SPA Annual Meeting Reviews
Session III: PEDx Lecture: Error Traps in Out-of-OR Anesthesia
Reviewed by Sharon A. Ashley, MD, MPH, MBA
Professor, University of California, Davis
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Dr. Ashley |
Error Traps in Out-of-OR Anesthesia
Elizabeth Eastburn, DO
Elizabeth Eastburn, DO, Harvard Medical School began by identifying the locations where anesthesia services are provided out of the operating room including; Interventional Radiology, Cath Lab, MRI, GI Procedure Unit, Nuclear Medicine and Radiation Oncology. She stated there are several common problems for all of the non-operating room anesthesia (NORA) units: Equipment – the MRI compatible pumps and monitors can present problems with function and programming. Her conspiracy theory:
Pharmacokinetics, pharmacodynamics, and metabolism of all anesthetics are different when administered in non-operating room settings.
Communication with proceduralists presents unique issues including; variable or unknown duration of the procedure, unfamiliarity with the procedure and the risks, variable positioning of the patient, and care for critically ill patients. All these issues can prolong the procedure or add to the complexity of the case.
How do we communicate effectively with our peers in NORA situations? The common conversations should include the following in remote areas:
Necessity versus convenience is the rate limiting factor and we commonly hear, this is “just a quick study/scan/procedure, patient just needs a ‘little bit of sedation’.” She reminded us that this is the real problem and that our colleagues do not have a clear picture of the risks of anesthesia in sick and healthy patients in NORA locations. We must remember that we are typically located away from colleagues and quick support in an emergency situation.
Dr. Eastburn reminded us: DO NOT PANIC.
A case was presented of a 2-year-old with failing single ventricle physiology who requires MH precautions. She advised that we should get all of the details, share your mental model with colleagues/radiologists, be explicit, and dispel assumptions. Use the huddle to voice concerns and make plans for a crisis scenario. Include the support staff and do a verbal run through of what to do if there is a dysrhythmia, airway difficulty, cardiac arrest, vascular access, or unplanned PICU admission.
For EMERGENCIES IN NON-OPERATING ROOM SYSTEMS, Dr. Eastburn suggested the following:
Because there may also be barriers to provide safe care, she suggests:
- Establish a reliable stat alert system. Discuss and perform in situ and multidisciplinary simulation of problems in the remote area.
- SIMULATION
- Remember that there is limited access to the patient – come out of the scanner
- The area is often dark – Magnet is always on!
- Equipment and medications are in non-standard locations on the cart – check supplies, emergency drugs, inform the nursing staff of the location of critical items
- Unfamiliar with procedure – talk with the Radiologists to gain information
- Unfamiliar with you – make sure that the team knows who you are
- How to call for help: establish a protocol before induction PRACTICE IT/SIMULATE.
In summary, Dr. Eastburn reminded us that NORA is like being in space: NO ONE CAN HEAR YOU SCREAM!
