler, and relies on evaluations by peerattorneys, the state bar, and the appointment of alegal hearing officer (usually a retired judge). After ahearing, a recommendation is made by the hear-ing officer to the state Supreme Court, and a decision isthen made by the state Supreme Court regarding theattorney’s continued right to practice. The process endsthere. There is no right of appeal to another court of law.

A physician has a far lengthier process to gothrough, both with the hospital, and/or with the stateboard of medical examiners. This is justified in manyways in order to ensure that a physician’s error injudgment is not used as “proof” of general incompe-tence for purely economic reasons. The federalHealthcare Quality Improvement Act of 1986 estab-lished many ground rules for fair hearings for physi-cians before their privileges can be restricted orrevoked by hospitals. Among other provisions, theseground rules limit severely the ability of those with aneconomic interest in the outcome from having a role indetermining the outcome, and guarantees the physi-cian’s right of representation by an attorney at all levelsof fair hearings. Similarly, it limits the liability of hear-ing committee members, providing they act in goodfaith. There is also an appellate process afforded aphysician whose privileges have been restricted orrevoked. In addition, a series of court challenges usu-ally follows any official action by a hospital board,which, unlike the attorney’s situation, does not ensurea trial by the physician’s professional peers.

It should be understood that these 2 processesare the processes through which attorneys andphysicians have their privileges or licensurerevoked or modified, and are independent of thetort trials regarding accusations of malpractice.Regarding limitations of practice rights, the legalsystem is far more streamlined for the attorney,which may or may not be in the individual attor-

ney’s best interest. Although the system for thephysicians seems to better serve the interests of theindividual physician, it also involves many attor-neys at all levels of the proceedings, is slow andtedious, is very expensive for all parties except theparticipating attorneys, and often gives rise to theunjustified criticism that “physicians do not do agood job of policing themselves.”

Given the strong economic competitivenessbetween physicians in the marketplace today,should physicians and hospitals have more autonomyin the revocation or limitation of physicians’privileges and licensure? Having such autonomy, Ibelieve, would lead to abuse in many instances, andultimately would not serve the best interests of thepublic at large or the medical community. In spite ofsuch potential abuse, if the public truly wishesthe medical community to have a greater ability toregulate itself, the medical community has noability to do so under the current legal system.Changes in the system would need to be made, andthe power to make those changes rests with the fed-eral and state legislatures, one hopes, with responsi-ble medical community input and participation.However, in light of the economic impact of thestrong participation by attorneys in the physicianhearing process, does anyone seriously think that thelegal system wants the medical community to havemore autonomy in determining the privileges orlicensure of a given physician? Given the current legalprocesses and economic climate, the criticism of themedical community’s “failure to police itself” shouldbe redirected toward better public education aboutthe justified legal limits on the medical community’sautonomy in deciding its members’ right to practice.

David A. Cross, MDScott and White Memorial Hospital and ClinicAssociate Professor of AnesthesiologyTexas A&M Health Sciences CenterTemple, TX

Readers SponsorSuccessfulLegislationTo the Editor:

I could not agree more with the article in theSpring 2006 APSF Newsletter entitled “AdverseEvents Require Communication and Disclosure.”1

As a current applicant to Indiana University Schoolof Medicine, I think legislation banning the use ofan apology or other statements of sympathy as evi-dence of fault in medical malpractice lawsuits iscrucial for the future of medicine. One such exam-ple of such legislation was House Enrolled Act No.1112, co-authored by my grandmother, representa-tive Phyllis Pond, and signed by Indiana governorMitch Daniels to become effective on July 1, 2006.Of the 4 house co-authors (Foley, Thomas, Kuzman,and Pond), 3 are attorneys and 1 is an educator. Bothsponsors in the senate (Kenley and Bray) are attor-neys. It was a bipartisan effort to allow a person toexpress true concern in case of an accident or adversemedical outcome. The bill specifically states in chap-ter 1, section 3 that “any statement, gesture, act, con-duct, or a writing that expresses sympathy, anapology, or a general sense of benevolence” may notbe used as evidence in an accident or medical mal-practice suit. The bill does, however, still allow admis-sion of “a statement of fault into evidence.”2 I think itis absurd that in many states health care providers feelthey cannot express sympathy for fear of a lawsuit.With malpractice patient compensation reaching anall time high, $104 million in 2004 in the state of Indi-ana alone,3 legislation allowing caregivers to commu-nicate sympathy to patients without fear of a lawsuitmay greatly reduce this figure across the board andfoster better physician patient relations. Remembercommunications of sympathy are not admissible;however, admission of fault may still be admitted intoevidence.

Gregory C. PondFort Wayne, IN

References

1. Trombly ST. Adverse events require communication anddisclosure. APSF Newsletter 2006;21(1)1-3

2. Indiana Code-IC 34-43.5 As amended effective July 1,2006. Available online at: http://www.in.gov/legisla-tive/bills/2006/PDF/HE/HE1112.1.pdf. Accessed June7, 2006.

3. Indiana Malpractice Bill May Take Sting from Docssaying ‘I’m sorry.’ Insurance Journal, January 23, 2006.Available online at http://www.insurancejournal.com/magazines/midwest/2006/01/23/features/65678.htm.Accessed June 7, 2006.

Letters to the EditorDetermination of PhysicianCompetency is Complex

See YourAPSF Website

atwww.apsf.org


To the Editor:

I was deeply troubled by the “Adverse EventsRequire Communication and Disclosure” article inthe Spring Newsletter. I am, like many other physi-cians, extremely conscientious about patient careand have an excellent rapport with most all mypatients. I am completely honest with patients andtheir families when unexpected complicationsdevelop, and am a huge proponent of direct conversa-tions with patients during their hospitalizationand with family members immediately aftersurgery if problems do arise. However, I am incomplete opposition to mandated disclosurerequirements of the Joint Commission on Accredita-tion of Healthcare Organizations (JCAHO) and TheMedical Care Availability and Reduction of Error Actin Pennsylvania.

Ms. Trombly, an attorney, starts the article bystating that formalizing the handling of near missesand actual adverse events has become common-place in other industries such as aviation and man-ufacturing. This certainly is true, but the airlineindustry is not mandated to send a formalized letterout to every passenger 7 days after it lands if it hadto change the course of another plane to avoid ahead-on collision at 30,000 feet. These complicationsare all handled “in house” unless the industry itselfdetermines it is best to handle them otherwise or ismandated by a court to do so—there is no legalstatute requiring this disclosure.

The article continues and describes JCAHO ‘sinstitution of a requirement for disclosure of “unan-ticipated outcomes.” She then talks about the legisla-tion passed in Pennsylvania in 2002, entitled “TheMedical Care Availability and Reduction of ErrorAct,” which requires a hospital, an ambulatorysurgery facility, or a birth center to notify a patient(or patient’s family) of a “serious event” in writingwithin 7 days. The Act defines serious event as “anevent, occurrence or situation involving the clinicalcare of a patient in a medical facility that results in thedeath or compromises patient safety and results in anunanticipated injury requiring the delivery ofadditional health care services to the patient.”

Here we go again! Physicians are being treatedlike second-class citizens in this country. All wehave heard for the last 5 years is the protection of indi-vidual patient’s privacy. Patients can knowingly carrythe AIDS virus and never divulge it to anyone. If theyare embarrassed that they take an MAO inhibitor fordepression they do not have to tell their health care

provider if they choose not to. If they were treated fora cocaine overdose last week at another hospital anddo not want the records transferred to the hospitalthat is now taking care of them, they are completelywithin their rights. We now cannot put their namesup on any board that can be seen by other patientsand sometimes have almost taken the wrong patientback to the OR so that we can “respect” their privacy.Yet, a physician is supposed to divulge every detail ofvirtually any unexpected event, regardless of howharmless or mundane it may be, within 7 days after itoccurs in writing to the patient. Fairness to thephysician—certainly not!

When I took civic class in middle school I learnedthat we had 3 branches of government (judicial, exec-utive, and legislative) so that there was a checks andbalances system to our government. However, theJCAHO has no checks and balances system. If the hos-pital or outpatient facility fails their inspection or doesnot heed their request it will not receive Medicarefunding. Lord Acton in 1887 described this type ofpower the best: “Power tends to corrupt, and absolutepower corrupts absolutely.” The JCAHO requirementfor disclosure and The Medical Care Availability andReduction of Error Act are an infringement of theFifth Amendment to the Constitution. Despite whatattorneys and JCAHO may believe, physicians do notforfeit their civil liberties in this country when theytake the Hippocratic oath.

I will quote this relevant portion of the FifthAmendment: “(No person) shall be compelled in anycriminal case to be a witness against himself.” At firstglance many will say we are not talking about a crime.That is not completely true. First, the constitution issaying that even a criminal should be extended thisright. If that is true, and it is true, a physician shouldat least expect this concession. Secondly, if the physi-cian sends a mandated letter to the patient or theirfamily and attempts to explain his role in the unex-pected poor outcome of this event and it is sus-pected from this explanation that the physician actedin a negligent manner, it can quickly become a crimi-nal lawsuit. Finally, by enacting a law that mandatesdisclosure, if disclosure is not forthcoming, that indi-vidual has now committed a criminal act. The powerof the JCAHO and the Pennsylvania legislature doesnot supercede the power of the framers of our Consti-tution.

The last topic I will address is the belief that it ispossible not to increase your litigation liability withthese mandated disclosure requirements. If I askyou to place a black box in your car that only regis-

ters times you exceed 75 miles per hour and thenask you to turn this into your State Patrol office atthe end of each month, do you think you wouldincrease the likelihood of being issued a citation forspeeding? If you went into your local county policestation and told them that you often smoked potand used methamphetamine on the weekends, buthad never been charged with drug possession, doyou think that the next time your local police officerstops you for a traffic violation that there would bea greater likelihood he would ask for a blood testand/or search your vehicle for drugs? If you put abreathalyzer on your automobile to record youralcohol level every time you started your car andyou kept a record of this for a year and at the end ofthat year a police officer looked at the levels of alcoholyou were driving under, do you think there would bea greater likelihood you would be issued a DUI cita-tion than if you were being stopped on a randombasis by your local police? Would it not be a reason-able request to put breathalyzers on all vehicles toprevent so many DUI fatalities? The ACLU would saythat this encroaches on our civil liberties, even if it isbeneficial to the public. Anyone who believes thatmandatory disclosure legislation will not increase ourlegal liability and jeopardize our ability to practicemedicine is either being disingenuous or is certifiablyinsane.

Let me be crystal clear. I am a strong advocateof telling the patient and their family about anycomplications that arise during a surgical proce-dure, especially if unanticipated. I also believe thatyou should present this information to the patientand their family members with compassion andsincerity. However, I do not believe that this disclo-sure should be mandated. The decision of when and if disclosure is to be made to the patient or theirfamily members should be retained by the physicianunless we as a society wish to alter the FifthAmendment of the Constitution. We should alwaysstrive for improvement, and in my opinion this canbe obtained through M&M conferences that aresheltered from litigation, and a continuous qualityimprovements assessment of our practices. Toadvocate mandatory disclosure for virtually allunexpected/unanticipated events will only lead toa quagmire of what events must be disclosed, finesfor not reporting certain events, and more determina-tions made by a jury of our “peers.”

Keith McLendon, MDAtlanta, GA

Letter to the EditorReader Seeks Balance in Disclosure Requirements


To the Editor:Dr. Flowerdew's recent letter regarding physical

presence during the administration of anesthesiaappropriately addresses the issues involved in radia-tion therapy patients and also recognizes the need forphysical presence to "actually administer the anes-thetic."1 The inherent danger from radiation to theprovider exists (should one remain present in theroom during treatment) and justifies monitoring froma safe distance. This is NOT true for MRI anesthesia,as no significant or recognized physical danger existsin the scanner room to justify monitoring from thenext room. The nature of our invasive professiondemands rapid evaluation and direct access topatients, ventilators and monitoring equipment,whenever possible. Clearly, when a qualifiedprovider (i.e., CRNA) is physically present to providecontinuous patient care at the bedside, an attendingphysician can provide direction/supervision fromoutside the room.

To suggest that intensive care physicians be avail-able for electronic remote consultation can, however,detract attention from the paramount need to have ananesthesia caregiver at the bedside, to continuallymonitor as per ASA basic standards and guidelines.One might hope that ICU patients in Maine also haveICU nurses in close proximity to the patient, espe-cially with their physicians at great distances. Dr.Flowerdew’s inference, however, does describe thetype of contemporary care ICU patients receive inMRI scanners, when anesthesia is not administeredby anesthetists: patients are alone in the scanner, onventilators with very limited capabilities and alarms,often with sedation and vasoactive infusions, andoften without end tidal CO2 or all other "routine mon-itors" (i.e., arterial pressure traces and volumetricpumps) they were afforded previously in the ICU andduring transport. Removal of all primary providersfrom the scanner room further decreases safety, as Ihave previously reported, especially when the scan-ner room door is closed and opening this doorrequires the scan to be interrupted.2

Mark Warner, MD, may have challenged theaudience of his 2005 Rovenstine Lecture to look fornew ways to deliver anesthesia care as Dr. Flowerdewreported, but I do not think Dr. Warner intendedsafety to be actively compromised. We as a professionhave been intimately involved with standards for safesedation in all other hospital areas. I personally viewthe contemporary challenge to be in insuring thesafety of all patients in MRI scanners, by promotingspecific national standards for this unique andincreasingly commonplace procedure, whenever anyform of life support or sedation is employed. Thisrequires defining the benchmark of care via our spe-cialty; thus, raising the threshold for all specialties tofollow, by "standing near by in the MRI" and with

every appropriate monitor used by conventional stan-dard or during prior care/transport.

In the same issue of this Newsletter, the new ASAand AANA guidelines requiring audible alarms forpulse oximetry and CO2 monitors have been intro-duced and raise a new question: Will/do currentavailable models reliably provide volumes adequateto overcome the MRI noise and earplugs used whilein the scanner rooms?3 Possibly sound amplification,optical alarms, or other new technologies (i.e., withspeakers inside protective headsets) may be needed inthis special environment to insure a high level of careinside the scanner room. Similarly, if ICU (or anes-thetized) patients continue to be monitored from out-side the scanner room, will these monitors berequired to alarm to the adjacent room, or will they beturned on, or even be utilized/connected when noone is in the scanner room to react to them? We allrecognize the shortcomings of ECG monitors duringMRI scanning and the inability of audible alarms toring to the next room through the closed doors of anMRI scanner. Just what are the “national standards”for MRI monitoring, alarm settings, response times,and qualifications of the “monitoring personnel,”especially when an ICU patient on vasoactive infu-sions is placed on a ventilator in a MRI scanner? Ithink adequate “standards” remain to be adequatelydefined for ICU patients. Scanner technicians are nottypically trained nurses or otherwise qualified tomonitor intensive care patients or sedation from thescanner room. Are gravity infusions via “dial-a-flow”or micro-drip sets with intermittent NIBP measure-ments used when MRI compatible pumps and pres-sure transducers are not available? Should this beacceptable now, when modern technology is at hand?Shouldn’t nurses and respiratory technicians be phys-ically present in the scanner to monitor their patientsand equipment, just as in the ICU? The radiologyphysicians are furthermore not typically present orparticularly familiar/engaged with life supportequipment either, especially in the “off hours,” whenscanners run around the clock to amortize their acqui-sition costs.

Paul M. Kempen, MD, PhDPittsburgh, PA

References

1. Flowerdew RM. Radiation prevents presence in room.ASPF Newsletter 2006; 21(1):19.

2. Kempen PM. Stand near by in the MRI. ASPF Newsletter2005; 20(2):32 and 36.

3. Notice: ASA and AANA modify standards to includeaudible alarms. ASPF Newsletter 2006;21(1):2.

Letter to the EditorICU Patients Need CarefulMonitoring in the MRI

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

George A. Schapiro, ChairAPSF Executive Vice President

Elizabeth Holland ...................Abbott Laboratories

Sean Lynch...............................Anesthesia Healthcare Partners

Cliff Rap ...................................AnesthesiologistsProfessional InsuranceCompany

Nassib G. Chamoun ...............Aspect Medical Systems

William Floyd..........................Aspect Medical Systems

Raul A. Trillo, MD ..................Baxter Healthcare

Michael S. Ferrara ...................Becton Dickinson

Tim Vanderveen .....................Cardinal Healthcare

Thomas W. Barford.................Datascope Corporation

Robert Clark ............................Dräger Medical

Brian Mulnix............................Endo Pharmaceuticals

Paul A. Baumgart....................GE Healthcare

Tim Hagerty ............................Hospira

Steven C. Mendell ...................LMA of North America

Joe Kiana ..................................Masimo

Bert de Jong, MD.....................Organon

Dominic Corsale......................Oridion

Walter Huehn..........................Philips Medical Systems

Edward C. Mills ......................Preferred PhysiciansMedical Risk RetentionGroup

Ron Richard .............................ResMed

Andrew Rose ...........................Smiths Medical

Joseph Davin ...........................Spacelabs

Ann S. Lofsky, MD..................The Doctors Company

William T. Denman, MD........Tyco Healthcare

Terry Wall ................................Vital Signs

Abe Abramovich

Casey D. Blitt, MD

Robert K. Stoelting, MD


FDA and NIOSH Issue Warning About OxygenRegulator Fires and Incorrect Use of Seals The following report was issued on April 24, 2006, to warn providers of fires that may occur at theinterface of oxygen regulators and cylinder valves resulting from the incorrect use of CGA 870 seals.

FDA has received 12 reports in which regulators used with oxygen cylinders have burned or exploded, in some cases injuring person-nel. Some of the incidents occurred during emergency medical use or during routine equipment checks. FDA and NIOSH believe thatimproper use of gaskets/washers in these regulators was a major factor in both the ignition and severity of the fires, although there arelikely other contributing factors.

Two types of washers, referred to as CGA 870 seals, are commonly used to create the seal at the cylinder valve / regulator interface: Thetype required by many regulator manufacturers is a metal-bound elastomeric sealing washer that is designed for multiple use appli-cations. The other common type, often supplied free-of-charge with refilled oxygen cylinders, is a plastic (usually Nylon®) crush gasketsuitable for single use applications.

The nylon crush gaskets require higher torque than the elastomeric sealing washers in order to seal the cylinder valve / regulator inter-face, and if they are used again, they require more torque with each successive use. The cylinder valve / regulator connection is designedto be hand-tightened. If the crush gaskets are re-used, the need for increased torque may require using a wrench or other hand tool,which can deform the crush gasket and damage the cylinder valve and regulator. This can result in leakage of oxygen past the cylindervalve seat and across the nylon crush gasket. According to a forensic analysis supported by FDA and NIOSH, “flow friction” causedby this leakage of compressed oxygen across the surface of the crush gasket may produce enough thermal energy to spontaneouslyignite the nylon gasket material.

Recommendations FDA and NIOSH recommend that plastic crush gaskets never be reused, as they may require additional torque to obtain the neces-sary seal with each subsequent use. This can deform the gasket, increasing the likelihood that oxygen will leak around the seal andignite.

The following general safety precautions should also be taken to avoid explosions, tank ruptures, and fires from oxygen regulators.

• Always “crack” cylinder valves (open the valve just enough to allow gas to escape for a very short time) before attaching regulatorsin order to expel foreign matter from the outlet port of the valve.

• Always follow the regulator manufacturer’s instructions for attaching the regulator to an oxygen cylinder.

• Always use the sealing gasket specified by the regulator manufacturer.

• Always inspect the regulator and CGA 870 seal before attaching it to the valve to insure that the regulator and seal are in good condi-tion and the regulator is equipped with only one integral metal and rubber seal that is in good condition. Avoid plastic seals.

•Tighten the T-handle firmly by hand, but do not use wrenches or other hand tools that may over-torque the handle.

•Open the post valve slowly, while maintaining a grip on the valve wrench so that it can be closed quickly if gas escapes at the junc-ture of the regulator and valve.

Reporting to FDA To report your experience regarding the devices in this Notification, please use MedWatch, the FDA’s voluntary reporting program. Youmay submit reports to MedWatch by phone at 1-800-FDA-1088; by FAX at 1-800-FDA-0178; by mail to MedWatch, Food and DrugAdministration, 5600 Fishers Lane, Rockville, MD 20857-9787; or online at http://www.fda.gov/medwatch/report.htm.

Getting More Information If you have questions about this notification, please contact April Stubbs-Smith, Office of Surveillance and Biometrics (HFZ-510), 1350Piccard Drive, Rockville, Maryland, 20850, by Fax at 301-594-2968, or by e-mail at [email protected]. You may also leave a voicemailmessage at 301-594-0650 and we will return your call as soon as possible.

See “Fires,” Next Page


FDA medical device Public Health Notifications are available on the Internet athttp://www.fda.gov/cdrh/safety.html. You can also be notified through email on the daythe safety notification is released by subscribing to our list server. To subscribe, visithttp://list.nih.gov/archives/dev-alert.html.

Editor’s Note:

The preceding warning and recommendations were issued by Daniel Schultz, MD,Director, Center for Devices and Radiological Health, Food and Drug Administration andNancy Stout, EdD, Director, Division of Safety Research, CDC, NIOSH.

The letter encouraged all readers to copy and distribute this information. TheAPSF Newsletter is pleased to be able to assist in the dissemination of this importantsafety information.

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

Figure 1 : Examples of crush gaskets available for CGA 870 type medical post valves.

Figure 2: Examples of some sealing washers available for CGA 870 Style medical post valves.

“Fires,” From Preceding Page

Crush Gaskets

Sealing Washers

Grey Nylon Yellow Nylon Blue Nylon Polyethylene

Aluminum & Buna N

Brass & Viton Brass & Viton


Inside This Issue• Risk of Hyperglycemia

• New Q and A Column

• Dear SIRS

• Report on SOAP Panel

• Aftermath of an MH Death

• Oxygen Cylinder Fire Warning

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

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