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HSNZ NOV 2013 Crisis: A time of great danger or trouble whose outcome decides whether possible bad consequences will follow. Other professions like ours: Aviation Spaceflight Nuclear power and chemical manufacturing Military Command – Fighter Pilots in combat Fire fighting Complex and Dynamic Event driven and dynamic Complex and tightly coupled Uncertain Risky What makes Anesthesia different from other specialties? Dynamism Time pressure Intensity Complexity Uncertainty Risk The stress of anesthesia Anesthesiology, by its nature, involves crises The combination of complexity and dynamism makes crises much more likely to occur and more difficult to deal with. Up to our elbows… Anesthesia involves direct physical involvement in the tasks of patient care including: - performance of invasive procedures - administration of rapidly acting, potentially lethal medications - operation of increasingly complex devices During crises, knowledge is not enough.. Management of the environment, the equipment and the patient care team This involves aspects of cognitive and social psychology, sociology and anthropology Old View Adequate Training + Qualified Trainee = Ability to handle Crisis Situations New View Each individual is affected by multiple factors…. – Individual strengths and vulnerabilities – Distractions, biases, errors – Environment, Equipment – Physiologic factors such as fatigue, emotional stress, illness It happened all of a sudden… Crisis perceived as sudden in onset and rapid in development In retrospect one can usually identify an evolution from underlying triggering events Gaba DM, Fish KJ, Howard SK: Crisis Management in Anesthesia 1994 Triggering events may initiate a problem. A problem is an abnormal situation that requires attention but is unlikely by itself to cause harm. Problems can evolve and if not detected or corrected can lead to adverse outcomes. Adverse Outcome… The events that trigger problems do not occur at random They emerge from three sets of underlying conditions: – Latent errors – Predisposing factors – Psychological precursors 1. Latent Errors: …errors whose adverse consequences may lie dormant within the system for a long time, only becoming evident when they combine with other factors to breach the system’s defenses, most likely spawned by those whose activities are removed in space and time from direct control: designers, adminstrators, managers. 2. Predisposing Factors: The external environment constitutes predisposing factors. In aviation this is weather. In anesthesia these are the patient’s underlying diseases and the nature of the surgery 3. Psychological Precursors Can predispose the surgeon or anesthesia provider to commit unsafe acts that may trigger a problem “Performance Shaping Factors” including fatigue, boredom, illness, drugs, environment (noise, illumination) Vigilance… Both Aviation and Anesthesia are describe as…”99% boredom and 1% Sheer Terror….” 99% Boredom…. 1% Sheer Terror Interesting Parallels Preop Evaluation Machine/Equipment check Induction Deepening Anesthesia Intraop Lightening Anesthesia Emergence Preflight Aircraft and preflight checklist Take Off Gaining Altitude Cruise Altitude Descent Landing Dials, Knobs and Alarms “Cruising, Stormy and Crashing” Similar Environments… High Stress Potential Work hours and Performance Equipment Dependent Production Pressures Communication and Team Approach Multiple Tasking Accident Evolution Vigilance… …Ability of observers to remain alert to stimuli for prolonged periods of time… Warm J, Presentation at the panel on vigilance, 1992 ASA annual meeting Team …a distinguishable set of two or more people who interact dynamically, independently, and adaptively toward a common and valued goal/objective/mission, who have each been assigned specific roles or functions to perform and who have a limited life-span of membership Simulators Simulation Training Allows practice in situations that rarely occur in real life Safe environment for practicing crises situations Mandatory training in Netherlands, Belgium, Sweden and Germany Allows safe environment for research Making Things Safer Since the early 1980s, the Anesthesia Patient Safety Foundation (APSF) has been instrumental in reducing the number of anesthesiarelated deaths from 1 in 10,000 to about 1 in 200,000. Technological advances -- such as pulse oximeters, capnometers, and oxygen regulators have been key factors. Also, simulators are now used in anesthesia for practice and training. Online CME sponsored by Massachusetts Medical Society, file:///C:/Documents%20and%20Settings/Christopher/Deskt op/New%20Folder/New%20Folder/Online%20CME%20%2 0A%20Success%20Story%20in%20Safety.htm CASE 1 You are anaesthetising a young women for an appendicectomy. She is clinically moderately dehydrated due to poor oral intake and vomiting. Shortly after intubation, her bp dropped to 70/40. immediaetly put on 1 pint colloid run fast. But, instead of bp pick up, now her bp is unrecordable, she became flushed, and her lungs are very difficult to ventilate What are your differential diagnosis? What are your immediate actions? Stop administration of suspected agent/s Maintain airway/give 100% O2 Lay patient flat and keep leg elevated Give adrenalin -im at a dose of 0.5-1.0 mg repeated every 15 min if required -iv at a dose of 0.1 mg for hypotention or cardiovascular collapsed – titrated up to 0.5-1.0 mg as required Give iv fluid – crystalloid or colloid Other secodary theraphy to consider? Antihistamine – iv chlorpheniramine 10-20 mg slow bolus Corticosteroid – iv hydrocort 100-200 mg Bronchodilators Consider bicarb ( 0.5-1.0 mmol/kg ) How would you investigate this patient for suspected anaphylaxis? Serum tryptase Urine methylhistamine Skin prick test Why do the tests Full explaination to patient / spause -give medic-alert bracelet Record in the case note - ? red colour Inform GP CASE 2 As the medical officer oncall for emergency OT, you are anaesthetising a young lady, who came for twisted ovarian cyst. As she well fasted and ASA 1, no obvious features of difficult airway, you choose modified RSI using rocuronium of 1 mg per kg. initially ventilation was uneventful. Laryngoscopy revealed CL III and not improved with manipulation. After 3rd attemp still cannot intubate and pt start to desaturate What will you do? Call for expert / senior help ventilate with 100%via a face mask Ensure optimal intubating / ventilating position May use oropharyngeal / nasopharyngeal airway Do not attemp >4 intubation and >2 LMA insertion If able to ventilate Consider Wake up the patient -defer surgery -RA -tracheostomy under LA -awake FOI OR anaesthesia with mask ventilation – if appropriate If successfully intubated/LMA Proceed with surgery If LMA /ILMA – can attemp intubation OR wake up patient -defer surgery -RA Difficult / unable to ventilate Airway obstructed? Try LMA IF failed – surgical airway -needle OR surgical cricothyrodotomy -transtracheal jet ventilation Other helpful gadgets Glidescope with glidescope stylet Airtract, KingVision C tract C max Bonefill semirigid fibrescope Trachlight Combitube Extubation of difficult airway When to extubate Where to extubate Deep extubation? Leak test Exchange catheter Clear documentation and post op visit CASE 3 A 33 year old lady is planned for laparoscopic cystectomy under GA. Induction and intubation done uneventfully. ETT anchored at level 20 cm. 5 minutes after abdomen inflated with CO2 gas, SPO2 dropped and ventilator alarm activated high pressure What is yr ddx -bronchospasm -ETT problem -Breathing system / ventilator problem Immediate action -FIO2 100% -manually ventilate to assess compliance Is it truly bronchospasm Quick inspection of breathing system ETT Auscultation Severe bronchospasm O2 100% Bronchodilator ( via ETT or parenteral ) -via ETT 4-8 puff terbutaline or salbutamol -cont nebulizer – salbutamol -s/c bricanyl 0.25 mg -or bricanyl infusion ( 3mg/50cc ) Corticosetroid – hydrocort 200mg Ipratropium bromide – MDI / Nebs Iv adrenalin 10mcg may be considered if anaphylaxis cannot be excluded Mg sulfate Iv ketamine Iv lignocaine 1.5-2 mg/kg Aminophylline Simultaneously, consider looking for the cause of bronchospasm – and treat accordingly Watch for cardiac arrythmias ABG if indicated ?CXR if suspected pneumothorax May consider ICU ventilator if difficult ventilation Discuss with surgeon if bronchospasm not CASE 4 You are the anaesthetist oncall for delivery suit. You are called urgently to a delivery room where a women in the second stage of labour has collapsed. Just prior to this she became extremely breathless and went blue, according to the midwife. She is now not breathing DRSABC Call for immediate help from a senior obstetrician and anaestetist If not breathing / no pulse – CPR and get defibirillator Establish AIRWAY – early intubation Establish BREATHING – 100% O2 CIRCULATION – large bore branula, GXM, blood Ix, blood sugar Commence fluid resuscitation Left lateral tilt / uterine displacement After 5mins, consider LSCS – to aid resuscitation There is no evident of blood loss. What is the DDx The causes of sudden cardiovascular collapse in pregnancy are -AFE -pulmonary thrombo-embolism -venous air embolism Occult haemorrhage ICB Drug toxicity MI Sepsis Rare 1:20,000 but devastating 50% died first hour, 85% overall mortality Usually complicated with -APO -DIC -uterine atony -Xtreme hypoxia - shunts Further Mx -ICU -supportive CASE 5 LA toxicity