Patient safety During Anesthesia
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Transcript of Patient safety During Anesthesia
Safe Anaesthesia practice- Current Trends
Dr Surjya Prasad UpadhyaySpecialist Anaesthesiology
NM hospital DIP
Safety? Whose safety?
Anesthesia is an area in which very impressive improvements in safety have been made. The Institute of Medicine; (National Academy of Medicine)
How safe is surgery and anesthesia?
1 death per 5,000 anesthetics administered during the 1970s, to 1 death per 200,000-300,000 in 1999.
Today’s surgical patients are sicker and aged than ever.
5% of all surgical patients die within one year of surgery.
Surgical Patients over 65 years, 10% die within one year of surgery.
Dr. Jeana Havidich; 2014 ASA Convention:
3.2 million anaesthesia case data: 2010-2013.
Complication rate: decreased from 11.8 percent to 4.8 percent
Evening or holiday procedures: no increase in complications
Healthier patients having elective daytime surgery: highest minor
complications
Serious complications highest in pt >50 years
Complications of anaesthesia
Major Complications Minor complicationsCardiac arrest
Peioperative MI
Aspiration
Anaphylaxis
Drug overdose/ toxicity
Awareness
Convulsion
Nerve palsies
Organ injury-
Malignant hyperthermia
Airway obstruction
Post op Nausea / vomiting
Sore throat
Persistent sedation
Haemodynamic instability
Pneumonia
Delirium
Shivering
Organ dysfunction- kidney/liver
Cognitive defect
10 common causes of cardiac arrest under anaesthesia
1. Drug overdose/ adverse reaction
2. Rhythm disturbances
3. Peri-op MI
4. Airway obstruction
5. High spinal
6. Lack of vigilance
7. Bleeding
8. Over-dosage of inhalation agent
9. Aspiration
10.Technical problem in anaesthesia system
Anaesthesiology: A High risk Speciality
Anaesthesiology is a high-risk speciality as compared with other specialities in medicine
Anaesthesia Vs Aviation industry The safety of airline travel-highest:
Increased in air traffic density; More take-offs and landings with
less separation between aircraft.
Practice of anesthesiology similar like aviation:
Take off and landing: similar to induction and recovery
Increased No of Surgical patient; diverse age group;
Increasing co-morbidities; complex surgical procedure.
Fatal accident/ complications still happened.
Lets look at the mortality from Anaesthesia
In 1950: 3.7 in 1000 anaesthetics 1980: 1 in 10,000 anaesthetics 2000: 1 in 300,000- anaesthetics
Mortality: GA Vs RTA Now Lets Compare the Mortality from GA with an
event that anyone, anywhere on this Mother earth can face
So, A patients has HIGHER chances of dying from RTA than from exposure to General Anaesthesia.
2013: WHO released “Global Status report on road safety;
RTA mortality 18 per 100,000 people/year
Mortality From GA: 1 in 300,000
GA Vs RTA
What makes anaesthesia safe ?
What makes anaesthesia safe ? Monitoring equipments
Safer drugs, equipment
Advanced in airway management
Anaesthetist skill and knowledge
Guideline and protocol: EBM
Surgical skill
Factors influencing risk of Anaesthesia?
Patient status: age, co-morbidities
Procedure –: urgency, invasive
Facility: resources, equipment, monitoring
Skill/ expertise- anaesthetist, surgeon
Readiness, fatigue of the physicians
Where Safety Starts ?Where Safety Starts ?
Patient
Facilities, Equipment, and Medications Anaesthetist’s Skill
Surgeon’s Skill
Survival DependsSurvival Depends..............
Facilities, resources; Equipment, and Medications Quantity and Quality
Anaesthetist Skill
HELP
Referal
10%
20%
60%
10%
Safe Anaesthesia Practice
Protocol
Crisis management / guideline
Training / skill development/ updation- CPD activities
Evidence based medicine; Transforming evidence into practice
The goal is to provide highest standard of care and safety in any setting
International Task Force on Anaesthesia Safety And Approved by World Federation of Societies of Anaesthesiologists (WFSA)
HIGHLY RECOMMENDEDHIGHLY RECOMMENDED
Minimum standards that would be expected in all anaesthesia care for elective surgical procedures
“Mandatory" standards
Mandatory standardMandatory standard
Pre-anaesthesia checks/ Care
Safe Conduct of anaesthesia
Monitoring during anaesthesia
Post Anaesthesia Care
Pre-anaesthesia checksPre-anaesthesia checksCheck patient risk factors
ASA 1 2 3 4 5 6 EAirwayMallampati Aspiration risk?Allergies?Abnormal investigations?Medications?Co-morbidities?Formulate anaesthetic plan
Pre operativePre operative CounselingCounseling
Associated risk - Possible complication - Remote complication
Anaesthesia plan:
- GA
- Regional
Postop care
- Pain management
- post-op monitoring/ care
Check resources? Before starting Anaesthesia
Choice of Anaesthesia Judged by type of patient / procedure/ facility Chose the Simplest and safest technique Variety of options available
- LA
-LA + Sedation
-Regional +/- sedation
- GA with LMA/i-gel
- GA with ETT
- GA + Regional combination Try to minimise the multiple combinations
Standard monitoring recommended by ASA
MedicationMedication Human error: most common All drugs should be clearly labelled; cross check before
administering
Unanticipated Difficult Airway Unanticipated Difficult Airway
Post-anaesthesia Care
Facilities and personnels Monitoring Pain relief Discharged criteria
Documentation: Legal aspects
Post CrisisPost Crisis
Avoid blame cultureDevelop Help Culture
Post Crisis: Recommendations for colleaguesPost Crisis: Recommendations for colleagues
Be aware that such an adverse event could happen to you also
Discuss with your colleague or seniors. This is not weakness. This represents appropriate professional behaviour
Listen to what your colleague wants to tell and support him/her with your professional expertise
A professional work-up of that case based on fact is important for analysis and learning out of medical error.
Senior/ colleague should offer support in discussing and briefing with patient/relative after an medical error.
Changing definition of Anaesthesia
Word anaesthesia was coined from two greek words: “an” meaning without and “aesthesis” meaning sensation.
Traditionally the goal of anaesthesia were described as Amnesia, analgesia, and muscle relaxant.
More recently, Anaesthesia can be considered as a science of reflex management.
Aims of General Anaesthesia In real there are Only 2 aims of GA
1. Narcosis: unrousable unconsciousness
2. Reflex Depression:
Reflexes may Motor : Movement, coughing Autonomic reflexes Cardiovascular: BP, HR changes Neuro-endocrine: Cortisol, vasopressin
ANAESTHESIA“A Modern Concept”
Reflex depression: Main aim of general anaesthesia Consciousness and reflex depression act in different level. Reflex depression has nothing to do with consciousness Amnesia and muscle relaxation are desirable but not mandatory
for GA.
Genera Anaesthesia can thus be defined as:
A reversible iatrogenic state characterised by unrousable unconsciousness and reflex depression.
Present Global scenario Anaesthesiologist no more confined to operative room only Perioperative physician Emergency / ICU care / trauma Pain physician Palliative care provider Evidence based practice of some perioperative issues and
Current trends in Anaesthesia perioperative care
Reducing aspiration risk (fasting guideline)
Infant and children: formula milk- 6 hrs Breast milk: 4 hrs Clear fluid: 2 hrs
Adult Heavy meal: 8 hrs Light meal 6 hrs Clear fluid: 2 hrs
All Trauma patients;Pregnant Patient in labour:
Considered to be full stomach
Obese Diabetic
Pt with GERDHiatus Hernia
Considered to be high risk for aspiration:Gastroprophylaxis even in full fasted state
Restrictive Vs liberal fluid
Rational use of Blood
Postoperative pain Multimodal Analgesia
Preemptive/ preventive analgesia
Avoidance of Opioids
Greater use of regional Anaesthesia technique
Regular analgesic- No SOS or PRN dosing for pain
Individualised treatment
Identify problematic patient; formulate a pain management plan
Why Opioid free analgesia? PONV-- delay start of feeds
Bladder/ bowel function
Sedation: delayed mobilisation; discharge Respiratory: Obstructive breathing, Silent aspiration, Postoperative
pulmonary complications.
Immuno - suppressant effects- would infection. Cancer recurrence/ metastasis Persistent post-op pain into chronic pain
Hypothermia:peri-operative morbidity/mortality
Consequences of hypothermia
Shivering/oxygen requirement increased: myocardial oxygen supply /
demand
Infection: Directly depress immune function, Vasoconstriction-
reduced tissue oxygen- predispose to infection
Delay would healing
Bleeding / transfusion: Depressed platelet and coagulation
Depressed Cardiac function and risk for arrythmias
Delay recovery from anaesthesia
Oxygen therapy (hyperoxia) No evidence that hyperoxia reduces surgical infection
AVOID trial: Air Vs oxygen in MI; Harm by excess oxygen
Pao2 independent predictor of mortality after stroke in ventilated pt. (Crit Care Med. 2014 Feb;42(2):387-96.)
Hyperoxia; not good for pulmonary physiology:
Targeting normal SPO2 by giving high oxygen in ARDS- worse
outcome. (Ann Am Thorac Soc. 2014 Nov;11(9):1449-53)
Routine supplementation of oxygen in postop: may be more harmful
than benefit
Postoperative infection: Anaesthetic role
Antibiotic prophylaxis Hand hygiene Aseptic precaution for invasive procedure Glycemic control Avoidance of hypothermia Fluid and blood product Oxygen- avoiding hypoxia / hyperoxia Regional anaesthesia technique
Anaesthesia Future prospective
Surgical revenue: major portion of hospital revenue:
Perioperative Physician / leader: perioperative coordinator
Anaesthesiologist: identify and correct perioperative risk;
improve outcome and pt satisfaction
Surgeon: focus on new and more specialised technical
procedure
Uncontrolled pain- patients' dissatisfaction in hospitals.
As anesthesiology, we know pain and how to treat it.
Safety first Unless Safe Anaesthesia is provided--> Safe Surgery will not
be Possible and -->Safety of Patient cannot be ensured.
So, Safe Anaesthesia-->Safe surgery-->Safe Patient
SAFE ANAESTHESIA PRACTICE SAFE ANAESTHESIA PRACTICE
Thank youThank you