SAFE ANAESTHESIA PRACTICE

1. SAFE ANAESTHESIA PRACTICE Dr.J.Edward Johnson

2. What do you mean by that ? • Safety of the Anaesthetist ? • Safety of the Surgeon ? • Safety of the Patient ?

3. SAFE ANAESTHESIA PRACTICE • Protocals • Crisis Management • Tips and Tricks for Anaesthesia

4. PROTOCALS

5. 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)

6. International Standards for a Safe Practice of Anaesthesia 2010 The goal always in any setting is to practice to the highest possible standards

7. "HIGHLY RECOMMENDED" • Minimum standards that would be expected in all anaesthesia care for elective surgical procedures • “Mandatory" standards

8. Peri-anaesthetic care and monitoring standards • Pre-anaesthetic care • Pre-anaesthesia checks • Monitoring during anaesthesia

9. Pre-anaesthesia checks PRE ANAESTHETIC CHECK LIST Patient name ________________ Number ___________ Date of Birth ­__/__/__ Procedure____________________________________ Site_______

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

14. 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

15. Crisis Management during anaesthesia

16. Crisis Management • Crisis Management Manual developedby 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

17. Crisis Management Manual‘‘Core’’ algorithm - COVER ABCD – A SWIFT CHECK Crisis management algorithm ‘‘COVER ABCD’’

18. Crisis management algorithm ‘‘COVER ABCD’’

19. Sub Algorithm – Crisis Management

20. Crisis management manual Ref. • 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

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

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

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

24. 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.

25. Anaesthetist Skill • Learn one or two alternate method of Airway skill • Practice it in routine cases

26. Post Crisis

27. 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 .

28. 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..

29. 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

30. 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

31. Tips and Tricks for Anaesthesia

32. Facilities and Equipments (LMA ) Macintosh Airways Magill Igel Miller (GEB) Polio Endotracheal Tube Introducer Mc Coy

33. Infra - glottic Invasive Airways Cricothyrotomy Tracheostomy

34. Unanticipated Difficult Airway

35. 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 intrathecalbupivacaine • 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

36. OBESE - AIRWAY

37. AIRWAY CORRECTION Build a BIG RAMPPPP

38. Perianesthetic Management of Laryngospasm

40. The Laryngospasm Notch Technique

41. The Laryngospasm Notch Technique

42. Unorthodox method: not generally accepted, better than nothing

43. Emergency Airway

44. SAFE ANAESTHESIA PRACTICE

45. Thank you