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Smartflow: Anesthesia Modernization (S.A.M.)
Share PrintTo decrease a facility’s expenditure on anesthesia gases, providers can lower their fresh gas flow during an anesthetic. This approach is completely safe for patients and reduces risks of surgical site infections caused by hypothermia. This solution can be easily taught through methodical, clear, and consistent education. However, health care providers are understandably resistant to change, especially when the necessary behavior change seems complicated. Through an educational approach, providers will be asked explicitly to stop using desflurane and nitrous oxide, and to decrease their fresh gas flows to under 2 liters.
Origin:
April 2022, Richmond VA Medical Center (Richmond, Virginia)
Adoptions:
9 successful, 7 in-progress
Awards and Recognition:
iNET Seed Investee, iNET Spread Investee, Quality on Parade People's Choice Winner 2023, VA Lean Yellow Belt awardee: January 2024, VA Strong Practice Forum: February 202, Featured ... iNET Seed Investee, iNET Spread Investee, Quality on Parade People's Choice Winner 2023, VA Lean Yellow Belt awardee: January 2024, VA Strong Practice Forum: February 202, Featured Innovation on Diffusion Marketplace Newsletter: February 2024, Entrepreneur in Residence: Innovation Ecosystem Fellowship FY2025, OHIL Sponsored BETS awardee, VA Innovation Unit: Phase 1 awardee, AVANA CRNA of the Year: 2025
Partners:
Anesthesiology, Diffusion of Excellence, Healthcare Innovation and Learning, iNet Seed-Spark-Spread Innovation Investment Program, Innovation Ecosystem, Nursing, Office of Healthcare Innovation and Learning (OHIL), Surgery, VHA Innovators Network
Recent Updates
Overview
Problem
One challenge slowing widespread low flow adoption is the FDA insert guidance for the use of sevoflurane, which recommends keeping flows above 2 liters due to risks associated with carbon absorbers from 20 years ago. While this warning is no longer relevant due to innovation in carbon absorbers, many anesthesia practitioners still follow its guidance. Low flow anesthesia is a proven method that is safe, efficient, effective, and endorsed by the American Society of Anesthesiologists, American Association of Nurse Anesthesiologists, and the Anesthesia Patient Safety Foundation. Because practitioners may not have training in low flow practices, know the context of the FDA insert, or understand low flow’s benefits, SAM takes an educational and human-centered design approach to teach about and encourage adoption of low flow practices.
Healthcare providers are often inundated with new information, research, and procedures. Therefore, clear, understandable messaging is critical to any education-centered program such as SAM. A prototype educational series was delivered to various anesthesia provider groups throughout the investment cycle. A program was iteratively developed that met users' needs without complicating the material. See more
Videos
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Solution
Videos
Respiratory gas conditioning is important to protect the lungs and is a universal standard of care. Cold and dry respiratory gases reduce ciliary activity in the respiratory epithelium. The reduction of mucociliary clearance can lead to atelectasis and infections, conditions referred to as postoperative pulmonary complications. Various studies demonstrated, that protective ventilation approaches allow the reduction in incidence of postoperative pulmonary complications (PPC). Warming and humidifying the respiratory gases using low-flow anaesthesia can reduce these negative effects on the respiratory epithelium.
Anesthesia providers can set targets for end-tidal oxygen (EtO2) and end-tidal anesthetic agent (EtAA), and the Et Control software2 will automatically and efficiently adjust fresh gas concentrations to quickly achieve and maintain these targets, even with changes in the patient’s hemodynamic and metabolic status. Providers can switch to manual fresh gas control at any time. Safety mechanisms help maintain targets, so providers can practice low-flow anesthesia with confidence.
The ecoFLOW feature shows how much anesthetic agent is being consumed and shows the anesthetic agent costs associated with each case. This features allows providers to track agent costs, helps support low-flow anesthesia practices and may help hospitals achieve their sustainability goals in reducing greenhouse gas emissions
The Circle Breathing System Explained in under 2 minutes.
Low Flow Anesthesia - 100 Years Later
- Printable methodology for performing low flow anesthesia with Sevoflurane Low Flow with Sevofluranve
- Printable methodology for performing low flow anesthesia with Isoflurane Low Flow with Isoflurane
- Memo about Desflurane elimination, eliminating use of pipeline Nitrous Oxide, and transitioning practice to low flow. Memo from Assistant Under Secretary for Health for Clinical Services
- Low-flow, Minimal-flow, and Metabolic-flow anesthesia: Clinical Techniques The Low Flow Book
- Reference List Comp Ref
- Gas Man® is the answer for teaching, experimenting and planning anesthesia administration on the computer before trying it in the operating room. Gas Man® is used by hundreds of practicing anesthesia providers and dozens of medical and veterinary teaching programs around the world. GasMan: Uptake and Distribution
- 16-minute podcast on how to perform low flow safely from Dr. Jeff Feldman, the creator of the APSF low flow course. How Low Can You Go? Keeping Patients Safe During Low-Flow Anesthesia Care
Files
Links
Results
Diffusion tracker
Does not include Clinical Resource Hubs (CRH)
Implementation
Timeline
-
1-3 months
Process buildout-identify champions/early adopters at local facilities-engage section and executive leadership for support-provide implementation guide-train anesthesia providers on low flow-provide local marketing materials-ongoing support -
3-6 months
-monitor for adoption process locally-engage site champion, support as needed -
6-12 months
Metrics-monitor local purchasing data-monitor national purchasing data-highlight trends and celebrate wins
Departments
- Quality Management
- Anesthesia
- Pharmacy
- Biomed
- Purchasing and supplies
Core Resources
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Files
- In this review article, comprehensive information is given about the theory and basics of low flow anesthetic techniques. Mainly, however, practical aspects of low flow anesthesia are discussed to enable the reader to perform this technique safely in clinical practice, Low Flow Theory
- CO2 absorbents were introduced into anesthesia practice in 1924 and are essential when using a circle system to minimize waste by reducing fresh gas flow to allow exhaled anesthetic agents to be rebreathed. For many years, absorbent formulations consisted of calcium hydroxide combined with strong bases like sodium and potassium hydroxide. When Sevoflurane and Desflurane were introduced, the potential for toxicity (compound A and CO, respectively) due to the interaction of these agents with absorbents became apparent. Studies demonstrated that strong bases added to calcium hydroxide were the cause of the toxicity, but that by eliminating potassium hydroxide and reducing the concentration of sodium hydroxide to <2%, compound A and CO production is no longer a concern. Carbon Dioxide Absorption During Inhalation Anesthesia: A Modern Practice
- Clinical techniques for use with rebreathing systems. Low-flow, minimal-flow and metabolic-flow anaesthesia
Links
- However, extensive research has found no evidence of harm in humans due to sevoflurane use with low FGF. Notably, countries of the European Union never introduced minimal FGF restrictions and routinely use low FGF in practice. Furthermore, purposeful selection of CO2 absorbent can eliminate any remaining safety concerns surrounding low flow sevoflurane. ASA Statement on the Use of Low Gas Flows for Sevoflurane
Risks and mitigations
| Risk | Mitigation |
|---|---|
| Low adoption rate | Leadership can mitigate this risk with support of practice change. The reason behind low adoption should be explored and mitigated. Often, motivation and awareness are quite frequently the underlying reason. |
Comment
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