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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