anesthesia topic of the week – Page 2

Clinical Forum: Sevoflurane with RSI in Obese Patient

With the growing Obesity epidemic in America, anesthetists are continually facing the risk of induction and intubation with a potentially difficult airway. Many theories are in the literature about the “best” technique for safe induction of the morbidly obese patient. Pre-oxygenation is essential and proper positioning increases the odds of successful airway management.

A recent article by Toso et al. published in the European Journal of Anesthesiology (Eur J Anaesthesiol. 2011 Nov;28(11):781-7. described adding a component of inhalation anesthesia to the rapid sequence induction technique for morbidly obese patients. In this study, the authors positioned and pre-oxygenated patients. When ready for induction, the researchers turned on Sevoflurane and after 30 seconds of breathing the agent, they followed with a rapid sequence induction using propofol, alfentanil and Succinylcholine. All patients were easily intubated on the first attempt and there were not occasions of desaturation.

The authors demonstrated that adding Sevoflurane to the RSI sequence provided conditions for a safe and controlled induction of anesthesia.

Click here to read an abstract of the original article. Return to Procrna.com and share your opinion with your colleagues.

Legal Topic: Documentation

Same Song Different Verse – If It Wasn’t Documented…..

Consider for a moment, that you or a colleague is facing legal action that, on the face of things, appears absurd. How absurd? Well, think for a moment about the first time that you learned how to place an intravenous (IV) line. The first thing that you were taught to do (after determining the correct patient, catheter size, and limb selection) was – clean the site. Traditionally we used alcohol either provided in an IV start kit or provided by our facility. How many of us thought about, or consulted the relevant science, regarding which preparation solution was actually better for patient care?

Now lets take it up notch. Consider what you do as an anesthesia provider when you are preparing to place an epidural catheter or a subarachnoid block. Most of the kits that we used in school and current practice have supplied within them a skin cleansing preparation. According to one manufacturer, B. Braun (bbraunusa.com/images/bbraun_usa/bbrauncatalog.pdf; F3), the supplied cleaning preparation in standard single dose epidural trays is povidone iodine. Again, how many of us question the skin preparation solution provided in a kit by a manufacturer that our facility has chosen to select for us? Relevant science indicates that a better skin preparation solution for neuraxial blocks is chlorhexidine. Furthermore, this solution is optimal when used from a single use package, instead of poured from a multi-use container.

What is the importance of such minutiae? Well, suppose a post-partum patient presented to the ER 4 days after discharge from the mother-baby unit of Smallville Community Hospital with the following symptoms: low grade fever, back ache, intermittent weakness of the right lower extremity. During her ER workup, the on call anesthesiologist, Dr. Nurves, is consulted since the patient had an epidural for labor analgesia. After his physical exam, Dr. Nurves suspects the patient has an epidural abscess. He orders an MRI that confirms his suspicions. Now fast forward 18 months. The patient decides to file a claim against her anesthesia providers for causing the pain and disability from which she now suffers. She suspects her current problems are from the epidural abscess…….

When an attorney is tasked to evaluate this type of claim, the attorney will seek a healthcare professional who is familiar with the standards of care surrounding the activities related the client’s labor epidural for analgesia. Imagine the professional conundrum provided by the following clause on the anesthesia record “Sterile prep and drape” without further elaboration. Would it make any difference if we added another detail: the epidural was placed by a trainee (either physician or nurse) and the use of the trainee was NOT noted on the anesthesia record. Additionally, the patient, and her spouse, recalls multiple attempts at placing the epidural; this is also not noted on the chart. So how does one determine if standards of customary practice were met in such a situation? The use of the trainee, and the multiple attempts at placing the epidural catheter are not documented in the records. These items are not facts in evidence. It is a fact however, that if cultures are obtained from an epidural abscess with bacterium that are not normally found in the epidural space, AND the patient’s physical exam prior to the placement of the epidural does not specifically indicate a bacterial infection in the area where the epidural catheter was to be placed AND (perhaps most importantly to us) the modality for transmission of bacterium into the epidural space is under the exclusive control of the anesthesia provider, then supporting data can be introduced to create a scenario whereby the anesthesia providers who placed the epidural catheter caused the epidural abscess AND the related sequela. What type of supporting data? Standards of care regarding neuraxial blockade; sterile skin preparation; and care documentation. Documents of professional standards, along with several peer- reviewed clinical reports regarding sterile skin preparation are readily available in any medical library (electronic or traditional) or via the world wide web.

A well researched review providing the who, what, when, where, and why of how we are supposed to practice our craft can speak volumes to a trier of fact (a judge or a jury) as to whether or not a patient’s claim has merit. So what is the take home message: Know and adhere to your professional standards of care (review them if necessary) and keep up with the state of your science.

Pamela Chambers, MSN, CRNA, EJD
www.lexterraeconsulting.com

References
Barash, P.G., Cullen, B.F., & Stoelting, R.K. Clinical Anesthesia 3rd Ed. Ch 26 Epidual and Spinal Anesthesia p 651 Lippincott Raven, New York 1997

Birnbach D.J. et al, Povidone Iodine and skin disinfection before initiation of epidural anesthesia. Anesthesiology. 1998; 88:668-672

Nagelhout, J. J., Zaglaniczny, K.L. Nurse Anesthesia 3rd Ed. Ch 44 Obstetric Anesthesia p 1066 Elsevier Saunders, St. Louis 2005

Stoelting, R. K., Miller, R.D. Basics of Anesthesia 3rd Ed., Ch. 12 Spinal and Epidural Anesthesia p 173, Churchill Livingstone, New York. 1994

Pamela Chambers, MSN, CRNA, EJD
www.lexterraeconsulting.com

Standards, the Expert Witness

Submitted by Pamela Chambers, MSN, CRNA, EJD

Click here for Lex Terrae consulting

As we all know, legislative bodies enact the laws that we must all abide by – whether we are aware of them or not. Ignorance of the law is rarely a defense to violating it, whereas professions set their own standards of care. Ignorance of the standard of care while not illegal, may be described as poor practice. But how does the public – or the courts, know what constitutes poor practices? How would a court determine the standard of care for nurse anesthesia practice in Temple, TX; or in Dallas, TX; or in Bay City, TX?

The United States Supreme Court held that expert opinion is only admissible when it is generally accepted as reliable the relevant scientific community Frye v. United States, 54 App.D.C. 46, 293 Fed.1013 (1923). The decision handed down in Daubert v. Merrell Dow Pharmaceuticals, Inc., 509 U.S. 579, 113 S.Ct. 2786, 125 L.Ed.2d 469 (1993) went a step further in clarifying that expert testimony must have a valid scientific connection to the issues of a particular case. So why is this important to know?

Upon review of Carolan v. Hill, 553 N.W. 2d 882, Iowa 996, the issue on appeal was the admissibility of expert testimony. The harm suffered by the plaintiff (Carolan) was ulnar nerve damage sustained during the administration of anesthesia for a surgical procedure unrelated to plaintiff’s arm. The trial court refused to allow the plaintiff’s expert witness testimony. The trial court relied upon its interpretation of the Iowa Code regarding who could establish standard of care. On appeal, the Iowa Supreme Court clarified the interpretation of the law in Iowa. The relevant code noted that a “person” qualified to provide expert testimony shall be so qualified based on medical or dental qualifications that relate directly to the issues in the case at bar. Furthermore, if the legislature had intended qualified individuals be restricted to physicians and dentists, it would have done so explicitly. In this instance, this issue was reversed (overturned the jury verdict for the defendant anesthesiologist) and remanded to the lower court. Plaintiff’s expert witness was a Nurse Anesthetist.

The Federal Rules of Evidence, rule 702, state the following with regard to expert witnesses: A witness who is qualified as an expert by knowledge, skill, experience, training, or education may testify in the form of an opinion or otherwise if: the expert’s scientific, technical, or other specialized knowledge will help the trier of fact to understand the evidence or to determine a fact in issue; the testimony is based on sufficient facts or data; the testimony is the product of reliable principles and methods; and the expert has reliably applied the principles and methods to the facts of the case. This rule is based largely on Daubert, but has been amended and modified as other landmark decisions (such as Kumho Tire Co. v. Carmichael, 119 S.Ct. 1167 (1999) have been decided regarding expert testimony.

Daubert set forth a non-exclusive checklist for trial courts to use in assessing the reliability of scientific expert testimony. The specific factors delineated by the Daubert Court are (1) whether the expert’s technique or theory can be or has been tested—that is, whether the expert’s theory can be challenged in some objective sense, or whether it is instead simply a subjective, conclusory approach that cannot reasonably be assessed for reliability (i.e. an opinion); (2) whether the technique or theory has been subject to peer review and publication; (3) the known or potential rate of error of the technique or theory when applied; (4) the existence and maintenance of standards and controls; and (5) whether the technique or theory has been generally accepted in the scientific community. The Court in Kumho held that these factors might also be applicable in assessing the reliability of nonscientific expert testimony, depending upon “the particular circumstances of the particular case at issue.” 119 S.Ct. at 1175.

So what does all of this mean? How does affect your practice if it affects it at all? Consider this, when you make a decision as to which nondepolarizing muscle relaxant you will use (when you have a choice) ask yourself if the decision you’ve made is accepted practice. When you decide to conduct your anesthetic in a manner that you deem best for your patient, ask yourself if the methods that you use are (still) relevant and valid? If any of us are practicing the “way we’ve always done it”, ask yourself this question – Is this defensible in a court of law?

About the author: Pamela Chambers is a staff CRNA a Central Texas regional trauma center and the affiliated Children’s hospital. Ms Chambers received her MSN in 2000 while on active duty in the U.S. Army; then received her Executive Juris Doctor (EJD) in Health Law in 2008 from Concord Law School. Ms. Chambers owns Lex Terrae Consulting a health law research and consulting firm and also teaches Legal Nurse Consulting for Kaplan University. Ms. Chambers is not an attorney. The information provided is legal research and should not replace consultation with an attorney or physician when warranted. Click here to learn more about Lex Terrae Legal consulting services.

Radiation Exposure to Anesthetists

Radiation exposure has long been a concern to Radiologists and their assistants. Lead aprons, thyroid shields and more recently leaded eyeware have reduced their exposure to radiation. Anesthetists are frequently assigned to sedate / anesthetize patients in the interventional radiology suite. Like the Radiologist, the anesthetist is exposed to radiation danger.

In a study by Anastasian, ZH, et al published in Anesthesiology, the facial exposure to radiation was compared between the Radiologist and the Anesthetist. Both providers wore lead aprons. The Radiologist wore leaded eyeglasses and stayed behind a leaded acrylic shield to the extent possible. The Anesthesiologist also was instructed to stay behind a leaded shield to the extent possible and to keep maximum distance from the source of radiation.

The authors of the study demonstrated that the Anesthesiologist had a 3 fold increase in facial exposure to radiation than did the Radiologist, thus increasing the risk of developing cataracts. Exposure of the Anesthesiologist was correlated to the number of pharmacologic interventions performed during the case.

The best ways to reduce exposure to radiation are distance and shielding. Lightweight leaded eyeglasses reduce exposure of the cornea by 98% and are recommended for those spending significant time administering anesthesia for interventional radiology

Click here to review the work by Anastasian, ZH et al.

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Opioid-Induced Respiratory Depression

The Anesthesia Patient Safety Foundation is committed to the safe and reliable administration of every anesthetic. An area of concern has been respiratory depression in the immediate postoperative period secondary to narcotic administration. The following information comes directly from the foundation;

The APSF believes that clinically significant, drug-induced respiratory depression in the postoperative period remains a serious patient safety risk that continues to be associated with significant morbidity and mortality since it was first addressed by the APSF in 2006.1 The APSF envisions that “no patient shall be harmed by opioid-induced respiratory depression in the postoperative period,” and convened the second multidisciplinary conference on this serious patient safety issue in June of this year in Phoenix, AZ, with 136 stakeholders in attendance. The conference addressed “Essential Monitoring Strategies to Detect Clinically Significant Drug-Induced Respiratory Depression in the Postoperative Period.”

Click here to read the full report by the APSF regarding drug-induced depression in the postoperative period. After reading the report, click the back arrow to return to this site and leave a comment for your colleagues.

LMA in the Prone Position

The LMA (Laryngeal Mask Airway) has been a common airway management device used by the Anesthesia community for two decades. Because the device does not “secure” the airway like a cuffed endotracheal tube would, anesthetists are selective about the patient population and type of surgery when deciding whether or not to use the LMA. Our international colleagues seem to have been bolder with the use of the LMA and report its use in the lateral and sitting positions. An Article by Ng Published in Anesthesia and Analgesia reported a series of over 200 patients who were safely induced in the prone position with the LMA inserted after induction. Click here to read the article and then return to procrna.com and leave a comment. Let us know about your experience using the LMA in the non-supine patient.