Anaesthesia 2014, 69, 785–798
Correspondence
Figure 2 Front lower panel of iVentTM201 ventilator.
Fig. 2), and vice-versa with the clear flow sensor tube (ie to ‘C’ rather than ‘B’), resulting in a persistent ventilator alarm, failure to ventilate the patient’s lungs and arterial desaturation to 90%. The error was recognised quickly, without further harm for the patient. Although the manufacturers have colour-coded the male/female components of the tubes/connectors to avoid confusion, the blue dot that would normally indicate to which Luer connector the blue tubing should be connected had faded. We suggest that where there is potential for misconnection between Luer connectors, misconnections will inevitably continue to occur. This case is another example of how misconnection could be avoided by using non-Luer connectors. R. Mahajan S. Gulati M. Jatinder Government Medical College, Jammu, India Email: [email protected]
792
No external funding and no competing interests declared.
References 1. Paparella S. Inadvertent attachment of a blood pressure device to a needleless IV Y-site: surprising, fatal connections. Journal of Emergency Nursing 2005; 31: 180–2. 2. Sharpe P, Scott S, Gross JM. An evaluation of non-Luer safety connectors for neuraxial procedures. Anaesthesia 2013; 68: 562–70. 3. Stone BA. Avoid luer connectors on blood pressure cuffs. Anesthesiology 2002; 97: 765–6. doi:10.1111/anae.12770
Cold – or hot? The risk of fire in the operating department We were interested to read the interim and follow-up reports into the fire in Bath Intensive Care Unit in 2011 [1, 2]. We would like to report a near miss that could have resulted in a fire in one of our anaesthetic rooms, the root cause analysis of which uncovered contributory latent and human errors
relating to the design of the anaesthetic room, the refrigerator and the daily theatre equipment checklist. Rolls of gamgee tissue that were stored loosely on top of a wall-mounted refrigerator had obstructed airflow through a grille covering the rear mounted condenser, resulting in superheating of the condenser and scorching of the gamgee tissue. The interior temperature of the refrigerator was measured as 22 °C, and drug ampoules stored within it were warm to touch. As part of the daily equipment checklist, the refrigerator temperature had been recorded daily between 20–23 °C for the previous three weeks, without this problem’s having been acknowledged. There had been several recent incidents in which thermometers had failed, which may have contributed to this fixation error. The design and wording of the checklist encouraged box-ticking, rather than proper equipment assessment. No harm resulted from this incident, which was investigated according to the hospital’s Adverse Incident Monitoring System, with immediate action taken to remove the gamgee tissue. Redesign of the equipment checklist has included the instruction “Confirm fridge temp < 5 degrees”. We have also recommended that either the refrigerator is replaced by a model with the condenser placed underneath, or a shelf is placed the minimum safe height above the refrigerator to allow adequate airflow. We would urge readers to take similar precautions.
© 2014 The Association of Anaesthetists of Great Britain and Ireland
Correspondence
Anaesthesia 2014, 69, 785–798
D. G. Maloney C. Hinchcliffe R. M. Knights J. D. Walker Ysbyty Gwynedd, Bangor, UK Email: [email protected] No external funding and no competing interests declared. Previously posted on the Anaesthesia correspondence website: www.anaesthesia correspondence.com.
References 1. Kelly FE, Hardy R, Hall EA, et al. Fire on an intensive care unit caused by an oxygen cylinder. Anaesthesia 2013; 68: 102–4. 2. Kelly FE, Hardy R, Henrys P. Oxygen cylinder fire – an update. Anaesthesia 2014; 69: 511–3. doi:10.1111/anae.12749
Extended roles for videolayngoscopy Montague and colleagues describe use of the Glidescopeâ (Verathon Medical United Kingdom Ltd., High Wycombe, UK) to guide placement of nasopharyngeal airways and balloon catheters visually in patients having cleft palate surgery [1]. As well as facilitating tracheal intubation, we have used videolaryngoscopy during facial reconstructive surgery for the extensive facial deformity and scarring caused by noma (cancrum oris), in survivors presenting to the Facing Africa charity in Ethiopia (see www.facing africa.org). Intubation in patients affected by noma is complicated by significant midface defects, restricted mouth opening with trismus [2],
and risk of airway compromise and soiling during microvascular free flap surgery. We use either the Glidescope or the McGrath MACâ (Aircraft Medical, Edinburgh, UK) to inspect the airway routinely after surgery and guide oropharyngeal suction, and find this technique consistently to be more effective than ‘blind’ suction and less stimulating than using direct laryngoscopy [3]. Similarly, videolaryngoscopy enables nasogastric feeding tube placement under direct vision. We commend these extended roles for videolayngoscopy for use by colleagues in the wider general surgical population. J. K. Gordon Sheffield Teaching Hospitals, Sheffield, UK Email: [email protected] G. Rodney Ninewells Hospital, Dundee, UK D. R. Ball Dumfries and Galloway Royal Infirmary, Dumfries, UK The Glidescope is supplied to the charity by Verathon Medical and the Mcgrath MAC by Aircraft Medical. Previously posted on the Anaesthesia correspondence website: www.anaes thesiacorrespondence.com.
References 1. Montague J, Cadier M, Williams S. Novel uses of the Glidescopeâ in cleft palate surgery. Anaesthesia 2014; 69: 393. 2. Coupe M, Johnson D, Seigne P, Hamlin B. Airway management in reconstructive surgery for Noma (cancrum oris). Anesthesia and Analgesia 2013; 117: 211–8. 3. Popat M, Mitchell V, Dravid R, Patel A, Swampilli C, Higgs A. Difficult Airway Society guidelines for the management
© 2014 The Association of Anaesthetists of Great Britain and Ireland
of extubation. Anaesthesia 2012; 67: 318–22. doi:10.1111/anae.12757
Teaching fibreoptic bronchoscopy using smart phones Smart devices are becoming increasing popular for teaching airway skills with a number of applications (‘apps’) and adaptors becoming available [1, 2]. We have found that the performance of an iPhoneâ (Apple Inc., Cupertino, CA, USA)modified fibreoptic bronchoscope compares well with an unmodified fibreoptic bronchoscope, and could provide a low-cost solution for teaching fibreoptic airway skills [3]. There are many advantages for using smart devices to teach airway skills. Compared with traditional video stacks, phones, phablets, pads and tablets [4] are relatively cheap, portable and don’t require external power supplies or light sources. High-quality camera optics enable rea-time image acquisition, storage, manipulation and transmission via a spectrum of wireless technologies including Bluetooth, NFC (near field communication), WiFi, and 3G. Images can also be transmitted to larger screens in theatre for teaching purposes, intra-operative assessment in the case of shared airway surgery or streamed via third party applications to other smart devices (Fig. 3) or websites. Virtual simulation software has reportedly been useful for teaching fibreoptic and neonatal intubation skills [5]. 793
Correspondence
Figure 2 Front lower panel of iVentTM201 ventilator.
Fig. 2), and vice-versa with the clear flow sensor tube (ie to ‘C’ rather than ‘B’), resulting in a persistent ventilator alarm, failure to ventilate the patient’s lungs and arterial desaturation to 90%. The error was recognised quickly, without further harm for the patient. Although the manufacturers have colour-coded the male/female components of the tubes/connectors to avoid confusion, the blue dot that would normally indicate to which Luer connector the blue tubing should be connected had faded. We suggest that where there is potential for misconnection between Luer connectors, misconnections will inevitably continue to occur. This case is another example of how misconnection could be avoided by using non-Luer connectors. R. Mahajan S. Gulati M. Jatinder Government Medical College, Jammu, India Email: [email protected]
792
No external funding and no competing interests declared.
References 1. Paparella S. Inadvertent attachment of a blood pressure device to a needleless IV Y-site: surprising, fatal connections. Journal of Emergency Nursing 2005; 31: 180–2. 2. Sharpe P, Scott S, Gross JM. An evaluation of non-Luer safety connectors for neuraxial procedures. Anaesthesia 2013; 68: 562–70. 3. Stone BA. Avoid luer connectors on blood pressure cuffs. Anesthesiology 2002; 97: 765–6. doi:10.1111/anae.12770
Cold – or hot? The risk of fire in the operating department We were interested to read the interim and follow-up reports into the fire in Bath Intensive Care Unit in 2011 [1, 2]. We would like to report a near miss that could have resulted in a fire in one of our anaesthetic rooms, the root cause analysis of which uncovered contributory latent and human errors
relating to the design of the anaesthetic room, the refrigerator and the daily theatre equipment checklist. Rolls of gamgee tissue that were stored loosely on top of a wall-mounted refrigerator had obstructed airflow through a grille covering the rear mounted condenser, resulting in superheating of the condenser and scorching of the gamgee tissue. The interior temperature of the refrigerator was measured as 22 °C, and drug ampoules stored within it were warm to touch. As part of the daily equipment checklist, the refrigerator temperature had been recorded daily between 20–23 °C for the previous three weeks, without this problem’s having been acknowledged. There had been several recent incidents in which thermometers had failed, which may have contributed to this fixation error. The design and wording of the checklist encouraged box-ticking, rather than proper equipment assessment. No harm resulted from this incident, which was investigated according to the hospital’s Adverse Incident Monitoring System, with immediate action taken to remove the gamgee tissue. Redesign of the equipment checklist has included the instruction “Confirm fridge temp < 5 degrees”. We have also recommended that either the refrigerator is replaced by a model with the condenser placed underneath, or a shelf is placed the minimum safe height above the refrigerator to allow adequate airflow. We would urge readers to take similar precautions.
© 2014 The Association of Anaesthetists of Great Britain and Ireland
Correspondence
Anaesthesia 2014, 69, 785–798
D. G. Maloney C. Hinchcliffe R. M. Knights J. D. Walker Ysbyty Gwynedd, Bangor, UK Email: [email protected] No external funding and no competing interests declared. Previously posted on the Anaesthesia correspondence website: www.anaesthesia correspondence.com.
References 1. Kelly FE, Hardy R, Hall EA, et al. Fire on an intensive care unit caused by an oxygen cylinder. Anaesthesia 2013; 68: 102–4. 2. Kelly FE, Hardy R, Henrys P. Oxygen cylinder fire – an update. Anaesthesia 2014; 69: 511–3. doi:10.1111/anae.12749
Extended roles for videolayngoscopy Montague and colleagues describe use of the Glidescopeâ (Verathon Medical United Kingdom Ltd., High Wycombe, UK) to guide placement of nasopharyngeal airways and balloon catheters visually in patients having cleft palate surgery [1]. As well as facilitating tracheal intubation, we have used videolaryngoscopy during facial reconstructive surgery for the extensive facial deformity and scarring caused by noma (cancrum oris), in survivors presenting to the Facing Africa charity in Ethiopia (see www.facing africa.org). Intubation in patients affected by noma is complicated by significant midface defects, restricted mouth opening with trismus [2],
and risk of airway compromise and soiling during microvascular free flap surgery. We use either the Glidescope or the McGrath MACâ (Aircraft Medical, Edinburgh, UK) to inspect the airway routinely after surgery and guide oropharyngeal suction, and find this technique consistently to be more effective than ‘blind’ suction and less stimulating than using direct laryngoscopy [3]. Similarly, videolaryngoscopy enables nasogastric feeding tube placement under direct vision. We commend these extended roles for videolayngoscopy for use by colleagues in the wider general surgical population. J. K. Gordon Sheffield Teaching Hospitals, Sheffield, UK Email: [email protected] G. Rodney Ninewells Hospital, Dundee, UK D. R. Ball Dumfries and Galloway Royal Infirmary, Dumfries, UK The Glidescope is supplied to the charity by Verathon Medical and the Mcgrath MAC by Aircraft Medical. Previously posted on the Anaesthesia correspondence website: www.anaes thesiacorrespondence.com.
References 1. Montague J, Cadier M, Williams S. Novel uses of the Glidescopeâ in cleft palate surgery. Anaesthesia 2014; 69: 393. 2. Coupe M, Johnson D, Seigne P, Hamlin B. Airway management in reconstructive surgery for Noma (cancrum oris). Anesthesia and Analgesia 2013; 117: 211–8. 3. Popat M, Mitchell V, Dravid R, Patel A, Swampilli C, Higgs A. Difficult Airway Society guidelines for the management
© 2014 The Association of Anaesthetists of Great Britain and Ireland
of extubation. Anaesthesia 2012; 67: 318–22. doi:10.1111/anae.12757
Teaching fibreoptic bronchoscopy using smart phones Smart devices are becoming increasing popular for teaching airway skills with a number of applications (‘apps’) and adaptors becoming available [1, 2]. We have found that the performance of an iPhoneâ (Apple Inc., Cupertino, CA, USA)modified fibreoptic bronchoscope compares well with an unmodified fibreoptic bronchoscope, and could provide a low-cost solution for teaching fibreoptic airway skills [3]. There are many advantages for using smart devices to teach airway skills. Compared with traditional video stacks, phones, phablets, pads and tablets [4] are relatively cheap, portable and don’t require external power supplies or light sources. High-quality camera optics enable rea-time image acquisition, storage, manipulation and transmission via a spectrum of wireless technologies including Bluetooth, NFC (near field communication), WiFi, and 3G. Images can also be transmitted to larger screens in theatre for teaching purposes, intra-operative assessment in the case of shared airway surgery or streamed via third party applications to other smart devices (Fig. 3) or websites. Virtual simulation software has reportedly been useful for teaching fibreoptic and neonatal intubation skills [5]. 793
