NEWSLETTER The Official Journal of the Anesthesia Patient Safety Foundation Volume 26, No. 2, 21-40 Circulation 94,429 Fall 2011 www.apsf.org ® Inside: Tribute to Jeep Pierce ......................................................................................................Page 23 Methadone Article References .......................................................................................Page 28 Dear SIRS: Reusable Anesthesia Breathing Circuits Considered .........................Page 30 Threshold Monitoring, Alarm Fatigue, Patterns of Death .......................................Page 32 Donors .......................................................................................................................... Pages 36-37 Dr. John Walsh Receives Cooper Patient Safety Award ...........................................Page 38 Monitor Displays: Non-Moving vs. Moving Waveforms...................................................... 39 Letters to the Editor ............................................................................... Pages 25, 27, 29, 38, 39 See “Monitoring,” Page 26 2) If “Yes” to electronic monitoring, who should be mon- itored (inclusively or selectively) and what monitors/ technology should be utilized? Dr. Stoelting opened the conference by asserting that continuous electronic monitoring of oxygenation and/or ventilation may allow for more rapid diagno- sis and prevention of drug-induced, postoperative respiratory depression. He commented that we cannot wait for the perfect technology before we intervene, and that “maintaining the status quo in hopes that a different result will occur is unrealistic.” He noted that the goal of the conference was to utilize the available evidence to discern the best monitoring strategies for providing effective early warning of postoperative respiratory depression. Dr. Overdyk followed and noted that this compli- cation occurs more frequently and is much easier to detect than awareness under general anesthesia where significant resources have been invested in research and monitoring. He believes that this initia- tive should become a “national patient safety prior- ity.” Dr. Overdyk discussed research that demonstrated that approximately one-third of code blue arrests in hospitals are from respiratory depres- sion, 2 and that naloxone is administered in about 0.2- 0.7% of patients receiving postoperative opioids. 3,4 Following these introductory remarks, family members of patients who died from drug-induced respiratory depression recounted their loved ones’ medical tragedies. They all noted the lack of monitor- ing for their loved ones during their last days in the hospital after undergoing elective routine surgery. Matthew B. Weinger, MD, and Lorri A. Lee, MD, for the Anesthesia Patient Safety Foundation The APSF believes that clinically significant, drug-induced respiratory depression in the postop- erative period remains a serious patient safety risk that continues to be associated with significant mor- bidity and mortality since it was first addressed by the APSF in 2006. 1 The APSF envisions that “no patient shall be harmed by opioid-induced respiratory depression in the postoperative period,” and convened the second multidisciplinary conference on this serious patient safety issue in June of this year in Phoenix, AZ, with 136 stakeholders in attendance. The conference addressed “Essential Monitoring Strategies to Detect Clinically Significant Drug-Induced Respiratory Depression in the Postoperative Period.” Attendees included clinicians and researchers from nursing, anesthesia, and surgery (more than half of conference attendees), with representation from the Veterans Health Administration, the American Society of Anesthesiologists, the American Association of Nurse Anesthetists, American Academy of Anesthesiologists Assistants, American Hospital Association, American College of Surgeons, American Society of PeriAnesthesia Nurses, the Joint Commission, Association for the Advancement of Medical Instrumentation, American Society of Healthcare Risk Management, Institute for Safe Medication Practices, and other societies and non-profit agencies.Additionally, malpractice insurers and family members of patients who have died from this complica- tion provided input on the scope and impact of the problem, and representatives from the monitoring tech- nology industry (about one-fourth of attendees) dis- cussed the potential for improved monitoring of patients’ respiratory status in the postoperative period. Drs. Robert K. Stoelting, APSF president, and Frank J. Overdyk, adjunct professor of Anesthesiology at the Medical University of South Carolina, co-moderated the conference consisting of 24 brief presentations, 6 small breakout groups, and a discussion session. Two questions were posted to all speakers and audience members: 1) Should electronic monitoring be utilized to facilitate detection of drug-induced postoperative respiratory depression? They implored the group to enact changes immedi- ately that would prevent such future tragedies. Dr. Matthew B. Weinger, professor of Anesthesiology at Vanderbilt University, showed multiple studies that provide evidence for frequent use of naloxone for postoperative opioid-induced respiratory depression. He stated that the literature suggests that in the U.S. about 0.3% of postoperative patients receive naloxone rescue accounting for up to 20,000 patients annually. He further estimated that one-tenth of these patients suffer significant sequelae. Dr. Weinger also provided evidence demonstrating that all types of parenteral opioids and routes are involved in these events. He then discussed the reli- ability, sensitivity, specificity, and response time for the various types of monitors for oxygenation and ventilation to detect respiratory depression. For patients who are not intubated, pulse oximetry was the best monitor when supplemental oxygen was not being utilized. In the presence of supplemental oxygen, capnography fared best (see Table 1). 1 After this presentation, Dr. Nikolaus Gravenstein, a professor at the University of Florida, highlighted the remarkable observation that patients having vital signs checked every 4 hours are left unmonitored 96% of the time. He noted, as did many speakers, that supplemental oxygen may mask hypoventilation, and that under these circumstances pulse oximetry is a very late detector of respiratory depression. Lethal hypercarbia is possible despite normal oxygen “No Patient Shall Be Harmed By Opioid-Induced Respiratory Depression” [Proceedings of “Essential Monitoring Strategies to Detect Clinically Significant Drug-Induced Respiratory Depression in the Postoperative Period” Conference]
This document is posted to help you gain knowledge. Please leave a comment to let me know what you think about it! Share it to your friends and learn new things together.
Transcript
NEWSLETTERThe Official Journal of the Anesthesia Patient Safety Foundation
Volume 26, No. 2, 21-40 Circulation 94,429 Fall 2011
www.apsf.org
®
Inside: Tribute to Jeep Pierce ......................................................................................................Page 23Methadone Article References .......................................................................................Page 28Dear SIRS: Reusable Anesthesia Breathing Circuits Considered .........................Page 30Threshold Monitoring, Alarm Fatigue, Patterns of Death .......................................Page 32Donors .......................................................................................................................... Pages 36-37Dr. John Walsh Receives Cooper Patient Safety Award ...........................................Page 38Monitor Displays: Non-Moving vs. Moving Waveforms...................................................... 39Letters to the Editor ...............................................................................Pages 25, 27, 29, 38, 39
See “Monitoring,” Page 26
2) If “Yes” to electronic monitoring, who should be mon-itored (inclusively or selectively) and what monitors/technology should be utilized?
Dr.Overdykfollowedandnotedthatthiscompli-cationoccursmorefrequentlyandismucheasiertodetectthanawarenessundergeneralanesthesiawheresignificantresourceshavebeeninvestedinresearchandmonitoring.Hebelievesthatthisinitia-tiveshouldbecomea“nationalpatientsafetyprior-i ty.” Dr. Overdyk discussed research thatdemonstratedthatapproximatelyone-thirdofcodebluearrestsinhospitalsarefromrespiratorydepres-sion,2andthatnaloxoneisadministeredinabout0.2-0.7%ofpatientsreceivingpostoperativeopioids.3,4
Matthew B. Weinger, MD, and Lorri A. Lee, MD, for the Anesthesia Patient Safety Foundation
TheAPSFbelievesthatclinicallysignificant,drug-inducedrespiratorydepressioninthepostop-erativeperiodremainsaseriouspatientsafetyriskthatcontinuestobeassociatedwithsignificantmor-bidityandmortalitysinceitwasfirstaddressedbytheAPSFin2006.1TheAPSFenvisionsthat“no patient shall be harmed by opioid-induced respiratory depression in the postoperative period,”andconvenedthesecondmultidisciplinaryconferenceonthisseriouspatientsafetyissueinJuneofthisyearinPhoenix,AZ,with136stakeholdersinattendance.Theconferenceaddressed“EssentialMonitoringStrategiestoDetectClinicallySignificantDrug-InducedRespiratoryDepressioninthePostoperativePeriod.”
Attendeesincludedcliniciansandresearchersfromnursing,anesthesia,andsurgery(morethanhalfofconferenceattendees),withrepresentationfromtheVeteransHealthAdministration,theAmericanSocietyofAnesthesiologists,theAmericanAssociationofNurse Anesthet is ts , American Academy ofAnesthesiologistsAssistants,AmericanHospitalAssociation,AmericanCollegeofSurgeons,AmericanSociety of PeriAnesthesia Nurses, the JointCommission,AssociationfortheAdvancementofMedical Instrumentation,American Society ofHealthcareRiskManagement, Institute forSafeMedicationPractices,andothersocietiesandnon-profitagencies.Additionally,malpracticeinsurersandfamilymembersofpatientswhohavediedfromthiscomplica-tionprovidedinputonthescopeandimpactoftheproblem,andrepresentativesfromthemonitoringtech-nologyindustry(aboutone-fourthofattendees)dis-cussedthepotentialforimprovedmonitoringofpatients’respiratorystatusinthepostoperativeperiod.
Drs.RobertK.Stoelting,APSFpresident,andF r a n k J . O v e r d y k , a d j u n c t p r o f e s s o r o fAnesthesiologyattheMedicalUniversityofSouthCarolina,co-moderatedtheconferenceconsistingof24briefpresentations,6smallbreakoutgroups,andadiscussionsession.Twoquestionswerepostedtoallspeakersandaudiencemembers:
1) Should electronic monitoring be utilized to facilitate detection of drug-induced postoperative respiratory depression?
D r. M a t t h e w B . We i n g e r, p ro f e s s o r o fAnesthesiologyatVanderbiltUniversity,showedmultiplestudiesthatprovideevidenceforfrequentuseofnaloxoneforpostoperativeopioid-inducedrespiratorydepression.HestatedthattheliteraturesuggeststhatintheU.S.about0.3%ofpostoperativepatientsreceivenaloxonerescueaccountingforupto20,000patientsannually.Hefurtherestimatedthatone-tenthofthesepatientssuffersignificantsequelae.Dr.Weingeralsoprovidedevidencedemonstratingthatalltypesofparenteralopioidsandroutesareinvolvedintheseevents.Hethendiscussedthereli-ability,sensitivity,specificity,andresponsetimeforthevarioustypesofmonitorsforoxygenationandventilationtodetectrespiratorydepression.Forpatientswhoarenotintubated,pulseoximetrywasthebestmonitorwhensupplementaloxygenwasnotbeingutilized.Inthepresenceofsupplementaloxygen,capnographyfaredbest(seeTable1).1
“No Patient Shall Be Harmed By Opioid-Induced Respiratory Depression”[Proceedings of “Essential Monitoring Strategies to Detect Clinically Significant Drug-Induced Respiratory Depression in the Postoperative Period” Conference]
APSF NEWSLETTER Fall 2011 PAGE 22
NEWSLETTERThe Official Journal of the Anesthesia Patient Safety Foundation
Address all general, contributor, and sub scription cor-respondence to:Administrator,DeannaWalkerAnesthesiaPatientSafetyFoundationBuildingOne,SuiteTwo8007SouthMeridianStreetIndianapolis,IN46217-2922e-mailaddress:[email protected]:(317)888-1482
by John H. Eichhorn, MD, and Jeffrey B. Cooper, PhD
EllisonC.Pierce,Jr.,MD,affectionatelyknowntosomanyas“Jeep,”wasthecornerstoneoftheconcep-tionandevolutionofanesthesiapatientsafety.HispassingonApril3,2011,atage82wasatremendouslosstoeveryoneinvolvedwithanesthesiainparticu-larandheathcareingeneral.Patientsaswellaspro-vidersperpetuallyoweDr.Pierceagreatdebtofgratitude,forJeepPiercewasthepioneeringpatientsafetyleader.Hemadeahugedifferenceinthesafetyof health care for everyone.A truevisionary,hesawwhatneededtobeseenandsaidwhatneededtobesaid.Hewason a perpetual mission to preventpatientsfrombeinginjuredorkilledbyanesthesiacare.Whenheembarkedonthatmission,hedidnotknowthattheimpactwouldextendfarbeyondthespe-cialtytowhichhedevotedhislife.
WhilehehadexperiencedclosecallsintheORlikeallanesthesiologists,Dr.Piercedidnotdescribebeingdirectlyinvolvedinaseriousanesthesiaacci-dent.However,wehaveaninterestingrevelationononesourceofDr.Pierce’spassionforsafetyfromarecollectionofRobertH.Bode,MD.Dr.Bode,along-time,closeassociateofDr.PierceandformervicechairmantoDr.PierceattheNewEnglandDeaconessHospitalinBoston(andcurrentlyaffiliatedwithNewEnglandBaptistHospitalandasso-ciateprofessorofAnesthesiaatBostonUniversitySchoolofMedicine)spokeatthememorialserviceheldatthehistoricTrinityChurchindowntownBoston.Hetoldofhow,duringthetimescoveredbyDr.Pierce’searlyandmiddlecareer,themostgrievousanesthesiaerrorscausingcatastrophicoutcomesincludedunrec-ognizedesophagealintubationsanddis-connec t ions f rom the brea th ingapparatus.Dr.Piercewitnessed theimpactofsuchanoccurrencefirsthand.Itinvolvedthe18-yearolddaughterofoneofhisfriends.Shearrestedanddiedduringanesthesiafordentalsurgeryafteranaccidentalesophagealintuba-tion,whichwasnotrecognizeduntilitwastoolate.FromthewayJeeptoldthatstoryonafewoccasions,itsurelywasoneofseveralstimulithatprovokedhimtoworktowardpreventingallsuchtragicanestheticaccidents.Andbecausehewassodedicatedtoanes-thesiology,hepursuedthisquestwithallofhisvigoranddoggedpersistencebecauseheknewitwasthemostimportantthingthathecoulddoforourspe-cialty.Fortunatelyforallofus,healsohadthe
D r. P i e rc e re c o u n t e d i n t h eRovenstinelecture1hisearlyinterestinanesthesiaaccidents:“In1962,Ibecameinterestedinanesthesiapatientsafety.IhadjoinedLeroyVandamatthePeterBentBrighamHospitalasdefactovicechairman.Inhisinimitableway,onedayheassignedmethesubject,‘anes-thesiaaccidents,’tobegivenasaresi-dent'slecture.Istillhavenotesinmyfilesfromthattalk,whichbeganasacollectionofanesthesiamishapsthatIknew about personally.” He oftenrepeatedhissaddisbeliefregardinghowmanypatientsheheardaboutfromalloverthecountrywhowereinjured or killed by unrecognizedesophagealintubations.Inthe1970s,whenhewaschairofAnesthesiaatthe
A Tribute to Ellison C. (Jeep) Pierce, Jr., MD, the Beloved Founding Leader of the APSF
American Society ofAnesthesiologistsAnnualMeeting.1HerecountedhowhefirstgaveanesthesiaasaresidentinJuly1954,whentheequipmentandprac-ticeswereprimitivebytoday’sstandards.CyclopropanewasoftenusedwithanIVstartedonlyafterinduction,althoughthiopentalwascommonandsometimesalsousedasamaintenanceinfusion.Tonsillectomywasdonewithopendropetherandnoendotrachealtube.Rectaldrugadministrationwasemployedand,also,spinalswereverycommon—includingforupper
APSF NEWSLETTER Fall 2011 PAGE 24
Dr. Pierce Proclaims “Protect Patients First”InhisRovenstinelecture,1Dr.Pierceemphasized
JamesF.English,MD,whosucceededDr.Piercea s p re s i d e n t o f A n e s t h e s i a A s s o c i a t e s o fMassachusettsin1998,spokeofhisclosefriendandmentorat thememorialservice.He laudedDr.Pierce’sremarkablesuccessesandcontinued,“Jeepdidn'taccomplishallthisbybeingashrinkingviolet.Hehadaverystronganddistinctpersonality.He
forwardtobecomewhatisnowaglobalmovementtopreventneedlessinjuriesanddeathsfromerrorsbothhumanandsystem-induced.Hewasanattractor,someoneweallwantedtohelptoaccomplishhisgoals.WhenheassembledthenimbleindependentteamthatwouldbuildtheAPSF,hewasinclusiveandstrategic.Beyondanesthesiologists,theoriginalBoardofDirectorsincludedlawyers,pharmaceuticalanddevicemanufacturers,abiomedicalengineer,riskmanagers,nurseanesthetists,malpracticeinsurers,and representatives from the Food and DrugAdministration,theJointCommission,theAmericanCollegeofSurgeons,andtheAmericanMedicalAssociation.AsDr.Piercenoted,suchdiversityofstakeholderscertainlywasnotpossibleinthestruc-turedenvironmentoftheASAatthattime.Heknewjusthowfarhecouldgo,justwhatkindsofpeopletogetherwereneededtodothejob.
ISPAMM and APSFSoonafter,Dr.Piercehelpedorganizeandhostan
unprecedented and important gathering—theInternationalSymposiumonPreventableAnesthesiaMortalityandMorbidityinBoston.Stronglystimu-latedbythatenergeticassemblage,Dr.Piercecon-ceivedoftheideaoftheAnesthesiaPatientSafetyFoundation(APSF).Throughhischarisma,politicalknow-how,patience,andpersistence,hecreatedandwasthefirstpresidentoftheorganizationthathasbeenthebeaconforpatientsafetyinanesthesiaandfarbeyond.
Piercewasfarfromunidimensional.Hehadotherlovesaswell—surelythemostforhislatewife,Elizabeth,andhischildrenChipandWendy,andhis3grandchildren.Also,inasocialmoment,he’drevealhispassionforlargepipeorgansandtheirmagicalmusic,includingtheoneatBoston’sTrinityChurchwherehismemorialservicewasheld.Hetraveled the world to see the special ones.Functionallya“renaissanceman,”helovedoperaandarchitecture,too,butespeciallyhistory.WinstonChurchillwashishero;hereadallhecouldaboutthegreatleaderandstatesman(anddisplayedaChurchillbustinthevestibuleofhisapartment,agiftfromtheAPSFonhisretirementaspresident).Dr.Piercealwayshadadelightfulsenseofhumor
Dr. John Eichhorn, Professor of Anesthesiology at the University of Kentucky, was the founding editor of the APSFNewsletter and remains on the Editorial Board and serves as a senior consultant to the APSF Executive Com-mittee. Dr. Jeffrey B Cooper, Director, Center for Medical Simulation and Professor of Anaesthesia, Harvard Medical School, Boston, MA, is Executive Vice President of the APSF and one of the founding members of the Executive Committee.
RayR.Maddox,PharmD,fromSt.Joseph’s/CandlerHealthSysteminSavannah,GA,sharedhisexperienceduringthegeneralaudiencediscussionses-sion.Hishospitalinstitutedcapnographywithorwithoutpulseoximetrymonitoringover5yearsagoforallpatientsreceivingparenteralorneuraxialopi-oidspostoperativelyaftersomehigh-severityadverseeventsinvolvingopioids.Theyfoundearlyintheirbetatestingthatitwasnotpossibletoreliablypredictopioidresponsivenessbasedonriskstratificationandelectedtomonitorallpatientsreceivingpostoperativeopioids.Todate,theyhavenothadanyrespiratoryarrestsrelatedtotheadministrationofpostoperativeopioids since they insti tuted the increasedmonitoring.6
Table 1. Comparison of Available Monitoring Modalities for Detection of Opioid-Induced Respiratory Depression in the Postoperative Period
Monitoring Modality Sensitivity * Specificity Reliability Response Time
PetCO2 (intubated) High High High Fast
SpO2 (no O2 supplement) High Moderate-High High Fast
PetCO2 (unintubated) High Moderate-High§ Moderate Fast
PaCO2 High High High Slow
PvCO2 High Moderate High Slow
PtcCO2 Moderate High Low-Moderate‡ Medium
SpO2 (with O2 supplement) Moderate Moderate High Slow
Clinical assessment (skilled clini-cian)
Moderate Moderate-High Moderate Slow
Respiratory rate (newer technol-ogy)
Moderate Moderate† Moderate Medium
Tidal volume (unintubated) Moderate Moderate Low Medium
C h e s t w a l l i m p e d a n c e (for respir. rate)
Low-Moderate Low† Low Medium
Clinical assessment (less skilled clinician)
Low-Moderate Low-Moderate Low-Moderate Slow
* Definitions: Sensitivity = positive in the presence of respiratory depression (low false negative rate); Specificity = negative in the absence of respiratory depression (low false positive rate); Reliability = accuracy and availability (likelihood of an available and accurate reading at the time of respiratory depression); Response time = average time from the onset of respiratory depression until the variable reads abnormally if it is going to do so.
§ If PetCO2 is high, this is highly specific for respiratory depression. However, if is low, because of unknown dead space, it can only be used as a measure of respiratory rate.
‡ New PtcCO2 technologies may be more reliable. † In some patients, respiratory rate alone may not be a good measure of opioid-induced respiratory depression.
Dr. J . Paul Curry, c l in ica l professor o fAnesthesiologyattheUniversityofCaliforniainLosAngelesDavidGeffenSchoolofMedicine,andstaffanesthesiologist at Hoag Memorial HospitalPresbyterianinNewportBeach,CA,andDr.LarryA.Lynn,apulmonaryintensivistandtheexecutivedirectoroftheSleepandBreathingResearchInstituteinColumbus,OH,presenteduniquedatadescribing3differentpatternsofunexpectedhospitaldeaths.Thesepatternsincludedprogressivemetabolicacido-sis(e.g.,sepsis),opioid-inducedcarbondioxidenar-cosis,anddrug-inducedarousalfailurewithsleepapnea(seearticleonpage32).Theyshoweddifferenttrendsinpulseoximetryvalues,minuteventilation,respiratoryrate,andarterialcarbondioxidelevelsassociatedwitheachofthese3patternsofdeath.9Theynotedthathealthcareprovidersarenotwelleducatedaboutthesepatternsandmaymissearlywarningsigns.Further,theybelievethatmonitorswiththresholdalarms(i.e.,alarmuponreachingaspecificvalue)arenotusefulbecauseoftheirinabilitytodistinguishmeaningfulfromnuisancealarms,dependingonthedeathmechanism.Theyalsodis-cussedthatearlydetectionofdeterioratingpatientconditionswillbepoorwhenthresholdalarmssuchaspulseoximetryaresettolowervaluestoreducetheincidenceof“false”alarms.Drs.CurryandLynnencouragedindustrytodevelopsmarttechnologiesthatcoulddetectthespecificpatternsofvitalsignspreceding these types of death and alert careproviders.
Inagreementwiththeuseofsmarttechnologiesfor pattern recognition, Dr. Richard E. Moon,ProfessorofAnesthesiologyandMedicineatDukeUniversity,suggestedthatmultimodalmonitoringwasnecessarytodetectpostoperative,drug-inducedrespiratorydepression.Hebelievedwecouldincor-poratethetechnologyusedwithautomatedimplant-ablecardioverter-defibrillators(AICD)thatutilizecomplextime-dependentpatternrecognitionalgo-rithmsbasedonreferencewaveforms.Dr.MarkR.Montoney,MD,MBA,ExecutiveVPandCMO,VanguardHealthSystems,Nashville,TN,concurredthatsmarttechnologiesmustbedevelopedthatcanreliablydetectearlyprogressionofclinicalinstabilityandtriggerpromptcaregiverresponses.Dr.ElizabethA.Hunt,apediatricintensivistfromJohnHopkinsUniversitySchoolofMedicinealsoobservedthatpro-gressivetypesofmultimodalmonitoringforvitalsignsthatcouldbeincorporatedtoidentifypatternsandpercentdeviationfrombaselinevitalsignswould
DavidA.Scott,MB,BS,PhD,AssociateProfessorofAnaesthesiaatSt.Vincent’sHospitalinMelbourne,Australia,presenteddatashowingtheimportanceoftheassessmentofsedationlevelinpreventingventila-toryimpairmentfromopioids.Henotedthatopioidsaffectconsciousness(sedation),airwaytone,andcen-tralrespiratorydriveandthatmonitoringstrategiesshouldaddressalloftheseparameters.Heagainespoused the importance of assessing trends.ConsistentwithDr.Scott’spresentation,ChrisPasero,RN-BC,apainspecialistfromElDoradoHills,CA,alsocommentedontheimportanceofnursesbeingabletoassessanddocumentsedationlevelsaspartofamultimodalmonitoringstrategytodetectdrug-inducedrespiratorydepression.Someaudiencemem-berssuggestedthatsedationshouldbethesixthvitalsign.Ms.Paseroalsoadvocatedforindividualizedpaintreatmentstrategieswithanemphasisonmulti-modalanalgesia.
Other speakers provided evidence that allpatientscouldbenefitfromincreasedpostoperativemonitoring,andthattheincreasedcostsofmonitor-ingwouldbeoffsetfinanciallybyimprovedout-comes.Withcontinuousmonitoring,patientshadfewertransferstotheintensivecareunitandbettersurvivalifin-hospitalarrestsoccurred,comparedtopatientswithtraditionalmonitoringevery2-4hours.Supportiveofthissupposition,expertsintheimple-mentationofrapidresponseteamsincludingDr.MichaelA.DeVita,anintensivistfromSt.Vincent’sHospitalinBridgeport,CT,providedevidencethatwhileincreasedmonitoringimprovedsurvivalforin-hospitalarrests,thepatients’associatedmedicalcon-ditions only predicted about 50% of arrest ornear-arrestevents.10Inotherwords,riskstratificationofpatientsusingaspecificsetofpredictorscouldmissuptohalfofthosewhowillhaveseriousinpa-tientevents.Dr.GeorgeT.Blike,aprofessorofAnesthesiaatDartmouthUniversity,observedthatoneoftheessentialdifferencesseparatingthebestandworstqualityhospitalswasnottheirnumberofcomplications,buttheirmanagementofcomplica-tionsoncetheyoccur.Hesummarizedhisresearchinwhichpatientswhowereundercontinuouspostop-erativepulseoximetrysurveillancewithalarmsthatalertednursesofabnormalvitalsignshadsignifi-cantlyfewerrescuesandunanticipatedtransferstotheintensivecareunit.11
TimothyW.Vanderveen,PharmD,MS,fromCareFusion,RogerS.MeccaMD,fromCovidien,Catherine W. Parham, MD, MBA, from GEHealthcare,MichaelO’Reilly,MD,MS,fromMasimo(andaprofessorofAnesthesiologyandPerioperativeCare,UniversityofCalifornia,Irvine),DavidLain,PhD,JD,FCCP,RRTfromOridionCapnography,andAndreasBindszusfromPhilipsHealthcareallpro-videdtheirthoughtsoncontinuouselectronicmoni-toring to prevent drug-induced respiratorydepressioninthepostoperativeperiod.Theseindus-tryleadersupdatedtheaudienceonthecurrentlyavailablemonitorsofoxygenationandventilation.Pulseoximetrymonitorswiredtoacentrallocationwithalarms,nasalcapnographymonitorsthatalertproviders,pulseoximetryand/orcapnographymon-itorsintegratedintoPCApumpsthatcanalarmandhaltthedeliveryoffurtheropioid,andacousticmoni-torsofrespiratoryratecoupledwithpulseoximetrythatalertprovidersofabnormalsituationswerealldiscussed.
Followingtheformallectures,audiencememberswereassignedtobreakoutgroupstoreachconsensusonthetwoquestionsposedattheopeningofthecon-ference.Summariesoftheirgroupsessionswerepro-videdby thegroup leaders to thereassembledparticipants.Therewasexcellentagreementacrossallgroupsthatelectronicmonitoringshouldbeutilizedtofacilitatedetectionofdrug-inducedpostoperativerespiratorydepression.Similarly,mostgroupsbelievedallpatientsreceivingpostoperativeopioidsshouldbemonitoredcontinuously,butthatthispro-cessmayneedtobeimplementedinagradedfashionbecauseofresourcelimitations.Thedurationofmon-itoringrecommended,particularlyinlightofDr.Chung’spresentation,wasnotclear.Additionally,managementofoutpatientspostoperativelywasnotadequatelyaddressedatthismeeting.
14.RegenthalR,KruegerM,KoeppelC,PreissR.Druglevels:therapeuticandtoxicserum/plasmaconcentra-t ions of common drugs. J Cl in Monit Comput 1999;15:529-44.
Insummary,theconsensusofconferenceattend-eeswasthatcontinualelectronicmonitoringshouldbeutilizedforinpatientsreceivingpostoperativeopi-oids.Whensupplementaloxygenisnotbeingused,pulseoximetrywasthoughttobethemostreliableandpracticalmonitorcurrentlyavailable.Ifsupple-mentaloxygenisadded,thenmonitorsofventilation(e.g.,capnography)werethoughttobenecessarytodetecthypoventilation.Improvededucationofallcareprovidersonthedangersofpostoperativeopi-oids,andbetterassessmentofsedationlevelwerethoughttobecriticalstepsinthepreventionofpost-operativedrug-inducedrespiratorydepression.Itwasacknowledgedthatlimitedresourcesmayresultinastagedimplementationofcontinualmonitoringstrategieswiththehighestriskgroupsbeingmoni-toredfirst,butwiththegoalofmonitoringallinpa-tients receiving postoperative opioids. Riskstratificationwasshowntobeinsufficienttoeradicatepos topera t ive opio id- induced resp i ra torydepression.
A summary of the conclusions and recommen-dations from this conference can be found at the APSF website at http://apsf.org/announcements.php?id=7 or by clicking on the link under Announcements at www.apsf.org, and a brief Meeting Report of the proceedings of the confer-ence will be published in Anesthesia and Analgesia (in press).
Dr. Weinger is the Norman Ty Smith Chair in Patient Safety and Medical Simulation, and Professor of Anesthe-siology, Biomedical Informatics, and Medical Education at Vanderbilt University School of Medicine and a Senior Staff Physician Scientist in the Geriatric Research Educa-tion and Clinical Center (GRECC) in the VA Tennessee Valley Healthcare System. Dr. Lee is an Associate Professor in the Department of Anesthesiology and Pain Medicine at the University of Washington and Co-editor of the APSFNewsletter.
9. LynnLA,CurryJP.Patternsofunexpectedin-hospitaldeaths:Arootcauseanalysis.Patient Safety in Surgery2011;5:3.
10.GalhotraS,DeVitaMA,SimmonsRL,etal.Maturerapidresponsesystemandpotentiallyavoidablecardiopulmo-naryarrestsinhospital.Qual Saf Health Care2007;16:260-5.
R. Mauricio Gonzalez MDClinical Assistant Professor of AnesthesiologyBoston University School of MedicineVice Chairman of Clinical AffairsDepartment of AnesthesiologyBoston Medical Center
TheInternationalOrganizationforStandardization(ISO)hasaddressedbreathingsystemfiltersforanes-theticandrespiratoryuseandpromulgatedastan-dard, ISO 23328-1.13 A key point is that thisinternationalstandardrequiresfiltervalidationbymeansofastandardizedtestusinga0.3micronparti-clechallenge.Italsomandatesspecifictidalvolumesandflowratestobeusedtoinsureconsistencyandaccuracyoftesting.Thistypeofstandardizationpro-videsamoreconsistentandscientificallyobjectivemethodforjudgingtheeffectivenessofafilterandshouldbeusedalongwithstudiesthatevaluatefiltra-tionperformanceinamoistenvironment.
Fromthestandpointofinfectioncontrolandcir-cuitreuseitisimportanttothinkofthecircuitsasapartofthemachine,ratherthanaseparateentity.Theentirecirclesystemmaybecomecontaminated,including the soda lime, and the machine.17,18Bernardsetal.foundinfectiouscontaminationbyAcinetobacter baumanniiincriticalcareunitventila-tors.Criticalcareventilatorsaresimilarenoughtoanesthesiamachinestoraiseconcernthatthelattermayserveasvehiclesforinfectionaswell.19
Reusable Anesthesia Breathing Circuits Considered
The information provided is for safety-related educational purposes only, and does not constitute medical or legal advice. Individual or group responses are only commentary, provided for pur-poses of education or discussion, and are neither statements of advice nor the opinions of APSF. It is not the intention of APSF to provide specific medi-cal or legal advice or to endorse any specific views or recommendations in response to the inquiries posted. In no event shall APSF be responsible or liable, directly or indirectly, for any damage or loss caused or alleged to be caused by or in connection with the reliance on any such information.
Dear SIRS refers to the SafetyInformation Response System. Thepurpose of this column is to allowexpeditiouscommunicationoftechnology-relatedsafetyconcernsraisedbyourreaders,withinputandresponsesfromm a n u f a c t u r e r s a n d i n d u s t r yrepresentatives. This process wasdeveloped by Dr. Michael Olympio,former chair of the Committee onTechnology, and Dr. Robert Morell,co-editorofthisnewsletter. Dear SIRS madeitsdebutintheSpring2004issue.Dr.AWilliamPaulsen,currentchairoftheCommitteeonTechnology,isoverseeingthecolumnandcoordinatingthereaders'inquiriesandtheresponsesfromindustry.
alkalosis (RA)despite subsequentprogressiveincreasesinaniongapandlacticacidlevels.Thisstageoccurswellbeforethedevelopmentofdomi-natemetabolicacidosis(MA),whichisusuallyassoci-ated with its late and terminal stages. Theseprogressivepatternphases(initialisolatedRAfol-lowedbymixedRAandMA,followedbydominateMA)comprisethetypicalprogressionofTypeIPUHD,andareshowninFigure1.
Tosummarize,thisuniqueTypeIprocessstartswitharisingminuteventilationandafallingPaCO2,thenalateslowfallinSPO2andamorerapidriseinminuteventilation(andatthispointasevereriseinrespiratoryrateandmarkedadditional fall inPaCO2),followedthenbyarapiddropinSPO2(oftenonlynowpassingthroughtheSPO2alarmthreshold).Ifsupplementaloxygenisprovided,theSPO2canremainstableevenclosertothedeathpoint, prolonging the false sense of security.ThresholdbreachesofRR,SPO2,ortheMEWSaregenerallylateandunpredictablemarkersoftheTypeIpattern.
Type II Pattern of Unexpected Hospital Death (CO2 Narcosis)
Classiccasesofthisareseeninaccidentalnar-coticoverdose,andthosepatientswithhypoventila-tion syndromes, such as adult patients withcongenitalcentralhypoventilationsyndrome,e.g.,PHO2XBmutations.16
OnereasonarousaldelaybecomessocriticalisthatSPO2isabletofallatveryrapidratesduringapnea.Manyphysiciansaccustomedtowitnessingpreoxygenatedapnealackafullappreciationfortheextremelyearlyandverysteepdesaturationslopesseeninrecumbent,obesepatientswithapnea.Infact,sincepostoperativefunctionalresidualcapacitydoesnothavedefinablelowerlimits,oxygendesaturationratesmayinsomecasesexceed1.5%persecondwithSPO2fallingtocriticalvalueswithnotimeforcon-t e m p o r a n e o u s h y p e rc a r b i a t o d e v e l o p . 2 8Occasionallyapatient'sarterialoxygensaturationfallstoapointwherethebrainnolongerreceives
Department of Anesthesiology and Perioperative Care, Newport Beach, CA. and a Clinical Professor, Department of Anesthesiology, David Geffen School of Medicine, UCLA.
Dr. Lynn is a pulmonary and critical care physician and serves as executive director of the Sleep and Breathing Research Institute in Columbus Ohio. He also serves on the FDA standards committee for pulse oximetry monitoring.
Disclosure: Dr. Curry has nothing to disclose. Dr. Lynn holds patents and receives royalties relating to inventions in the field of patient monitoring and pattern detection.
4. Ghanem-ZoubiNO,VardiM,LaorA,etal.Assessmentofdisease-severityscoringsystemsforpatientswithsepsisingeneralinternalmedicinedepartments.Crit Care 2011;15:R95.
8. MikkelsenME,MiltiadesAN,GaieskiDF,etal.Serumlac-tateisassociatedwithmortalityinseveresepsisindepen-dent of organ failure and shock. Crit Care Med 2009;37:1670-7.
16.AnticNA,MalowBA,LangeN,etal.PHOX2Bmutation-confirmedcongenitalcentralhypoventilationsyndrome:presentationinadulthood.Am J Respir Crit Care Med 2006;174:923-7.
20.HajihaM,DuBordMA,LiuH,etal.Opioidreceptormechanismsatthehypoglossalmotorpoolandeffectson tongue muscle act ivi ty in vivo. J Physio l 2009;587:2677-92.
21.WhiteDP.Opioid-inducedsuppressionofgenioglossalmuscleactivity: is itclinicallyimportant?J Physiol 2009;587:3421-2.
KathyHart.......................... Nihon Kohden America
DominicCorsale................ Oridion
DanielR.Mueller............... Pall Corporation
MarkWagner...................... PharMEDium
WalterHuehn..................... Philips Medical System
StevenR.Sanford,JD....... Preferred Physicians Medical Risk Retention Group
J.C.Kyrillos........................ ResMed
Dr.RainerVogt .................. SenTec AG
CindyBaptiste..................... Sheridan Healthcorp, Inc.
TomUlseth.......................... Smiths Medical
JosephDavin...................... Spacelabs
CaryG.Vance..................... Teleflex
SusanK.Palmer,MD......... The Doctors Company
WilliamFox......................... WelchAllyn
AbeAbramovich
CaseyD.Blitt,MD
RobertK.Stoelting,MD
A N E S T H E S I A P A T I E N T S A F E T Y F O U N D A T I O N
CORPORATE ADVISORY COUNCIL
SUPPORT YOUR APSFPlease make checks payable to the APSF and mail donations to
Anesthesia Patient Safety Foundation (APSF)520 N. Northwest Highway, Park Ridge, IL 60068-2573
or make your donation online at www.APSF.org
APSF NEWSLETTER Fall 2011 PAGE 36
Anesthesia Patient Safety FoundationC O R P O R AT E S U P P O R T E R PA G E
APSF is pleased to recognize the following corporate supporters for their exceptional level of support of APSF in 2011
Founding Patron
Founded in 1905, the American Society of Anesthesiologists is an educational, research, and scientific association with 46,000 members organized to raise and maintain the standards of anesthesiology and dedicated to the care and safety of
patients. http://www.asahq.org
Grand Patron
Covidien is committed to creating innovative medical solutions for better patient outcomes and delivering value through clinical leadership and excellence in everything we do. http://www.covidien.com
Sponsoring Patron
Baxter’s Global Anesthesia and Critical Care business is a leading manufacturer in anesthesia and peri-operative medicine, providing all three of the modern inhaled anesthetics for general anesthesia, as well products for PONV and
hemodynamic control. http://www.baxter.com
Benefactor Patrons
Abbott is a broad-based health care company devoted to bringing better medicines, trusted nutritional products, innovative medical devices and advanced diagnostics to patients and health care professionals around the world. www.abbott.com
Masimo is dedicated to helping anesthesiologists provide optimal anesthesia care with immediate access to detailed clinical intelligence and physiological data that helps to improve anesthesia, blood, and fluid management decisions. www.masimo.com
Oridion offers all patients and clinical environments the benefits of capnography. . . the only indication of the adequacy of ventilation and the earliest indication of airway compromise. www.oridion.com
PharMEDium is the leading national provider of outsourced, compounded sterile preparations. Our broad portfolio of prefilled O.R. anesthesia syringes, solutions for nerve block pumps, epidurals, and ICU medications are prepared using only the highest standards. www.pharmedium.com
Supporting PatronPreferred Physicians Medical: Providing malpractice protection exclusively to anesthesiologists nationwide. PPM is anesthesiologist founded, owned, and governed. PPM is a leader in anesthesia specific-risk management and patient safety initiatives. www.ppmrrg.com
APSF NEWSLETTER Fall 2011 PAGE 37
Anesthesia Patient Safety Foundation
Supporting Patron ($15,000 to $24,999)Linde Healthcare (lifegas.com) Preferred Physicians Medical (ppmrrg.com)Patron ($10,000 to $14,999)CareFusion (carefusion.com)Spacelabs Medical (spacelabs.com)Sustaining Donor ($5,000 to $9,999)Anesthesiologists Professional Assurance Company
CAS Medical Systems (casmed.com)Dräger Medical (draeger.com)LMA of North America (lmana.com)McKesson Provider Technologies (mckesson.com)Mindray, Inc. (mindray.com)Nihon Kohden America, Inc. (nihonkohden.com)Pall Corporation (pall.com)ResMed (resmed.com)SenTec AG (sentec.com)Sheridan Healthcorp, Inc. (shcr.com)Smiths Medical (smiths-medical.com)Teleflex Medical (teleflex.com)
The Doctors Company Foundation (thedoctors.com)WelchAllyn (welchallyn.com)Sponsoring Donor ($1,000 to $4,999)Anesthesia Business Consultants (anesthesiallc.com)Allied Healthcare (alliedhpi.com)Armstrong Medical (armstrongmedical.net)Belmont Instrument Corporation
(belmontinstrument.com)Codonics (codonics.com)Cook Critical Care (cookgroup.com)iMDsoft (imd-soft.com)
King Systems (kingsystems.com)METI Learning (meti.com)TRIFID Medical Group LLC (trifidmedical.com)W.R. Grace (wrgrace.com)
Corporate Level Donor ($500 to $999)Promed StrategiesWolters Kluwer
Subscribing SocietiesAmerican Society of Anesthesia Technologists and
Technicians (asatt.org)
Note: Donations are always welcome. Donate online (www.apsf.org) or send to APSF, 520 N. Northwest Highway, Park Ridge, IL 60068-2573.(Donor list current through September 1, 2011.)
Corporate Donors Founding Patron ($500,000 and higher) American Society of Anesthesiologists (asahq.org)
Community Donors
(includes Anesthesia Groups, Individuals, Specialty Organizations, and State Societies)
Sponsor ($200 to $749)Sean S. Adams, MDLeslie Andes, MDAnesthesia Associates of Columbus, GADonald E. Arnold, MDBalboa Anesthesia GroupRobert L. Barth, MDWilliam C. Berger, MDBerkshire Medical Center (National Nurse
Anesthetists Week)Vincent C. Bogan, CRNAAmanda Burden, MDJohn Busch (Engineering Controls for
Medicine)Michael Caldwell, MDLillian K. Chen, MDJoan M. Christie, MDMarlene V. Chua, MDMelvin Cohen, MDColorado Society of AnesthesiologistsR. Lebron Cooper, MDDavid S. Currier, MDGlenn E. DeBoer, MDJan Ehrenwerth, MDBruce W. Evans, MDCynthia A. Ferris, MDJane C. K. Fitch, MD/Carol E. Rose, MDMark P. Fritz, MDWayne Fuller, MDGeorgia Association of Nurse AnesthetistsJames J. Gibbons
Ian J. Gilmour, MDRichard Gnaedinger, MDGoldilocks Anesthesia FoundationJames D. Grant, MDJoel G. Greenspan, MDWilliam L. Greer, MDGriffin Anesthesia AssociatesAlexander A. Hannenberg, MD (in honor
of Kansas City Society of Anesthesiologists)
Daniel E. Headrick, MDJ ohn F. Heath, MDSimon C. Hillier, MDVictor J. Hough, MDEric M. HumphreysPaul M. Jaklitsch, MDRobert E. Johnstone, MDKansas Society of AnesthesiologistsCeleste Kir schnerMichael G, Kral, MDRodney C. Lester, CRNAKevin P. Lodge, MDMaine Society of AnesthesiologistsAsif Malik, MDGregory B. McComas, MDE. Kay McDivitt, MDTricia A. Meyer, PharmDMississippi Society of AnesthesiologistsRoger A. Moore, MDNew Jersey State Society of
AnesthesiologistsNew Mexico Society of AnesthesiologistsSara M. Norvell, MDL. Charles Novak, MDDucu Onisei, MDMichael A. Olympio, MDSrikanth S. Patankar, MDMukesh K. Patel, MDPennsylvania Association of Nurse
AnesthetistsGaylon K. Peterson, MDDrs. Beverly and James PhilipRichard C. Prielipp, MDJohn Rask, MDRhode Island Society of AnesthesiologistsJanet and Howard SchapiroSanford Schaps, MDSociety for Neuroscience in
Anesthesiology and Critical Car eSociety for Obstetric Anesthesia and
PerinatologySouth County Anesthesia Association
South Carolina Society of Anesthesiologists
Shepard B. Stone, PASteven J. Thomas, MDUniversity of Maryland Anesthesiology
AssociatesVail Valley AnesthesiaVermont Society of AnesthesiologistsVirginia Society of AnesthesiologistsThomas L. War r en, MDJimmie Watkins, MD, DDS, PhDMatthew B. Weinger, MDDonald L. Weninger, MD (in honor of
Willard Albrecht, MD)Andrew Weisinger, MDWest Virginia State Society of
AnesthesiologistsWichita Anesthesiology, CharteredG. Edwin Wilson, MDWisconsin Academy of Anesthesiologist
AssistantsGerald L. Zeitlin, MD
In MemoriamIn memory of William J. Beightler, MD
(Texas Society of Anesthesiologists)In memory of E. H. Boyle, MD
(Philip F. Boyle, MD)In memory of Jose M. Brito-Suarez, MD
(Texas Society of Anesthesiologists) In memory of Hank Davis, MD
(Sharon Rose Johnson, MD)In memory of Steve Edstrom, MD
(Larry D. Shirley, MD)In memory of Margie Frola, CRNA
(Sharon Rose Johnson, MD)In memory of Andrew Glickman, MD
(Sharon Rose Johnson, MD)In memor y of Roy C. Kang, MD (Texas
Society of Anesthesiologists)In memory of Stevon S. Kebabjian, DO
(Texas Society of Anesthesiologists)In memory of Max K. Mendenhall, MD
(Texas Society of Anesthesiologists) In memory of Ellison C. Pierce, Jr., MD
(founding president of APSF) (multiple donors)
In memory of Robert Romero, MD (Texas Society of Anesthesiologists)
In memory of Sylvan E. Stool, MD (Lawrence M. Borland, MD)
In memory of Leroy D. Vandam, MD (Dr. and Mrs. George Carter Bell)
Grand Patron ($150,000 to $199,999)
Sponsoring Patron ($50,000 to $99,000)
Benefactor Patron ($25,000 to $49,999)
Masimo Foundation(masimo.com)
Sustaining Professional Organization ($25,000 and higher)
PharMEDium Services (pharmedium.com)
Oridion Capnography (oridion.com)
Online donations accepted at www.apsf.org
Covidien (covidien.com)
Baxter Anesthesia and Critical Care (baxter.com)
American Association of Nurse Anesthetists (aana.com)
At itsgraduationceremonyonJune16, theDepartmentofAnesthesia,CriticalCareandPainMedicine(DACCPM)oftheMassachusettsGeneralHospitalawardeditsthirdannualJeffreyB.CooperPatientSafetyAward,whichisnamedinhonoroftheAPSFexecutivevicepresident.ThisyeartheawardwasgiventoDr.JohnWalshforhismanyenhance-mentsandapplicationsofthedepartment’sanesthe-siainformationsystem,whichhehasspearheadedsinceitsinceptionover10yearsago,andforhisdedi-cationtotheteachingofsafemedicationadministra-tionpracticeswithinthedepartment.Theentiredepartmentvotesonthisawardeachyear,basedonthefollowingsolicitationemail:
“Thisawardhonorsthededicationandcontribu-tionsofDr.JeffreyB.Coopertopatientsafety.Dr.CooperisaProfessorofAnaesthesia,HarvardMedicalSchool,andtheExecutiveDirectoroftheCenterforMedicalSimulation.Theintentistoannuallyrecognizetheexemplarycontributionsofanindividualmemberofthedepartmenttotheprovisionofsafepatientcare.Anothergoaloftheawardistofosteracultureofsafetyamongthemembersofthedepartment:What can you do to promote safe patient care?”
Eligible persons included members of theDACCPMattendingstaff,clinicalfellows,residents,nurseanesthetists,criticalcare/monitoringnurses,anesthesiatechnicians,andbiomedicalengineers.CandidateswerenominatedbaseduponhowtheirpracticeexemplifiesDr.Cooper’sidealsforpatient
Dr. John Walsh Receives MGH Annual Cooper Patient Safety Award
Dr. Robert Peterfreund (right), Department Quality Assurance Committee Chair, presents the award to Dr. John Walsh.
Editor’s note:
If your department or organization recognizes patient safety efforts with an award of any kind, please let the APSFNewsletterknow.
Dr. Robert Peterfreund (right), Department Quality Assurance Committee chair, presents the award to Dr. John Walsh.
Figure 1. Top panel is the front view of a vial of propofol (left) next to a vial of Rotaglide (right). Bottom panel is the back side of these vials.
APSF NEWSLETTER Fall 2011 PAGE 39
Request for Applications (RFA) for the
Patient Safety Investigator Career Development Award Program
(DEADLINE DECEMBER 31, 2011)
APSF is soliciting applications for training grants to develop the next generation of patient safety scientists.
In this initial, proof-of-concept RFA, we intend to fund one ($150,000 over 2 years) Patient Safety Career Development Award (PSCDA) to the sponsoring institution of a highly prom-ising new patient safety scientist. Please see the APSF website
As an example, the Datascope “Expert”(DatascopeCorporation,Paramus,NJ)haswave-formsthatdonotmoveacrossthescreen;thestaticwaveformsgetreplacedaseachnewsweepcomesby.Ittakesabout6secondsforeachsweepacrossthescreenoftheECG,pulseoximeter,andpressurewaveforms.Ittakesabout15secondsforthesweepofthecapnograph.IfonequicklycountstheECG,pres-sure,orpulseoximeterdisplayedwaveformsandmultipliesthatnumberby10,ormultipliesthenumberofcapnographwaveformsby4,onecancloselyestimatetherateperminute.Sometimesthereareartifactsthatcausethenumericaldisplaytobe
Jonathan V. Roth, MDAssociate Professor of AnesthesiologyDepartment of AnesthesiologyAlbert Einstein Medical CenterThomas Jefferson School of MedicinePhiladelphia, PA
®
APSF NEWSLETTER Fall 2011
Anesthesia Patient Safety FoundationBuilding One, Suite Two8007 South Meridian StreetIndianapolis, IN 46217-2922
NONPROFIT ORG.U.S. POSTAGE
PAIDWILMINGTON, DEPERMIT NO. 674
In this issue:
Featured Article:
“No Patient Shall Be Harmed By Opioid-Induced Respiratory Depression”
Also:
Tribute to Jeep Pierce Dear SIRS: Reusable Anesthesia Breathing Circuits Considered