Conference Reviews: Monday, May 19
Advise We Don't Have Fuel: Lessons from Avianca Flight 52- Communication and Safety
Reviewed by Pradip Kamat, MD
David Bundy, MD presented how the lessons learned from the unfortunate crash of Avianca Flight 52 could be applied to the practice of pediatric sedation. Avianca Airlines Flight 52, a Boeing 707-321B, was a scheduled international flight from Bogota, Columbia to John F. Kennedy (JFK) International Airport in New York. Poor weather conditions in the Northeast United States led to the flight being put into a holding pattern three times for a total of 1 hour and 17 minutes. During the third holding pattern, the flight crew reported that the airplane was running out of fuel, and that it could not reach an alternate airport, Boston-Logan International. Subsequently, the flight crew executed a missed approach to JFK. While trying to return to the airport, the airplane had a loss of power to all four engines and crashed in a wooded residential area in Cove Neck, Long Island, New York approximately 16 miles from the airport. Here is what we can learn from this mishap.
1) Communication: The Avianca flight was in a holding pattern due to weather/air traffic related conditions. There were “handoffs” about the flight pattern of the Avianca airplane from one traffic controller to the other, which resulted in miscommunication. Similar situations may result when a child is being sedated and handoff between sedation physicians can result in an adverse outcome. Using structured communication tools such as SBAR (situation, background, awareness and recommendation) can help improve communication.
2) Plane launch (or a sedation in a child): There are options. Plane landing (or rescuing a child from deep sedation) safely is mandatory. Sedation physicians should be able to manage the airway and appropriately rescue a child from deep sedation.
3) External environment: The plane and its crew faced severe weather, darkness and other conditions making flying difficult and unsafe. This can happen in sedation; for example, monitor malfunction leading to unsafe sedation conditions. The big question providers need to ask is if sedation of a patient can wait until external conditions are more favorable. Pre-procedure, pre-sedation huddle or checklist can help improve safety.
4) Busy congested airport(s): There is a rush to do more with fewer resources during busy/peak times at airports leading to unsafe conditions for flights taking off and landing. Such conditions can prevail in sedation whenever there are limited resources (fewer nurses), and increased demand (more patients scheduled than the staff can handle). Proper planning and scheduling of patients will do away with unsafe conditions.
5) Cultural gaps or hierarchy: Dr. Bundy highlighted the Hofsteds power distance index. In many cultures the hierarchy is respected and not questioned even if the person in the position of power (in charge) is not making the correct decision. The crew/staff may refuse to speak up or interrupt if an error is being made and could thus compromise safety. Sedation nurses (or even residents or fellows rotating in sedation) must ask questions if they find that an unsafe decision is being made by an attending while providing sedation to a child. Some of the questions that should be asked are the following:
- Is this child a candidate for sedation or should this patient be referred for care by an anesthesiologist?
- Is the choice of drug correct and what about the dose?
- Is a time out/checklist done prior to sedation?
- Is resuscitation/rescue equipment readily available and working?
In summary, advance planning, appropriate communication and teamwork will contribute to providing safe sedation.
Why do Opioids Work Differently in Different People? A Focused Primer on Molecular Biology for the Clinician
Reviewed by Janey Phelps, MD
Myron Yaster, MD is a pediatric anesthesiologist and world renowned for his pioneering work in pediatric anesthesia and pediatric pain management. Dr. Yaster began the presentation with an overview of basic genomics. He then skillfully outlined basic protein formation and described why some individuals metabolize drugs differently than others based on the cytochrome P450 system.
He highlighted the fact that pediatric pharmacology related to sedation/anesthesia is more challenging. First, the percentage of body fat and body water changes with age and the effective and lethal dose of anesthetic drugs can be very similar, unlike the effective and lethal dosages of antibiotics. Second, there is a very small therapeutic window of safety and a difference in how one drug and one dose will affect one child compared with another. Finally, this is in large part due to a patient’s genomic make up, specifically the cytochrome P450 system.
Dr. Yaster spent some time discussing codeine and the variable response in patient populations. Codeine is a pro-drug that is converted into morphine by the cytochrome (CYP) 2D6 enzyme and in most patients 10% of codeine is turned into morphine. In patients who have up-regulation of CYP 2D6, they can convert up to 30% of codeine into morphine which could be catastrophic to the patient. And a subgroup of patients, as well as all infants, do not have CYP 2D6 enzymes and will not receive any analgesic benefit from codeine. In this example, he not only discouraged the use of codeine based on these reasons, but also emphasized the advantage of having a patient’s genome so the physician knows if codeine, or other drugs, will be effective.
Another benefit of knowing an individual’s genome is to identify patients who may have a predilection of addiction based on a SNP (single nucleotide polymorphism), A118G. This is a common SNP that occurs in ~20% of the population and has a dramatic effect in terms of pain and addiction. This knowledge can again lead to customizing anesthesia/analgesia based on the individual. Dr. Yaster concluded that within the next decade we can anticipate having access to our patients’ genome and use that data to model our pharmacology treatment plans.
I Can See You Now: Telemedicine and Sedation Safety
Reviewed by Judson Barber, MD
As an SPS first, S. David McSwain, MD delivered his presentation remotely via the same technology commonly used in telemedicine. This was not merely for demonstration purposes but out of necessity since he was in Baltimore attending the American Telemedicine Association (ATA) Annual Meeting. Dr. McSwain gave a brief overview of the history of telemedicine as well as some of the technology involved. Today, telemedicine can range from something as simple as “Facetime” on a smart phone to flat screen high-definition systems costing several thousands of dollars. As if to emphasize that no system is perfect, there were a couple of technical glitches during the presentation that were quickly resolved.
Dr. McSwain emphasized telemedicine as a tool in sedation for patient evaluation/triage and consultation. For example, a patient who lives 100 miles from the tertiary children’s hospital can have at least a portion of their pre-sedation screening via telemedicine instead of having to make an additional trip for this purpose. On the contrary, Dr. McSwain did not advocate sedation providers using telemedicine to “remotely sedate” patients. The presentation concluded with the demonstration of some of the more advanced tools available with telemedicine systems. In yet another SPS first, a vendor at the ATA meeting performed a live video laryngoscopy on herself.
BREAKOUT SESSION: Sedation in the Age without Chloral Hydrate
Reviewed by Jason Reynolds, MD
This breakout presentation presented two examples of how sedation programs have approached replacing chloral hydrate sedation within their institution.
The first example involved a large volume audiology clinic that was performing almost 1,000 chloral hydrate sedations per year. The program switched to a nurse-administered intranasal dexmedetomidine regimen. Initial comparison of outcomes demonstrated a similar sedation success rate between those patients receiving chloral hydrate and those patients receiving dexmedetomidine. While there were no serious adverse events in the dexmedetomidine group, the presenters noted that the number of patients receiving dexmedetomidine was not large enough to make a definitive conclusion about the safety profile of this regimen. Their conclusion was that intranasal dexmedetomidine appears to be an effective regimen for accomplishing audiology studies that were historically accomplished with chloral hydrate and that additional studies are needed to determine the optimal dose and safety profile.
A second example involved a smaller audiology program that switched the entire practice to an IV propofol-based regimen. The rationale for this selection surrounded the near 100% efficacy of this sedation regimen along with the established safety profile for this sedation regimen in the context of an organized sedation program. The outcomes compared to chloral hydrate in this institution were the change from an approximately 60% procedure completion rate to almost 100%.
Overall this session presented two viable options to consider for “sedation in the age without chloral hydrate.”