WHO Surgical Safety Checklist & Mortality

A large population cohort study in a surgical setting in Scotland finds a remarkable 36% relative decrease in perioperative mortality since implementation of the WHO Surgical Safety Checklist.

No such trend in improvement was observed in the non‐surgical cohort. While causality is always difficult to prove, no other baseline demographics changed to explain the results. Most importantly, “This study provides further evidence that the success of checklist implementation is more pronounced when it is supported by a cohesive and wider approach to patient safety”, and also stresses the importance of “creating a culture of communication and teamwork that supports patient safety”.

Full text

Aluminum Release by Fluid Warmers

Many fluid and blood warming devices exist. Some use disposable aluminum (aluminium) coated plates in their cartridges; these may be coated or uncoated, the latter allowing the fluid to be in direct contact with the heated aluminum plate.

This study compared the two systems. They found that uncoated aluminium plates in an enFlow warmer can lead to a risk of administering potentially harmful concentrations of aluminium when balanced crystalloid solutions are used; by contrast, normal saline showed only small increases. The mechanism is unclear, but heat, low flow and longer infusion caused striking increases in Aluminum release.

Aluminum has been linked to neurological injury (especially in neonates), encephalopathy, osteomalacia, and renal injury.

Coating for aluminium within medical devices in direct contact with infusion fluids is recommended, but further studies on what implications these findings have for health and safety are needed.

Many hospitals have withdrawn the devices for now.


Global Safe Anesthesia

The APSF summarize the basic standards of anesthesia safety as iterated by the World Health Organization – World Federation of Societies of Anaesthesiologists, and the SAFE-T summit.

It estimates 5 billion people do not have access to safe surgery and anesthesia and advocates for basic training and competence in individuals dedicated to anesthesia, as well as the drive to make both pulse oximetry and capnography as basic universal standards of monitoring, if only aspirational for now.


Global Capnography

As the heading suggests, an editorial and article makes a plea to make global capnography available and affordable as a standard of care especially in low and middle income countries to prevent avoidable deaths from esophageal intubation.

Much progress has been made on global oximetry projects such as the ASA Lifebox and other western countries supplying pulse oximetry to low and middle income countries, a standard of care (aspirational sometimes) of anesthesia. Now the effort is on to also make capnography a basic standard, which will recognize esophageal intubation or obstruction/ ventilation failure faster than the oxygen saturation shows.

Both monitors are recommended in the recently published World Health Organization – World Federation of Societies of Anaesthesiologists (WHO‐WFSA) standards.


Failed Laryngoscopy and Intubation

The full text review is gated for non subscribers but provides a thoughtful reflection on terminology, preparation, skill acquisition, VortexApproach , SGAs, eFONA etc.

Some practical advice is also offered on topics such as apneic nasal oxygenation to prolong time to desaturation, bougie assisted supraglottic airways, and the steps in emergency front of neck airway (eFONA), reviewed elsewhere in this blog – blog link

Optimimizing using ‘best effort” in each part is emphasized: facemask, supraglottic airway, and intubation, leaning on the philosophy of the Vortex Approach ( link )

Journal link

Anesthesia in MRI Units

A full text guidance from Anaesthesia for anesthesia providers in MRI units. The focus is on having leaders, and properly trained and experienced staff familiar with the challenges of the MRI unit. Detailed descriptions of anesthesia administration and monitoring are provided along with discussion of devices and their classification as safe, conditional or unsafe.


Summary Infographic

Adverse Effects of Medical Treatment and Mortality

Mortality from adverse effects of medical treatment has shown a modest decline in the US over a couple of decades although geographical variation was observed. Important flags for perioperative care are signalled by the breakdown: 8.9% were due to adverse drug events, 63.6% to surgical and perioperative adverse events, 8.5% to misadventure, 14% to adverse events associated with medical management, 4.5% to adverse events associated with medical or surgical devices, and 0.5% to other.

Other salient features not unexpected were the large representation of the elderly, but also the young, including neonates.


Previous work has highlighted that there is a need for comprehensive geriatric assessment in the elderly with comorbidity, frailty and polypharmacy ( link ), and the young may benefit from specialized pediatric care also ( link )

OR Fires

Another (gated) review seeks to bring attention to the issue of Operating Room fires. It reviews the “fire triangle” of ignition, fuel and oxidizer; the contribution and risks of such factors as electrosurgery, laser, drills, fibreoptic light sources, defibrillators, alcohol skin prep, intestinal gas, drapes and oxygen.

Oxygen is one of the key modifiable factors and advice is to maintain FiO2 below 30%. Over 80% of all OR fires are in surgery on the head, neck and upper chest and a similar percentage under sedation, where local oxygen concentrations can easily increase with nasal cannula flow above (or even less with draping) 4l/min. A lethal combination of oxygen, drapes and alcohol based preps can develop waiting for the cautery to spark a fire, particularly lethal near the patient airway.

Should a fire occur, recommendations are to stop the flow of all airway gases, disconnect the breathing circuit, remove tracheal tubes in airway fires and irrigate with saline, and remove burning materials, extinguish the fire and restore room air breathing.

Fire risk should be included in checklists at briefing and/or timeouts.


A (free!) guideline is also available from the FDA here

WHO Surgical Safety Checklist In Emergency Laparotomy

A global cohort study explored the use and impact of the WHO Surgical Safety Checklist in emergency laparotomy. Once again, the findings were striking in that checklist use in emergency laparotomy was associated with a significantly lower perioperative mortality rate. Checklist use in low‐Human Development Index (HDI) countries was half that in high‐HDI countries.

The authors importantly note that the association with lower mortality “is likely to reflect broader health system differences that prioritize safe and effective surgical care, yet the checklist plays an important part”. It focuses a team on better communication, collaboration, empowerment and behavioural changes.


ICDs and Electromagnetic Interference

Bipolar cautery is ideal to minimize electromagnetic interference with Implantable Cardioverter Defibrillators (ICDs).

Where monopolar is used, this study employed protocolized placement of electrosurgery dispersive electrode positioning to divert return current away from the ICD. They found no interference from below-umbilicus procedures but 7% in above-umbilicus procedures and as high as 29% in cardiac surgery (using underbody Megadyne, described as alarmingly high!).

The findings support recommendations that reprogramming and suspending anti-tachycardia functions may be unnecessary in below-umbilicus procedures. However higher risk exists in above-umbilicus procedures and especially in cardiac surgery and underbody dispersive electrodes.