Safety Lecture Part 5

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Patient and Provider Safety in Anesthesia Part 5:

Professor: Maribeth Massie, CRNA, MS, Ph.D.(c) ANE 507: Basic P rinciples of Anesthesia I Patient and Provider Safety in Anesthesia Part 5

Laser safety:

Laser safety 10/18/2011 2 Effective to treat certain diseases but creates risk of fire, especially to patient airway and eye damage to patient and staff LASER: L ight A mplification of the S timulated E mission of R adiation Bureau of Radiological Health assigns lasers to four categories US FDA regulates manufacturing and marketing of lasers but does not regulate laser safety

Laser safety:

Laser safety American National Standards Institute (ANSI) Z136.3-2005 most commonly used laser standard addressing medical laser safety Compliance voluntary Requires Laser Safety Officer (LSO) at institutions that utilize Class IIIB and IV lasers Occupational Safety and Health Administration (OSHA) identified hazards with use of medical lasers and developed safety standards

Laser safety:

Laser safety 10/18/2011 4 Produced when electrical current directed thru medium and focused on a target 3 features: Coherence: light waves are in phase with each other Collimation: light waves move in parallel direction Monochromaticity: all light waves have same wavelength

Laser safety:

Laser safety 10/18/2011 5 Lasers named for lasing medium in use Type of medium determines wavelength (wl) of light produced by laser Different wl have different effect on tissues Lasers with long wl are readily absorbed by H2O and effect most body tissues and pigments Lasers with short wl are strongly absorbed by Hgb and other pigments but pass readily thru clear substances

Types of lasers:

Types of lasers 10/18/2011 6 CO2 laser Wl 10,600 nm Absorbed by all tissues that contain H2O Produces shallow depth of penetration and is precise Most commonly used for ENT, NS, GYN, and plastics procedures

Types of lasers:

Types of lasers 10/18/2011 7 Nd:YAG laser Wl 1064 nm Neodynium-doped-yttrium-aluminum-garnet Absorbed by pigmented tissues and transmitted thru clear substances Penetrates tissues to depth of 2-6 mm Most commonly used for coagulation and debulking tumors Can transmit thru fiberoptic cables and reach trachea/bronchi

Types of lasers:

Types of lasers 10/18/2011 8 KTP laser Wl 532 nm Potassium-titanyl-phosphate Visible emerald green color Produced by passing Nd:YAG laser thru KTP medium to shorten wl Effect between CO2 and Nd:YAG with precise focusing and good coagulation Penetrates to depth of 0.5-2 mm Used for airway procedures and NS

Types of lasers:

Types of lasers 10/18/2011 9 Argon Wl 488- 515 nm Absorbed by pigments and passes thru clear substances Shallow tissue penetration so good for eye procedures, especially retina and dermatology/plastics

Types of lasers:

10/18/2011 10 Types of lasers Helium Visible red light incorporated into other lasers to function as aiming beam

Eye protection:

Eye protection 10/18/2011 11 Type of protection depends on laser used Lasers with long wl (CO2) are absorbed by all surfaces and therefore can effect cornea and lens of eye SO clear glasses are suitable Lasers with short wl easily pass thru clear substances and are absorbed by pigments so they can pass thru lens of eye and damage retina SO colored glasses are suitable

Eye protection:

Eye protection 10/18/2011 12 Tape eyes when laser used Do not use petroleum-based lubricant because of risk of fire Filtration masks should be worn if viruses suspected

Operating room fires:

Operating room fires Fire triad: 3 elements necessary for a fire to start Ignition source/heat Fuel Oxidizer Ignition sources Electrosurgical cautery , lasers, tools such as drills and fiberoptic light cords Fuel Paper & cloth drapes, gauze drsg’s , ETT, gel mattresses, face and body hair, equipment Oxidizers Oxygen, Nitrous oxide, air Oxygen and Nitrous function equally as oxidizers

Preventive strategies to reduce airway fires:

Preventive strategies to reduce airway fires 10/18/2011 14 Limit O2 to 40%Avoid N2O; supports combustion Use O2:Helium (Heliox) mixture to reduce risk of fire Helium has high thermal conductivity and is more resistant to ignition Lower viscosity beneficial for increased resistance resulting from smaller ID tubes or airway obstruction ETT cuff rupture often prelude to fire Cuff should be inflated with saline/methylene blue Saline-moistened gauze should be placed proximal to tube cuff

Endotracheal tubes:

Endotracheal tubes 10/18/2011 15 PVC tubes ignite easily,especially at the radiopaque barium sulfate strip, producing toxic materials Red rubber tubes are more resistant to initial ignition, slower to burn and produce less toxins but they tend to melt and produce CO Silicone tubes less combustible but concerns with inhalation of silica ash

Endotracheal tube wraps:

Endotracheal tube wraps 10/18/2011 16 Application of metallic foil (aluminum or copper) may protect PVC or red rubber tubes Only Merocel Laser-Guard ET wrap (Medtronic) has FDA approval Meticulous attention to wrapping is mandatory Apply in spiral, overlapping manner Leaving any area of tube exposed negates use of wrap

Laser-resistant ETT’s:

Laser-resistant ETT’s 10/18/2011 17 Laser-Flex Tracheal Tube (Nellcor/Mallinckrodt) Stainless steel spiral tube with 2 cuffs Resistant to CO2, KTP, Nd:YAG lasers Bovina Fome-Cuff (Portex) Silicone and aluminum spiral tube Polyurethane self-inflating foam cuff covered with silicone Laser Shield II (Medtronic) Reflective aluminum-wrapped silicone tube covered with fluroplastic material Cuff is inflated with saline and methylene blue is in inflation valve for immediate detection of rupture

Laser-resistant ETT’s:

Laser-resistant ETT’s 10/18/2011 18 Laser-Trach (Kendall/Sheridan) Red rubber tube with copper foil Lasertubus (Rusch) Soft, white rubber tube with lower 17 cm covered with Merocel wrap 2 high volume cuffs, one inside the other Potential of an airway fire still exists with all tubes!

If airway fire occurs…:

If airway fire occurs… 10/18/2011 19 Prompt action is imperative Disconnect ETT and extubate immediately Turn off O2 Irrigate site with H2O if smoldering Establish airway; reintubate; trach? Admit to ICU for at least 24 hours Monitor ABG’s Consider mechanical ventilation Steroids Antibiotics

Final Points for the Administration of Anesthesia to ENT patients:

Final Points for the Administration of Anesthesia to ENT patients 10/18/2011 20 Intubation and ventilation Secure the ETT Communication with the surgeon Laser surgery Most cases are outpatient

Latex Allergies:

Latex Allergies Allergies to latex, the milky sap of the rubber tree Hevea brasiliensis, can be described as an antigenic response to the proteins found in NRL The three recognized reactions to latex include: non-allergic irritant contact dermatitis type IV cell-mediated allergies type I Ig E-mediated allergies.

Non-allergic irritants contact dermatitis:

Non-allergic irritants contact dermatitis Skin rash, commonly affects the regular wearers of powdered and non-powdered latex gloves Type IV cell-mediated allergies, the most common immune system reaction to latex, represent a delayed hypersensitivity to one or more of the 300-plus chemicals used to manufacture latex Typically develop allergic contact dermatitis within 49 to 96 hours of exposure and, through continued exposure, may acquire the antibodies that can trigger a type I latex allergy

Type I IgE-mediated allergies:

Type I IgE-mediated allergies Represent an immediate hypersensitivity to actual latex proteins and include two subgroups The first causes hives, itchy and watery eyes, runny nose, sneezing, wheezing, asthma, abdominal pain, nausea, diarrhea and skin rashes The second and more serious, causes anaphylaxis

Latex Allergies Spread and Cross-React with Food:

Latex Allergies Spread and Cross-React with Food Ongoing exposure to products made of NRL, especially direct skin contact with gloves, causes most allergic reactions Surgical procedures cause some of the most severe reactions  direct contact with moist areas of the body and internal surfaces causing faster, easier absorption of the allergen Inhalation of airborne proteins, released when powdered gloves get snapped off, can enter the eyes or mucous membranes and also cause a reaction

Latex-sensitive individuals:

Latex-sensitive individuals Should avoid exposure to bananas, avocados, kiwis, peaches, cherries, apricots, figs, papayas, tomatoes, potatoes and chestnuts These fruits, vegetables and nuts contain the same allergy-producing proteins found in NRL and can trigger a reaction Genetically engineered fruits and vegetables contain the same DNA markers as latex and should be avoided as well

Screening for latex allergies:

Screening for latex allergies Skin prick, skin patch and radioallergosorbent (RAST) tests screen for latex allergies Skin prick tests, which can induce anaphylactic shock, should be performed only under the supervision of an allergy specialist and with appropriate emergency backup equipment on hand RAST tests identify specific IgE antibodies to latex in the blood and confirm an NRL allergy diagnosis All can produce inconclusive results, such as false positives and negatives, that require further testing or a diagnosis based on patient medical history

Preop evaluation: History or risk for latex allergy:

Preop evaluation: History or risk for latex allergy History of chronic care with latex-based products History of spina bifida, urological reconstructive surgery History of repeated surgical procedures (e.g., >9) History of intolerance to latex-based products: balloons, rubber gloves, condoms, dental dams, rubber urethral catheters History of allergy to tropical fruits History of intraoperative anaphylaxis of uncertain etiology Health care workers, especially with a history of atopy or hand eczema

Operating Room Management of the Patient With Latex Allergy :

Operating Room Management of the Patient With Latex Allergy 1. Identify each patient who is at risk. A careful history frequently will elicit episodes of previous allergic reactions or risk factors. 2. Patients who have a suggestive history and confirmatory laboratory findings must be managed with complete latex avoidance. 3. When possible, the patient should be scheduled for elective surgery as the first case of the day. Airborne latex-laden particles are presumed to be at their minimum levels at that time. 4. Signs displaying “Latex Allergy” should be posted on all O.R. doors. No one should enter the O.R. with latex gloves, without scrubbing after taking off latex gloves or while wearing latex-laden clothing from previous latex exposure. 5. Preview all equipment to be used, looking for possible latex-containing products. 6. A latex-free cart should accompany the patient throughout his/her hospital stay.

Intraoperative management: anesthesia equipment:

Intraoperative management: anesthesia equipment Latex-free gloves, airways, endotracheal tubes Masks — polyvinylchloride if available or old, well-washed black rubber masks Rebreathing bags — neoprene if available or old, well-washed black rubber bags Ventilator bellows — neoprene or silicone if available or old, well-washed black rubber bellows Breathing circuit — disposable, polyvinylchloride, packaged separately from a latex rebreathing bag Remove rubber stoppers from multidose vials Beware of latex intravenous injection ports, Penrose-type tourniquets and rubber bands; use nonlatex glove as tourniquet; tape latex injection ports or use silicone injection ports or stopcock Blood pressure cuffs — if new latex, cover with soft cotton Ambu -type bag — assure that bag and valve do not have latex components — alternative is silicone self-inflating bag Check syringe plungers; reconstitute medications every six hours Dilute concentration of epinephrine (0.01 mg/ml, or 1:100,000) available

Treatment of a Latex Allergic Reaction :

Treatment of a Latex Allergic Reaction 1. Contact dermatitis and Type IV reactions: a. Avoid irritating skin cleansers. b. Topical corticosteroids can be applied locally for rashes or hives. 2. Type I latex reactions: a. Mild reactions respond well to antihistamines, and topical nasal steroids may be useful. b. Hives are treated with antihistamines and systemic steroids. c. A reaction with airway involvement may require the use of systemic steroids, bronchodilators, endotracheal intubation and epinephrine. d. In the case of anaphylaxis, a formal anaphylaxis protocol is advisable. 3. Latex-free precautions must accompany the patient throughout the perioperative period (PACU, ICU and discharge unit). 4. The details of any allergic reaction should be clearly documented on the patient’s chart. Report any latex-induced reactions to the FDA MedWatch program (1-800-FDA-1088).

Acute management: Initial therapy:

Acute management: Initial therapy 1. Stop administration/reduce absorption of offending agent (Consider a variety of potential routes of exposure-administration, including mucosal contact and inhalation) 2. Remove all latex from the surgical field 3. Change gloves 4. Discontinue all antibiotic and blood administration 5. Maintain the airway and administer 100 percent O2 6. Intubate the trachea (as indicated) 7. Administer 25-50 ml/kg of crystalloid or colloid (as indicated) 8. Administer epinephrine Intravenous: 0.1 mcg/kg or approximately 10 mcg in an adult Subcutaneous (in the absence of an I.V.): 300 mcg (0.3 mg) Endotracheal : five to 10 times the intravenous dose, or 50-100 mcg in an adult From a metered dose inhaler: 3 inhalations of 0.16 to 0.20 mg epinephrine/inhalation From a nebulizer: eight to 15 drops of 2.25 percent epinephrine in 2 ml normal saline 9. Discontinue all anesthetic agents 10. Consider use of Military Anti-Shock Trousers (MAST) 11. Display prominent signs such as “latex allergy” or “latex alert” on the inside of the operating room as well as on the entry doors for those entering

Secondary therapy:

Secondary therapy 1. Administer antihistamine Diphenhydramine 1 mg/kg I.V. or IM (maximal dose 50 mg) Ranitidine 1 mg/kg I.V. (maximal dose 50 mg) 2. Administer glucocorticoids Hydrocortisone 5 mg/kg initially and then 2.5 mg/kg q 4-6 hours Methylprednisolone 1 mg/kg initially and 0.8 mg/kg q 4-6 hours 3. Administer aminophylline for bronchospasm (may be ineffective during anesthesia) Loading dose 5 to 6 mg/kg Continuous infusion 0.4-0.9 mg/kg/hr (check blood level) 4. Administer inhaled Beta-2 agonists for bronchospasm 5. Administer a continuous catecholamine infusion for blood pressure support Epinephrine 0.02-0.05 mcg/kg/min (2-4 mcg/min) Norepinephrine 0.05 mcg/kg/min (2-4 mcg/min) Dopamine 5-20 mcg/kg/min Isoproterenol (same dosing as epinephrine) 6. Administer sodium bicarbonate 0.5 to 1 mg/kg initially, with titrations using arterial blood gas analysis


References American Latex Allergy Association (ALERT): American Academy of Allergy Asthma & Immunology : Thanks to my friend Steve Alves for the use of some of his slides!

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