Anaesthesia
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We present the use of the SensaScope, an S-shaped rigid fibreoptic scope with a flexible distal end, in a series of 13 patients at high risk of, or known to have, a difficult intubation. Patients received conscious sedation with midazolam or fentanyl combined with a remifentanil infusion and topical lidocaine to the oral mucosa and to the trachea via a trans-cricoid injection. Spontaneous ventilation was maintained until confirmation of tracheal intubation. ⋯ Difficulties included a poor view associated with a bleeding diathesis and saliva, transient loss of spontaneous breathing, and difficulty in advancing the tracheal tube in a patient with unforeseen tracheal narrowing. A poor view in two patients was partially improved by a high continuous flow of oxygen. The SensaScope may be a valuable alternative to other rigid or flexible fibreoptic scopes for awake intubation of spontaneously breathing patients with a predicted difficult airway.
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Comparative Study
Histopathological effects on epidural tissue of bolus or continuous infusions through an epidural catheter in ewes.
This study was performed to evaluate the histopathological effects of epidural drug injection given either by intermittent bolus or continuous infusion through a catheter on epidural tissue. Fourteen ewes received intermittent bolus injections of morphine with bupivacaine, or a bolus of the same drugs followed by continuous infusion for 5 days. After 5 days, histopathological examination of the epidural space revealed mild to moderate inflammatory changes, and focal fibrosis surrounding the catheter in all ewes. The similarity of the inflammatory reaction in the control and drug treated groups seems to indicate that neither intermittent bolus or continuous infusion after a bolus dose caused histopathological changes in the epidural space beyond that caused by the catheter itself.
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Multicenter Study Controlled Clinical Trial
Clinical assessment of a new anaesthetic drug administration system: a prospective, controlled, longitudinal incident monitoring study.
An interesting and thought-provoking study, even with its flaws.
The authors concluded that system changes surrounding anaesthetic drug delivery reduce medication error.
A ‘care bundle’ approach was taken to improve drug safety through system design and human factors considerations:
- Coloured drug labels with barcodes.
- Computerised drug crosscheck.
- Computerised allergy and drug expiration alerts.
- Re-organised anaesthesia workplace, focusing on the drug administration workflow.
- Prefilled syringes for: calcium chloride, ephredrine, fentanyl, lidocaine, magnesium sulphate, metaraminol, midazolam, neostigmine, and pancuronium.
- Automated computerised anaesthetic record.
But the problems...
No randomisation, no blinding, observational study, completely voluntary use of the safety system and self-reporting of errors...
Were the improvements due to the intervention, or simply a greater interest and priority given to anaesthetic safety? (Would it matter?)
In only 15% of anaesthetics was the new system (voluntarily) used, and thus may represent anaesthetists more motivated to prioritise medication safety over convenience or convention.
Finally error is being used (not unreasonably) as a surrogate marker for patient harm. (Although the authors did try to sneak in... “a non-significant reduction (p=0.055) in the harm attributable to drug administration error” 🙄)
Final word of caution
Even this quite impressive system was not immune to error. There were 19 cases of violation of the video and/or audio crosscheck before drug administration. Automated safety systems are obviously no panacea.
Additionally, although there was an observed reduction in all drug errors, there was no reduction specifically in drug substitution error.
Nonetheless a refreshing and novel approach to anaesthetic drug safety, beyond the typical admonishment to just be safer.
More on the system used:
- Webster (2001): The frequency and nature of drug administration error during anaesthesia
- Merry (2001): A new, safety-oriented, integrated drug administration and automated anesthesia record system
- Webster (2004): A prospective, randomised clinical evaluation of a new safety-orientated injectable drug administration system in comparison with conventional methods.