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Aluminum: The Hidden Danger in Blood Warmers

Posted on by Stephen Alexander

Recently, there have been growing concerns from regulatory agencies, such as the FDA, as to the safety of aluminum containing medical devices, especially those involved with the infusion of fluids into patients. Just this past year, the FDA has recalled six intravenous fluid warming products due to evidence showing increased levels of aluminum. According to the FDA, “Exposure to toxic levels of aluminum may not be easily recognized and exposure effects may cause serious adverse events including death”. Some manufacturers have provided a potential solution by using coated aluminum surfaces. While these solutions certainly show improvement, they still release detectable levels of aluminum into infused fluids. The question is, are these levels safe or not? In this article, I will unfold some information about the recent recalls, the risk in aluminum, and other safety considerations regarding blood/fluid warmer. But I would like to start by making it clear to the reader that —

I’m not an expert, just an informer. First let me say that I am no expert in the field of toxicology, therefore it is beyond me to say for certain the safety of aluminum based warmers. That job I leave to regulatory agencies such as the FDA. However, once I reviewed the evidence and recalls put out by the FDA, I felt that I needed to make sure other providers are aware of the risks and recent recalls of these products. We should trust the sophisticated and rigorous medical approval system that we have in place. Therefore, it is my viewpoint that aluminum-based heaters that are regulatory cleared must be 100% safe to use. Nonetheless, we as critical care paramedics, nurses, and physicians must, as a minimal requirement, understand the risks associated with this method of warming. We owe it to our patients to be as well informed and up to date with the risks of certain treatments we provide, especially given the growing number of recalls of aluminum based warming devices.

Peer reviewed research of the risks. Aluminum toxicity can lead to a plethora of diseases ranging from Alzheimer’s, autism, breast cancer, to pancreatitis and pneumonia just to name a few (Igbokwe, 2019). In infants, aluminum toxicity is associated with impaired neurological development (Bishop, 1997). What’s even more alarming is that aluminum can also cause decreased iron absorption and anemia. Imagine trying to infuse blood products to correct anemia, and exposing your patient to toxic aluminum that causes the problem you are trying to reverse! Recalls of blood/fluid warmers due to the potential of aluminum leaching are typically identified as Class I recalls. These are the most serious as they are for devices that may cause serious injury or death! Patients most at risk are pediatric patients, specifically neonates and infants, pregnant women, geriatric populations, and those with decreased renal function or on dialysis.

Why manufacturers like to use aluminum in fluid warmers. Aluminum is used in a wide spectrum of medical devices, and when compared to other materials, it’s easy to see why. Aluminum has a large strength-to-weight ratio. This means that aluminum compared to other materials is stronger and lighter. Aluminum is also a good thermal conductor. In addition, aluminum is very malleable, thus it can be formed to almost any specification. Aluminum is a plentiful material as well; in fact, it is the most abundant metal in earth’s crust, making it very cost effective. All these reasons are why we find aluminum, not just in medical equipment, but in our everyday lives. It’s a good, plentiful, strong material that has countless applications. However, this article seeks to explain why using aluminum may not be the best option with respect to blood/fluid warmers.

Advancements in analytical technology have changed the stance on aluminum. If aluminum is unsafe, then why did the FDA approve of its use in fluid warmers initially? The answer is basically “you don’t know what you don’t know”. Regulatory agencies such as the FDA are only as good as the technology they have available to them. In recent years, advancements in technology have enabled regulators to measure more accurately the levels of aluminum produced from blood warmers that use that material. Keep in mind that when the FDA approved aluminum containing medical devices, it was before sensitive testing instruments were used to detect the minimum allowable limits of aluminum that is set forth today. This means that there was no way of knowing if these devices were leaching aluminum or not into the infused fluids. Therefore, these devices were developed, approved, and put on the market. Only until recently are regulatory agencies capable of measuring the threshold limits produced by these products, and the results — for some of these devices — are concerning.

Increased concern over aluminum containing warmers evident by 3 FDA recalls of 6 warming devices in just 6 months. Since March of this year there have been three separate recalls on fluid warmers that contain aluminum. The FDA has warned that the aluminum used in the heating elements is leaching into the fluids and being infused into patients. In March of 2021 ThermaCor 1200 disposable sets were recalled. The customers were notified of a Toxicological Assessment that there was potential aluminum leaching into fluids. Later, Eight Medical International’s Recirculator disposables were recalled in July of this year. The most recent recall was of 4 Smith Medical’s Level 1 configurations for the same reason, leaching of aluminum. This is on top of yet another global recall of the enFlow device in 2019. With so many recalls in such a short period, it does raise concern that blood warmers containing aluminum in their heating elements pose a potential risk to patients. You can read the FDA’s Letter to Health Care Providers on the recent recalls here.

Researchers find that coated aluminum may not prevent leaching. Manufacturers of blood/fluid warmers with aluminum heaters often make a distinction between uncoated and coated aluminum heaters. The latter (i.e. coated aluminum) is expected to be safer for patients, compared with non-coated aluminum. This makes sense. However, even blood/fluid warmers that utilize coated aluminum may pose a risk to patients. In June of 2019, researchers found that aluminum was still detectable in fluids infused with devices that use coated aluminum. The study compared aluminum release of coated and uncoated fluid-warming devices. The results of the study found that while aluminum release was less in coated devices, it still was elevated above baseline. In fact, the researchers stated that “our methodology does not have the ability to differentiate between the concentrations we measured and the FDA threshold.”(Perl, 2019).

Manufacturers may be predisposed to maintain the status quo. Despite the recent recalls, the default claim of manufacturers that use aluminum heaters is that the aluminum remains below the acceptable limits set forth by regulatory agencies. However, the accuracy of this claim is debatable, and the data that is used to defend these claims is often open for contradicting interpretations. At least in one recent case, the Canadian FDA publicly refuted such a claim proposed by Smiths Medical. Without getting into the specifics of this particular case, it’s easy to understand why manufacturers may resist a change. It goes without saying that they must trust that their solution is 100% safe in order to commercialize it. However, is it possible that this high level of confidence may also be fueled by some sort of an ‘organizational predisposition’? Let me try to explain: these manufacturers assumed significant risks and invested millions of dollars to overcome the demanding regulatory barriers that stand between any medical device innovation and the marketplace. Even after commercializing the product, they had to invest significant budgets in continuous engineering and regulatory affairs. Therefore, they need to see positive returns following these huge investments, otherwise future innovation might suffer. Certainly, a very complex and delicate situation that manufacturers must contend with.

Other associated risks of blood/fluid warming. It should be noted that warming fluids does come with other risks besides aluminum leaching. Let’s review some of these other risks:

  • Hemolysis. One risk is hemolysis due to the age of blood products given. This isn’t necessarily a risk associated only with warming blood products, but just a general risk overall. As the products age, red blood cells have a higher chance of rupturing. That’s why it’s important to infuse blood products before the expiration date.
  • Excessive sheer force, turbulence, and cavitation. 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. Why don’t you simply try to look under the hood of your chosen warmer?
  • Over/under heating. Another risk is over/under heating the fluids/blood being infused. I believe that under heating is a bigger and more common issue especially with high flows and with intermittent flow methods. If your agency requires high flows or uses an infusion device that utilizes intermittent flow, most warmers cannot keep up with the job. If the warmer can’t physically warm the fluids to body temperature at the rate being infused, you’re introducing hypothermic fluids into your patient. Even room temperature fluids are far below body temperature, especially for severely sick patients suffering from shock.
  • Aggressive heat transfer process. It seems logical that a relaxed heat transfer process from the heat exchanger to the blood/fluids 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.
  • 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 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.

A solution. Clearly the wrong answer to prevent aluminum leaching from blood/fluid warmers is to not utilize a warmer. Myself and other colleagues have written extensively about the importance of warming fluids, especially blood products in rapid transfusions. You can read some of those articles here .One practical solution to this problem is utilizing a warmer that is aluminum free in the first place, or, if you decide to use an aluminum warming solution, then do your due diligence about the solution. There are several prehospital and hospital solutions that are aluminum free, such as the Thermal Angel, Quantum, and Ranger, to name just a few. QinFlow’s Warrior is another excellent example of an aluminum-free warmer: it has battery and AC power sources and it therefore fits both prehospital and hospital settings. It has amazing performance levels, measured in maximum delivery rates. And as importantly, its per-use price is very competitive. You can read more about the Warrior here.

Summary & Conclusion. New, more sensitive, monitoring technology has made it possible for regulatory agencies to detect trace levels of aluminum, before unknown to us. Exposure to toxic levels of aluminum, according to the FDA, “may cause serious adverse events including death”. With that information, three recalls of 6 devices have been issued within the past few months over growing concern of elevated aluminum levels in fluids infused by products containing aluminum heating elements. We’ve seen that not even coated aluminum surfaces prevent leaching into fluids. The only way to ensure that zero aluminum is leaching into your patients is most probably to utilize solutions that are aluminum free. While there are several options out there, the QinFlow’s Warrior is a good place to start. Their fluid path is 100 percent aluminum free. They are also amongst the most cost efficient solutions on the market. A true win win. QinFlow’s disposable cassettes have a comfortable and gentle priming volume of 19mL. Finally, the Warrior is rugged enough to withstand high pressures of intermittent flow and can warm near freezing blood products to body temperature within seconds, safely!

***

Bishop NJ, Morley R, Day JP, Lucas A. Aluminumneurotoxicity in preterm infants receiving intravenous-feeding solutions. New England Journal of Medicine 1997;336: 1557–61

Igbokwe, I. O., Igwenagu, E., & Igbokwe, N. A. (2019). Aluminium toxicosis: a review of toxic actions and effects. Interdisciplinary toxicology, 12(2), 45–70. https://doi.org/10.2478/intox-2019-0007

Perl, T., Kunze-Szikszay, N., Bräuer, A., Quintel, M., Röhrig, A.L., Kerpen, K. and Telgheder, U. (2019), Aluminium release by coated and uncoated fluid-warming devices. Anaesthesia, 74: 708-713. https://doi.org/10.1111/anae.14601

Stephen Alexander

Stephen Alexander is a Critical Care Paramedic residing in Little Rock Arkansas. He enjoys writing informative and educational articles about pre-hospital medicine. Stephen started his career in EMS by enlisting in the Army as a 68W Combat Medic. He then attended the U.S Army Flight Medic program through UTHSCSA and received his paramedic license through NREMT. He then went to RUSH Advanced Trauma Training Program in Chicago and attained his CCEMTP. He currently flies for the Arkansas Army National Guard MEDEVAC unit.

Full article can be found here: https://www.qinflow.com/aluminum-the-hidden-danger-in-blood-warmers/

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Innovative MAC anesthesia approach to reducing nausea and vomiting!

Patients experience nausea and vomiting 30-50% of surgical recoveries!  There are NO positive reviews from a patient that vomits post-surgery.  PONV is costly in many ways including slowed patient recovery, poor patient experience and in increased staffing needs.  Reducing PONV can help make hospitals and surgery centers become more productive, more pleasant and more profitable and anesthesia providers happier. 

Aromatherapy from the vanilla infused Capnomask O2/CO2 mask is a safe and effective tool for anesthesia to use to reduce PONV, provide oxygen and monitor the patients breathing to assure safe MAC anesthesia. 

The vanilla infused Capnomask offers a drug-free therapy to give anesthesia a proactive way to reduce the chance of a patient experiencing nausea and vomiting.  The Capnomask offers other advantages including:

  • Excellent patient oxygenation of over double the FiO2 of nasal oxygen canula.
  • Capnomask acts as a physical shield or barrier reducing atomization of a patient’s exhalation thus protecting nurses, surgeons and anesthesia by reducing the spread of germs including Covid19.
  • Capnomask comes preassembled with oxygen tubing and 10’ EtCO2 sample line to safely monitor a patient’s breathing to assure no hypoventilation incidents.
  • Vanilla infused scent reduces nausea and vomiting reducing PONV.
  • Low cost of Capnomask compared to cost of DIY or Do It Yourself options of converting a standard oxygen mask with IV catheter and adding an EtCO2 sample line.
  • Reduced anesthesia time to set up DIY version for MAC cases. 

Further benefits of the Capnomask:

  • Reducing Costs
    • Reduced staffing costs and resources used to administer and monitor PONV treatments
    • Reduced drug costs and side effects of nausea prevention drugs
    • Reduced involvement of pharmacy and medication costs
    • Reduced length of recovery time and improved PACU throughput
    • Improved HCAHPS scores with less PONV
  • Adding Value
    • Preventing nausea with the aromatherapy of Capnomask improves patient experience.
    • Satisfaction scores improve with the reduction in PONV
    • Less staff required for PONV intervention if prevented by proactively using Capnomask
    • Capnomask may be considered an added component of ERAS or Enhanced Recovery after Surgery
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Corneal Abrasion; problem what problem?

Well, it all depends on which side of the fence you are sitting on. Most medical definitions describe a corneal abrasion as a painful scrape or scratch on the surface of the clear part of the eye. This clear tissue of the eye is known as the cornea, the transparent window covering the iris, the circular coloured portion of the eye. Descriptions also state that in most cases the cornea heals in a couple of days and all symptoms pass.

A patient on the other hand would probably describe a corneal abrasion as painful to say the least. In fact, it may be extremely painful. This is because the cornea has a high concentration of nerve endings, so it is going to be really painful. Alongside the extreme pain they may feel as though there is something in their eye. The eye will look red, vision will be blurred and there will be excessive tearing. They may be sensitive to light but closing the eye may only cause the pain to intensify. There may be vision loss and headaches which will cause concern.

So, this can be an extremely uncomfortable situation for someone to be in and they need treatment immediately to relieve the pain and allow them to see clearly.

How does a corneal abrasion occur? The answer is, quite easily. Minor abrasions can be caused by:

  • Poking your eye with a fingernail, pen, or makeup brush.
  • Rubbing it too hard.
  • Wear poor-fitting or dirty contact lenses or wearing them for too long.
  • Walking into something like a branch of a tree.

More serious abrasions can occur from:

  • Getting chemicals in your eye.
  • Get dirt, sand, sawdust, ash, or some other foreign matter in your eye, especially at work and not wearing eye protection.
  • Play sports or engaging in high-risk physical activity without eye protection.

You may be surprised to learn that a corneal abrasion can occur when you are having an operation and are anaesthetised. How can that possibly happen, you are probably thinking. Again, the answer is quite easily. But before we consider how a corneal abrasion can occur in the operating theatre, we need to look at how the eye behaves when it is anaesthetised, and the steps taken to protect your eyes when you have an operation.

A general anaesthetic can have several effects on your eyes, including:

  • It can cause lagophthalmos which is a failure of the eyelids to fully close. During normal sleep, lid closure is maintained by the tonic contractions of the orbicularis muscle. Lagophthalmos only occurs in about 4% of people during normal sleep. However, under anaesthesia one study demonstrated that 59% of patients failed to have complete eyelid closure.(1)
  • Tear production and stability are significantly reduced which causes the cornea to dry out.
  • Bell’s phenomenon is a protective mechanism that turns the eyes upwards to protect the cornea. It occurs naturally during sleep, but this mechanism is also lost during general anaesthesia.

Therefore, you can see that the eyes are compromised when you are given a general anaesthetic and so must be protected from being damaged. But how common is getting a corneal abrasion in the operating theatre, what causes it and what is done to protect the eyes?

A corneal abrasion is the most frequent ocular complication of general anaesthesia.(2) The American Society of Anaesthesiologists’ closed claims analysis of ocular injuries associated with general anaesthesia, 35% were corneal abrasions, of which 16% resulted in permanent ocular damage.(3)

Because the eyes are compromised during general anaesthesia, almost anything can cause a corneal abrasion. The list is endless. A watch strap, name badge, the anaesthetist’s hands, facemasks, drapes, instruments laryngoscope, skin preparation solutions, or the direct irritant effect of inhalational anaesthetic agents. In recovery the eye may be injured by face masks, the patient’s fingers, or the bed linen. However, most corneal abrasions are caused by the failure of the eyelids to close properly leading to corneal drying.(4) I will return to this point later.

It’s clear that the eyes need some solid protection to prevent them from being damaged. So, what is done in today’s modern, high tech expensive operating theatre? They do this.

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Usually, a theatre technician will use some general-purpose tape that is lying on a trolley or in their pocket and your eyes will be taped shut. Prior to taping a protective ointment or gel may be applied. However, we all know that adhesiveness of tape varies and that used in the operating theatre is no different. Too little stick may not ensure or maintain complete eyelid closure, leading to moisture loss from the eye. Too much stick may cause eyelid bruising, irritation and skin tears or eyelash loss on removal. Tape used is usually opaque making it difficult to tell if the patients’ eyes are completely closed. Frequent removal and reapplication of the tape makes it less sticky and prone to falling off Additionally, the anaesthetist may need to check pupil dilation and the tape needs to be removed and reapplied whilst wearing surgical gloves. Not an easy thing to do!

So, back to our patient. Despite taping the patient’s eyes being taped during an operation, the tape was opaque, and no one spotted that the eyes opened during the operation causing the cornea to dry out. When the patient woke up, they had a really painful and sore red eye. A saline washout of the eye was tried but that didn’t work. In the end an ophthalmologist was called to examine the patient and a corneal abrasion, caused by the eye drying out was diagnosed. This required treatment including pain management, antimicrobial prophylaxis, a pressure patch, and close monitoring meaning the patient was in hospital for an extra day.

Could all this have been avoided? Could the anaesthetist have spotted that the patients’ eyes had opened during the operation and closed them? Could a corneal abrasion have been avoided and the patient not had such a painful experience? Could the hospital have avoided all those extra treatment costs such as consultant time, drugs, and bed usage?

Instead of using opaque general-purpose tape to protect the patients’ eyes, the hospital should have used EyePro™ instead.

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Why should we use EyePro™ instead of tape?  EyePro™ is a unique eyelid cover designed by an anaesthetist to maintain eyelid closure during general anaesthesia.

It ensures rapid, complete, and safe eyelid closure. By sealing around the eye circumferentially, all moisture is retained, thus preventing the eye from drying out. Additionally, a clear central window allows direct observation of eyelid closure.

EyePro™ has a patented dual zone design whereby an inner transparent window allows intra-operative assessment of eyelid closure, while an outer, more rigid, opaque zone allows for easy handling and excellent conformity to the eye socket. The inner window has a gentle adhesive which helps to maintain eyelid closure and reduces eyelid trauma and/or eyelash removal. The outer zone has slightly stronger adhesive that maintains eyelid closure for extended periods. Also, non- adhesive tabs allow for easy handling, application, and removal, even while wearing gloves.

Additionally, each pair of EyePro™ comes packaged together in a sterile wrap to decrease the risk of cross contamination. In a world where we are going to have to live with Covid-19 anything that reduces the risk of infection must be a good thing. But that will be the subject of another article.

EyePro™ is more expensive than tape I hear you say. Yes, it is. That’s because it has been specifically designed for one purpose; to protect the eyes during general anaesthesia. In doing so, EyePro™ provides a superior level of protection against corneal abrasions. And don’t forget those extra treatment costs such as consultant time, drugs, and bed usage. An extra day in hospital would cost approximately $1800/day in the USA, $AUD1000/day in Australia, £400/day in the UK and €600 in the EU.

EyePro™ is a major advance in keeping the patients’ eyes safe during general anaesthesia. Remember, most corneal abrasions are caused by the failure of the eyelids to close properly leading to corneal drying. EyePro™ allows the anaesthetist to ensure the eyes remain closed, thereby reducing the risk of corneal abrasion. This leads to a better patient experience, quicker recovery time and a reduction in the use of valuable hospital resources such as drugs, bed occupancy and clinical time. Additionally, within the overall cost of treating the patient EyePro™ could also save you money. It really is a no brainer!!!

References:

  1. Batra YK & Bali IM. Corneal abrasions during general anaesthesia. Anaesthesia and Analgesia 1977; 56: 363– 5.
  2. Terry TH, Kearns TP, Grafton‐Loue J, Orwell G. Untoward ophthalmic and neurological events of anaesthesia. Surgical Clinics of North America 1965; 45: 927– 9.
  3. Gild WM, Posner KL, Caplan RA, Cheney FW. Eye injuries associated with anaesthesia. Anaesthesiology 1992; 72: 204– 8.
  4. White E, Crosse MM. The aetiology and prevention of peri‐operative corneal abrasions. Anaesthesia, 1998, 53, pages 157–161
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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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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
niall-shannon-european-business-manager-innovgas.png

Author: Niall Shannon, European Business Manager, Innovgas

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

Original Post Here

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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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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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The Cost of Postoperative Respiratory Adverse Events

Respiratory impairment following general anaesthesia can pose a significant problem. Adverse and critical respiratory events (AREs and CREs) have been responsible for increased morbidity and mortality. The main cause of AREs after surgery is related to the use of neuromuscular blockers (NMBAs) during general anaesthesia. The action of NMBAs might not cease completely at the end of the procedure, leading to residual muscle paralysis. Postoperative residual neuromuscular blockade, aka postoperative residual curarization (PORC), ranks among the top three critical events in the post-anesthesia care unit (PACU) that require emergency intervention.1 It has been estimated that approximately 40% of the patients brought to the PACU have residual blockages.2 Apart from the obvious effects on patients’ life and health, AREs can have other consequences. Caregivers have to undergo increased physical and emotional stress, which can affect delivery of care to other patients in the PACU. Financial costs can increase for both patients and hospitals as substantial critical care resources are devoted to solving such problems.

How big is the problem of residual neuromuscular blockade?

Muscle paralysis is estimated using a clinical tool called train-of-four ratio (TOFR). Residual neuromuscular blockade is believed to have significant clinical effects if the TOFR goes below 0.9.3 With just a single dose of intermediate acting NMBAs, it has been shown that up to 45% of patients can have residual blockade (TOFR < 0.9).4 Lower TOFRs have been associated with increased risk of CREs. This was demonstrated by Murphy et al, who collected data of over 7400 patients who had received general anaesthesia.5 They found that the incidence of critical respiratory events in this group of patients due to residual blockade was 0.8%. Based on these statistics, Brull et al estimated that each year about 81,000 people in the United States and almost 0.5 million people worldwide experience CREs after general anaesthesia.2

What is the main cause of CRE after surgery?

It was shown that the incidence of CREs was higher by 50% in patients who had TOFR less than 0.76

While there can be several causes of CRE, a large proportion of cases have been associated with residual neuromuscular blockade. In one study by Bissenger et al, it was shown that the incidence of CREs was higher by 50% in patients who had TOFR less than 0.7.6 In a separate case-control study, Murphy et al compared TOFRs in patients who had developed CREs and controls who did not have CREs. They showed that while patients in the control group had TOFRs above 0.7, 78.3% of patients who had CREs had TOFRs that were below 0.7.3 Xara et al also investigated the determinants of AREs in 340 patients who underwent surgery. They found that patients who were administered NMBAs during the surgical procedure had increased incidence of AREs (79%) as compared to those who did not receive them (55%).7 They also noted that the incidence of ARE was increased in patients who had received neostigmine. Grosse-Sundrup et al showed that the use of intermediate NMBAs increased the risk of postoperative desaturation and re-intubation.8

What are the costs involved?

Residual neuromuscular blockade can cause upper airway obstruction, aspiration and pharyngeal dysfunction. These situations may require emergency intervention in the form of re-intubation and positive pressure ventilation. The costs associated with these interventions can be considerable. Patients who develop respiratory complications after surgery generally often have to be hospitalised for longer, which increases costs.

The cost of treatment for patients with respiratory complications was $62,000, compared to $5000 without complications, with an additional 92,000 more ICU admissions per year10

Zhan et al found that postoperative respiratory failure (that did not include pulmonary embolism) increased hospital stay by nine additional days, and translated to an additional $53,000 in healthcare costs.9

A report developed by the National Surgical Quality improvement program showed that patients with respiratory complications stayed at the hospital for at least 14 days longer vs. those who did not have these complications.10 The same report estimated the cost of treatment for patients with respiratory complications was around $62,000, while those without such complications were set back by a mere $5,000 in comparison. On a national level, pulmonary complications after surgery lead to 92,000 more ICU admissions per year, which alone imposes a burden of $3.42 billion annually.

What is the best way to deal with the situation?

Residual neuromuscular blockade can be avoided by monitoring neuromuscular status during the surgical procedure. If neuromuscular function is allowed to return to optimal levels prior to extubating the patient, chances of residual blockade in the PACU decrease. Ideally, the anaesthetist should be able to monitor the TOFR, so that it may be allowed to reach the critical threshold of 0.9 prior to extubation.

What kind of monitoring works best?

Severe hypoxaemia occurred in 21.1% of patients in the conventional group but in none of the patients in the acceleromyography group11

There are three methods to monitor neuromuscular function—clinical, qualitative monitoring and quantitative monitoring. Clinical methods (such as head-lift and grip-strength tests) have low sensitivity and specificity, and are not really suited for patients prior to extubation. Qualitative evaluation using peripheral nerve stimulators is a common practice. However, it involves subjective assessment of TOFR and studies have shown that TOFRs above 0.4 may not be effectively detected by this method. Quantitative (or objective) methods of calculating TOFR, using techniques such as mechanomyography, electromyography and acceleromyography, have proven more effective. Murphy et al assessed the risk of residual neuromuscular blockade and AREs in patients who were monitored by both qualitative and quantitative means.11 Patients were randomised for NMB monitoring using either conventional peripheral nerve stimulators or acceleromyography. Residual NMBs in the PACU were documented in 30% of patients in the conventional group and only 4.5% of patients in the acceleromyography group. More significantly, severe hypoxaemia occurred in 21.1% of patients in the conventional group but in none of the patients in the acceleromyography group.

The bottom line is this: quantitative neuromuscular transmission monitoring has the potential to reduce residual blockades, decrease CRE risk, and reduce costs.

Stimpod NMS450X Neuromuscular Transmission Monitor

The Stimpod NMS450X Neuromuscular Transmission Monitor

The Stimpod NMS450X is a standalone neuromuscular transmission monitor that can easily be integrated into the anaesthetic setup. During reversal of neuromuscular blockade, the monitor automatically initiates TOFR monitoring, which continues until recovery is complete. Its portable design makes it easy to shift between the OR and PACU, and it can easily be attached to the IV pole. Its economical pricing and proven efficacy make it a sensible investment for hospitals who wish to make optimum use of resources and cut costs in the long term. For more details, visit xavant.com or request a quotation.

References

  1. Strauss P, Lewis M. Identifying and Treating Postanesthesia Emergencies. Or Nurse. 2015 Nov 1;9(6):24-30.
  2. Brull, S. J., & Kopman, A. F. Current Status of Neuromuscular Reversal and Monitoring: Challenges and Opportunities. Anesthesiology 2017; 126(1): 173-90.
  3. Murphy GS, Szokol JW, Avram MJ, et al. Postoperative Residual Neuromuscular Blockade is Associated with Impaired Clinical Recovery. Anesth Analg. 2013;117(1):133–141
  4. Debaene B, Plaud B, Dilly MP, Donati F. Residual Paralysis in the PACU After a Single Intubating Dose of Nondepolarizing Muscle Relaxant with an Intermediate Duration of Action. Anesthesiology 2003;98: 1042–8
  5. Murphy GS, Szokol JW, Marymont JH, Greenberg SB, Avram MJ, Vender JS: Residual Neuromuscular Blockade and Critical Respiratory Events in the Postanesthesia Care Unit. Anesth Analg 2008; 107:130–7
  6. Bissinger U, Schimek F, Lenz G. Postoperative Residual Paralysis and Respiratory Status: A Comparative Study of Pancuronium and Vecuronium. Physiol Res/Acad Sci Bohemoslovaca. 2000; 49(4):455–462
  7. Xará D, Santos A, Abelha F. Adverse Respiratory Events in a Post-anesthesia Care Unit. Archivos de Bronconeumología (English Edition). 2015 Feb 1;51(2):69-75.
  8. Grosse-Sundrup M, Henneman JP, Sandberg WS, et al. Intermediate Acting Non-depolarizing Neuromuscular Blocking Agents and Risk of Postoperative Respiratory Complications: Prospective Propensity Score Matched Cohort Study. BMJ. 2012;345:6329.
  9. Zhan C, Miller MR: Excess Length of Stay, Charges, and Mortality Attributable to Medical Injuries During Hospitalization. JAMA 2003; 290: 1868–1874
  10. Dimick JB, Chen SL, Taheri PA, Henderson WG, Khuri SF, Campbell DA. Hospital Costs Associated with Surgical Complications: A Report from the Private-sector National Surgical Quality Improvement Program. J Am Coll Surg. 2004;199(4):531–537
  11. Murphy GS, Szokol JW, Marymont JH, Greenberg SB, Avram MJ, Vender JS, Nisman M. Intraoperative Acceleromyographic Monitoring Reduces the Risk of Residual Meeting Abstracts and Adverse Respiratory Events in the Postanesthesia Care Unit. Anesthesiology: The Journal of the American Society of Anesthesiologists. 2008 Sep 1;109(3):389-98.
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Increased PACU Length of Stay – A Costly Matter

Postoperative residual curarization (PORC), also known as residual neuromuscular blockade, refers to the residual muscle paralysis that occurs after emergence from general anesthesia. PORC stems from the use of neuromuscular blocking agents (NMBAs). It is defined as a Train-of-Four (TOF) ratio of <0.9 and may occur in around 41% of patients who receive intermediate-acting neuromuscular blockers.1 PORC has been associated with critical respiratory events and impaired postoperative respiratory functions.2 It is also independently associated with an increased length of stay (LOS) in the post-anesthesia care unit (PACU). The increased PACU length of stay in turn impacts operating room throughput and results in prolonged waiting time for new PACU admissions.3

The Use of Quantitative NMT Monitoring to Avoid PORC

Subjective tests of NMT monitoring are not sensitive enough to detect residual weakness

Quantitative neuromuscular transmission (NMT) monitoring can help reduce the incidence of PORC. Neuromuscular monitoring is recommended when neuromuscular blockers have been administered as a part of general anesthesia. It can be carried out through subjective techniques, such as clinical assessment or peripheral nerve stimulation (qualitative monitoring), or with the help of objective or quantitative NMT monitors that provide a numeric value representing the depth of neuromuscular blockade. There is mounting evidence that clinical or subjective tests of NMT monitoring are not sensitive enough to detect residual weakness and do not predict adequate neuromuscular recovery. Quantitative or objective neuromuscular monitors should therefore be used whenever non-depolarizing NMBAs are administered.4,5,6

The Stimpod NMS 450X is a quantitative neuromuscular monitor that uses a 3D acceleromyography (AMG) transducer which is effective in detecting the full force of muscle contraction. It minimizes the risk of residual neuromuscular blockade and associated adverse respiratory events.7 As discussed below, this leads to a decrease in the average length of stay in the PACU and substantial cost savings for the hospital.

Reduction in the PACU Length of Stay as a Cost-reducing Measure

The economic structure of the PACU determines whether a cost-saving measure such as reducing the PACU length of stay is likely to reduce hospital costs. Hospital costs can be divided into fixed and variable components. Fixed costs are one-time costs that do not change in relation to the number of surgical cases. These include capital expenditures, such as gurneys, monitors, and the physical plant of the PACU. On the other hand, variable costs are directly related to the number of surgical cases, and include X-ray films, pharmaceuticals, dressings, and laundry.

The only real way of reducing PACU costs is to increase the productivity of the PACU and the staff

It is important to bear in mind that reducing the PACU length of stay will only affect variable costs. Small reductions in the length of time that patients stay in a PACU are unlikely to impact fixed costs at ambulatory surgery centers, which include the labor costs of staffing the PACU with full-time nurses.8 This means that reducing the length of stay of a patient in the PACU by one minute is not equivalent to saving one minute of PACU costs. Therefore, the only real way of reducing PACU costs is increasing the productivity of the PACU and the staff working in it.

Reduction in the Peak Number of Patients Improves Productivity and Reduces Costs

A reduction in the peak number of patients in the PACU is the most effective way to increase the productivity of the PACU and its staff. One way of doing this is to use anesthetic agents that permit a quicker discharge of patients from the PACU. However, if for example the average total time a patient stays in the PACU is 120 minutes, then for a modern anesthetic drug to reduce the peak number of PACU patients by 25%, the drug would have to reduce the mean time to discharge from a total of 120 minutes to just 34 minutes. Such a drastic change is unrealistic and therefore this method is limited in its effectiveness to achieve a substantial increase in PACU productivity.8

Optimization of the time of arrival of patients into the PACU is the single most important measure

For a PACU with salaried or full-time hourly employees, optimization of the time of arrival of patients into the PACU is the single most important measure that can reduce the peak number of patients in the PACU and decrease the peak requirements of nursing staff. This increases PACU productivity and results in PACU cost savings.8 According to a study conducted by Butterly et al., the mean length of stay in the PACU for patients with PORC was found to be 323 minutes whereas the length of stay for patients without PORC was 243 minutes.3 This shows that using the Stimpod NMT monitor for performing objective monitoring and avoiding residual neuromuscular blockade can save up to 80 minutes of the PACU time per patient. The Stimpod thus makes possible the “unrealistic” change that results in a significant reduction in peak patient numbers in the PACU.

Decrease in Operating Room Holding Time Results in Cost Reduction

Postoperative residual curarization results in delayed discharge of the patient from the PACU. If the PACU gets filled up with patients, the next patient has to wait before leaving the operating room resulting in operating room holds. The operating room/PACU system becomes congested. This has debilitating financial fallout as it increases the operating room costs. For instance, if all the operating rooms are filled up with patients waiting for PACU beds, some surgical cases may be delayed or cancelled. Also, in some situations, incentive salaries may have to be paid to the nurses and anesthetists for the extra time that they monitor patients in the operating rooms.3,9,10

The Stimpod quantitative NMT monitor provides an excellent solution to this problem—it minimizes the incidence of PORC and with it PORC-induced delay in PACU discharge. The increased availability of beds in the PACU allows for a quicker release of patients from the operating room. This cuts down operating room costs.

Stimpod NMS 450X—The Ultimate Cost-Saving Option

Stimpod NMS450X Neuromuscular Monitor

The Stimpod NMS450X Neuromuscular Monitor reduces the incidence of residual paralysis in 97% of patients

The Stimpod NMS 450X is a fully-automated neuromuscular monitor that supports Train-of-Four (TOF), Double Burst (DB), Post-Tetanic Count (PTC), Tetanus and Twitch Stimulation modes to perform accurate, real-time neuromuscular monitoring. It uses OneTouchTM technology that allows an entire case to be monitored—starting from automatic electrode placement to extubation—with the press of a single button. The Stimpod begins TOF monitoring and moves to PTC when a deep block is achieved. It detects the depth of neuromuscular blockade throughout the procedure and automatically reinitiates TOF monitoring when the patient begins the reversal process. The monitoring continues until the patient is more than 90% recovered.

The Stimpod NMS 450X is an all-in-one solution for quantitative NMT monitoring that can

  • minimize the incidence of PORC
  • reduce the length of stay in the PACU
  • increase the PACU productivity by decreasing the peak number of patients
  • decrease the operating room hold time

In short, it’s the perfect cost-saving measure for any PACU.

References

  1. Naguib M, Brull SJ, Johnson KB. Conceptual and technical insights into the basis of neuromuscular monitoring. Anaesthesia 2017; 72: 16–37.
  2. Boon M, Martini C, Dahan A. Recent advances in neuromuscular block during anesthesia. F1000Res. 2018;7:167. Published 2018 Feb 9. doi:10.12688/f1000research.13169.1
  3. Butterly A, Bittner EA, George E, Sandberg WS, Eikermann M, Schmidt U. Postoperative residual curarization from intermediate-acting neuromuscular blocking agents delays recovery room discharge. Br J Anaesth 2010; 105: 304–9.
  4. Duţu M, Ivaşcu R, Tudorache O, et al. Neuromuscular monitoring: an update. Rom J Anaesth Intensive Care. 2018;25(1):55–60. doi:10.21454/rjaic.7518.251.nrm
  5. Abdulatif M. Neuromuscular transmission monitoring: Beyond the electric shocks and the shaking hands. Saudi J Anaesth. 2013;7(2):115–117. doi:10.4103/1658-354X.114045
  6. Naguib M, Brull SJ, Kopman AF, et al. Consensus statement on perioperative use of neuromuscular monitoring. Anesth Analg 2018; 127: 71–80.
  7. Murphy GS, Szokol JW, Marymont JH, Greenberg SB, Avram MJ, Vender JS, Nisman M. Intraoperative acceleromyographic monitoring reduces the risk of residual neuromuscular blockade and adverse respiratory events in the postanesthesia care unit. Anesthesiology 2008;109:389–98.
  8. Macario A., D. Glenn and F. Dexter, 1999, What can the postanesthesia care unit manager do to decrease costs in the postanesthesia care unit?, J Perianesth, vol 14, pp. 248-93.
  9. McLaren JM, Reynolds JA, Cox MM, et al. Decreasing the length of stay in phase I postanesthesia care unit: an evidence-based approach. J Perianesth Nurs. 2015;30:116-123.
  10. Cammu G. Sugammadex: Appropriate Use in the Context of Budgetary Constraints. Curr Anesthesiol Rep. 2018;8(2):178–185. doi:10.1007/s40140-018-0265-6
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Bell Medical 2018 Anesthesia Meetings Schedule

Rubber Flex Connector

Bell Medical’s mission is to introduce innovative technology to anesthesia providers in hospitals and surgery centers.  We show our commitment to this mission by supporting anesthesia societies such as the American Association of Anesthesiologist or ASA, the American Association of Nurse Anesthetist or AANA and the American Society of Technicians and Technologists or the ASATT.  We also attend numerous state anesthesia meetings for both MDs and CRNAs.  We invest over $50,000 annually to attend both national, regional and state association meetings.  The listing below is some of the anesthesia meetings we attend to exhibit our innovative technologies.  Please visit our booth!

ASATT at Bally’s Las Vegas, NV August 23-25
AANA in Boston, MA September 23-25
MOANA in St. Louis, MO October 19-21
WANA in Spokane, WA October 7-9
VANA in Norfolk, VA October 13
ASA in San Francisco, CA October 13-15
FANA in Tampa, FL October 19-21
EMS Worldwide in Nashville, FL October 31-November 2
NCANA in Cherokee, NC November 2-4
PGA in New York City, NY December 8-10

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Amsorb Plus Review

When choosing a type of CO2 absorbent, it is important to understand the absorbents environmental impact, effect on patient safety, ease of use and the effect on the consumption of volatile anesthetics. Today we are going to review Amsorb vs. soda limes that contain traces of Sodium Hydroxide, NaOH, such as Medisorb, Sodasorb, Dragersorb and others.

Environmental Impact

Soda limes can have a pH of up to 14 and may require disposal as a hazardous waste according to U.S. Federal Code of Regulations. Soda limes contain sodium hydroxide and are considered corrosive.

Amsorb Plus has a pH of less than 12.5 and is safe for our water table and landfills where it will break down into harmless organic compounds. Amsorb Plus comes with certification of such (see Amsorb Plus disposal document). Kaiser Permanente independently tested all the types of CO2 absorbents readily available on the market and determined Amsorb Plus to be the only one that was safe for disposal in regular landfills. Other types of CO2 absorbents had higher pH and needed to be red bagged and incinerated at greater expense. Amsorb Plus is not harmful in disposal to the environment which translates into a cost savings for hospitals and surgery centers since red bagging is expensive and time consuming.

Patient Safety

Soda limes are known to degrade volatile anesthetics to Carbon Monoxide, Compounds A – F, and Formaldehyde.

Amsorb Plus has no strong alkali and is incapable of producing any of these toxins. Clinical Anesthesia by Barash, 2012, recommends using Amsorb Plus by name and states doing so: (Amsorb Plus)

eliminates all of the potential complications related to anesthetic breakdown and therefore minimizes the possibility of additional costs from those complications, including additional laboratory tests, hospital days, and medical/legal expenses. Adoption of [Amsorb Plus] into routine clinical practice is consistent with the patient safety goals of our anesthesia society.

Ease of Use & Consumption of Volatile Anesthetic

Soda Lime users generally change absorbent based on color change and never know for sure when to change product. Users usually error on the side of caution and change soda lime more often (a wasteful and confusing practice) because if they don’t change soda lime it is possible to endanger the patient by producing toxins such as Compound A, Formaldehyde and Carbon Monoxide. Soda Lime includes a dye that changes color to indicate exhaustion. However, it does not retain color change for long before reverting back to looking fresh. The user can never be sure when product should be changed. Ask any clinician that has used a soda lime and they will verify it is not uncommon to begin a case with what they think is fresh absorbent only to immediately find out they have high levels of FiCO2 and rapid color change of their absorbent.

Soda Limes “adsorbs” (significant amounts of volatile anesthetic which means clinicians wait longer periods of time for their machines and vaporizers to equilibriate. They are less able to reach desired drug percentages without increasing vaporizer settings.

Amsorb Plus has permanent, consistent, and reliable color change. Thus allowing the user to easily tell the state of the absorbent at a glance. Amsorb Plus also adsorbs far less anesthetic vapor than soda limes so machines and vaporizers reach equilibriation faster and accurately reach desired drug percentages without needing to increase vaporizer settings above what is desired for patient inspiration. This saves time and money (utilizing less anesthetic vapor).

Amsorb vs. Soda Lime Review Summary

Soda Lime Amsorb Plus
Environmental Impact
Patient Safety
Ease of Use & Consumption of Volatile Anesthetic