Clinical Case of the Month: You’re setting up to give anesthesia for a laparoscopic cholecystectomy. How many syringes and labels do you draw up and prepare? For a D & C? For an open abdominal aortic aneurysm repair?
Discussion: Try something new. When preparing for a cholecystectomy, open two syringes, both unlabelled, and don’t open any ampules until the patient is in the OR. More on that later.
Let’s examine two questions: Why do we label syringes, and why do we load syringes with drugs ahead of time? The answer to the first question is easy — we label syringes because we want to know what’s inside of them. The Institute of Medicine’s report from 1999, entitled, To Err is Human: Building a Safer Health Care System, reported that 98,000 patients died in U.S. hospitals each year due to medical errors. Administering the wrong drug is a known anesthesia risk which we all try to avoid.
In a study of 55,426 anesthetics in Norway over 36 months, drug error was reported in 63 cases, or 0.11% of cases. (Fasting S, Can J Anaesth.2004 Oct;51(8):853-4.) Drug errors included 28 syringe swaps, 9 ampule swaps, 8 ‘other wrong drug’ cases, and 18 cases where the wrong dose of the correct drug was given. In the second 18 months of their study, they switched to color-coded syringe labels, and found their results unchanged except for a decreased number of ampule swaps (P=.04). They concluded that drug errors were uncommon, that syringe swaps occurred most often between syringes of equal size, and that drug errors were not eliminated by color-coding of labels.
In a study of 896 drug errors reported in Australia, syringe and drug preparation errors accounted for 452 (50.4%) incidents, including 169 (18.9%) involving syringe swaps where the drug was correctly labeled but given in error, and 187 (20.8%) due to selection of the wrong ampule or drug labeling errors. (Abeysekera A, Anaesthesia. 2005 Mar;60(3):220-7). Contributing factors included inattention, haste, drug labeling error, communication failure, and fatigue. Factors minimizing the events included prior experience and training.
According to the first reference, a drug error was reported about once per 1000 cases in Norway. I’d ask you to consider how many incidents of drug error occur, versus how many are actually reported. I submit that the real prevalence probably exceeds the amount of cases that anesthesiologists admit to, and the real prevalence is significantly greater than .11%. And even though labeling syringes is important and mandated, it fails to decrease medication error to zero. In the future, we may see computerized visual and auditory bar-code verification of ampules and/or labels just before drug administration.
My second question to you was “why do we load syringes with drugs ahead of time?” Common sense answers might be, “because it makes our work more efficient,” or “we might need them fast, and we don’t want to draw the drugs up at the last moment.” Opinions regarding the preparation of pre-drawn emergency syringes differ. In a study from New Zealand, a quarter of respondent anesthesiologists routinely drew up emergency drugs, and a third either never or very infrequently did so(Ducat CM, Anaesth Intensive Care. 2000 Dec;28(6):692-7). Among the drugs most commonly drawn up were succinylcholine, atropine, and ephedrine. Pediatric, obstetric, or vascular cases were cited as factors which prompted anesthesiologists to draw up one or more of these drugs.
Drug wastage is a known to be a significant portion of anesthesia drug budgets. In one fiscal year, the cost of unadministered drugs at Rhode Island Hospital was $165,667 (Gillerman RG, Anesth Analg. 2000 Oct;91(4):921-4). Efficiency indexes, defined as the percent of a restocked drug that was actually administered to patients, were as follows: succinylcholine, 33%, propofol, 49%, rocuronium, 61%, and thiopental, 31%. In a study at UC San Diego, drug wastage was quantitated in 166 cases during a two week period (Weinger MB, J Clin Anesth. 2001 Nov;13(7):491-7). Based on hospital drug acquisition costs, $1802 of drugs were wasted in two weeks. Six drugs accounted for three quarters of the total wastage: phenylephrine (20.8%), propofol (14.5%), vecuronium (12.2%), midazolam (11.4%), labetolol (9.1%), and ephedrine (8.6%).
Think about it, my colleagues. Do you really need to draw up atropine and ephedrine before every case?
I queried Fred Hurt from the Stanford OR Pharmacy, and he gave me the following drug ampule acquisition costs: atropine $.23, ephedrine $.74, phenylephrine $2.47, vecuronium $2.51, rocuronium $18.89, succinylcholine $1.93, propofol 20ml $4.76, and propofol 50 ml $11.91.
I’ll admit, in the scope of the healthcare budget of the United States, these numbers are miniscule, and you may not give a damn if your unused atropine and ephedrine costs Stanford 97 cents. But let’s go back to the first paragraph, and a technique to avoid drawing up a lot of drugs and labeling them. Part of the rationale is to avoid drug wastage, but the greater issue is the KISS principle — Keep It Simple Stupid. In a 20 year career you’ll do 14,000 cases, and any practice that avoids wasted time and energy on each case is of value.
Try this: For a cholecystectomy, use an unlabelled 5 ml syringe to draw 2 mg of midazolam from its already labeled ampule, and inject it into the patient’s IV. Minutes later, use the same syringe to draw 100 micrograms of fentanyl from its already labeled ampule, and inject it into the patient’s IV. Then use a second syringe, a 20 ml syringe, to draw 200 mg of propofol from its already labeled ampule, and inject it into the patient’s IV. Finally, use the first syringe to draw 10 ml of Lactated Ringers from the IV bag and inject it into an already labeled ampule of vecuronium, mix it up, and inject 0.1mg/kg of vecuronium into the patient’s IV.
Reusing the same syringe on the same patient for several single-patient use ampules is safe. The ampules are already labeled — why add another intermediate step and store them in a labeled syringe? The exception to this practice is for drugs that need to be diluted — this would include phenylephrine (for a case you expect you might need it, such as vascular surgery or geriatric surgery), or narcotics such as morphine and meperidine. These syringes need to be prepared and labelled. Syringes should not be carried over from one patient to the next.
Like Burger King used to say, “Have it your way!” You don’t have to agree with or accept the above suggestions, but I’d be interested in hearing if you’ve changed your mind, 14,000 cases from now.
Published in September 2017: The second edition of THE DOCTOR AND MR. DYLAN, Dr. Novak’s debut novel, a medical-legal mystery which blends the science and practice of anesthesiology with unforgettable characters, a page-turning plot, and the legacy of Nobel Prize winner Bob Dylan.
In this debut thriller, tragedies strike an anesthesiologist as he tries to start a new life with his son.
Dr. Nico Antone, an anesthesiologist at Stanford University, is married to Alexandra, a high-powered real estate agent obsessed with money. Their son, Johnny, an 11th-grader with immense potential, struggles to get the grades he’ll need to attend an Ivy League college. After a screaming match with Alexandra, Nico moves himself and Johnny from Palo Alto, California, to his frozen childhood home of Hibbing, Minnesota. The move should help Johnny improve his grades and thus seem more attractive to universities, but Nico loves the freedom from his wife, too. Hibbing also happens to be the hometown of music icon Bob Dylan. Joining the hospital staff, Nico runs afoul of a grouchy nurse anesthetist calling himself Bobby Dylan, who plays Dylan songs twice a week in a bar called Heaven’s Door. As Nico and Johnny settle in, their lives turn around; they even start dating the gorgeous mother/daughter pair of Lena and Echo Johnson. However, when Johnny accidentally impregnates Echo, the lives of the Hibbing transplants start to implode. In true page-turner fashion, first-time novelist Novak gets started by killing soulless Alexandra, which accelerates the downfall of his underdog protagonist now accused of murder. Dialogue is pitch-perfect, and the insults hurled between Nico and his wife are as hilarious as they are hurtful: “Are you my husband, Nico? Or my dependent?” The author’s medical expertise proves central to the plot, and there are a few grisly moments, as when “dark blood percolated” from a patient’s nostrils “like coffee grounds.” Bob Dylan details add quirkiness to what might otherwise be a chilly revenge tale; we’re told, for instance, that Dylan taught “every singer with a less-than-perfect voice…how to sneer and twist off syllables.” Courtroom scenes toward the end crackle with energy, though one scene involving a snowmobile ties up a certain plot thread too neatly. By the end, Nico has rolled with a great many punches.
Nuanced characterization and crafty details help this debut soar.
Click on the image below to reach the Amazon link to The Doctor and Mr. Dylan:
Learn more about Rick Novak’s fiction writing at ricknovak.com by clicking on the picture below: