#207 Patient Safety During Prone Positioning, Loss of Resistance Syringe Concerns, and Lidocaine versus Fentanyl for Induction
Jun 18, 2024
Anesthesia Patient Safety Foundation
Unlock the essential strategies for ensuring patient safety during anesthesia in the prone position! On this episode, host Alli Bechtel welcomes Taizoon Dhoon, an associate professor at the University of California, Irvine, who shares his expertise from his recent article in the APSF newsletter. Dhoon sheds light on the often-overlooked risks of prone positioning, detailing the physiological changes and positioning injuries that can arise. This discussion is a treasure trove of knowledge for anesthesia professionals, aiming to elevate patient care practices and enhance collaborative efforts among medical teams.
Our journey begins with an in-depth review of recommended practices and preoperative considerations, emphasizing the critical role of thorough exams, patient history evaluations, and cardiac assessments. Discover the actionable steps you can take to improve safety, from pre-surgical planning to additional monitoring during procedures. Whether you're an experienced anesthetist or new to the field, this episode provides the insights and tools you need to navigate the complexities of prone positioning with confidence and precision. Tune in and empower your practice with expert advice and practical recommendations.
We are covering two bonus articles to discuss concerns with the Perifix® L.O.R. syringe (B-Braun, Melsungen, Germany) that is used with the loss of resistance (LOR) technique to confirm the epidural space, and we are diving into the literature. Our literature review summary takes you through the 2023 article, "Comparison of the hemodynamic effects o opioid-based versus lidocaine-based induction of anesthesia with propofol in older adults: a randomized controlled trial."
Unlock the essential strategies for ensuring patient safety during anesthesia in the prone position! On this episode, host Alli Bechtel welcomes Taizoon Dhoon, an associate professor at the University of California, Irvine, who shares his expertise from his recent article in the APSF newsletter. Dhoon sheds light on the often-overlooked risks of prone positioning, detailing the physiological changes and positioning injuries that can arise. This discussion is a treasure trove of knowledge for anesthesia professionals, aiming to elevate patient care practices and enhance collaborative efforts among medical teams.
Our journey begins with an in-depth review of recommended practices and preoperative considerations, emphasizing the critical role of thorough exams, patient history evaluations, and cardiac assessments. Discover the actionable steps you can take to improve safety, from pre-surgical planning to additional monitoring during procedures. Whether you're an experienced anesthetist or new to the field, this episode provides the insights and tools you need to navigate the complexities of prone positioning with confidence and precision. Tune in and empower your practice with expert advice and practical recommendations.
We are covering two bonus articles to discuss concerns with the Perifix® L.O.R. syringe (B-Braun, Melsungen, Germany) that is used with the loss of resistance (LOR) technique to confirm the epidural space, and we are diving into the literature. Our literature review summary takes you through the 2023 article, "Comparison of the hemodynamic effects o opioid-based versus lidocaine-based induction of anesthesia with propofol in older adults: a randomized controlled trial."
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.
Speaker 2:
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. For the past two weeks, we have discussed the underappreciated dangers of the prone position for patients during anesthesia care. This is an important time to remain vigilant, since patients are at risk for positioning injuries as well as significant physiologic changes while in the prone position. Today we are going to hear from one of the authors of the APSF newsletter article. Then it's time to catch up on a couple more articles between issues, so stay tuned.
Speaker 2:
Before we dive into the episode today, we'd like to recognize BD, a major corporate supporter of APSF. Bd has generously provided unrestricted support to further our vision that no one shall be harmed by anesthesia care. Thank you, bd. We wouldn't be able to do all that we do without you. We are returning to the article between issues the underappreciated dangers of the prone position, published on the 30th of April 2024, and written by Taizun Dun and colleagues. To follow along with us, head over to apsforg and click on the newsletter heading to APSForg and click on the newsletter heading. The second one down is Articles Between Issues and from here scroll down until you get to our featured article today, I will include a link in the show notes as well. To help kick off the show today we are going to hear from one of the authors. Here he is now.
Speaker 3:
Hi, my name is Taizun Doon. I'm an associate professor at the University of California, Irvine, and serve as a vice chair for quality and patient safety for the Department of Anesthesiology and Perioperative Care.
Speaker 2:
I asked Doon why he wrote this article. Let's take a listen to what he had to say.
Speaker 3:
Let's take a listen to what he had to say, the goal of our article is to review the potential injuries associated with the prone position, but also focus on the physiologic changes that occur with it. In our article, we really wanted to focus on the physiologic changes that can occur with the prone position. This type of understanding is crucial in high-risk patients, even those undergoing a low-risk procedure. For example, a patient with cardiopulmonary disease may not be able to tolerate an ERCP in the prone position due to the potential changes that can occur.
Speaker 2:
I also asked Dune what he hopes to see going forward. Here is his response.
Speaker 3:
The goal of our article was to raise awareness and understanding among anesthesia professionals about the potential pressure-related injuries and physiologic changes that can occur when the prone position is used. We hope that this knowledge will improve communication and collaboration between anesthesia professionals with our surgical and procedural colleagues and, in turn, enhance patient care.
Speaker 2:
Thank you so much to Dune for contributing to the show today and for your excellent article. Before we move on to our next article, between issues, let's do a quick review of the recommendations for keeping patients safe during anesthesia care in the prone position. Let's start with preoperative considerations, which include the following Complete a thorough and focused preoperative exam for all patients who will require prone positioning, with consideration for patient history, airway examination and pre-existing neurological deficits. Discuss the anticipated duration of the procedure and proposed positioning. Evaluate the patient's capacity for prone positioning depending on comorbidities and risk factors. If needed. Attempt positioning in the desired position with the patient in an empty operating room before the day of surgery to demonstrate that it is possible to safely obtain prone positioning. Document with photographs, important details and extra equipment that may be needed for safe positioning on the day of surgery. Complete a preoperative cardiac evaluation with consideration for functional status and exercise capacity. It is important to have a low threshold for further testing in high-risk patients. Stress echocardiography can help to determine the risk of ischemic heart disease, as well as provide vital information about right ventricular function, pulmonary hypertension and valvular heart disease. Plan for additional monitoring and appropriate access, with availability of inotropes, vasopressors and pulmonary vasodilators if needed. It's time to move into the operating room. Interoperative considerations include the following Secure the endotracheal tube carefully to prevent dislodgement or malposition. Obtain appropriate peripheral and central access, as well as intra-arterial catheter placement while supine prior to positioning prone Teamwork. During prone positioning, with about five to six team members, including the anesthesia professional and surgeon, to ensure careful and safe positioning for the surgery or procedure. Careful arm positioning with movement of the arms independent of the other arm to prevent shoulder joint injury, especially during the initial prone positioning and during the repositioning supine at the end of the case. Keep the axilla free from tension. Additional padding may be needed around the ulnar nerve. No-transcript.
Speaker 2:
Once the patient is in the prone position, you have more work to do. First, check the vital signs. Is the patient hemodynamically stable? Are your monitors working? The bed should remain in the room until hemodynamic stability is confirmed. For patients who become unstable once in the prone position, it is possible to quickly reposition, supine and resuscitate. Evaluate and treat the cause of the hemodynamic changes without delay. Next, make sure that appropriate padding is used to help keep your patient safe Throughout the case. You will need to check pressure points as well as the eyes, mouth and neck for proper positioning to help prevent any pressure-related injuries. Post-operative considerations, once the patient has been repositioned supine, include determining the safe time to extubate, depending on the presence of any facial, lingual and glottic edema. Patients with significant edema may need to remain intubated and monitored in the intensive care unit until the edema has resolved and it is safe to extubate. Patients who can be extubated at the end of the case may require higher levels of care postoperatively in the intensive care unit, depending on the patient's comorbidities, the surgical procedure and any significant hemodynamic changes. Anesthesia professionals are charged with understanding the patterns of pressure-related injuries and physiologic changes that may occur during a procedure in the prone position and remain vigilant to help keep patients safe.
Speaker 2:
And now it's time to move on to another article between issues. Here we go. Our next featured article is from April 16, 2024, and it is Loss of Resistance, epidural Syringes with a Retraction Stop and the Risk of Accidental Dural Puncture, by Tatsumi Yakushuji and colleagues. To follow along with us, head over to APSForg and click on the newsletter heading Second. One down is article between issues, and then scroll down until you get to our featured article today. I will include a link in the show notes as well.
Speaker 2:
This is a letter to the editor about the Perifix LOR syringe by B Braun that is designed to be used for the loss of resistance technique during epidural placement. To detect the epidural space. This syringe is designed to slide easily with minimal contact area between the barrel and the plunger. There is a stop built into the syringe at the back of the barrel to prevent the plunger from being pulled out of the barrel during retraction. Check out figure 1 in the article, which is a photograph of the syringe with the plunger pulled back to the built-in stop. This is marked by the black arrow. At this point the plunger tip should stop at the number eight on the syringe, which is the white arrow. The authors describe being able to retract the plunger past the stop by applying a bit more force. Once the plunger is pulled back past the stop, then it is not possible to re-engage the plunger back into the barrel easily. This makes sense because the syringe is not designed for the plunger to be able to be pulled beyond the built-in stop in the first place. As a result, if the syringe was inadvertently pulled past the stop during epidural placement, there is a risk for accidental dural puncture because the loss of resistance will not occur even though the needle tip reaches the epidural space.
Speaker 2:
Now it's time to head over to the In the Literature section. Our third featured article is a summary of the study Comparison of the Hemodynamic Effects of Opioid-Based vs Lidocaine-Based Induction of Anesthesia with Propofol in Older Adults a Randomized Controlled Trial A randomized controlled trial. This summary was completed by Sud and Panday and published on the APSF website on April 29, 2024. This summary is of the April 2023 article in Anesthesia, critical Care and Pain Medicine by Amin and colleagues. Check out the show notes for the full citation and the link to the APSF summary article. Here's the summary.
Speaker 2:
This was a randomized controlled trial conducted in Cairo University to compare the hemodynamic profiles of lidocaine versus opioid-based induction with propofol. 100 patients were included in the study and met the criteria of age, over 60 years old, asa 1 to 3, and undergoing non-cardiac surgery. Induction of anesthesia involved patients receiving 1 mg per kg of lidocaine in the lidocaine group or 1 microgram per kg of fentanyl in the fentanyl group. With propofol induction. Hypotension was defined as mean arterial blood pressure less than 65 mmHg or a greater than 30% reduction from the patient's baseline. Results revealed the following 0% or 0 out of 47 patients in the lidocaine group developed hypotension. 61%, or 28 out of 46 patients, developed hypotension in the fentanyl group and 13% developed severe hypotension in the fentanyl group and 13% developed severe hypotension. The mean blood pressure dropped in both groups from pre-induction level, with a more pronounced decrease in the fentanyl group. One patient in the fentanyl group experienced bradycardia as well. Intubation conditions were similar between the two groups. In conclusion, lidocaine-based regimen reduced post-induction hypotension in older patients when compared with a fentanyl-based induction.
Speaker 2:
Are you using lidocaine or fentanyl for induction for older patients? Will this article change the way you practice? The In the Literature section is a great way for you to stay up to date on the latest in perioperative patient safety. 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. The June 2024 APSF newsletter has been released. We are so excited to feature many of these excellent articles here on the podcast. In the meantime, you can check out the articles online over at APSForg and click on the newsletter heading. The first one down is the current issue, which is now the June 2024 APSF newsletter. Stay tuned for all new podcast episodes on these articles soon. Until next time, stay vigilant so that no one shall be harmed by anesthesia care.