Blog Post 4 - AF

Author: Adin Field

Date: October 6, 2019

Project: Anesthesia Delivery and Monitoring

Team Members: Adin Field, Gordon Ellis, Jordon Bibian, Anagha Arvind

Blog Contents:

1. Design Review 1 Feedback

2. Summary of Team's CAD experience

3. Interview Transcript

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Design Review 1 Feedback

After our first design review presentation, we received valuable feedback from our peers and instructors. While the comments were mostly positive, a common criticism was that our presentation should have been more succinct. The content of our presentation was well received as informative and thoughtful, but the amount of relevant information we included ended up being difficult to compact into just 8 minutes. This also resulted in dense, wordy slides, that didn't efficiently convey our content. In future, we will be sure to put only the most important points on the slides, along with visual aids such as pictures and graphs, leaving the finer details to be presented orally.

Regarding the content of our design review, there were some observations that we intend to consider when creating the written DR1 Report. From our peer feedback, it seems that we could do a better job clarifying which solution we have chosen to pursue and what it actually involves. Summarizing the role of each component of "The KDM Solution" and more explicitly defining our desired specifications will not only help when presenting the system to others, but will also give us more cohesive goals to work toward when developing our first prototype.

Moving forward, we are encouraged by the positive feedback we received, and ready to improve upon the mistakes that were pointed out to us.

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Summary of Team's CAD experience

Our team is relatively experienced with Computer Aided Design (CAD) software. Two team members are studying Mechanical Engineering and a third has taken BU's CAD course. Our combined experience should allow us to effectively and efficiently utilize CAD as a tool in our prototyping process. Below is a brief breakdown of each team member's CAD experience.

Anagha Arvind: Took ME359, BU's CAD course. Familiar with Creo parts, assemblies, and mechanisms.

Gordon Ellis: Exposure to CAD limited to in-class demonstration and homework.

Jordan Bibian: Significant experience with Creo having taken ME359. Additional CAD experience designing alignment gauges for CT X-ray tubes/detectors during a summer internship.

Adin Field: Experience with Creo, Onshape, and Solidworks from a combination of coursework as well as research/internships. Also familiar with GibbsCAM.

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Interview Transcript

Name Sara Shekhar

Contact info Phone Number

Short bio/background

- Anesthesia training in India after med school there

- British degree in anesthesia

- Residency in US at Pittsburgh for 14 years

- Umass Worcester for 6 years

- Primary focus in trauma, transplant and neural anesthesia

Time/date of call 4:30 – 5:30 September 30, 2019

Interview questions

1. How do you deliver and monitor anesthesia depth currently, and what features do you

prefer in the methods you use?

• IV filtration through cannula into vein of patient in the Operating room.

• Gas anesthesia inhalation through mask most common method

• HR, BP, Oxygenation monitored, while supportive breathing tube is inserted into trachea for intubation => ventilator breathes for the patient as they stop the patient from breathing on their own; gas anesthesia is administered throughout

• Uses nerve blocks so patient cannot feel anything at operation site for 3-4 hours

• Anesthesia dosage is tailored for the type of surgery and patient

• Patient vitals constantly monitored while anesthesia depth is not always

• Special monitoring circumstances: lots of bleeding/blood loss, hypotension, IV anesthesia, EKG, brain activity monitored with BIS but not always, eyes monitored

• Devices used: EKG monitor, BP cuff, pulse ox, arterial line especially if blood loss is rapid (like in liver transplants or in some radioactive settings)

• Multiple devices are used to measure vitals

• Current system is good

• Main feature missing: wireless monitoring

• Staff in operating room trip over wires often as it is crowded and cluttered

• Muscle relaxers stop resp. total intra anesthesia IV Propofol. Always anesthetic on top of anesthesia

2. In your time being an anesthesiologist, have you had a patient experience intraoperative awareness?

• 2 patients have experienced it during her practice

• First patient (40 yo M) had it towards the end of cardiac surgery in India

• During transport BP was low so meds were off, so staff had to attend to that.

• During post op said he heard the attending surgeon using a curse word

• No distress reported and counseling denied

• 2nd patient in Pittsburgh

• Gas ran out and senior resident didn’t check vaporizer despite monitor showing levels of vapor.

• Patient remembered lights in operating room but remained ok. No pain reported.

• 1 or 2 colleagues have experienced something similar, but suing is rare

• General anesthesia is known to drop BP and HR and have adverse effects on breathing because of ventilation; therefore patient should not hear or feel = awareness

• Vs. sedation during which patient can hear and feel a little bit; no breathing tube insert because used in minor procedures like endoscopies and cosmetic surgeries

• Patient’s cardiac and respiratory rates decides anesthesia vs. sedation.

• When patient has too much trauma, emergency C sections and blood loss, usually anesthesia is not given so awareness more likely

• Sometimes patient still think they need anesthesia while in recovery

3. What is the procedure when too much anesthesia is delivered? What are the steps to correct it?

• When vitals are off, alarm goes off. Then staff finds out reason for drop in BP or whatever the problem is. Could be too much anesthetic or blood loss, while HR should be 40-120 beats per minute

• Time limit to figure out the issue – takes time for body to react so enough time to find out there are problems problem.

• Staff has algorithms for diff problems and situations

• Death can happen but rare. Ventilation usually helps. Blood pressure meds, CT scan, titrating anesthetic, diff gas blood solubility measured if complications occur

• Allergic reaction and unexpected responses are most worrisome

4. What is a typical day like for you? How many patients do you usually see/ procedures do you usually do?

• 2 operating rooms run at the same time

• Contains nurse anesthetists, resident surgeon, circulating nurses and anesthesiologist goes from room to room

• If low on staff, pressing a button will ask any free anesthetic nurses for help

• Multiple procedures daily, depending on cases. On avg 5-10 cases

• Break between cases for cleaning operating room and while patient is in post-op

• 55 hours week, 1 weekend call a month

5. What is the preoperative and postoperative procedures?

• Preoperative: Patient is interviewed. Asked about medical problems, allergies, recent hear attacks, lung and heart sounds heard, family history of anesthesia problems, height weight, physical examination, airway examination

• Looking for space in mouth for tube to fit. Male and female adult tubes are similar. Because children’s trachea is funnel shaped, children’s tube is shaped different

• Check neck mobility => difficult with thick necks, neck surgery or enlarged thyroid.

• Tell them what is going to happen. We are going to use general anesthesia, watch your vitals… After the administration, we will ask you to follow command. Then breathing tube is inserted.

• Post-op: Patient is in recovery, breathing tube comes out and patient is helped breathe on their own again.

• Nausea and vomiting common but Meds given. Teeth and tongue injury rare but happens. Seizure, stroke heart attack rare but taken into consideration.

• Soreness in throat => drinking. No drinking/ eating 8 hours before testing

• Preparation of surgery: in morning, resident checks anesthesia machine, checking if gas works and filled, check ventilators, O2 calibration, no hypoxic mixture, once given nitrous oxide but not anymore, leak test, suction, airway equipment, OG tube, temp monitor, induction medication drawn. Done again for every case. 15 -20 mins usually. Case dependent

• Counseling offered post-op for awareness incident

6. Have you practiced in a different country? If so, how does it differ from the US?

• Railway hospital in India in ‘89

• No monitors then; all based on manual readings and physical examinations

• No muscle relaxers, nerve agents used so no paralysis

• Patient is intubated but not ventilated, so patient is still breathing on their own

• If ventilation needed, manual ventilation with bag

• Recording used to be on paper, but now electronic

• Hospitals are developing to have more basic monitors; available at big and small cities

• No arterial line and complicated things

• Since change, she likes seeing one patient a time

7. Do you stay with the patient who is under or do you monitor other patients? (India)

• 2-3 pts in one room.

• 1 attending surgeon and 3 residents anesthesiologists

• 1 resident 1 attending when busy

• All patients come in the morning and line up. Nurses keep on seeing them and clearing them for anesthesia

8. Have you heard of ketamine being used as an alternative in low resource settings? What do you think about it?

• Used in India in children

• Can cause some euphoria and hallucinations

• Phase/face anesthetic.

• No BP drop. Doesn’t start bleeding.

• Pain relief

• Ketamine is now used in US hospitals for patient on opiates, as only NMDA receptor detects ketamine

• No addictive properties

9. Possible Observation?

• Will find out soon

Key Take-aways

• Anesthesia Delivery and Monitoring procedure is very case dependent and even varies from country to country. However, there is multitasking involved in regardless of population of country in which procedure is done.

• Few instances of ketamine already being used in a few developing areas, and applications even emerging in the US

• Wireless monitoring seems to be a feature needed in operating rooms. Can be difficult in low resource settings