Clinical Conference 15 Dec 04 George P. Topulos, M.D. Department of Anesthesia and Perioperative Medicine Brigham & Women’s Hospital

Case Presentation - 1 60 yof o/w well - breast lumpectomy and axillary node mapping Uneventful iv induction and oral ETT Ventilator on, O2/N2O/Desflurane/fentanyl No NMB at request of surgeon Patient movement and BP, Desflurane Several minutes go by Reservoir bag is collapsed No alarms (I think) What would you do now?

Case Presentation - 2 Switch to bag (manual) ventilation Unable to ventilate or fill reservoir bag despite O2 FGF up to max. What would you do now? Call for help Wake up patient and cancel surgery?

Case Presentation - 3 Switch to manual resuscitator (ambu bag) for ventilation Connect to O2 and capnograph! Patient starts to move around Total iv anesthesia What if you could not find manual resuscitator? What would you do now?

Clinical Problem Solving Recognize Best guess at Diagnosis Temporize Mechanism Context Specific Therapy Evaluate Success of Therapy Re-evaluate Diagnosis How bad is it? If the problem is not serious you may want to skip the temporary intervention. "Mechanism" means think about the physiological mechanisms that can cause the problem. "Context" means think about the clinical context (situation) in which it happened. If we find a patient with hypoxemia we must have a way to think about : what could be wrong, how can we distinguish between the possibilities, and how can we make it better. Otherwise we will be forced to memorize a long (and always incomplete) list of potential problems, we will not be likely to discover new kinds of problems, and we will not see how to fix them. Try to think about the fundamental mechanisms behind the problems we see. Think mechanistically and quantitatively. Intuitions are not enough. If I ask what are the causes of hypoxia do not think of a disease; e.g., a PE may release bad humors which in turn may result in hypoxemia, but think of mechanisms not diseases. On the one hand, a model will help guide our thinking through a complicated problem. On the other hand must keep in mind this is only a model, it is oversimplified, incomplete, and probably wrong in ways we do not know. So keep an open and critical (skeptical) mind; the model can also cause us to fail to discover new kinds of problems.

Assign someone to take care of the patient and nothing else! Crisis Management - 1 Assign someone to take care of the patient and nothing else! (fly the plane, point at the man over board) They ignore the equipment problem.

Show Simulator Movie Show Simulator Movie of plane crash

Crisis Management - 2 Don’t panic – do not stare at the anesthesia machine. Don’t ignore it either. “It would be unthinkably awful if this were true so it must not be real.” While you are thinking have the nurse call your staff and say you want them NOW. This is no time for YOU to be on the phone. Do not fixate on a single measurement or monitor look at the other vital signs. Look at the patient and the surgical field. Make sure you have not forgotten something you did. Life is not a multiple-choice test, do all of this in 30 seconds.

Case Presentation - 4 Unable to find leak, clinical engineers, another attending who happened in. Automatic "leak test" OK (and was before case). Disconnect from patient and still a big circuit leak. Switch anesthesia machines? If so how when and with what help? if could not get another anesthesia machine use an ICU vent and iv anesthesia. later point out it was first case of the day (was it)

Causes of Circuit Leaks Involve Patient NG tube Cuff leak ETT out Lung leak Do Not involve Patient Circuit disconnect CO2 canister Vaporizer leak

OR Biomedical Engineering Machine Post-Mortum Jim Philip and OR Biomed Team Page 3-1055 or call 3-1987 Vaporizer - worked without problem on another Fabius Another Vaporizer in same slot created leak on this Fabius No leak with Vaporizer off Big leak with Vaporizer on Why? What happens when the Vaporizer is turned on? 5 minutes, only

SelectaTec® Mounting Vaporizer is out of circuit until switched on That is why cannot be used below the first marking Control Dial Release Selectatec Manifold Vaporizer-specific innards

SelectaTec® Mounting

SelectaTec® Mounting Vaporizer leak will be missed during pre-use check Unless it is turned on Loose vaporizer will leak at connection Only when it is switched on Misalignment of Vaporizer will cause the leak observed Any anterior or posterior movement will do this Alignment peg creates correct alignment

Vaporizer misaligned Purposeful misalignment

Big Leak only when switched on

Vaporizer off and misaligned Purposeful misalignment

No leak detected

Followup Manufacturer (Draeger) informed of “Failure of Pre-use Check” Understood to be interaction of SelectaTec Vaporizers and back bar with Draeger “No Fresh Gas Hose” design Resolution by Manufacturer ? Resolution at BWH Inspect vaporizer mounting Perform additional or primary leak test With desired Vaporizer on

Black Slide

What is wrong with this picture? MRT case cryoablation of kidney tumor. RF Noise in MR images caused by battery charger in infusion pump. Pump plugged in but turned off. Was in the MR room but at least 15 ft from magnet. Get picture of the pump 03 Dec 04 from Paul Morrison There are 3 images: Series 4 image 8: image with artifact Series 4 image 19: image with artifact (changed frequency direction) Series 7 image 7: image with "Topulos filter." <<MRT041202_Ser04 i008.jpg>> <<MRT041202_Ser04 i019.jpg>> <<MRT041202_Ser07 i007.jpg>>  MRT case cryoablation of kidney tumor.