Fatigue among Anesthesia Personnel Dr. Abdullah M. Kaki, MD, FRCPC, Department of Anesthesia & Critical Care, Faculty of Medicine, King Abdulaziz University Kaki, Dubai, March 7, 2013
Definition • Is the inability or unwillingness to continue effective performance and is caused by excessive workload, stress, sleep loss, and circadian disruption. Kaki, Dubai, March 7, 2013
Fatigue • Achilles' heel of the medical profession. 1 Kaki, Dubai, March 7, 2013
Once Upon A Time (On-call Duties) • • • Attend & anesth all emergency cases in OR Member of code blue team Member of trauma team Epidural provider to all pregnant ladies (LR) Attend all meconium stained deliveries Provide outside services (consultations, cardioversion, …) • Preop visit for some consultants Other wise you can sleep Kaki, Dubai, March 7, 2013
Kaki, Dubai, March 7, 2013
Health care is 24 / 7 service Anesthesiologists deliver critical around-the-clock care to a variety of patients. Fatigue is Physiological challenge Circadian pattern alertness and performance sleep. Patient safety has taken center stage in health care Kaki, Dubai, March 7, 2013
Kaki, Dubai, March 7, 2013
• In March 1984, Libby Zion, 18 yr old New York Hosp by parents with a high fever, dehydration, and chills admitted to medical ward. • She was never examined by an attending physician; (intern and a junior resident), both up for 18 hrs. She became increasingly delirious, placed in physical restraints. AM, she was dead. • Death has been attributed to the inexperience and fatigue of resident physicians who lacked the direct supervision of an attending physician. Kaki, Dubai, March 7, 2013
Fatigue risks safety • Circadian factors were identified as contributing to the errors that resulted in the nuclear accident at Three Miles Island Chernobyl. • Fatigue resulting from the work–rest patterns of managers was an important component of the flawed decision-making that contributed to the space shuttle Challenger accident. Kaki, Dubai, March 7, 2013
Fatigue risks safety • N. S. F. 1: 2 drivers driven while drowsy /yr, 1: 5 “nodded off” while driving. • Fatigue 100, 000 crashes/ yr 76, 000 injuries & 1, 550 fatalities. • Recently, fatigue is the cause in 15– 20% of all transportation accidents, > ETOH + drugs in RTA. Kaki, Dubai, March 7, 2013
Intraop patient care requires • Cognitive demands: data collection, evaluation of its relevance to pt status, development and implementation of plans to maintain desired pt status, monitoring the outcome of interventions, and prompt response to acute changes Sleep providers can not have adequate sleep Kaki, Dubai, March 7, 2013
Does fatigue impair performance? • Loss of sleep & circadian disruption • reduced attention–vigilance, impaired memory and decision-making, prolonged reaction time, and disrupted communications. • increased risk for the occurrence of errors, critical incidents, and accidents. • Speed-accuracy trade-off effect. • Microsleeps Kaki, Dubai, March 7, 2013
• Denisco et al. on a simulated monitoring task: subjects were asked to monitor and record time of significant deviation of clinical variables (HR, BP) lower “vigilance scores” in the group that had been on call. • Interpret ECG changes and to do simple mathematical calculations is compromised among sleep-deprived house officers. • Speed and quality of ETT was among ER doctors working night shift opp to their performance while working during day. Kaki, Dubai, March 7, 2013
Fatigue effects on health • Several studies: long-term exposure to shift independent risk factor for GI & CVS diseases. • A recent study: ♀ working night shift 60% > risk for breast ca compared with ♀ never worked the late shift. • A meta-analysis (29 studies, 160, 000 ♀ ) evaluated physically demanding work, prolonged standing, long work hrs, and cumulative “fatigue score”. Positive assoc between that and preterm births, PIH, SGA. Kaki, Dubai, March 7, 2013
• Sleep restriction immunity, endocrine functions, cerebral metabolism. • A prospective study (1000, 000 persons with cancer): reported ♂ daily sleep times < 4 h were 2. 8 times more likely to have died within a 6 -year than ♂ had 7. 0– 7. 9 h of sleep. Kaki, Dubai, March 7, 2013
Sleep Factor • Microsleep • Brief, uncontrolled, and spontaneous episodes of physiologic sleep • last sec – min, intermittent in onset, difficult to predict, individual underestimates level of sleepiness. • occur during low workload or when maximally sleepy. • Frequent and longer microsleeps increase the number of errors of omission. Kaki, Dubai, March 7, 2013
Sleep Inertia • Period of reduced ability to function optimally immediately on awakening. • Impaired performance for 15 - 30 min after awakening. • Common during early morning circadian trough (2 to 5 AM). • Awakened out of deep sleep to provide emergency care to pts (e. g. , emergency C/S or emergency ETT). Kaki, Dubai, March 7, 2013
• The risk of LDP was greater at night (00: 00 -8: 00) among inexperienced practitioners. Kaki, Dubai, March 7, 2013
Evaluation of physiologic sleepiness in anesthesia residents • Using MSLT, evaluated physio daytime sleepiness of anesth residents under 3 different conditions: • “baseline” (daytime shift, no on-call in the previous 48 hrs), • “post-call” (immediately after a 24 -hr work ), • “sleep extended” residents allowed to arrive for work at 10 AM for 4 consecutive days. • MSLT score of 6. 7 ± 5. 3 min in “baseline” • 4. 9 ± 4. 7 min in “post-call”, both scores revealing the nearly pathologic levels of daytime sleepiness (narcolepsy or sleep apnea). • “baseline” group slept an average of 7. 1 ± 1. 5 hrs / night, “post-call” 6. 3 ± 1. 9 hrs “sleep-extended”, the subjects extended their sleep to an average of more than 9 hrs / night, and MSLT scores were in the normal range (12. 0 ± 6. 4 minutes). • Data indicate that under “normal” working conditions, residents studied were physiologically sleepy to nearly pathologic levels. Kaki, Dubai, March 7, 2013
Risks to Patients and Healthcare Providers • In 2 studies of anesth 50% reported having committed an error in medical judgment due to fatigue. Cooper et al. , using critical incident method of evaluating anesth errors, estimated that human error played a role in 80% of anesth mishaps & fatigue in 6% of reported critical incidents. • In a survey of New Zealand anesthesiologists 86% reported having committed a fatigue-related error. • Data from 5, 600 reports of critical incidents to the Australian Incident Monitoring Study (1987 -1997) fatigue was listed as a contributing factor in (3%). Kaki, Dubai, March 7, 2013
• Needle stick injuries, Among residents and medical students, a 50% greater risk of sustaining a blood borne pathogen exposure during night work than during days. • Residents (Ped & ER) suffer twice expected number of accidents, while driving home after being on call. • Retrospective study among anesthesia trainees, 8 accidents were reported. “protective” circadian alerting effect during the drive home (8– 10 am). Kaki, Dubai, March 7, 2013
Effect on Mood • Pilcher and Huffcutt, a meta-analysis: effects of sleep deprivation on performance (medical and nonmedical) (19/56 published studies, 1, 932 total sample size). • Sleep-deprived subjects performed at a level 1. 37 < rested subjects, impact was on mood and cognitive measures, with little change in motor performance. Kaki, Dubai, March 7, 2013
Correction Strategies • Education: During 7 yr of medical school and residency, little or no information regarding sleep, sleep disorders, and related topics. • Lacking this knowledge, physicians are unlikely to appreciate the need for change. • Alertness Strategies: • planned naps: NASA study (naps in the cockpit). 40 -min nap performance by 34% and physiologic alertness by 54% compared with a no-nap condition. Kaki, Dubai, March 7, 2013
• Caffeine use widely used stimulant. Pharmacologic onset of caffeine occurs 15– 30 min after ingestion and lasts about 3– 4 h. Tolerance reduces its alerting effects. A significant performance and alertness boost (200 mg of caffeine, 100 -600 mg). • Good sleep habits • Light therapy • Noise • Temp Kaki, Dubai, March 7, 2013
Better Scheduling • On call no more often than every 3 rd night. • Prohibited from “administering anesthesia on the day after in-house overnight call (free of duty for 24 hr). • Working 80 total hrs /week (Ideal 45 -50 hr) • Avoid any surgery between 2 am and 5 am. Kaki, Dubai, March 7, 2013
• Modafinil or pimoline is non-amphetamine wakefulness agents. • Treat narcolepsy or OS apnea • Used by military, Not in medical field Kaki, Dubai, March 7, 2013
Melatonin • Hormone by pineal gland with sleep-promoting effects • Used for jet lag and for shift work. • Doses of 0. 3– 80 mg. • It has circadian phase-shifting effects • Studies evaluating the efficacy of melatonin in shift workers have yielded mixed results. Kaki, Dubai, March 7, 2013
Anesthesiologist Pilot Responsibility 1 -2 pt 10 -800 passengers Minimum Rest pre/ post-duty period 0 10 hr Max flying time 24 hr 14 hr Max duty / wk 40 - 80 hr 30 hr On-call 3 -4 days daily Kaki, Dubai, March 7, 2013
Long term plan 1) Implement education program regarding fatigue risks, physiologic factors, and effective countermeasures required for individuals throughout the healthcare system. 2) Implementation of effective alertness strategies through education and appropriate institutional policies. 3) Recommendations for work–rest schedules in health care similar to those that have been promulgated in aviation. Kaki, Dubai, March 7, 2013
Thanks For any reference pls send me an email at amkaki@yahoo. com Kaki, Dubai, March 7, 2013
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