ANAESTHESIA ANAESTHESIA [ SAFE PRACTICE][ SAFE PRACTICE]

Presented by:Presented by:

Prof .med. Nabil Housin MohyeddinProf .med. Nabil Housin Mohyeddin

Anesthesiologist &IntensivistAnesthesiologist &Intensivist

What do you mean by that ?What do you mean by that ?

Safety of the Anaesthetist ?

Safety of the Surgeon ?

Safety of the Patient ?

SAFE ANAESTHESIA PRACTICESAFE ANAESTHESIA PRACTICE

Protocols

Crisis Management

Tips and Tricks for Anaesthesia

PROTOCOLSPROTOCOLS

International Standards for International Standards for Safe Practice of Safe Practice of Anaesthesia 2010 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 International Standards for a Safe Practice Anaesthesia 2010 Anaesthesia 2010

The goal always in any setting is to practice to the highest possible standards

""HIGHLY RECOMMENDED"HIGHLY RECOMMENDED"

Minimum standards that would be expected in all anaesthesia care for elective surgical procedures

“Mandatory" standards

Peri-anaesthesia care and Peri-anaesthesia care and monitoring standardsmonitoring standards

Pre-anaesthesia carePre-anaesthesia checksMonitoring during

anaesthesia

Pre-anaesthesia checksPre-anaesthesia checksPRE ANAESTHETIC CHECK LIST Patient name ________________ Number ___________ Date of Birth -__/__/__Procedure____________________________________ Site_______

Check patient risk factors(if yes - circle and annotate)

Check resources Present and Functioning

ASA 1 2 3 4 5 EAirwayMallampati (pictures)Aspiration risk?Allergies?Abnormal investigations?Medications?Co-morbidities?

NNNNN

Airway Masks Airways Laryngoscopes (working) Tubes BougiesBreathing Leaks (a FGF of 300 ml/minute maintains a pressure of > 30 cm H2O)

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Check patient risk factors(if yes - circle and annotate)

Check resources Present and Functioning

ASA 1 2 3 4 5 EAirwayMallampati (pictures)Aspiration risk?Allergies?Abnormal investigations?Medications?Co-morbidities?

Soda lime (color - if present) Circle system (2-bag test if present)SuctionDrugs and Devices Oxygen cylinder (full and off) Vaporizers (full and seated) Drips (IV secure) Drugs (labelled - TIVA connected) Blood / fluids available Monitors - alarms on Humidifiers, warmers and thermometersEmergency Assistant Adrenaline Suxamethonium Self inflating bag Tilting table

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Monitoring during Monitoring during anaesthesiaanaesthesia

OxygenationAirway and ventilationCirculation TemperatureNeuromuscular functionDepth of anaesthesiaAudible signals and alarms

HIGHLY RECOMMENDED

RECOMMENDED SUGGESTED

Oxygenation Oxygen supply :

Oxygenation of the patient :

- Supplemental oxygen -Un interrupted supply

- Visual examination, - Adequate illumination - Pulse oximetry

- Inspired oxygen concentration - Oxygen supply failure alarm -Hypoxic Guard

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Airway and ventilation

- Observation - Auscultation - The reservoir bag

- Precordial, - Pretracheal, or -Oesophageal stethoscope - Capnography

- Continuous measurement of the inspiratory and/or expired gas volumes, and of the concentration of volatile agents

Circulation Cardiac rate and rhythm :

Tissue perfusion :

Blood pressure :

-Palpation of the pulse - Auscultation of the heart sounds - Pulse oximetry

- Clinical examination- Pulse oximetry

- At least every 5 mts

- Electrocardiograph- Defibrillator

- Capnography

- NIBP - IABP

HIGHLY RECOMMENDED RECOMMENDED SUGGESTED

Temperature - At frequent intervals

- Continual electronic temperature measurement

Neuromuscular function

- Peripheral nerve stimulator

Depth of anaesthesia

- Degree of unconsciousness (clinical observation)

- Continuous measurement of the inspiratory and/or expired gas volumes, and of the concentration of volatile agents

- BIS Monitor

Audible signals and alarms

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 Crisis Management during during anaesthesiaanaesthesia

Crisis ManagementCrisis 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 analyzing incident reports from the 4000 Australian Incident Monitoring Study (AIMS) reports and designed Core Algorithm & 24 Sub-Algorithms

Crisis Management ManualCrisis Management Manual‘‘C‘‘Coreore’’ ’’ algorithm - algorithm - COVER ABCD COVER ABCD – A SWIFT CHECK– A SWIFT CHECK

Crisis management algorithm ‘‘COVER ABCD’’

Crisis management algorithm ‘‘COVER ABCD’’

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Crisis management manual Ref.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_Start.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 ?Where Safety Starts ?

Patient

Facilities, Equipment, and Medications Anesthetist's Skill

Surgeon’s Skill

Survival Depends.......Survival Depends.......

Facilities, Equipment, and Medications Quantity and Quality

Anesthetist Skill

HELP

Referral

10%

20%

60%

10%

Where Safety Starts ?Where Safety Starts ?

Patient

- Optimized patient (CVS, RS, Renal, Liver)

ASA risk

Well controlled Hypertension

Well controlled Diabetes

Haemodynamically stabile

MedicationMedicationAll 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 SkillAnaesthetist SkillLearn one or two alternate

method of Airway skillPractice it in routine cases

Post CrisisPost Crisis

CounselingCounseling

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 Recommendations for senior staff membersmembers

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 Recommendations for colleaguescolleagues

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 Recommendations for healthcare professionals directly involved in an professionals directly involved in an

adverse eventadverse 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 behavior

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 Tips and Tricks for AnaesthesiaAnaesthesia

Facilities and Equipments Facilities and Equipments

Macintosh

Magill

Miller

Polio

Mc Coy

(GEB)

Endotracheal Tube Introducer

(LMA ) Airways

Igel

Infra - glottic Invasive Infra - glottic Invasive AirwaysAirways

Cricothyrotomy Tracheostomy

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Techniques to decrease hypotension with Techniques to decrease hypotension with neuraxial anesthesia for cesarean delivery. neuraxial anesthesia for cesarean delivery.

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

AIRWAY CORRECTION

Build a BIG RAMPPPP

Perianesthetic Management of Laryngospasm Perianesthetic Management of Laryngospasm

The Laryngospasm Notch The Laryngospasm Notch TechniqueTechnique

The Laryngospasm Notch The Laryngospasm Notch TechniqueTechnique

Unorthodox method: not generally Unorthodox method: not generally accepted, better than nothingaccepted, better than nothing

Emergency AirwayEmergency Airway

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Thank youThank you