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Phases of Anaesthesia

Phases of Anaesthesia. Jeremy Radcliffe National Hospital for Neurology & Neurosurgery, UCLH, London. Commendation. Local coordinators and reporting clinicians Patients’ descriptions, which allowed NAP5 interpretation RCoA Bulletin 87, September 2014 p.28 ; ‘Introductory remarks’.

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Phases of Anaesthesia

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  1. Phases of Anaesthesia Jeremy Radcliffe National Hospital for Neurology & Neurosurgery, UCLH, London

  2. Commendation Local coordinators and reporting clinicians Patients’ descriptions, which allowed NAP5 interpretation RCoA Bulletin 87, September 2014 p.28 ; ‘Introductory remarks’

  3. Definitions • Phases (‘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

  4. Expectations ‘Classic’ ?

  5. Expectations • ‘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’ ….

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

  7. Causation Induction (not 10% classed ‘syringe’ error) Maintenance Unintended awareness during neuromuscular blockade Emergence Unintended neuromuscular blockade during awareness

  8. 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%

  9. Causation • Induction • The ‘Gap’: Airway,

  10. Causation • 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.’

  11. Experience % Induction Maintenance 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

  12. Recommendations Distilled: 23 Research implications noted: 15

  13. Caution Other clinical issues before adopting changes to practice. Until NAP5, all current pressures on the anaesthetist are to reduce/minimise anaesthetic agent exposure.

  14. 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.

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