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1976 – Oh what a Year!!

In 1976 Steve Jobs and Steve Wozniak started a small computer company and called it Apple Computers. The first commercial supersonic Concorde flight took place between London and New York. The film “Rocky” was released and Jimmy Carter was elected president of the USA. NASA’s Viking 1 Lander touches down on Mars and they also reveal their prototype space shuttle called “The Enterprise”. Abba, the Eagles, Queen and David Bowie helped create the sounds of 1976.

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At the same time, Margaret Piehl was a nurse working in a small community hospital ICU in America. She noted that when patients with acute respiratory distress syndrome (ARDS) were placed in the prone position their oxygenation levels improved. Margaret described this phenomenon in a ground-breaking paper published in Critical Care Medicine in 1976. Together with physician Robert Brown she described the improvements in arterial oxygenation on 5 patients brought about by “extreme position changes”(1)

In the following years other physicians studied this observation to understand who would benefit from the technique, when it should be carried out and how long a patient should be in the prone position. It took many years of clinical trials to confirm that prone positioning improves arterial oxygenation. Finally in 2013 the PROSEVA(2) trial was published in the New England journal of Medicine. This trial showed that early intervention with the use of prone positioning in ARDS patients with the most severe hypoxemia resulted in a 17% absolute reduction in mortality. Prone positioning has the most impact on survival of ARDS patients than any other intervention. Thank you, Margaret Piehl, for your keen eye back in 1976.

For over 40 years this remarkable but simple technique has helped save the lives of many ARDS patients in ICU and the world barely noticed. Scroll forward to 2020 and Covid 19 sweeps across the globe. Images appear on our TV screens of ICU’s full of desperately ill Covid 19 patients being treated by incredible nurses and doctors. ARDS is often associated with Covid 19, resulting in many patients being proned. We see proning in action and start to take an interest in Margaret Piehl’s observation.

So, what is proning, how is it carried out and how does it prevent any patient, with ARDS, whether they have Covid 19 or not, from dying.

Proning is a manual handling procedure where a patient’s position is changed, so they are lying on their front, face down, in a “prone” position. The aim is to change the way the patient is resting, which is usually going from lying on their back to their front and back again. That sounds quite straight forward. All you have to do is move the patient from lying on their back to lying on their stomach.

But they probably have Covid 19 with associated ARDS and are sedated. They will be on a ventilator, and they may have a chest drain, cannulas and ECG leads in place.

You begin with the patient in this position with all the attached leads etc

The Intensive Care Society
The Intensive Care Society

And end up with them in a prone position

The Intensive Care Society
The Intensive Care Society

It can be quite a complicated manoeuvre that is described brilliantly in the Intensive Care Society Guidelines for Prone Positioning in Adult Critical Care(3):

  • You need at least 5 trained healthcare professionals with someone taking control at the head of the patient.
  • Staff are allocated to manage the airway and the drains etc. and are positioned along the side of the patient.
  • The patient is on a clean sheet with a slide sheet underneath.
  • Pillows are placed strategically on the patient who is then covered with another sheet leaving the head and neck free.
  • The edges of the top and bottom sheets are rolled together to tightly wrap the patient.
  • The patient is then moved to the edge of the bed and turned through 90°, so they are lying on their side.
  • The rolled-up sheet is pulled up from beneath the patient whilst the patient is carefully turned into the prone position.
  • All the leads and ETT are checked to ensure they are not kinked.
  • The patients’ arms are placed in the “swimmers” position, head turned to one side, and they are nursed at 30° in the reverse trendelenburg position.

Most hospitals maintain patients in a prone position for at least 12 hours per day, though practices vary. Throughout the time the patient is in the prone position, the head and arms are moved regularly to prevent pressure damage. This requires at least 3 healthcare professionals including an anaesthetist at the top of bed to manage the airway when changing head position. Proning sessions continue until there is a sustained improvement in oxygen levels, or if proning does not improve oxygen levels.

AP: Zhang Yuwei via Xinhua
AP: Zhang Yuwei via Xinhua

With all this extra workload in ICU, caring for seriously ill Covid 19 patients, it doesn’t surprise me when I hear that ICU staff are exhausted. This is a demanding role and ICU staff deserve the highest praise from us all.

Prone positioning can help a severely ill Covid 19 patient in many ways:

  • In the supine position, the lungs are compressed by the heart and abdominal organs. Gas exchange is reduced in areas of collapsed lung, resulting in low oxygen levels. In the prone position, lung compression is less, improving lung function.
  • The body has mechanisms to adjust blood flow to different portions of the lung. In ARDS, an imbalance between blood and air flow develops, leading to poor gas exchange. Prone positioning redistributes blood and air flow more evenly, reducing this imbalance and improving gas exchange.
  • With improved lung function in the prone position, less support from the ventilator is needed to achieve adequate oxygen levels. This may reduce risk of ventilator-induced lung injury, which occurs from overinflation and excess stretching of certain portions of the lung.
  • Prone positioning may improve heart function in some patients. In the prone position, blood return to the chambers on the right side of the heart increases and constriction of the blood vessels of the lung decreases. This may help the heart pump better, resulting in improved oxygen delivery to the body.
  • Because the mouth and nose are facing down in the prone position, secretions produced by the disease process in the lung may drain better.

The benefits of proning severely ill patients are very clear but there are risks associated with the procedure. Placing patients in this position may put them at risk for complications such as pressure injuries, airway complications, facial injuries, peripheral nerve injuries, musculoskeletal injuries, and cognitive impairment.

The Intensive Care Society Guidelines(3) recommend that there should be no direct pressure on the eyes. Unfortunately, this is not always possible and prone nursed patients may suffer direct pressure on the eyes or raised orbital/ophthalmic pressure due to gravitational effects or periocular swelling. This can cause number of complications including acute primary angle closure glaucoma, ischaemic optic neuropathy, vascular occlusion, orbital apex syndrome and corneal abrasions. In a busy ICU full of seriously ill patients taking care of the proned patients’ eyes can be missed. Eye care can contribute enormously to improved patient recovery by ensuring the eyes are not painful or swollen and vision isn’t blurred. Additionally, painful corneal abrasions and infections are avoided.

The Intensive Care Society Guidelines(3) recommend that prior to proning, the eyes are assessed, cleaned, ointment applied and then covered with eye coverings. Eye condition should be checked every 2 to 4 hours and corneal clarity checked.

It surely makes sense that the eye covering of choice in this situation should be EyePro.™ which has clear advantages over micropore tape. EyePro™ is sterile and 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™ was 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.

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References:

  1. Piehl MA and Brown RS. Use of extreme position changes in acute respiratory failure. Critical Care Med 1976;4(1):13-14. 
  2. PROSEVA trial: Prone positioning in severe ARDS. New Engl J Med 2013;368(23):2159-2168.
  3. The Intensive Care Society Guidelines for Prone Positioning in Adult Critical Care. Published November 2019.
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Author: Niall Shannon, European Business Manager, Innovgas

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

Interested in a Free Sample?

Free samples of NoPress, EyePro & BiteMe available upon request.
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No One’s Safe Until Everybody’s Safe

5.4.2021

It’s unclear who first made this comment about the Covid-19 pandemic, but it is being used by health care leaders around the world to encourage their people to get the Covid-19 vaccination. Vaccines have played an important role throughout history in keeping us well.

Evidence exists that early attempts to inoculate people against smallpox were reported in China as early as the 16th Century. Smallpox scabs could be ground up and blown into the recipient’s nostrils or scratched into their skin. The practice, known as “variolation”, came into fashion in Europe in 1721, with the endorsement of English aristocrat Lady Mary Wortley Montagu.

The next development which turned out to be much safer than variolation, originated from the observation that dairy farmers did not catch smallpox. The 18th Century English physician, Edward Jenner, hypothesised that prior infection with cowpox, which is a mild illness spread from cattle, might be responsible for the suspected protection against smallpox.

In 1796, Jenner inoculated an eight-year-old boy by taking pus from the cowpox lesions on a milkmaid’s hands and introducing the fluid into a cut he made in the boy’s arm. Six weeks later, Jenner exposed the boy to smallpox, but he did not develop the infection then, or on 20 subsequent exposures. The origin of the term comes from the Latin for cow or “vacca”.

Edward Jenner vaccinating his child against smallpox; coloured engraving.  Image: Wellcome Library, London (CC BY 4.0)
Edward Jenner vaccinating his child against smallpox; coloured engraving. Image: Wellcome Library, London (CC BY 4.0)

In 1881 French microbiologist Louis Pasteur demonstrated immunisation against anthrax by injecting sheep with a preparation containing forms of the organism that causes the disease. Four years later he developed a protective suspension against rabies. Jenner’s approach was to use a virus similar to, but safer than, smallpox to prevent disease. Pasteur on the other hand developed a weakened or attenuated form of the virus or bacteria to treat the patient.  

This was the birth of vaccinations and heralded a new era in the treatment of diseases around the world using injections containing live, weakened, or killed viruses to produce immunity against an infectious disease. In the early 20th century, we saw the development of vaccines to protect against whooping cough (1914), diphtheria (1926), tetanus (1938), influenza (1945) and mumps (1948). Later vaccines were developed for polio (1955), measles (1963) and rubella (1969) with the world being announced smallpox free in 1980.

Vaccine technology still uses the approaches developed by Jenner and Pasteur but has developed enormously in recent years with a number of new approaches. These include:

  • A subunit vaccine, which is made from proteins found on the surface of infectious agents e.g. Influenza, Hepatitis B.
  • Inactivated toxins of infectious organisms e.g., Tetanus, Diphtheria, Whooping cough.
  • Gene sequencing and editing has allowed the mass production of antigens that are used in vaccines and made the production of attenuated vaccines safer and more effective.
  • Recombinant DNA technology has also been used effectively to develop vaccines e.g., Human papillomavirus.

Today there are around 30 diseases around the world that are treated and controlled by vaccination programmes making us all healthier and allowing us to live longer.

So here we are in 2021 and vaccines will once again help us fight against another highly infectious disease, Covid-19. There are currently 10 vaccines licensed around the world that offer protection against Covid-19. Staggeringly, there are 88 vaccines in clinical development and 184 in pre-clinical development.

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The speed of development of these vaccines has been nothing short of remarkable and their efficacy rates are equally impressive. However, public attitudes to vaccines appears to have shifted markedly to what it was when this type of treatment was introduced. People either trust vaccines or they don’t. Then we have the antivaxxers who believe vaccines are unsafe and infringe their human rights. Antivaxxers also use social media to actively spread misinformation to persuade people to their point of view. Antivaxxers have been pumping out misinformation for a number of years now, so it’s useful to see if they have had any success.

Claims about the Covid-19 vaccine made by the antivaxxer community include:

  • The vaccine alters your DNA.
  • The vaccine causes infertility.
  • Bill Gates is inserting microchips into people.
  • The virus is being used as a ploy to move a country to a “police state”.
  • Don’t be a guinea pig for pharmaceutical companies.

A number of surveys have been conducted assessing public reaction to having a Covid-19 vaccination. The Imperial College London YouGov Covid-19 Behaviour Tracker Data Hub gathers global insights on people’s behaviours in response to COVID-19. Data represents the share of respondents who have not received a COVID-19 vaccine and who agree with the following statement: “If a COVID-19 vaccine were made available to me this week, I would definitely get it.” Respondents were presented with a 1 to 5 scale, ranging from “Strongly agree” (1) to “Strongly disagree” (5). The following chart shows monthly data on the willingness of unvaccinated individuals to receive the COVID-19 vaccine. They asked this question in November 2020 with the following results:

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You can see that in those countries surveyed there is a wide variation in the willingness to be vaccinated ranging from 67% in the U.K. to only 40% in France. A study conducted by Ipsos on behalf of the World Economic forum found similar results.

Is this vaccine hesitancy the result of antivaxxer misinformation? There is no doubt that some of the claims made by antivaxxers will have resonated with some people. However, when you ask people objectively about vaccine hesitancy the reasons are quite straight forward. “Side effects”, “long term effects on health” and “how well the vaccine works” were the top three reasons for reporting negative sentiment towards the vaccine and this was consistent across all population groups. These concerns are not unreasonable. It is important to note that as more and more people are vaccinated, vaccine hesitancy is declining. In fact, in England 95% of the over 50’s have been vaccinated which is way higher than scientists thought could be achieved.

To ensure high rates of vaccination so that a population can gain “herd” immunity, health care leaders need to target vaccine hesitancy messaging very carefully. This is because hesitancy rates vary by population sub-group.

A survey carried out by the Office of National Statistics in the U.K. in early 2021 revealed that vaccine hesitancy was highest in:

  • 16–29 year olds.
  • Black or Black British adults.
  • Parents with child aged 0-4 years.
  • Adults living in the most deprived area.

It’s pretty clear that as vaccine programmes are rolled out around the world, governments and health care workers will have to work hard to ensure the majority of their people are vaccinated. Only then can we stop saying no one’s safe until everybody’s safe and we can start getting back to a normal life and fix some of the other issues this pandemic has caused.

  • We need to be more vigilant against infections, particularly with vulnerable hospitalised patients. That’s why sterile EyePro™ should be the only eyelid cover used to maintain eyelid closure during general anaesthesia or deep sedation.
  • As surgery returns and we start to reduce the huge backlog of patients waiting for routine surgery, hospitals must ensure they deliver a great patient experience by protecting patients’ eyes from trauma by using NoPress™, our foam and rigid plastic shield designed specifically to protect anaesthetised patient’s eyes from externally applied pressure.
  • Enhance the patient experience further, by guarding against dental damage and/or negative pressure oedema through the use of BiteMe™ our purpose designed, air-filled, soft plastic bite block.

So, no one’s safe until everybody’s safe and although vaccines will help the world recover, it’s important we do our utmost to protect patients from infection as well as non Covid-19 complications that can be easily avoided. By using our products, you will optimise your care and ensure your patients have the best experience they can possibly receive.

Author: Niall Shannon, European Business Manager, Innovgas

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

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

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

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

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

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

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

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

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

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

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

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

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Novaerus NanoStrike Airborne Disinfection Technology

Novaerus NanoStrike Airborne Disinfection Technology

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

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

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

 How does NanoStrike Protect?

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

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

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

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

Breathe easy with Bell Medical and NanoStrike Technology.

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The Eyes are the Window to Your Soul

We all know this quote, but its origin is a little unclear. It has been attributed to William Shakespeare, Leonardo Da Vinci, the philosopher Cicero and even the bible.

Whatever the origins of this well-known quote, throughout history we have been aware that our eyes are incredibly precious organs. Not only do they allow us to see the world around us but through them we can tell what a person feels and thinks.

However, despite being aware that somehow our eyes are special, we have been a bit blasé about protecting them. Eye protection has evolved over time(1) via several different routes including:

  1. Combat – To lose an eye in battle and wear an eye patch was once considered an honour. The use of helmets did offer some protection. The use of gas during World War 1 resulted in gas masks with glass windows to protect the eyes from the deadly gas. More recently the rise of IEDs resulted in the percentage of combat causalities hospitalised due to ocular trauma increasing from 2% in 1914 to 13% in the 1990s Desert Storm conflict. In modern armies today eye protection is mandatory.
  2. Sports and Recreation – Jousting required the riders to wear helmets with visors, but eye injuries were common. King Henry II, the French-born King of England, suffered an eye injury during a jousting tournament in 1559.  The king had not fastened his visor upon returning to the arena and a splinter from his opponent’s lance entered his right orbit. Complications resulted in the death of ‘the young lion’ from his eye injury. His death significantly changed the respective roles of France and England and the course of Western civilisation and history. Recently, ice hockey, Baseball and Basketball were the first sports to embrace eye protection followed by Squash, Cricket Hockey and Lacrosse.
  3. Occupational Eye Injuries – The rise of industry in the late 19th century resulted in a huge increase in mining and metalwork. This led to a surge in corneal abrasions in miners, heat cataracts in foundry workers and arc eye in welders. Gradually, visors and goggles. . Gradually, improved understanding of the impact resistance of materials and the nature of hazards brought about improvements in visors and goggles in the workplace

Thankfully, mainly due to the rise of Health and Safety, eye protection is now mandatory in many workplaces. There is good reason why this is necessary. Thousands of workers suffer painful eye injuries each year around the world. Many are minor but around 10-20% result in partial or full blindness. Equally, we only have two eyes and whilst some parts of the eye can be transplanted, a complete eyeball transplant is not yet possible. So, we need to do everything we can to protect our eyes as much as we can.

The most common types of injuries are:

  • Invasion of foreign bodies – The eye/s may sometimes be invaded by small foreign particles (e.g. dust from manufacturing activities) which can cause irritation and inflammation. Chemical Eye Burns – Both highly acidic (pH <4) and highly alkaline (pH >10) substances are toxic to the eye and cause chemical eye burns if they come into contact with the surface of the eye. Such substances are commonly found in the workplace, for example in laboratory chemicals or industrial cleaning products.Penetrating Injuries – When an object pierces the eye, penetration occurs, and this can lead to loss of vision or blindness. Staples, nails and flying debris commonly cause this type of injury.Blunt trauma injuries – These are injuries which do not penetrate the skin and do not result in external bleeding.  The eye is struck by a heavy object and this can cause the eye to bleed internally.Allergic conjunctivitis – Is common amongst workers in the food handling and agricultural sectors who are regularly exposed to spices, fruits, and vegetables. Eye diseases associated with ultraviolet radiation exposure – Outdoor workers are often exposed to ultraviolet radiation (in the form of sunlight) in excessive quantities. Artificial sources of ultraviolet radiation are also found in a range of workplaces and can damage the eyes. These include welding arcs, germicidal lamps, and lasers. Computer use disorders – Using a computer for extended periods of time is associated with a range of temporary eye disorders including pain and altered vision.

Of course, when we go about our daily lives, we meet all sorts of people wearing eye protection. These can be construction site workers, the mechanic fixing your car, the gardener mowing your lawn, the person mending your shoes. Many jobs now take eye protection seriously.

Eye protection is also taken seriously even if you are unfortunate to be here –

However, can you guess by looking at these photographs what the problem is?

Where is the eye protection for the patient? Everyone else in theatre has eye protection so why not the patient? A nurse will take a roll of non-sterile tape that has been lying in theatre and tape your eyes. A piece of equipment could hit you in the eye or even someone’s elbow. You are the most vulnerable person in the room and yet nothing is done to protect your eyes from an infection, a corneal abrasion or even a trauma blow. Surely, if a gardener or a cobbler has eye protection then patients undergoing surgery should equally have their eyes protected.

References:

  1. Hoskin A.K, Mackey D.A, Agrawal R, Watson S. (2019). Eye Injuries across history and the evolution of eye protection. Acta Ophthalmologica, 97: 637–643.

Author: Niall Shannon, European Business Manager, Innovgas

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

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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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Anesthesia Hygiene – Infectious Control

Anesthesia Machine Covers Prevent Infections!


Guidance issued by Society for Healthcare Epidemiology of America (SHEA): “…explore the use of disposable covers”

Anesthesia Hygiene machine covers have tear away pouches that hold and contain contaminated supplies such as laryngoscopes and yankauer suction! The use of disposable covers is endorsed by SHEA and ASPF.

Anesthesia Hygiene Covers protect your patient and your anesthesia machine from pathogens and infectious diseases. To view videos and more information on our webpage Anesthesia Hygiene Covers and anesthesiahygiene.com .