OPERATION ROOM HAZARDS

BY ABAYNEH BELIHUNAKSUM UNIVERSITY DEPARTMENT OF ANESTHESIOLOGY

Definition

• Hazard: a situation that poses a level of threat to life, health, property, or environment.

• A hazard does not exist when it is not happening. • Anesthesia and surgery are conducted in

technologically intense envt……potentially hazardous.

The most common hazards in OR

• Fires and Explosion • Static Electricity• Electrical Hazards• Radiation Injury• Air Pollution and • Power Failure

Fires explosions• Both of these can cause death or injury to the

patient. • Only occur if we have 3 things: – spark or a hot surface, – flammable substance and– source of oxygen

Sources of sparks or heat – Static electricity– Faulty electrical switches and apparatus, e.g. saws, plaster

cutters and drills– Foreign matter, e.g. dirt or grease in the oxygen or nitrous oxide

cylinders – Diathermy – Open flames.• Flammable substances: Includes ether, ethyl chloride and

solution in sprits. The addition of oxygen increased flammability.

Static electricity 1• Electricity present in the atm. • Occurs if two materials which conduct

electricity poorly are brought into contact and then separated.

• If there is friction or movement between the two, a spark is produced and a spark, of course, can produce an explosion.

Static electricity 2

• EX. Woolen fabrics, non-conducting rubber, and synthetic materials such as nylon.

• Should be avoided in the OR, using graphite impregnated yellow coded rubber instead.

OTHER PRECAUTIONS TO REDUCE STATIC ELECTRICITY 1

• Conductor floor (Concrete or conductive rubber or plastic, placed on floors)

• Avoid wool, plastic and nylon fabrics and wear cotton or other anti-static outer clothes instead.

• Wear aprons of conductive rubber. • Wear anti-static boots or conductive canvas

overshoes. • Maintain humidity of 60%. Static sparks are

more frequent when the air is dry.

OTHER PRECAUTIONS TO REDUCE STATIC ELECTRICITY 2

• Ventilation- Anesthetic gases are heavier than air and tend to collect at ground level.

• Regular inspection of electric switch & apparatus

• Firefighting equipment should always be available

• Smoking and open flames must be forbidden

Electrical hazards 1•  They may occur when patients are: – In contact with faulty electrically-operated medical

equipment – Accidentally connected to electric circuits by spillage of

blood or saline– Dependent on electrical equipment to replace or

support vital organ functions – Exposed to fire or explosions – Undergoing treatment when safe levels of electrical

energy are exceeded.

Electrical hazards 2Electric shock:• When the body actually becomes part of

an electrical circuit with significant current• Wiring defects, faulty equipment

components and deteriorated insulation • Lack of maintenance and misuse are the

usual causes.  

Electrical hazards 3Macroshock • Most common • occurs when the body conducts an electric current

which does not pass directly through the heart. • Mild sensory stimulation@5 to 10 mA• @50 to 60mA- muscular contraction • @100mA- breathing becomes extremely difficult. • Somewhere above this level respiratory paralysis,

cardiac arrest and severe burning occur.

Electrical hazards 4Microshock• When very tiny currents, such as

100µA, are intentionally passed directly thru heart muscle– e.g. direct cardiac catheterization, CO

measmt

Electrical hazards 5• High frequency currents above 50 hertz are less

likely to produce electric shock but can cause burns and interference with other devices such as pacemakers.

• DC is less likely to cause VF than high frequency AC (above 50Hz) but can cause muscle contraction.

• Nerve damage often occurs with high currents. • The SC may be involved by large currents passing

from head to foot or from arm to arm.

Electrical burns and electrically initiated burns

• Three types– Carbonization of skin (from burns at

very high temperatures of 1,000°C) – Flame burns – Direct heating of tissues produce

coagulation and necrosis at entry and exit points and associated injury in muscle and BV.

Electrosurgical units

• Diathermy are arranged so that current from the active electrode flows through the patient and back to the generator

• Don’t use electric blankets in conjunction with electro-surgery.

Air pollution 1• RISKS

– Spontaneous miscarriage, – Congenital abnormalities and – Liver disorders.

• Waste anesthetic gases escape from:– Faulty valves– The ventilator– Poorly fitted components in the breathing circuit– Spilt anesthetic drugs– Expired gases from the spill valve of the anesthetic breathing

system– Gases exhaled by the patient

Remedies

• This pollution can be reduced by – Regular thorough inspection of all anesthetic equipment – Limit or avoid the use of inhalational gases and agents

e.g., circle system, TIVA and RA– An efficient scavenging system.– Closed circuits– Anti spill devices

POWER FAILURE!!!

Power failure

• Critical areas employing electrically driven equipment such as respirators (Ventilators) and dialysis machines require standby equipment (i.e. generators).

ANESTHESIA RELATED

HAZARDS/ RISKS

RISK • Risk is the potential that a chosen

action will lead to a loss or an undesirable outcome.

• Risk is a ubiquitous, natural part of life, because everything we do, including doing nothing, poses uncertain outcome.

• Occasionally the term refer to the outcome itself (e.g., death as one risk of anesthesia).

Anesthesia risk and accidents

• Accident is an unplanned, unexpected, and

undesired event

• Because there are no standard methods for

assigning causality yet, no accurate estimates of

the rate of adverse out-come

• Errors related to AW mgt, monitoring, and sudden

cardiac arrest during SA, equipment failures, or

nerve injuries.

Adverse respiratory events• The most serious hazards in anesthesia. • Causes of death and brain damage are inadequate

ventilation, esophageal intubation, and difficult ETI. • Cases in the first 2 causes were judged to have been

preventable if better monitoring had been employed. • Anticipated difficult ETI- refer to better institution or

surgical AW should be performed before anesthesia.

Failure to monitoring

• An important contributor to anesthesia adverse events.

• There are numerous ways in which pulse oximetry, capnometry, and automated blood pressure monitors can give false information, leading to missed or incorrect diagnoses.

Medication errors• The most frequent error in anesthesia, and

in healthcare practice in general. • Similarity of drug names, containers, and

label colors

Medication errors• Dosing errors related to the frequent need for

individual • Error in numerical calculations when drawing and

mixing drugs for bolus administration or IV infusion. • Wrong drug (e.g., among various insulin formulations)• Flushing a catheter with a solution containing another

potent drug, • Confusion in the programming of infusion pumps

Recommendation• Read the label carefully 3 times!

Errors in diagnosis

• Especially during the management of critical events.

Equipment errors and failures• Current anesthesia machines and

associated technology incorporate substantial safety features.

• Frequent and can occur in many ways, but rarely causes injury directly.

• Equipment associated injury; it is more likely to be from misuse than from overt failure of a device.

lack of standard practice and unusual situations

• Accidental dislodgement of ETT during transportation

• Undiluted phenytoin by rapid IV infusion - refractory HN, arrhythmias, and death.

• Undiluted K+ by rapid IV infusion - VF and cardiac arrest.

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

lack of standard practice and unusual situations

• Inadvertent IV injection of LA- neurologic and cardiac toxicity, which can be fatal (especially with bupivacaine).

• Air embolism during the placement or removal of central venous catheter

• Limb necrosis if the tourniquet is left on the patient for a prolonged period

Summary of Risk Management

RISK IS UBIQUITOUS

RISK ASSESSMENT Stratification, prioritization and intervention

WHAT IF YOU FAIL TO DO ALL THIS?

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Enhancing patient safety • Avoidance, prevention, and

amelioration of adverse outcomes or injuries

• Quality of care: Extent to which health services for individuals and populations increase likelihood of desired health outcomes and are consistent with current professional knowledge.

…………• Patient safety is focused on prevention of injury. • Quality assurance generally deals with the

broader spectrum of quality, including the success of treatments.

• Risk management is focused on proactive patient safety, based on the principle that prevention of injuries via error reduction and system improvements

Practical elements 1

• Avoidance of unnecessary risk taking

• Almost unending anticipation of what might go

wrong,

• Projection of actions in anticipation of failure and,

above all, mindfulness

• Being patient centered……..PATIENT IS ABOVE

OUR EGO!

Practical elements 2

Maintaining vigilance:

• The anesthesia provider must maintain alertness and be aware of, compensate for, and counteract the forces working against vigilance.

• Fatigue and sleep deprivation are probably the most common causes of lapses in vigilance.

Practical elements 3• Practice in a system of care• Teamwork• Preparation• Monitoring• Control for human factors: organized

arrangement of supplies and drugs, esp labeling, and establishing and adhering to local standards.

Practical elements 4• Care to keep IV cannula and monitoring cables

orderly, lighting, and reducing clutter, noise, and distractions

• Infection Control• Antibiotic administration in the perioperative

interval reduces postoperative wound infection. • Surgical wound infection rates are increased 3-fold

by hypothermia.

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Anesthesia crisis management • Seek assistance early and quickly inform others• Establish clarity of roles for each person involved in

mgt. of event (event manager)• Use effective communication processes • Use resources effectively and identify what

additional resource (people, supplies, equipment, transportation) are available to manage situation.

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CRISS MANAGEMENT DURING ANESTHESIAC1

Circulation

Adequacy of peripheral circulation (rate, rhythm, and character of pulse). If pulse is absent (CPR)

C2

Color Note saturation. Examine for evidence of central cyanosis,Pulseoximetry

O1

Oxygen Check rotameter settings; ensure inspired mixture is not hypoxic.

O2

Oxygen analyzer

Adjust inspired oxygen concentration to 100% Check that oxygen analyzer shows a rising oxygen concentration distal to common gas outlet.

V1

Ventilation

Ventilate lungs by hand to assess breathing circuit integrity, airway patency, chest compliance, and air entry by “feel,” careful observation, and auscultation. Also inspect capnograph’s trace if available

V2

Vaporizer

Check all vaporizer filler ports, seating’s, and connections for liquid or gas leaks during pressurization of the system. Consider possibility of wrong agent being in vaporizer.

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CRISIS MANAGEMENT DURING ANESTHESIA (CONT…)

E1

ETT check ET tube (if in use) Ensure no leaks or kinks or obstructions. Check capnograp, oximeter for possible endobronchial position

E2

Elimination

Eliminate anesthetic machine and ventilate with self-inflating (e.g., Ambu) bag with 100%

R1

Review monitor

Oxygen analyzer, capnograph, oximeter, blood pressure, ECG, temperature and NMJ monitor)

R2

Review all other equipt

Review all other equipment in contact with or relevant to patient (e.g., diathermy, humidifiers, heating blankets, endoscopes, probes, prostheses, retractors…

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CRISIS MANAGEMENT DURING ANESTHESIA (CONT…)A Air way Check patency of non-intubated airway. Consider

laryngospasm, FB, blood, gastric contents, or nasopharyngeal or bronchial secretions

B Breathing

Assess pattern, adequacy, and distribution of ventilation. Consider, examine, and auscultate for bronchospasm, pulmonary edema, lobar collapse, and pneumo- or hemothorax

C Circulation

Repeat evaluation of peripheral perfusion, pulse, BP, ECG, and filling pressures and any possible obstruction to venous return, raised intra thoracic pressure (e.g., inadvertent PEEP)

D Drugs Review intended (unintended) drug or substance administered Consider whether problem may be a consequence of an unexpected effect, a failure of administration, or wrong dose, route, or manner of administration of drug

HAZARDS FOR ANASTHETISTS

• Fire & explosions• Electrical accidents• Pollutions by anesthetic agents• Radiations• Infections• Incompatibilities / allergies• Stress• Chemical dependence

OR

Infections

• Physical spread-HSV,CMV• Blood borne-HIV,HBV,HCV• Air borne-Mtb

Infections • Blood borne diseases thro’ Needle stick injuries-

HIV:0.3%, HBV:3%, HCV30%• 32% had at least 1 NSI in the preceding 12M.

(only half of them took treatment).• More risk with hollow-core & large bore• NSI more in non dominated hands• NSI more during disposal of contaminated

needles.• Anesthesiologists have risk for occupational

infection during 30years of exposure-0.045-4.5%

Infections-HIV• Health care workers contribute 5% of

total cases• 4% of emergency department pts are

unidentified cases.• Pts considered infective if both

screening (ELISA) & confirmatory (western blot, indirect fluorescent ab) tests are positive.

Infections-HIV• 54 reported cases of occupationally

acquired HIV(1998).

• 88% of them had H/O NSI• ? Quantity of inoculums- ( a case report :100-

200µml of blood thro” i.v. produced HIV).

• Risk for the pts- 6 cases reported.

Infections-HBV

• Non immunized HCW- higher risks• 17.8% 0f seropositive among anesthesiologist• 30% became positive after 11 years of exposure• Disinfectants & gloves are not completely

protective- viruses viable for >14 days in needles, gloves, & surfaces.

Infections-HCV

• No immunization available• No specific treatment available• Advice: serologic monitoring for HCV

& LFT 3-6 monthly.

InfectionsManagement of occupational infections.SAFE PRACTICE1. Protective equipments2. Washing methods3. Disposal methods

Infections - CDC recommendationsUniversal precautions-1980 -considering as all pts, blood & body

fluids are infective.Isolation precautions-1996 -2 tier recommendations

1. Standard precautions -to be followed for handling all pts as infective.

2. Transmission based precautions -for handling pts known to be / suspected of being risks.

Infections -CDC recommendationsTransmission based precautions• Based on properties of specific pathogens • Airborne precautions [measles, varicella, Tb] -to

prevent from small particles<5µm by specific filters air handling devices.-HEPA, Negative pressure environment

• Droplet precautions [HBV, mycoplasma, streptococcal pharyngitis, rubella]-to prevent from large particles>5µm, keep distance>1m

• Contact precautions [HAV, HSV, viral conjunctivitis]

Incompatibilities / AllergiesLatex allergy• Type IV/ type I• Risk groups :

1. Spina bifida,2. Urogenital abnormalities ,3. HCW, 4. Rubber factory workers.

Latex allergyManagements

1. Identification of risk groups2. Use latex free objects-latex free environment 3. Tests: RAST[radio-allergo-sorbent test] SPT Sr.histamine Urinary histamine Sr.IgE Sr.compliments Sr.tryptase

Tests for anaphylaxis

Screening tests

Latex allergyManagements-drug regimens• Preoperative protocol:

1. Dipenhydramine -1mg/kg,po/iv,q 6hr at 13,7,1hr before surgery

2. Prednisolone -1mg/kg,po/iv,q 6hr at 13,7,1hr before surgery or hydro cortisone 4g/kg

3. Ranitidine - 2mg/kg po, 1mg/kg iv,q 12hr at 13,1hr before surgery

• Postop protocol -drugs to be repeated for 12hrs

Stress• Inevitable, universal phenomenon to

which no one is immune• Job related stress are unavoidable

but may be controlled• 2 types-Unavoidable & Avoidable• Unavoidable-professional stress • Avoidable-sleep related

StressUnavoidable Stress• Professional Stress• Co-worker relationships• Work load• Litigations• Peer review• Professional dissatisfaction• Administrative responsibilities

StressAvoidable Stress• Sleep related-altered sleep pattern,

sleep deprivation• Coincide with natural sleep peaks• Identification of sleep disturbances• Regulations of working hours

Chemical dependenceSelf administration of drugs & suicide rates are high

amonganesthesiologist.• Addiction :compulsive, continued use of drugs

inspite of adverse, a chronic, relapsing condition resulting from long term effects of drugs on brain, due to molecular, structural, cellular, & functional changes.

• Dependence: physical / psychological inability to control drug use

• Abuse :use of drugs in detrimental way but not to the point of addiction. a pre addiction level, can easily quit. a voluntary act.

Chemical dependence

Causes• Stress• Availabilities• Curiosity for experimentation• Drug potency• Others-genetic predisposition

Chemical dependence

Management • Identification• Intervention• Referral• Rehabilitation

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References • Safe anesthesia –third edition• Ronald D Miller and Manuel C Pardo, Jr • Airway management in emergencies, George Kovacs and J.

Adam Law, 2008 • Clinical Anesthesiology, 4th Edition, G. Edward Morgan, Jr.,

Maged S. Mikhail, Michael J. Murray • Clinical Anesthesia, 5th Edition by Barash, Paul G.; Cullen,

Bruce F.; Stoelting, Robert K. 2006 • Miller’s Anesthesia, 7th edition by Ronald D. Miller, 2010 • Decontamination of medical equipment, update in

anesthesia content number 7, 1997