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Spotlight Case February 2003

Apnea in a Patient UnderGeneral Anesthesia

webmm.ahrq.gov


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Source and Credits This presentation is based on February 2003

SurgeryAnesthesia Spotlight Case

See full casecommentary on webmm.ahrq.gov CME credit is available online Commentary by: Paul Barach, MD, MPH; University

of Chicago

Editor, AHRQ WebM&M: Robert Wachter, MD Spotlight Case Editor: Tracy Minichiello, MD

Managing Editor: Erin Hartman, MS
http://webmm.ahrq.gov/http://webmm.ahrq.gov/


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Clinical Objectives

At the conclusion of this educational activity,participants should be able to:

List the causes of prolonged apnea in theoperating room

Describe the steps in management of

apnea in the operating room


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Patient Safety Objectives

At the conclusion of this educational activity,participants should be able to:

State the prevalence of medication errors

List the causes of wrong drugadministration in the operating room

Describe system checks available toprevent medication errors in the operatingroom


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Case: Unexplained ApneaA 15-year-old boy with no past medicalhistory underwent elective right knee

arthroscopy and debridement undergeneral anesthesia. After uneventfulinduction of anesthesia, the surgeonsrequested antibiotic prophylaxis with

cefazolin 1 gram, which theanesthesiology team administered.


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Case (cont.): Unexplained ApneaBefore the first incision, 50 mcg ofFentanyl was administered. About 2

minutes later, the patient became apneic.The surgeon and anesthesiologistassumed the patients apnea was due toopiate sensitivity and assisted ventilation

by hand for 30 minutes. However, despitea rise in the end-tidal CO2 to 70mm Hg,spontaneous respirations did not return.


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Etiology of Apnea During Anesthesia

Anesthetic agents

Opiates Barbiturates

Benzodiazepines

Hypocarbia-induced respiratorydepression


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Risk Factors for Prolonged Apnea

Hyperventilated patients

Extremes of age Renal failure

Pulmonary or hepatic dysfunction

Hypothermia


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Risk Factors for Prolonged Apnea(cont.)

Acidosis

Neuromuscular blockade overdose

Aminoglycosides or intravenousmagnesium

Neurological impairment or injury


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Clinical Management of Apnea Ensure adequate oxygenation and ventilation

Maintain normocarbia or slight hypercarbia

Increase O2flow to breathing circuit to enhanceelimination of inhalation anesthetics

Send blood samples for ABG and serum

electrolyte levels Conduct a neurological examination


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Clinical Management of Apnea(cont.) Review doses of medication administered

Check for syringe swap of opiates, hypnotics,

muscle relaxants, anticholinergics If the error in drug administration is recognized

immediately after injection:

Stop the IV

If there is blood pressure cuff on arm of IV, inflateto slow entry of drug to central circulation


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Consider reversal of specific drugs such asopiates, benzodiazepines, anticholinergics

If residual blockade is present: Administer reversal medication neostigmine

along with glycopyrrolate

Reassure patient; continue short-acting

sedation

Consider 1 gm calcium chloride (foraminoglycosides)

Clinical Management of Apnea(cont.)


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Case (cont.): Unexplained Apnea

Because the apneic episode lasted longer than30 minutes, the anesthesia team began to

question their initial assumption that the apneawas due to opiate sensitivity. They had obtainedthe cefazolin from the medication drawer of theanesthesia cart. The anesthesia team examined

the drawer and found vials of cefazolin andvecuronium (a long-acting paralytic agent) inadjacent medication slots.


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Case (cont.): Unexplained Apnea

The vials were of the same size andshape, with similar red plastic caps.

The team realized that the patient hadreceived vecuronium 10 mg, notcefazolin 1 g, and that the observedapnea was therefore due tounrecognized muscle relaxation.


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Medication Errors

#1 cause of adverse and preventablepatient events

7000 deaths annually

45% of adverse drug events are

caused by errors

Leape LL, et al. New Eng J Med. 1991;324:377-384.IOM Report (1999)To Err is Human.


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Medication Errors in the OR

Anesthesiology self-report systemfound 71/1089 (7%) incidents related

to syringe or ampoule swap

Out of 58 events related tomedications in the OR, 71% involvedmuscle relaxants

Cooper JB, et al. Anesthesiology. 1984;60:34-42.Leape LL, et al. JAMA. 1995;274:35-43.


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Causes of Medication Errors in OR Failure to label syringes

Incorrect matching of labels on

syringes/ampoules

Failure to read label on vial/ampoule

Misuse of decimal points/zeroes Inappropriate abbreviations


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Risk Factors for Medication Errors in OR Unfamiliar settings

New drug packaging or ampoules

Similarly appearing ampoules are storedclose together in the medication carts

Syringes prepared by other personnel

Handwritten labels used Poor lighting conditions

Multiple medications


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Similar Vials: Cefazolin and Vecuronium


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Similar Vials: Atropine & Phenylephrine


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Medication Cart Drawer


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When to Suspect Wrong Drug

Administration in the Operating Room Unusual response or lack of response to drug

administration: pounding heart, mental statuschanges, apnea, muscle weakness, or visual

disturbances Extreme or unexpected increase or decrease in

blood pressure or heart rate

Unexpected or persistent muscle relaxation

Unexpected change or lack of change, in levelof consciousness

Incorrect ampoule found to be open in work area


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Steps if Wrong Drug Administration is Suspected

Check the syringes and ampoules usedduring the case

Check to see if unexpected low volume

remains in syringe Inspect open ampoules

Impound sharps container for inspection of

ampoules and syringes at later time Consider drawing blood levels to ascertaindrug given


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Case (cont.): Unexplained ApneaHand ventilation was continued to achievenormocapnia until the muscle relaxant had

dissipated and neostigmine could beadministered. After reversal of musclerelaxation, apnea resolved, anesthesiawas discontinued, and the patient was

transported safely to the post-operativecare unit, where he recovered fully andwas discharged.


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Take-Home Points

Medication errors are the #1 cause ofpreventable adverse events, including death

Causes of wrong drug administration include: Failure to label medications

Mislabeling of syringe or ampoules

Failure to confirm identification of the medicationby reading label carefully

System checks should be used to prevent orreduce chances of inadvertent drug/vial swap


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To reduce medication errors in the OR:

Label syringes with color-coded, pre-printed labelsconforming to ASTM standards

Use easily identified ready-to-use syringes toadminister emergency drugs

Standardize location of medications on anesthesia cart

Always review 6 Rights (patient, drug, dose, route,

time, concentration)

Used computerized drug order entry and barcodingsystems when available

Take-Home Points (cont.)


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