The World Federation of Societies of Anaesthesiologists Minimum Capnometer Specifications 2021-A Guide for Health Care Decision Makers.

Capnometry, the measurement of respiratory carbon dioxide, is regarded as a highly recommended safety technology in intubated and nonintubated sedated and/or anesthetized patients. Its utility includes confirmation of initial and ongoing placement of an airway device as well as in detecting gas exchange, bronchospasm, airway obstruction, reduced cardiac output, and metabolic changes. The utility applies prehospital and throughout all phases of inhospital care. Unfortunately, capnometry devices are not readily available in many countries, especially those that are resource-limited. Constraining factors include cost, durability of devices, availability of consumables, lack of dependable power supply, difficulty with cleaning, and maintenance. There is, thus, an urgent need for all stakeholders to come together to develop, market, and distribute appropriate devices that address costs and other requirements. To foster this process, the World Federation of Societies of Anaesthesiologists (WFSA) has developed the "WFSA-Minimum Capnometer Specifications 2021." The intent of the specifications is to set the minimum that would be acceptable from industry in their attempts to reduce costs while meeting other needs in resource-constrained regions. The document also includes very desirable and preferred options. The intent is to stimulate interest and engagement among industry, clinical providers, professional associations, and ministries of health to address this important patient safety need. The WFSA-Minimum Capnometer Specifications 2021 is based on the International Organization for Standardization (ISO) capnometer specifications. While industry is familiar with such specifications and their presentation format, most clinicians are not; therefore, this article serves to more clearly explain the requirements. In addition, the specifications as described can be used as a purchasing guide by clinicians.

Assessment of Anesthesia Capacity in Public Surgical Hospitals in Guatemala.

BACKGROUND: International standards for safe anesthetic care have been developed by the World Federation of Societies of Anaesthesiologists (WFSA) and the World Health Organization (WHO). Whether these standards are met is unknown in many nations, including Guatemala, a country with universal health coverage. We aimed to establish an overview of anesthesia care capacity in public surgical hospitals in Guatemala to help guide public sector health care development. METHODS: In partnership with the Guatemalan Ministry of Public Health and Social Assistance (MSPAS), a national survey of all public hospitals providing surgical care was conducted using the WFSA anesthesia facility assessment tool (AFAT) in 2018. Each facility was assessed for infrastructure, service delivery, workforce, medications, equipment, and monitoring practices. Descriptive statistics were calculated and presented. RESULTS: Of the 46 public hospitals in Guatemala in 2018, 36 (78%) were found to provide surgical care, including 20 district, 14 regional, and 2 national referral hospitals. We identified 573 full-time physician surgeons, anesthesiologists, and obstetricians (SAO) in the public sector, with an estimated SAO density of 3.3/100,000 population. There were 300 full-time anesthesia providers working at public hospitals. Physician anesthesiologists made up 47% of these providers, with an estimated physician anesthesiologist density of 0.8/100,000 population. Only 10% of district hospitals reported having an anesthesia provider continuously present intraoperatively during general or neuraxial anesthesia cases. No hospitals reported assessing pain in the immediate postoperative period. While the availability of some medications such as benzodiazepines and local anesthetics was robust (100% availability across all hospitals), not all hospitals had essential medications such as ketamine, epinephrine, or atropine. There were deficiencies in the availability of essential equipment and basic intraoperative monitors, such as end-tidal carbon dioxide detectors (17% availability across all hospitals). Postoperative care and access to resuscitative equipment, such as defibrillators, were also lacking. CONCLUSIONS: This first countrywide, MSPAS-led assessment of anesthesia capacity at public facilities in Guatemala revealed a lack of essential materials and personnel to provide safe anesthesia and surgery. Hospitals surveyed often did not have resources regardless of hospital size or level, which may suggest multiple factors preventing availability and use. Local and national policy initiatives are needed to address these deficiencies.

Human Factors Evaluation of the Universal Anaesthesia Machine: Assessing Equipment with High-Fidelity Simulation Prior to Deployment in a Resource-Constrained Environment.

BACKGROUND: Anesthesia providers in low- and middle-income countries face many challenges, including poor availability of functioning equipment designed to meet their environmental, organizational, and resource constraints. These are serious global health disparities which threaten access to care and patient safety for those who receive surgical care. In this study, we conducted a simulation-based human factors analysis of the Universal Anaesthesia Machine (UAM®), a device designed to support anesthesia providers in austere medical settings. Our team anticipated the introduction of the UAM® to the two major referral hospitals in Freetown, Sierra Leone. A prior observational study had identified these two hospitals as having environmental conditions consistent with an austere environment: an unstable electrical grid, as well as limited access to compressed oxygen, biomedical support, and consumables. Although the Baltimore simulation environment cannot reproduce all of the challenges present in a resource-constrained environment such as Sierra Leone, the major impediments to standard anesthesia machine functionality and human factors-associated use can be reproduced with the use of high-fidelity simulation. Using anesthesia care providers who have limited UAM® familiarity, this study allowed for the examination of machine-user issues in a controlled environment in preparation for further field studies concerning equipment introduction, training and device deployment in Sierra Leone. The goals of this study were: 1. to assess the usability of the UAM® (machine-user interface, simulated patient use, symbology, etc.) across different provider user groups during simulation of use in scenarios depicting routine use in healthy patients, use in clinically challenging patients and use in environmentally-challenging scenarios in a controlled setting devoid of patient risk, and 2. To gather feedback on available UAM manuals and cognitive aides and UAM usability issues in order to guide development of curricula for training providers on use of the UAM® in the intended austere clinical environments. METHODS: Residents, fellows, attending physician anesthesiologists, student nurse anesthetists, and nurse anesthetists participated in a variety of simulations involving the Universal Anaesthesia Machine® at the Johns Hopkins Medicine Simulation Center between September 2012 and July 2013. Data collected included participant demographics, performance during simulation scenarios captured with critical action checklists, workload ratings captured with the National Aeronautics and Space Administration Task Load Index (NASA TLX), and participant reactions to UAM® use captured through a post-session survey and semi-structured usability debriefing. The scenarios were: 1. normal use (machine check, induction, and maintenance of an uneventful case), 2. use in a challenging clinical condition (acute onset of bronchospasm) and 3.use in an adverse environmental event (power failure). Critical action checklists and workload ratings were analyzed by Analysis of Covariance (ANCOVA) to control for participant demographics. Usability debriefings were analyzed qualitatively. RESULTS: Thirty-five anesthesia providers participated in the study. Overall participant ratings, observations of performance in simulation scenarios, and usability debriefings indicated a high level of usability for the UAM®. Mean participant ratings were high for ease of use (5.4 ± 0.96) and clarity of instruction (6.2 ± 0.87) on a 7-point scale in which higher ratings indicate more positive perceptions. After adjusting for clinical experience, workload ratings were significantly higher in the bronchospasm scenario than in the normal/routine use (P = 0.046; 95% CI, 0.33-34.7) or power failure scenarios (P = 0.012; 95% CI, 5.24-37.9). Thirty-two specific usability issues were identified and grouped into five themes: device design and labeling, machine use during simulation scenarios, user-anticipated errors or hazards, curriculum issues, and overall impressions of the UAM®. CONCLUSIONS: The UAM® design addresses many of the key challenges facing anesthesia providers in resource-constrained settings. The simulation-based human factors evaluation described here successfully identified opportunities for continued refinement of the initial device design as well as issues to be addressed in future curricula and cognitive aides.

General Thoracic Surgery in Rwanda: An Assessment of Surgical Volume and of Workforce and Material Resource Deficits.

BACKGROUND: Benchmarking operative volume and resources is necessary to understand current efforts addressing thoracic surgical need. Our objective was to examine the impact on thoracic surgery volume and patient access in Rwanda following a comprehensive capacity building program, the Human Resources for Health (HRH) Program, and thoracic simulation training. METHODS: A retrospective cohort study was conducted of operating room registries between 2011 and 2016 at three Rwandan referral centers: University Teaching Hospital of Kigali, University Teaching Hospital of Butare, and King Faisal Hospital. A facility-based needs assessment of essential surgical and thoracic resources was performed concurrently using modified World Health Organization forms. Baseline patient characteristics at each site were compared using a Pearson Chi-squared test or Kruskal-Wallis test. Comparisons of operative volume were performed using paired parametric statistical methods. RESULTS: Of 14,130 observed general surgery procedures, 248 (1.76%) major thoracic cases were identified. The most common indications were infection (45.9%), anatomic abnormalities (34.4%), masses (13.7%), and trauma (6%). The proportion of thoracic cases did not increase during the HRH program (2.07 vs 1.78%, respectively, p = 0.22) or following thoracic simulation training (1.95 2013 vs 1.44% 2015; p = 0.15). Both university hospitals suffer from inadequate thoracic surgery supplies and essential anesthetic equipment. The private hospital performed the highest percentage of major thoracic procedures consistent with greater workforce and thoracic-specific material resources (0.89% CHUK, 0.67% CHUB, and 5.42% KFH; p < 0.01). CONCLUSIONS AND RELEVANCE: Lack of specialist providers and material resources limits thoracic surgical volume in Rwanda despite current interventions. A targeted approach addressing barriers described is necessary for sustainable progress in thoracic surgical care.

Anaesthesia for ear surgery in remote or resource-constrained environments.

BACKGROUND: The successful provision of middle-ear surgery requires appropriate anaesthesia. This may take the form of local or general anaesthesia; both methods have their advantages and disadvantages. Local anaesthesia is simple to administer and does not require the additional personnel required for general anaesthesia. In the low-resource setting, it can provide a very safe and effective means of allowing middle-ear surgery to be successfully completed. However, some middle-ear surgery is too complex to consider performing under local anaesthesia and here general anaesthesia will be required. CONCLUSION: This article highlights considerations for performing middle-ear surgery in a safe manner when the available resources may be more limited than those expected in high-income settings. There are situations where local anaesthesia with sedation may prove a useful compromise of the two techniques.

Humanitarian Surgical Missions: Guidelines for Successful Anesthesia Support.

Many anesthesiologists and CRNAs are provided little training in preparing for a humanitarian surgical mission. Furthermore, there is very little published literature that outlines how to plan and prepare for anesthesia support of a humanitarian surgical mission. This article attempts to serve as an in-depth planning guide for anesthesia support of humanitarian surgical missions. Recommendations are provided on planning requirements that most anesthesiologists and CRNAs do not have to consider on routinely, such as key questions to be answered before agreeing to support a mission, ordering and shipping supplies and medications, travel and lodging arrangements, and coordinating translators in a host nation. Detailed considerations are included for all the phases of mission planning: advanced, mission-specific, final, mission-execution, and postmission follow-up planning, as well as a timeline in which to complete each phase. With the proper planning and execution, the anesthetic support of humanitarian surgical missions is a very manageable task that can result in an extremely satisfying sense of accomplishment and a rewarding experience. The authors suggest this article should be used as a reference document by any anesthesia professional tasked with planning and supporting a humanitarian surgical mission.

Financial and environmental costs of reusable and single-use anaesthetic equipment.

BACKGROUND.: An innovative approach to choosing hospital equipment is to consider the environmental costs in addition to other costs and benefits. METHODS.: We used life cycle assessment to model the environmental and financial costs of different scenarios of replacing reusable anaesthetic equipment with single-use variants. The primary environmental costs were CO 2 emissions (in CO 2 equivalents) and water use (in litres). We compared energy source mixes between Australia, the UK/Europe, and the USA. RESULTS.: For an Australian hospital with six operating rooms, the annual financial cost of converting from single-use equipment to reusable anaesthetic equipment would be an AUD$32 033 (£19 220), 46% decrease. In Australia, converting from single-use to reusable equipment would result in an increase of CO 2 emissions from 5095 (95% CI: 4614-5658) to 5575 kg CO 2 eq (95% CI: 5542-5608), a 480 kg CO 2 eq (9%) increase. Using the UK/European power mix, converting from single-use (5575 kg CO 2 eq) to reusable anaesthetic equipment (802 kg CO 2 eq) would result in an 84% reduction (4873 kg CO 2 eq) in CO 2 emissions, whilst in the USA converting to reusables would have led to a 2427 kg CO 2 eq (48%) reduction. In Australia, converting from single-use to reusable equipment would more than double water use from 34.4 to 90.6 kilolitres. CONCLUSIONS.: For an Australian hospital with six operating rooms, converting from single-use to reusable anaesthetic equipment saved more than AUD$30 000 (£18 000) per annum, but increased the CO 2 emissions by almost 10%. The CO 2 offset is highly dependent on the power source mix, while water consumption is greater for reusable equipment.

The Universal Anaesthesia Machine (UAM): assessment of a new anaesthesia workstation built with global health in mind.

The Universal Anaesthesia Machine has been developed as a complete anaesthesia workstation for use in low- and middle-income countries, where the provision of safe general anaesthesia is often compromised by unreliable supply of electricity and anaesthetic gases. We performed a functional and clinical assessment of this anaesthetic machine, with particular reference to novel features and functioning in the intended environment. The Universal Anaesthesia Machine was found to be reliable, safe and consistent across a range of tests during targeted functional testing.

Development of An Assessment Test for An Anesthetic Machine.

OBJECTIVE: The study is aimed to develop and assess the quality of an evaluation form used to evaluate the nurse anesthetic trainees' skills in undertaking a pre-use check of an anesthetic machine. MATERIAL AND METHOD: An evaluation form comprising 25 items was developed, informed by the guidelines published by national anesthesiologist societies and refined to reflect the anesthetic machine used in our institution. The item-checking included the cylinder supplies and medical gas pipelines, vaporizer back bar, ventilator anesthetic breathing system, scavenging system and emergency back-up equipment. The authors sought the opinions of five experienced anesthetic trainers to judge the validity of the content. The authors measured its inter-rater reliability when used by two achievement scores evaluating the performance of 36 nurse anesthetic trainees undertaking 15-minute anesthetic machine checks and test-retest the reliability correlation scores between the two performances in the seven days interval. RESULTS: The five experienced anesthesiologists agreed that the evaluation form accurately reflected the objectives of anesthetic machine checking, equating to an index of congruency of 1.00. The inter-rater reliability of the independent assessors scoring was 0.977 (p = 0.01) and the test-retest reliability was 0.883 (p = 0.01). CONCLUSION: An evaluation form proved to be a reliable and effective tool for assessing the anesthetic nurse trainees' checking of an anesthetic machine before the use. This evaluation form was brief clear and practical to use, and should help to improve anesthetic nurse education and the patient safety.

A Case Illustrating the Costs of Quality Improvement: Nine Months to Move Needles and Syringes on the Anesthesia Cart.

Powerful entities are pushing physicians to become more involved with quality improvement (QI). We report a QI project to standardize and improve the ergonomics of the anesthesia medication and supply cart. Simply obtaining approval to make minor changes to the cart involved 54 phone calls, 164 e-mails, 4 presentations, 2 forms, 9 meetings, and 4 months of time. Confusion over fiscal matters further delayed the project by an additional 3 months. A combination of competing regulations, administrative overprocessing, and the lack of dedicated QI financial resources made simple improvements a challenge. The costs of participating in QI deserve attention.

Example of cost calculations for an operating room and a post-anaesthesia care unit.

OBJECTIVE: The aim of this study was to evaluate the cost of an operating room using data from our hospital. Using an accounting-based method helped us. METHODS: Over the year 2012, the sum of direct and indirect expenses with cost sharing expenses allowed us to calculate the cost of the operating room (OR) and of the post-anaesthesia care unit (PACU). RESULTS: The cost of the OR and PACU was €10.8 per minute of time offered. Two thirds of the direct expenses were allocated to surgery and one third to anaesthesia. Indirect expenses were 25% of the direct expenses. The cost of medications and single use medical devises was €111.45 per anaesthesia. The total cost of anaesthesia (taking into account wages and indirect expenses) was €753.14 per anaesthesia as compared to the total cost of the anaesthesia. The part of medications and single use devices for anaesthesia was 14.8% of the total cost. CONCLUSION: Despite the difficulties facing cost evaluation, this model of calculation, assisted by the cost accounting controller, helped us to have a concrete financial vision. It also shows that a global reflexion is necessary during financial decision-making.

A survey of healthcare industry representatives' participation in surgery: some new ethical concerns.

OBJECTIVE: To provide preliminary evidence of the types and amount of involvement by healthcare industry representatives (HCIRs) in surgery, as well as the ethical concerns of those representatives. METHODS: A link to an anonymous, web-based survey was posted on several medical device boards of the website http://www. cafepharma.com. Additionally, members of two different medical device groups on LinkedIn were asked to participate. Respondents were self-identified HCIRs in the fields of orthopedics, cardiology, endoscopic devices, lasers, general surgery, ophthalmic surgery, oral surgery, anesthesia products, and urologic surgery. RESULTS: A total of 43 HCIRs replied to the survey over a period of one year: 35 men and eight women. Respondents reported attending an average of 184 surgeries in the prior year and had an average of 17 years as an HCIR and six years with their current employer. Of the respondents, 21 percent (nine of 43) had direct physical contact with a surgical team or patient during a surgery, and 88 percent (38 of 43) provided verbal instruction to a surgical team during a surgery. Additionally, 37 percent (16 of 43) had participated in a surgery in which they felt that their involvement was excessive, and 40 percent (17 of 43) had attended a surgery in which they questioned the competence of the surgeon. CONCLUSIONS: HCIRs play a significant role in surgery. Involvement that exceeds their defined role, however, can raise serious ethical and legal questions for surgeons and surgical teams. Surgical teams may at times be substituting the knowledge of the HCIR for their own competence with a medical device or instrument. In some cases, contact with the surgical team or patient may violate the guidelines not only of hospitals and medical device companies, but the law as well. Further study is required to determine if the patients involved have any knowledge or understanding of the role that an HCIR played in their surgery.

Utility of a low-cost wireless force platform as a potential clinical test of balance recovery after neuraxial anaesthesia.

INTRODUCTION: Recovery of balance after neuraxial anaesthesia can remain delayed after simple clinical tests have demonstrated motor recovery. Dynamic posturography tracks the small movements or sway of a person standing as still as possible on a force platform and has been investigated as an objective measure of the ability to walk following anaesthesia. These are expensive laboratory devices, limiting their clinical utility. One measured variable is path length, the cumulative distance travelled in the horizontal plane by the centre of pressure of a person standing on the platform over 1min. Path length might potentially be measured using the Nintendo® Wii-Fit Balance Board™. METHODS: The feasibility of intercepting raw wireless data from a Wii-Fit Balance Board™ using custom software to calculate path length was explored. Subsequently, path lengths were measured using both this and a laboratory platform simultaneously. In a random order 20 volunteers (a) stood for 1min, feet together, eyes open (conventional baseline test); and (b) stood for 1min, feet together, eyes closed (simulating residual anaesthesia with increased sway). For each device, the ratio b:a was calculated as an index of performance reduction when eyes were closed. RESULTS: Path lengths ranged from 58.5 to 243cm, mean bias 9cm (Wii-Fitlaboratory platform) and 95% confidence limits of 0.04 to -0.13. CONCLUSIONS: The path lengths were in close agreement and the Wii-Fit Balance Board™ may be worthy of further investigation as a tool to objectively assess readiness to ambulate following neuraxial anaesthesia.

The microbiological and sustainability effects of washing anaesthesia breathing circuits less frequently.

In the presence of single-use airway filters, we quantified anaesthetic circuit aerobic microbial contamination rates when changed every 24 h, 48 h and 7 days. Microbiological samples were taken from the interior of 305 anaesthetic breathing circuits over a 15-month period (3197 operations). There was no significant difference in the proportion of contaminated circuits when changed every 24 h (57/105 (54%, 95% CI 45-64%)) compared with 48 h (43/100 (43%, 95% CI 33-53%, p = 0.12)) and up to 7 days (46/100 (46%, 95% CI 36-56%, p = 0.26)). Median bacterial counts were not increased at 48 h or 7 days provided circuits were routinely emptied of condensate. Annual savings for one hospital (six operating theatres) were $AU 5219 (£3079, €3654, $US 4846) and a 57% decrease in anaesthesia circuit steriliser loads associated with a yearly saving of 2760 kWh of electricity and 48 000 l of water. Our findings suggest that extended circuit use from 24 h up to 7 days does not significantly increase bacterial contamination, and is associated with labour, energy, water and financial savings.

[The choice of a pediatric anesthesia ventilator]. / Comment choisir un respirateur d'anesthésie pédiatrique?

The technology of anesthesia ventilators has substantially progressed during last years. The choice of a pediatric anesthesia ventilator needs to be led by multiple parameters: requirement, technical (pneumatic performance, velocity of halogenated or oxygen delivery), cost (purchase, in operation, preventive and curative maintenance), reliability, ergonomy, upgradability, and compatibility. The demonstration of the interest of pressure support mode during maintenance of spontaneous ventilation anesthesia makes this mode essential in pediatrics. In contrast, the financial impact of target controlled inhalation of halogenated has not be studied in pediatrics. Paradoxically, complex and various available technologies had not been much prospectively studied. Anesthesia ventilators performances in pediatrics need to be clarified in further clinical and bench test studies.

Closed-loop fluid resuscitation: robustness against weight and cardiac contractility variations.

BACKGROUND: Surgical patients present with a wide variety of body sizes and blood volumes, have large differences in baseline volume status, and may exhibit significant differences in cardiac function. Any closed-loop fluid administration system must be robust against these differences. In the current study, we tested the stability and robustness of the closed-loop fluid administration system against the confounders of body size, starting volume status, and cardiac contractility using control engineering methodology. METHODS: Using an independently developed previously published hemodynamic simulation model that includes blood volumes and cardiac contractility, we ran a Monte-Carlo simulation series with variation in starting blood volume and body weight (phase 1, weight 35-100 kg), and starting blood volume and cardiac contractility (phase 2, contractility from 1500 [severe heart failure] to 6000 [hyperdynamic]). The performance of the controller in resuscitating to the target set point was evaluated in terms of milliliters of blood volume error from optimal, with <250 mL of error defined as "successful." RESULTS: One thousand simulations were run for each of the 2 phases of the study. The phase 1 mean blood volume error ± SD from optimal was 25 ± 59 mL. The phase 2 mean blood volume error from optimal was -60 ± 89 mL. The lower 95% Clopper-Pearson binomial confidence interval for resuscitation to within 250 mL of optimal blood volume for phase 1 and 2 was 99.6% and 97.1%, respectively. CONCLUSION: The results indicate that the controller is highly effective in targeting optimal blood and stroke volumes, regardless of weight, contractility or starting blood volume.

Implementing a perpetual anesthesia setup standardized for the trauma room in a level I trauma center.

The trauma room in a level I trauma center is a dynamic environment that provides little room for error. Significant variability can exist if anesthesia providers set up the room differently. Standardization provides a system that is consistent, reliable, and cost-effective. This study examines the process of creating and implementing a standardized anesthesia setup in the trauma room of a level I trauma center. As a result of this study, the medication cart and airway setups have been standardized. Providers are encouraged to only draw up medications that will be immediately used and to ensure that prefilled syringes have been incorporated into the pharmacy formulary. Using the EZ Endo prestyleted endotracheal tube (ETT) vs a regular ETT with stylet has yielded an annual cost savings of $2,673. Ensuring that items such as an esophageal temperature probe, humidifier, and nasogastric tube are available but unopened has provided a savings of $1,989.25 per year. The reservoir bag has been changed to a latex-free bag, and 3 central line kits including an arterial line kit are routinely stocked. An ultrasound machine dedicated for central line access, GlideScope, rapid fluid infuser, and Airtraq laryngoscope have all been incorporated into the permanent setup in the trauma room.