Safety in Anesthesia

• Anesthetists are responsible for patient safety during operations

• Anesthesiology is a high-risk specialty as compared with other specialties in medicine

Why

The risk of anesthesia

• Anesthesia may contribute to death in about 1 per 10,000 anesthetics.

• Many other patients suffer serious and costly nonfatal injuries such as permanent neurologic damage (paraplegia and vegetative).

• Now we can see anesthesia event can cause severe results

• So we should find out factors threatening patient safety in the operation room and search for strategies to deal with them

There are many factors threatening patient safety in the operation rooms

Equipment

• Causes: – Design flaw– User error– malfunction

• Strategies: pre-use checkout

Patient

• Causes – Underlying diseases: hyperthyroidism-thyroid

storm, diabetes-ketoacidosis or hyperosmolar come

– Allergic reaction to some drug• Strategies– Preoperative evaluations

Anesthetist and Surgeon

• Human factors affecting performance such as :fatigue noise, boredom, long hours, hunger, tension

• System failures are the main reason for accidents– Check anesthetic machine– Oxygen supply– A backup O2 tank– Never shut down audible alarms (very important)

Emergency ventilation equipment

• Human error is a strong contributor– Deviations from accepted anesthesia practices– A lapse in vigilance and no attention to detail

• Vigilance and attention to detail are essential for a safety conducted anesthetic.

• Vigilance lets anesthetists find abnormal signs as early as possible

• Vigilance allows the anesthetist to to remain aware of surrounding events and signals while performing other tasks.

II. General safety strategies

A. Prepare a preoperative plan

• Preoperative visit to the patient to let us know the patient’s condition in detail.

• Make an anesthesia plan to let us know clearly how to perform the anesthesia and how to deal with possible crisis.

• Check anesthesia machine, monitors and other devices.

• Prepare the workspace to make us work mare conveniently and efficiently. Arrange equipment and appropriate monitors in a way that facilitates this. So we can clearly observe the patient and easily manipulate all devices

• Check backup equipment

• Know the location of emergency supplies and equipment

• Label all medications

B. Develop situational awareness

• Use systematic approach to scanning the machine monitors, patient, surgical field, and surroundings.

• If one vital sign is anomalous, quickly assess the measurement and observing what is happening on the surgical field.

C. Verify observations

Cross-check observations Assess co varying variables Review it with a second person.

D. Implement compensatory responses

If something wrong happens urgently, first implementing time-buying measures. E.g., increase the fraction of inspired oxygen when oxygen saturation falls; administer intravenous fluids or vasopressors when hypotension occurs.

Then search out any correctable primary cause and treat it appropriately.

E. Prepare for crisis

If there is any critical events happened (cardiac arrest, malignant hyperthermia or difficult intubation), call for help early (WHY), then use accepted protocols for emergencies and resuscitation (e.g., advanced cardiac life support, malignant hyperthermia protocols).

F. Enhance teamwork; communicate

To enhance teamwork and communication, address surgeons and nurses early in the case by knowing names. Make requests and delegate tasks clearly and specifically by name (e.g., “Jack, do task X and tell me when task X is completed.”)

G. Compensate for stressors

Anesthetist is a stressful job. If you feel very tires, ask for a relief.

Reduce various stressors: noise, fatigue, interpersonal tension, etc. Optimize the work environment.

H. Recognize and address production pressures

• Patient safety must remain the highest priority• In big hospitals, anesthetists have a greant deal of

workload. There are many operations everyday. Anytime we can’t sacrifice patient safety in order to emphasize production. If there is on adequate preoperative evaluation, preparation, or monitoring, it is unsafe to anesthetize the patient. You must address concerns explicitly to surgeons and cancel the operation.

I. Learn from close calls

Every mistake is an opportunity to learn and improve.

Analysis and feedback of adverse events to identify and assess system problems.

III. Crucial errors to know and avoid

A. Airway errors

As we know, patients receiving general anesthesia have no spontaneous respiration due to use of muscular relaxants, their respiration is controlled by machine via endo-trecheal tube. So we must ensure oxygen supply and avoid accidental extubation during sugeries ( esp. a prone surgery) and transport. Once it happens, the result is severe. It can cause severe hypoxia and directly threaten the patient life.

Prone position

How to avoid

• Check the system and guarantee it to function well

• Verify an endotracheal tube by auscultating for breath sounds bilaterally and by detecting end-tidal CO2

• Fix the tube solidly• Closely observe vital signs

Verify an endotracheal tube

B. Medication errors

• Administration of undiluted potassium by rapid intravenous infusion can cause ventricular fibrillation and cardiac arrest.

• Neostigmine given without an antimuscarinic drug can cause asystole, severe bradycardia and antrioventricular block and can be fatal.

• Succinylcholine can cause severe hyperkalemia and dysrhythmias, may trigger malignant hyperthermia.

• Medications to which a patient is allergic can cause anaphylaxis.

• Administering the wrong blood can cause an incompatibility reaction that can be fatal.

How to avoid

• Be familiar with the medication you use, know clearly its indications and contraindications.

• Administrate the medication strictly according to instructions.

• Know the patient’s history of allergy• Cross-check blood type.

c. Procedure errors

• Inadvertent intravascular injection of local anesthetics during a nerve block can cause neurologic and cardiac toxicity, which can be fatal (especially with bupivacaine).

• Avoidable epidural hematomas may develop when spinal or epidural anesthetics are performed in patients who have coagulopathies.

• Air embolisms may occur during the placement or removal of central venous catheters and may cause significant hemodynamic instability. (decumbens position can avoid it).

How to avoid

• Adequate preoperative evaluation of patients • Manipulation according to standards and

guidelines.• Vigilance.

IV. Quality assurance

• The aim is improving the quality of care and minimizing the risk of injury from anesthesia.

A. Documentation

• Any adverse events should be reported truthfully, discussed, analyzed to identify causes and assess system problems. So we can learn from them and develop patterns to prevent recurrence.

B. Standards and guidelines

• Anesthetists should be aware of their institution’s safety policies and procedures. These should include those for monitoring, response to an adverse event, handoff checklist, resuscitation protocols, perioperative testing, and any special procedures or practices for the use of drugs, equipment, and supplies.

C. Safety training

• Anesthesia providers should obtain training in safety to learn and maintain basic skills. Simulation techniques should be used. In reality, for one doctor, the opportunity to confront a critical event is rare, the best way to learn critical-event management skill is using simulator. After training on simulator repeatedly, when crisis happens, you can manage it efficiently.

V. Standards and protocols

Standards for basic anesthetic monitoring

1. Qualified anesthesia personnel shall be present in the room throughout the course of all general anesthetics, regional anesthetics, and monitored anesthesia care.

2. Continually evaluated the patient’s respiration, circulation and temperature.

2.1 Respiratory monitor

• Oxygenation– An oxygen analyzer– Pulse oximeter

• Ventilation – Clinical signs– Capnometry– Continual end-tidal carbon dioxide analysis must be

used with tracheal intubation.– Some form of monitoring with an audible alarm must

be used during mechanical ventilation.

2.2 Cardiac vascular monitor

• Continuous EKG• Blood pressure and heart rate at least every 5

min• One or more of the following– Palpation of a pulse– Auscultation of heart sound– Pulse oximetry

• CVP and arterial blood pressure

2.3 Temperature monitor

• When clinically significant changes in body temperature are intended, anticipated, or suspected.

Handoffs

• Periodic breaks should be given to the primary individuals providing anesthesia.

• The following information should be clearly presented.

a. Prior clinical details

• The patient’s diagnosis, surgery, allergies, past medical and surgical history, relevant medications, and any pertinent normal or abnormal laboratory values or studies.

b. Intraoperative management

• Status of surgery, airway assessment and management techniques, anesthetic plan and current status, current vital signs with an explanation for any apparent abnormalities or trends, intravenous access and monitoring, blood loss and volume status assessment, anticipated need for additional medications (e.g., narcotics, muscle relaxation or reversal, antiemetics).

Guidelines for action after an adverse anesthesia event

The anesthesiologist involved in an adverse event should do the following:

a. Provide for continuing care of the patient.b. Notify the anesthesia operating room

administrator as soon as possible. If a resident or certifield registration

• The objectives are to limit patient injury from a specific adverse event associated with anesthesia and to ensure that the causes of the event are identified so that a recurrence can be prevented.