Transcript safe anaesthesia practice

SAFE
ANAESTHESIA
PRACTICE
Dr.J.Edward Johnson
What do you mean by that ?

Safety of the Anaesthetist ?

Safety of the Surgeon ?

Safety of the Patient ?
SAFE ANAESTHESIA PRACTICE
 Protocals
 Crisis
 Tips
Management
and Tricks for Anaesthesia
PROTOCALS
International Standards for a
Safe Practice of
Anaesthesia 2010

Developed by the International Task
Force on Anaesthesia Safety

Adopted by the World Federation of
Societies of Anaesthesiologists (WFSA)
International Standards for a Safe Practice of
Anaesthesia 2010
Anaesthesia standards (in
order of adoption)
HIGHLY RECOMMENDED
Setting
Level 1
Infrastructure
Basic
Small hospital / health centre
HIGHLY RECOMMENDED +
RECOMMENDED
Level 2
Intermediate
Small hospital / health centre
HIGHLY RECOMMENDED
+
RECOMMENDED
Level 3
Optimal
Referral hospital
+ Suggested
The goal always in any setting is to practice to the highest possible standards
"HIGHLY RECOMMENDED"

Minimum standards that would be
expected in all anaesthesia care for
elective surgical procedures

“Mandatory" standards
Peri-anaesthetic care and
monitoring standards
Pre-anaesthetic care
 Pre-anaesthesia checks
 Monitoring during anaesthesia

Pre-anaesthesia checks
PRE ANAESTHETIC CHECK LIST
Patient name ________________ Number ___________ Date of Birth __/__/__
Procedure____________________________________ Site_______
Check patient
risk factors
(if yes - circle and
annotate)
ASA 1 2 3 4 5 E
Airway
Mallampati (pictures)
Aspiration risk?
Allergies?
Abnormal
investigations?
Medications?
Co-morbidities?
N
N
N
N
N
Check resources
Present and
Functioning
Airway
-
Masks
Airways
Laryngoscopes (working)
Tubes
Bougies
Breathing
Leaks (a FGF of 300 ml/minute
maintains a pressure of > 30 cm
H2O)
Check patient
risk factors
(if yes - circle and
annotate)
ASA 1 2 3 4 5 E
Airway
Mallampati (pictures)
Aspiration risk?
Allergies?
Abnormal
investigations?
Medications?
Co-morbidities?
Check resources
Present and
Functioning
Soda lime (colour - if present)
Circle system (2-bag test if present)
Suction
Drugs and Devices
Oxygen cylinder (full and off)
Vaporisers (full and seated)
Drips (IV secure)
Drugs (lebeled - TIVA connected)
Blood / fluids available
Monitors - alarms on
Humidifiers, warmers and
thermometers
Emergency
Assistant
Adrenaline
Suxamethonium
Self inflating bag
Tilting table
-
Monitoring during anaesthesia
Oxygenation
 Airway and ventilation
 Circulation
 Temperature
 Neuromuscular function
 Depth of anaesthesia
 Audible signals and alarms

Oxygenation
Oxygen supply :
HIGHLY
RECOMMENDED
RECOMMENDED
- Supplemental oxygen
-Un interrupted supply
- Inspired oxygen concentration
- Visual examination,
Airway and
ventilation
- Observation
- Auscultation
- The reservoir bag
- Precordial,
- Pretracheal, or
-Oesophageal stethoscope
- Capnography
-Palpation of the pulse
- Auscultation of the
heart sounds
- Pulse oximetry
- Electrocardiograph
- Clinical examination
- Pulse oximetry
- Capnography
- At least every 5 mts
- NIBP
Circulation
Cardiac rate and
rhythm :
Tissue perfusion :
Blood pressure :
-
- Oxygen supply failure alarm
-Hypoxic Guard
Oxygenation of
the patient :
- Adequate illumination
- Pulse oximetry
SUGGESTED
--
- Continuous
measurement of the
inspiratory and/or
expired gas volumes,
and of the
concentration of
volatile agents
- Defibrillator
- IABP
HIGHLY
RECOMMENDED
Temperature
Audible signals and
alarms
SUGGESTED
- Continual electronic
- At frequent intervals temperature
measurement
Neuromuscular
function
Depth of
anaesthesia
RECOMMENDED
- Peripheral nerve
stimulator
- Degree of
- Continuous
unconsciousness
(clinical observation)
measurement of the
inspiratory and/or
expired gas volumes, and
of the concentration of
volatile agents
- BIS Monitor
Available audible signals (pulse tone of the pulse oximeter) and audible
alarms (with appropriately set limit values) should be activated at all
times and loud enough to be heard throughout the operating room
Crisis Management during anaesthesia
Crisis Management

Crisis Management Manual developed
by Australian Patient Safety Foundation
Qual Saf Health Care 2005;14

Working groups from several countries
including the USA, UK and Australia after
analysing incident reports from the 4000
Australian Incident Monitoring Study
(AIMS) reports and designed Core
Algorithm & 24 Sub-Algorithms
Crisis Management Manual
‘‘Core’’ algorithm - COVER ABCD – A SWIFT CHECK
Crisis management algorithm ‘‘COVER ABCD’’
C1
Circulation
Establish adequacy of peripheral circulation ((rate, rhythm and character
of pulse) - CPR
C2
Colour
Note saturation. Pulse oximetry - Test probe on own finger
O1
Oxygen
Check rotameter
Ensure inspired mixture is not hypoxic
O2
Oxygen
analyser
Adjust inspired oxygen concentration to 100%
Check that the oxygen analyser shows a rising oxygen concentration
V1
Ventilation
Ventilate the lungs by hand
To assess circuit integrity, airway patency, chest compliance and air entry
by ‘‘feel’’ and auscultation. (Capnography)
V2
Vaporiser
Note settings and levels of agents
Gas leaks during pressurisation
Consider the possibility of the wrong agent
Crisis management algorithm ‘‘COVER ABCD’’
E1
Endotracheal tube Check the endotracheal tube (leaks or kinks or obstructions)
E2
Elimination
Eliminate the anaesthetic machine and ventilate with self-inflating
bag
R1
Review monitors
Review all monitors in use
R2
Review equipment Review all other equipment in contact with or relevant to the
patient (e.g. diathermy, humidifiers, heating blankets, endoscopes,
probes, prostheses, retractors and other appliances).
A
Airway
Check patency of the unintubated airway
(Consider laryngospasm or presence of foreign body, blood, gastric
contents, nasopharyngeal or bronchial secretions)
B
Breathing
Assess pattern, adequacy and distribution of ventilation
C
Circulation
Repeat evaluation of peripheral perfusion, pulse, blood pressure,
ECG and and any possible obstruction to venous return, raised
intrathoracic pressure or tamponade of the heart
D
Drugs
Review drug or substance administration
Wrong drug, Wrong dose
Sub Algorithm – Crisis Management
A
Obstruction of the natural airway
A
Laryngospasm
Regurgitation, vomiting and aspiration
Difficult intubation
Desaturation
Bronchospasm
Pulmonary oedema
Bradycardia
Tachycardia
Hypotension
Hypertension
Myocardial ischaemia
Cardiac arrest
Problems associated with drug administration during anaesthesia
A
A
B
B
B
C
C
C
C
C
C
D
A
A
A
A
*
*
*
*
*
*
Awareness
Embolism
Pneumothorax
Anaphylaxis and allergy
Vascular access problems
Trauma: development of a sub-algorithm
Sepsis
Water intoxication
Crisis management during regional anaesthesia
Recovering from a crisis
Crisis management manual Ref.

Crisis management during anaesthesia: the
development of an Anaesthetic Crisis
Management Manual
http://qualitysafety.bmj.com/content/14/3/e1.full.html

Anaesthesia Crisis Management Manual
http://www.apsf.com.au/crisis_management/Crisis_Management_Sta
rt.htm

This article cites 42 articles, 30 of which can be
accessed free at:
http://qualitysafety.bmj.com/content/14/3/e1.full.html#ref-list-1
Where Safety Starts ?
Patient
Facilities, Equipment, and Medications
Surgeon’s Skill
Anaesthetist’s Skill
Survival Depends.......
Referal
10%
HELP
10%
20%
Anaesthetist Skill
60%
Facilities, Equipment, and Medications
Quantity and Quality
Where Safety Starts ?
Patient
- Optimized patient (CVS, RS, Renal, Liver)
ASA risk
Well controlled Hypertension
Well controlled Diabetes
Haemodynamically stabilsed
Medication

All drugs should be clearly labelled

The label on both ampoule and syringe
should be read carefully before the drug is
drawn up or injected

Ideally drugs should be drawn up and
labelled by the anaesthetist who
administers them.
Anaesthetist Skill
Learn one or two alternate method of Airway
skill
 Practice it in routine cases

Post Crisis
Counseling

Pre operative counseling
- Possible complication
- Remote complication
• Post operative counseling
- The Swiss Foundation for Patient Safety has
published guidelines describing the actions to take after an
adverse event has occurred .
Recommendations for senior staff members

A severe medical error is an emergency

Confidence between the senior staff and the involved
professional

Involved professionals need a professional and objective
discussion with, as well as emotional support from, peers
in their department

Seniors should offer support for the disclosing
conversation with the patient and/or the relatives

A professional work-up of that case based on facts is
important for analysis and learning out of medical error.
Ex..
Recommendations for colleagues

Be aware that such an adverse event could
happen to you also

Offer time to discuss the case with your
colleague. Listen to what your colleague
wants to tell and support him/her with your
professional expertise

Address any culture of blame either directly
from within the team or by any other
colleagues
Recommendations for healthcare professionals
directly involved in an adverse event

Do not suppress any feelings of emotion you may encounter
after your involvement in a medical error

Talk through what has happened with a dependable colleague
or senior member of staff. This is not weakness. This represents
appropriate professional behaviour

Take part in a formal debriefing session. Try to draw conclusions
and learn from this event. Ex..

If possible talk to your patient/their relatives and engage with
them in open disclosure conversations

If you experience any uncertainties regarding the management
of future cases seek support from colleagues or seniors
Tips and Tricks for Anaesthesia
Facilities and Equipments
Macintosh
(LMA )
Airways
Magill
Igel
Miller
(GEB)
Polio
Endotracheal Tube Introducer
Mc Coy
Infra - glottic Invasive Airways
Cricothyrotomy
Tracheostomy
Unanticipated Difficult Airway
Techniques to decrease hypotension with
neuraxial anesthesia for cesarean delivery.
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Leg wrapping
Prehydration or co-load with intravenous colloid solution
Co-load with crystalloid intravenous solution
Lower dose intrathecal local anesthesia supplemented
with opioid
Maternal left uterine displacement positioning
Consider epidural instead of spinal anesthesia
Phenylephrine infusion with rapid crystalloid co-load
Phenylephrine infusion with low-dose intrathecal
bupivacaine
Phenylephrine infusion or boluses titrated to maintain a
consistent heart rate
Expert Review of Obstetrics & Gynecology
Katherine W Arendt; Jochen D Muehlschlegel; Lawrence C Tsen
OBESE - AIRWAY
AIRWAY CORRECTION
Build a BIG RAMPPPP
Perianesthetic Management of Laryngospasm
The Laryngospasm Notch Technique
The Laryngospasm Notch Technique
Unorthodox method: not generally
accepted, better than nothing
Emergency Airway
SAFE ANAESTHESIA PRACTICE
Thank you