Clinical Anesthesiology: Lessons Learned from Morbidity and Mortality Conferences

548 Pages·2014·37.127 MB·English

by  Ankur P. Patel MD (auth.), Jonathan L. Benumof (eds.)

Jonathan L. Benumof Editor
Clinical
Anesthesiology
Lessons Learned from
Morbidity and Mortality
Conferences
123
Clinical Anesthesiology

Jonathan L. Benumof
Editor
Clinical Anesthesiology
Lessons Learned from Morbidity
and Mortality Conferences
Editor
Jonathan L. Benumof
Department of Anesthesiology
University of California, San Diego
School of Medicine
San Diego , California
USA
ISBN 978-1-4614-8695-4 ISBN 978-1-4614-8696-1 (eBook)
DOI 10.1007/978-1-4614-8696-1
Springer New York Heidelberg Dordrecht London
Library of Congress Control Number: 2013954905
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Foreword
One of the fi rst things I did when I joined the UCSD faculty in January of 2000 was
attend the Wednesday morning Anesthesiology Morbidity and Mortality Conference
(we now call it the Departmental “Continuous Quality Improvement Conference”
for the sake of “Quality Improvement Correctness”). I was joining as general fac-
ulty, having served as Clinical Director for a number of years at my previous institu-
tion. I considered myself a “go to” person for complex clinical issues, and was
accustomed to being the “big kid on the block.”
The Departmental Morbidity and Mortality Conference was amazing. First, I
noticed that the conference was moderated by a senior faculty with superb teaching
skills (Dr. Benumof). The resident was expected to present the case, but the learning
points, and, yes, arguments about the medical and anesthetic care were provided by
the faculty. The presenting resident was virtually immune from harm! This was a
learning environment far superior to the classic conference in which the presenting
resident would simply stand alone at the front of the room, receiving criticism (dag-
gers?) from all angles by the faculty. I later found that it was not uncommon for
experts from other services to be invited, and that this was the fl agship teaching
exercise for the department. To this day we have all resident applicants attend this
conference, so they experience, fi rst hand, this learning experience our residents and
faculty enjoy weekly.
The second thing I noticed was that the academic quality and information pro-
vided at the conference were outstanding. I may have previously considered myself
a clinical expert, but these UCSD folks were in a completely different league. When
the conference was over, I proceeded directly to the campus bookstore, recognizing
that my level of knowledge was not going to suffi ce in this place, with the likes of
Dr. Jon Benumof moderating the case conferences. The moderators here have
inspired me to “raise my game” many notches, and I will forever be grateful to them
for this.
When I was a resident, I was told by my Chair, Dr. Paul Poppers, that one should
take copious notes at the Morbidity and Mortality conferences and save the write-
ups in a binder with the notes for later review. By doing this I would be prepared for
very complex cases, and I’d also be prepared for the board examination. I found his
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vi Foreword
advice to be sage, and I advise our residents similarly. The residents, however,
almost never follow this advice, occupying the conference time with listening,
answering the occasional “pimping” question, and eating muffi ns. The residents just
don’t seem to want to take notes. My fear about their not taking notes is that they
will forget all the great teaching points presented at the conferences.
By writing this book, Dr. Benumof and the authors have fully addressed this
issue for all of us! Herein is a wonderful compilation of UCSD case discussions,
with chapters that are far superior to any notes one could take. The chapters have
very readable prose, tables, fi gures, and other information that will be invaluable to
any practitioner or student of anesthesiology. I still think the attendees of our con-
ferences should take notes, and I still do. This relevant, well-written collection,
however, allows us the luxury of simply listening (or reading), and eating muffi ns if
we want to, while we learn the critical points of caring for some of the most com-
plex patients in some of the most challenging circumstances.
San Diego, CA, USA Gerard R. Manecke Jr., MD
Pref ace
This book is a compilation of selected cases presented at the weekly University of
California San Diego Medical Center Department of Anesthesiology Morbidity and
Mortality (M&M)/Quality Improvement (QIC) conference that I moderated over
the last 4–5 years. For all cases presented, a narrative of the case was prepared and
published to the department by the person presenting the case (usually an anesthesia
resident) prior to the actual case presentation. Whenever I moderated a case, I made
notes as to what were the questions and the lessons going to be during the actual
presentation of the case at the conference; these questions and lessons were those
that I thought arose naturally from the narrative of the case.
During the actual presentation of the case, the answers to questions and the
teaching of lessons was provided by the audience (usually the learned faculty) and
by me by the communication vehicles of speech, using an eraser board, and by pro-
jection of prepared slides. Immediately after the case conference I made additional
notes of what actually happened and the educational dialogue that had occurred at
the conference. It is the preconference and immediate post-conference notes on the
M&Ms/QICs that form the basis of the book, i.e., what were the questions answered
and lessons learned.
For each of the previously presented cases that I selected for this book, I selected
a senior resident (majority of the case chapters) or a faculty person to write the case
chapter. The senior residents who wrote the case chapters took a department-
approved writing-of-the-book 1 month elective in their third year with me. With
both the senior residents and faculty, I discussed in detail the narrative of the case
and my notes on questions answered and lessons learned that had naturally popped
out of the narrative of the case and actually happened at the conference. Each author
wrote multiple drafts of each chapter in close consultation with me until a high-
quality fi nal teaching product was arrived at. Each chapter consists of the narrative
of the case followed by the lessons learned/questions answered.
The manner of preparation of each case chapter, as described above, has one
limitation, and that is occasionally the data in the narrative is incomplete. I cannot
remember why a piece of data, that may seem logical and desirable to have been
included in the narrative in the fi rst place, was not in the narrative or in my notes:
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viii Preface
unfortunately these occasional little informational pieces are lost. Usually the
answers to questions and the lessons learned will make a small comment on this
minor problem.
Why produce this book and what is unique about this book? This book is a
unique valuable teaching-of-anesthesia contribution for several reasons. First, it is
unique in that the questions answered and lessons learned fl ow naturally out of real
cases that actually happened. As a consequence of this format, many of the ques-
tions raised and lessons offered are unique because real cases generate issues in a
way that traditional textbooks cannot do and do not cover. Just a few examples are:
Why does a right main-stem bronchial intubation sometimes cause a hyper-
expanded right lung? How to make anesthesia for offi ce and same day surgery safe
and effi cient; practical aspects of doing many procedures and managing situations
and complications that are simply not covered anywhere else. Simply browsing
through the titles of the lessons learned for each case in this book will prove this
point. Second, if the facts of these real cases happened once, then they are going to
happen again; so it is no leap in logic that this book will be instructive, and preven-
tive of, the same problems that will come up in the future. Third, since the answers
to questions and lessons learned fl ow naturally from real cases, it is simply more fun
and much easier to understand, absorb, learn, and remember the educational mate-
rial from this book than from a traditional book. Indeed, it is very possible that the
way readers remember all the teaching material in all the cases is that they remem-
ber the real cases.
Finally, for all the reasons above, the reader gets to learn anesthesia in a way that
has never been done before; try it, you will like it.
San Diego, CA, USA Jonathan L. Benumof, MD
Contents
Part I Respiration-Related Cases
1 Cannot Ventilate, Cannot Intubate Due to
Airway Hemorrhage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Ankur P. Patel
L-1: How do you know when you are effectively positive pressure
ventilating a patient? What is the utility of the self-infl ating bag? . . . . . 4
L-2: What are the causes for false-negative end-tidal
CO readings? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
2
L-3: How does an anesthesiologist know when there is
a cannot ventilate, cannot intubate situation? . . . . . . . . . . . . . . . . . . . . . 8
L-4: What is the best/optimal attempt at (A) laryngoscopy
and (B) ventilation by mask?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
L-5: How does an anesthesiologist decide whether to use a
supraglottic or subglottic rescue approach in a cannot
ventilate, cannot intubate situation?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
2 Pulmonary Edema Following Attempted Nasal Intubation
for Mandibular Fracture Repair . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Zakir Rangwala
L-1: What is the anatomy of the mandible? Where can
fractures occur? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
L-2: What fractures are of particular concern? Airway concerns? . . . . . 14
L-3: What is optimal preparation for nasal intubation?. . . . . . . . . . . . . . 15
L-4: What are the specifi c preparations for fi beroptic
nasal intubation? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
L-5: What is the mechanism of pulmonary edema? . . . . . . . . . . . . . . . . 16
L-6: What is negative pressure pulmonary edema?
How should it be treated?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
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