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 Management

Tips 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)

Setting Infrastructure

HIGHLY RECOMMENDED Level 1 Small hospital / health centre

Basic

HIGHLY RECOMMENDED + RECOMMENDED

Level 2 Small hospital / health centre

Intermediate

HIGHLY RECOMMENDED + RECOMMENDED

+ Suggested

Level 3 Referral hospital

Optimal

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 carePre-anaesthesia checksMonitoring during

anaesthesia

Pre-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 (colour - if present) Circle system (2-bag test if present)SuctionDrugs 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 thermometersEmergency Assistant Adrenaline Suxamethonium  Self inflating bag Tilting table

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Monitoring during anaesthesiaOxygenationAirway 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 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

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 rotameterEnsure 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 handTo assess circuit integrity, airway patency, chest compliance and air entry by ‘‘feel’’ and auscultation. (Capnography)

V2 Vaporiser Note settings and levels of agentsGas leaks during pressurisationConsider 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, raisedintrathoracic pressure or tamponade of the heart

D Drugs Review drug or substance administrationWrong drug, Wrong dose

Crisis management algorithm ‘‘COVER ABCD’’

Sub

Algo

rith

m –

Cri

sis

Man

agem

ent

A Obstruction of the natural airwayA LaryngospasmA Regurgitation, vomiting and aspirationA Difficult intubationB DesaturationB BronchospasmB Pulmonary oedemaC BradycardiaC TachycardiaC HypotensionC HypertensionC Myocardial ischaemiaC Cardiac arrestD Problems associated with drug administration during anaesthesiaA AwarenessA EmbolismA PneumothoraxA 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_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 ?

Patient

Facilities, Equipment, and Medications Anaesthetist’s Skill

Surgeon’s Skill

Survival Depends.......

Facilities, Equipment, and Medications Quantity and Quality

Anaesthetist Skill

HELP

Referal

10%

20%

60%

10%

Where Safety Starts ?Patient - Optimized patient (CVS, RS,

Renal, Liver) ASA risk Well controlled Hypertension Well controlled Diabetes Haemodynamically stabilsed

MedicationAll 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 SkillLearn one or two alternate method of

Airway skillPractice 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

Magill

Miller

Polio

Mc Coy

(GEB)

Endotracheal Tube Introducer

(LMA ) Airways

Igel

Infra - glottic Invasive Airways

Cricothyrotomy Tracheostomy

Unan

ticip

ated

Diffi

cult

Airw

ay

Techniques to decrease hypotension with 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 rateExpert 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

AN

AEST

HES

IA P

RACT

ICE

Thank you