Transcript Crisis Management

HSNZ
NOV 2013
Crisis:
A time of great danger or trouble
whose outcome decides whether
possible bad consequences will follow.
Other professions like ours:





Aviation
Spaceflight
Nuclear power and chemical manufacturing
Military Command – Fighter Pilots in combat
Fire fighting
Complex and Dynamic




Event driven and dynamic
Complex and tightly coupled
Uncertain
Risky
What makes Anesthesia different
from other specialties?






Dynamism
Time pressure
Intensity
Complexity
Uncertainty
Risk
The stress of anesthesia
Anesthesiology, by its nature,
involves crises
The combination of complexity and
dynamism makes crises much more likely
to occur and more difficult to deal with.
Up to our elbows…
 Anesthesia involves direct physical
involvement in the tasks of patient care
including:
- performance of invasive procedures
- administration of rapidly acting,
potentially lethal medications
- operation of increasingly complex
devices
During crises, knowledge is not
enough..
 Management of the environment, the
equipment and the patient care team
 This involves aspects of cognitive and social
psychology, sociology and anthropology
Old View
 Adequate Training + Qualified Trainee =
Ability to handle Crisis Situations
New View
 Each individual is affected by multiple
factors….
– Individual strengths and vulnerabilities
– Distractions, biases, errors
– Environment, Equipment
– Physiologic factors such as fatigue, emotional
stress, illness
It happened all of a sudden…
 Crisis perceived as sudden in onset and
rapid in development
 In retrospect one can usually identify an
evolution from underlying triggering events
Gaba DM, Fish KJ, Howard SK: Crisis Management in
Anesthesia 1994
Triggering events may initiate a
problem. A problem is an
abnormal situation that requires
attention but is unlikely by itself to
cause harm. Problems can evolve
and if not detected or corrected can
lead to adverse outcomes.
Adverse Outcome…
The events that trigger problems do
not occur at random
 They emerge from three sets of underlying
conditions:
– Latent errors
– Predisposing factors
– Psychological precursors
1. Latent Errors:
…errors whose adverse consequences
may lie dormant within the system for a
long time, only becoming evident when
they combine with other factors to breach
the system’s defenses, most likely
spawned by those whose activities are
removed in space and time from direct
control: designers, adminstrators,
managers.
2. Predisposing Factors:
 The external environment constitutes
predisposing factors.
 In aviation this is weather. In anesthesia
these are the patient’s underlying diseases
and the nature of the surgery
3. Psychological Precursors
 Can predispose the surgeon or anesthesia
provider to commit unsafe acts that may
trigger a problem
 “Performance Shaping Factors” including
fatigue, boredom, illness, drugs,
environment (noise, illumination)
Vigilance…
 Both Aviation and
Anesthesia are
describe as…”99%
boredom and 1%
Sheer Terror….”
99% Boredom….
1% Sheer Terror
Interesting Parallels
 Preop Evaluation
 Machine/Equipment
check
 Induction
 Deepening Anesthesia
 Intraop
 Lightening Anesthesia
 Emergence
 Preflight
 Aircraft and preflight
checklist
 Take Off
 Gaining Altitude
 Cruise Altitude
 Descent
 Landing
Dials, Knobs and Alarms
“Cruising, Stormy and Crashing”
Similar Environments…







High Stress Potential
Work hours and Performance
Equipment Dependent
Production Pressures
Communication and Team Approach
Multiple Tasking
Accident Evolution
Vigilance…
 …Ability of observers to remain alert to
stimuli for prolonged periods of time…
Warm J, Presentation at the panel on
vigilance, 1992 ASA annual meeting
Team
 …a distinguishable set of two or more
people who interact dynamically,
independently, and adaptively toward a
common and valued goal/objective/mission,
who have each been assigned specific roles
or functions to perform and who have a
limited life-span of membership
Simulators
Simulation Training
 Allows practice in situations that rarely occur
in real life
 Safe environment for practicing crises
situations
 Mandatory training in Netherlands, Belgium,
Sweden and Germany
 Allows safe environment for research
Making Things Safer
 Since the early 1980s, the Anesthesia Patient Safety Foundation
(APSF) has been instrumental in reducing the number of anesthesiarelated deaths from 1 in 10,000 to about 1 in 200,000. Technological
advances -- such as pulse oximeters, capnometers, and oxygen
regulators have been key factors. Also, simulators are now used in
anesthesia for practice and training.
Online CME sponsored by Massachusetts Medical Society,
file:///C:/Documents%20and%20Settings/Christopher/Deskt
op/New%20Folder/New%20Folder/Online%20CME%20%2
0A%20Success%20Story%20in%20Safety.htm
CASE 1
 You are anaesthetising a young women for
an appendicectomy. She is clinically
moderately dehydrated due to poor oral
intake and vomiting. Shortly after intubation,
her bp dropped to 70/40. immediaetly put on
1 pint colloid run fast. But, instead of bp
pick up, now her bp is unrecordable, she
became flushed, and her lungs are very
difficult to ventilate
 What are your differential diagnosis?
 What are your immediate actions?





Stop administration of suspected agent/s
Maintain airway/give 100% O2
Lay patient flat and keep leg elevated
Give adrenalin
-im at a dose of 0.5-1.0 mg repeated every 15 min
if required
 -iv at a dose of 0.1 mg for hypotention or
cardiovascular collapsed – titrated up to 0.5-1.0
mg as required
 Give iv fluid – crystalloid or colloid
 Other secodary theraphy to consider?
 Antihistamine – iv chlorpheniramine 10-20
mg slow bolus
 Corticosteroid – iv hydrocort 100-200 mg
 Bronchodilators
 Consider bicarb ( 0.5-1.0 mmol/kg )
 How would you investigate this patient for
suspected anaphylaxis?
 Serum tryptase
 Urine methylhistamine
 Skin prick test
 Why do the tests




Full explaination to patient / spause
-give medic-alert bracelet
Record in the case note - ? red colour
Inform GP
CASE 2
 As the medical officer oncall for emergency
OT, you are anaesthetising a young lady,
who came for twisted ovarian cyst. As she
well fasted and ASA 1, no obvious features
of difficult airway, you choose modified RSI
using rocuronium of 1 mg per kg. initially
ventilation was uneventful. Laryngoscopy
revealed CL III and not improved with
manipulation. After 3rd attemp still cannot
intubate and pt start to desaturate
 What will you do?
 Call for expert / senior help
 ventilate with 100%via a face mask
 Ensure optimal intubating / ventilating
position
 May use oropharyngeal / nasopharyngeal
airway
 Do not attemp >4 intubation and >2 LMA
insertion
If able to ventilate
 Consider






Wake up the patient
-defer surgery
-RA
-tracheostomy under LA
-awake FOI
OR anaesthesia with mask ventilation – if
appropriate
If successfully intubated/LMA





Proceed with surgery
If LMA /ILMA – can attemp intubation
OR wake up patient
-defer surgery
-RA
Difficult / unable to ventilate




Airway obstructed? Try LMA
IF failed – surgical airway
-needle OR surgical cricothyrodotomy
-transtracheal jet ventilation
Other helpful gadgets







Glidescope with glidescope stylet
Airtract, KingVision
C tract
C max
Bonefill semirigid fibrescope
Trachlight
Combitube
Extubation of difficult airway





When to extubate
Where to extubate
Deep extubation?
Leak test
Exchange catheter
 Clear documentation and post op visit
CASE 3
 A 33 year old lady is planned for
laparoscopic cystectomy under GA.
Induction and intubation done uneventfully.
ETT anchored at level 20 cm. 5 minutes
after abdomen inflated with CO2 gas, SPO2
dropped and ventilator alarm activated high pressure
 What is yr ddx
 -bronchospasm
 -ETT problem
 -Breathing system / ventilator problem
Immediate action
 -FIO2 100%
 -manually ventilate to assess compliance
Is it truly bronchospasm
 Quick inspection of breathing system
 ETT
 Auscultation
Severe bronchospasm






O2 100%
Bronchodilator ( via ETT or parenteral )
-via ETT 4-8 puff terbutaline or salbutamol
-cont nebulizer – salbutamol
-s/c bricanyl 0.25 mg
-or bricanyl infusion ( 3mg/50cc )
 Corticosetroid – hydrocort 200mg
 Ipratropium bromide – MDI / Nebs
 Iv adrenalin 10mcg may be considered if
anaphylaxis cannot be excluded
 Mg sulfate
 Iv ketamine
 Iv lignocaine 1.5-2 mg/kg
 Aminophylline
 Simultaneously, consider looking for the
cause of bronchospasm – and treat
accordingly
 Watch for cardiac arrythmias
 ABG if indicated
 ?CXR if suspected pneumothorax
 May consider ICU ventilator if difficult
ventilation
 Discuss with surgeon if bronchospasm not
CASE 4
 You are the anaesthetist oncall for delivery
suit. You are called urgently to a delivery
room where a women in the second stage of
labour has collapsed. Just prior to this she
became extremely breathless and went
blue, according to the midwife. She is now
not breathing
 DRSABC
 Call for immediate help from a senior
obstetrician and anaestetist
 If not breathing / no pulse – CPR and get
defibirillator
 Establish AIRWAY – early intubation
 Establish BREATHING – 100% O2
 CIRCULATION – large bore branula, GXM,
blood Ix, blood sugar
 Commence fluid resuscitation
 Left lateral tilt / uterine displacement
 After 5mins, consider LSCS – to aid
resuscitation
 There is no evident of blood loss. What is
the DDx
 The causes of sudden cardiovascular
collapse in pregnancy are








-AFE
-pulmonary thrombo-embolism
-venous air embolism
Occult haemorrhage
ICB
Drug toxicity
MI
Sepsis







Rare 1:20,000 but devastating
50% died first hour, 85% overall mortality
Usually complicated with
-APO
-DIC
-uterine atony
-Xtreme hypoxia - shunts
 Further Mx
 -ICU
 -supportive
CASE 5
LA toxicity