SAFE ANAESTHESIA PRACTICE

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SAFE ANAESTHESIA PRACTICE

• Dr.J.Edward Johnson

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What do you mean by that ?

• Safety of the Anaesthetist ?
• Safety of the Surgeon ?
• Safety of the Patient ?

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SAFE ANAESTHESIA PRACTICE

• Protocals
• Crisis Management
• Tips and Tricks for Anaesthesia

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PROTOCALS
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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)

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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
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"HIGHLY RECOMMENDED"

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

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Peri-anaesthetic care and monitoring standards

• Pre-anaesthetic care
• Pre-anaesthesia checks
• Monitoring during anaesthesia

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Pre-anaesthesia checks
PRE 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 E Airway Mallampati (pictures) Aspiration risk? Allergies? Abnormal investigations? Medications? Co-morbidities? N N N N N Airway Masks Airways Laryngoscopes (working) Tubes Bougies Breathing Leaks (a FGF of 300 ml/minute maintains a pressure of gt 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 E Airway Mallampati (pictures) Aspiration risk? Allergies? Abnormal investigations? Medications? Co-morbidities? 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 - - - - - - - - - - - - - - - - - -
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Monitoring during anaesthesia

• Oxygenation
• Airway and ventilation
• Circulation
• Temperature
• Neuromuscular function
• Depth of anaesthesia
• Audible signals and alarms

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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 - - -
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
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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
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Crisis Management during anaesthesia
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Crisis Management

• Crisis Management Manual developed by Australian
  Patient Safety Foundation
  Qual Saf Health Care 200514
• 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

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Crisis Management ManualCore 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 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
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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
Crisis management algorithm COVER ABCD
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Sub Algorithm Crisis Management
A Obstruction of the natural airway
A Laryngospasm
A Regurgitation, vomiting and aspiration
A Difficult intubation
B Desaturation
B Bronchospasm
B Pulmonary oedema
C Bradycardia
C Tachycardia
C Hypotension
C Hypertension
C Myocardial ischaemia
C Cardiac arrest
D Problems associated with drug administration during anaesthesia
A Awareness
A Embolism
A Pneumothorax
A Anaphylaxis and allergy
Vascular access problems
Trauma development of a sub-algorithm
Sepsis
Water intoxication
Crisis management during regional anaesthesia
Recovering from a crisis
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Crisis management manual Ref.

• Crisis management during anaesthesia the
  development of an Anaesthetic Crisis Management
  Manual http//qualitysafety.bmj.com/content/14/3/e
  1.full.html
• Anaesthesia Crisis Management Manual
  http//www.apsf.com.au/crisis_management/Crisis_Ma
  nagement_Start.htm
• This article cites 42 articles, 30 of which can
  be accessed free at http//qualitysafety.bmj.com/
  content/14/3/e1.full.htmlref-list-1

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Where Safety Starts ?
Patient
Surgeons Skill
Facilities, Equipment, and Medications
Anaesthetists Skill
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Survival Depends.......
Referal
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HELP
10
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Anaesthetist Skill
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Facilities, Equipment, and Medications
Quantity and Quality
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Where Safety Starts ?

• Patient
• - Optimized patient (CVS, RS, Renal, Liver)
• ASA risk
• Well controlled Hypertension
• Well controlled Diabetes
• Haemodynamically stabilsed

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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.

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Anaesthetist Skill

• Learn one or two alternate method of Airway skill
• Practice it in routine cases

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Post Crisis
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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 .

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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..

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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

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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

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Tips and Tricks for Anaesthesia
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Facilities and Equipments
(LMA )
Macintosh
Airways
Magill
Igel
Miller
(GEB)
Polio
Endotracheal Tube Introducer
Mc Coy
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Infra - glottic Invasive Airways
Cricothyrotomy
Tracheostomy
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Unanticipated Difficult Airway
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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 rate

Expert Review of Obstetrics Gynecology
  Katherine W Arendt Jochen D Muehlschlegel
Lawrence C Tsen
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OBESE - AIRWAY
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AIRWAY CORRECTION
Build a BIG RAMPPPP
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Perianesthetic Management of Laryngospasm
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The Laryngospasm Notch Technique
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The Laryngospasm Notch Technique
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Unorthodox method not generally accepted, better
than nothing
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Emergency Airway
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SAFE ANAESTHESIA PRACTICE
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Thank you