Spotlight Case February 2003

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Spotlight Case February 2003

• Apnea in a Patient Under General Anesthesia

webmm.ahrq.gov
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Source and Credits

• This presentation is based on February 2003
  SurgeryAnesthesia Spotlight Case
• See full casecommentary on webmm.ahrq.gov
• CME credit is available online
• Commentary by Paul Barach, MD, MPH University
  of Chicago
• Editor, AHRQ WebMM Robert Wachter, MD
• Spotlight Case Editor Tracy Minichiello, MD
• Managing Editor Erin Hartman, MS

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Clinical Objectives

• At the conclusion of this educational activity,
  participants should be able to
• List the causes of prolonged apnea in the
  operating room
• Describe the steps in management of apnea in the
  operating room

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Patient Safety Objectives

• At the conclusion of this educational activity,
  participants should be able to
• State the prevalence of medication errors
• List the causes of wrong drug administration in
  the operating room
• Describe system checks available to prevent
  medication errors in the operating room

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Case Unexplained Apnea

• A 15-year-old boy with no past medical history
  underwent elective right knee arthroscopy and
  debridement under general anesthesia. After
  uneventful induction of anesthesia, the surgeons
  requested antibiotic prophylaxis with cefazolin 1
  gram, which the anesthesiology team administered.

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Case (cont.) Unexplained Apnea

• Before the first incision, 50 mcg of Fentanyl was
  administered. About 2 minutes later, the patient
  became apneic. The surgeon and anesthesiologist
  assumed the patients apnea was due to opiate
  sensitivity and assisted ventilation by hand for
  30 minutes. However, despite a rise in the
  end-tidal CO2 to 70mm Hg, spontaneous
  respirations did not return.

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Etiology of Apnea During Anesthesia

• Anesthetic agents
• Opiates
• Barbiturates
• Benzodiazepines
• Hypocarbia-induced respiratory depression

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Risk Factors for Prolonged Apnea

• Hyperventilated patients
• Extremes of age
• Renal failure
• Pulmonary or hepatic dysfunction
• Hypothermia

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Risk Factors for Prolonged Apnea (cont.)

• Acidosis
• Neuromuscular blockade overdose
• Aminoglycosides or intravenous magnesium
• Neurological impairment or injury

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Clinical Management of Apnea

• Ensure adequate oxygenation and ventilation
• Maintain normocarbia or slight hypercarbia
• Increase O2 flow to breathing circuit to enhance
  elimination of inhalation anesthetics
• Send blood samples for ABG and serum electrolyte
  levels
• Conduct a neurological examination

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Clinical Management of Apnea (cont.)

• Review doses of medication administered
• Check for syringe swap of opiates, hypnotics,
  muscle relaxants, anticholinergics
• If the error in drug administration is recognized
  immediately after injection
• Stop the IV
• If there is blood pressure cuff on arm of IV,
  inflate to slow entry of drug to central
  circulation

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Clinical Management of Apnea (cont.)

• Consider reversal of specific drugs such as
  opiates, benzodiazepines, anticholinergics
• If residual blockade is present
• Administer reversal medication neostigmine along
  with glycopyrrolate
• Reassure patient continue short-acting sedation
• Consider 1 gm calcium chloride (for
  aminoglycosides)

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Case (cont.) Unexplained Apnea

• Because the apneic episode lasted longer than 30
  minutes, the anesthesia team began to question
  their initial assumption that the apnea was due
  to opiate sensitivity. They had obtained the
  cefazolin from the medication drawer of the
  anesthesia cart. The anesthesia team examined the
  drawer and found vials of cefazolin and
  vecuronium (a long-acting paralytic agent) in
  adjacent medication slots.

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Case (cont.) Unexplained Apnea

• The vials were of the same size and shape, with
  similar red plastic caps. The team realized that
  the patient had received vecuronium 10 mg, not
  cefazolin 1 g, and that the observed apnea was
  therefore due to unrecognized muscle relaxation.

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Medication Errors

• 1 cause of adverse and preventable patient
  events
• 7000 deaths annually
• 45 of adverse drug events are caused by errors

Leape LL, et al. New Eng J Med.
1991324377-384.IOM Report (1999)To Err is
Human.
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Medication Errors in the OR

• Anesthesiology self-report system found 71/1089
  (7) incidents related to syringe or ampoule swap
• Out of 58 events related to medications in the
  OR, 71 involved muscle relaxants

Cooper JB, et al. Anesthesiology. 19846034-42.
Leape LL, et al. JAMA. 199527435-43.
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Causes of Medication Errors in OR

• Failure to label syringes
• Incorrect matching of labels on syringes/ampoules
• Failure to read label on vial/ampoule
• Misuse of decimal points/zeroes
• Inappropriate abbreviations

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Risk Factors for Medication Errors in OR

• Unfamiliar settings
• New drug packaging or ampoules
• Similarly appearing ampoules are stored close
  together in the medication carts
• Syringes prepared by other personnel
• Handwritten labels used
• Poor lighting conditions
• Multiple medications

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Similar Vials Cefazolin and Vecuronium
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Similar Vials Atropine Phenylephrine
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Medication Cart Drawer
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When to Suspect Wrong Drug Administration in the
Operating Room

• Unusual response or lack of response to drug
  administration pounding heart, mental status
  changes, apnea, muscle weakness, or visual
  disturbances
• Extreme or unexpected increase or decrease in
  blood pressure or heart rate
• Unexpected or persistent muscle relaxation
• Unexpected change or lack of change, in level of
  consciousness
• Incorrect ampoule found to be open in work area

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Steps if Wrong Drug Administration is Suspected

• Check the syringes and ampoules used during the
  case
• Check to see if unexpected low volume remains in
  syringe
• Inspect open ampoules
• Impound sharps container for inspection of
  ampoules and syringes at later time
• Consider drawing blood levels to ascertain drug
  given

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How to Prevent Wrong Drug Administration

• Check for correct patient, drug name,
  concentration, dose, route, time
• Use drug labels that conform to ASTM standards
• Label syringes carefullyuse preprinted
  color-coded adhesive labels
• For emergency drugs, use ready-to-use syringes
  prepared according to ASTM standards
• Standardize location of medications
• Discard unlabeled vials, syringes
• Bar coding

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Case (cont.) Unexplained Apnea

• Hand ventilation was continued to achieve
  normocapnia until the muscle relaxant had
  dissipated and neostigmine could be administered.
  After reversal of muscle relaxation, apnea
  resolved, anesthesia was discontinued, and the
  patient was transported safely to the
  post-operative care unit, where he recovered
  fully and was discharged.

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Take-Home Points

• Medication errors are the 1 cause of preventable
  adverse events, including death
• Causes of wrong drug administration include
• Failure to label medications
• Mislabeling of syringe or ampoules
• Failure to confirm identification of the
  medication by reading label carefully
• System checks should be used to prevent or reduce
  chances of inadvertent drug/vial swap

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Take-Home Points (cont.)

• To reduce medication errors in the OR
• Label syringes with color-coded, pre-printed
  labels conforming to ASTM standards
• Use easily identified ready-to-use syringes to
  administer emergency drugs
• Standardize location of medications on anesthesia
  cart
• Always review 6 Rights (patient, drug, dose,
  route, time, concentration)
• Used computerized drug order entry and barcoding
  systems when available

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