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SAFE SAFE ANAESTHESIA ANAESTHESIA PRACTICEPRACTICE
Dr.J.Edward JohnsonDr.J.Edward Johnson
What do you mean by What do you mean by that ?that ?
Safety of the Anaesthetist ?
Safety of the Surgeon ?
Safety of the Patient ?
SAFE ANAESTHESIA PRACTICESAFE ANAESTHESIA PRACTICE
Protocals
Crisis Management
Tips and Tricks for Anaesthesia
PROTOCALSPROTOCALS
International Standards International Standards for a for a Safe Practice of Safe Practice of Anaesthesia Anaesthesia 20102010
Developed by the International Task Force on Anaesthesia Safety
Adopted by the World Federation of Societies of Anaesthesiologists (WFSA)
International Standards for a Safe International Standards for a Safe Practice of Practice of Anaesthesia 2010 Anaesthesia 2010
The goal always in any setting is to practice to the highest possible standards
""HIGHLY RECOMMENDEDHIGHLY RECOMMENDED""
Minimum standards that would be expected in all anaesthesia care for elective surgical procedures
“Mandatory" standards
Peri-anaesthetic care and Peri-anaesthetic care and monitoring standardsmonitoring standards
Pre-anaesthetic carePre-anaesthesia checksMonitoring during anaesthesia
Pre-anaesthesia checksPre-anaesthesia checksPRE ANAESTHETIC CHECK LIST Patient name ________________ Number ___________ Date of Birth __/__/__Procedure____________________________________ Site_______
Check patient risk factors(if yes - circle and annotate)
Check resources Present and Functioning
ASA 1 2 3 4 5 EAirwayMallampati (pictures)Aspiration risk?Allergies?Abnormal investigations?Medications?Co-morbidities?
NNNNN
Airway Masks Airways Laryngoscopes (working) Tubes BougiesBreathing Leaks (a FGF of 300 ml/minute maintains a pressure of > 30 cm H2O)
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Check patient risk factors(if yes - circle and annotate)
Check resources Present and Functioning
ASA 1 2 3 4 5 EAirwayMallampati (pictures)Aspiration risk?Allergies?Abnormal investigations?Medications?Co-morbidities?
Soda lime (colour - if present) Circle system (2-bag test if present)SuctionDrugs 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 thermometersEmergency Assistant Adrenaline Suxamethonium Self inflating bag Tilting table
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Monitoring during Monitoring during anaesthesiaanaesthesiaOxygenationAirway and ventilationCirculation TemperatureNeuromuscular functionDepth of anaesthesiaAudible signals and alarms
HIGHLY RECOMMENDED
RECOMMENDED SUGGESTED
Oxygenation Oxygen supply :
Oxygenation of the patient :
- Supplemental oxygen -Un interrupted supply
- Visual examination, - Adequate illumination - Pulse oximetry
- Inspired oxygen concentration - Oxygen supply failure alarm -Hypoxic Guard
--
-
-
Airway and ventilation
- Observation - Auscultation - The reservoir bag
- Precordial, - Pretracheal, or -Oesophageal stethoscope - Capnography
- Continuous measurement of the inspiratory and/or expired gas volumes, and of the concentration of volatile agents
Circulation Cardiac rate and rhythm :
Tissue perfusion :
Blood pressure :
-Palpation of the pulse - Auscultation of the heart sounds - Pulse oximetry
- Clinical examination- Pulse oximetry
- At least every 5 mts
- Electrocardiograph- Defibrillator
- Capnography
- NIBP - IABP
HIGHLY RECOMMENDED RECOMMENDED SUGGESTED
Temperature - At frequent intervals
- Continual electronic temperature measurement
Neuromuscular function
- Peripheral nerve stimulator
Depth of anaesthesia
- Degree of unconsciousness (clinical observation)
- Continuous measurement of the inspiratory and/or expired gas volumes, and of the concentration of volatile agents
- BIS Monitor
Audible signals and alarms
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 Crisis Management during during anaesthesiaanaesthesia
Crisis ManagementCrisis Management 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 ManualCrisis Management Manual‘‘C‘‘Coreore’’ ’’ algorithm - algorithm - COVER ABCD COVER ABCD – A SWIFT CHECK– A SWIFT CHECK
Crisis management algorithm ‘‘COVER ABCD’’
Crisis management algorithm ‘‘COVER ABCD’’
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Crisis management Crisis management manual manual RefRef..
Crisis management during anaesthesia: the development of an Anaesthetic Crisis Management Manual http://qualitysafety.bmj.com/content/14/3/e1.full.html
Anaesthesia Crisis Management Manual http://www.apsf.com.au/crisis_management/Crisis_Management_Start.htm
This article cites 42 articles, 30 of which can be accessed free at: http://qualitysafety.bmj.com/content/14/3/e1.full.html#ref-list-1
Where Safety Starts ?Where Safety Starts ?
Patient
Facilities, Equipment, and Medications Anaesthetist’s Skill
Surgeon’s Skill
Survival Depends.......Survival Depends.......
Facilities, Equipment, and Medications Quantity and Quality
Anaesthetist Skill
HELP
Referal
10%
20%
60%
10%
Where Safety Starts ?Where Safety Starts ?
Patient - Optimized patient (CVS, RS,
Renal, Liver)
ASA risk Well controlled Hypertension Well controlled Diabetes Haemodynamically stabilsed
MedicationMedicationAll 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 SkillAnaesthetist SkillLearn one or two alternate method of
Airway skillPractice it in routine cases
Post CrisisPost Crisis
CounselingCounseling
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 Recommendations for senior staff membersmembersA 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 Recommendations for colleaguescolleagues
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 Recommendations for healthcare professionals directly involved in an professionals directly involved in an adverse eventadverse 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 Tips and Tricks for AnaesthesiaAnaesthesia
Facilities and Equipments Facilities and Equipments
Macintosh
Magill
Miller
Polio
Mc Coy
(GEB)
Endotracheal Tube Introducer
(LMA ) Airways
Igel
Infra - glottic Invasive Infra - glottic Invasive AirwaysAirways
Cricothyrotomy Tracheostomy
Unanti
cipate
d D
ifficu
lt
Unanti
cipate
d D
ifficu
lt
Air
way
Air
way
Techniques to decrease hypotension Techniques to decrease hypotension with neuraxial anesthesia for with neuraxial anesthesia for cesarean delivery. 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 rateExpert Review of Obstetrics & Gynecology Katherine W Arendt; Jochen D Muehlschlegel; Lawrence C Tsen
OBESE - AIRWAY
AIRWAY CORRECTION Build a BIG RAMPPPP
Perianesthetic Management of Perianesthetic Management of Laryngospasm Laryngospasm
The Laryngospasm Notch The Laryngospasm Notch TechniqueTechnique
The Laryngospasm Notch The Laryngospasm Notch TechniqueTechnique
Unorthodox method: not Unorthodox method: not generally accepted, better generally accepted, better than nothingthan nothing
Emergency AirwayEmergency Airway
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Thank youThank you