Close Call In Honduras With A Nosebleed
During a recent volunteer medical mission to Honduras, we had a close call with a blood clot in the airway following nasal surgery. This article discusses that event. Read More …
Category: Patient Safety
Intubation With Airway Bleeding and Massive Emesis
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? This article discusses two prior cases and offers suggestions on intubation when massive emesis or blood interfere with visualization. Read More …
Avoiding Pediatric Drug Errors
Pediatric medication errors are distressingly common. This article discusses various ways to reduce the risk of administering an incorrect medication dose to a child. Read More …
Ventilation Perfusion Mismatch
There are 2 types of mismatch: dead space and shunt. Alveolar gas exchange depends not only on ventilation of the alveoli but also on circulation of blood through the alveolar capillaries. This makes sense. You need both oxygen in the alveoli, and adequate blood flow past alveoli to pick up oxygen, other wise oxygen cannot be delivered.
When the proper balance is lost between ventilated alveoli and good blood flow through the lungs, ventilation/perfusion mismatch is said to exist. The ventilation/perfusion ratio is often abbreviated V/Q. V/Q mismatch is common and often effects our patient’s ventilation and oxygenation. Read More …
Help! My Anesthesia Machine’s Not Working!
There is nothing quite as scary as being in the middle of administering an anesthetic and having your anesthesia machine fail. In my 36 years of anesthesia practice I’ve had this happen to me a few times. Knowing how to quickly troubleshoot your machine, and knowing how to protect your patient are important, potentially life-saving skills. It helps to have thought through the steps to rescue the situation before it happens to you. This article discussed the steps you should take if your machine fails. Read More …
Codeine Risk In Children, Especially Those With Sleep Apnea
Although the initial FDA warnings about potentially fatal codeine overdose in children were released in 2012, I’m recently discovered that a few of my surgeon and nursing colleagues were still unaware of the potential risks. This article reviews some of the risks of using codeine in the pediatric population as well as the patient’s at highest risk for potentially fatal respiratory depression. Read More …
Alert: We May All Be Over-Inflating Our LMA Cuffs!
The laryngeal mask airway, or LMA, is so commonly used, and so apparently safe, that it’s easy to become complacent. Research is showing that it’s apparently very common for us to over-inflate our LMA cuffs — to the potential harm of our patients. This article discusses some of the risks of overinflation, the predispositions to overinflation, and some of the strategies to avoid it. Read More …
Potential Tongue Ischemia with LMA Supreme
When we place anything in the mouth, be it an endotracheal tube, oral airway or LMA, we are typically extremely careful to protect the teeth. We take care to avoid cutting the lips with the teeth. But we often take the safety of the tongue for granted. I recently recognized a potential problem while using an LMA supreme that could have caused tongue ischemia if not recognized and corrected. Read More …
Apneic Oxygenation: Increase Your Patient’s Margin Of Safety During Intubation
Breathing room air, oxygen saturation drops precipitously to below 90% within about a minute of the start of apnea in the average healthy adult. While preoxygenation is one of the most important safety measures we can use prior to induction of anesthesia and in preparation for intubation, apneic oxygenation can allow even more time for intubation to occur. Apneic oxygenation using nasal cannula can significantly delay the onset of critical hypoxia.
Preoxygenation Can More Than Double The Time To Hypoxia During Apnea
While breathing room air, oxygen saturation drops precipitously to below 90% within about a minute of the start of apnea in the average healthy adult. One of the most important safety measures we use in anesthesia is to preoxygenate our patients prior to induction of anesthesia and in preparation for intubation. This is especially true if we are planning a rapid sequence induction. Adequate preoxygenation can more than double the time to hypoxia during apnea, allowing more time for intubation to occur.
Preoxygenation increases the margin for safety. It treats any pre-existing hypoxemia in the critically ill patient. It also postpones the onset of hypoxia while the patient is apneic during the intubation attempt. This becomes especially important if the intubation attempt becomes difficult and prolonged.
Speed of onset of hypoxia with apnea depends on metabolic rate and on the actual amount of oxygen available in the patient’s functional residual capacity. To see how preoxygenation can effect this let’s review some physiology. Read More …
Don’t Withhold Oxygen From That CO2 Retainer
There is often a great deal of confusion about how to manage the care of a patient with COPD because of concern about inducing CO2 retention. This fear of causing CO2 retention sometimes causes providers to withhold or withdraw oxygen inappropriately. Understanding some of the respiratory physiology behind CO2 retention will allow you to make more informed decisions. This discussion will explain why withholding or withdrawing oxygen from a sick CO2 retainer may, or may not, be the wrong thing to do. Read More …
Ventilate and Intubate But Don’t Forget Communicate
Many years ago I was participating in a volunteer medical mission to Kenya when I learned a valuable lesson in communication which I often share with my students. It involves a failure to communicate on multiple levels that almost caused some major problems. Read More …
Avoiding Medication Errors
Humans are fallible and medication errors are very easy to permit’s easy to give a medication error if you aren’t constantly vigilant. Presented are a series of steps to perform every time a medication is administered that will help prevent medication error. Read More …
Use Of A Nasal Airway To Assist Ventilation During Fiberoptic Intubation
Attaching a nasal airway to a breathing circuit as a tool to assist or control ventilation is a very helpful trick to have in challenging airway management situations. This technique is particularly helpful during blind nasal intubation or fiberoptic intubation in young children after induction of general anesthesia for surgery, although it can be used in adults. Here we discuss use of this technique for a case of accidental extubation of a patient with Ludwig’s Angina.
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How Does Hypoventilation Cause Hypoxemia?
I often find that my students sometimes confuse oxygenation and ventilation as the same process. In reality they are really very different. Ventilation exchanges air between the lungs and the atmosphere so that oxygen can be absorbed and carbon dioxide can be eliminated. Oxygenation is simply the addition of oxygen to the body.Why do we need to understand this? Let’s look at some common examples. Along the way we will painlessly use the Alveolar Gas Equation to explain two common scenarios:
how hypoventilation causes hypoxia,
why abruptly taking all supplemental oxygen away from a carbon dioxide retainer will hurt them. Read More …
Tongue Necrosis From Endotracheal Tube Compression
Tongue necrosis from compression by an endotracheal tube or oral airway is a rare, but devastating complications when it occurs. It can occur with poor endotracheal tube positioning, flexed head and neck positioning, impaired blood flow, and shock. It is important to familiarize ourselves with this entity so that we as anesthesia providers can minimize the risks.
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Plastic In the Airway: An Unsuspected Aspiration Hazard
I saw a potential aspiration hazard in the OR today. How many times a day do we routinely peel plastic wrappers off of airway equipment? If I’m at the surgicenter, I might need 7 face masks, a variety of LMAs and endotracheal tubes and an oral airway or two. Take a look Read More …
A Case of Endotracheal Tube Obstruction
Normally we view patients who are intubated as being protected in terms of ventilatory support. However, being intubated makes the patient vulnerable to a variety of potential problems. Rapid deterioration of an intubated patient can be a challenging and frightening scenario because the providers must rapidly troubleshoot the causes as well as treat. Here a case of endotracheal tube obstruction and its management is described. Read More …
Our Procedural Cast Offs Can Place Our Patients at Risk of Pressure Injury
Health care workers are sometimes careless when it comes to leaving discarded odds and ends that come with our needles and catheters in patient beds. These objects can cause pressure sores and nerve injuries, especially inpatients who are at high risk of pressure injury. We must always be alert to safeguard our patients. Read More …
Protect Yourself From Infection In The Workplace
There are several animal and avian viruses that show the potential of becoming easily transmissible to humans. MERS, H7N9 and H5N1 are already spreading in humans, although not easily. The last major jump from animal to human occurred with the 1918 flu pandemic where an estimated 40 million people died. Mortality from MERS is currently 330-40% in the Middle East and 10% in South Korea. As health care workers, how we approach infectious disease precautions will have a lot to do with how safe we and our patients are in the workplace. Read More …