Bell Medical purchased Bay State Anesthesia of New England on April 1, 2022. Bell Medical plans to continue to use the Bay State Anesthesia name and to run the operation with all current sales and service staff with little change in the eye of the customer, according to Kevin Lueders, President. Bay State Anesthesia has been providing anesthesia and respiratory specialty products and services to the New England market since 1970. Bell Medical, headquartered in St. Louis, Missouri, is a national distributor that has specialized in anesthesia sales and service since 1975. Visit the company websites at: www.BellMedical.com and www.bay-state.com or contact Kevin Lueders at 314-772-5600 or [email protected] with questions.
Quantitative Neuromuscular Monitoring in Clinical Practice: A Professional Practice Change Initiative. Wade Weigel, MD at Virginia Mason Medical Center, Seattle, WA
Virginia Mason Medical Center has 28 anesthetizing locations. A total of 20,181 electronic charts and 2,807 manually reviewed charts were examined over a 4 year period (2016-2020)
History of Nerve Stimulator installations at Virginia Mason MC
In 2016, every operating room contained a peripheral nerve stimulator
– Digistim II (Neuro Technologies)
– EZ Stim II (LifeTech)
– TOF-Watch SX (Organon)
– Intellivue NMT (Philips)
In 2017, the STIMPOD NMS450X was introduced in 24 locations, replacing the previously installed stimulators
In 2018, Twtichview monitors were introduced in 4 locations, primarily to cover tucked-arm procedures (robotic, cardiac etc). There was a significant cost implication, estimated at $9600 per annum for the EMG electrodes per Twitchview monitor.
Great example of only using EMG where it is needed. If Virginia Mason had to standardize on Twitchview monitors for all their locations, this would have incurred an additional cost of $230,400 per annum, compared to the $38,400 when using it in only select locations – a great saving for the hospital. Also note that only 4 Twitchview monitors (14% of total sites) were needed to cover tucked-arm procedures.
PACU length of stay was reduced by 7% (p<0.001)
Pulmonary complications overall reduced by 42% (p = 0.011)
Average Sugammadex dosage decreased by 14% (p < 0.001)
Subjective assessment decreased from 82% of cases (pre-implementation) to 5% of cases (post-implementation)
TOF Ratios > 90% increased from 3% of cases (pre-implementation) to 92% of cases (post-implementation)
Continued on next page:
“Frequent error messages and inability to attain measurements historically impeded uniaxial acceleromyography enthusiasm. Introduction of the triaxial monitor (STIMPOD NMS450X), which measured three dimensions of movement, worked more reliably, which facilitated acceleromyography monitor use.”
“In contrast, TwitchView array failures that included failed current delivery, failed signal return, poor-quality signal, and inaccurate readings (e.g., train-of-four count 0 with four visible thumb movements) demotivated providers from using the TwitchView given the cost of each array.”
The takeaway here is not that Twitchview is necessarily bad, but that EMG is difficult. AMG is still the most reliable, consistent and cheapest method of monitoring NMBA’s. Xavant continues to invest in both technologies, as we believe both of these technologies are needed to drive adoption of Objective NMT Monitoring.
Closing statement: “Achieving and documenting a train-of-four ratio greater than or equal to 0.9 after administration of a nondepolarizing neuromuscular blocker is not a quixotic goal. This result was achieved in a busy tertiary hospital. However, attaining this endpoint requires more than just placing a quantitative monitor at each anesthetizing location. Ongoing educational effort and follow-up are required. We think our experience provides a useful road map to this end. Anesthesia providers are solely responsible for properly rescuing patients from the states of paralyses they initiate. This should occur for all patients as verified by quantitative measurement and documentation of train-of-four ratios greater than or equal to 0.9.”
For more information on QTOF monitoring and the Stimpod 450X please contact Bell Medical at [email protected]
Bell Medical has received a purchase order for 7 WellAir Novaerus 900 for Gates Ventures (Bill and Melinda Gates Foundation). The Novaerus system is the only system that destroys airborne viruses, bacteria, and other pathogens at the DNA level. It uses patented plasma technology to be 99.99% effective. Call us at 314-772-5600 or email [email protected] for more information and customized quotes.
Joanna Blondeau, CRNA, Staff CRNA, MedStream Anesthesia, Hilton Head Island, S.C.
Most airway management for anesthesia providers and airway experts is routine, predictable, uneventful and straightforward. However, when a challenging airway occurs in a clinical situation, it can lead to adverse effects and life-threatening consequences for the patient and anxious moments for the provider. The inability to successfully open the airway to ventilate or secure an airway with intubation are among the most challenging clinical situations that anesthesia providers encounter. Opening and securing the airway in a timely fashion is key to improving outcomes. Despite some improvements in airway management,1 these difficult events still contribute to morbidity and mortality and closed legal claims in anesthesia.2-4
Advanced airway tools have improved outcomes. Video laryngoscopes, laryngeal mask airways, positive airway pressure (PAP) devices, high-flow nasal cannula (HFNC) devices and cricothyrotomy kits all offer options for managing airways to assist patient breathing. However, core airway tools—the oropharyngeal airway (OPA) and nasopharyngeal airway (NPA)—have not advanced to address current patient needs, leaving a gap in airway management.
In the United States, the average patient is taller, heavier and older than patients from previous generations.5 These older, heavier patients are often prone to obstructive sleep apnea (OSA). Current OPA designs do not reach the distal pharyngeal tissue beyond the tongue that commonly obstructs the airway.6 An NPA can stimulate epistaxis, further compromising the airway. As a result, the risk for hypoxia due to upper airway obstruction during and after anesthesia has increased as well.7,8
To address challenges from apnea, hypoventilation or soft tissue obstruction during sedation or positive pressure ventilation, some anesthesia providers have begun to use a new distal pharyngeal airway (DPA) (Figure 1). The DPA stents open distal pharyngeal tissue beyond the tongue (Figure 2). When used with a connector, the airway also can bypass difficult mask ventilation variables with patients who have a beard, are obese or have OSA (Figure 3).
Figure 1. Distal pharyngeal airway.
All images courtesy of McMurray Medical.
Figure 2. Placement of the distal pharyngeal airway device.
Figure 3. Intraoral positive pressure ventilation while manually closing the nares and mouth.
Two case studies illustrate the utility of the new DPA device in obtaining a patent airway under urgent and difficult circumstances.
Case Report 1
A 60-year-old male with a body mass index (BMI) of 30 kg/m2 was hospitalized with COVID-19. The patient was intubated and on a ventilator in the ICU for two weeks. The surgeon was to perform a tracheostomy in the OR under general anesthesia. A bronchoscope was placed in the endotracheal tube to provide visualization of the percutaneous needle and wire placement. As the anesthesia team (anesthesiologists and CRNAs) carefully retracted the bronchoscope, the ETT inadvertently became dislodged. Oxygen saturation dropped quickly to approximately 30%. Mask ventilation and reintubation attempts by two different anesthesia providers, using both direct laryngoscopy and video laryngoscopy, were unsuccessful due to laryngeal edema from prolonged intubation. As the team was preparing for an emergent tracheostomy, an anesthesia provider quickly placed a DPA and started positive pressure intraoral ventilation. Oxygen saturation returned to baseline and the trach was subsequently successfully placed in a controlled setting.
Case Report 2
A 40-year-old male with a BMI of 40 and a medical history of cervical stenosis and bilateral arm neuropathy presented for anterior cervical discectomy and fusion (ACDF) surgery. A general anesthetic was started without incident, but intubation was challenging. After the surgical procedure was successfully completed, a hard collar was placed, and the awake patient was extubated with no coughing. However, in the recovery room, upper airway obstruction developed after the patient was medicated for pain, leading to desaturation and hypoxia.
Knowing that the patient had a challenging airway with excessive neck tissue and a large head, and that the surgeon did not want the collar to be removed to prevent disruption of the cervical repair, anesthesia personnel effortlessly placed the DPA. Intraoral ventilation was initiated and oxygen saturation reached baseline. With the DPA in place, the patient was assisted with occasional intraoral bag ventilation when saturation dropped. The DPA was removed when the patient was awake enough to maintain an open airway and adequate ventilation. The DPA proved to be an effective tool to keep the patient breathing without disrupting the surgical repair.
After this event, the nurses in this recovery room routinely used the DPA as an urgent intervention while waiting for anesthesia personnel to arrive with additional assistance. Staff who have limited intubating skills can place the DPA easily, helping to manage hypoxia quickly.
Airway management can be challenging in some patients. Airway tools have evolved, but traditional OPAs and NPAs historically relied upon as essential airway management devices have not advanced appreciably since their creation many decades ago. Today’s patients are more susceptible to upper airway obstruction due to increased weight, age and OSA. There is now a third option available to add to the core set of airway management tools. DPAs are easy-to-use devices that quickly open the distal tissue beyond the base of the tongue, helping to provide a patent airway, ventilation and a lower risk for hypoxia.
Blondeau reported no relevant financial disclosures.
- Cook TM. Strategies for the prevention of airway complications – a narrative review. Anaesthesia. 2018;73(1):93-111.
- Larson SL, Matthews RW, Jordan L, et al. Improving patient outcomes through closed-claims analysis: salient characteristics and patterns associated with respiratory events. AANA J. 2018;86(3):201-208.
- Mora JC, Kaye AD, Romankowski ML, et al. Trends in anesthesia-related liability and lessons learned. Adv Anesth. 2018;36(1):231-249.
- Cook TM, Scott S, Mihai R. Litigation related to airway and respiratory complications of anaesthesia: an analysis of claims against the NHS in England 1995-2007. Anaesthesia. 2010;65(6):556-563.
- NCD Risk Factor Collaboration (NCD-RisC). A century of trends in adult human height. ELife. 2016;5:13410.
- Garvey J, Pengo M, Drakatos P, et al. Epidemiological aspects of obstructive sleep apnea. J Thorac Dis. 2015;7(5):920-929.
- Ogden CL, Carroll MD, Kit BK, et al. Prevalence of childhood and adult obesity in the United States, 2011-2012. JAMA. 2014;311(8):806-814.
- Krogh M. Obesity and anesthesia practice. In: Nagelhout J, Elisha S, Plaus K, eds. Nurse Anesthesia. 6th ed. Elsevier Saunders; 2018:998-1014.
Used with permission from Anesthesiology News 3/2022
Selecting the right blood/fluid warmer for your organization is a critical decision. Nowadays, due to multiple recent recalls of aluminum warmers — that according to the FDA’s warning their aluminum leaching levels “may cause serious adverse events including death”– decisionmakers should be fully aware of what’s inside their warmers of choice. The last thing you want is to face a recall situation just after you have invested considerable funds in procuring new warming devices.
A study published in 2019 expressed concerns regarding non-coated aluminum solutions. At the same time, the authors stated that “Even in a coated warming device, aluminum concentrations are detectable, but remain below the limit of quantification, LOQ (i.e. our methodology does not have the ability to differentiate between the concentrations we measured and the FDA threshold)”. Of note, some of the recent devices that were recalled are based on coated aluminum. Similarly, in TCCC’s recent Management of Hypothermia in Tactical Combat Casualty Care guidelines (2020), the authors also raised a concern regarding the utilization of aluminum warmers.
The risk of aluminum toxicity is nonexistent with the Warrior line, which is utilizing commonly-used medical-grade stainless steel coil for the fluids path and heat exchange functions. Our compact disposable unit (CDU) also includes PVC line with standard luer lock connection, to fit common blood/IV lines. A few temperature sensors are attached to the coil and report the blood/fluid temperature hundreds of time per second to the controller. Based on these readings, the controller regulates the energy distribution so as to ensure 38 degree Celsius output temperature.
Our technology is packaged in a compact and lightweight Expanded Polypropylene (EPP) casing. As per the British Plastic Federation, EPP “is a highly versatile closed-cell bead foam that provides a unique range of properties, including outstanding energy absorption, multiple impact resistance, thermal insulation, buoyancy, water and chemical resistance, exceptionally high strength to weight ratio and 100% recyclability”. With its excellent thermal insulation properties, the EPP casing ensures that heat is not dissipating; thus, allowing unmatched efficiency which is then translated into top warming performance.
Our technology is designed to address risks that may be associated with blood/fluid warming:
- Hemolysis. Hemolysis might be accelerated by suboptimal design of the fluid path of the warming element. You expect your blood/fluid line to be smooth and homogeneous, then why make exceptions for the warmer’s fluid path (or as it is often called, the cassette)? In other words, preferably the fluid path of the warmer should be designed in an ‘undisrupted’ fashion. That is, and to the extent possible, the fluid path design should avoid for example abrupt turns, connection points, and flow changes (e.g. from a wide to narrow carrier and vice versa) in order to minimize sheer force, turbulence, cavitation, and air bubble formation, to name just a few potential complications associated with high flows and elevated pressure. Our fluid path has been designed in an undisrupted fashion so as to address the complications listed above.
- Over/under heating. Another risk is over/under heating the blood/fluid being infused. Under heating is a more common issue especially with high flows and with rapid intermittent (bolus) flow methods, since most warmers cannot keep up with the job. If the warmer is unable to warm the fluids to body temperature at the rate being infused, you are introducing hypothermic fluids into your patient. Even room temperature fluids are far below body temperature, especially for severely sick patients suffering from shock. Our technology has been designed to support high flow rates and rapid intermittent (bolus) flow methods.
- Aggressive heat transfer process. It seems logical that a relaxed heat transfer process from the heat exchanger to the blood/fluid is safer than an aggressive heat transfer process. Therefore, why not add this to your evaluation criteria? The most relaxed heat transfer mechanisms require a warming surface of 15-20 ml. We all love solutions with small priming volume, but we need to acknowledge that this may come at a ‘price’. And the price is a potentially aggressive heat transfer process from the heater to the blood, especially at elevated flows. With its 19ml priming volume, our heat exchange process is amongst the most relaxed heat exchange processes in the industry.
- Unavailability. One of the most prominent risks associated with your blood/fluid warmer over the past years is that you will not be able to use it since there is a shortage of disposable sets or (as explained in the first part of this mail) due to a recall of the device. Ask users of enFlow, Level 1, ThermaCor, Thermal Angel, and several others to understand how frustrating this can get. And if there is one thing that COVID taught us, it is that complex solutions lead to complex supply chains and therefore to many months of lead times when the unexpected strikes. Therefore, make sure that the consumable of your solution of choice is simple enough to manufacture in large quantities, fast! Make sure that there are no chips that need to be placed into this consumable, otherwise you will be at the mercy of the market availability of chips, which is currently experiencing significant shortages. Our CDU has been designed for mass production and we have not experienced any shortage due to the adverse impact of COVID on global supply chains.
Finally, it should be noted that not only that our technology delivers unmatched performance, but also our per-use price is very affordable, especially compared with other modern warming solutions. A true win-win solution.
For more information click below,
Initially created on JANUARY 15, 2022 BY ARIEL KATZ, CEO QINFLOW
Rapid infusers are a great option for treating patients with severe hemorrhage. However, they require significant commitment from the hospitals: they are expensive to purchase, expensive to operate, and expensive to maintain. As importantly, they require significant ongoing investment in training so as to keep the staff adequately comfortable using them. Too often emergency personnel would avoid using their state-of-the-art rapid infusers simply because they are overwhelmed with their complex operation and time-consuming troubleshooting. In today’s environment, that requires hospital to rely on ‘travelling nurses’ to complement their staff. The situation is worsened since continuous education on rapid infusers is simply impractical.
Therefore, a growing number of hospitals are approaching us with a similar request: “we need a bridge to the rapid infusers”, they say. Indeed, there are other more practical solutions to transfuse warm blood fast. When used with flow-inducing devices such as pressure bag, hand pump, push-pull, electro-mechanical pump, or LifeFlow infuser, the Warrior line of next-generation blood warmers is an excellent bridge to the rapid infusers. The following paragraphs introduce some of the key benefits of the Warrior over rapid infusers.
- Speed. It is important to note that in over 95% of the cases rapid infusers are not required. The patient will receive anywhere between 1 and 3 units of blood and rushed to the OR. In such instances, we celebrate that the Warrior delivers 1-3 units of warmed blood to patients much faster than rapid infusers, simply because set up time is reduced to just a few seconds.
- Simplicity. Moreover, unlike rapid infusers, anyone can be trained to operate the Warrior. This removes the pressure that only a few expert nurses can operate the device flawlessly, as is often the case with rapid infusers. In addition, and unlike rapid infusers, troubleshooting the Warrior is fast and easy. The Warrior’s simplicity has even greater value in situations of a mass casualty event since a stretched medical staff will greatly struggle to operate multiple rapid infusing devices concurrently.
- Portability. One additional key advantage of the Warrior over rapid infusers is its portability. With rapid infusers, warm blood cannot be administered during a patient’s transfer to the next level of care, whereas the Warrior has been designed to facilitate patient’s transports (from field to ED, trauma, OR, and ICU). Unlike rapid infusers, the Warrior can be simply attached to the bed during patient’s transfer from ED to OR, thus freeing the hands of caregivers to perform more important stuff.
- Unique Continuum of Emergency Care Proposition. The portability aspect enables a unique continuum of care proposition, whereby the same consumable can be used across the entire continuum of emergency care, thus simplifying patient handoff between emergency settings and reducing costs. If fully adopted by the hospital, further ROI benefits can be attained by streamlining training efforts, reducing dependency on dedicated staff, reducing spare part inventory, and eliminate monthly service calls and calibration endeavors that raid infusers typically require. If the hospital has a critical care transport team, treatment with the Warrior can commence even prior to the arrival of the patient to the ED.
- Pediatric Applications. Another benefit of the Warrior is its ability to operate even with small-size catheters, designed for pediatric patients. Rapid infusers are limited to larger catheters which is part of the reason that a growing number of pediatric hospitals have adopted the Warriors along with the LifeFlow infusion device.
- Maintenance Free. The Warrior does not require any routine service or any annual calibration. It requires just one inspection every 5 years. Rapid infusers typically demand monthly service and calibration endeavors that overload the biomed team.
- Aluminum Free. The Warrior is aluminum free; some rapid infusers contain aluminum in their fluid path.
- Improved ROI. Finally, cost — both capital and consumables — is another huge benefit of the Warrior over rapid infusers. A rapid infuser may cost $30k. At this price you can get approximately 8 Warrior AC devices… A rapid infuser’s consumables are in the range of hundreds of dollars, considerably higher than the Warrior’s Compact Disposable Unit. There are also significant benefits related to reduction of indirect costs, such as simplified training, elimination of spare inventory, and elimination of complex service requirements, to name just a few.
To summarize, even the best-equipped medical centers are too often reluctant to use their rapid infusers due to their complexity. In such cases, therefore, the patients will get cold blood/fluid. While the Warrior is not a rapid infuser, it will outperform rapid infusers in greater than 95% of the cases, when just a few units of blood/fluid are required. In such cases, the Warrior will perform the job faster, more effectively, and more economically than the over-sized, complex, and expensive to operate rapid infusers. Even in those few cases that rapid infusers are required, the Warrior can be used initially so as to accelerate the delivery of the first few units of blood to the patient. In all these cases, the Warrior acts as an optimal bridge to the rapid infusers. Contact us for more information.
- Simple to Operate: Easy one-button operation enhances patient safety
- Immediate Warming: From 4C to 38C (39F to 100F) in just a few seconds
- Fast delivery: KVO to 290ml/min at consistent 38C for 4C fluids and up to 500ml/min for 20C fluids(AC mode)
- Hybrid Power Source: Equipped with both battery (3-5 liters) and AC Power source
- No Calibration or Maintenance: One year warranty, 5 years between service cycles
- Affordable Consumables: Cost effective consumable design
- Self-Regulating: Warming automatically adjusts to address changes in flow rates maintaining 38Coutput temperature
- Portable and light weight: Warrior is ideal for helicopter EMS, Ambulance and ED/OR
- Unique Continuum of Care: Warrior and consumable can be used from field to hospital simplifying patient handoff between EMS, ED and OR thus reducing costs.
- Tested and Compatible by 410 Medical for use with LifeFlow rapid infuser
- FDA, CE and Health Canada approved. ISO certified.
Special tiered pricing for Premier contract members. Give us a call 314-772-5600 or email [email protected] for further information.
Michael Preston, Bell Medical, Kentucky sold 14 Novaerus NV900s to Gateway Community Action for protecting all involved with their Head Start Program.
Good news line is OPEN for Air Purification!
Lindsay Public School system in Oklahoma orders $284,000 worth of Novaerus Nano Strike air purifiers for school district. They are installing 111 NV900s for their classrooms and 22 NV200s for offices and 4 NV400s for their practice gym and 4 Defend 1050s for their large gym and concession area.
Schools systems are protecting their students and faculty with Nano-Strike technology. Watch our 2 minute video on Nanostrike: Novaerus Nanostrike Air Purifier and Disinfection Technology – Bell Medical, Inc
Northeast Georgia Medical Center in Gainsville, GA has ordered and received 10 Warrior AC systems from Bell Medical and QinFlow for use in their operating rooms.
This is our third order in the last 3 months for Warrior fluid warmers. Children’s of Alabama, Birmingham, AL purchased 8 Warriors including the Warrior Hybrid and Warrior AC including the Warrior base unit with battery operation. Kings Daughters Children’s hospital in Norfolk, VA. Has also invested in the Warrior with 8 systems.
Warrior uses medical grade stainless steel tubing and state of the art micro processing to automatically adjust and control the temperature of fluids. Warrior delivers 38 degrees C consistently regardless of flow rates from KVO to 290ml/min. The Warrior is perfect for the operating room, ED and Trauma but also has battery option offering unique portability for patient transport to ICU or use on Helicopter. Combat hypothermia with the Warrior! WE ARE ON A ROLL WITH WARRIOR! Why: Because Smith’s Level One is on recall for aluminum leaching and Smith’s Hotline is having warming set supply shortages AND the Warrior is amazing! The Warrior is the only fluid warmer approved to work with the LifeFlow rapid infuser and the only warmer that excels in handling intermittent flow rates. Bell Medical has the GOOD STUFF!