OR Today Magazine June 2022 by MD Publishing

Water Management

Instrument Storage and Transport

Malignant Hyperthermia

Justin Fontenot

HSPA

MARKET ANALYSIS

CE ARTICLE

LIFE IN AND OUT OF THE OR

SPOTLIGHT ON

JUNE 2022

Compliance Responsibilities

Risk assessment Conflict management The ability to interpret data Integrity

Facilities face many rules, regulations and laws PAGE 40

Detail orientation Communication Problem-solving

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OR TODAY | June 2022

contents features

COMPLIANCE RESPONSIBILITIES: FACILITIES FACE MANY RULES, REGULATIONS AND LAWS Hospitals and ambulatory surgery centers (ASCs) must comply with myriad rules, regulations and laws from an alphabet soup of regulatory entities.

The surgical instrument storage and

The goal of this continuing education

The Eisenhower Matrix provides a

transport market is expected to mirror

program is to provide information about

framework for how to organize our work

the overall surgery market and experience

malignant hyperthermia, including

and prioritize the most important tasks.

continued growth in coming years.

perioperative signs.

MARKET ANALYSIS

CE ARTICLE

EQ FACTOR

OR Today (Vol. 22, Issue #6) June 2022 is published monthly by MD Publishing, 1015 Tyrone Rd., Ste. 120, Tyrone, GA 30290. POSTMASTER: See address changes to OR Today at 1015 Tyrone Rd., Ste. 120, Tyrone, GA 30290. For subscription information visit www.ortoday.com. The information and opinions expressed in the articles and advertisements herein are those of the writer and/or advertiser, and not necessarily those of the publisher. Reproduction in whole or in part without written permission is prohibited. © 2022

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EVENTS

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8 News & Notes 16 HSPA: A New Standard for Water Management 18 AAMI: Sterility Assurance Community Sweeps AAMI Awards 20 Joint Comission: Medication Storage and Security Assessment is Key to Patient Medication Safety 22 CCI: A Whole New Thing: The NPDA-BC Credential

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IN THE OR

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24 M arket Analysis: Instrument Storage and Transport Market Growth Expected 25 Product Focus: Instrument Storage and Transport 30 CE Article: Malignant Hypothermia

Beyond Clean Vangie Dennis, MSN, RN, CNOR, CMLSO, Assistant Vice President, Perioperative Services with AnMed Health System

OUT OF THE OR

44 Spotlight On: Justin Fontenot 46 Health 48 Fitness 50 EQ Factor 52 Nutrition 54 Recipe 56 Pinboard

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INDUSTRY INSIGHTS

news & notes

Vicarious Surgical Announces Cleanroom Qualification Vicarious Surgical Inc., a next-generation robotics company seeking to improve the cost, efficiency and outcomes of surgical procedures, has announced qualification of its cleanroom for manufacturing of the Vicarious System. The cleanroom substantially augments the company’s existing capabilities by providing an environmentally controlled and easily expandable space for precision assembly. Through rigorous testing, the qualification process ensures the space meets stringent efficiency and quality criteria. Cleanroom qualification is an essential step in the manufacturing process for the Vicarious System. “Our commitment to improving patient outcomes, increasing the efficiency of surgical procedures, and reducing health care costs drives everything we do – and that commitment starts with a safe, quality-controlled manufacturing process before the Vicarious System reaches the

operating room,” said Adam Sachs, CEO and co-founder of Vicarious Surgical. “Completing our cleanroom facility ensures we are prepared to develop and finalize our system safely, a critical milestone on our path to bringing our solution to market.” The Vicarious System is designed with a focus on abdominal access and visualization to perform surgical procedures through a single port, offering surgeons unprecedented visualization, surgical site access, and ease of use to enable more consistent and precise procedures, faster patient recoveries and ultimately better outcomes, according to a news release. The system is portable and can be moved from one operating room to another. For more information, visit vicarioussurgical.com.

Surgical Drape Helps Reduce Surgical Site Contamination Cardinal Health has launched the first surgical incise drape using industry-leading antiseptic Chlorhexidine Gluconate (CHG), according to a news release The drape features Avery Dennison’s patented BeneHold CHG adhesive technology, which helps reduce the risk of surgical site contamination with organisms typically associated with surgical site infections (SSIs). The incise film is strong, conformable and breathable and provides a sterile surface to create a barrier to contamination. The adhesive helps prevent edge lift of the drape, while still removing easily after surgery without harming fragile skin. “CHG is trusted as a topical antiseptic for surgical patient skin preparation,” said Tina Keller, senior consultant in clinical operations at Cardinal Health, “and utilizing the antimicrobial properties of CHG in the actual adhesive of the surgical drape is an innovative approach that is intended to improve patient care by further reducing the risk of microbial contamination.”

OR TODAY | June 2022

In addition to preparing a patient’s skin for surgery, incise drapes are utilized as a method of helping protect the wound from horizontal bacterial contamination during surgery, which may be present on the patient’s surrounding skin. “The BeneHold CHG adhesive technology is perfectly suited for incise film applications. The adhesive helps prevent edge lift and maintain a sterile surgical site, while a breathable film encourages good adhesion without damage on removal, including from fragile skin,” said Barbara Van Rymenam, global director of innovation platforms at Avery Dennison Medical. “Avery Dennison is delighted to be partnering with Cardinal Health to bring this innovative technology and product offering to the operating room.” The Cardinal Health Surgical Incise Drape with CHG meets the International Organization for Standardization and the United States Food and Drug Administration requirements for cytotoxicity, irritation, acute systemic toxicity, skin sensitization and pyrogenicity.

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news & notes

End-tidal Control Software Receives FDA Approval GE Healthcare has announced the FDA pre-market approval (PMA) for its End-tidal (Et) control software for general anesthesia delivery on its Aisys CS2 Anesthesia Delivery System. GE Healthcare is the only manufacturer approved to offer general anesthesia delivery with end-tidal concentration control in the U.S. The company initially released the technology in Europe in 2010. Anesthesia providers use Et control software to care for patients in over 100 countries. The Et control software semi-automates the delivery of anesthesia using software, allowing anesthesia providers to set targets for end-tidal oxygen and anesthetic agent. Once targets are set, the software quickly achieves and maintains those targets, regardless of changes in the patient’s hemodynamic and metabolic status. The Et control software improves anesthesia delivery accuracy and simplifies workflows while reducing drug waste, lowering the cost of care and greenhouse gas emissions. “In the past, we continually adjusted vaporizer setting and fresh gas flow to control inspired concentration in an attempt to achieve and maintain the end-tidal concentration we wanted for our patients. To

have direct control of the end-tidal concentration that reflects the drug level in the patient’s blood is a big step forward for our ability to personalize a patient’s care. Additionally, low-flow anesthesia has benefits for hospitals and the environment,” said Dr. Jim Philip, anesthesiologist and director of clinical bioengineering, department of anesthesiology, perioperative and pain medicine, Brigham and Women’s Hospital. Philip, who has been a leading proponent for approval of automated control of inhalation drug administration for years, has also served as a paid consultant for GE Healthcare from April 2020 to December 2021. “Anesthesia providers in the U.S. will have access to the most advanced anesthesia tools available to improve patient care,” said Eric Ruedinger, general manager of GE Healthcare’s anesthesia and respiratory care business. “As the long-standing global leader in anesthesia delivery, GE Healthcare invested in the development and clinical validation of this Et control algorithm, and we are committed to creating clinically relevant solutions that will enhance anesthesia practices into the future.” For more information, visit gehealthcare.com/etc.

Cox Expands Prosight Platform Cox Communications recently announced the addition of hand hygiene monitoring capabilities to its real-time location services (RTLS) platform Cox Prosight. According to the Center for Transforming Healthcare, 2 million patients contract healthcare-associated infections (HAIs) every year and 99,000 succumb to the infection. Cox Prosight’s hand hygiene monitoring capabilities enable hospitals to observe hand hygiene events to the latest Joint Commission and Leapfrog standards and help reduce preventable HAIs. Each sanitizer dispenser facility-wide is equipped with a sensor that transmits real-time data into a dashboard. This enables users to monitor the overall number of hand hygiene opportunities throughout a facility and compliance by staff group, job role, individual employee, department

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and shift. It’s designed to enable the infection prevention team in hospitals to meet stringent Leapfrog requirements. Hand hygiene is just one way Cox Prosight is improving hospital operations. Leveraging RTLS and Cox’s Prosight Core Internet of Things (IoT) platform, Cox Prosight provides hospital administrators and staff with advanced asset tracking, environmental monitoring, staff safety alerts and patient/visitor experience solutions. Cox Prosight is already at work in the field with impactful results. Cox’s longtime health care partner Ochsner Lafayette General has been using Cox Prosight for over six months, tracking 5,400 pieces of equipment, multiple staff members to ensure efficient operations. For more information, visit coxprosight.com.

June 2022 | OR TODAY

INDUSTRY INSIGHTS

news & notes

Aerobiotix Shares New Technologies Aerobiotix has developed two new technologies to disinfect operating room (OR) air which often includes surgical smoke plume, volatile organic compounds, bacteria and viruses. Aerobiotix showcased the Illuvia Sense with real-time data capturing features by deploying more than 20 units to help disinfect the air at the 2022 AORN Global Surgical Conference and Expo. Additionally, nurses could learn more about the AeroCure Vac – a device protecting patients and hospital staff from airborne dangers arising from aerosol generating procedures. The environmental risks from contaminated OR air are well documented. Perioperative nurses report twice the incidence of respiratory problems compared to the general population. Surgical smoke plume, bone cement, skin prep solutions and anesthetic gases can carry volatile organic compounds and other hazardous compounds known to cause cancer if inhaled. Illuvia Sense is a directional flow surgical air disinfection system that improves overall environmental safety in the OR and reduces the risk of surgical site infections, according to a press release. “We know the risks associated with contaminated OR air for health care workers and patients,” said Dr. David Kirschman, Aerobiotix president and CEO. “The most common cause of occupational injury for registered nurses comes from exposure to airborne contaminants, and airborne bacteria is a leading cause of surgical site infections. Our proven technologies reduce those risks and nurses at AORN will get to see it firsthand.” Kirschman is a former neurosurgeon who developed the Illuvia Sense and AeroCure Vac technologies following his experiences in the OR. Standard operating room ventilation delivers clean air directly over the surgical site. However, these systems leave a ring of contaminated air around the clean air of the surgical table, called the “dirty donut,” which may continue to pose a danger to the patient and staff. “Any movement in the OR can disrupt contaminants in the dirty donut and scatter them into the surgical site,” explained Dr. Courtney Adams, Aerobiotix vice president of clinical and medical affairs. “Anything and anyone passing through the dirty donut can

OR TODAY | June 2022

potentially re-expose the surgical site to contaminated air. This includes surgical staff, drapes, instruments, implants, gloves and other surgical equipment.” Illuvia Sense helps eliminate the dirty donut using ultraviolet germicidal technology, HEPA filtration and carbon-copper filters to inactivate over 99.9% of bacteria, viruses and spores in the air — including SARS-Cov-2. The unit operates quietly and independently without disrupting OR workflows. The FDA registered medical air disinfection device is proven to eliminate microbes throughout the OR and not just the surgical site. The Illuvia system has been shown to reduce airborne contamination during surgery by 50-70% in peer reviewed, published and independent studies. The latest generation of the Illuvia system further advances this technology by utilizing an advanced suite of sensors to provide critical real-time intraoperative environmental data to surgical stakeholders. The AeroCure Vac uses a semi-rigid vacuum tube which is placed near the patient during aerosol generating procedures (AGPs). AGPs include endotracheal intubation and extubation, oral and pharyngeal procedures, bronchoscopy, pulmonary function testing, and respiratory treatments and suctioning. Data shows health care workers who regularly perform AGPs have three times the risk of clinically significant respiratory infections. The AeroCure Vac has also been shown to reduce total particles generated during electrocautery by 97% at periphery of room, reduce the concentration of bioaerosols at distances of 4-6 inches, and reduce VOC levels (ppm) generated during the mixing of bone cement at distances of 3-14 inches away from the source, with a 97% reduction observed at 3 inches. AeroCure Vac evacuates contaminated air from near the source. The unique combination of technologies not only pulls particles away from patients and medical staff, but goes a step further in mitigating the risk by subjecting those particles to UV light. The treated air is then returned to the room at floor level. By collecting and eliminating bacteria and viruses carried via aerosols, the AeroCure Vac creates a better protected environment for patients and staff. For more information, visit www.aerobiotix.com.

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SurgicAir Zero debuts in Twin Cities Precision Air has announced the completion of its fourth SurgicAir Zero O.R. Airflow System at TRIA Orthopedic Center Woodbury, a specialty orthopedic and urgent care facility in the Twin Cities metro area. This technology produces zero-particle air in operating rooms and in health care settings, something that has never before been achieved. TRIA is currently testing it at its Woodbury location, according to a news release. The SurgicAir Zero System is a quantum leap in OR airflow quality – far exceeding today’s minimum standards. While numerous studies have proven airborne pathogens are a major source of contamination in the OR, minimum codes for air quality have not kept up, the release adds. “TRIA’s investment in the SurgicAir Zero System shows an innovative approach to infection control. The need for this COVID-capable technology is growing as health care leaders strive to protect patients and create a safe, comfortable experience for everyone in the room,” said Derek Weinschenk, Precision Air president. This technology also enables TRIA to continue critical surgeries during the COVID-19 pandemic with fewer risks to surgical staff and patients. Testing data shows airborne contaminants from procedures like intubation or cauterization are more quickly controlled, leading to 75% less exposure for everyone in the room compared to basic ventilation systems. Surgeons and health care leaders at TRIA who have implemented the system have shared their enthusiasm for the technology. “Our SurgicAir Zero System provides a comfortable, quiet OR environment. However, it is the peace of mind of having clean air in our surgical field that I find to be the largest benefit of this system,” said Dr. Gavin Pittman, orthopedic surgeon at TRIA Orthopedics.

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INDUSTRY INSIGHTS

news & notes

Pixee Medical Launches Knee+ Pixee Medical has announced that its Knee+ AR computer-assisted orthopedic solution is going to be commercially available in the USA. A press release states that it is a “perfect fit for ambulatory surgical centers (ASCs).” Knee+ is a patented platform designed to help orthopedic surgeons perform surgery through the realtime 3D positioning of instruments, right in their field of view. Knee+ is intuitive and consists of proprietary software using a unique proprietary tracking system running on off-the-shelf smart glasses, with no bulky capital equipment or disposables required. “Since our first surgery in the USA in Boston in October 2021, we have organized a successful round of surgeries on multiple clinical sites across the USA.

OR TODAY | June 2022

We are now ready and confident to launch the product in the leading worldwide market for orthopedics,” states Sébastien Henry, founder and CEO of Pixee Medical. “Our solution is the only imageless and open platform for total knee surgery available in the U.S.” Pixee will soon be adding new features to its Knee+ platform, with soft tissue balancing, kinematic alignment and data connectivity. It will also be expanding its portfolio with a mixed reality product for total shoulder arthroplasty and with an easy-to-use cup orientation and leg length controlling AR tool for total hip arthroplasty. Knee+ is now compatible with surgical hoods. For more information, visit pixee-medical.com.

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FDA Clears Sterizone VP4 Sterilization Process Innovia Medical has announced that the Sterizone VP4 sterilization process has been cleared by the United States Food and Drug Administration (FDA), (510(k) number, K210836. The Sterizone VP4 Sterilization System offers a low-temperature sterilization system which can quickly process high volumes of heat and moisturesensitive devices using vaporized hydrogen peroxide, an environmentally friendly sterilant. “The demand for a low-temperature sterilizer offers an alternative for today’s advanced surgical tools

which cannot tolerate high temperature sterilizers. Sterizone VP4 is the solution of choice,” said Aaron Lieberman, director of sales and marketing, Innovia Medical. InstruSafe Instrument Protection Trays provide 360 degrees of protection during sterilization and subsequent transportation and storage. The trays are validated for steam and low-temperature sterilization cycles and are available in any shape or size. InstruSafe Trays have 510(k) clearance for each sterilization cycle.

Alpha Brain Waves Can Predict Post-Surgery Pain Patients who are most likely to suffer severe pain following an operation can be reliably identified using a new technique developed at the University of Birmingham. The technique could allow clinicians to plan additional preventative pain medication during surgery for vulnerable patients. This could mean patients are likely to experience less acute pain during recovery and are also less likely to go on to suffer chronic symptoms. In a pilot study, published in the British Journal of Anaesthesia, a team of researchers showed how electroencephalography (EEG) can be used to measure brain activity in patients about to undergo chest surgery, or thoracotomy. Before surgery, the team measured the patients’ alpha waves, brain signals which oscillate between 8 and 14 Hz. Then, over 72 hours following surgery, patients were asked to score their pain on a scale from 1-10. The researchers were able to demonstrate a clear link between the patient’s alpha waves and their responses to pain. In particular, they found that people whose alpha waves oscillated below 9 Hz were much more vulnerable to severe pain post-surgery. Dr. Ali Mazaheri of the University of Birmingham’s Centre for Human Brain Health and School of Psychology is the senior author of the study. “The experience of being in pain is complicated and subjective, but it’s clear that these alpha waves are a reliable indicator of how severely an individual will experience pain,” Mazaheri said. “That offers clinicians a really valuable biomarker that they can use to

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prevent pain becoming an issue, rather than treating it after it has taken hold and become a serious, and potentially chronic problem.” The study was carried out by Samantha Millard, in the Centre for Human Brain Health, in collaboration with researchers in the University’s Institute of Inflammation and Ageing, University Hospitals Birmingham NHS Foundation Trust. It involved 16 patients about to undergo surgery to treat lung cancer. The alpha waves measured before surgery were able to predict, with 100 percent accuracy, which patients would report a pain score after surgery of 7/10 or higher. This work extends findings from a longstanding collaboration between Mazaheri and Dr. David Seminowicz (Western University, Canada), in which work led by Dr. Andrew Furman (University of Maryland Baltimore) showed PAF is a reliable predictor of pain sensitivity across multiple pain models and timescales (Furman 2018, 2019, 2020, 2021). The new study adds a crucial piece to this literature: the first validation of the pain sensitivity biomarker in a clinical population. While more work is required to determine the precise nature of the link between alpha waves and pain, the team believe it is related to specific pathways in the brain that are known to relay sensory messages from the thalamus – the brain’s central hub for sensory information. Since alpha waves are, in part, regulated by the thalamus, the team believe their frequency directly reflects the balances between pathways which signal pain and those which suppress it.

June 2022 | OR TODAY

INDUSTRY INSIGHTS

news & notes

VirtaMed Announces Inclusive Knee Simulation Model VirtaMed has announced the release of enhanced simulation training modules for arthroscopic knee surgeries. In a first for VirtaMed, these latest training modules will now be available on simulators with two different skin tones. “It is important to learn medical skills in a realistic environment, and that means training on simulators that reflect the diversity of both patients and trainee physicians,” said Dr. Raimundo Sierra, founder and CEO of VirtaMed. “VirtaMed is committed to encouraging diversity and inclusion in the education of medical skills, and we believe these values should also be reflected in the simulator hardware. This is just one step in the right direction toward more equitable health care education and delivery.” A 2005 report released by the Institute of Medicine documented that “racial and ethnic minorities receive lowerquality health care than white people – even when insurance status, income, age and severity of conditions are comparable.” While not referring specifically to surgical outcomes, the report and similar studies have indicated that people of color are less likely to receive effective treatments, due in part to implicit bias from health care providers. In developing the new simulators, VirtaMed collaborated with knee experts Dr. Jacqueline Brady, Dr. Cassandra Lee and Dr. Patrick Joyner from the AANA Knee Taskforce. VirtaMed and AANA knee experts identified high-priority new cases and features with the most potential impact for training the next generation of surgeons. The VirtaMed ArthroS is unique in simulation training as trainees are able to palpate and distract a physical model while at the same time performing a virtual surgery. The new training options are the most recent in a series of updates stemming from a collaborative agreement between VirtaMed and the AANA to advance and improve arthroscopy surgery skill training and develop standards for proficiency-based training curricula. Since 2018, AANA experts have collaborated with VirtaMed to provide expert input on cases and courses for training on the fundamentals of arthroscopy (FAST), and the knee, shoulder and hip joints. For more information, virtamed.com/arthros.

OR TODAY | June 2022

Nihon Kohden America Launches Life Scope G5, G5Max Nihon Kohden America recently announced the expansion of the Life Scope G Series with the U.S. market introduction of Life Scope G5 and G5Max, a new series of bedside monitoring systems. “Created by clinicians, for clinicians – these patient monitors provide more data, more insights and more efficiency for better patient outcomes,” a news release states. “The advanced features of Life Scope G5 and G5Max combine fully optimized, adaptable monitors with an enterprise level server and software applications customized to the needs of clinicians. With consistent user interfaces that are easy to use and streamline workflows, clinicians are empowered to spend more time with their patients and less with technology,” the release adds. The Life Scope G5 is configured as an all-in-one system with a transport monitor nested in the back of the unit and is available in a 12.1-inch display. For a larger high-performance screen, the G5Max is available in a 15.6-inch display with a true flat tempered glass front. Both Life Scope G5 and G5Max allow users to configure the alarms to meet their clinical needs and reduce alarm fatigue. The Life Scope G5 and G5Max offer advanced EGG parameter monitoring such as continuous QTc or QRSd, advanced atrial fibrillation algorithm, enhanced review capability ST analysis and event recall. “With one continuous patient record, from admit to discharge, the Nihon Kohden patient monitoring system gives you more,” the release states. For more information, visit us.nihonkohden.com.

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Lazurite’s ArthroFree Wireless Camera System Receives FDA Market Clearance Lazurite announced that its ArthroFree System is the first and only wireless camera system for minimally invasive surgery to receive U.S. Food and Drug Administration (FDA) market clearance. The ArthroFree System incorporates the company’s proprietary low-heat, high-intensity Meridiem light technology along with advanced camera, battery and wireless transmission technologies. It is designed to deliver improved operating room productivity, patient safety and economic value through cost-savings, energy efficiency and reduced setup/breakdown times. The modular system also is designed to be drop-in compatible with patient data consoles, surgical displays and endoscopes found in minimally invasive operating rooms. “I’ve had the opportunity to use the ArthroFree camera in the laboratory, and I’m absolutely amazed at the quality of the picture and the way the device feels in my hands,” said Mark Schickendantz, M.D., director of the Center for Sports Health at the Cleveland Clinic. “What’s incredible is to be able to use an arthroscope that doesn’t have the cumbersome cables. That is just absolutely incredible.” “With ArthroFree, you have excellent quality images and simultaneously you have a clean, streamlined, uncluttered surgical field. It’s all built into the camera. When you

news & notes

pick it up and pop in the battery, it’s on. In a few years, I think, this is going to be the standard,” said University Hospitals Health System trauma surgeon Jeffrey Ustin, M.D. “The ArthroFree System provides freedom of movement we’ve never had before,” said Laith Jazrawi, M.D., chief of sports medicine at NYU Langone Orthopedic Hospital. “You don’t have to move cables around. The camera is lightweight and easy to handle. I can’t imagine a surgeon who wouldn’t want this.” Eugene Malinskiy, chief executive officer and cofounder of Lazurite, emphasized the company’s commitment to creating high value innovation in partnership with the medical community. “The idea for what is now the FDA-cleared ArthroFree System was born from the very real need to create a safer, more efficient operating room for the benefit of everyone involved – from patients to surgeons to OR teams to clinics and hospitals,” Malinskiy said. Malinskiy and his team believe, “that this truly is the beginning of the operating room of the future. The entire endoscopic market will benefit from our minimally invasive surgical equipment advancement going forward.”

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June 2022 | OR TODAY

INDUSTRY INSIGHTS HSPA

A New Standard for Water Management BY SUSAN KLACIK, BS, CRCST, CIS, CHL, ACE, FCS he Joint Commission (TJC) released a new water management standard (EC.02.05.02. EPs 1-4), which took effect on January 1, 2022. Water quality is a very important component of medical device processing. While this new standard is designed to improve the quality and safety of care provided to immunocompromised hospital patients, it also contains water management measures that impact medical device processing.

This new standard requires that an individual or team be responsible for oversight and implementation of the water management program, including but not limited to development, management and maintenance activities. Author’s note: Because water is fundamental to medical device processing, it is advisable to have representation from the sterile processing department involved in interdisciplinary activities that address water management. The standard also specifies required elements to be included in the water management program, such as a basic diagram that maps water supply sources, treatment systems, processing steps, control measures and end-use points. The water risk management plan is based on the information in the diagram and includes an evaluation of the physical and chemical conditions of each step of the water flow diagram. There is also a requirement for an annual review of the water management program (and whenever

OR TODAY | June 2022

changes occur); this includes having a plan for addressing the use of water in areas of buildings where water may have been stagnant for a period (e.g., areas that have temporarily closed due to COVID-19).

Documentation is essential Individuals or team members responsible for the water management program should document results of all monitoring activities, corrective actions and procedures to follow whenever a test result falls outside acceptable limits (this includes when a probable or confirmed waterborne pathogen indicates action is necessary). It is important to document corrective actions that were taken when control limits are not maintained; when changes have been made to the water system that would add additional risk; when new equipment or at-risk water systems have been added that could generate aerosols or be a potential source for Legionella; and when a new wing or building has been commissioned. Health care facilities’ water systems are often comprised of complex distribution pathways with areas of stagnation, exposure to a variety of plumbing materials, and wide variability in temperature, pH, and disinfectant types and levels. These conditions can promote the development of biofilm and opportunistic pathogens such as Legionella, nontuberculous mycobacteria, and Pseudomonas species. Because of the nature of water systems in health care settings, water exposure while in the facility can

place patients at risk for infection from waterborne pathogens (or even at the risk of outbreak exposure). Further, the Centers for Disease Control and Prevention (CDC) has conducted outbreak investigations that demonstrate how most problems leading to healthcareassociated infection outbreaks could be prevented by effective water management programs. To prevent issues related to poor water quality, TJC adopted this standard as part of an effective water management program that includes individual or team oversight, evaluation of water supply sources, water monitoring protocols and corrective actions. Additional resources are available that describe the water quality requirements for medical device processing, including AAMI TIR34:2014, Water for the reprocessing of medical devices, which is currently under review and is being upgraded to a standard. Water quality is also addressed in the AORN 2022 Guideline for Care and Cleaning of Surgical Instruments. To download the new Joint Commission water management standard, visit: https://www.jointcommission. org/-/media/tjc/documents/standards/ r3-reports/r3-report-water-management-final_nov1.pdf. – Susan Klacik, BS, CRCST, CIS, CHL, ACE, FCS, serves as a clinical educator for the Healthcare Sterile Processing Association (HSPA) and has served as the HSPA (formerly IAHCSMM) representative to the Association for the Advancement of Medical Instrumentation (AAMI) since 1997.

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pro tip: don’t forget to stick out your tongue.

Another important thing to know is that Key Surgical now has more weights and sizes of double-bonded, SMS sterilization wrap than ever before. With sizes starting at 18”x 18” and up to 54”x 54” and weights from 100 to 600, wrapping the various size trays in SPD (making sure to always leave the ‘tongue’ out) will be easier said and done. call

800.541.7995

or visit keysurgical.com

INDUSTRY INSIGHTS AAMI

Sterility Assurance Community Sweeps AAMI Awards AMI recently announced that deserving individuals and teams have received AAMI Awards for their work in standards development.

“These award recipients exemplify how standards development is enriched by the collaboration and leadership of volunteer experts,” said Amanda Benedict, vice president of standards, AAMI. “AAMI standards could not have obtained the global recognition they have achieved if it were not for these volunteer developers’ outstanding commitment to improving patient safety.”

Standards Developer Award This award recognizes major contributions to the development or revision of a specific AAMI or international standard. This year’s recipients are: Carolyn Braithwaite-Nelson has served in AAMI standards development for more than 20 years, participating in AAMI sterilization standards technical committees. Serving as co-chair for Working Group 8, she was instrumental in the revision of AAMI ST72:2019, Bacterial Endotoxins – Test methods, routine monitoring, and alternatives to batch testing. During the development of ISO 11737-3 (DIS) – bacterial endotoxin testing, she was hailed as a “voice of manufacturers,” ensuring equal representation during the international standards writing process.

OR TODAY | June 2022

Mary Ann Drosnock served as the co-chair of AAMI’s Working Group 84 from its inception, leading the first effort to create ANSI/AAMI ST91:2015, a first-of-its-kind document outlining best practices for the sterile processing of endoscopes. Seven years later, that document has been extensively updated for staff and patient safety. To wrap up this essential work during a global pandemic was a test of her leadership and “a demonstration in what a co-chair and a standards developer should embody,” added Nancy Chobin, president of Sterile Processing University. Susan Klacik is a long-time AAMI member and standards development volunteer, having previously cochaired two sterile processing working groups before becoming the current co-chair of Working Group 40 for steam sterilization hospital practices. In this capacity, Klacik led the effort to amend AAMI’s premiere Sterilization Standards document, ANSI/AAMI ST79:2017, Comprehensive guide to steam sterilization and sterility assurance in health care facilities. And her work is not done yet! Klacik is now leading the early development of a firstof-its-kind document to addresses the safe transport of medical devices to and from external locations.

Carolyn Braithwaite-Nelson

Mary Ann Drosnock

AAMI Technical Committee Award This is awarded to up to two AAMI technical committees to recognize their

Susan Klacik

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INDUSTRY INSIGHTS AAMI

outstanding efforts for the greater health technology field. Attention is paid to the results and expected impact of the committees’ hard work, especially in the case of field-defining standards or other guidance. This year, AAMI has recognized Working Group 84, which designed the newly published standards document ANSI/AAMI ST91:2021, Flexible and semi-rigid endoscope processing in health care facilities. Importantly, the document is the product of seven years of deliberation and research conducted by the working group and reflects the consensus of industry, clinicians, and sterilization professionals from around the world. “The revision of the standard represents a complete overhaul to the 2015 version and incorporated innumerable changes in general information, annexes, recommendations and requirements,” explained Drosnock, former co-chair of the group and director of clinical affairs for Healthmark Industries. “Ultimately, this will lead to improved patient outcomes and reduced instances of infections related to endoscopes because of the additional steps that will have to be taken for conformance with the standard.” Additionally, AAMI has recognized Working Group 2, which saw the development and advancement of three im-

portant documents for the radiation sterilization field. After two years of development, AAMI TIR 76, Sterilization of health care products – Radiation-Substantiation of a selected sterilization dose at a specified sterility assurance level: Method VDmaxSD-S was issued alongside a new web-based electronic calculation tool to assist the industry in establishing appropriate radiation dosage. AAMI/CDV-2 TIR104, Guidance on transferring health care products between radiation sterilization sites or modalities, is a new document that also published earlier this year, 2022. “This is a document that will be instrumental to the industry to provide much needed guidance for the transfer of dose between radiation source types,” said Elaine Daniell of Edan-SA Consulting, co-chair of the group. Finally, a popular international standard providing guidance on radiation sterilization process control was adopted as ANSI/AAMI/ISO/TS 11137-4 by the working group to publish later this year, 2022. “This document was fundamental in getting international agreement with controlling and monitoring of the radiation sterilization process for standardization across geographies,” Daniell explained.

Working Group 84 co-chairs Garland-Rhea Grisby (left) and Melinda Benedict (right) stand with former co-chair Mary Ann Drosnock (middle) for a certificate presentation during AAMI’s Sterilization Standards Week. The trio will be presented with a plaque during the 2022 AAMI eXchange.

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June 2022 | OR TODAY

INDUSTRY INSIGHTS

Joint Comission

Medication Storage and Security Assessment is Key to Patient Medication Safety By Maura Naddy, MSN, RNC-OB, CJCP uring clinical practice and studies, health care professionals, especially nurses, quickly become educated on reviewing the “Five Rights” or “Five Rs” for safe medication practices: Right patient, Right drug, Right dose, Right route and Right time.

These five principles are key to assisting in the reduction of medication errors. However, another often overlooked safety practice that is just as important to medication safety, is implementing medication storage and security practices. These practices, occur well before the medication ever reaches a patient. According to American Society of Health System Pharmacists (ASHP), “Careful arrangement of medication storage in a pharmacy and throughout a hospital can help reduce the risk of medication error. In a pharmacy, product arrangement should minimize unintended selection of the wrong product or dosage form” (273). Specifically, within an ambulatory care setting, it is important to recognize that some facilities do not have a pharmacy onsite, so careful arrangement needs to be identified from a different perspective, depending on the type of services offered at each individual location. For specific guidance on storage of each medication, health care organizations should first refer to specific laws and regulations associated with storage, along with the manufacturer’s instructions for use, which are generally printed on the inserts found within

OR TODAY | June 2022

the medication packaging. Another important area to consider is the overall security and safety of the medication’s storage location. The medication management chapter of the “Joint Commission Comprehensive Accreditation Manual” features several requirements that focus on safe medication storage and security. These requirements are designed to assist health care organizations in maintaining medication integrity, promoting availability of medications when needed, minimizing diversion and reducing dispensing errors. Although recommended, but not required, performing a risk assessment of the areas where medications may potentially be stored can provide health care organizations specific guidance on the complexities of storage and security, and assist in implementing storage processes and designs that will promote quality and safety of medication practices within the organization. Within the ambulatory care setting, ambulatory surgery centers (ASCs) provide services which ultimately impact how medications are stored and secured. Offering patients a variety of services can create additional challenges based on the complexity and risk level of the care provided. Specifically, ambulatory surgery centers (ASCs) are required to meet a plethora of state, federal and other safety requirements because of the dynamic variable of services provided within these facilities. The Centers for Medicare and Medicaid Services (CMS) defines an ASC as, “any distinct entity that operates exclusively for the

purpose of providing surgical services to patients not requiring hospitalization and in which the expected duration of services would not exceed 24 hours following an admission.” According to Association of periOperative Registered Nurses (AORN), “Perioperative medication use and administration, postoperative management, medication disposal, staff member and physician education, proper documentation in the medical record by all disciplines, pharmacoeconomics, pharmacy compounding needs, and controlled medication management and oversight are all important components of this segment of care.” Based on these services, it is important that health care organization’s leaders assess each area where medications may be stored to ensure safe medication practices within their facility. ASCs can take some of the following actions to achieve safe medication practices: • Perform a security assessment to identify any gaps or risk points • Consider a multidisciplinary approach in security assessment to ensure all levels of staff are included • Collaborate with a pharmacist or pharmacy consultant to ensure guidelines and safe practices are achieved for each individual medication available within the ASC • Use Automated Dispensing Cabinets for storage of high-risk or all medications available and limit override capabilities

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INDUSTRY INSIGHTS

Joint Comission

• Separate look-alike and sound-alike (LASA) medications to reduce the occurrence medication errors • Ensure proper medication storage based on temperature requirements and ensure they are consistently maintained at the appropriate temperature • Address proper documentation and disposal of partially used medications • Locate and make available required emergency carts/ kits/medications Interdisciplinary teamwork is imperative to ensuring safe medication practices within any health care setting. Ensuring safe medication practices will ultimately help health care organizations, including ASCs, promote and

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provide the safest quality care for their patients. Additionally, it will assist health care organizations through their journey to achieving zero patient harm. – Maura Naddy, MSN, RNC-OB, CJCP, is the senior associate director, SIG operations and quality assurance at the The Joint Commission.

REFERENCES https://www.ashp.org/-/media/assets/policy-guidelines/docs/guidelines/ preventing-medication-errors-hospitals.ashx https://aornjournal.onlinelibrary.wiley.com/doi/10.1002/aorn.12635 https://psnet.ahrq.gov/primer/medication-errors-and-adverse-drug-events

June 2022 | OR TODAY

INDUSTRY INSIGHTS CCI

A Whole New Thing: The NPDA-BC Credential By James X. Stobinski n this column, I would like to discuss a very exciting development for the CCI; the recent launch of our sixth credential – Nursing Professional Development Advanced – Board Certified (NPDA-BC). This credential is very different than the more familiar certifications such as CNOR and CSSM.

The accreditation board for nursingspecific credentials is the Accreditation Board for Specialty Nursing Certification (ABSNC). It has had accreditation standards for these portfolio-based credentials but to date no certification has achieved accreditation. It is difficult to maintain accreditation for small nursing specialties because of the low volume for certification examinations. Portfolio programs are a good fit for these small groups as the psychometric standards for portfolios are different and allow for lower volumes. At the recent American Board of Nursing Specialty (ABNS) meeting in Charleston, South Carolina, one theme came through repeatedly 22

OR TODAY | June 2022

– the potential for synergy among nursing certification boards when working together. In this respect, CCI (in its collaboration on the NPDA-BC credential) was a bit ahead of the curve. The NPDA-BC credential presents a career path for perioperative nurse educators. The orientation process for nurses new to perioperative nursing is a long and resourceintensive path. Perioperative nurse educators are essential to the success of novice perioperative nurses. The collaboration with Association for Nursing Professional Development (ANPD) is an example of what is possible in these partnerships where resources can be combined for mutual benefit. ANPD brings intellectual capital of tremendous value in its recently revised “Scope and Standards of Practice and the Core Curriculum for Nursing Professional Development.”

REFERENCES Association for Nurses in Professional Development. (2017). Core Curriculum for Nursing Professional Development, 5th Edition. Association for Nurses in Professional Development. (2022). Scope & Standards of Practice, 4th Edition. Competency and Credentialing Institute. (2022). Nursing Professional Development Advanced – Board Certified. Accessed March 13, 2022 at: https://www.cc-institute.org/ npda-bc/learn/ Fukada, M. (2018). Nursing Competency: Definition, Structure and Development. Yonaga Acta Medica. 61(1): 1–7. doi: 10.33160/yam.2018.03.001.

– James X. Stobinski, Ph.D., RN, CNOR CNAMB, CSSM(E), is CEO of the Competency and Credentialing Institute.

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IN THE OR

market analysis

Instrument Storage and Transport Market Growth Expected Staff report he surgical instrument storage and transport market is expected to mirror the overall surgery market and experience continued growth in coming years.

Surgical instruments are specially designed tools or devices for performing specific actions or carrying out desired effects during a surgery or operation, such as modifying biological tissue or to provide access for viewing it. A press release from iHealthcareAnalyst Inc. states that the global market for surgical instruments will reach $15 billion by 2027, growing at a compound annual growth rate (CAGR) of 3.9% over the forecast period, driven by advanced technologies such as smart instruments with integrated sensors. Other factors driving market growth include an increasing number of surgical procedures, growing elderly population and high demand for minimally invasive procedures globally, according to the release. Allied Market Research states that the surgical equipment market growth can be attributed to the surge in prevalence of chronic disorders amongst geriatric popula-

OR TODAY | June 2022

tion, increase in number of surgical procedures, and surge in demand for technologically advanced surgical procedures such as minimally invasive surgeries and laparoscopic surgeries. However, uncertainty in reimbursements and lack of trained professionals restrict the market growth. The global surgical equipment market was valued at $31.7 billion in 2019 and is estimated to reach $44.4 billion by 2027, according to Allied Market Research. Grand View Research is another firm that expects the global surgical market to continue to see growth in the coming years. “The global surgical equipment market size was valued at $9.32 billion in 2020 and is expected to grow at a compound annual growth rate (CAGR) of 9.8% from 2021 to 2028,” according to Grand View Research. “Large unmet surgical needs, growing health care costs, rising geriatric population and increasing surgical volume are the key factors projected to drive the market growth during the forecast period. The long-term cost comparison study of medicine therapy with surgery revealed that early surgery is considered more cost-effective as

compared to continuous medication. Patient awareness about the cost benefits of early surgical intervention is increasing with efficient patient counseling during physician visits.” In addition, with the growing burden of health care expenditure in many countries, the product demand is expected to increase over the forecast period, according to Grand View Research. The growing geriatric population across the globe is one of the key factors expected to propel market growth. According to the CDC, around 60% of all surgical procedures were performed on people aged 45 years and above. “As per the United Nations 2019 report, around 16% of the total world population will be aged 65 years and above by 2050. Poor health care coverage over surgeries, shortage of surgical workforce, and low accessibility to surgical need in the low-middle income countries are anticipated to restrain the market growth to some extent. It is estimated that 9 out of 10 people living in low-middle income countries do not have access to affordable and safe surgical care when needed,” Grand View Research adds.

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IN THE OR

product focus

AESCULAP

Aicon Sterile Container System Introducing – the AESCULAP Aicon Sterile Container System. With features that help streamline processes and reduce the possibility of wet sets, Aesculap’s next generation rigid container is everything you’d expect from the market leader. The new AESCULAP Aicon Container delivers greater sterility confidence, 100% container and basket synchronization, up to a 47 percent less dry time with the Enhanced Drying System1 and up to a 200 percent increase in sterile aseptic area.2 Learn more at aesculapusa.com/aicon. 1

Based on FDA Claims. Data on file.

Data on file.

CIVCO

TEE Probe Transport Tray and Storage Cabinets CIVCO’s TEE Probe Transport Trays and Ultrasound Probe Storage Cabinets are designed to streamline probe turnover, helping to make the transportation and storage of ultrasound probes as efficient as possible. The TEE Transport Tray’s reversible push tab-locked lid makes clean/dirty indication easy, and the disposable molded fiber tray and paper lid are made from recyclable materials, eliminating time and resources needed to clean a reusable tray. The Ultrasound Probe Storage Cabinet’s HEPA filtration system provides continuous clean airflow in a dry environment, ensuring that transesophageal, vaginal/rectal, and general-purpose probes stay safe and clean during storage. For more information, visit civco.com.

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June 2022 | OR TODAY

IN THE OR

product focus

Cygnus

Medical Tray Belts Cygnus Medical Tray Belts protect wrapped trays from external damage that can occur during sterilization, storage and transport. The belts provide a cushioned barrier from the many sharp edges that easily rip and tear sterile wrapping, and can prevent abrasion marks and damage caused by dragging wrapped trays. They also reduce the risk of wet packs and other moisture-related problems during steam sterilization. Now available in convenient 30- and 46-inch pre-cut lengths (TBPC30 or TBPC46), or 100-foot rolls (TBR3100NP). For low-temperature sterilization, Cygnus offers BeeSafe Belts (HCB0392). For more information, visit cygnusmedical.com.

Hänel Storage Systems

Rotomat Automated Sterile Storage Carousel Hänel’s Rotomat carousel stores, tracks and manages sterile instruments and PPE in the OR, SPD and central supply. This sterile storage solution makes use of a room’s full height to save floor space, allowing hospitals to store more in less space. The Rotomat improves inventory control, case cart pick accuracy, workplace ergonomics and inventory security with a real-time audit trail of picks, stocks, par levels and expiration dates. The system seamlessly integrates with other hospital software platforms (Lawson, CensiTrac, SPM, etc.), is designed for maximum uptime with built-in redundancies allowing 24/7/365 operation and can be customized to any application.

OR TODAY | June 2022

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IN THE OR

product focus

InstruSafe

da Vinci Tray Protection Products Protect expensive instruments during sterilization, storage and transportation with a tray designed for easy and secure placements. InstruSafe Trays are designed in collaboration with Intuitive Surgical Inc., the maker of the da Vinci Surgical System. Instruments are organized with a medical grade silicone providing 360 degrees of protection. Discover the line of da Vinci protection products and start protecting instruments today.

Henry Schein

Miltex Instrument Cassettes Miltex Instrument Cassettes, distributed by Henry Schein Medical, are manufactured with passivated stainless steel and are available in a variety of sizes and configurations to meet all storage needs. The cassettes also feature a doublehinged, “Tuck-Away” lid that folds under for easy storage during use. This ensures that the lid is not misplaced during procedures, saves valuable space over single-hinge lids, and provides an incline for better instrument viewing and access during procedures. Silicone strips and mats are also available to assure instrument adhesion and retention when the lid is closed. These soft cushion options are customized to fit perfectly into Miltex Cassettes and protect your instrument investment long into the future. For more information, visit HenrySchein.com/ASC.

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June 2022 | OR TODAY

IN THE OR

product focus

KARL STORZ

No-Wrap Sterilization Containers KARL STORZ No-Wrap Sterilization Containers help realize cost savings while protecting equipment investment and reducing the environmental impact of reprocessing. These custom designed containers are a trusted system for protection of endoscopic instrumentation during sterilization, transport and storage. KARL STORZ wrap-free containers provide effective sterilization while reducing waste and enhancing efficiency by eliminating the need for traditional medical blue wrap required for use with traditional sterilization systems. For more information, visit karlstorznetwork1.com/protection1.

Medline

Biohazard Transport Container Medline’s new biohazard transport container safely holds and transports contaminated instruments and devices from the point of use to reprocessing while meeting OSHA blood-borne pathogen standards. Made of durable puncture-resistant plastic, the easyto-clean containers offer a leak-resistant top and bottom, locking lid for safe handling, gripping handles to securely carry the container and a visible biohazard label in accordance with OSHA standards. This red transport container is easily cleaned and consists of three parts, including a detachable inner basket, a base that can handle instrument loads weighing up to 25 pounds and a lid with a thick inner gasket. For more information, visit medline.com.

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IN THE OR

product focus

Welmed

Drawstring Pad Welmed’s Drawstring Pad is a clean, impervious and absorbent field to place scopes and instruments for safe and sanitary transport to the sterile processing department for cleaning and reprocessing. Features include: • Drawstring Pad with blue polyethylene liner and side panels, 39” x 30” • Absorbent center pad for effective fluid control • Durable, puncture resistance design to easily carry weight of two scopes • Two convenient “drawstring” pull cords for secure and easy closure Additional designs are also available. For more information, visit welmed.us/contact-us.

Pegasus

Hygieia Rack System The Pegasus Hygieia Rack System is an 100% aluminum sealed structure with no open holes, movable shelves without tools and standard rails and heavyweight telescopic slides. It features high-density, flexible storage for greater capacity without stacking, protecting packs. Optional add-ons include a no-touch system with built-in handles and silicone pads that virtually eliminate human handling during reprocessing. Stainless shelves/baskets resist contamination and go directly into the autoclave and CSPS container storage system that maintains sterility during SPD to OR transport with ergonomic shelves to access the heaviest containers and helps protect packs from tears. For more information, visit pegasusmedical.net.

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June 2022 | OR TODAY

CE570 ce567

IN THE OR

continuing education

Malignant Hyperthermia alignant hyperthermia (MH) is a life-threatening syndrome associated with an anesthetic trigger. Awareness of MH by all perioperative team members, from those working in the preoperative holding area to those in the Post Anesthesia Care Unit (PACU), is important in preventing negative patient outcomes. The preoperative nurse plays a crucial role in averting an MH crisis by interviewing every surgical patient for a personal and family history of MH.

The goal of this continuing education program is to provide OR nurses, physicians, and surgical technologists with information about malignant hyperthermia, including perioperative signs and management of patients who develop malignant hyperthermia. Imagine that you are an OR nurse assessing your first patient of the day. You help the patient to the OR and onto the table. Standard monitors are applied. You note that this is the 30-year-old patient’s first surgery. He receives routine anesthesia induction medications that include fentanyl IV (Sublimaze®), propofol (Diprivan®), and succinylcholine (Anectine®). Intubation is uneventful. The patient is placed on air and oxygen at 50% flow for each with desflurane (Suprane®) 6% inhalational agent. Within minutes, the anesthesia provider notes muscle rigidity in the patient and an increase in exhaled carbon dioxide, heart rate, and blood pressure. The provider 30

OR TODAY | June 2022

suspects malignant hyperthermia based on these initial findings. As a vital part of the team, what will you do to help? What is the best plan of action? How can you help save this patient’s life? Malignant hyperthermia is a potentially life-threatening hypermetabolic state of muscle activity resulting from a defect in skeletal muscle receptors that allows excessive calcium accumulation. It is primarily encountered intraoperatively after the administration of a triggering anesthetic agent. In rare cases, MH can manifest within one hour postoperatively in the PACU. MH is triggered by depolarizing neuromuscular agents such as succinylcholine or volatile halogenated anesthetic agents such as ether, enflurane, methoxyflurane, desflurane, sevoflurane (Ultane®), or isoflurane (Forane®) (MHAUS, 2017a). Providers who work in dental and emergency care settings should also be aware of MH as they frequently administer some of the triggering agents. MH is an autosomal dominant pharmacogenetic clinical syndrome during which a hypermetabolic state develops and becomes a life-threatening emergency (MHAUS, 2017a; Phillips, 2016). The patient’s body becomes hyperthermic because of increased metabolic activity within the skeletal muscle. During an MH crisis, the skeletal muscles are stimulated to contract, muscle metabolism increases, and depolarization occurs with passage of calcium into the intracellular space. The muscles cannot relax and exposure to one or more of the triggering agents causes a rapid intracellular and

Relias LLC guarantees this educational program free from bias. The planners and authors have declared no relevant conflicts of interest that relate to this educational activity. See Page 37 to learn how to earn CE credit for this module.

Goal and Objectives After taking this course, you should be able to: • Identify patients at risk for malignant hyperthermia • Differentiate the early and late signs and symptoms of malignant hyperthermia • Describe the diagnosis and treatment of malignant hyperthermia

extracellular imbalance of calcium that leads to significant energy use and heat production. At the cellular level, as continuing attempts to correct the hypercalcemia are made, heat production increases. Muscle cell relaxation occurs when reuptake of calcium by the sarcoplasmic reticulin occurs. In patients with MH, it appears as if they have an unregulated passage of calcium from the sarcoplasmic reticulum into the intracellular space causing sustained muscle contraction (Zhou, 2015). Calcium is an extracellular ion of the soft tissue that is necessary for nerve impulse transmission, muscle contraction, cardiac function, and blood coagulation. WWW.ORTODAY.COM

IN THE OR

continuing education There is also a build-up of lactic acid and carbon dioxide. The increased amount of intracellular calcium causes sustained muscle rigidity that increases metabolism in both oxygen-dependent and independent pathways, increasing overall oxygen consumption as well as leading to severe lactic acidosis. Lactic acidosis occurs when the body obtains energy by breaking down glucose reserves without the use of oxygen, also known as anaerobic metabolism. As the levels of lactic acid increase, the muscle membranes break down, releasing myoglobin and potassium stores. The elevated levels of myoglobin, also termed rhabdomyolysis, can lead to kidney damage. As extracellular potassium increases, high levels may predispose patients to cardiac conduction abnormalities, arrhythmias, and even sudden death (MHAUS, 2017a; Phillips, 2016; Zhou, et al., 2015). The etiology of MH, in most cases, is a defect of the genetic receptor that controls calcium release from the sarcoplasmic reticulum of the muscle cell wall. No single gene mutation causes MH susceptibility. However, more than 170 variations in the ryanodine receptor 1 gene (the intracellular calcium channel gene, also called RYR1) have been linked to MH susceptibility (Phillips, 2016; Zhou, et al., 2015; Litman, et al 2020).

History MH was identified in the 1960s in Australia by researchers when a 21-year-old patient told his physicians he was more concerned about receiving anesthesia than having surgery for his broken leg. Ten close relatives had died when under anesthesia during minor procedures. The anesthesiologist thought the deaths were caused by ether so he gave the young man a new anesthetic gas, halothane. The patient became cyanotic and displayed erratic vital signs, including hyperthermia. Monitoring end-tidal carbon dioxide and body temperature were not the standard of care at that time. The anesthesiologist treated the patient symptomatically and packed him in ice. The patient became WWW.ORTODAY.COM

the first recorded person to survive an MH crisis. One of the researchers traced the autosomal dominant inheritance of the family’s severe reaction to anesthesia over three generations. He later published his findings in The Lancet (Denborough et al., 1970). The patient had surgery later under spinal anesthesia without incident. Malignant hyperthermia does not discriminate among races. All ethnic groups are affected in all parts of the world. Reactions develop more frequently in males than females by a 2-to-1 ratio. MH is not X-linked as are many other muscular diseases such as muscular dystrophy. The incidence of MH reactions ranges from 1 in 100,000 for adults to 1 in 30,000 pediatric anesthetic administrations, with the prevalence of the genetic abnormalities being as great as 1 in 2,000 people. Overall, this amounts to approximately 500 to 800 surgical cases that are complicated by MH each year. The true prevalence is difficult to define because of unrecognized mild or aborted reactions. Some patients have had previous surgery under general anesthesia without any reactions (Phillips, 2016). The highest incidence of MH is in males with a median age of 39 (Phillips, 2016). Patients who have an increased muscular build or muscular deformity are associated with a greater risk of death during an MH crisis. Early studies concluded that mortality ranged between 70% and 90% before treatment options and monitoring devices for carbon dioxide levels were developed. Later studies showed that with appropriate diagnosis and treatment, the mortality rate fell to around 5% (MHAUS, 2017b). Animal studies have shown that some genetically similar mammals, particularly swine, display hypermetabolic symptoms similar to those in humans when exposed to triggers such as depolarizing neuromuscular blockers and volatile anesthetic gases (MHAUS, 2017a; Phillips, 2016). Nondepolarizing neuromuscular agents, barbiturates, sedatives, and nitrous oxide do not trigger the syndrome and can be

used to perform a surgical procedure without danger. These anesthetic agents and drugs keep the patient anesthetized for surgery and allow for endotracheal intubation, which is frequently required. Local and regional anesthetics are also safe in that they have not been implicated in MH reactions (MHAUS, 2017a).

Signs and Symptoms The most common initial sign of acute MH is an unexplained rise in end-tidal carbon dioxide, known as hypercarbia. Carbon dioxide levels rise above the normal 35 to 45 mmHg range despite increasing the respiratory rate for the ventilator settings. This rise in carbon dioxide of more than 60 mmHg is a hallmark indicator of MH (MHAUS, 2017c). Muscle rigidity after the administration of a depolarizing agent, especially masseter spasm or trismus (contraction of the jaw muscles), is another potential sign of MH. Trismus can be present in the absence of MH and is not uncommon in small children (Phillips, 2016). Unexplained tachycardia and tachypnea are also early signs of MH. Ventricular fibrillation, a lethal heart dysrhythmia that can be seen on an electrocardiogram, can develop within minutes of the onset of MH and may rapidly lead to death (Phillips, 2016; MHAUS, 2017c). Later signs of MH include metabolic acidosis, hyperthermia sometimes as high as 107 degrees Fahrenheit, and evidence of rhabdomyolysis. Rhabdomyolysis is the catabolism (breakdown) of skeletal muscle associated with excretion of myoglobin (a protein in muscle fibers) in the urine (MHAUS, 2017c). Rhabdomyolysis is characterized by dark brown urine caused by myoglobinuria with hyperkalemia (increased potassium). There is increased myoglobin and total creatine kinase (CK) levels in blood samples, resulting from muscle membrane breakdown. The myoglobin in the urine causes damage to the renal tubules and ultimately causes renal failure (Phillips, 2016; Chavez, 2016). June 2022 | OR TODAY

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continuing education Arterial blood gas analysis and lab findings reveal metabolic acidosis. Severe hyperthermia (core temperature greater than 104 F [40 C]) results from a marked increase in oxygen consumption and increased carbon dioxide production during sustained muscular contraction. Remember, hyperthermia is usually a later sign of MH (Walter & Carraretto, 2016). Patients exposed to extreme body temperature elevation for prolonged periods of time experience more central nervous system (CNS) complications post event. An example of a CNS complication is seizure activity (Walter & Carraretto, 2016). Vasoconstriction associated with protracted muscle contraction may cause widespread multisystem organ failure and disseminated intravascular coagulation (DIC). Further life-threatening conditions arising from MH include compartment syndrome of the limbs secondary to profound muscle swelling (Litman et al., 2020; Gupta & Hopkins, 2017).

Diseases That Mimic Other diseases may be confused with MH including trismus, central core disease, and neuroleptic malignant syndrome. Patients who exhibit trismus during induction of anesthesia are difficult to intubate, and loss of airway is a significant concern. The safest course of action is to assume that masseter spasm is due to MH and to postpone elective surgery under general anesthetic (MHAUS, 2017a; Phillips, 2016). Patients with masseter muscle rigidity are at greater risk for MH and should be tested. Because masseter muscle rigidity can be one of the initial signs of MH and half of the patients exhibiting masseter muscle rigidity are susceptible to progressing to MH, it is recommended to stop infusion of the triggering agent. Refer the patient for testing rather than continue to expose the patient to a possible MH incident (Gupta & Hopkins, 2017). Central core disease is an inherited myopathy characterized by muscle 32

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weakness and hypotonia. Central core disease shares the same RYR1 gene mutations that MH exhibits. Patients with central core disease are more susceptible to MH and should be treated carefully (Litman et al., 2020). Neuroleptic malignant syndrome (NMS) is characterized by hyperthermia, muscle rigidity, autonomic instability, and altered consciousness in patients receiving antidopaminergic agents. NMS is caused by an imbalance of neurotransmitters in the CNS and shares many symptoms with MH including an elevated temperature (although mild), muscle rigidity, tachycardia, and elevated CK levels. Although this syndrome is separate from MH, many clinicians believe it is safer to avoid triggering agents in patients who have experienced neuroleptic malignant syndrome to decrease the possibility of MH (Zhou, 2015; Gupta & Hopkins, 2017). A variety of unusual conditions may resemble MH under anesthesia including sepsis, thyroid storm, pheochromocytoma, and iatrogenic overheating from sources such as warming blankets, heat lamps, and room temperature. MH is associated with more dramatic degrees of metabolic acidosis and venous desaturation (the decrease of oxygen in the venous blood) than these other diseases and conditions. Sepsis shares several characteristics with MH including fever, tachycardia, and metabolic acidosis (Gupta & Hopkins, 2017). In patients with poorly controlled hyperthyroidism, thyroid storm can cause tachycardia, tachydysrhythmias (especially atrial fibrillation), hyperthermia, and hypotension. Thyroid storm presents with hypokalemia and generally develops postoperatively. Pheochromocytoma is a vascular tumor in the adrenal glands that produces and secretes norepinephrine and epinephrine. It is associated with dramatic increases in heart rate and blood pressure but not the rise in end-tidal carbon dioxide or hyperthermia as in an MH crisis. Iatrogenic overheating can come from sources such as heat

lamps and humidifiers on the ventilator (Litman et al., 2020; Gupta & Hopkins, 2017). After succinylcholine is administered, hyperkalemia can occur in young patients who have muscular dystrophy, causing sudden cardiac arrest. Patients with crush injury, burn patients, and patients with muscular dystrophy should not receive succinylcholine. Often confused with MH, sudden hyperkalemic cardiac arrest syndrome (increased levels of potassium that cause arrhythmia/asystole) can occur in young males during or shortly after receiving anesthesia (MHAUS, 2017a, Phillips, 2016). When exposed to anesthetic triggering agents, these patients can develop life-threatening potassium levels that lead to dysrhythmias and muscle catabolism. The rise in potassium after giving succinylcholine mimics the hyperkalemia associated with MH. Therefore, it is best to avoid this drug with this patient population. These patients do not exhibit the classic rise in temperature or the marked muscle rigidity of MH (Rosenberg et al., 2005).

At-Risk Patients MH is a genetically associated entity which is more commonly seen in males than in females. MH is either diagnosed after sustaining an acute crisis of MH after receiving an offending agent or via the caffeine halothane contracture test (CHCT). The CHCT is considered the gold standard for diagnosis of MH in suspected or at-risk patients and uses skeletal muscle that is newly biopsied. The test involves assessing for contracture of muscle fibers in the presence of halothane or caffeine (Gupta & Hopkins, 2017). The contracture test is performed after an open thigh muscle biopsy at a specially designated testing center. The fresh muscle is then exposed to increasing concentrations of halothane and caffeine within one hour of procurement. Because of the relative complexity of the test, only a few centers worldwide perform it. Four are in the U.S., and one WWW.ORTODAY.COM

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continuing education is in Canada. If a muscle biopsy cannot be performed, genetic analysis is a reasonable method by which to identify mutations of the RYR receptor on the skeletal muscle. However, this is not always a conclusive method of diagnosing MH. Molecular genetics testing can be performed and sent by postal mail through several centers in the U.S. The Malignant Hypothermia Association of the United States lists locations for caffeine contracture and genetic testing for MH syndrome susceptibility at its website (Gupta & Hopkins, 2017). DNA analysis, started in 1990, requires only a blood test and offers an alternative to CHCT. A negative DNA result, however, cannot be used alone to rule out susceptibility because of the heterogeneity of the disorder as well as dissimilarity within families (Gupta & Hopkins, 2017). Because of the vast number of mutations that may cause MH, a specific family mutation must be identified to perform a genetic test. Molecular genetic testing via RYR1 screening analysis is in its beginning stages and will become more useful as additional research identifying causative mutations is completed. It is worth noting that testing is expensive and not always covered by insurance (Gupta & Hopkins, 2017). A sample test from buccal cells, white blood and muscle cells, or other tissues can be used for mutation analysis of RYR1. There are now screens for many common mutations (MHAUS, 2017b). Preoperative testing will be recommended for relatives of patients with known MH susceptibility and patients who experience suspicious clinical episodes of MH (Phillips, 2016; Gupta & Hopkins, 2017; Denholm, 2016). Additional methods for testing have been used including the insertion of a microdialysis catheter directly into skeletal muscle and testing B-lymphocytes that harbor RYR1 protein and release calcium when stimulated with caffeine. Neither has been sufficiently validated to be clinically useful. Susceptible patients should undergo validated, trusted testing WWW.ORTODAY.COM

to protect themselves and their families from future surgery/anesthetic preventable MH complications (Phillips, 2016; Gupta & Hopkins, 2017).

Treatment Rapid, effective treatment of MH requires simultaneous actions by all team members including nurses, surgical technologists, anesthesia staff, and other types of physicians. All staff should be familiar with the location of the MH supplies and the treatment protocol. Early recognition of MH is critical so that treatment can be started expediently. Interaction among team members is crucial to manage an MH crisis. An important step in the immediate treatment of suspected MH is for the anesthesiologist to stop the administration of triggering agents and flush the ventilator with 100% oxygen (Phillips, 2016; MHAUS, 2017b; MHAUS, 2017c; Isaak & Stiegler, 2016). Every member of the surgical team should have a specific role in the effort to prevent confusion and duplication of the treatment efforts (Isaak & Stiegler, 2016). Rapid administration of dantrolene sodium (Dantrium® or Revonto®) is the first-line medication treatment for suspected MH. It is a direct-acting muscle relaxant. Introduced into clinical practice in 1979, dantrolene sodium continues to be the primary treatment for MH. The dantrolene sodium molecule is highly lipophilic (capable of dissolving in fats) which ensures a rapid crossing of the blood-brain barrier. It works by binding to the RYR1 receptor, thus inhibiting calcium release from the sarcoplasmic reticulum. Dantrolene sodium impairs the excitation-contraction coupling of the muscle cell membrane in muscular contraction. This leads to skeletal muscle relaxation and resolution of MH by restoring intracellular calcium balance and decreasing metabolism (MHAUS, 2017c). Dantrolene sodium is supplied in glass vials that contain 20 mg of lyophilized dantrolene sodium, 3 grams of mannitol (Osmitrol®), and sodium hydroxide

(for pH balance at 9.5), which are in a yellow powder form. Each vial requires 60 mL of sterile injectable water as a diluent and requires vigorous shaking for several minutes. Only preservative-free sterile injectable water should be used to reconstitute any form of dantrolene sodium because of the large quantities (around 700 mL) required for administration. It can take up to 36 vials of dantrolene sodium to stabilize and maintain the patient in an MH crisis (Phillips, 2016; MHAUS, 2017c). The initial dose of dantrolene sodium is 2.5 mg/kg given IV every five minutes and then titrated to a suggested upper limit of 10 mg/kg as necessary based on lab results and clinical response (Phillips, 2016; Denborough, 1970; MHAUS, 2017b). A response is evident with muscular relaxation, lowered end tidal carbon dioxide levels, and improvement in tachycardia (MHAUS, 2017c). More may be given as needed. For example, a 70-kg person would require an initial dose of 175 mg, or nine vials, reconstituted every five minutes until MH symptoms subside, followed by repeated dosage as clinically indicated and/ or every 10 to 15 hours for 24 to 48 hours post-event (Zhou et al.,2015). The weight-based dosage for pediatric patients is the same as for adults (Phillips, 2016; MHAUS, 2017b). A critical preoperative assessment factor is to document every patient’s weight in kilograms for rapid use in the event of need for emergency medication (Phillips, 2016; MHAUS, 2017b; Denholm, 2016; Litman et al., 2019). Summary of doses of dantrolene: • Initial Dose of dantrolene • 2.5 mg/kg given IV every five minutes a suggested upper limit of 10 mg/kg • Sample dose of dantrolene • 175 mg, or nine vials, reconstituted every five minutes until MH symptoms subside Large quantities of reconstituted dantrolene sodium are needed. Therefore, a central line may be necessary. June 2022 | OR TODAY

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Muscular contractions make peripheral veins unreliable and incapable of handling large infusions. Tissue necrosis can result if the drug extravasates from a peripheral IV line. Dantrolene sodium is continued at 1 mg/kg every four to six hours after the crisis is controlled and is continued for 72 hours after the episode (Phillips, 2016; MHAUS, 2017b; MHAUS, 2017c). The perioperative nurse plays a helpful role in mixing this medication (Isaak & Stiegler, 2016; Litman et al., 2019). Slightly warmed sterile water, 96.8 F to 100.4 F (36 C to 38 C), can speed up the process. Dantrolene sodium is available in generic form. The recommended shelf supply is 36 vials to stabilize and treat the patient during an MH crisis. More drug should be available to maintain the patient postoperatively in the critical care or intensive care unit (Phillips, 2016; MHAUS, 2017b). In July 2014, the U.S. Food and Drug Administration approved a new form of dantrolene sodium, Ryanodex®. It is supplied in 250-mg vials with 125 mg mannitol and requires only 5 mL of room temperature, non-bacteriostatic sterile water for reconstitution, minimizing the risk of fluid overload (MHAUS, 2017b). It can be mixed in 20 seconds by the same person who administers the drug. The benefits of this newer medication include that it can be mixed and given more quickly and efficiently along with a lower likelihood of fluid overload. A central line may not be necessary. The drug must be administered via syringe and not incorporated into an IV bag infusion. The rapid-dissolving formula in one vial is enough to stabilize the patient in crisis. Reconstituted dantrolene sodium should be protected from direct sunlight and must be used within six hours of mixing (Phillips, 2016). Other diluents such as D5W or saline change the effects of dantrolene 34

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sodium. Lactated Ringer’s solution can increase metabolic acidosis and should not be used. Mannitol is included to protect the kidneys against myoglobinemia through diuresis (muscle damage causes myoglobin to be released into the bloodstream). The use of additional mannitol during the crisis should take into account the amount contained in the dantrolene during dosage calculations (Phillips, 2016; MHAUS, 2017b). Dantrolene sodium should only be used in pregnant and lactating women if the benefits outweigh the risks (Phillips, 2016). The long-term risks of dantrolene on breastfeeding has not been fully researched. Some studies suggest that it can cause muscle weakness in the breastfed infant and also respiratory depression. It crosses the placenta, and it also passes into breast milk. Although considered relatively nontoxic and having no absolute contraindications, dantrolene sodium is used with caution in patients with hepatic disease and the elderly, because the liver metabolizes it (Phillips, 2016; MHAUS, 2017b). Another treatment measure is to cool the patient by all routes available if core temperature is greater than 102.2 F (39 C). This can be done by instilling nasogastric lavage with iced solution; applying ice packs along heat transfer points like the groin, axilla, and neck or base of skull; and taking more aggressive measures as needed. Care needs to be taken so that as the crisis diminishes, the patient does not become hypothermic. Cooling procedures may conclude at a core temperature of < 100.4 F (<38 C) (MHAUS, 2017c). A Foley catheter should be inserted to monitor renal function. This catheter should not be used for cooling irrigations, because the irrigant could be confused with output.

The goal is to maintain urine output at 300 mL per hour (Phillips, 2016). Labs and blood gases should be drawn to evaluate electrolytes, potassium, CK levels, and coagulopathies. Sodium bicarbonate may be administered in the setting of severe acidosis. (MHAUS, 2017c). The urine should be observed for myoglobin. Hyperkalemia should be treated by typical protocols including hyperventilation with 100% oxygen and the administration of bicarbonate, albuterol, glucose, and insulin IV as needed. Administration of calcium chloride or calcium gluconate should be considered in cases of lifethreatening hyperkalemia (MHAUS, 2017c). Hyperkalemic patients with EKG changes should receive calcium to stabilize the cardiac membrane. However, there is a potential risk to worsen the MH as it is a calciumdriven pathology. CK levels track the severity of rhabdomyolysis, and repeated serum chemistry panels monitor renal function. Dysrhythmias, which might include sinus or ventricular tachycardia or ventricular fibrillation, should be treated symptomatically (Phillips, 2016). Calcium channel blockers, such as verapamil (Calan®, Verelan®), are contraindicated with dantrolene sodium as this drug combination might cause hyperkalemia (Phillips, 2016; Litman et al, 2020). The Malignant Hyperthermia Association of the United States sponsors a 24-hour emergency hotline for medical professionals, 800-644-9737. Because many tasks and interventions must be completed rapidly, anesthesia staff should solicit extra help in caring for the patient (Isaak & Stiegler, 2016). This is one example of many in which the perioperative team member is a tremendous asset in caring for the patient with MH. After team members control the crisis, they continue with monitoring of WWW.ORTODAY.COM

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and caring for the patient. The following interventions should be part of the patient’s care (Phillips, 2016; Litman et al, 2020; MHAUS, 2017c; Litman et al, 2019): Because the patient is at risk for developing acute myoglobinuric renal failure, urine output should be maintained at 2mL/kg/hour by administering IV fluids followed by furosemide (Lasix) and mannitol. Kidney dysfunction can worsen if urine volume is reduced. Ideal output is 300 mL per hour. The perioperative nurse should monitor the patient’s core body temperature. Patients can become hypothermic because of cooling measures. If the patient is hypothermic (97 F [36.1 C] or less), a warming blanket or forced air warmer may be provided and IV fluids warmed before infusion, if necessary. High or low potassium levels (outside the normal range of 3.5 mEq/L to 5 mEq/L) should be assessed to prevent continued heart dysrhythmias. IV potassium boluses may be given slowly for hypokalemia. Hyperkalemia may be lowered by typical protocols which may include administering glucose and insulin; sodium bicarbonate; and albuterol, and by increasing ventilation, which drives potassium back into the cell. The patient should be observed in the critical care or intensive care unit for 24 to 72 hours. The patient should be evaluated for the need for continued mechanical ventilation and administration of maintenance dantrolene sodium. Elevated liver function values are often observed 12 hours to 36 hours after the event, as well as DIC with coagulopathy, thrombocytopenia, and abnormal bleeding. Post-event, the patient may complain of muscle pain and weakness caused by the prolonged contractions. Pain medication may be necessary (Phillips, 2016). The patient and family should be referred for MH testing, and required WWW.ORTODAY.COM

forms should be submitted to the MH registry at the North American Malignant Hyperthermia Registry(Phillips, 2016; Denholm, 2016; MHAUS, 2017a).

Preventive Measures A thorough anesthetic history determines whether a patient or family member has experienced an MH episode in the past. If there is any likelihood of an episode, no triggering agents should be used, and tape should be placed over the inhalation agents in the OR. Regional or local anesthetics may be a more suitable choice for patients at risk for MH (MHAUS, 2017a). Several types of patients should avoid triggering agents because of their health history. For instance, patients with Duchenne muscular dystrophy and central core disease should not receive triggering agents. Patients younger than age 12 are at risk for undiagnosed muscular dystrophy. Therefore, succinylcholine should be avoided in elective procedures to prevent a hyperkalemic response (MHAUS, 2017a; Phillips, 2016). All patients should have their core temperatures and end-tidal carbon dioxide monitored when under general anesthesia. The anesthesia machine should be prepared for a susceptible patient by flushing it with 100% oxygen at a rate of 10 L/minute for 20 minutes, using a fresh circuit and removing all the vaporizers. Examples of safe medications that may be used are barbiturates, benzodiazepines, opioids, and nitrous oxide (Phillips, 2016; Walter & Carraretto, 2016; Denholm, 2016; Litman et al., 2019). Malignant hyperthermia is a life-threatening syndrome. Awareness of MH by all perioperative team members from those working in the preoperative holding area to those in the PACU is important in preventing negative patient outcomes (Phil-

lips, 2016; Denholm, 2016; MHAUS, 2017a). The preoperative nurse plays a crucial role in averting an MH crisis by interviewing every surgical patient for a personal and family history of MH. Perioperative and perianesthesia nurses can help patients by being knowledgeable about the signs and symptoms of MH, implementing evidence-based care, and educating patients and families about MH. Finally, the entire OR team should coordinate its efforts to work efficiently together to ensure the best possible care for their patients (Phillips, 2016; Walter & Carraretto, 2016; Denholm, 2016; Litman et al., 2019).

Summary Now that you have finished viewing the course content, you should have learned the following: • How to identify patients at risk for malignant hyperthermia • Information used to differentiate the early and late signs and symptoms of malignant hyperthermia • The diagnosis and treatment of malignant hyperthermia Malignant hyperthermia is a lifethreatening syndrome associated with an anesthetic trigger. Perioperative and perianesthesia team members can help patients by being knowledgeable of the risks of malignant hyperthermia and its signs and symptoms, implementing evidence-based care, and educating patients and families about MH. Awareness of MH by all perioperative team members, from those working in the preoperative holding area to those in the PACU, is important in preventing negative patient outcomes. The preoperative nurse plays a crucial role in averting an MH crisis by interviewing every surgical patient for a personal and family history of MH.

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continuing education

Course Contributors:

Clinical Vignette

The content for this course was revised by Laura Stallings, CST, BS. Laura Stallings is a certified surgical technologist with a Bachelor of Science degree. She has worked in the OR since 2007. Laura is currently an instructor in the surgical technology program at Southeast Community College.

Juan Martinez, a 20-year-old male, arrives at the OR for a laparoscopic cholecystectomy, and standard monitors are applied. His initial blood pressure is 133/74 mmHg, heart rate 95, and oxygen saturation 98% on room air. Juan is 5 feet 10 inches tall and weighs 195 pounds. He is given fentanyl (Sublimaze®) 150 mcg IV, propofol (Diprivan®) 200 IV, lidocaine (Xylocaine®) 50 mg IV, and succinylcholine (Anectine®) 180 mg IV as determined by his health history. After an uneventful induction and intubation with a No. 8 endotracheal tube, the patient is placed on oxygen at a 2-liter flow rate with desflurane (Suprane®) inhalation agent at 6% concentration. The nurse notes an elevated heart rate of 120 beats/minute and blood pressure of 180/105 mmHg, but she assumes it is in response to intubation. The nurse anesthetist adjusts the ventilator settings for a tidal volume of 900 mL and a respiratory rate of 10 breaths/minute. The end-tidal carbon dioxide (ETCO2) level reads 44 mmHg. She places an esophageal temperature probe and gets a core reading of 96.9 F (36.1 C). After several minutes, the patient’s vital signs are HR 144 beats/minute, BP 205/115 mmHg, ETCO2 55 mmHg, and temperature 98.2 F (36.8 C). Working with the nurse anesthetist, the RN troubleshoots the anesthesia circuit, increases the respiratory rate to blow off more carbon dioxide and draws a venous blood gas to send for evaluation. The nurse anesthetist gives an additional 100 mcg of fentanyl IV with no decrease in the patient’s heart rate. Upon closer examination, Juan exhibits muscle contracture in his jaw, alarming the staff and alerting the team to the possibility of malignant hyperthermia.

This course was reviewed by Daniel Migliaccio, MD. Dr. Migliaccio is currently faculty at the University of North Carolina at Chapel Hill, North Carolina. He is on the editorial board for Pediatric Emergency Medicine Reports. He completed his residency in Emergency Medicine at Stanford University. He has an Honors Certificate in Medical Education from the Clinical Teaching Scholars Honors Program at Stanford University. He is the Vice President of the Young Physician Section of American Academy of Emergency Medicine and has had editorial roles in various journals. This course was edited by Relias staff writer Olive Peart, MS, RT (R) (M). Olive Peart is an established author, educator, and radiographer. She has authored several textbooks and regularly presents mammography and other radiography-related topics at seminars throughout the United States and Canada plus internationally via webinars. Acknowledgment: Nancymarie Phillips, PhD, RN, RNFA, CNOR(E), and Dawn Demangone-Yoon, MD, were the previous authors of this educational activity but have not influenced the content of the current version of this course.

1. What venous blood gas and lab results would the clinician expect to find for Juan? A. Hyperkalemia, hypercarbia with a PaCO2 greater than 60 mEq B. Hypokalemia, hypocarbia with a PaCO2 less than 45 mEq C. Hyponatremia, pH greater than 7.45 D. Hypernatremia, pH greater than 7.45 Feedback: High potassium results from the breakdown of muscle, and a rise in carbon dioxide of more than 60 mEq is the hallmark indicator of malignant hyperthermia.

2. What is the first step the anesthesia provider should take in caring for Juan? A. Call for a stat portable chest X-ray B. Assess for a high fever C. Discontinue all triggering anesthetic agents and provide 100% oxygen D. Proceed with the surgery Feedback: Rapid, effective treatment of MH requires simultaneous actions by the perioperative nurses and physicians. An important step in the immediate treatment of suspected MH is for the anesthesiologist to stop the administration of triggering agents and flush the ventilator with 100% oxygen.

3. Which agent was a trigger for Juan’s malignant hyperthermia episode? A. B. C. D.

Propofol Fentanyl Desflurane Lidocaine

Feedback: Inhalation agents, like desflurane (Suprane®), can trigger episodes of malignant hyperthermia.

4. Which test can definitively determine malignant hyperthermia in Juan? a. DNA testing b. MRI c. CT scan d. Caffeine halothane contracture test Feedback: Caffeine halothane contracture test is the best test for definitive diagnosis of malignant hyperthermia in the patient.

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ce567

How to Earn Continuing Education Credit References 1.

Chavez, L.O., Leon, M., Einav, S., Varon, J. (2016). Beyond muscle destruction: a systematic review of rhabdomyolysis for clinical practice. Critical Care, 20(1):135. doi: 10.1186/s13054-016-1314-5.

Denborough, M.A., Forster, J.F.A., Hudson, M.C., Carter, N.G., Zapf, P. (1970). Biochemical changes in malignant hyperpyrexia. Lancet, 295(7657):1137-1138. doi: 10.1016/S0140-6736(70)91214-6.

Denholm, B.G. (2016). Using informatics to improve the care of patients susceptible to malignant hyperthermia. AORN Journal, 103(4):365-376. e1-4. doi: 10.1016/j.aorn.2016.02.001.

Gupta, P.K., Hopkins, P.M. (2017). Diagnosis and management of malignant hyperthermia, BJA Education, 17(7), 249–254. https://doi. org/10.1093/bjaed/mkw079

Isaak, R.S., Stiegler, M.P. (2016). Review of crisis resource management (CRM) principles in the setting of intraoperative malignant hyperthermia. Journal of Anesthesia, 30(2):298-306. doi:10.1007/s00540-0152115-8.

Litman, R.S., Jones, S.B., Crowley, M. (2020). Malignant hyperthermia: Diagnosis and management of acute crisis. UpToDate. https://www. uptodate.com/contents/malignant-hyperthermia-diagnosis-and-management-of-acute-crisis

Litman, R.S., Smith, V.I.; Larach, M.G., Mayes, L.; Shukry, M.; Theroux, M.C.,Watt, S., Wong, C.A. (2019). Consensus statement of the malignant hyperthermia association of the United States on unresolved clinical questions concerning the management of patients with malignant hyperthermia, Anesthesia & Analgesia, 128(4), 652-659. doi: 10.1213/ ANE.0000000000004039

Malignant Hyperthermia Association of the United States (MHAUS). (2017a). Safe and unsafe anesthetics. http://www.mhaus.org/healthcareprofessionals/be-prepared/safe-and-unsafe-anesthetics

Malignant Hyperthermia Association of the United State (MHAUS). (2017b). FAQs: dantrolene. http://www.mhaus.org/faqs/dantrolene

10.

Malignant Hyperthermia Association of the United States (MHAUS). (2017c). Managing an MH crisis. http://www.mhaus.org/healthcareprofessionals/managing-a-crisis

11.

Phillips, N. (2016). Berry and Kohn’s Operating Technique. 13th ed. Elsevier; 617-619.

12.

Rosenberg, H., Ganesh, A., Saubermann, A. J., & Nicolson, S. C. (2005). MHAUS reports 3 unique cases of hyperkalemic cardiac arrest. Anesthesia Patient Safety Foundation, 20(2). https://www.apsf.org/article/ mhaus-reports-3-unique-cases-of-hyperkalemic-cardiac-arrest/

13.

Walter, E.J., & Carraretto, M. (2016). The neurological and cognitive consequences of hyperthermia. Critical Care, 20(1):199. doi: 10.1186/ s13054-016-1376-4.

14.

Zhou, J., Diptiman, B., Allen, P.D., Pessah, I.N. (2015). Malignant hyperthermia and muscle-related disorders. In: Miller RD, Cohen NJ, Eriksson LI, et al, eds. Miller’s Anesthesia. 8th ed. Saunders.

1. Read the Continuing Education article. 2. Go online to ce.nurse.com to take the test for $12. If you are an Unlimited CE subscriber, you can take this test at no additional charge. You can sign up for an Unlimited CE membership at https://www.nurse.com/ sign-up for $49.95 per year.

Deadline Courses must be completed by 6/30/2023 3. If the course you have chosen to take includes a clinical vignette, you will be asked to review the vignette and answer 3 or 4 questions. You must answer all questions correctly to proceed. If you answer a question incorrectly, we will provide a clue to the correct answer. 4. Once you successfully complete the short test associated with the clinical vignette (if there is one), proceed to the course posttest. To earn contact hours, you must achieve a score of 75%. You may retake the test as many times as necessary to pass the test. 5. All users must complete the evaluation process to complete course. You will be able to view a certificate on screen and print or save it for your records.

Accredited In support of improving patient care, OnCourse Learning (a Relias LLC company) is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team. OnCourse Learning is also an approved provider by the Florida Board of Nursing, the District of Columbia Board of Nursing, and the South Carolina Board of Nursing (provider #50-1489). OnCourse Learning’s continuing education courses are accepted by the Georgia Board of Nursing. Relias LLC is approved by the California Board of Registered Nursing, provider #CEP13791.

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agents and provide 100% oxygen. 3. Answer: C, Desflurane. 4. Answer: D, Caffeine halothane contracture test. 1. Answer: A, Hyperkalemia, hypercarbia with a PaCO2 greater than 60 mEq. 2. Answer: C, Discontinue all triggering anesthetic

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Compliance

Responsibilities Facilities face many rules, regulations and laws BY DON SADLER Risk assessment Conflict management The ability to interpret data Integrity Detail orientation Communication Problem-solving

OR TODAY | June 2022

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ospitals and ambulatory surgery centers (ASCs) must comply with myriad rules, regulations and laws from an alphabet soup of regulatory entities. These include CMS, OSHA, HHS, the CDC and HIPPA, to name just a few. Penalties and fines for failure to comply with these entities’ various rules and regs can be severe. This makes compliance a critical issue for every health care organizations.

What is Health Care Compliance? Beverly Kirchner, BSN, RN, CNOR, CNAMB, has been actively involved in helping hospitals and ASCs understand and meet their compliance responsibilities. She defines compliance for health care organizations as “an ongoing process undertaken to meet or surpass the legal, principled (ethical and moral) and professional standards that are valid and relate to the health care organization and its departments.” Kirchner says that CMS regulations for hospitals and ASCs are a major part of compliance. “Each entity has its regulations, but in the case of hospitals ORs, several regulations cross to both departments, such as life safety, construction and HIPAA.” “OSHA and HIPAA are also a big part of ASC and hospital compliance requirements and responsibilities,” Kirchner adds. “And states have licensure laws with WWW.ORTODAY.COM

which hospitals and ASCs must comply.” David Hoffman is the founder of David Hoffman & Associates, PC, a consulting firm that focuses on legal, regulatory and clinical compliance for health care organizations. Before starting his firm, Hoffman was a federal prosecutor specializing in health care fraud. “Compliance for hospitals and ASCs is a very complex, highly regulated issue,” says Hoffman. “It takes a lot of teamwork among health care staff to make sure that all of the applicable rules and regulations are being followed.” According to Hoffman, health care organizations are subject to the Federal False Claims Act, which is a federal civil fraud statute. The penalties for filing false medical claims currently range from $11,803 and $23,607 per claim, he says. But that’s just the beginning – treble damages, or triple this amount, are also added. “Now you’re into some real money,” says Hoffman. The intent standard under the False Claims Act covers knowledge of false information resulting in submission or causing the submission of a false claim. According to Hoffman, this is defined not only as having actual knowledge of a false claim, but also as deliberate ignorance of the truth or falsity of the information or reckless disregard of the truth or falsity of the information. “So the ‘ostrich’ defense doesn’t work,” says Hoffman. “Physicians can’t put their heads in the sand and say billing and proper coding are not their responsibility.”

The Main Question According to J.D. Buchert, MSN, M.Ed., MS, RN, quality & safety

manager, surgical services division at Parkland Hospital in Dallas, Texas, the main question when it comes to the consequences of not following laws and regulations is whether the event falls under ordinary non-compliance or gross negligence? “In other words, did the facility know whether they placed the patient in danger or not?” says Buchert. “Non-compliant facilities tend to be at risk for higher financial losses, license revocation, business disruption, poor patient outcomes, loss of trust from patients and staff, and reputation damage. And this is all in addition to potential fines.” Loss of Medicare certification is another potential consequence of non-compliance, says Kirchner. “In a worst-case scenario, the facility could actually close,” she says. According to Kirchner, health care facilities that are found to be non-compliant may be able to avoid closure by working with the Office of Inspector General (OIG). “The OIG has the authority to enter into an agreement known as a corporate integrity agreement, or CIA, in exchange for not sanctioning an organization,” says Kirchner. “We have learned that these agreements usually last five years and the organization must hire a monitor to oversee the quality of care.”

Role of the Compliance Officer One of the most important keys to remaining in compliance is formalizing an ethics and compliance program. And this starts with appointing a compliance officer. “A compliance officer is an employee who ensures the organization is compliant with outside regulatory and legal requirements,” says Kirchner. “The compliance officer also ensures that internal June 2022 | OR TODAY

“Non-compliant facilities tend to be at risk for higher financial losses, license revocation, business disruption, poor patient outcomes, loss of trust from patients and staff, and reputation damage. And this is all in addition to potential fines.”

- J.D. Buchert, MSN, M.Ed., MS, RN

policies, procedures and bylaws are honored and followed while monitoring day-to-day behaviors within the organization.” A compliance officer will also audit and test processes to ensure compliance, disclose any breaches, and check the compliance hotline regularly, investigating any complaints. Kirchner lists five key tasks of a health care compliance officer: 1. Identification of problems or potential problems 2. Problem prevention 3. Monitoring and detecting problems 4. Problem resolution 5. Providing advice about compliance According to Kirchner, there are two kinds of health care compliance officers: • A Corporate Compliance Officer (or Chief Compliance Officer) leads large groups of people toward obeying standards of conduct. These include bylaws, codes of conduct and policies and procedures. • A Regulatory Compliance Officer ensures the organization follows all industry standards, rules and regulations. “He or she is responsible for ensuring the organization has internal controls to manage risks, monitor for compliance, identify potential compliance risk, develop strategies to mitigate risk and oversee policy devel-

OR TODAY | June 2022

opment,” says Kirchner. Buchert elaborates. “The corporate compliance officer’s focus is on ensuring that hospital processes and procedures comply with the law,” he says. “The regulatory compliance officer focuses on the internal aspect of controlling and managing risk by integrating standards from outside sources into the practice setting.” Kirchner says that health care compliance officers should possess a number of key skills including: • Risk assessment • Conflict management • Integrity • The ability to interpret data • Detail orientation • Communication • Problem-solving “The health care compliance officer reports directly to the facility’s governing board,” says Kirchner. “The compliance officer assures the governing board that the facility’s leadership and team are compliant with all relevant laws, rules and regulations; that there is a compliance plan and code of conduct in place; and that compliance reporting is completed per state, federal and accreditation body requirements.” Staffing in ASCs usually doesn’t allow for a dedicated compliance officer with no other responsibilities, says Kirchner. “This is unlike most hospitals, where the compliance officer usually has a whole team helping oversee

auditing and compliance,” she says. “If ASCs can afford to hire a dedicated compliance officer,” Kirchner adds, “I recommend they do so to help ensure the facility remains in compliance.”

Biggest Compliance Challenges Hospitals and ASCs face a number of challenges when it comes to remaining in compliance. At the top of the list is simply keeping up with all of the laws, rules and regulations they have to follow, along with changes that are made, usually at least annually. Updating their facilities’ compliance plan and its policies and procedures and performing audits are other big compliance challenges faced by hospitals and ASCs. Kirchner says that staff education is critical to meeting the biggest compliance challenges. “How can you achieve compliance if the staff doesn’t know what regulations, laws and accrediting standards must be followed?” she says. Hoffman agrees. “Knowledge and education are key,” he says. “Physicians and billing departments need to be aware of their compliance obligations and know what all the rules and risks are.” Buchert says high levels of physician and nurse turnover magnify compliance challenges. “The recent mass exodus of health care workers is definitely making compliance more difficult,” he says.

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Buchert points to recent changes in filing for Medicare and private insurance reimbursement as an example of how turnover can lead to compliance problems. “If a health care facility improperly files reimbursement by accident, this can be construed as fraud and abuse of the payment system,” he says. “That’s why compliance with proper coding and billing is critical.” Hoffman believes that the biggest compliance issue facing hospitals and ASCs is medical necessity. “Is there really a need for the surgery?” he says. “Is it medically necessary? Billing for unnecessary procedures is a big compliance concern today.”

Create a Culture of Compliance According to Hoffman, the most important thing hospitals and ASCs can do to remain in compliance is to create a culture of compliance that starts at the top. “You’ve got to have buy-in from the C-suite,” he says. “Compliance is everyone’s responsibility, including upper management.” “HHS OIG guidance calls for hospitals and other health care organizations to create a culture of compliance,” adds Kirchner. “This type of culture endorses preventing, detecting and resolving behavior that does not follow government and state laws, including public and private health care program requirements.” Buchert stresses the importance of building employee engagement. “All employees need to understand their obligations and the role they play in keeping the facility compliant,” he says. “This includes identifying areas of weakness and focusing on a plan to rectify potential problems.”

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Hospitals and ASCs should also maintain all documentation and data related to their compliance efforts. “This includes audit procedure records from the patients’ first moments in the facility to when they are discharged to determine if policies and procedures were followed,” says Buchert. “This will provide a foundation for understanding what is happening in the facility,” he adds. “It’s a quality role that can save the facility money in the long run.” Buchert also recommends forming an interdisciplinary team to focus on compliance. “The compliance officer should chair this team and set forth responsibilities for administration and enforcement of the compliance process,” he says. Kirchner points out that even with a full-time compliance officer, the officer’s scope is limited. “It’s hard to keep up with all the different departments and all the rules, regulations and laws that govern health care,” she says. “Department leaders and staff need to be aware of the compliance requirements for their areas and work with the compliance officer to ensure the department is meeting and exceeding them.”

forward successfully.” “A compliant facility can reward its staff and patient population on many levels,” Buchert adds. “But the pride carried by a compliant facility truly does lead to higher employee retention, success as a business and better patient outcomes.” “Simply put, compliance means safety,” says Kirchner. “It helps ensure that the staff, patients and visitors are in an environment that promotes respect, transparency and quality care. Compliance not only protects the people, but it protects the business as well.”

Benefits of Focusing on Compliance Taking appropriate steps to make sure your hospital or ASC remains in compliance brings benefits beyond minimizing financial losses, business disruption and license and certification revocation. “As a former military man, I find that compliance brings organization and serenity to a health care facility,” says Buchert. “When a facility is compliant, it runs like a smoothly oiled machine. All parts work well together to move the whole unit

June 2022 | OR TODAY

SPOTLIGHT ON:

justin

Fontenot

By Matt Skoufalos n the 21 years he’s given to the nursing profession, Justin Fontenot, DNP, RN, NEA-BC, knows that the patients with whom he’s interacted have changed his life. The intimate connections the profession has afforded him to the people in his care, and the ways in which that work affirms their mutual humanity, have underscored his desire to leave the profession a more inclusive field than when he entered it.

“We have to know people,” Fontenot said. “We have to know how people want to die; how people want to be treated. We have to be the calming voice of reason for both patients and families, and I feel like that is one of the highest honors of humanity; to actually understand humans.” 44

OR TODAY | June 2022

“I am the adult I am today because of so many patients and their families, and their impact that they probably don’t even know they had on my life,” he said. “To be a part of a profession that is at the root and the fabric of humanity is one of the greatest gifts that anybody can give.” With several nurses in his extended family, Fontenot grew up wondering whether a health care career would be on his horizon, too. It wasn’t until his mother fell ill with chronic pain during his teenaged years that he experienced the workings of the system firsthand. Symptomatically, she presented with shoulder pain that the doctors she saw believed was related to cardiac issues. But after several tests showed that nothing was wrong with her heart, Fontenot said some physicians “went as far as to suggest

that it was all in her head.” “The process was kind of infuriating,” he said. “They kept working her up for cardiac [disease], and finding there wasn’t anything wrong with her heart. It wasn’t her heart at all; it was a deadly cancer that was manifesting itself.” Sadly, within two months of that cancer diagnosis, Fontenot’s mother succumbed to her illness. Had she had health insurance, she would have been able to get screenings that could have saved her life. The motivation of that moment propelled Fontenot into a career in health care. “I was raised in a small, impoverished community, and we were an uninsured family,” he said. “My family were hard-working people who worked for small businesses and local people, and they didn’t provide benefits. “I got into health care in that WWW.ORTODAY.COM

moment, and I knew I was going to be a champion for equitable access in health care,” Fontenot said. “I wanted to come into the profession in some kind of way and make an impact.” Beyond Fontenot’s commitment to improving access to care for impoverished and marginalized communities, his mother’s medical conditions also exposed him to the ways in which institutional bias is perpetuated among practitioners in the field. The conventional understanding that women experience cardiac symptoms differently from men led to his mother’s perspectives on her body being dismissed, ultimately, until it was too late. “It’s more about not hearing women versus the fact that they experience different symptoms,” Fontenot said. “There’s a difference between not listening and assuming. The way we stop perpetuating bias is by letting all of that go and listening to each individual patient.” “When I realized I could be a nurse, and work in health care, and work at the bedside with patients, and teach future health care workers, I make it a point to add these things into my curriculum,” he said. Fontenot is a first-generation high-school graduate in his family; neither of his parents nor his older siblings earned a high-school diploma. As such, he experienced some systemic barriers to his education that were related to growing up poor; namely, after graduating high school at 17, he enrolled directly in college, and failed out during his first semester. Upon resetting his plans, Fontenot discovered that his local community college offered an entry-level nursing degree. Three years later, he graduated as a licensed practical nurse, and began working directly in bedside patient care in medical-surgical units. Thereafter, he enrolled at South WWW.ORTODAY.COM

Louisiana Community College, worked his way through an associate degree in nursing, and passed the clinical exam. These were his first steps toward the professional advancement that higher education would offer. “Before I even got my bachelor’s degree, I had made it into a leadership position,” Fontenot said. “I thought, ‘If I want to teach, I have to go back to school.’ ” Fontenot then enrolled in an RN/ BSN program at Western Governors University, from which he also earned a master’s of science in nursing degree with a concentration in leadership and administration. After a decade in home care nursing and hospice management, he

In addition to continuing his research and education work, Fontenot also has his sights set on academic leadership roles. At the LHC Group Myers School of Nursing at the University of Louisiana at Lafayette, where he is an assistant professor, Fontenot is keenly aware of the opportunity to use his perspective to overcome institutional biases. As an openly gay, male nursing professional, Fontenot believes his outlook on the world can help break down barriers to future nurses like him who are entering the profession. “The way our workforce looks today is very dependent on what our academic workforce looks like,” he said. “I hope to position myself in

“We have to know how people want to die; how people want to be treated. We have to be the calming voice of reason for both patients and families, and I feel like that is one of the highest honors of humanity; to actually understand humans.” decided to pursue a doctorate in nursing practice (DNP) from Grand Canyon University in Phoenix, Arizona, and today, he’s pursuing a DNP-to-Ph.D. program. “In nursing, you really need the research doctorate in academics if you want to go a little further in administrative roles,” Fontenot said. “The bulk of our work is mentoring and teaching future health care professionals, but I split my time between serving the university, engaging in scholarship and research, and teaching. My goal and passion is developing a body of research that will allow me to continue that work.”

a position of administration so that when people look at our university, they can see that a gay boy from the South can be a dean of nursing if they wanted to. That’s exactly how we change the way the workforce looks.” “When you don’t have a faculty that represents the growing diversity of the area that we’re in, then people don’t believe there’s a place for them,” he said. “I hope that I at least show people that nursing is open, not just for women, but for all kinds of men. Nursing is for everyone who feels compelled or called to share that gift of caregiving in our communities.”

June 2022 | OR TODAY

OUT OF THE OR health

Good Hydration May Reduce Long-Term Risks for Heart Failure By National Institutes of Health taying well-hydrated may be associated with a reduced risk for developing heart failure, according to researchers at the National Institutes of Health. Their findings, which appear in the European Heart Journal, suggest that consuming sufficient amounts of fluids throughout life not only supports essential body functioning, but may also reduce the risk of severe heart problems in the future.

Heart failure, a chronic condition that develops when the heart does not pump enough blood for the body’s needs, affects more than 6.2 million Americans, a little more than 2% of the population. It is also more common among adults ages 65 and older. “Similar to reducing salt intake, drinking enough water and staying hydrated are ways to support our hearts and may help reduce long-term risks for heart disease,” said Natalia Dmitrieva, Ph.D., the lead study author and a researcher in the Laboratory of Cardiovascular Regenerative Medicine at the National Heart, Lung, and Blood Institute (NHLBI), part of NIH. After conducting preclinical research that suggested connections between dehydration and cardiac fibrosis, a hardening of the heart muscles, Dmitrieva and researchers looked for similar associations in large-scale population studies. To start, they analyzed data from more than 15,000 adults, ages 45-66, who enrolled in the Atherosclerosis Risk in Communities (ARIC) study between 1987-89 and shared information from medical visits over a 25-year period.

OR TODAY | June 2022

In selecting participants for their retrospective review, the scientists focused on those whose hydration levels were within a normal range and who did not have diabetes, obesity or heart failure at the start of the study. Approximately 11,814 adults were included in the final analysis, and of those, the researchers found, 1,366 (11.56%) later developed heart failure. To assess potential links with hydration, the team assessed the hydration status of the participants using several clinical measures. Looking at levels of serum sodium, which increases as the body’s fluid levels decrease, was especially useful in helping to identify participants with an increased risk for developing heart failure. It also helped identify older adults with an increased risk for developing both heart failure and left ventricular hypertrophy, an enlargement and thickening of the heart. For example, adults with serum sodium levels starting at 143 milliequivalents per liter (mEq/L) – a normal range is 135-146 mEq/L – in midlife had a 39% associated increased risk for developing heart failure compared to adults with lower levels. And for every 1 mEq/L increase in serum sodium within the normal range of 135-146 mEq/L, the likelihood of a participant developing heart failure increased by 5%. In a cohort of about 5,000 adults ages 70-90, those with serum sodium levels of 142.5-143 mEq/L at middle age were 62% more likely to develop left ventricular hypertrophy. Serum sodium levels starting at 143 mEq/L correlated with a 102% increased risk for left ventricular hypertrophy and a 54% increased risk for heart failure. Based on these data, the authors conclude serum sodium levels above 142 mEq/L in middle age are associated with

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OUT OF THE OR health

increased risks for developing left ventricular hypertrophy and heart failure later in life. A randomized, controlled trial will be necessary to confirm these preliminary findings, the researchers said. However, these early associations suggest good hydration may help prevent or slow the progression of changes within the heart that can lead to heart failure. “Serum sodium and fluid intake can easily be assessed in clinical exams and help doctors identify patients who may benefit from learning about ways to stay hydrated,” said Manfred Boehm, M.D., who leads the Laboratory of Cardiovascular Regenerative Medicine. Fluids are essential for a range of bodily functions, including helping the heart pump blood efficiently, supporting blood vessel function and in orchestrating circulation. Yet many people take in far less than they need, the researchers said. While fluid guidelines vary based on the body’s needs, the

researchers recommended a daily fluid intake of 6-8 cups (1.52.1 liters) for women and 8-12 cups (2-3 liters) for men. The Centers for Disease Control and Prevention also provides tips to support healthy hydration. This research was supported by the Division of Intramural Research at NHLBI. Other coauthors include Delong Liu, Ph.D., from the Laboratory of Vascular and Matrix Genetics and Colin O. Wu, Ph.D., from the Office of Biostatistics Research. The ARIC study has been supported by research contracts from NHLBI, NIH, and the Department of Health and Human Services.

Study Middle age serum sodium levels in the upper part of normal range and risk of heart failure. European Heart Journal, 2022. Doi: https://doi.org/10.1093/eurheartj/ehac138.

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OUT OF THE OR fitness

Simple Home Gym Must Have – Kettlebell By Miguel J. Ortiz he kettlebell is arguably one of the most underutilized pieces of equipment in the gym because most people don’t know or understand how to use it. The variety in which you can use a kettlebell is fantastic, because of its unique design and hold positions. The kettlebell can help improve strength as well as overall joint stability, stabilization and general hand-eye coordination. The various ways one can use a kettlebell make it a must have for the home gym

You don’t need to buy every weight or size of kettlebell. Once you get used to the different movements, you’ll understand why you may want to change or increase weights. However, I would start light with a kettlebell between 10 and 20 pounds depending on how comfortable you’re feeling. Kettlebells force you to utilize more muscle groups than usual because of the type of exercise you’re doing or how you are holding it. In this column, I want to share my three favorite kettlebell movements. I do them weekly within my own workout routine. I highly recommend adding them to yours. The first move is a classic, the Kettlebell Swing. This move is great for hip and core strength. It helps develop 48

OR TODAY | June 2022

coordination and stabilization. It’s talked about a lot and most people believe that this is the only exercise for the kettlebell – it’s not. This move is the basis for many other exercises especially as your kettlebell skill increases. The swing requires you to control the weight throughout the entirety of the movement which forces a higher level of focus. When you master the swing, it will help you with more advanced movements. When I have a lighter weight, I usually go for higher reps (15-20 ). When working on power and lifting a heavier kettlebell, I go for fewer reps (6-8). The second exercise requires a lot more balance, The Kettlebell Windmill. This exercise requires a good bit of flexibility in the legs. I recommend first trying it without any weight at all. This is also a great exercise to see the difference between a kettlebell and a dumbbell as the same size weight will feel completely differently when preforming this movement. The kettlebell will require more stabilization which will increase muscular activation around the shoulder and hip joints. The movement should be done slowly and controlled since you are hinging at the hip. Protecting your back by bracing your core is of upmost importance. Because of the stability and endurance, I will do 12-15 reps a side with a lighter weight. If I’m challenging my strength stabilization I will do 4-8 reps on each side with a heavier weight.

The third movement is my favorite. This movement combines strength, coordination, stabilization and power. It is the Kettlebell Snatch. It is good to learn the Kettlebell Swing before stepping into this movement. You’ll also notice I need to catch the kettlebell at the top of the motion so that it softly lands on the other side of my wrist. This is where the coordination comes in. You need power from the hips to initiate the kettlebell swinging up and enough strength and finesse to smoothly press it above your head. Once caught above your head, you want to keep the kettlebell close to the body on the way down to load it, absorbing into the hips so you can properly go into the next swing. Have fun with these movements. If you are short on time, I would do these three exercises together in a circuit workout of 4 rounds with 10 reps of each. Stay active and make sure to grab a kettlebell and get to work. – Miguel J. Ortiz is a personal trainer in Atlanta, Georgia. He is a Master Trainer for Pain-Free Performance and a Certified Nutritional Consultant with more than a decade of professional experience. He can be found on Instagram at @migueljortiz. Readers can find videos of the exercises under the “videos” tab at tinyurl.com/ORTfitness.

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OUT OF THE OR EQ Factor

Time Management is a Misnomer By Daniel Bobinski ime and again we hear about the need for good time management, but if we examine that phrase, we realize it’s not accurate. Every person on the planet gets the same amount of time every day: 24 hours. Nobody gets more, nobody gets less, and no matter how much we try, we cannot speed up nor slow down time. In truth, what we’re really talking about with “time management” is managing our actions.

With that in mind, the third habit of Steven Covey’s book, “7 Habits of Highly Effective People,” is “Put First Things First.” A good tool to help us do this is the Eisenhower Matrix, which examines each task we do with two criteria. By way of review, those criteria are urgency and importance. Urgent activities are things that require immediate attention. Important activities are those that contribute to our mission, values and highpriority goals. The Eisenhower Matrix gives us four categories, or quadrants. They are: • Quadrant 1: Urgent – Important

•

Quadrant 2: Not Urgent – Important • Quadrant 3: Urgent – Not Important • Quadrant 4: Not Urgent – Not Important Essentially, the matrix provides a framework for how to organize our work and prioritize the most important tasks. Again, think task management instead of time management. Quadrant 1 tasks (urgent and important) are those that impact our long-term goals but have immediate negative consequences if they’re not done. It’s recommended that people learn to differentiate Quadrant 1 from Quadrant 3 tasks (Urgent and Non-Important), which are things that are deemed urgent but don’t necessarily help us reach our long-term goals. Most people spend a lot of time in Quadrant 1, mainly because they don’t take time to schedule and prioritize important but non-urgent items (Quadrant 2). The main problem with Quadrant 1 activities is they tend to stress us out. Know that Quadrant 1 items will never totally disappear, but we can minimize the quantity of

Quadrant 1 items by incorporating more Quadrant 2 activities into our calendar. This is what Covey meant when he said we shouldn’t prioritize our schedule, but rather schedule our priorities. People often ask, “I’d love to eliminate the stressful Quadrant 1 tasks by doing more Quadrant 2 tasks, but where can I possibly find the time?” The answer to that question is fairly straightforward: Eliminate Quadrant 4 activities and delegate Quadrant 3 activities. Quadrant 4 actions are not important and not urgent (such as computer games), so why do them? The answer is we often do Quadrant 4 activities as a mental break from doing stressful Quadrant 1 things! Once we’re aware of that, we can consciously choose to do more Quadrant 2 things instead of Quadrant 4. We can also make room for Quadrant 2 tasks if we delegate Quadrant 3 activities. Turning over urgent but not-important things to someone else can be a great way to develop skills in others. Why not take the next week and inventory your tasks? By prioritizing Quadrant 2 tasks, we end up making better use of our time. Daniel Bobinski, M.Ed. is a best-selling author and a popular speaker at conferences and retreats. For more than 30 years he’s been working with teams and individuals (1:1 coaching) to help them achieve excellence. He was also teaching Emotional Intelligence since before it was a thing. Reach Daniel by email at DanielBobinski@protonmail.com or his office at 208-375-7606.

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OUT OF THE OR nutrition

9 Ways to Crank Up the Nutrients By Kirsten Serrano f you want to subscribe to a particular way of eating, let it be nutritvorism. Nutrivores follow the nutrients, not the fads. When you are cooking for yourself or others, take the nutrivore challenge and crank up the nutrients, not the dogma.

Over the years, I have developed some tips and tricks to add more nutrients to meals I am already preparing. Try these: 1

Meals and entrees that start with ground meat are an excellent place to add in lots of bonus produce. I add items like riced cauliflower, shredded carrot, minced mushrooms (the mushrooms I practically turn into a paste in my food processor before adding to hide them from my daughter) and chopped parsley – to name a few. Soup can be a nutrient gold mine. Start with really good purchased or homemade bone broth. Add as many vegetables as you can think of and let it simmer with some kombu

OR TODAY | June 2022

seaweed in the broth. If you have picky eaters or vegetables you would like to hide, use your stick blender to puree the broth and vegetables and then add the protein (if using one.) Frozen produce is an easy lastminute addition. Frozen greens are my favorite kitchen hack. Frozen spinach, kale and the like can be added to almost anything. Frozen produce can also become a quick side in a pinch. Look for frozen riced broccoli, cauliflower and sweet potato which can be tossed into a million things as well. The fact that it is in small pieces means it almost melts into the dish. Frozen mushrooms, peppers and even onions are versatile and nutrient dense. Adding nutrients is easier when they are convenient. Small produce is magic. I love produce that is in small pieces. It cooks quickly and that means it can be added to many dishes to add nutrients. Some of my favorites to have on hand are chopped onions, shredded carrots and shaved Brussels sprouts. Carrots have a neutral enough flavor that they do not dras-

tically change a recipe, they just up the nutrition. Shredded carrots seem to melt into tomato sauces. Shaved Brussels sprouts turn into an instant side with a quick sauté. Replace ground beef or chicken with liver for part of your ground meat. This is a great way to start eating some organ meat without sitting down to a plate of liver and onions. Embrace fermented foods. Adding fermented veggies to a taco or salad is a zing of flavor while increasing your produce and your probiotic exposure. It may sound weird, but I love sauerkraut in the morning with eggs. Nuts and seeds are a quick way to add nutrients. Add nuts and seeds to raw salads. I keep an array of nuts and seeds in my freezer in canning jars to keep them fresh and add them whenever possible. Everything Bagel Seasoning adds great flavor to skillets and casseroles. Herbs and spices are the original superfoods. Adding herbs (especially fresh) wakes up flavors while adding nutrient density. Using fresh garlic matters. You can buy it already WWW.ORTODAY.COM

OUT OF THE OR

nutrition

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peeled (but not pre-chopped to keep more nutrients intact) to make it faster to work with. Crush or chop it each time you need it and allow it to sit for 10-15 minutes before adding. This allows an enzyme reaction to take place that makes it a bigger health boost. Nutrition boosters to have next to the stove. Keep these next to your stove and sprinkle into everything: seaweed flakes, nutritional yeast and Himalayan or Real Salt.

Nutrivorism is a mind shift you can make gradually as you collect information and hacks to increase nutrients in small ways. These small changes add up and make a real difference. Go forth and eat your nutrients.

Kirsten Serrano is a nutrition consultant, chef, farmer, food literacy educator and the best-selling author of “Eat to Your Advantage.” You can find out more about her work at SmallWonderFood.com.

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OUT OF THE OR recipe

Fish with bok choy INGREDIENTS: • 1 Minute Brown Rice Cup

Recipe

• salt, to taste • pepper, to taste • 1 white fish fillet • 1 tablespoon butter • 1 teaspoon sesame oil • 1 teaspoon grated ginger • 2 baby bok choy, quartered • 1 teaspoon soy sauce

the

By Family Features

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OUT OF THE OR recipe

Quick and Easy Dishes for Dining Al Fresco armer weather is often welcome

W for a variety of reasons and dining

outdoors can help take that appreciation to the next level. Keeping ingredients lists short and prep time minimal also allows you to spend more time enjoying the sunshine and blue skies al fresco with the ones you love.

Even when you’re short on time, you can take mealtime from the dining room to the deck with an ingredient like Minute Rice Cups. Available in 13 varieties, including White and Brown rice, the convenient, single-serving, BPA-free cups are ready in just 90 seconds or less. Perfect for taking to the office for lunch or as an on-the-go snack,

Fish with bok choy

the cups can also be used as a quick and easy base for nearly any meal occasion. For example, this simple Fish with Bok Choy features plenty of complex flavors with flaky white fish, crisp bok choy and 100% whole-grain brown rice. The brown rice provides the ideal texture for the ginger, sesame and nutty notes in this dish, and the whole recipe can be on the table in 10 minutes. Because white fish fillets are neutral and mild, they absorb all the flavors from the dish, and are an ideal protein for those with busy schedules due to their short cooking time. To find more quick and easy recipes perfect for enjoying outdoors, visit MinuteRice.com.

In medium skillet over medium-high heat, melt butter. Cook fish 2 minutes on each side. Remove fish from pan and keep warm.

In same pan, add sesame oil and ginger. Cook 1 minute.

Add bok choy to pan and stir-fry 2 minutes. Add soy sauce; stir to incorporate. Top rice with fish and serve with bok choy.

Prep time: 3 minutes Cook time: 7 minutes Servings: 1

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Heat rice according to package directions. Set aside.

Add salt and pepper to both sides of fish, to taste.

June 2022 | OR TODAY

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“OR Today magazine is full of helpful information and education. It includes all aspects of surgical services and that is important to me. There are ads of new equipment that can improve efficiency in the departments.” – Mary Peterson, Whitman Partners

ve this a h y e h T . d in k e u “Nurses are a uniqcare for others, which is l flaw.” insatiable need to ta fa d n a th g n e tr s t r both their greates so t and nursing profes ris eo th e rs nu an ic – Jean Watson, Amer

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SIMPLE TIPS

TO ATTRACT HUMMINGBIRDS TO YOUR YARD By FAMILY FEATURES hroughout the warmer months, many backyards play host to a variety of birds, including hummingbirds. When you see flowers and trees begin to bud and bloom and other migrating birds, like warblers, that’s nature’s way of letting you know it’s time to ready your yard for hummingbirds

It’s enchanting watching hummingbirds – named for the humming sound of their fast-flapping wings – as their tiny size and speed make them natural wonders. Hummingbirds can fly 2530 miles per hour, flapping their wings an estimated 70 times per second. They fly in every direction, even backwards, which only hummers can do, and float majestically in midair. The birds get their brilliant color from the iridescence in the arrangement of their feathers, not color pigment. Plus, they have the fastest metabolism of any animal on Earth, burning 1-2 times their body weight in food daily. Hummingbirds draw nectar from its source into their mouths, lapping it up almost 12 times per second. To increase your chances of observing these petite powerhouses at home, consider these tips from the experts at Cole’s Wild Bird Products:. Be conscious of beneficial insects. Hummingbirds rely on insects, which provide essential protein, to complement the nectar they crave. To attract insects, try placing rotting fruit near feeders and leave it until insects arrive for hummers’ easy eats. Leave spiderwebs alone: Hummingbirds use spiderwebs as construction material to hold their nests together and pluck insects caught in the webbing. Offer a water mister: Hummingbirds adore bathing; a mister gives them the fine spray they prefer. Once soaked, they’re off to find a preening perch. Provide tiny perches. Leave small, sturdy, bare branches for hummingbirds, to perch on for rest, preening and hunting. Perches provide vantage points to see danger and launching pads to swiftly pounce on insects. Once hummingbirds find a favorite perch, they’ll use it repeatedly. Hang hummingbird feeders first. Feeders are one of the most

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effective ways to consistently entice and encourage hummingbirds to come visit. However, not all feeders are created equal. For example, Cole’s Hummer High Rise Feeder is scientifically designed with elevated perches to make hummingbirds feel safe and comfortable, which encourages their consistent return. Although hummingbird feeders can attract bees and ants, this feeder is uniquely designed to keep pests at bay. It doesn’t drip, so large bees can’t get to the nectar, plus it has a built-in ant moat to keep ants away from nectar when filled with plain water. Since birds drink from the moat, never use any repellents or additives. Hummingbirds are territorial and not likely to share feeders, so hang multiple feeders far enough apart to attract more birds. To ensure a steady stream of birds, hang feeders in the shade to avoid fermentation of sugar-based liquids, check feeders biweekly to keep food fresh and clean feeders as needed with one part white vinegar to four parts water. Plant flowers. Trumpet honeysuckle, bee balm and sage plants are particularly attractive to hummingbirds and provide rich nectar. Hummingbirds consume 1 1/2 times their body weight daily, eating every 10-15 minutes and visiting 1,0002,000 flowers per day. Choose the right nectar. Not all nectar is alike, and hummingbirds can taste the difference. Almost all commercial nectars contain one sugar source – sucrose – because it’s cheaper to make. However, real flower nectar contains three sugar sources – sucrose, fructose and glucose – in varying amounts depending on the flower. Researched and designed to attract the greatest variety of hummingbirds, Cole’s Nature’s Garden is a high energy, nutrient-rich nectar that combines all three types of organically sourced sugars North American hummingbirds love, with a spring water base. It closely mimics the sugar ratios they favor and provides a healthier, nutritious, all-natural alternative to table sugar. Don’t forget, hummingbirds have memories like elephants; once they discover your hummer-friendly habitat, they’ll come back every year if there’s a reliable food source. Learn more at coleswildbird.com..

June 2022 | OR TODAY

INDEX

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ALPHABETICAL AIV Inc.…………………………………………………………………15

Cygnus Medical………………………………………………… BC

MD Technologies Inc.……………………………………… 47

ALCO Sales & Service Co.…………………………………51

Ecolab Healthcare…………………………………………… 23

OR Today Webinar Series……………………………… 38

ASP……………………………………………………………………… 59

Healthmark Industries Company, Inc.……… 5,39

Ruhof Corporation…………………………………………… 2,3

C Change Surgical………………………………………………21

I.C. Medical, Inc.…………………………………………………… 4

Soma Technology…………………………………………… 53

CIVCO Medical Solutions………………………………… 11

Key Surgical…………………………………………………………17

CATEGORICAL ANESTHESIA

GENERAL

REPROCESSING STATIONS

Soma Technology…………………………………………… 53

AIV Inc.…………………………………………………………………15

CIVCO Medical Solutions………………………………… 11

C-ARM

HOSPITAL BEDS/PARTS

MD Technologies Inc.……………………………………… 47

Soma Technology…………………………………………… 53

ALCO Sales & Service Co.…………………………………51

CARDIAC PRODUCTS

INFECTION CONTROL

C Change Surgical………………………………………………21

ALCO Sales & Service Co.…………………………………51

CIVCO Medical Solutions………………………………… 11

ASP……………………………………………………………………… 59

CARTS/CABINETS

CIVCO Medical Solutions………………………………… 11

Healthmark Industries Company, Inc.……… 5,39

Cygnus Medical………………………………………………… BC

Key Surgical…………………………………………………………17

Healthmark Industries Company, Inc.……… 5,39

SINKS

ALCO Sales & Service Co.…………………………………51 CIVCO Medical Solutions………………………………… 11 Cygnus Medical………………………………………………… BC Healthmark Industries Company, Inc.……… 5,39

CS/SPD CIVCO Medical Solutions………………………………… 11 MD Technologies Inc.……………………………………… 47 Ruhof Corporation…………………………………………… 2,3

DISINFECTION ASP……………………………………………………………………… 59 CIVCO Medical Solutions………………………………… 11

MD Technologies Inc.……………………………………… 47 Ruhof Corporation…………………………………………… 2,3

INSTRUMENT STORAGE/TRANSPORT CIVCO Medical Solutions………………………………… 11

Ruhof Corporation…………………………………………… 2,3

RESPIRATORY Soma Technology…………………………………………… 53

SAFETY

Ruhof Corporation…………………………………………… 2,3

SMOKE EVACUATION I.C. Medical, Inc.…………………………………………………… 4

Cygnus Medical………………………………………………… BC

STERILIZATION

Key Surgical…………………………………………………………17

ASP……………………………………………………………………… 59

Ruhof Corporation…………………………………………… 2,3

Cygnus Medical………………………………………………… BC

INVENTORY CONTROL Key Surgical…………………………………………………………17

Healthmark Industries Company, Inc.……… 5,39 MD Technologies Inc.……………………………………… 47

SURGICAL

Cygnus Medical………………………………………………… BC

MONITORS

Ruhof Corporation…………………………………………… 2,3

Soma Technology…………………………………………… 53

DISPOSABLES

ONLINE RESOURCE

ALCO Sales & Service Co.…………………………………51

OR Today Webinar Series……………………………… 38

CIVCO Medical Solutions………………………………… 11

OR TABLES/BOOMS/ACCESSORIES

Cygnus Medical………………………………………………… BC

ENDOSCOPY

Soma Technology…………………………………………… 53

Healthmark Industries Company, Inc.……… 5,39

CIVCO Medical Solutions………………………………… 11

OTHER

Key Surgical…………………………………………………………17

AIV Inc.…………………………………………………………………15

TELEMETRY

MD Technologies Inc.……………………………………… 47

PATIENT MONITORING

AIV Inc.…………………………………………………………………15

Ruhof Corporation…………………………………………… 2,3

AIV Inc.…………………………………………………………………15

TEMPERATURE MANAGEMENT

FALL PREVENTION

POSITIONING PRODUCTS

C Change Surgical………………………………………………21

ALCO Sales & Service Co.…………………………………51

Cygnus Medical………………………………………………… BC

WASTE MANAGEMENT

FLUID MANAGEMENT

REPAIR SERVICES

MD Technologies Inc.……………………………………… 47

Ecolab Healthcare…………………………………………… 23

Cygnus Medical………………………………………………… BC

MD Technologies Inc.……………………………………… 47

Soma Technology…………………………………………… 53

Cygnus Medical………………………………………………… BC Healthmark Industries Company, Inc.……… 5,39

OR TODAY | June 2022

MD Technologies Inc.……………………………………… 47 Soma Technology…………………………………………… 53

SURGICAL INSTRUMENT/ACCESSORIES C Change Surgical………………………………………………21

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BETTER TOGETHER.

Engineered to work together, the suite of products from ASP provides seamless integration and intelligent software to simplify your department’s processes and help you achieve peace of mind. Rest easier knowing that you can rely on built-in safeguards, step-by-step on-screen instructions, automated documentation, and reconciliation of sterilizer and BI records.

COMPLIANCE MADE SIMPLE. STERRAD® Systems with ALLClear® Technology • ALLClear® Technology reduces workflow interruptions • System notifications help ensure compliance • On-screen instructional guides help reduce human-error

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• Built-in safeguards help ensure compliance and error free operation • Step-by-step instructions make STERRAD VELOCITY® Reader simple to operate • Designed to work optimally with STERRAD® Sterilizers

• Synchronizes STERRAD® Sterilizers and STERRAD VELOCITY® Systems to simplify workflow

Contact your ASP Representative or call 888-783-7723 for more information. 15 or 30 minutes to results dependent on software version. Refer to the IFU for actual time to results.

Capitalized product names and ALLClear® are trademarks of ASP Global Manufacturing, GmbH. Important Information: Prior to use, refer to the complete instructions for use (IFU) supplied with the device(s) for proper use, indications, contraindications, warnings and precautions. The third-party trademarks used herein are the properties of their respective owners.

OR Today Magazine June 2022

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CE Article: Malignant Hypothermia