SAFE ANAESTHESIA PRACTICE Dr J Edward Johnson

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 Tips Management 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) HIGHLY RECOMMENDED + RECOMMENDED Setting Level 1 Small hospital / health centre Level 2 Small hospital / health centre Infrastructure Basic Intermediate HIGHLY RECOMMENDED + RECOMMENDED Level 3 Referral hospital Optimal + Suggested 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 care Pre-anaesthesia checks Monitoring during anaesthesia

Pre-anaesthesia checks PRE ANAESTHETIC CHECK LIST Patient name ________ Number ______ Date of Birth __/__/__ Procedure__________________ Site_______ Check patient risk factors Check resources ASA 1 2 3 4 5 E Airway Mallampati (pictures) Aspiration risk? Allergies? Abnormal investigations? Medications? Co-morbidities? N N N Present and Functioning Airway (if yes - circle and annotate) - Masks Airways Laryngoscopes (working) Tubes Bougies Breathing Leaks (a FGF of 300 ml/minute maintains a pressure of > 30 cm H 2 O)

Check patient risk factors (if yes - circle and annotate) ASA 1 2 3 4 5 E Airway Mallampati (pictures) Aspiration risk? Allergies? Abnormal investigations? Medications? Co-morbidities? Check resources Present and Functioning 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 -

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

HIGHLY RECOMMENDED Oxygenation Supplemental Oxygen supply : -Un interruptedoxygen supply - Inspired oxygen concentration Oxygenation of the patient : - Visual examination, -- Airway and ventilation - Observation - Auscultation - The reservoir bag - Precordial, - Pretracheal, or -Oesophageal stethoscope - Capnography -Palpation of the pulse - Auscultation of the heart sounds - Pulse oximetry - Electrocardiograph - Clinical examination - Pulse oximetry - Capnography - At least every 5 mts - NIBP SUGGESTED Circulation Cardiac rate and rhythm : Tissue perfusion : Blood pressure : - Adequate illumination - Pulse oximetry - - Oxygen supply failure alarm -Hypoxic Guard - Continuous measurement of the inspiratory and/or expired gas volumes, and of the concentration of volatile agents - Defibrillator - IABP

HIGHLY RECOMMENDED Temperature Audible signals and alarms SUGGESTED - Continual electronic - At frequent intervals temperature measurement Neuromuscular function Depth of anaesthesia RECOMMENDED - Peripheral nerve stimulator - Degree of - Continuous unconsciousness (clinical observation) measurement of the inspiratory and/or expired gas volumes, and of the concentration of volatile agents - BIS Monitor 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 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 Crisis management algorithm ‘‘COVER ABCD’’ C 1 Circulation Establish adequacy of peripheral circulation ((rate, rhythm and character of pulse) - CPR C 2 Colour Note saturation. Pulse oximetry - Test probe on own finger O 1 Oxygen Check rotameter Ensure inspired mixture is not hypoxic O 2 Oxygen analyser Adjust inspired oxygen concentration to 100% Check that the oxygen analyser shows a rising oxygen concentration V 1 Ventilation Ventilate the lungs by hand To assess circuit integrity, airway patency, chest compliance and air entry by ‘‘feel’’ and auscultation. (Capnography) V 2 Vaporiser Note settings and levels of agents Gas leaks during pressurisation Consider the possibility of the wrong agent

Crisis management algorithm ‘‘COVER ABCD’’ E 1 Endotracheal tube Check the endotracheal tube (leaks or kinks or obstructions) E 2 Elimination Eliminate the anaesthetic machine and ventilate with self-inflating bag R 1 Review monitors Review all monitors in use R 2 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 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

Obstruction of the natural airway A Sub Algorithm – Crisis Management A Laryngospasm Regurgitation, vomiting and aspiration Difficult intubation Desaturation Bronchospasm Pulmonary oedema Bradycardia Tachycardia Hypotension Hypertension Myocardial ischaemia Cardiac arrest Problems associated with drug administration during anaesthesia A A B B B C C C D A A * * * Awareness Embolism Pneumothorax 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/e 1. full. html Anaesthesia Crisis Management Manual This article cites 42 articles, 30 of which can be accessed free at: http: //www. apsf. com. au/crisis_management/Crisis_Management_Sta rt. htm http: //qualitysafety. bmj. com/content/14/3/e 1. full. html#ref-list-1

Where Safety Starts ? Patient Facilities, Equipment, and Medications Surgeon’s Skill Anaesthetist’s Skill

Survival Depends. . . . Referal 10% HELP 10% 20% Anaesthetist Skill 60% Facilities, Equipment, and Medications Quantity and Quality

Where Safety Starts ? Patient - Optimized patient (CVS, Renal, Liver) ASA risk Well controlled Hypertension Well controlled Diabetes Haemodynamically stabilsed

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.

Anaesthetist Skill Learn one or two alternate method of Airway skill Practice 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 (LMA ) Airways Magill Igel Miller (GEB) Polio Endotracheal Tube Introducer Mc Coy

Infra - glottic Invasive Airways Cricothyrotomy Tracheostomy

Unanticipated Difficult Airway

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

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 ANAESTHESIA PRACTICE

Thank you