#201 Enhancing Regional Anesthesia Practices for Superior Patient Safety, Part 2
May 07, 2024Episode 201
Anesthesia Patient Safety Foundation
Ever found yourself grappling with the complexities of peripheral nerve blocks and patient safety? This episode is a treasure trove of insights as we unpack the February 2024 APSF newsletter article by the esteemed trio Christina Ratto, Joseph Szokol, and Paul Lee, shedding light on the crucial precautions necessary for regional anesthesia procedures. Get ready for an enriching conversation with Paul Lee, Division Chief of Regional Anesthesia and Clinical Assistant Professor of Anesthesiology at Keck Medical Center, as he shares valuable personal experiences and stresses the need for meticulous safety checks.
Navigate through the nuances of handling emergencies, like dealing with seizures or arrhythmias associated with LAST, with confidence. We cover the must-know local anesthetic systemic toxicity checklist, providing concrete steps and dosing recommendations to ensure patient stability in a crisis. This is more than just another clinical discussion; it's about arming yourself with the knowledge to elevate patient care to the highest standard. Join us for an episode packed with actionable takeaways for any anesthesia professional dedicated to the noble cause of patient safety.
Ever found yourself grappling with the complexities of peripheral nerve blocks and patient safety? This episode is a treasure trove of insights as we unpack the February 2024 APSF newsletter article by the esteemed trio Christina Ratto, Joseph Szokol, and Paul Lee, shedding light on the crucial precautions necessary for regional anesthesia procedures. Get ready for an enriching conversation with Paul Lee, Division Chief of Regional Anesthesia and Clinical Assistant Professor of Anesthesiology at Keck Medical Center, as he shares valuable personal experiences and stresses the need for meticulous safety checks.
Navigate through the nuances of handling emergencies, like dealing with seizures or arrhythmias associated with LAST, with confidence. We cover the must-know local anesthetic systemic toxicity checklist, providing concrete steps and dosing recommendations to ensure patient stability in a crisis. This is more than just another clinical discussion; it's about arming yourself with the knowledge to elevate patient care to the highest standard. Join us for an episode packed with actionable takeaways for any anesthesia professional dedicated to the noble cause of patient safety.
You're listening to the Anesthesia Patient Safety Podcast, the official podcast of the Anesthesia Patient Safety Foundation. We're bringing you the very best from the APSF newsletter and website, as well as the latest information in perioperative patient safety. Thanks for joining us.
Alli Bechtel:
Hello and welcome back to the Anesthesia Patient Safety Podcast. My name is Allie Bechtel and I'm your host. Thank you for joining us for another show. We are starting our next 200 episodes right now and continuing the conversation from last week all about anesthesia, patient safety considerations and peripheral nerve blocks. So make sure that you have your ultrasound machine plugged in Before we dive into the episode today.
Alli Bechtel:
We'd like to recognize Preferred Physicians Medical Risk Retention Group, a major corporate supporter of APSF. Preferred Physicians Medical Risk Retention Group has generously provided unrestricted support to further our vision that no one shall be harmed by anesthesia care. Thank you, preferred Physicians Medical Risk Retention Group. We wouldn't be able to do all that we do without you. We are returning to the February 2024 APSF newsletter, and our featured article again today is Safety Considerations in Peripheral Nerve Blocks by Christina Rado, joseph Skokul and Paul Lee. To follow along with us, head over to apsforg and click on the newsletter heading First. One down is the current issue, then scroll down until you get to our featured article today. I will include a link in the show notes as well. We have exclusive content from Paul Lee, another author of the article. Here he is now.
Paul Lee:
Hi, my name is Paul Lee and I am the Division Chief of Regional Anesthesia and Clinical Assistant Professor of Anesthesiology at Keck Medical Center of the University of Southern California.
Alli Bechtel:
I asked Lee why he is interested in this topic. Let's take a listen to what he had to say.
Paul Lee:
This topic has been an area of interest for me for many reasons. I've witnessed or reviewed multiple incidents during the timeout period prior to a block where the patient was at risk or harmed, whether it's a needle being injected into the wrong leg or application of an antiseptic the patient was allergic to, or a thoracic epidural being started even though the patient had just received heparin. Many adverse events can be avoided by a simple reminder of safety surrounding neuraxial and peripheral nerve blocks, of safety surrounding naraxial and peripheral nerve blocks.
Alli Bechtel:
Thank you so much to Lee for helping to kick off the show today. We are going to be hearing more from him, so stay tuned. And now it's time to get back into the article. Our show ended last week by talking about the local anesthetic systemic toxicity checklist. We are going to start by reviewing it now. I will include this checklist in the show notes as well. This is figure one from the article.
Alli Bechtel:
Here are the first steps Call for help, get the last rescue kit, consider cardiopulmonary bypass team and with these three steps, also consider early administration of lipid emulsion. From here we are going to review the lipid emulsion administration box. Keep in mind that the order of administration bolus or infusion and method of infusion manually IV roller pump are not critical. For over 70 kgs, bolus 100 mLs over 2 to 3 minutes and then 250 mLs over 15 to 20 minutes. If the patient remains unstable, repeat the bolus and double the infusion. For less than 70 kgs, bolus 1.5 mLs per kg over 2-3 minutes and then infuse 0.25 mLs per kg per minute. Consider using a pump for patients who are less than 40 kgs. If the patient remains unstable, then repeat the bolus and double the infusion. Now, if we continue with the algorithm.
Alli Bechtel:
If the patient has a seizure, the next steps are ensure adequate airway benzodiazepine preferred If only propofol is available. Consider low dose of about 20 mg increments If the patient has an arrhythmia or hypotension. Remember that last resuscitation is different from standard ACLS. Make sure that you avoid local anesthetics, beta blockers, calcium channel blockers and vasopressin. For epinephrine, a smaller-than-normal dose is preferred. So start with less than 1 microgram per kg For patients who remain stable. Continue the lipid emulsion for more than 15 minutes after hemodynamic stability has been achieved. The maximum dose of lipid emulsion is 12 mLs per kg Once stable. Continue to monitor the patient for 2 hours after a seizure, 4 to 6 hours after cardiovascular instability and, as appropriate, following a cardiac arrest. Phew, we made it to the end of the checklist and that was a great review, so that we are ready in case of a last event.
Alli Bechtel:
Do you perform your blocks on patients who are awake or under sedation, or perhaps under general anesthesia? There is a case report published in 1998, of a thoracic epidural that was placed in a patient under general anesthesia. The patient suffered a spinal cord injury and permanent paraplegia after four attempts at epidural placement. What about peripheral nerve blocks, though?
Alli Bechtel:
There is not a lot of literature on the safety and risks of regional blocks in adults under general anesthesia. For pediatric patients, it is considered safe to perform regional blocks under general anesthesia. The Pediatric Regional Anesthesia Network is a multi-institutional research consortium which contains a registry of over 50,000 regional anesthetic blocks in pediatric patients under 18 years old. Check out the study. Asleep vs Awake Does it Matter? Pediatric Regional Block Complications by Patient State, a report from the Pediatric Regional Anesthesia Network. I will include the citation in the show notes as well. The results reveal postoperative neurologic symptoms under general anesthesia at a rate of 0.93 per 1,000, compared with 6.82 per 1,000 in sedated and awake patients, with no cases of paralysis and only one case of a small sensory deficit in a sedated patient that lasted for more than six months. The authors of this study concluded that regional anesthetic blocks in pediatric patients under general anesthesia is as safe as in sedated or awake children. This was a prospective study that supports the prevailing standard of care in pediatric anesthesia for placing blocks in anesthetized patients. In adult patients, the more common practice is performance of regional blocks prior to induction of general anesthesia. It is likely that sedation may be beneficial to improve safety and success of the block with greater patient satisfaction. Going forward, we need more studies to evaluate the risk and benefit for regional anesthesia under general anesthesia in adult patients.
Alli Bechtel:
Next up, we are talking about prevention of wrong-sided blocks. These are never events that still occur, actually at a rate of 7.5 per 10,000 procedures. First, let's define never event. This is an egregious medical error that should never happen and was first introduced in 2001 by Ken Kaiser, the former CEO of the National Quality Forum. The term also includes adverse events that are unambiguous, serious and usually preventable, and usually preventable. The first never event list was created in 2002, and now there are seven categories with 29 serious reportable events. Check out Table 1 in the article for a list of factors that contribute to wrong-sighted blocks. We are going to review the list now Failure to verify site preoperatively, failure to mark area adequately by the surgeon, rushed, inadequate or absent, anesthesia timeout Distractions, patient position changes, scheduling changes and poor communication.
Alli Bechtel:
There are important steps to take to help keep patients safe and avoid this big threat to anesthesia patient safety. Before starting your block, make sure to perform a visual confirmation of the correct block location with the patient and nurse according to your institution-specific standards. Maybe that patient has a wristband marked with the word yes on the side corresponding to the surgery, or a clear mark by the surgeon and anesthesiologist performing the procedure. It is important for the patient to participate in the process prior to administration of sedation or anesthesia to help decrease errors and improve patient satisfaction and patient safety. This transforms patients into active participants and helps improve confidence in the healthcare professionals taking care of them. Another important consideration is for the anesthesia professional performing the block to discuss the operative procedure with the patient before providing anesthesia or sedation. The next step is for the patient to verbalize agreement with the correct procedure and surgical site, with documentation of the discussion and patient verbalization on the consent form. Communication barriers for patients with sight and hearing impairments or non-English speaking patients, or depending on the emotional status, need to be considered as well, so that the patient can participate fully in the preoperative discussions, with appropriate documentation in the medical record, such as including the interpreter's ID number. The responsibilities for the pre-procedural nurse or procedure team include the following Verify documentation such as the consent form, history of present illness and diagnostic data. Identify any discrepancies or uncertainties. Discuss these discrepancies with the surgical team prior to starting the procedure.
Alli Bechtel:
We are just about ready to perform the peripheral nerve block, the responsible anesthesia professional should use the universal protocol and take a pre-procedural timeout. Check out figure 2 in the article for a visual depiction of a pre-procedure timeout, which should be performed immediately prior to incision or starting the nerve block. This needs to be performed in the same location as where the procedure will be performed. So if you are performing the block in the operating theater, then the timeout needs to be conducted in the operating theater as well. The team members participating in the block theater, then the timeout needs to be conducted in the operating theater as well. The team members participating in the block need to be involved in the timeout, and this includes the anesthesia professional performing the block, the circulating nurse and any other active participants who will be performing the procedure. Let's review the steps in the timeout.
Alli Bechtel:
Let's review the steps in the timeout First confirm patient identity using two patient identifiers, including name and date of birth. Confirm agreement with the procedure that is to be done. Verify the correct side and site. Verify the anticoagulation status and any allergies. Proceed with the block or procedure. We made it to the end of the article. The authors highlight that regional anesthesia is a safe supplement or alternative to general anesthesia, with benefits that include improved patient satisfaction and decreased opioid usage. Anesthesia professionals must ensure maximum safety while delivering excellent care. Important safety considerations include using ultrasound guidance when available, being able to recognize and provide treatment for last, and executing pre-procedural checklists to avoid the never event of a wrong-sided block. Thank you to the authors for highlighting these important regional anesthesia patient safety considerations. Before we wrap up for today, we are going to hear from Lee again. I also asked him what is next for his research in this area. This is what he had to say.
Paul Lee:
My research largely centers most around regional anesthesia and enhanced recovery after surgery. Some of our upcoming projects include looking at utility of oral methadone and outpatient orthopedic surgeries and another project looking at the role of a PEX2 block for arthroscopic rotator cuff repairs. My hope is that these projects will add to the expanding research in our community, further improving upon our surgical patients' satisfaction.
Alli Bechtel:
Thank you so much to Lee for contributing to the show today. We will stay tuned to learn more about these exciting projects going forward. If you have any questions or comments from today's show, please email us at podcast at apsforg. Please keep in mind that the information in this show is provided for informational purposes only and does not constitute medical or legal advice. We hope that you will visit apsforg for detailed information and check out the show notes for links to all the topics we discussed today. And check out the show notes for links to all the topics we discussed today.
Alli Bechtel:
The APSF newsletter is published three times a year. We are still discussing the amazing February newsletter articles and the next newsletter release is fast approaching, in June. There are also new articles published in between newsletter releases over at APSForg. Have you read any of these articles yet? The APSF Workplace Violence Prevention Video Triggered Workshop, published online on March 11, 2024. An article between issues Teamwork in the Operating Room an Essential for Patient Safety, published on the 8th of April 2024. And an In the Literating Room, an Essential for Patient Safety, published on the 8th of April 2024. And an In the Literature article a dose-finding study of Sigamidex for reversal of rocuronium in cardiac surgery patients and postoperative monitoring for recurrent paralysis, published on April 15th 2024. Head over to APSForg and click on the patient safety resources. Fourth one down is news and updates. We hope that you will check these out. Until next time, stay vigilant so that no one shall be harmed by anesthesia care.