The Case of the Sweaty Patient:
Despite a zero-tolerance policy at many institutions and organizations, wrong-sided blocks still occur, although many go unreported. Yet as a near miss at Duke University Medical Center helps illustrate, implementation of an anesthesiologist-led block protocol helps prevent such accidents from taking place.
“We’ve always had an institutional guideline for surgeons to mark the limb if it’s a unilateral procedure,” began Jeff C. Gadsden, MD, associate professor of anesthesiology at the Durham, N.C., institution. “But then the anesthesiologist arrives to do a peripheral nerve block, and in the course of getting things prepped, the patient gets turned to facilitate block placement, and the next thing you know the wrong limb’s been blocked.
“Medically speaking, it’s not as disastrous as doing surgery on the wrong side,” he added. “But still, it’s an invasive procedure, and there are complications that sometimes happen with nerve blocks.”
If It Can Happen, It Probably Will
In the case at hand, a 59-year-old woman presented for right total knee arthroplasty. Her anesthetic plan included a spinal anesthetic, single-shot sciatic nerve (posterior capsule) block and an adductor canal catheter. Per surgical protocol, the surgeon initialed the operative site. “In this case, the surgeon initialed the site in a spot that was on the inside of the knee,” Dr. Gadsden said in an exclusive interview with Anesthesiology News.
The anesthesia team placed the spinal anesthetic, followed by the posterior capsule block. “Dr. Suraj Yalamuri and I did the proper checks and ticked off all the boxes to make sure we were doing the correct side,” he noted. “But when we turned the patient back over, the resident exposed the thigh for the next block, and we noticed that there was a surgeon’s mark on both knees”.
As it turns out, the surgeon had initialed the site in a place where the knees would touch one another. That combined with a sweaty patient enabled the initials to appear as a mirror image on the opposite knee. “I’ve never seen that kind of thing before, which made it a bit scary when we did see the contralateral mark,” Dr. Gadsden admitted. “We both thought, ‘Uh oh, what have we done?’”
And while this situation may have otherwise been the blueprint for a wrong-sided block, the institution’s newly implemented protocol—a modification to the existing pre–anesthetic block timeout protocol—helped stem the possibility of error. “We had instituted a procedure for the anesthesiologist to make a separate initial at the site where the needle was going to be put through the skin,” he explained at the 2016 annual meeting of the American Society of Regional Anesthesia and Pain Medicine (abstract 1576).
Specifically, the new procedure calls for the anesthesiologist to take several steps to ensure blocks are performed on the correct side:
Review the surgical consent to determine laterality.
Visualize the surgical site marking and cross-check against the electronic medical record.
The anesthesiologist then marks the block site with his or her initials and the word “BLOCK”; block marking must be visible at all times during block placement.
The preoperative nurse, attending anesthesiologist and anesthesia provider performing the block will re-timeout before needle insertion.
After all previous steps have been completed, the nurse will give the needle to perform the block.
As Dr. Gadsden sees it, the step of having the anesthesiologist sign the site makes the difference between success and failure. “We’ll do three or four different timeouts for a single patient,” he said. “I’m a firm believer that people get timeout fatigue and that there’s a real risk of going through the motions. But signing the site is an added active step, in addition to remembering that when the needle is in hand, you’re only going through ink.
“So, had the resident not taken the extra step of marking his own block site, there may have been some confusion and, ultimately, an adverse outcome,” he explained. “But he was very quickly able to figure out that everything was fine.”
And while nothing is a sure thing, Dr. Gadsden was confident that fail-safe protocols such as this will help reduce the incidence of wrong-sided blocks even further.
“As with anything, there’s always a balance between trying to keep things easy enough that they’re not a complete burden to the workflow. But I think the solution our department came up with is a good one—it seems to be working for us.”
Admir Hadzic, MD, PhD, director of the North American Institute for Continuing Education and consultant in anesthesiology at Ziekenhuis Oost-Limburg, in Genk, Belgium, agreed that the unilateral nature of nerve blocks poses a very real risk for a wrong-sided block.
“All institutions have protocols for performing a ‘timeout’ or checklist to assure that the block is performed on the correct patient, correct extremity and correct side,” Dr. Hadzic said. “However, there currently does not exist a standard, universally accepted procedure, and every institution uses its own, adapted to local practices.
“The problem is real,” Dr. Hadzic continued, citing literature (Reg Anesth Pain Med 2014;39:195-199). “It can lead to surgery on the wrong side, and continues to occur despite a number of recommendations in the literature suggesting a protocoled approach.
“However, whatever procedure is used in a given institution, the most common culprit is actually forgetting to implement the checklist or timeout procedure in a busy clinical practice.”
To reinforce the timeout procedure and ensure 100% compliance with the timeout process, the New York School of Regional Anesthesia has developed custom “timeout” ultrasound probe covers (Figure 2). The ultrasound probe cover requires removal of the “timeout” sticker before the ultrasound probe can be applied, ensuring that the operator is 100% in compliance with the checklist as the last line of defense.