DEFINITION AND RATES

A medication error is “a failure in the treatment process that leads to, or has the potential to lead to, harm to the patient.”¹ In general, perioperative medication errors are under-reported. Rates of medication errors are difficult to accurately quantify as few studies have observed anesthesia professionals going through the process of medication ordering and administration. In one large, institutional study of adult patients, the self-reported incidence of medication errors was 0.004% (10/280,488) whereas the direct observation incidence was 5.3% (193/3671), suggesting that only severe medication errors with sequelae may be reported.² In pediatric anesthesia, the estimated incidence of medication errors using self-reports is between 0.01% (276/2,316,635) to 1.92% (37/1,925).^3-4,7 Pediatric patients have large variations in body weight resulting in high variability in dosing calculations. This makes children both at higher risk of medication errors as well as higher risk for harm from these errors compared to adult patients.⁶

COMMON CAUSES THAT LEAD TO MEDICATION ERROR

Anesthesia professionals work under high intensity conditions where multiple doses and classes of drugs are given during fast-paced clinical scenarios. This environment predisposes anesthesia professionals to medication errors. Moreover, anesthesia professionals routinely take ownership of the entire drug administration process, including prescribing, preparation, and administration. Hazards exist throughout this process (Figure 1).

Figure 1: Primary pediatric medication errors in the perioperative setting during different phases of handling: preparation, prescribing, or administration. Adapted and modified with permission from Lobaugh LMY et al. Anesth Analg. 2017; 125:936–942.7

Wake Up Safe, a national pediatric anesthesiology quality collaborative, found that sedatives and hypnotics/opioids are the most common medications resulting in an error.

It also found that the highest incidence of medication errors was during administration (N = 179), followed by prescribing (incorrect knowledge of dose, N = 67), then preparation (N = 30) (Figure 2), next page. The most common error type during administration was the wrong dose (N = 84), followed by syringe swap (accidental administration of the wrong syringe, N = 49). Fifty-seven incidents (21%) of reported medication errors involved medication infusions as opposed to bolus administrations. Of note, nearly all (97%) of the medication errors were deemed to be preventable.⁷

Figure 2: Phase of handling and incidence of perioperative medication errors in pediatric patients: administration, prescribing, and preparation.

Adapted and modified with permission from Lobaugh LMY et al. Anesth Analg. 2017; 125:936–942.7

HOW DO WE CONTROL THE RISK DURING MEDICATION ADMINISTRATION?

The critical step in medication administration occurs once the syringe is pushed or infusion started.⁸ Once the drug reaches the patient, there is potential for an immediate and irreversible change to their condition. This administration process comes with inherent possibility for error and harm. Some technological and process-based interventions can help mitigate or even eliminate harm potentially caused by the error (Table 1).

Table 1: Technological and Process-Based Interventions Reduce Medication Errors.

A FOCUS ON PEDIATRIC MEDICATION ERRORS:

For the pediatric population, specific evidence-based mitigation techniques should be considered (Figure 3).

Figure 3: Bow-tie Analysis of Intraoperative Medication Errors.

POC = Point-Of-Care

The Anesthesia Medication Template (AMT) drug organization system is a formal and standardized method of organizing medications in the anesthesia workplace. This tool lessens cognitive burden and has been shown to facilitate the selection of correct syringes from the anesthesia workspace as well as correct drug dose administration.⁹ During simulation at a freestanding pediatric academic hospital, use of an AMT reduced incidence of overall drug dosing errors from 10.4 to 2.4 per 100 medication administrations. During phase 2 implementation, use of the AMT decreased the mean monthly error rate that reached pediatric patients from 1.24 to 0.65 errors per 1000 anesthetics. Of the errors that reached the patient, the AMT helped reduce the rate of medication swaps, miscalculation, and timing errors from 0.80 to 0.26 per 1000 anesthetics.⁹

Another mitigating technique is using prefilled syringes. Multiple patient safety groups including the APSF and Wake Up Safe advocate for prefilled syringes, which can provide standardized and enhanced labeling, along with ready-to-use medication doses.^10-12 This practice can mitigate ampule/vial swap errors and may also decrease the risk of syringe swap.¹¹ In a 2016 qualitative research study, System Vulnerabilities (SVs) compared provider-filled and prefilled syringe systems. SV is defined as an “activity or event that has the potential to reduce safety, efficiency of provider workflow, or increase drug costs and waste.”¹² More SVs were identified in the provider-filled system compared to the prefilled syringe system, including errors due to illegible handwriting and errors due to similar medication packaging.¹² Despite its safety profile, reports of medication errors related to look-alike prefilled syringes have been published involving select manufacturers. These reports emphasize the importance of selecting prefilled pharmaceuticals that meet standards set by the American Society for Testing and Materials as well as being visually distinguishable once assembled for use.^13-14

A third modality is the use of point-of-care barcode scanning systems.^15-17 An observational study investigating the efficacy of barcode medication-verification technology implementation in an inpatient adult populationsuggested a 41% reduction in dose, route, documentation, and administration errors and a 51% reduction in potential adverse drug events.¹⁵ In a 2022 study out of a quaternary academic children’s hospital, implementation of an electronic labeling system demonstrated a 3.6% reduction in the average daily medication discrepancy rate. Pre-implementation, the average daily medication discrepancy rate was 9.7%, decreasing to a statistically significant 6.1% (X²₁ = 43.9; P < .0001) post-implementation.¹⁶ Limitations to these technologies include user feasibility, compliance, cost, and availability.^15-17 Technology, while it can be incredibly useful, needs to be used in the manner for which it was intended to function in a way to mitigate medication errors. When functioning outside of intended purposes, technology can pose a risk. For example, barcode scanning only works well provided that the systems link with the EMR and that the barcode provided registers appropriately. In addition, utilization of point of care barcoding technology requires partnership with pharmacy for system updates, label changes, and medication shortage management.

CONCLUSION

Direct observation via published studies of adult and pediatric anesthesia providers in the operating room estimates a medication error rate of up to 5%.² The harm caused by medication errors is reported to be as high as three times more in pediatric patients than adults. The adverse event drug rate is highest among neonates. Potential medication error mitigation strategies include utilizing prefilled syringes, EMR decision support, medication organization aides, and barcode scanning systems.

REFERENCES

1. Aronson JK. Medication errors: definitions and classification. Br J Clin Pharmacol. 2009;67:599–604. PMID: 19594526.
2. Nanji KC, Patel A, Shaikh S, et al. Evaluation of perioperative medication errors and adverse drug events. Anesthesiology. 2016;124:25–34. PMID: 26501385
3. Gariel C, Cogniat B, Desgranges FP, et al. Incidence, characteristics, and predictive factors for medication errors in paediatric anaesthesia: a prospective incident monitoring study. Br J Anaesth. 2018;120:563–570. PMID: 29452813
4. Feinstein MM, Pannunzio AE, Castro P. Frequency of medication error in pediatric anesthesia: a systematic review and meta-analytic estimate. Paediatr Anaesth. 2018;28:1071–1077. PMID: 30375106
5. Leahy IC, Lavoie M, Zurakowski D, et al. Medication errors in a pediatric anesthesia setting: Incidence, etiologies, and error reduction strategies. J Clin Anesth. 2018;49:107–111. PMID: 29913393
6. Kaushal R, Bates DW, Landrigan C, et al. Medication errors and adverse drug events in pediatric inpatients. JAMA. 2001;285:2114–2120. PMID: 11311101
7. Lobaugh LMY, Martin LD, Schleelein LE, et al. Medication errors in pediatric anesthesia: a report from the Wake Up Safe Quality Improvement Initiative. Anesth Analg. 2017; 125:936–942. PMID: 28742772. PMID: 28742772
8. Muschara T, Farris R, Marinus J. Critical steps: managing what must go right in high-risk operations. 1st edition, CRC Press, 2021.
9. Grigg EB, Martin LD, Ross FJ, et al. Assessing the impact of the anesthesia medication template on medication errors during anesthesia: a prospective study. Anesth Analg. 2017;24:1617–1625. PMID: 28079581
10. Wahr JA, Abernathy JH 3rd, Lazarra EH, et al. Medication safety in the operating room: literature and expert-based recommendations. Br J Anaesth. 2017;118:32–43. PMID: 28039240
11. Eichhorn JH. APSF hosts medication safety conference: consensus group defines challenges and opportunities for improved practice. APSF Newsletter. 2010;25:1–8. https://www.apsf.org/article/apsf-hosts-medication-safety-conference/ Accessed August 13, 2024.
12. Yang Y, Rivera AJ, Fortier CR, Abernathy JH 3rd. A human factors engineering study of the medication delivery process during an anesthetic: self-filled syringes versus prefilled syringes. Anesthesiology. 2016;124:795–803. PMID: 26845139
13. Parr G, Desvarieux T, Fisher D. Medication error related to look-alike prefilled syringes. APSF Newsletter. 2019; 34:2. https://www.apsf.org/article/medication-error-related-to-look-alike-prefilled-syringes/ Accessed August 13, 2024.
14. Hand W, Cancellaro V. “No read” error related to prefilled syringes. APSF Newsletter. 2018;33:1. https://www.apsf.org/article/no-read-errors-related-to-prefilled-syringes/ Accessed August 13, 2024.
15. Poon EG, Keohane CA, Yoon CS, et al. Effect of bar-code technology on the safety of medication administration. N Engl J Med. 2010;362:1698–1707. PMID: 20445181
16. Thomas JJ, Bashqoy F, Brinton JT, et al. Integration of the Codonics Safe Label System® and the Omnicell XT® Anesthesia Workstation into pediatric anesthesia practice: utilizing technology to increase medication labeling compliance and decrease medication discrepancies while maintaining user acceptability. Hosp Pharm. 2022;57 PMID: 35521011
17. Jelacic S, Bowdle A, Nair BG, et al. A system for anesthesia drug administration using barcode technology: the Codonics Safe Label System and Smart Anesthesia Manager. Anesth Analg. 2015;121:410–421. PMID: 24859078

DEAR RAPID RESPONSE:

In 2013, my colleagues and I reported a case of hypoventilation to the APSF Newsletter due to a massive leak from a defective Drägersorb disposable absorbent canister (CLIC®) (Drägerwerk AG & Co. KGaA, Lübeck, Germany), which was replaced during surgery while using the Fabius GS premium anesthesia workstation (Drägerwerk AG & Co., Lübeck, Germany).¹ Since our report appeared in the APSF Newsletter, similar cases have been reported on other Dräger anesthesia machines such as Perseus A500² and Primus.³ Despite these reports, there have been no specific actions to prevent future occurrences, so the risk of hypoventilation after replacing a CO₂ absorber during surgery has continued. Furthermore, this risk is not unique to Dräger anesthesia machines although the implications of a leaky canister are different depending upon the machine design. In this report, our prior experience is summarized and the impact of a leaky canister on ventilation is described for different machine designs. To inform anesthesia professionals about this risk, a “WARNING” should be added to the Instructions for Use (IFU) for all anesthesia machines that provide the option to change the absorbent canister during a procedure.

When the Fabius GS machines were introduced to our department, it was the first time we could replace the absorbent canister during a procedure. This practice was adopted to more completely utilize the absorbent. For the case we reported in the previous APSF Newsletter, the canister was changed during the procedure without apparent problems. At the end of the procedure, when switching to manual ventilation, the breathing bag collapsed and could not be inflated, despite maximizing the fresh gas flow (FGF) or repeatedly pressing the oxygen flush valve. The patient’s endotracheal tube was disconnected from the anesthesia machine and ventilation continued with a Jackson-Rees circuit and an external oxygen tank. The patient restored spontaneous breathing and was extubated uneventfully. Investigation revealed a large hole in the absorbent canister as the reason for the inability to create pressure in the circuit. The unique design of the Fabius machine, which incorporates a fresh gas decoupling valve, allowed for adequate mechanical ventilation, but complete ventilation failure in manual mode.

The current anesthesia workstations with piston ventilators manufactured by Drägerwerk AG & Co. have a unique design that uses a fresh gas decoupling (FGD) valve in the breathing system to prevent fresh gas from entering the circuit during inspiration. The CLIC adaptor makes it possible to replace an absorbent canister during surgery. The FGD valve is located between the piston-type ventilator and the fresh gas inlet, and a CO₂ absorber is located between the fresh gas inlet and the breathing bag (Figure 1). The FGD valve ensures inspiratory pressure is maintained during mechanical ventilation even if a leaky absorbent canister is correctly attached to the CLIC adaptor. During the expiratory phase of mechanical ventilation, as the piston retracts, ambient air can be drawn from the defect in the absorber into the anesthesia circuit. The gas concentrations in the circuit are altered by the entrained ambient air but, depending upon the size of the leak, the concentration changes may not be readily apparent. With manual ventilation, however, positive pressure is created by the reservoir bag and a defect in the canister can then make ventilation impossible with a collapsed breathing bag and potential injury to the patient.

The anesthesia workstations with turbine-type ventilators (Dräger Perseus and Zeus) do not have a FGD valve, but the breathing bag fills with fresh gas and functions as a reservoir for the ventilator (Figure 2).⁴ During mechanical ventilation, inspired gas is taken from the FGF and the reservoir bag. When there is a leak in the absorbent canister,² during mechanical ventilation, tidal volume is not altered, but the gas concentrations in the circuit are altered as ambient air can enter the circuit through the canister. The impact on gas concentrations depends upon the size of the leak and the total FGF with a greater impact for larger leaks and lower FGF. Since the breathing circuit has unidirectional flow, fresh gas should continue to fill the reservoir bag during mechanical exhalation. Manual ventilation may be difficult or impossible depending upon the size of the leak.

Dräger is not the only manufacturer to offer absorbent replacement during surgery. GE Healthcare (Madison, WI), Mindray North America (Mahwah, NJ) and Getinge USA (Mahwah, NJ) all offer the same feature, and the machine design will determine the impact on the breathing circuit of placing a canister with an undetected leak. There is a report of leakage occurring in a GE anesthesia machine after replacing a damaged disposable canister.⁵ GE and Mindray anesthesia machines have an ascending bellows ventilator and no FGD valve. During mechanical ventilation, the reservoir bag is excluded from the circuit. If there is a leak in the canister, the bellows will collapse during inspiration and make mechanical ventilation impossible (Figure 3).⁶ During manual ventilation, the bellows is excluded, but the reservoir bag will collapse making ventilation impossible. The size of the leak will determine how quickly either the bellows or reservoir bag collapse, but if either occurs there is a leak until proven otherwise and the canister may be the source if it was recently changed.

Another type of anesthesia machine circuit design is the volume reflector, which is included in Getinge anesthesia machines and the Mindray A9. While there are no published reports of a leaky canister with the volume reflector design, the consequences can be understood by inspecting the circuit design (Figure 4).⁷ In this circuit, a ventilator and a breathing bag are located upstream of the absorber. Like the bellows design, during mechanical ventilation, the reservoir bag is excluded from the circuit, and during manual ventilation, the ventilator is excluded. The volume reflector ventilator provides a continuous supply of 100% oxygen as the drive gas. Under normal conditions, the drive gas pushes gas to the patient, but does not enter the patient circuit. In the event of a canister leak, the drive gas may provide some ventilation to the patient depending upon the size of the leak, but will dilute the anesthetic in the circuit and change the oxygen concentration. Manual ventilation may not be possible if there is a large leak, and the bag will collapse.

Current practices intended to reduce the environmental footprint when using a circle anesthesia system include reducing FGF and using the CO₂ absorbent to completion. Achieving the absorbent goal requires waiting to change the absorbent until inspired CO₂ is present,⁸ which is the rationale for allowing an intraprocedure exchange. While there is benefit to this feature, our experience and other reports underscore the risks of an undetected canister leak. While a leaking canister will be detected by the preoperative leak test, it is only apparent by ventilation failure and/or changes in gas concentrations when replaced during a procedure.

Therefore, my colleagues and I are reluctant to follow the practice of replacing the absorber during surgery due to the risk of personnel failing to recognize the problem and respond in a timely fashion, potentially leading to patient harm. Instead, we continue to rely upon the color change of the absorbent to determine when to replace the canister. Typically, the canister is replaced before the start of anesthesia and a leak test is done after the replacement. Leaks in the canister will therefore be detected before patient care. When a long procedure is planned, we replace the canister beforehand in order to reduce the possibility of replacement during surgery. Unfortunately, we have not been able to take full advantage of the CLIC adapter on the Dräger anesthesia machine.

The problem of inability to detect a leaky canister until it results in difficulty ventilating is inherent to the design of modern anesthesia machines. Piston ventilators from Dräger with a FGD valve and turbine ventilators without a FGD valve will continue mechanical ventilation and the problem may not be apparent until switching to manual ventilation. Other ventilator designs (bellows and volume reflector) should demonstrate a failure to ventilate fairly soon after canister replacement. Manufacturers who provide the ability to change absorbent during a procedure should inform users about the risk of an undetected canister leak and the problems likely to result depending upon the circuit design. We suggest that all manufacturers add an appropriate “WARNING” to the IFU of their anesthesia workstations. In the case of Dräger piston ventilators, we propose the following example:

WARNING

Replacement of a CLIC disposable CO₂ absorbent canister during a procedure has the attendant risk of impossible manual ventilation if the replacement has an undetected leak. Due to the FGD valve, mechanical ventilation will not be altered significantly if there is a canister leak. Visual inspection of the canister is essential to detect any defect of the disposable canister before replacement. After intraprocedure canister replacement, tidal volume and inspiratory pressure as well as gas concentrations in the circuit should be carefully monitored for any changes. A manual resuscitation device, auxiliary oxygen supply and intravenous anesthetics should always be readily available to prevent patient injury in the event of an anesthesia machine failure.

REFERENCES

1. Kuruma Y, Kita Y, Fujii S. Exchanging a CLIC absorber in the middle of the surgery. APSF Newsletter. 2013;27:64–65. https://www.apsf.org/article/exchanging-a-clic-absorber-in-the-middle-of-the-surgery/ Accessed August 13, 2024.
2. Watanabe H, Moriyama K, Tokumine J, et al. Massive leak in carbon dioxide absorber of Perseus A500 did not inhibit mechanical ventilation but manual bag ventilation: a case report with experimental reproduction. A A Pract. 2021;15:e01425. PMID: 33740784
3. Rey A, Malezieux O, Potie A. The fresh gas flow decoupling valve and the potential for leaks in the anaesthetic circle breathing system. Anaesth Rep. 2021;9,e12141. PMID: 34881364
4. Instructions for use. Perseus A500 SW 1.1n ( https://www.draeger.com/Content/Documents/Content/IfU_Perseus_A500_SW_1.1n_EN_9054101.pdf. Accessed August 9, 2024)
5. Sano H, Suzuki T, Kaneda Y. Gas leak due to a damaged GE disposable multi absorber canister used with an EZchange module following its reinstallation during anesthesia. Can J Anesth. 2015;62:96–97. PMID: 25326266
6. Kaminoh Y. LiSA. 2015;22:984–990. (in Japanese)
7. Lucangelo U, Ajcevic M, Accardo A, et al. FLOW-I ventilator performance in the presence of a circle system leak. J Clin Monit Comput. 2017;31:273–280. PMID: 27062381
8. Feldman JM, Hendrickx J, Kennedy RR. Carbon dioxide absorption during inhalation anesthesia: a modern practice. Anesth Analg. 2021;132:993–1002. PMID: 32947290

Editor’s Note: Intraprocedure Replacement of CO₂ Absorbent Canisters

by Jeffrey Feldman, MD, MSE

The circle anesthesia system is specifically designed to reduce inhalation agent waste and greenhouse gas pollution by allowing the anesthesia professional to reduce fresh gas flow causing rebreathing of exhaled anesthetics. Carbon dioxide absorption is required to safely and effectively reduce fresh gas flow. Carbon dioxide absorbents also contribute to the waste stream and offset the advantages gained by reducing fresh gas flow although the net benefit favors reducing fresh gas flow.¹ Changing absorbent based upon the appearance of indicator alone increases absorbent waste by discarding unused absorbent. To minimize absorbent waste, it is useful to utilize the absorbent until it becomes ineffective, which is indicated when inspired CO₂ begins to appear in the capnogram.² This practice is only practical when using an anesthesia machine designed to allow for absorbent canister replacement without interrupting positive pressure ventilation or anesthetic delivery. The major anesthesia machine manufacturers all provide options that allow for intraprocedure replacement of absorbent canisters.

In this issue of the Newsletter, Yuki Kuruma, MD, revisits her previously published report of manual ventilation failure due to replacing the absorbent canister during a procedure with one that has a leak due to a crack or hole in the housing.³ In the current article, Kuruma emphasizes that the risk of failed ventilation due to replacing a faulty canister intraoperatively has not changed since the original report in 2013. Indeed, all of the existing machine designs have that risk, and Kuruma reviews how the impact of a faulty canister can manifest depending upon the machine design. Furthermore, the manufacturers that offer an option for replacing the absorbent during a procedure have not provided specific warnings about the risks of doing so if the canister has a leak nor any best practice for mitigating the risk.

CO₂ absorbent canisters are typically plastic housings containing absorbent material with engineered adapters unique to each anesthesia machine manufacturer. During shipping and stocking, it is quite possible for these canisters to be damaged in a manner that causes a leak when placed in the breathing circuit. The pre-use checkout, whether it is automated or manual, should detect any leaks in the absorbent canister. When the canister is changed intraoperatively, however, it is not practical to perform a leak test since an alternate method of anesthetic delivery and ventilation would be required. As a result, the clinician must rely upon inspection of the canister to identify any potential leaks as well as vigilance once the canister is changed for any untoward impact. The problem is that it can be difficult to identify all sources of leaks by inspection alone.

Depending upon the machine design, placing a leaky canister into the circuit during a procedure will cause changes in gas or anesthetic concentrations and/or failure to ventilate manually, mechanically or both. Furthermore, even if there is no problem with the new canister, when it is first placed, it contains only room air and will alter the concentrations in the circuit as the volume of gas in the canister reaches equilibrium with the rest of the circuit. This change in concentration is especially noticeable when using low fresh gas flow.

Kuruma’s suggestion to provide a warning in the IFU, while desirable, is not likely to prevent problems since the IFU is not reliably read. There are some additional options for practices that could help to identify a leaky canister and mitigate patient risk if a leaky canister is placed intraoperatively.

• Before replacing the canister, inspect the new canister for any signs of damage or cracking. If any are present, select another one from inventory.
• After replacing the canister, reduce fresh gas flow and provide several manual breaths by squeezing the reservoir bag and observing the monitored values for inspiratory pressure and delivered tidal volume. If it is difficult to create the desired pressure or deliver the intended tidal volume, a leak in the canister should be suspected. This procedure should be useful for all anesthesia machine designs since manual ventilation is impacted similarly in all of the machines.
• Increase fresh gas flow for a few minutes after the integrity of the canister is confirmed and monitor the gas concentrations in the circuit to foster the mixing of desired gas concentrations inside the new canister.

While these practices should help to identify a leaky canister and prevent patient harm, there are some additional possibilities for ensuring the canister is intact before intraoperative replacement.

• Perform a leak test on a supply of absorbent canisters using an anesthesia machine and store these tested canisters in a protected box to be available for replacement.
• Develop a device that can be used to pressure test a canister before it is placed into service. Since the intraoperative change adapters are standardized for each manufacturer, the companies are well positioned to design a pressure testing device that could reside in a supply room for testing a replacement before it is used.

The practice of changing absorbent canisters intraoperatively based upon an inspired CO₂ threshold is a desirable method to minimize the amount of unused absorbent that is discarded, thereby reducing absorbent waste. The information provided here is not intended to discourage the practice of intraprocedure absorbent replacement, but to ensure that providers are aware of the impact of a canister leak. Guidance is provided to help mitigate the risk to patients. Manufacturers of canisters designed for intraoperative replacement are encouraged to provide an appropriate warning and consider recommending best practices for detecting leaks, or developing methods for testing canisters for leaks before they are placed into service.

REFERENCES

1. Feldman JM, Lo C, Hendrickx J. Estimating the impact of carbon dioxide absorbent performance differences on absorbent cost during low-flow anesthesia. Anesth Analg. 2020;130:374–381. PMID: 30925559
2. Feldman JM, Hendrickx J, Kennedy RR. Carbon dioxide absorption during inhalation anesthesia: a modern practice. Anesth Analg. 2021;132:993–1002. PMID: 32947290
3. Kuruma Y, Kita Y, Fujii S. Exchanging a CLIC absorber in the middle of the surgery. APSF Newsletter. 2013;27:64–65. https://www.apsf.org/article/exchanging-a-clic-absorber-in-the-middle-of-the-surgery/ Accessed August 13, 2024.

Dräger Anesthesia Workstations & Intraoperative CO₂ Canister Exchange

by David Karchner, MBA; Hans Ulrich Schuler, MSEE, MBA; and Bjoern Goldbeck, MSEE

DEAR EDITOR,

We would like to thank Yuki Kuruma, MD, for her article in this issue of the APSF Newsletter where she reviews the risk of introducing a leak into the breathing circuit following intraprocedure replacement of the CO₂ absorbent canister. We also thank the APSF for the opportunity to respond to Dr. Kuruma’s submission.

Sustainable practices that reduce waste are important. In anesthesia practice, CO₂ absorbent canister disposal presents an opportunity to minimize waste. Towards that end, many vendors like Dräger have implemented options that support replacing the CO₂ canister during a procedure, enabling users to utilize a larger percentage of each canister’s CO₂ absorbent potential instead of replacing the canister at the beginning of the procedure when the CO₂ absorbent is not completely utilized.

Each of Dräger’s anesthesia machines provides the opportunity to choose between the traditional “loose fill” CO₂ absorbent, which are always refilled when the anesthesia machine is not in use, and the “CLIC” canister, which provides the opportunity to replace the canister during a procedure based upon evidence that the absorbent is almost completely utilized like elevated inspired CO₂. The loose fill approach inevitably discards useful absorbent material, whereas the CLIC canister minimizes the waste of useful absorbent. Regardless of the strategy, it is important for clinicians to understand the CO₂ absorbent canister is part of the breathing system, and introducing a canister with a leak can negatively impact the ability to ventilate the patient.

As Kuruma’s submission indicated, the option for intraprocedure canister replacement is not unique to Dräger, and there will be different responses from each anesthesia machine design when/if a leak is introduced with a damaged CO₂ absorbent canister. While gas concentrations may change with a leak, the inability to ventilate mechanically, manually, or both could also occur. Kuruma observed that it was possible to continue mechanical, but not manual, ventilation when installing a CO₂ canister with a leak that cannot be overcome by increasing fresh gas flow, in a machine with piston or turbovent ventilators. This author requests that anesthesia machine manufacturers provide a warning in their Instructions for Use (“IFU”) outlining this risk. In response to the report to APSF in 2013 by Kuruma et. al., various explicit warnings, and additional information have been included in the different IFUs of Dräger anesthesia workstations and into the IFU of the CLIC Absorber itself (Figures 1-3).

Similar warnings are presented in the IFUs for the Perseus A500 and Atlan A350.

In addition to these warnings, Dräger anesthesia workstations are equipped with monitoring devices and associated alarms to help identify problems related to intraoperative placement of a leaky absorbent canister. Gas concentration monitoring is essential to safe anesthesia practice and undesired alterations in oxygen, and anesthetic concentrations are easily detected when using appropriately set alarm limits. Breathing circuit pressure and volume alarms are also important to identifying circuit leaks.

We thank Yuki Kuruma, MD, again for bringing the risk of intraprocedure canister exchange to the attention of the anesthesia community and to our attention as a manufacturer. With this information, we as the manufacturer can continuously improve and update our IFU of the relevant medical devices and support users to be better prepared to avoid patient harm.

Intraoperative CO₂ Canister Exchange When Using GE HealthCare Anesthesia Systems

by John Beard, MD, and Robert Meyers, BS

GE HealthCare anesthesia systems can support intraoperative exchange of carbon dioxide (CO₂) canisters. GE HealthCare anesthesia systems use a bellows design (conceptual diagram, Kuruma, Figure 3) with either the Compact Breathing System (CBS) or the Advanced Breathing System (ABS) depending on the anesthesia machine family. The CBS (Figure 1) supports intraoperative exchange of a CO₂ canister as a standard configuration while the ABS (Figure 2) requires the addition of the optional EZ Change Canister Module.

The CBS is designed with a cam-style lifting mechanism that raises the lower tray (nest) and aligns the absorbent canister with the breathing system ports. The lifting assembly is designed to seal the canister in the breathing system and resist latching if there is any misalignment. When equipped with the optional EZ Change Canister Module, the ABS uses a rotating mechanism to guide the absorbent canister connectors into the mating ports, and is also designed to resist latching if the absorbent canister ports are not aligned. When the absorbent canister is not latched, both systems will display the informational message “CO₂ Absorber Out of Circuit” in the waveform area.

Additionally, disposable canisters (AMSORB Plus, Coleraine, Ireland) sold and distributed by GE HealthCare, are pressure tested at the manufacturer prior to shipping to ensure that leakage does not exceed 10 mL/min at 30 cmH₂O.

In the rare scenario where an intraoperative exchange of a CO₂ canister is associated with a breathing system leak, the bellows-based design of both the ABS and CBS mitigates the impact of the leak during both mechanical and manual ventilation for the following reasons:

• In scenarios where the fresh gas flow is greater than the breathing system leak, there will not be any impact on ventilation or patient gas concentration. The breathing systems in a bellows-based design are positive pressure in operation. This means room air will not be entrained through a canister leak and thus, patient gas will not be diluted by room air.
• In scenarios where the leak is greater than the fresh gas flow, it may still be possible to provide some positive pressure ventilation by either the bag or ventilator. Depending upon the size of the leak, some or all of the intended tidal volume may not reach the patient, and the bag or bellows will eventually collapse. Alarms will be triggered as described below.
• The bellows is a physical barrier between the patient gas and the ventilator drive gas. In the event of a leak in the canister, drive gas will not enter the breathing system and alter the concentration of patient gas.

GE HealthCare anesthesia systems also may help the clinician recognize the leak for the following reasons:

• The bellows and bag provide visual indicators of a leak.
  • The bellows is always visible to the clinician. When a leak is greater than the fresh gas flow, the bellows will collapse providing a visual indication to the users.
  • When the bag is selected, the bag will collapse when positive pressure ventilation is attempted.
• As outlined in the “Alarms and Troubleshooting” section of the anesthesia machine User’s Reference Manual,^3,4 the ABS and CBS systems also provide several alarm messages to help clinicians successfully detect a leak.
  • “System Leak?” alarm: This alarm occurs when the drive gas flow from the ventilator is greater than the flow measured by the inspiratory flow sensor (by ~30%) and will help to detect a decrease in delivered tidal volume. The CO₂ canister is between the drive gas and the inspiratory flow sensor making this the primary alarm to detect this failure prior to the bellows collapsing.
  • “TV not Achieved” alarm: This alarm occurs when the volume measured by the inspiratory flow sensor is less than the set tidal volume by ~10% for six mechanical breaths in a row. This alarm will occur in a volume targeted ventilation mode once the bellows collapses far enough to impact ventilation.
  • “Unable to Drive Bellows” alarm: This alarm occurs when the system detects that the ventilator driving pressure does not result in an equivalent increase in airway pressure. Like the “TV not Achieved” alarm, this alarm will occur once the bellows collapses far enough to impact ventilation.
  • “TVexp Low” alarm: This alarm occurs when the measured tidal volume is less than the user set alarm level. This alarm will occur once the bellows collapses far enough to impact ventilation.

When a clinician identifies a leak with a CO₂ absorbent canister, there are a number of solutions.

• If the leak is not too large, the quickest remedy is to attempt to raise the fresh gas flow above the level of the leak. If that is successful, the bellows (or bag) will reinflate and allow ventilation to continue until the problem can be resolved.
• If the leak is too large to be compensated by increasing fresh gas flow, an alternate method of ventilation (e.g., Mapleson circuit) should be employed and intravenous anesthesia considered.
• Once safe ventilation is assured, the leak in the breathing system can be resolved by exchanging the faulty canister.

In conclusion, GE HealthCare anesthesia systems can support intraoperative exchange of CO₂ canisters. In the rare scenario where an intraoperative exchange of the CO₂ canister is associated with a breathing system leak, the systems are designed to mitigate the impact of the leak, and also provide visual indicators and alarms to help clinicians recognize and address the leak.

REFERENCES

1. GE HealthCare Compact Breathing System Cleaning, Disinfection and Sterilization User’s Reference Manual. Datex-Ohmeda, Inc.; 2014.
2. GE HealthCare Advanced Breathing System Cleaning, Disinfection and Sterilization User’s Reference Manual. Datex-Ohmeda, Inc.; 2012.
3. GE HealthCare Aisys CS2 User’s Reference Manual. Datex-Ohmeda, Inc.; 2013.
4. GE HealthCare Carestation 750/750c User’s Reference Manual. Datex-Ohmeda, Inc.; 2017.

INTRODUCTION

As an anesthesia professional, you likely know that malignant hyperthermia (MH) strikes out of the blue and can rapidly lead to muscle rigidity, hyperthermia, elevated end tidal CO₂, respiratory and metabolic acidosis, and if not treated promptly and specifically, it can result in death. You also may know that, despite MH being inherited in an autosomal dominant manner, there is a higher incidence in males than females and that the syndrome occurs at a higher rate in children than adults.¹

Here we present a recent case of MH, give a historical perspective on the success anesthesia professionals have had in furthering our understanding of MH, and propose a future direction in which we may also play a critical role in caring for patients long after their acute episode—to ensure proper workup and understanding of post-episode sequelae.

MH CASE

An otherwise healthy 11-year-old girl presents to the hospital to have an incidentally discovered ovarian teratoma removed laparoscopically. She had no prior surgeries or encounters with anesthesia. Soon after induction of anesthesia with sevoflurane, paralysis with rocuronium, and intubation, she developed persistent tachycardia (heart rate 120 bpm from a baseline in the 80s), her temperature rose to 39.4°C, and her end-tidal CO₂ (ETCO₂) climbed to 110 mmHg. Muscle rigidity was also observed in the patient’s arms despite having received non-depolarizing neuromuscular blockade. As soon as these MH signs presented, help was called to assist in managing the crisis. The sevoflurane was discontinued, and Ryanodex® (dantrolene sodium, Eagle Pharmaceuticals, Inc., Woodcliff Lake, NJ, USA) was quickly administered. Within a few minutes, her heart rate, temperature, ETCO₂, and musculoskeletal tone all improved. Other stabilization measures included starting a total intravenous anesthesia (TIVA), obtaining additional IV access and an arterial line, active cooling with administration of cold IV fluids, and aggressive hydration. Once stabilized, the surgery was quickly completed, and the patient transferred to the ICU. Dantrolene treatment was continued. Notably her first creatine kinase (CK) was abnormally high at 34,000 IU. The patient was extubated the following day. Over the next few days, she continued to improve, and her rhabdomyolysis resolved.

Over multiple visits in the days following the event, the anesthesia professionals learned that the patient had previously had episodes of heat intolerance and that her grandmother had an incidental finding of chronically elevated CK, but had not undergone a muscle biopsy. A comprehensive genetic panel testing 129 genes associated with rhabdomyolysis and metabolic myopathy was ordered along with consultation with a geneticist and neurologist. The genetic testing revealed an alteration in the ryanodine receptor (RYR1), confirming the diagnosis of MH. Interestingly, while she was found to have a RYR1 variant which is officially characterized as a variant of unknown significance (VUS) by the National Human Genome Institute and American College of Medical Genetics, it is considered a pathogenic variant by the European MH group, and has previously been associated with elevated CK levels, rhabdomyolysis, and weakness.² She was ultimately discharged on postoperative day 5 with close follow-up with the medical genetics, neurology, and neuromuscular clinics.

MH: A SUCCESS STORY

This story of a patient developing MH and being successfully diagnosed and treated reflects the accumulated knowledge from scientific contributions of scientists over many years and from all over the world. Since the first description of MH in Melbourne, Australia, in 1960 by Denborough and Lovell, much progress has been made in terms of defining the pathophysiology, discovering an effective therapeutic treatment, and disseminating information about MH to the anesthesia community.³ As a result, MH mortality has declined from 70% to as low as about 10% in countries prepared for the syndrome with ready access to dantrolene and other supplies (Table 1),⁴ a coordinated approach to diagnosis and management including ICU observation, and post-episode coordination with family members of the person who experienced MH.

Table 1: MH Cart Medication and Supplies.

FUTURE DIRECTIONS

As in much of science, solving one problem often leads to more questions. In addressing these questions, it has become apparent that we should not think of MH as an episodic, idiosyncratic disorder, but as a pharmacogenetic disorder and an inherited myopathy with consequences that may be far removed from the anesthetic experience.

First, what do we know about the implications of RYR1 mutations outside of MH? Further study is needed to understand how RYR1 associated conditions (such as statin-induced myopathy, exertional rhabdomyolysis, heat stroke, and chronically elevated CK syndromes) relate to MH susceptibility (MHS).⁵ There is also a need to understand the role and efficacy of dantrolene for the treatment of these other syndromes.

Second, after an MH episode, how should we confirm a diagnosis of MHS? Advances in genetic testing to assess MHS have led genetics to essentially replace the tried-and-true muscle biopsy caffeine halothane contracture test in much of the world. The European MH society formally changed their recommendation to use genetics as the first line test in MHS diagnosis in 2015 and most MH experts around the world have followed this lead.⁶ In the US, there are only two centers (located in Minnesota and North Carolina) and the testing can cost up to $20,000 USD, which is generally not paid for by insurance companies. On the other hand, the cost of genetic testing has declined over 99% since the first sequencing of the human genome and is usually reimbursed by insurance companies. Specific costs vary by the type of test selected. A panel test for the three genes associated with MHS (RYR1, CACNA1S, and STAC3) costs less than $500 USD,7 versus a more comprehensive metabolic and myopathy panel which costs around $1,500 USD.⁸

Third, what is the role of the anesthesia professional in the care of MHS patients after their episode, and how should they interact with other providers such as geneticists and neurologists? Whose responsibility is it to advise family members on the significance of a pathogenic DNA variant predisposing to MH? Specialists who treat patients who have experienced an MH episode can help them to understand whether they are expected to make a full recovery, but they may be less able to address longer lasting questions such as if such patients are predisposed to rhabdomyolysis or muscle weakness, and for how long. A method of flagging an MHS diagnosis, including specific genetic variant, in the electronic medical record should be ensured. Artificial intelligence or third-party services that can process data across genetic testing platforms and improve communication of this critical diagnosis to practitioners can make care safer for MHS patients. Though the incidence of acute MH in MHS patients exposed to triggering agents is unknown and difficult to estimate, all MHS patients should be treated with a “clean” nontriggering anesthesia technique.^9-11 This includes avoidance of succinylcholine and volatile anesthetics, preparation of the anesthesia machine by flushing the circuit and ventilator with high flows over the manufacturer recommended amount of time or insertion of activated charcoal filters in the breathing circuit, use of fresh CO₂ absorbent, and taping off vaporizers to prevent accidental use. Intraoperative monitors should include EKG, pulse oximetry, blood pressure, core body temperature, and capnography for general anesthesia.¹²

Finally, MH has been reported from countries all over the world and there is no known ethnic propensity to MHS. A broader public health concern is how do resource-limited countries balance the cost of a life-saving drug dantrolene for an infrequent disorder, versus the need for expenditures on more frequently occurring disorders? A report from China in the February 2024 issue of Anesthesiology reported mortality from MH over 50% in areas without dantrolene.¹³ While it has been questioned in the US as to whether ambulatory facilities who do not routinely use volatile agents and reserve succinylcholine for emergency airway management need to stock dantrolene, there is evidence to show that stocking dantrolene is both cost-effective and optimal for safe patient care where triggering agents may possibly be used.^14-17

THE FOUR C’S OF MH MANAGEMENT

In our opinion it is time to broaden our perspective on the MH syndrome to regard the problem as not unique to anesthesiology and surgery. We need to expand patient care goals beyond the confines of managing the acute MH episode, to include appropriate follow-up and assessment of other potentially associated skeletal-muscle-related conditions. A multidisciplinary approach to the diagnosis, treatment, and genetic counseling for patients and families is of utmost importance. Therefore, we propose the 4C’s of MH Management:

1. Control the acute syndrome
2. Consult genetic and neurologic colleagues
3. Confirm with genetic testing
4. Communicate the results and plans for care with the patient, family, and other health care providers.

NEXT STEPS

It is within our scope of practice as anesthesia professionals to take these actions to improve the care of MHS patients going forward. The enlightened management of MH fits with the goals of the APSF and other patient safety organizations. Next steps include: 1) revision of MHS diagnostic testing recommendations by the Malignant Hyperthermia Association of the United States (MHAUS) to include genetic testing after all suspected MH cases, 2) creation of a system to connect anesthesia professionals who manage MH to clinical geneticists, genetic testing platforms, and neurologists familiar with MH, 3) assurance of communication of an MHS diagnosis in electronic medical records, and 4) dissemination of MH education globally, including advocating for stocking dantrolene in all centers where triggering agents may be used.

REFERENCES

1. Rosenberg H, Pollock N, Schiemann A, et al. Malignant hyperthermia: a review. Orphanet J Rare Dis. 2015;10:93. PMID: 26238698
2. Witting N, Laforêt P, Voermans NC, et al. Phenotype and genotype of muscle ryanodine receptor rhabdomyolysis-myalgia syndrome. Acta Neurol Scand. 2018;137:452–461. PMID: 29635721
3. Denborough MA. Malignant hyperthermia. 1962. Anesthesiology. 2008;108:156–157.
4. Malignant Hyperthermia Association of the United States (MHAUS) Professional Advisory Council. “What should be on an MH cart?” MHAUS.org. https://www.mhaus.org/healthcare-professionals/be-prepared/what-should-be-on-an-mh-cart/. Accessed July 20, 2024.
5. Fiszer D, Shaw MA, Fisher NA, et al. Next-generation sequencing of RYR1 and CACNA1S in malignant hyperthermia and exertional heat illness. Anesthesiology. 2015;122:1033–1046. PMID: 25658027
6. Hopkins PM, Rüffert H, Snoeck MM, et al. on behalf of European Malignant Hyperthermia Group. European Malignant Hyperthermia Group guidelines for investigation of malignant hyperthermia susceptibility. Br J Anaesth. 2015;115:531–539. PMID: 26188342
7. “Invitae Malignant Hyperthermia Susceptibility Panel.” Invitae. https://www.invitae.com/us/providers/test-catalog/test-03285. Accessed July 20, 2024.
8. “Metabolic Myopathy and Rhabdomyolysis Panel.” Blueprint Genetics. https://blueprintgenetics.com/tests/panels/neurology/metabolic-myopathy-and-rhabdomyolysis-panel/. Accessed July 20, 2024.
9. Ibarra Moreno CA, Hu S, Kraeva N, et al. An assessment of penetrance and clinical expression of malignant hyperthermia in individuals carrying diagnostic ryanodine receptor 1 gene mutations. Anesthesiology. 2019;131:983–991. PMID: 31206373
10. Shaw MA, Hopkins PM; Mission impossible or mission futile?: estimating penetrance for malignant hyperthermia. Anesthesiology. 2019;131:957–959. PMID: 31335544
11. Yu KD, Betts MN, Urban GM, et al. Evaluation of malignant hyperthermia features in patients with pathogenic or likely pathogenic RYR1 variants disclosed through a population genomic screening program. Anesthesiology. 2024; 140:52–61. PMID: 37787745
12. Rüffert H, Bastian B, Bendixen D, et al. European Malignant Hyperthermia Group. Consensus guidelines on perioperative management of malignant hyperthermia suspected or susceptible patients from the European Malignant Hyperthermia Group. Br J Anaesth. 2021;126:120–130. PMID: 33131754
13. Yu H, Tan L, Deng X. Improving dantrolene mobilization in regions with limited availability. Anesthesiology. 20241;140:1201–1202. PMID: 38329334
14. Joshi GP, Desai MS, Gayer S, Vila H Jr. Society for Ambulatory Anesthesia (SAMBA). Succinylcholine for emergency airway rescue in class B ambulatory facilities: the Society for Ambulatory Anesthesia position statement. Anesth Analg. 2017;124:1447–1449. PMID: 27984222
15. Litman RS, Smith VI, Larach MG, et al. Consensus statement of the Malignant Hyperthermia Association of the United States on unresolved clinical questions concerning the management of patients with malignant hyperthermia. Anesth Analg. 2019;128:652–659. PMID: 30768455
16. Larach MG, Klumpner TT, Brandom BW, et al.; Multicenter Perioperative Outcomes Group. Succinylcholine use and dantrolene availability for malignant hyperthermia treatment: database analyses and systematic review. Anesthesiology. 2019;130:41–54. PMID: 30550426
17. Aderibigbe T, Lang BH, Rosenberg H, et al. Cost-effectiveness analysis of stocking dantrolene in ambulatory surgery centers for the treatment of malignant hyperthermia. Anesthesiology. 2014;120:1333–1338. PMID: 24714119

Anesthesia professionals have consistently been leaders in patient safety and have long recognized the importance of hand hygiene in the anesthesia workspace.¹ Hand contamination is associated with pathogen transmission across multiple anesthesia workspace reservoirs, and genome analysis of bacteria cultured from provider hands and infection causing pathogens have confirmed that providers transmit pathogens that result in patient infections.^2,3,4 Staphylococcus aureus (S. aureus) transmission among anesthesia workspace reservoirs is associated with an increased risk of surgical site infection (SSI).⁵ In fact, SSI risk increases over fivefold when the pathogens are sensitive to the prophylactic antibiotic employed and ninefold when the pathogens are resistant to the prophylactic antibiotic employed.⁶ In order to reduce this risk, a multifaceted approach is indicated to prevent SSIs.⁷ When improved hand hygiene is incorporated as part of a multifaceted program, substantial reductions in S. aureus transmission and SSIs can be achieved.^8,9 These findings should provide the impetus for widespread improvements in hand hygiene compliance for all intraoperative personnel, with anesthesia professionals taking the lead.

The anesthesia workspace is a complex environment that includes the patient, the surgical bed/table, the anesthesia machine, the intravenous (IV) pole(s) with attached infusion devices, a cart with clean supplies, and medications stored within the cart or a separate medication station. Anesthesia professionals interact with the patient and multiple components of the anesthesia workspace during routine anesthesia practice.^10,11 Given the complexity of this environment, hand decontamination is necessary to interrupt transmission events and reduce infection propagation. The World Health Organization (WHO) defines events, after which hand hygiene should be performed as the, “Five Moments of Hand Hygiene.”¹² These moments that call for hand hygiene arethe following: before touching a patient, before a clean or sterile procedure, after touching a patient, after a task with a body-fluid exposure risk, and after touching the patient’s surroundings (Figure 1).¹² Compliance with WHO and similar recommendations would require the anesthesia professional to perform hand hygiene as often as 54 times per hour¹³ up to 150 times per hour.^11,13 However, studies reveal that anesthesia professionals perform hand hygiene less than once per hour.¹⁴ Clearly, there is substantial opportunity for some improvement. It might seem that fighting against the transmission of pathogens is impossible, given how ubiquitous bacteria are in our environment. However, research suggests that reducing the levels of S. aureus on provider hands to less than 100 colony-forming units (CFU) is an achievable goal that can help to protect our patients.^9,15

Figure 1: Your 5 Moments for Hand Hygiene. Geneva, Switzerland. World Health Organization. 2009. License: CC BY-NC-SA 3.0 IGO.

The APSF Patient Safety Priorities Advocacy Group: Infectious Disease recommends that anesthesia professionals perform hand hygiene at least approximately eight times per hour during anesthesia care.¹⁶ Washing one’s hands or using hand sanitizer at a frequency of eight times per hour optimally reduced environmental and stopcock contamination and subsequent infection development.¹⁴ However, the proper methodology to prompt hand hygiene compliance at this frequency is not clear.¹⁶ Important future research include products (e.g., alcohol-based or soap and water), dispenser locations, cleansing technique, and potential risks.

While hands can be effectively decontaminated using alcohol-based solutions, visibly contaminated hands or potential contact with spore-forming organisms should be decontaminated with soap and water.^14,17 Since scrub sinks must be outside the operating room, alcohol is the primary hand hygiene option for anesthesia professionals, and because it is associated with less skin irritation than soap and water, it may reduce the risk of irritated skin and higher bacterial counts on the irritated skin.^18,19

Dispenser locations should be determined by task density, which is the number of tasks that need to be done in a period of time. Health care infection prevention organizations recommend dispenser placement in locations that are easily accessible within the patient care arena.²⁰ Using dispensers placed outside the anesthesia work area (e.g., on the wall or near the entrance to the operating room) may disrupt patient care. The importance of task density is well-delineated. In one study, anesthesia professional use of a personalized, body-worn alcohol dispenser increased hand hygiene compliance 37-fold, and, in turn, reduced the incidence of environmental and stopcock contamination and health care associated infections.¹⁴ Other investigators evaluated dispenser placement on the intravenous pole to the left of the provider as part of a multifaceted program.^8,9 Dispenser placement in this location reduced the incidence of bacterial transmission and subsequent SSI development.^8,9

Because provider hand contamination is associated with environmental contamination, improving the frequency and quality of environmental cleaning may also help to augment hand hygiene improvement efforts. In one study, separating the anesthesia workspace into “clean” and “dirty” areas was associated with a reduction in the proportion of sites reaching ≥ 100 CFUs.^14,21 It is intuitive that alcohol dispensers should be placed in areas designated as clean. For example, the dispenser may be secured to the anesthesia machine or supply cart with a mounting rack, or on the intravenous pole. If secured to the intravenous pole, then caution should be taken to protect the patient, surgical field, and underlying electrical plugs from splashes and drips (Table 1).

Table 1: Potential Considerations for Hand Sanitizer Locations in the Anesthesia Workspace.

While anesthesia professionals must have ready access to a hand sanitizer, there are potential hazards to consider. All alcohol-based sanitizers contain 60–80% ethyl or isopropyl alcohol and water. This is because a sufficient water component is necessary to hydrolyze microorganism membranes and slow evaporation of the product.^22,23 Because alcohol products are flammable, fire codes regulate the total volume of sanitizers allowed within a procedure room and the minimum separation distance between alcohol dispensers. Dispensers must be separated by a minimum distance of four feet, and their combined volume in one room must not exceed 1.2 liters.²⁴ The Centers for Disease Control and Prevention also espouses these fire safety recommendations.²⁵ The volume for personalized, body-worn alcohol dispensers and one-handed alcohol pumps on an IV pole is less than 3 ounces.^8,9,14 While there have not been reports of fires related to hand sanitizers, it is risk worth considering.

In summary, improved hand hygiene by anesthesia professionals is an essential element of a multifaceted approach to reducing bacterial transmission and infection development. Eight hand hygiene events per hour during routine anesthesia care should be encouraged. Alcohol-based sanitizers in the anesthesia workspace should be placed in clean and easily accessible locations that are clearly visualized by the clinician.

REFERENCES

1. Warner MA, Warner ME. The evolution of the anesthesia patient safety movement in America: lessons learned and considerations to promote further improvement in patient safety. Anesthesiology. 2021;135:963–974. PMID: 34666350
2. Dexter F, Loftus RW. Estimation of the contribution to intraoperative pathogen transmission from bacterial contamination of patient nose, patient groin and axilla, anesthesia practitioners’ hands, anesthesia machine, and intravenous lumen. J Clin Anesth. 2024;92:111303. Epub 2023 Oct 22. PMID: 37875062.
3. Loftus RW, Brindeiro CT, Loftus CP, et al. Characterizing the molecular epidemiology of anaesthesia work area transmission of Staphylococcus aureus sequence type 5. J Hosp Infect. 2024;143:186–194. Epub 2023 Jul 13. PMID: 37451409.
4. Loftus RW, Brown JR, Koff MD, et al. Multiple reservoirs contribute to intraoperative bacterial transmission. Anesth Analg. 2012;114:1236–1248. Epub 2012 Mar 30. PMID: 22467892.
5. Hopf, Harriet W. MD. Bacterial reservoirs in the operating room. Anesthesia & Analgesia. 2015;120:p 700–702. PMID: 25790198
6. Loftus RW, Dexter F, Brown JR. Transmission of Staphylococcus aureus in the anaesthesia work area has greater risk of association with development of surgical site infection when resistant to the prophylactic antibiotic administered for surgery. J Hosp Infect. 2023;134:121–128. doi: 10.1016/j.jhin.2023.01.007. Epub 2023 Jan 21. PMID: 36693592.
7. Dexter F, Brown JR, Wall RT, Loftus RW. The efficacy of multifaceted versus single anesthesia work area infection control measures and the importance of surgical site infection follow-up duration. J Clin Anesth. 2023;85:111043. Epub 2022 Dec 23. PMID: 36566648.
8. Loftus RW, Dexter F, Goodheart MJ, et al. The effect of improving basic preventive measures in the perioperative arena on Staphylococcus aureus transmission and surgical site infections: a randomized clinical trial. JAMA Netw Open. 2020;3: e201934. PMID: 32219407
9. Wall RT, Datta S, Dexter F, et al. Effectiveness and feasibility of an evidence-based intraoperative infection control program targeting improved basic measures: a post-implementation prospective case-cohort study. J Clin Anesth. 2022; 77:110632. Epub 2021 Dec 17. PMID: 34929497.
10. Sharma A, Fernandez PG, Rowlands JP, et al. Perioperative infection transmission: the role of the anesthesia provider in infection control and healthcare-associated infections. Curr Anesthesiol Rep. 2020;10:233–241. Epub 2020 Jul 17. PMID: 32837343
11. Rowlands J, Yeager MP, Beach M, et al. Video observation to map hand contact and bacterial transmission in operating rooms. Am J Infect Control. 2014;42:698–701. PMID: 24969122
12. WHO guidelines on hand hygiene in health care: first global patient safety challenge clean care is safer care. Geneva: World Health Organization; 2009. 21, The WHO Multimodal Hand Hygiene Improvement Strategy. Available from: https://www.who.int/publications/i/item/9789241597906. Accessed July 5, 2024
13. Biddle C, Shah J. Quantification of anesthesia providers’ hand hygiene in a busy metropolitan operating room: what would Semmelweis think? Am J Infect Control. 2012;40:756–759. Epub 2012 Feb 9. PMID: 22325482.
14. Koff MD, Loftus RW, Burchman CC, et al. Reduction in intraoperative bacterial contamination of peripheral intravenous tubing through the use of a novel device. Anesthesiology. 2009;110:978–985. PMID: 19352154.
15. Dexter F, Walker KM, Brindeiro CT, et al. A threshold of 100 or more colony-forming units on the anesthesia machine predicts bacterial pathogen detection: a retrospective laboratory-based analysis. Can J Anaesth. 2024;71:600–610. English. Epub 2024 Feb 27. PMID: 38413516.
16. Charnin JE, Hollidge M, Bartz R, et al. A best practice for anesthesia work area infection control measures: what are you waiting for? APSF Newsletter. 2022;37:103-106. https://www.apsf.org/article/a-best-practice-for-anesthesia-
    work-area-infection-control-measures-what-are-you-waiting-for/ Accessed August 9, 2024.
17. WHO guidelines on hand hygiene in health care: first global patient safety challenge clean care is safer care. Appendix 2. Guide to appropriate hand hygiene in connection with Clostridium difficile spread. https://www.ncbi.nlm.nih.gov/books/NBK144042/. Accessed May 29, 2024.
18. Pedersen LK, Held E, Johansen JD, Agner T. Short-term effects of alcohol-based disinfectant and detergent on skin irritation. Contact Dermatitis. 2005;52:82–87. PMID: 15725285
19. Larson EL, Hughes CA, Pyrek JD, et al. Changes in bacterial flora associated with skin damage on hands of health care personnel. Am J Infect Control. 1998;26:513–521. PMID: 9795681
20. Glowicz JB, Landon E, Sickbert-Bennett EE, et al SHEA/IDSA/APIC practice recommendation: strategies to prevent healthcare-associated infections through hand hygiene: 2022 update. Infect Control Hosp Epidemiol. 2023;44:355–376. PMID: 36751708
21. Clark C, Taenzer A, Charette K, Whitty M. Decreasing contamination of the anesthesia environment. Am J Infect Control. 2014 Nov;42(11):1223-5. Epub 2014 Oct 30. PMID: 25444268.
22. Ali Y, Dolan MJ, Fendler EJ, Larson EL. Alcohols. In: Block SS, ed. Disinfection, sterilization, and preservation. Philadelphia: Lippincott Williams & Wilkins, 2001:229–254.
23. Rutala WA, Weber DJ, and the Healthcare Infection Control Practices Advisory Committee. Guideline for disinfection and sterilization in healthcare facilities, 2008. https://stacks.cdc.gov/view/cdc/47378 Accessed August 9, 2024.
24. National Fire Protection Association (NFPA). NFPA 101 Life Safety Code. 2018 edition. Quincy, MA: National Fire Protection Association; 2018. https://www.nfpa.org/codes-and-standards/all-codes-and-standards/list-of-codes-
    and-standards/detail?code=101 Accessed August 9, 2024.
25. Centers for Disease Control and Prevention (CDC). Clinical safety: hand hygiene for healthcare workers – fire safety and Alcohol-Based Hand Sanitizer (ABHS). https://www.cdc.gov/clean-hands/hcp/clinical-safety/?CDC_AAref_Val=https://www.cdc.gov/handhygiene/firesafety/index.htm Accessed July 5, 2024.