In Airway Emergencies Always Start With The Basics of Airway Management

We have just finished another round of Critical Event Training for my hospital’s Anesthesia and OR staff. One of the scenarios we ran was how to manage a failed airway: the dreaded “can’t intubate-can’t ventilate” scenario.

As an instructor, it’s important for me to set the stage realistically. The more real the scenario, the more the providers will learn and be able to apply the information should they ever find themselves in a comparable situation. I must observe as the trainees respond to the emergency, and then help the trainees self-analyze what went well — or not so well — during the scenario. Of course, discussion of how things went during a training scenario always leads to sharing of examples from past real life scenarios. And after 37 years of practice I’ve had a lot of sharable experiences.

One past case we discussed is particularly appropriate for those students around the country who are just beginning to learn airway management because the solution rested in basic airway management techniques. All illustrations from Anyone Can Intubate 5th Edition.

Case

The patient was a 50 yo, 5’ 10”, 110 kg male suffering from respiratory failure from sepsis. The intensivist was preparing to intubate  and had asked me, as the anesthesiologist on the code team that day, to come over to the ICU to provide an extra pair of hands in case the intubation proved difficult. However, as I entered the ICU it was clear that the situation had clearly changed for the worse. The intensivist had tried and failed the intubation and had then been unable to ventilate. He was just setting up for an emergent cricothyrotomy. The oxygen saturation was 50. A nurse was unsuccessfully attempting to ventilate the unresponsive patient.

I had brought a glidescope with me and I rushed to the head of the bed, intending to attempt another intubation to establish an airway. However, the first thing I saw was that the nurse, in her anxiety, was pushing the face mask down over the face and in the process, forcing the chin down over the neck. The whole head was bent steeply downward.

I quickly took over the airway, tilted the head back into the sniffing position and inserted an oral airway. I grabbed both jaw angles and pulled upward. The patient had a large round face and a thick neck which made keeping the mask seal challenging with one hand. I instead made the seal with both hands and asked the nurse to squeeze the bag. We were immediately able to ventilate and the saturation rose over the next minute into the mid 90s. Everyone in the room took a deep breath. I was then able to intubate using the Glidescope. Disaster was averted.

In this particular airway emergency, the lesson learned was to always start with the basics of airway management. Links are provided below to previous blog articles with greater detail on each topic. I recommend reading to the end for the big picture and then returning to the links for more in depth discussions.

Don’t Be Afraid To Ask For Help

Our intensivist called for assistance early.  Rarely will you be in a situation where you are the only person trained in intubation. Never hesitate to ask for help. That help can be getting equipment ready, aid in holding the head or neck in position, or asking someone else to intubate.

The faster that help can arrive, the better off you (and your patient) are. Ask early and apologize later if you don’t need the help. If I’m anticipating a potentially difficult intubation I will often ask a colleague to stand by as an extra pair of hands. I also make sure I have back up equipment like bougies, supraglottic airways, and videolaryngoscopy.

Can’t Intubate

A common error if you’re having trouble intubating is to keep trying the same thing over and over again. Change your blade from a curved MAC to a straight Miller blade or the reverse. Alter the patient’s head position, try cricoid pressure, have someone else try. Sometimes it’s your technique that’s making the intubation difficult.

Bear in mind, however, that the more laryngoscopies you perform, the more likelihood there is of increasing laryngeal edema or bleeding. This can worsen the airway and ultimately make ventilation difficult. Unless you quickly see evidence of impending success, it’s often better to switch to an alternative method of intubation like videolaryngoscopy when you can.

Of course, if the intubation is elective, such as for elective surgery, then you can always abort the intubation attempt and awaken the patient to perform an awake intubation.

Can’t Ventilate

This is a true emergency. Without the ability to ventilate, you have only minutes until life-threatening complications occur, including brain damage and death. You must always be prepared for loss of the airway because it can occur unexpectantly.

First, Open the Airway

The most common cause of airway obstruction is the collapse of tongue and soft tissue at the back of the throat over the larynx. Tilting the head and pulling the jaw upward lifts this tissue off the larynx and opens the airway.

A common cause of airway obstruction is the collapse of tongue and soft tissue at the back of the throat over the larynx. Tilting the head and pulling the jaw upward lifts this tissue off the larynx and opens the airway.

A common cause of airway obstruction is the collapse of tongue and soft tissue at the back of the throat over the larynx. Tilting the head and pulling the jaw upward lifts this tissue off the larynx and opens the airway.

Use the head tilt, chin lift maneuver or the triple airway maneuver. Even if you’re using cervical spine precautions (and keeping the head in a neutral position with the neck) you should still pull the jaw upward.These maneuvers lift the tongue, epiglottis and soft tissue upward and off the glottic opening.

The triple airway maneuver tilts the head, lifts the chin, and thrusts the jaw.

The triple airway maneuver tilts the head, lifts the chin, and thrusts the jaw.

Insert An Oral or Nasal Airway

Insert an nasal or an oral airway to treat airway obstruction. Nasal airways are better tolerated by semi-conscious patients. Oral airways are often used in unconscious patients to avoid the potential risk of nose bleed.

Always insert a nasal airway parallel to the floor of the nose.

Always insert a nasal airway parallel to the floor of the nose.

You can use a tongue blade to pull the tongue forward and then slide the oral airway in over the tongue to keep the tongue off the larynx.

You can use a tongue blade to pull the tongue forward and then slide the oral airway in over the tongue to keep the tongue off the larynx.

Oral and nasal airways are not mutually exclusive. If I’m having a really hard time ventilating a patient I will insert both an oral and a nasal airway. They work by different mechanisms and their function ca be additive. If the patient regains consciousness, and a gag reflex, to the extent that they are no longer tolerating the oral airway then you may have to remove it. Having a nasal airway in place helps maintain an airway that may still be somewhat precarious.

Pull The Face Into The Mask,
Never Push The Mask Onto The Face

A big mistake with ventilation is trying to seal the mask by pushing the mask down onto the face, as in this case. This maneuver invariably forces the chin downward, piling the soft tissue around the back of the tongue over the larynx and worsening airway obstruction.

The first step to a good mask seal is opening the airway.

The first step to a good mask seal is opening the airway. (All illustrations from Anyone Can Intubate 5th Ed., C. written MD)

To ventilate, start with a good mask seal. Always pull the face up into the mask by grasping the mandibular bone (not the soft tissue) and lifting the face into the mask to produce the seal. The face becomes sandwiched between your fingers pulling up and your thumb and forefinger sealing the mask against the face.

 

 

 

 

Apply the top of the mask to the bridge of the nose, where leaks often occur.

Apply the top of the mask to the bridge of the nose, where leaks often occur.

Pull the face into the mask, using the cheek tissue on either side to help make the seal.

Pull the face into the mask, using the cheek tissue on either side to help make the seal.

Seat the mask over the chin, making sure the lower lip is inside the mask.

Seat the mask over the chin, making sure the lower lip is inside the mask.

Note the finger positions. Thumb and forefinger press mask against the face and form a "C" shape. Remaining fingers grip mandible and form an "E".

Note the finger positions. Thumb and forefinger press mask against the face and form a “C” shape. Remaining fingers grip mandible and form an “E”.

 

Note the positions of the fingers. Thumb and forefinger press mask against the face and form a “C” shape. Remaining fingers grip mandible and form an “E”. You are literally pulling the face into the face with your fingers while your thumb is applying counter pressure. This push pull action also holds the head in extension and holds the airway open.

 

Don't just push the mask down, pull the patient's face into the mask t seal.

Don’t just push the mask down, pull the patient’s face into the mask to seal.

Use Two Person Ventilation When It’s Hard To Ventilate

Use good ventilation technique, based on your knowledge of basic physiology, to ventilate effectively, as previously discussed in this blog article.

If difficulty persists, use both your hands to seal the mask. Have a helper squeeze the bag for you. Place thumbs on top of the mask, index fingers on the bottom, bunching the soft tissue of the cheeks under the mask. Pull the jaw upward with your remaining fingers by spreading them along the jaw line, underneath the angle of the mandible. Pull up forcefully, squeezing the patient’s face between the mask and your hands. Hold just the bone. Pushing on the soft tissue under the jaw can force it into the airway and worsen obstruction.

Using both your hand to seal a mask is very efficient in long difficult ventilations. You must communicate carefully with the assistant squeezing the bag to ensure good ventilation.

Using both your hand to seal a mask is very efficient in long difficult ventilations. You must communicate carefully with the assistant squeezing the bag to ensure good ventilation.

Use of both hands makes it easier to shift the mandible forward and pull the obstructing tissue up and off the larynx. Move your fingers as needed to perfect your seal. You may still sometimes need a helper to stop leaks

When someone else is squeezing the bag, it’s especially important to verify adequate ventilation — since you can no longer feel the compliance of the bag yourself. Watch the chest rise, see the air condense on the mask (if mask is clear plastic), and have someone listen for breath sounds. Make sure your helper communicates any signs of obstruction or lack of seal immediately. This technique is a team effort.

Follow this link to a video on how to open an airway, insert an oral or nasal airway and apply a mask to ventilate. Ventilation using both one hand and two hands with an assistant is also demonstrated.  

Supraglottic Airways

If the goal is urgent ventilation, remember that intubation is only one way to ventilate.  Consider changing to an alternate method of ventilation, such as use of a supraglottic airway like the Laryngeal Mask Airway . If you can ventilate though an LMA you will have time to consider what further steps need to be taken to secure the airway.

In you still can’t ventilate, you must consider surgical options such as a jet ventilator or cricothyrotomy to quickly reestablish oxygenation. The intensivist was just beginning this step when I arrived on the scene.

Failed Airway Algorithm

A Failed Airway Algorithm

Crisis Management

In the stress and chaos of an emergency, it’s a common human failing that the brain can freeze in unfamiliar circumstances. Forgetting key steps and even techniques is common. That’s one of the main reasons why we perform Critical Event Training. It’s also the reason we all have to rectify with ACLS, PALS, BLS every 2 years. It’s easy to forget the basics if you don’t use them all the time.

The more familiar we are with a scenario, the more likely we will immediately perform the steps that are needed to resolve it, especially if those crises are rare in real life. In addition, Crisis Check Lists are increasingly being used to specifically help ensure that providers use all possible options during rare critical events such as cardiac arrests, pulmonary emboli, dysrhythmias, hypoxia, and others. If your hospital doesn’t have Crisis checklists consider obtaining them.  One such aide can be downloaded here.

Teamwork is also extremely important. Your team members must feel comfortable with making suggestions, pointing out potential problems, and keeping each other informed on what steps have been taken and which are needed. The value of treating patients as a team is that you can leverage the power of multiple brains in the room to solve the problem. You are much more powerful and likely to succeed as a group rather than trying to act alone.

Frequent practice, learning about how to treat those rare emergencies, and improving your ability to function as a team is important before you actually find yourself in a critical event.

May The Force Be With You

Christine Whitten MD

Author, Anyone Can Intubate 5th Edition.

 

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Close Call In Honduras With A Nosebleed

I recently visited Honduras with a Head and Neck surgical team. After a long day in the OR, while we were packing up to leave, a nurse from the ward ran in and said that one of the patient’s who had had a septoplasty that day for chronic sinusitis was bleeding. I immediately started setting up the OR again while our surgeon went over to the ward.

He quickly reappeared with the patient, a 6 ft tall, 100 kg man who had had a good airway earlier in the day when I intubated him for his surgery. Bleeding based on the surgeon’s looking inside the mouth did not appear to be serous at that time, but it had apparently been going on for a few hours before the patient complained. Our surgeon wanted to do an exam and then place Anterior epistaxis balloons: Rapid Rhino consists of an outer layer of carboxycellulose that promotes platelet aggregation, with an inflatable balloon that compresses the nasal cavity upon inflation tamponading the bleeding site. The plan was local anesthesia with some light sedation. I didn’t repeat an exam or an interview because I knew the patient and it was clear what was happening.

As we were positioning the patient, he said calmly, in Spanish, that he felt like he was drowning. I have to admit that I thought this was an exaggeration from a nervous patient because we were not suctioning much blood out of the oropharynx. We played him flat on the OR table with the head of the bed raised about 30 degrees. With this change in position his oxygen saturation fell from 98% to 95%. Things were happening quickly and I attributed this change in saturation to a loose and recycled oxygen saturation probe. We were reusing the probes as our supply was limited and the patient was fully awake. He had not received any sedation as yet.

I gave the patient 1 mg of versed and 50 mcg of fentanyl. I was going slow because I wanted the patient awake,  cooperative and able to protect his airway. After another 5 minutes he was still restless but fully awake. The surgeon asked for a little more sedation and I gave another 1 mg of versed. At this point the patient relaxed and became more cooperative. However, his oxygen saturation fell to 92%. I asked him to take deep breaths, which he did. He was  following all of my commands. Yet his saturation did not increase. I started adjusting the probe, looking for a technical reason for the change.

Suddenly, the patient coughed forcefully. A large organized clot about the size of a peach pit flew out of his mouth and onto the surgical drape. He looked up at me and smiled and said he didn’t feel like he was drowning any more.

I felt a chill run up my back. Where had that clot been? It was not in his mouth or our surgeon would have seen it or suctioned it. His voice had sounded normal with the few words I had heard him say, making it unlikely that it was above the cords. If it was esophageal, I don’t thinking coughing would have brought it out. That left intratracheal.

I’ve previously described an episode with a large organized clot in the trachea which complicated nasal surgery that had been done under conscious sedation. It’s possible that this patient’s slow and steady nasal bleeding had trickled down his trachea while he was sleeping after surgery. If I’m correct about where that clot was, that was a very close call. Had we done general anesthesia, my endotracheal tube might have either obstructed with the clot, or forced the clot down and onto the carina. Dealing with that in a small Honduran volunteer hospital is a scary thought.

In Hindsight

  1. I should have taken the time to do a quick history of what had happened during the day and after the surgery. My failure to do so was caused by my familiarity with the patient. It was also effected by the fact that we would have had to conduct that discussion in Spanish. I’m afraid that after several days of speaking Spanish my brain was tired of translating, so I took the easier path — I thought I knew everything I needed to know. Had I better explored what he meant by “feeling like he was drowning” I might have had some suspicions.
  2. I should have had Magill Forceps out on my station in case I did have to intubate. It’s possible that the clot might have been visible. But I should have been prepared for such a clot.

Would those steps have made any difference? I don’t know. We had no advanced resources available to us in Honduras. However, knowledge is power and it would have made diagnosis of a clot in the trachea much easier had problems occurred.

Even after 37 years of anesthesia practice it’s easy to get lulled into a false sense of security.

May The Force Be With You

Christine Whitten MD, Author Anyone Can Intubate, 5th Edition

 

 

 

 

 

 

 

 

 

 

Finding PEEP In a Bottle (of Water): Thinking Outside The Box

As you read this I am flying to Honduras with International Relief Team on a head and neck surgery medical mission. I will attempt to post mission updates from the hospital compound, pending internet connections. Participating in a medical mission to the developing world is never easy.

Medical personnel trained in a high tech environment take for granted the complex monitoring devices, multiple choices of drugs, and plentiful support peronnel which simplify our job. When medical volunteers travel to the developing world they are often unprepared for the potential hazards produced by outdated technology, unfamiliar and sometimes poorly maintained equipment, poor sanitation, limited supplies, and a malnourished, often poorly educated population.

Let me give you an example of one rather exciting case from early in my volunteer experience. Continue reading

MacGyvering In Anesthesia

I used to love the old TV show MacGyver, which featured an inventive hero who frequently had to improvise some clever device from ordinary objects in order to beat insurmountable odds and save the day.  The concept was so popular that the word MacGyver became a verb. Oxford Dictionaries state that to “MacGyver” is to make or repair something “in an improvised or inventive way, making use of whatever items are at hand”.

As I have traveled the developing world on medical missions I have often had to reinvent ways to do the things I take for granted in my sophisticated operating room, such as reassembling an anesthesia machine that fell apart right after intubation (see this story here) or improvising PEEP from some suction tubing and a bottle of water. (see that story here)

But being able to improvise is just as important in the settings of the more modern hospital. Continue reading

Hair Style Can Impact Intubation

Healing Little Heroes director dressed as Darth Vader at Ronald McDonald House, San Diego

Our Healing Little HeroesFoundation  founder dressed as Darth Vader at Ronald McDonald House, San Diego

Last weekend I spent time with the charity group Healing Little Heroes at the San Diego Rady’s Children’s Hospital, and Ronald McDonald House. The mission of Healing Little Heroes Foundation is to help pediatric patients in hospitals and outpatient settings to heal emotionally and mentally by appearing as Superheroes. My good friend, and general surgeon, Justin Wu, dressed below as Darth Vader, set up the Foundation.

On this day we arrived in full Star Wars costumes to entertain the kids and their families. I’m dressed as Queen Amidala. Which brings me to the topic of today’s conversation. Can hairstyle impact your intubation or even your anesthetic management? The answer is yes. There is no question that if Queen Amidala needed emergency intubation, that her hairstyle would get in the way. Continue reading

A Flood of Blood in the Airway

During intubation,  any liquid in the mouth that obscures the view of larynx not only hinders visualization, it risks aspiration. We’re used to being able to rapidly suction the mouth clear or secretions, blood, or vomit and then have a clear view of the larynx. But sometimes, either because of continued profuse bleeding or massive emesis, fluid continues to accumulate while we’re watching. How can you manage this situation and successfully intubate?

Case #1

The year was 1982. The patient was an 18 year old girl on the liver transplant list. She had end stage cirrhosis due to what at the time was called “non A- non B” hepatitis. She had been admitted to the ICU that day to be worked up for a stable upper GI bleed. The most likely etiology was her esophageal varices: superficial esophageal veins that have become abnormally distended due to portal hypertension in end stage liver disease. So far she had been rock stable — that was about to change.

When I, the ICU fellow, reached the bedside, the patient was coughing and sputtering blood onto the bed sheets and there was blood everywhere. Her varices were bleeding profusely and she was going to drown in her own blood if we didn’t intubate her now. Her blood pressure was 80/50 and her pulse was 150.

I ordered the crash cart and asked for blood to be brought from the blood bank while we were giving her a bolus of crystalloid. We kept her on her side, in trendelenburg position until the last possible moment to allow the blood to drain out of her mouth. Once ready, I administered an induction dose of ketamine and succinylcholine. Ketamine would help to maintain her blood pressure.

As the drugs took effect we laid her flat, still in steep trendelenburg. This position usually lets the blood pool up and away from the larynx allowing the intubator to see the landmarks. All I could see was a puddle of blood welling up. Sucking the blood through the yankauer catheter could not clear the mouth fast enough to keep it clear.  Intubation was impossible under these conditions; something needed to be changed, quickly.

We turned her onto her left side and placed the open end of the suction tubing itself into her mouth to allow it to suction continuously. The side position allowed the blood to drain out as fast as it entered her mouth and let the tongue fall to the left, where I wanted it to go anyway. I was able to intubate her.

After resuscitation with 9 units of blood, 4 units of FFP and a 6 pack of platelets plus about 5 liters of normal saline, the bleeding slowly stopped and we stabilized her. She eventually went on to successful transplant.

Afterward, I and the entire team went down to employee health for gamma globulin shots because we were covered in her blood and thus exposed to non-A, non-B virus.

Case #2

As I ran into the ICU to intubate during a cardiac arrest resuscitation effort, I knew immediately that this was not going to be easy. The nurses at the head of the bed were suctioning huge volumes of emesis out of the patient’s mouth. The patient was flat on her back and no one at the time was ventilating because they were afraid to stop suctioning to apply the mask.

I took a quick look with my laryngoscope but could see nothing but emesis.

Normally I would turn the patient left side down to let the emesis drain out and intubate with the patient on her side. However, I couldn’t turn the patient lateral without stopping chest compressions. I quickly put the bed into steep trendelenburg to get the emesis to puddle up and  away from the airway as best I could. I then placed the bare suction tubing into the back of the throat where it could suck emesis as soon as it appeared. I turned the patient’s face as far to the left as possible to let things drain.

I gave the patient several breaths with the ventilation bag, satisfied that the liquid was being removed and that little was going down the trachea. These days I often bring the glidescope with me when I go to an airway emergency because you never know if the patient you’ve been called to help has a difficult airway, or is in a difficult position, such as on the floor.  With an emergency intubation, minimizing repeated intubation attempts and rapidly establishing an airway can prevent further loss of patient stability.

With the patient still in steep trendelenberg and with my helper holding the suction catheter, ready to move it or remove it if I needed them to, I quickly used the glidescope to intubate.

We could now ventilate the patient. The hospitalist was ultimately able to establish a rhythm and eventually stabilized the patient.

Managing Blood or Other Secretions In the Airway

Active bleeding in the airway makes intubation very challenging: airway bleeding, in both the acute trauma and postoperative settings, means that the anatomy may be altered and landmarks difficult to identify; hemodynamic instability makes choice of sedative/hypnotic agents and muscle relaxants problematic; and usually, the patient has a stomach full of blood ready to aspirate.

In addition, the patient is at risk of aspiration. Hypoxia and even asphyxiation is possible if the airways are filled with blood and not oxygen. There is risk of inducing shock with induction agents. Finally, the providers are going to be exposed to the risk of any blood born pathogens.

Know how to deal with this dangerous and demanding situation.

  • Consider awake intubation, although that may not be an option. That wasn’t possible in either of the above cases. Also, fiberoptic bronchoscopy with massive fluid in the airway is extremely challenging. However, I have performed awake direct laryngoscopy in a patient in shock.
  • Always pre-oxygenate when you can, especially if you’re patient is awake. Your patient will b better able to tolerate longer periods of apnea.
  • You will need helpers, but they need you to direct their efforts to assist you. Think out loud, don’t make them guess your next move or possibly get in your way! Tell your helpers what you plan to do, what you’re worried about, what you need them to do, and when you need them to do it.
    • Place a helper, each with a suction, on either side of the patient .
    • They need to suction while you are intubating but they also need to avoid hitting your hand or obstructing your view.
  • Consider placing a orogastric or nasogastric tube  before you start and suction it completely if possible
  • Consider placing the bed in steep trendelenburg — this will not interfere with chest compressions if in progress
    • On the positive side, Trendelenburg allows fluid to puddle and drain away from the airway.
    • On the negative side, Trendelenburg  decreases functional residual capacity (the patient’s reserve “oxygen tank”) thereby decreasing how long they can hold their breath. It also shifts the larynx and tongue upward, which may potentially make intubation a bit more challenging.
  • Turn the patient onto the side if you can — left side is optimal since the tongue will shift out of the way of your laryngoscope blade. If you can’t, sometimes turning the face to the left side allows sufficient liquid to drain.
  • SUCTION IS KEY! You must ensure adequate suction. This may mean using unguarded suction tubing. If so,  make sure your assistant keeps it open as it will tend to suck up against the tongue and obstruct
  • Choose your induction medications wisely. Inducing shock is a real potential risk.
  • Be prepared for emergent cricothyrotomy.
    • Have the equipment and your helper ready to go.
    • Know when to stop intubation attempts. Failure to promptly recognize the failed airway leads to disaster!
  • Consider using your video laryngoscope if you have one, however be aware that the camera lens can be easily blocked by secretions. Direct laryngoscopy is often the best method
  • Protect yourself and your crew! Don protective gowns, wear a mask and eye protection. Wash well afterward and consider changing if your clothes are soiled.

What about an LMA?

Could you use an LMA in a can’t-intubate-can’t-ventilate scenario with massive amounts of blood or emesis in the airway?  Its definitely not optimal because of the aspiration risk and it depends on the source of bleeding.

  • If you’re dealing with a massive nose bleed, an LMA, especially if it’s an LMA with a gastric suction port like the LMA Supreme, could be used to protect the airway. In this case the blood is not within the channel of the LMA so ventilation is possible and you can suction the stomach through the gastric port.
  • If the bleeding is pulmonary, obviously the blood is coming from a source inside the LMA and an LMA would not be protective.
  • With bleeding gastric varices or massive emesis you could argue that placing a device like the LMA Supreme would allow you to vent the liquid away from the airway, allowing you to ventilate with some protection and perhaps even use the LMA’s channel to intubate.

Cricothyrotomy would be the more optimal way to proceed in the can’t intubate can’t ventilate scenario with massive airway hemorrhage as it definitively protects the airway. However, cricothyrotomy may or may not be an option depending on the equipment available and the skill set of the providers involved. If the choice is ventilation with a continued risk of aspiration vs. not ventilating at all, then by all means try an LMA.

Patients in shock frequently vomit, sometimes profusely. Trauma, nose bleeds, or esophageal varices can produce massive bleeding in the oropharynx. You need to be prepared at all times to deal with liquid in the airway.

May The Force Be With You!

Christine Whitten MD, author Anyone Can Intubate, 5th Edition

Safe Medication Administration For Our Smallest Patients

For the last 3 months, I’ve been teaching critical event training classes for our OR and Perioperative RNs, Anesthesia MDs and CRNAs, and OR techs in preparation for opening our new hospital in San Diego. Several of the scenarios involved pediatric cases. As part of that process, I’ve been reviewing with my providers ways to avoid the potentially deadly problem of pediatric drug dosing errors as well as ways to avoid them.

Pediatric drug errors are unfortunately common. The literature states that medication errors occur in 5% to 27% of all pediatric medication orders, a very sobering number. Considering that many of these errors occur in the smallest, and therefore most vulnerable, of our little patients, the potential impact is especially great. Let’s discuss some of the ways to make pediatric medication administration safer. Continue reading