Safe Anesthesia Medication Handling

Anesthesia is unique in terms of rapid injection of multiple medications often in a time critical fashion, and it is reported that medication error occurs 1-in-133 administrations. The authors of this Anaesthesia editorial argue for making safe medication handling a core competency in training. They also make several safety suggestions:

Handle one medication at a time.

Avoid distractions while preparing medications.

Check every vial  twice, once before drawing up and once after labelling

All syringes, including iv bags are labelled, ideally with standard colour‐coded labels.

Standard order and syringe sizing for each medication type

Do not draw up medications until they are needed.

Use a red‐barrelled syringe for NMBAs and draw up the whole ampoule into syringe (not available everywhere)  and never reuse a red‐barrelled syringe for reversal; do not place on work surface at the same time as reversal agents

Medications for emergencies, non-IV use, or specific purposes are not kept in the same place as i.v. medications.

All i.v. access points must be flushed or have a running i.v. line before leaving the OR

All medication‐related adverse events must be reported via an incident reporting system.



Intranasal Pediatric Sedation

Young children undergoing trans-thoracic echocardiography were sedated with intranasal Dexmedetomidine 2mcg/kg plus Ketamine 1mg/kg.  Sedation was successful in 96%, onset being about 16 minutes. Cyanotic heart disease, history of sedation failure, history of congenital heart disease surgery, and fever were independent risk factors for sedation failure. There were no serious adverse cardiorespiratory side effects.

This non-opioid combination was found to be effective with an acceptable safety profile.



Safe Use Of High-Flow Nasal Oxygen (HFNO)

The Anesthesia Patient Safety Foundation provide an excellent overview of the popular and expanding use of High Flow Nasal Oxygen (HFNO), devices which are in many cases supplanting BIPAP, and  used to provide apneic ventilation during intubation, as well as post extubation and weaning from ventilation. This review also adds some caution, in particular the danger of fire, and contraindications.



Physician Burnout

We are in the midst of an epidemic of physician fatigue, burnout, depression and suicide, concepts previously unspoken and felt to be signs of weakness in the ‘resilient ‘ physician.

A meta-analysis of 47 studies encompassing over 42,000 physicians found that burnout is associated with 2-fold increased odds for unsafe care, unprofessional behaviors, and low patient satisfaction. Depersonalization was in particular linked, and the findings were stronger in early career physicians.

The authors recommend that organizations invest in efforts to improve physician wellness, particularly for early-career physicians.




Time of Day and Emergency Surgery Mortality

Some studies have suggested worse outcomes and higher mortality in surgery after hours and in particular at weekends, although others did not corroborate  (see ‘weekend effect’ link ). One of the postulated mechanisms is fewer resources, staff and backup.

This single center study was in emergency surgery and did not identify an association of time of emergency surgery, categorised into one of three epochs (day, evening and night) with death up to 30 postoperative days. They do advise further larger studies with longer follow up to verify these findings. A large and sometimes disparate mix of emergencies including general, neuro, Cesarean under regional and sedation-only was studied  with minimal comorbidity information other than ASA status.




Anti-Psychotics for Delirium

The use of anti-psychotics for critical illness delirium has been controversial with a trend towards lack of beneficial effect for treatment or prophylaxis.  This latest study shows: “The use of haloperidol or ziprasidone, as compared with placebo, in patients with acute respiratory failure or shock and hypoactive or hyperactive delirium in the ICU did not significantly alter the duration of delirium.”

Non-pharmacological management remains the ideal goal although some would still use as a last resort for patient or staff safety.

NEJM link


Procedural Sedation- CAS Position Paper

A position paper from the Canadian Anesthesiologists’ Society on procedural sedation, incorporating patient selection and pre-procedural assessment and monitoring. A dedicated provider for deeper sedation is advised along with developing institutional guidelines and policies. Monitoring of oxygen saturation and capnography are vital. Fasting guideline as per ASA are recommended in all but the lightest sedation scenarios. Rescue equipment and medications should be available. Proper recovery and discharge assessment is required, such as the use of modified Aldrete scoring.