PRACTICAL APPROACHES TO CRISIS MANAGEMENT IN OBSTETRIC ANESTHESIA

Berrin Günaydın, MD, PhDGazi University School of Medicine

Department of Obstetric Anesthesia, Ankara, Turkey

www.berringunaydin.com

OUTLINE

Maternal MortalityChecklists

Surgical Safety ChecklistObstetric Anesthesia Safety Checklist

Charts Early Obstetric Warning Scoring System

Crisis Management

In the World234 million operations are performed per yearReported complications is nearly 3 - 16%

(mostly surgical-related adverse events)

Mortality related to operations is 0.4 - 0.9%

≅ 1 million deaths occur during operations per year but some are preventable in all countries

* inadequate anaesthetic safety practices * poor communication among team members human error

Communication problems (including women of ethnic minority, recently arrived immigrants, refugees )

LACK of knowledge, experience, and skillsLACK of preparing obstetric patients properly for

anaesthesia and operation LACK of vital sign monitoring…

Predelivery, during delivery and after delivery

Emergency posses the highest risk!!!!!!

Human error and substandard care is around 55-70 % (CMACE 2011)

Maternal Mortality Rate (MMR)(Number of woman who died from pregnancy

related causes within 42 days postpartum / the number of livebirths in that year) X 100 000

MMRUSA (SOAP 2011, 1996-2006):

7 – 13. 3 / 100 000

UK (CMACE 2006-2008)13.95 – 11.39 / 100 000

Turkey (2011 – 2013) 15.6 - 15.9 / 100 000

Main reasons for maternal mortality

Maternal mortality and anesthesia

Obesity a significant contributor to maternal death(CMACE 2011, www.thl.fi)

WHO guidelines- the pre-pregnant BMI >30

For Safe Anaesthesia Practice

Checklists to improve maternal safety

all steps should be checked verbally with the appropiate team member (a single person lead= the checklist coordinator) to ensure the key actions have been performed

Alerts the presence of risk factors that place the mother in an increased risk of complicationMaternal safetySave the mother for the baby!

Early Warning Scoring (EWS) chart is used in the general

adult population

“Therefore, need for use of a national modified early obstetric warning score(MEOWS) chart in all pregnant or postpartum women who become unwell and require either obstetric or gynaecology services. This will help in the more timely recognition, treatment and referral of women who have, or are developing, a critical illness during or after pregnancy.”

Vital signs monitoring…on maternity ward..delivery suite…?

RegionalObstetric Early Warning Score

ChartTrack and Trigger

Adapted from BHSCT EWS chart 2013 Gillian Morrow, Intrapartum Midwifery

Practice Educator, BHSCT

Who needs an observation by Chart?

All women whose clinical condition requires close observation; admitted early pregnancy, antenatal or postnatal

All post operative cases – in recovery and following transfer from theatre

Any woman giving cause for concern (medical or obstetric causes)

During/Following APH/PPH/Eclampsia

Suspected infection

High-risk women in delivery suite

MEOWS •identifies a very sick obstetric patient (currently used as high risk women)

•89% sensitive and 79% specific•(+) predictive value 39% (95%CI 32-46%)• (-) predictive value 98% (95%CI 96-99%)

• MEOWS has a value in structuring the surveillance of hospitalised women with established risk of morbidity

• However, lack of evidence based information limits its widespread routine use. There is still need for further research for its validation

MEOWS includesRespiratory RateOxygen SaturationTemperatureHeart rateBlood Pressure (graphic trend using arrows & dotted line)Neuro ResponsePain ScoreNausea

Taenzer AH et al Anesthesiology 2011; 115: 421-31 Roshan Fernando, SOAP 43 rd 2011, Nevada

Completing the MEOWS Chart

ALL relevant sections must be completed

Top section to include woman’s detailsDateFrequency of ObsTime (24 hr clock)Signature at bottom section –

to correlate with signature list in maternity case notes

Action Protocol

≥ 2 Yellow or 1 Red

Single Yellow

White Only • Continue observations as before

• Inform Midwife/Nurse in Charge• Recheck observations in 1 hr or

more frequently if clinically indicated)

• Inform Midwife/Nurse in Charge

• Immediately contact the on-call obstetric SHO/Reg to review the woman within 30 minutes (min)

• Recheck observations in 30 min (or more frequently if clinically indicated)

2 Red

> 2 Red

• Inform Midwife/Nurse in Charge• Immediately contact the on-call

obstetric SHO/Reg to review the woman within 20 mins

• Recheck observations in 15 min (or more frequently if clinically indicated)

• Inform Midwife/Nurse in Charge• Immediately contact the on-call obstetric

Reg using SBAR to review the woman within 20 min

• Discuss with Obstetric Consultant/Tutor• Recheck observations in 15 min (or

more frequently if clinically indicated)

Consider calling other specialties or Emergency Obstetric Team as

appropriate

Action Protocol

Regional OEWS Chart 2013

Action Protocol for Early Pregnancy, Antenatal and Postnatal

The colour trigger (yellow and red) is simple and visual. A numerical score is more complex

Red is the colour denoting serious patient condition requiring urgent action

Yellow is the colour suggesting that the patient condition is worsening requiring escalation of treatment

If the parturient becomes a patient…

Communication & Consultation is a MUST in maternity health station maternity clinic in the hospitalmaternity ward delivery suite operating room

Awareness might be provided about emergency and unpredictability of labour and delivery with more educational programs

The unpredictable nature of labour & delivery is a typical obstetric anesthesia

emergency!!!!! NO time to prepare the patient

(demographic and physiologic data)NO information of medical & obstetric history NO information of the course of labour & deliveryNO identification of common warning signsNO blood products availableLACK of additional personal, staff more

unexperienced…(out-off-office- hours) …BAD communication You have to

be prepared!

High risk parturients are increasing!!!Ageing of pregnant women increasing, too!!Cardiac diseaseObesityPsychic problems (suicidal attempt), other lifestyle-

related risk factors

(drugs, alcohol, smoking, violation etc.)Operative deliveries induce problems to next

pregnancy like placenta accreta (massive bleeding) Other pregnancy-related problems

Morbidly obese parturients…

BMI increases (BMI >40> 50 > 60)More airway/ventilation problems! Oxygenation!Unstable hemodynamics!Difficulties in iv-accessProblems in anesthesia techniques (either regional or general)

Big mother!!! Big baby!!!!!Induction of labour fails leading to operative delivery!!!

More operative deliveries

The rate of CS increases!!!!!!!!! PH increases because of increased incidence of

placental patology (e.g. placenta accreta) due to rise in CS rate (from 21 % in 1997 to 35 % in 2010 and increasing further!!!!)

The parturients may prefer CS vs VDMore arest of labor More complications of the normal course of laborMore induction of labor

MORE RISK PARTURIENTS

Operative deliveries and anesthesia choices

Regional anaesthesia is used commonly in obstetrics Spinals are for CS

Nordic Countries: > 90 %

Gazi University in Turkey ≅85 % Gunaydin & Kaya. Anesth Pain Intensive Care 2013;17:51-4.

Junior anaesthesiologists are less likely to be skilled/experienced in general anesthesia (GA) for CS

Definition of CrisisA sudden change in the course of a

patient’s disease

An unstable condition requiring action often described as ‘critical events’

Anesthesiologist mandate :Ensure safe resolution of a crisis in the

perioperative arena

WHY is crisis management difficult?

Challenges of the OR environmentDynamicComplex and uncertainRisky

Time pressurePoorly defined problems Incomplete feedback

Crisis Management Manual developed by Australian Patient Safety Foundation Qual Saf Health Care 2005;14

COVER ABCD

Circulation, Capnograph, and Colour (saturation)

Oxygen supply and Oxygen analyserVentilation (intubated patient) and VaporisersEndotracheal tube and Eliminate machine Review monitors and Review equipment  Airway (with face or laryngeal mask)  Breathing (with spontaneous ventilation)  Circulation (in more detail than above)  Drugs (consider all given or not given) A Be Aware of Air and Allergy

SWIFT CHECK of patient, surgeon, process, and responses.

The four levels of intensity for each of these components are represented by another mnemonic:

SCARE SCANCHECKALERTREADYEMERGENCY

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S

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Crisis Management for Crisis Management for Obstetric AnesthesiaObstetric Anesthesia

AIRWAY CORRECTION Build a BIG RAMPPPP

Equipments

Macintosh

Magill

Miller

Polio

Mc Coy

Endotracheal Tube Introducer

(LMA )

Airways

Igel

Tracheostomy

Cricothyrotomy

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Anesth Analg 2014

Anesth Analg 2014





Pharmacological Treatment of LAST 



Back to Basics

GOOD clinical knowledge of pregnancy GOOD practice and skills among doctors, midwives, nurses, and

other heath care professionals

may reduce potentially avoidable maternal morbidity & mortality

At first, recognize the crucial importance of patient medical and obstetric history and risk status

Then, consult the obstetrician, pediatrician and anesthesiologist

GOOD COMMUNICATION+TEAMWORK

EXCELLENT TEAM WORK FOR OBSTETRIC PATIENT SAFETY!!!!

THANK YOU