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As an anesthesia provider, my job is to be the chief safety officer in the operating suite. I help keep the patient alive and make a surgical procedure bearable for the patient. At the same time, I'm always thinking about what might go wrong, how I can prevent it and how I might prepare for a time when, inevitably, complications arise. Preparation pays off. Often when things start to go wrong, I've already dealt with the situation before the staff notices or the patient is hurt. Here are eight ways you and your anesthesia provider can make your perioperative care safer and more effective.
1. Put together an excellent team
Administering safe and effective anesthesia requires a balance of skill and personality among physicians, nurses, administrators and office personnel. Safety should come first, so it's important to hire professionals who have the proper training, experience and credentials.
Look for a board-certified or board-eligible anesthesiologist. Sometimes a facility's professional liability insurance may be lower if it employs or contracts with board-certified anesthesiologists. However, more years of practice may not necessarily mean a more knowledgeable and competent physician. In a systematic review published in the February 15, 2005, issue of the Annals of Internal Medicine, researchers reported that more than half of 62 studies reviewed showed that physicians with more clinical experience provided a lower quality of care. Ideally, the board-certified anesthesiologist should be enrolled in a maintenance-of-certification program even if the anesthesiologist's ABA certification is permanent.
Personality counts, too. An anesthesia provider needs to communicate effectively with other physicians, OR team members, patients and their families. Many patients fear the anesthesia more than the surgery, so the anesthesia provider needs to be able to quickly reassure and gain the trust of the patient.
2. Have the right equipment
Before a case begins, the anesthesia provider needs to verify that all the proper equipment and supplies are available and in place. While every OR is different, each should have equipment and supplies to deliver anesthesia, monitor the patient and deal with complications and emergencies. The basic airway management equipment is known by its mnemonic device, S.O.M.A., for suction, oxygen, mask and Ambu.
A properly equipped OR should have at least the following equipment.
- Bag valve mask. Anywhere any type of sedation is given, a self-inflating bag valve mask (Ambu mask) should be available. In operating rooms with an anesthesia machine, a mask should be available in case the anesthesia machine fails.
- Anesthesia machine with complete physiological monitoring. Some outpatient ORs are better equipped than others. Endoscopy suites, for example, often don't have an anesthesia machine. Without an anesthesia machine, the anesthesia provider has less flexibility to use inhalational agents such as sevoflurane or desflurane. Inhalational inductions can be used for challenging cases, such as patients with a difficult vascular access, certain airway issues such as a history of chemotherapy to the throat or a tumor in the airway, or some psychiatric conditions such as phobias. Maintaining anesthesia with inhalational agents decreases the need for intravenous anesthetics, which depend on a patient's metabolism for the timing of elimination rather than ventilation.
- Video laryngoscope. Having the ability to see the larynx and vocal cords is very helpful when intubating obese patients and those with big necks, large tongues or other problems related to a difficult airway. Different types of video laryngoscopes are available, including fiberoptic and single-use versions.
- Ultrasound imaging. More anesthesia providers are becoming familiar with these devices, which let the provider see where the needle is placed for regional anesthesia. Ultrasound can help the provider avoid hitting an artery or the wrong nerve and permits the drug to be deposited in the right place (see "Regional Done Right" on page 47).
- Cardiac arrest cart. The Joint Commission is very specific about the minimum requirements for a cart. One piece of equipment worth mentioning is an automated external defibrillator with transcutaneous pacing and synchronization features.
- Consciousness monitor. Not all anesthesia providers have embraced this concept. However, I believe that a consciousness monitor should be used in any case that requires an infusion or inhalational agent. The monitor lets the anesthesia provider titrate the anesthetic dosage to the appropriate level. This helps avoid oversedation, which can slow down recovery in the PACU, and also helps prevent intraoperative awareness, which is rare but worries many patients.
- Malignant hyperthermia kit. Although uncommon, malignant hyperthermia is a life-threatening complication in patients with a genetic predisposition that can be triggered by some inhalational agents and succinylcholine (sux). When MH occurs, act quickly. Each facility should have a portable kit that includes the antidote, dantrolene, IV administration sets, an Ambu mask, central venous pressure sets, syringes for blood gas analysis and urinary catheter set. The Malignant Hyperthermia Association of America has a list of recommended contents for the kit on its Web site (www.mhaus.org). Print the MH hotline number, (800) 644-9737, on the outside of your facility's kit.
3. Allow for some quality time with the patient
In the pre-operative evaluation, the anesthesia provider has just a few minutes to gather and process a huge amount of information while gaining the trust of the patient. To do this effectively, the anesthesia provider needs all of the pre-op patient information ahead of time.
Again, it helps if the provider has developed people skills. This surprises many who assume that an anesthesia provider doesn't need good communication skills since his patients are sedated or unconscious. I disagree with this generalization. The anesthesia provider needs to present confidence and empathy to instantly gain patient trust before the patient allows the release of control of basic functions — such as breathing — to the provider's care.
Anesthesia requires a human touch to put a nervous patient at ease. When appropriate, I continue conversations until I can feel that the patient is comfortable about what's about to happen. After surgery, this communication translates to better patient satisfaction.
4. Tailor the drugs to the patient
If you have 10 patients scheduled for the same procedure, most likely they all won't receive the same combination of medications. For example, an anxious patient may benefit from a benzodiazepine such as midazolam. In emergencies such as laryngospasm, or when a patient is likely to be difficult to intubate, succinylcholine or rocuronium (roc) can be used to relax the muscles along the airway. These neuromuscular blockers are commonly used in patients at risk for aspiration of gastric contents.
Painful procedures are likely to require opioid analgesics like fentanyl or non-steroidal anti-inflammatory medication (NSAIDs) such as ketorolac. Surgical stress and pharmacological side effects may combine with patient risk factors to result in PONV. This may require treatment with anti-emetics such as compazine, ondansetron or aprepitant (Emend).
Not all patients require the same dosage. An obese or muscular patient will require more anesthetic, while an older, frail patient will require less. The challenge is to use information about the human populations, but still titrate or adjust the drug dosing to the individual patient's needs. During the pre-operative interview, list current medications as well as drugs to be avoided, such as antibiotics for those allergic to them.
5. Create the best vascular access
How the patient will receive medication is nearly as important as which drugs will be administered. For infusion drugs, the upper limbs are well suited for inserting catheters. When looking for a good vein, the provider should work inward from the extremities.
Lower limbs are also an option, but they usually require more extension tubing. The patient's position may also come into play. Each location has its own risks. During endoscopy, in which the patient is in the lateral-prone position, the antecubital intravenous catheter has more chance of kinking where the arm folds in front of the elbow.
Also, it's easy to avoid confusion by using color-coded stopcocks — blue for veins and red for arteries. Color-coding is important for arterial lines because air or the wrong drug injected into an arterial line can result in vascular injury or stroke.
6. Be prepared for the worst
Complications are a statistical inevitability, especially as case volume increases. Therefore, it's important to have the appropriate drugs and devices available. Even in an outpatient setting, everyone in the OR should be aware that the most routine local anesthetic procedure may develop major complications requiring general anesthesia or resuscitation. For example, routine diagnostic laparoscopy could suddenly become complicated if a trocar causes major vascular injury and hemorrhagic shock, requiring a laparotomy to repair injury and a massive blood transfusion.
- Airway obstruction or respiratory arrest (apnea). When the carbon dioxide monitor displays a decrease in concentration of end tidal carbon dioxide, a partial or complete airway obstruction may have occurred. The anesthesia provider may need to lift the chin, add an airway or manually ventilate the patient. Having a variety of equipment on hand will help the provider when time is very short. The provider can ventilate manually with an Ambu bag or establish an airway with a laryngeal mask airway (LMA), which is placed just above the larynx. LMAs are available in single- and multiple-use models and some have a built-in bite block to further protect the airway.
An endotracheal tube is more reliable because it passes through the vocal cords and forces the airway to remain open. Because endotracheal tubes are more difficult to insert than LMAs, most anesthesia providers use a laryngoscope that lets the provider see the vocal cords directly, which makes intubation easier and makes injury to the vocal cords less likely. Stock your ORs with endotracheal tubes ranging from 3.5mm to 6.5mm in diameter for children and from 6.5mm to 8.5mm for adults.
- Local anesthetic toxicity. This is a common complication in cosmetic surgery that in the worst cases can lead to seizures, respiratory arrest and cardiovascular collapse. It occurs when a high dose of local anesthetic or a sodium channel blocker, such as lidocaine or bupivacaine, is mistakenly injected into a vein or artery rather than a slow-absorbing tissue like skin or fat. Symptoms include heart palpitations, ringing in the ears and numbness around the lips. If seizures begin, the anesthesia provider will need to sedate the patient with a hypnotic drug such as midazolam, diazepam, thiopental or propofol and provide supportive care.
- Abnormal heart rhythms. Cardiologists see atrial fibrillation all the time. But in an outpatient setting, change in the heart's normal rhythm is cause for serious alarm because of the risk of thromboembolism or hypotension. Stock your advanced cardiac life support crash cart with all resuscitative drugs including atropine, epinephrine, amiodarone and beta blockers such as metoprolol and labetalol. You should also keep an automated external defibrillator and transcutaneous pacemaker nearby.
7. Bring the patient back safely and on time
Anesthesia delivery is often compared to flying an airplane. The largest risks are during takeoff and landing. Anesthesia has three major phases: induction, maintenance and emergence. During emergence from anesthesia, as the surgical procedure is finishing, timing of the elimination of anesthetics is critical in order to have the patient in the proper condition at the right time. If the anesthesia provider ends the delivery of medication too soon, the patient may become undersedated while surgery is in progress. If the medication delivery ends too late, the patient will spend much longer than anticipated in the operating room and PACU.
8. Get the anesthesia provider involved in OR design
Architects and administrators usually design ORs with the surgeon in mind. Anesthesia is often an afterthought. As a result, anesthesia equipment and the needed electrical, gas and suction outlets often create unnecessary danger in the OR. The spaghetti of hoses for oxygen, air and suction and the electrical cords for anesthesia machines and monitors are tripping hazards.
If you're building a new facility or remodeling an OR, consult with an experienced anesthesia provider about the best place to locate outlets and how many would be ideal. You may determine that you need to run gas supply pipes on two sides of the room or from the ceiling in order to decrease clutter and reduce hazards. Proper design may increase front-end costs, but it's worth it in the long run.
Protecting our patients
The anesthesia provider works outside the spotlight in the operating theater. This is the way it should be. In the best cases, the patient remembers none of the trauma of the surgery and emerges satisfied with his experience. To make this happen, the anesthesia provider needs a combination of clinical and social skills. I call this the aesthetics of anesthetics. You can take advantage of this expertise by working with your anesthesia specialists. Together, you'll keep every patient as safe as possible.