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Doctor There’s a Problem in the Recovery Room

The operation had been a long, but it had been a success. The patient had been taken into the recovery room and was being looked after by theatre staff as they were slowly woken up. In theatre the anaesthetist was talking with colleagues about the operation.

Suddenly, a member of staff put their head through the door of the recovery room and looking at the anaesthetist said, “doctor there’s a problem in the recovery room.”

Upon entering the recovery room, the anaesthetist found that the patient, had started to recover but was biting down on the reinforced laryngeal mask airway (LMA). The anaesthetist tried to encourage the patient to stop biting, but that didn’t work. The patient bit right through the LMA and this part was removed from his mouth. Remarkably the patient could still breathe through the bitten off end. A few minutes later the patient had recovered enough to spit the remnants of the LMA out. The photographs below clearly show the aftermath. 

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Thankfully, that was a good outcome both for the patient and the anaesthetist and their team. But there are two other scenarios that could have occurred:

  • The patient could have broken their teeth and suffered dental damage. I wrote about this last year and pointed out the consequences both from a repair perspective and a financial one for the patient and the hospital.
  • Another more serious scenario is that the patient obstructs the lumen of the LMA or the LMA blocks the upper airway. There is a real risk of desaturation and negative pressure pulmonary oedema. This is a dangerous and potentially fatal condition. Negative pressure pulmonary oedema (NPPE) or post obstruction pulmonary oedema (POPE) is a clinical entity of great relevance in anaesthesiology and intensive care. The presentation of NPPE can be immediate or delayed, which therefore necessitates immediate recognition and treatment by anyone directly involved in the perioperative care of a patient.(1)

So, what do we know about negative pressure pulmonary oedema or Post Obstruction Pulmonary Oedema?

There are few studies in the public domain that look at the incidence of NPPE. The incidence of NPPE has been reported to be 0.05%–0.1% of all anaesthetic practices. However, it is suggested that it occurs more commonly than is generally documented. According to one estimate, NPPE develops in 11% of all patients requiring active intervention for acute upper airway obstruction (2) . In a small review of case reports where laryngeal mask is cited, 60% reported that the patient bit through the LMA and of that group ⅔ reported that the patient developed a pulmonary oedema (3) .

The review concluded, ”The vast majority of the papers found are case reports, though a single survey suggests that biting of an unguarded laryngeal mask airway (LMA) is not an uncommon event. Complications of biting include airway obstruction and the development of negative pressure pulmonary oedema, neither of which would be welcome events in the resuscitation area.”

In a U.K. national survey of the use of bite guards and critical incidents involving the laryngeal mask airway (3) a postal questionnaire was sent to 451 anaesthetists with a 42% response rate. 63% of consultants, 45% of SpRs and 43% of recovery staff never used a bite guard in conjunction with a laryngeal mask airway of any sort. However, biting of a laryngeal mask airway by a patient, resulting in airway obstruction, had been experienced by 18 users of the flexible laryngeal mask airway (7.3%) and 71 users of the standard laryngeal mask airway (18.8%).

The recovery staff reported an average of two incidents per month of laryngeal mask airway obstruction. The authors concluded that the use of a bite guard with a laryngeal mask airway is an uncommon practice but the occurrence of airway obstruction with the laryngeal mask airway is high.

An upper airway obstruction is the cause of negative pressure pulmonary oedema. A blocked or broken LMA caused by biting is one cause. Others include hanging, strangulation, upper airway tumours, foreign bodies, croup, choking, migration of Folly’s catheter balloon used to tamponade the nose in epistaxis, near drowning, goitre mononucleosis, big tonsils, hypertrophic adenoids, or a redundant uvula.

Once the upper airway is obstructed a very large, negative, intrathoracic pressure is generated by the patient’s increased effort to breathe. This causes pulmonary oedema or fluid build-up in the lungs resulting in acute respiratory failure. The onset of pulmonary oedema is usually rapid (within a few minutes after signs of upper airway obstruction). The patient will become agitated, may look frightened, will breathe rapidly, may become tachycardic, crackling sounds or rales may be heard with a stethoscope and pulmonary secretions become frothy and pink as progressive oxygen desaturation occurs.

Quick thinking and action are required to remove the blockage causing this emergency. If the blockage were caused by a broken LMA the patient would need to be rapidly re-anaesthetised and paralysed to allow the LMA to be removed. This would also allow reoxygenation to occur if the patient were desaturated. This intervention not only exposes the patient to more drugs but if desaturation carries on for long enough the situation can become an anaesthetic emergency. The Difficult Airway Society Guidelines for the management of tracheal extubation(4) recommend the following for the management of negative pressure oedema.

  1. Treat the cause: relieve the airway obstruction.
  2. Administer 100% O2 with full facial CPAP mask. In addition to relieving upper airway obstruction, CPAP may reduce oedema formation by increasing mean intrathoracic pressure and minimise alveolar collapse by increasing functional residual capacity, improving gas exchange, and reducing the work of breathing.
  3. Nurse the patient sitting upright.
  4. If there is fulminant pulmonary oedema with critical hypoxaemia, tracheal intubation and mechanical ventilation with PEEP are necessary. Less severe hypoxia responds to supplemental oxygen and ⁄ or non-invasive ventilation, or CPAP.
  5. Intravenous opioids may help reduce subjective dyspnoea.
  6. Chest radiography may exclude other complications of difficult airway management and causes of hypoxia (gastric aspiration, pre-existing infection, pneumothorax, barotrauma, pulmonary collapse).
  7. Frank haemoptysis may necessitate direct laryngoscopy and ⁄ or flexible bronchoscopy.
  8. Diuretics are often administered, but their efficacy is unproven.

The Difficult Airway Society also comment,” Post-obstructive pulmonary oedema may be prevented through use of a bite block during emergence.”

And so, let us finally consider the economics of managing a patient who develops negative pressure oedema from biting through their LMA. The first thing to say is that the patient would probably need to spend more time recovering in hospital either in the recovery room, on a ward, HDU or even ICU. Further investigations such as a chest x-ray or blood gas analysis might be needed. Interventions as described in the Difficult airway Society Guidelines may also be required.

Uncovering the daily cost of a hospital bed is not easy and the data is quite old. A stay in a hospital bed without factoring in investigations and/or interventions would cost approximately $1800/day in the USA, $AUD1000/day in Australia and £400/day in the UK. Private healthcare charges would be higher. In most health care systems around the world the daily cost of an ICU bed is in 4 figures. In the USA it is approximately $6000/day, Australia approximately $AUD4000/day and the UK approximately £2000/day. A bite block such as BiteMe™ costs $1.48 per patient and would reduce the incidence of negative pressure pulmonary oedema resulting in fewer patients needing to spend extra time in ICU.

I leave you to make your own mind up when it comes to cost effectiveness.

So, what can we determine from this article?

  • The incidence of NPPE is poorly understood and probably under reported.
  • NPPE can result in acute respiratory failure which is a dangerous and potentially fatal condition.
  • Biting through a laryngeal mask airway (LMA) is not an uncommon event.
  • Despite being recommended by the Difficult Airway Society the use of a bite block with a laryngeal mask airway is not a common practice.
  • Using a bite block in conjunction with an LMA would reduce the incidence of potentially fatal negative pressure pulmonary oedema caused by a patient biting through their LMA.
  • Using a bite block such as BiteMe™ to prevent NPPE caused by the patient biting through the LMA and the upper airway becoming blocked is a more cost-effective option than having the patient spend extra time in ICU.

By using a specifically designed bite block such as BiteMe™. Which is made of a very strong, but soft, plastic that resists the shear forces of a human bite very well reduces the risk of desaturation and/or Negative pressure pulmonary oedema if the patient’s airway device becomes obstructed.

The combination of the soft plastic surrounding a closed air-filled space means that when a patient bites down, there are two forces opposing the bite. This means BiteMe™ has a spongy recoil and therefore reduces the risk of the patient severing the LMA if they start biting during emergence.

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References

  1. Bhaskar B, Fraser JF. Negative pressure pulmonary edema revisited: Pathophysiology and review of management. Saudi J Anaesth. 2011 Jul-Sep; 5(3): 308–313.
  2. Tami TA, Chu F, Wildes TO, Kaplan M. Pulmonary edema and acute upper airway obstruction. Laryngoscope. 1986;96:506–9.
  3. Heptinstall E, Heptinstall L. Should Bite Guards Be Used with Laryngeal Mask Airways In Adults? Best Evidence Topics Database (BestBETS). March 2015.
  4. Popat M (Chairman),Mitchell V, Dravid R, Patel A, Swampillai C, Higgs A. Difficult Airway Society Guidelines for the management of tracheal extubation. Anaesthesia 2012, 67, 318–340
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Author: Niall Shannon, European Business Manager, Innovgas

This article is based on research and opinion available in the public domain.

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LifeFlow Blood and Fluid Infuser: Volume resuscitation when minutes matter!

LifeFlow offers improved resuscitation through earlier and controlled fluid delivery. LifeFlow is a hand operated rapid infuser for critically ill patients who require urgent fluid delivery. 

  • Controlled hand-operated rapid infuser
  • Easy to use, intuitive and safe
  • Four times plus faster than pressure bag delivering 500ml in less than 2 minutes
  • Reverses shock and restores tissue perfusion saving lives
  • Improves outcomes and reduces mortality
  • Easy set up and priming with set up in less than 40 seconds
  • Measured delivery with 10ml delivered with each trigger pull
  • Built in “force reducer” reducing infuser force protecting IV site from blow outs
  • Works with the QinFlow Warrior blood warmer
  • Eliminates “Pull/Push technique for pediatrics
  • Fluids can be delivered through 24 gauge catheter and blood through a 22g. 
  • 5 times faster than pressure bag
  • Great for hypotension
  • Safety system prohibits more than 200PSI pressure delivery

Click to view a short training video

Can be used with Warrior Blood and Fluid Warmer

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The face mask that could end the pandemic

By Keri Enriquez

Updated 10:24 AM ET, Sat January 23, 2021

 (CNN)Getting Americans masked up is a top priority for the Biden administration.

Biden, who calls wearing masks “a patriotic act,” signed an executive order Wednesday — his very first as President — to ask Americans to wear masks of their choice for the first 100 days of the new administration. The executive order also requires mask use on all federal property, though in this case, not just any old mask will do.

On Wednesday, after the inauguration, White House press secretary Jen Psaki showed off her bright white N95 mask in the press briefing room. “I wore it out, of course, here today and will continue to do that,” Psaki said after removing her medical-grade mask and before turning to questions.

CDC reports record number of daily Covid-19 vaccinations as states struggle with supply

N95 masks are considered the gold standard in personal protective equipment because they block 95% of large and small particles utilizing a unique electrostatic filter.

The filter works by trapping neutral particles like bacteria and viruses before they pass through the mask, protecting the wearer and those around them. It’s similar to how socks might get stuck to a blanket in the dryer. The N95 mask, which costs roughly $5, also fits securely to the face, eliminating most of the leakage that may occur with a loose-fitting cloth or paper mask.

Studies have shown that masks significantly decrease the chances of transmitting or contracting the coronavirus. But not all masks provide equal protection. Depending on the fabric and number of layers, homemade and simple cloth masks have a range of effectiveness that can be as low as 26%, which leaves the wearer vulnerable.

Some experts like Brigham and Women’s Hospital and Harvard Medical School physician Dr. Abraar Karan have been advocating for public use of N95 masks from the start of the pandemic. In an interview with CNN Chief Medical Correspondent Dr. Sanjay Gupta, Karan outlined why N95s are critical at this stage of the pandemic.

“If for four weeks the country essentially wore these masks in those risky settings like that indoors, what kind of difference do you think it would make?” Gupta asked.

“This would stop the epidemic,” Karan responded.

Dr. Gupta on Covid-19: This is the worst it’s ever been 05:46

The quality of protection a face mask can provide is crucial. A respiratory illness like the coronavirus is transmitted through aerosols, tiny particles that waft and hang in the air. Some virus-carrying particles are small enough to travel through or around lower-quality masks, making the wearer vulnerable to inhalation of viral particles.

“We know now that aerosols spread best when there is poor ventilation, crowding and close contact that’s prolonged,” Karan told Gupta in an interview. “So we were arguing that actually in those settings, cloth masks alone are not going to block aerosols.”

Karan is not the only expert who has been vocal in support of better quality masks for the general public. Former US Food and Drug Administration Commissioner Dr. Scott Gottlieb wrote in an op-ed in the Wall Street Journal that “encouraging Americans to wear higher-quality masks is a simple step that might make a difference.”

The biggest problem is lack of supply. This week marked a full year of the coronavirus, and the Biden administration has committed to invoking the Defense Production Act more often to boost manufacture of N95 masks and other critical supplies. Experts hope manufacturing will hit a speed to be able to sufficiently supply the population.

“An N95 that’s well-fitted clearly is the best that you can do,” National Institute of Allergy and Infectious Diseases Director Dr. Anthony Fauci told CNN Friday. “You could get production of that at a much higher rate now.”

Karan believes N95 masks could be an essential asset in reopening the economy as the vaccine rollout remains sluggish and quarantine fatigue soars.

The huge stakes of Biden’s new Covid-19 plan

“If we have better personal protection for people, they can more safely go back to work. They can more safely re-engage, especially if testing and tracing is not where we need it to be,” Karan said.

“This was going to be one way to get people back in and get the economy back up.”

Some European countries are already taking that step to prevent coronavirus spread within their borders. Earlier this week, Germany and France mandated that all citizens wear high filtration masks like the N95 in all public places.

After months of treating coronavirus patients, Karan says it’s time to invest in making sure masks people wear are even more effective. “Focus on getting better masks to as many people as possible, focus on the messaging around masks, be consistent with your messaging, make masks part of American culture to stop the epidemic.”

The key here is to always wear a mask whenever you’re in public. One study in Lancet Digital Health found that a 10% increase in mask-wearing could lead to a three-fold increase in the odds of maintaining control over virus transmission in a community. The ability to control the spread of the coronavirus is in our hands — and on our faces.

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Novaerus Defend 1050 air purifier approved by FDA as 510(k) Class II Medical Device

Novaerus Defend 1050 cleared by FDA as 510(k) Class II Medical Device to inactivate and filter out airborne virus and bacteria for medical purposes

Defend 1050 uses patented NanoStrike® technology to damage and inactivate airborne micro-organisms.

Dublin, Ireland and Stamford, CT – Novaerus, a WellAir company that delivers clean air solutions to help prevent the spread of infectious outbreaks, announced today that the U.S. Food and Drug Administration (FDA) cleared the Novaerus Defend 1050 (NV 1050) as a 510(k) Class II Medical Device to inactivate and filter out micro-organisms, including virus and bacteria, for medical purposes. The Novaerus Defend 1050 is the first system that uses NanoStrike®, a patented plasma generating technology, to receive FDA 510(k) clearance.

The Novaerus Defend 1050 is a free-standing, portable recirculating air cleaning system designed for additional frontline protection in healthcare settings such as operating rooms, intensive care units, in vitro fertilization labs, emergency rooms, waiting and treatment areas, neonatal units, and other critical environments including those performing aerosol-generating medical procedures (AGMP).

The Defend 1050’s NanoStrike technology uses a plasma field that rapidly inactivates micro-organisms at the molecular level. Within 15 minutes, the Defend 1050 has demonstrated a 4-log (99.99%) reduction of the MS2 bacteriophage RNA virus, an accepted surrogate for SARS-CoV-2. The Defend 1050 also showed a 4-log (99.99%) reduction in Bacillus Globigii endospores (bacterial spores) within 15 minutes, which was maintained over the prolonged operation (24 hours).

The Defend 1050 is currently used in hospitals and healthcare settings worldwide. Given the rapid spread of COVID-19, WellAir moved quickly to understand how this device could potentially combat the virus while moving it through a thorough FDA medical device clearance process. Additionally, the Defend 1050 meets relevant performance criteria in the FDA Guidance, which provides non-binding recommendations that may reduce the risk of viral exposure for patients and healthcare providers during the current public health emergency.

“Our team of outstanding engineers and scientists have been focused on delivering innovative and powerful airborne infection control devices. The FDA clearance on the Defend 1050 is a critical milestone for our company, validating our work to deliver a safe and effective medical device,” said Dr Kevin Devlin, WellAir CEO. “The Defend 1050 has demonstrated tremendous efficacy in third party testing against viruses, bacteria, VOCs, and particulate matter, which makes it an ideal solution for hospitals and healthcare settings. As we continue to see an alarming rise in the number of COVID-19 cases, we have moved quickly to make the device readily available.”

Defend 1050 utilizes multiple stages to reduce airborne micro-organisms. The first stage is a general air pre-filter that captures particles between 4 and 10 microns from the input airflow. This filtered air passes through a series of NanoStrike coils (plasma generators) that damage and inactivate micro-organisms on contact, including viruses and bacteria. The resulting inactive particulates are trapped by a HEPA (High-efficiency Particulate Air) filter. In a final cleaning stage, an activated carbon filter traps VOCs in the airstream before the air is released into the environment.

The Defend 1050 system is delivered complete with all components necessary for immediate use. It can be wheeled easily by a single person to the desired point of use and plugs into standard outlets. Five airflow speed settings enable optimization to each healthcare environment. The only routine maintenance required is a calendar-based filter change schedule.

If you are a medical or healthcare facility interested in learning more about the Novaerus Defend 1050 or other Novaerus products, additional information can be found here, or please contact us

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Xavant Technology Announces First Dual-Sensor Neuromuscular Patient Monitor

The Stimpod NMS450X NMT monitor for Anesthesia first to feature both AMG and EMG modalities in one single, portable patient monitoring system.  

Pretoria, South Africa, October. 15, 2019 – Xavant Technology, a pioneer in neuromuscular monitoring and innovative neuromodulation modalities, announced an addition to the company’s newest generation of Stimpod neuromuscular transmission monitor – the capability of utilizing either of the two most industry prominent types of monitoring sensors, AMG and EMG. The new Stimpod system and EMG sensor accessory will be exhibited at the American Society of Anesthesia (ASA) Annual Meeting, October 19-21 in Orlando, Florida alongside the company’s entire Stimpod portfolio for anesthesia.

“We are excited to announce the EMG modality to our Stimpod line of monitors,” stated Corlius Birkill, CEO of Xavant Technology. “By offering, for the first time, anesthesiologists and clinicians a choice in using either AMG or EMG, we can give them unparalleled clinical and budgetary benefits.” Mr. Birkill continued, “We believe quantitative or objective monitoring of patients who are undergoing neuromuscular block for surgery should be the standard of care. Our goal is to provide physicians with the most optimal and efficient tools to achieve that standard.”

The latest update to the AMG-based Stimpod NMS450X monitor series will enable the use for the first time ever, a dual sensor objective neuromuscular transmission monitor that enables anesthesiologists the choice of using either acceleromyography (AMG) with a reusable sensor or electromyography (EMG) with a disposable sensor to manage patients undergoing neuromuscular block during surgery or while being cared for in the intensive care unit.

By adding an EMG sensor accessory to the Stimpod, clinician opportunities in monitoring will be maximized. Being able to choose either AMG or EMG at site of service, hospitals can perform cost-effective entire-surgery monitoring with the platform that is optimal for that specific case. While AMG is a proven, accurate and cost-effective technology, the EMG sensor will simplify how clinicians monitor patients in more restrictive surgical cases, such as robotic surgery where restricting the hands is common. The EMG accessory is pending FDA clearance.

“The Stimpod NMT monitor is simple and economical way for hospitals to drive patient safety, Operating room, PACU, and ICU efficiency, and manage their very expensive paralytic and recovery drug budgets,” stated Xavant Chairman Roche van Rensburg. “We believe the data is fairly conclusive that hospitals can enhance safety outcomes related to residual neuromuscular block by utilizing objective NMT monitoring. But also important is the power to more effectively manage the time and cost-of-care efficacy for the hospital – we believe the Stimpod system can make a tremendous positive difference on both fronts,” added Mr. van Rensburg.

About Xavant Technology

By Xavant Technology October 17, 2019

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Novaerus NanoStrike Airborne Disinfection Technology

Novaerus NanoStrike Airborne Disinfection Technology

  • Table Top for Smaller Rooms ~120 sq. ft., NV200 delivers 50 CFM(Cubic Feet per Minute) airflow.
  • Wall Mountable, Pedestal Mounted or Roll Stand Mounted options for Medium Rooms ~900 sq. ft., NV900 delivers 150 CFM(Cubic Feet per Minute) airflow at fan speed 1 and 180 CFM at fan speed II.
  • Standalone for rapid remediation for larger common areas with a triple-stage Camfil filter, ~3,000 sq. ft., NV1050 delivers 533 CFM(Cubic Feet per Minute) airflow.
  • Novaerus NanoStrike Airborne Disinfection Technology protects against airborne viruses and bacteria. Nanostrike is the core, patented technology that uses Novaerus plasma-based technology killing all airborne microoganisms on contact providing protection against viruses and bacteria.

NanoStrike patented technology destroys viruses, microorganisms and bacteria at the DNA level:

  • Plasma coils create energy field that kills ALL germs and pathogens in sub-second time.
  • 99.9+% effective at eliminating Influenza pathogens, SARS-Cov-2(Covid-19), and MRSA
  • Kills ALL airborne microorganisms at the DNA level as small as 1 nanometer!
  • Total cell destruction ensures cells do not become viable as an infectious agent ever again.
  • Continuous 24/7 air disinfection and odor control with no disposables
  • Lowest cost of ownership operating 24/7 with no supplies needed for NV200 or NV900.
  • Plugs into standard power outlets plus wall mounts, pedestal stand or roll stand options
  • Independently tested and proven for use in ORs, ICUs, ED, Offices, Restaurants, etc.

 How does NanoStrike Protect?

NanoStrike utilizes an atmospheric plasma discharge like a lightning strike to kill and deactivate harmful airborne microoganisms.  NanoStrike plasma coils provide a deadly strike made up of multiple concurrent processes that work to rapidly destroy airborne pathogens.  The result is total destruction of all airborne pathogens! 

NanoStrike plasma coils create an electrostatic field bombarded by electroporation and electromagnetic field radiating heat and UV radiation in sub-second time to force cells down to one nanometer to explode with osmotic pressure resulting in total destruction of airborne pathogens. 

Novaerus does not filter virus and bacteria cells from the air it destroys them to the point of total destruction with no chance of reactivation or self-healing. 

NanoStrike can protect humans in hospitals, senior living facilities, long term care facilities, schools, locker rooms, casinos, railway stations, residences, hotel common areas, offices, manufacturing, meat processing plants and virtually any indoor environment where people gather.   

Breathe easy with Bell Medical and NanoStrike Technology.