NAP 5 The 5 th National Audit Project

NAP 5 The 5 th National Audit Project ■■■■■ Phases of Anaesthesia Jeremy Radcliffe National Hospital for Neurology & Neurosurgery, UCLH, London NAP 5 The 5 th National Audit Project

Commendation NAP 5 The 5 th National Audit Project ■■■■■ • Local coordinators and reporting clinicians • Patients’ descriptions, which allowed NAP 5 interpretation • RCo. A Bulletin 87, September 2014 p. 28 ; ‘Introductory remarks’ NAP 5 The 5 th National Audit Project

Definitions • Phases NAP 5 The 5 th National Audit Project ■■■■■ (‘dynamic’ vs. ‘stable’) – Induction and Transfer; before procedure – Maintenance; during procedure – Extubation and Emergence; • Allocation and assessment by review panel – – Experience Causation Avoidability Quality of care NAP 5 The 5 th National Audit Project

Expectations NAP 5 The 5 th National Audit Project ■■■■■ • ‘Classic’ ? NAP 5 The 5 th National Audit Project

Expectations NAP 5 The 5 th National Audit Project ■■■■■ • ‘Classic’ ? • Or brief recollection … ‘The patient reported having seen lights, people overhead and experienced pain (like “animals biting”). The patient tried to speak, but couldn’t. This lasted about a minute. The patient developed a new sleep disturbance, anxiety state and PTSD type symptoms’ …. NAP 5 The 5 th National Audit Project

NAP 5 The 5 th National Audit Project Expectations ■■■■■ • Studies and Publications focus on ‘Maintenance’ phase Induction Maintenance Emergence 50% 36% 18% ( n = 141 72 (58 i: 12 t) 51 26 ) ------------------------------------------- % Gender (F) ASA 1, 2 Emerg/Urgent Overweight NMB recorded 65 79 50~ 49 93 64 76 36 38 65 35 59 96 (survey) (42) (45) NAP 5 The 5 th National Audit Project

Causation NAP 5 The 5 th National Audit Project ■■■■■ • Induction (not 10% classed ‘syringe’ error) • Maintenance Unintended awareness during neuromuscular blockade • Emergence Unintended neuromuscular blockade during awareness NAP 5 The 5 th National Audit Project

NAP 5 The 5 th National Audit Project Causation / mechanism ■■■■■ • Induction – The ‘Gap’: Airway, Vaporiser, Transfer – Underdosing: Planned and Unplanned – Management of Induction: Opioid omitted, RSI, Thiopentone, dose titration • Maintenance – The Gap? – Underdosing: Planned and Unplanned – Uncertain (25%) • Emergence – NMB too long or too late = perceived residual paralysis No nerve stimulator use recorded in 88% NAP 5 The 5 th National Audit Project

Causation NAP 5 The 5 th National Audit Project ■■■■■ • Induction – The ‘Gap’: Airway, NAP 5 The 5 th National Audit Project

Causation NAP 5 The 5 th National Audit Project ■■■■■ • Induction – The ‘Gap’: Airway, ‘ ……. It was unclear whether the plan was to wake the patient up or to continue with attempts to secure the airway. ’ NAP 5 The 5 th National Audit Project

Experience % Induction Maintenance NAP 5 The 5 th National Audit Project ■■■■■ Emergence Distress 43 54 73 ------------------------------------------Experience paralysis 51 57 84 pain 49 (both 37) tactile 34 ------------------------------------------Preventable 58 74 88 Poor care quality 33 74 88 NAP 5 The 5 th National Audit Project

Recommendations NAP 5 The 5 th National Audit Project ■■■■■ • Distilled: 23 • Research implications noted: 15 NAP 5 The 5 th National Audit Project

Caution NAP 5 The 5 th National Audit Project ■■■■■ • Other clinical issues before adopting changes to practice. • Until NAP 5, all current pressures on the anaesthetist are to reduce/minimise anaesthetic agent exposure. NAP 5 The 5 th National Audit Project

NAP 5 The 5 th National Audit Project Practice Recommendations • • ■■■■■ Plan and review drug requirements. Develop Check-list and communication in ‘theatre’. Promote use of a nerve stimulator. Verbal reassurance should be a part of immediate actions if AAGA is suspected. NAP 5 The 5 th National Audit Project