HSNZ

NOV 2013

Crisis: Crisis:

A time of great danger or trouble A time of great danger or trouble whose outcome decides whether whose outcome decides whether

possible bad consequences will follow.possible bad consequences will follow.

Other professions like ours:Other professions like ours:

AviationAviation Spaceflight Spaceflight Nuclear power and chemical manufacturingNuclear power and chemical manufacturing Military Command – Fighter Pilots in combatMilitary Command – Fighter Pilots in combat Fire fightingFire fighting

Complex and DynamicComplex and Dynamic

Event driven and dynamicEvent driven and dynamic Complex and tightly coupledComplex and tightly coupled UncertainUncertain RiskyRisky

What makes Anesthesia different What makes Anesthesia different from other specialties?from other specialties?

DynamismDynamism Time pressureTime pressure IntensityIntensity ComplexityComplexity UncertaintyUncertainty RiskRisk

The stress of anesthesiaThe stress of anesthesia

Anesthesiology, by its nature, Anesthesiology, by its nature, involves crisesinvolves crises

The combination of complexity and The combination of complexity and dynamism makes crises much more likely dynamism makes crises much more likely

to occur and more difficult to deal with.to occur and more difficult to deal with.

Up to our elbows…Up to our elbows…

Anesthesia involves direct physical Anesthesia involves direct physical involvement in the tasks of patient care involvement in the tasks of patient care including:including:

- performance of invasive procedures- performance of invasive procedures

- administration of rapidly acting, - administration of rapidly acting, potentially lethal medications potentially lethal medications

- operation of increasingly complex - operation of increasingly complex devices devices

During crises, knowledge is not During crises, knowledge is not enough..enough..

Management of the environment, the Management of the environment, the equipment and the patient care teamequipment and the patient care team

This involves aspects of cognitive and social This involves aspects of cognitive and social psychology, sociology and anthropologypsychology, sociology and anthropology

Old ViewOld View

Adequate Training + Qualified Trainee = Adequate Training + Qualified Trainee = Ability to handle Crisis SituationsAbility to handle Crisis Situations

New ViewNew View Each individual is affected by multiple Each individual is affected by multiple

factors….factors….– Individual strengths and vulnerabilitiesIndividual strengths and vulnerabilities– Distractions, biases, errorsDistractions, biases, errors– Environment, EquipmentEnvironment, Equipment– Physiologic factors such as fatigue, emotional Physiologic factors such as fatigue, emotional

stress, illnessstress, illness

It happened all of a sudden…It happened all of a sudden…

Crisis perceived as sudden in onset and Crisis perceived as sudden in onset and rapid in developmentrapid in development

In retrospect one can usually identify an In retrospect one can usually identify an evolutionevolution from underlying from underlying triggeringtriggering events events

Gaba DM, Fish KJ, Howard SK: Crisis Management in Anesthesia 1994

Triggering events may initiate a Triggering events may initiate a problemproblem. A . A problemproblem is an is an

abnormal situation that requires abnormal situation that requires attention but is unlikely by itself to attention but is unlikely by itself to cause harm. Problems can evolve cause harm. Problems can evolve and if not detected or corrected can and if not detected or corrected can

lead to lead to adverse outcomesadverse outcomes..

Adverse Outcome…Adverse Outcome…

The events that trigger problems do The events that trigger problems do not occur at randomnot occur at random

They emerge from three sets of underlying They emerge from three sets of underlying conditions:conditions:– Latent errorsLatent errors– Predisposing factorsPredisposing factors– Psychological precursorsPsychological precursors

1. Latent Errors:1. Latent Errors:

……errors whose adverse consequences errors whose adverse consequences may lie dormant within the system for a may lie dormant within the system for a long time, only becoming evident when long time, only becoming evident when

they combine with other factors to breach they combine with other factors to breach the system’s defenses, most likely the system’s defenses, most likely

spawned by those whose activities are spawned by those whose activities are removed in space and time from direct removed in space and time from direct

control: designers, adminstrators, control: designers, adminstrators, managers.managers.

2. Predisposing Factors:2. Predisposing Factors:

The external environment constitutes The external environment constitutes predisposing factors. predisposing factors.

In aviation this is weather. In anesthesia In aviation this is weather. In anesthesia these are the patient’s underlying diseases these are the patient’s underlying diseases and the nature of the surgeryand the nature of the surgery

3. Psychological Precursors3. Psychological Precursors

Can predispose the surgeon or anesthesia Can predispose the surgeon or anesthesia provider to commit unsafe acts that may provider to commit unsafe acts that may trigger a problemtrigger a problem

““Performance Shaping Factors” including Performance Shaping Factors” including fatigue, boredom, illness, drugs, fatigue, boredom, illness, drugs, environment (noise, illumination)environment (noise, illumination)

Vigilance…Vigilance…

Both Aviation and Both Aviation and Anesthesia are Anesthesia are describe as…”99% describe as…”99% boredom and 1% boredom and 1% Sheer Terror….”Sheer Terror….”

99% Boredom….99% Boredom….

1% Sheer Terror1% Sheer Terror

Interesting ParallelsInteresting Parallels Preop EvaluationPreop Evaluation Machine/Equipment Machine/Equipment

checkcheck InductionInduction Deepening AnesthesiaDeepening Anesthesia IntraopIntraop Lightening AnesthesiaLightening Anesthesia EmergenceEmergence

PreflightPreflight Aircraft and preflight Aircraft and preflight

checklistchecklist Take OffTake Off Gaining AltitudeGaining Altitude Cruise AltitudeCruise Altitude DescentDescent LandingLanding

Dials, Knobs and AlarmsDials, Knobs and Alarms

““Cruising, Stormy and Crashing”Cruising, Stormy and Crashing”

Similar Environments…Similar Environments…

High Stress PotentialHigh Stress Potential Work hours and PerformanceWork hours and Performance Equipment DependentEquipment Dependent Production PressuresProduction Pressures Communication and Team ApproachCommunication and Team Approach Multiple TaskingMultiple Tasking Accident EvolutionAccident Evolution

Vigilance…Vigilance…

……Ability of observers to remain alert to Ability of observers to remain alert to stimuli for prolonged periods of time…stimuli for prolonged periods of time…

Warm J, Presentation at the panel on Warm J, Presentation at the panel on vigilance, 1992 ASA annual meetingvigilance, 1992 ASA annual meeting

TeamTeam

……a distinguishable set of two or more a distinguishable set of two or more people who interact dynamically, people who interact dynamically, independently, and adaptively toward a independently, and adaptively toward a common and valued goal/objective/mission, common and valued goal/objective/mission, who have each been assigned specific roles who have each been assigned specific roles or functions to perform and who have a or functions to perform and who have a limited life-span of membershiplimited life-span of membership

SimulatorsSimulators

Simulation TrainingSimulation Training

Allows practice in situations that rarely occur Allows practice in situations that rarely occur in real lifein real life

Safe environment for practicing crises Safe environment for practicing crises situationssituations

Mandatory training in Netherlands, Belgium, Mandatory training in Netherlands, Belgium, Sweden and GermanySweden and Germany

Allows safe environment for researchAllows safe environment for research

Making Things SaferMaking Things Safer

Since the early 1980s, the Anesthesia Patient Safety Foundation Since the early 1980s, the Anesthesia Patient Safety Foundation (APSF) has been instrumental in reducing the number of anesthesia-(APSF) has been instrumental in reducing the number of anesthesia-related deaths from 1 in 10,000 to about 1 in 200,000. Technological related deaths from 1 in 10,000 to about 1 in 200,000. Technological advances -- such as pulse oximeters, capnometers, and oxygen advances -- such as pulse oximeters, capnometers, and oxygen regulators have been key factors. Also, simulators are now used in regulators have been key factors. Also, simulators are now used in

anesthesia for practice and traininganesthesia for practice and training. .

Online CME sponsored by Massachusetts Medical Society, file:///C:/Documents%20and%20Settings/Christopher/Desktop/New%20Folder/New%20Folder/Online%20CME%20%20A%20Success%20Story%20in%20Safety.htm

CASE 1CASE 1

You are anaesthetising a young women for You are anaesthetising a young women for an appendicectomy. She is clinically an appendicectomy. She is clinically moderately dehydrated due to poor oral moderately dehydrated due to poor oral intake and vomiting. Shortly after intubation, intake and vomiting. Shortly after intubation, her bp dropped to 70/40. immediaetly put on her bp dropped to 70/40. immediaetly put on 1 pint colloid run fast. But, instead of bp 1 pint colloid run fast. But, instead of bp pick up, now her bp is unrecordable, she pick up, now her bp is unrecordable, she became flushed, and her lungs are very became flushed, and her lungs are very difficult to ventilatedifficult to ventilate

What are your differential diagnosis?What are your differential diagnosis?

What are your immediate actions?What are your immediate actions?

Stop administration of suspected agent/sStop administration of suspected agent/s Maintain airway/give 100% O2Maintain airway/give 100% O2 Lay patient flat and keep leg elevatedLay patient flat and keep leg elevated Give adrenalin Give adrenalin -im at a dose of 0.5-1.0 mg repeated every 15 min if -im at a dose of 0.5-1.0 mg repeated every 15 min if

requiredrequired -iv at a dose of 0.1 mg for hypotention or -iv at a dose of 0.1 mg for hypotention or

cardiovascular collapsed – titrated up to 0.5-1.0 mg as cardiovascular collapsed – titrated up to 0.5-1.0 mg as requiredrequired

Give iv fluid – crystalloid or colloidGive iv fluid – crystalloid or colloid

Other secodary theraphy to consider?Other secodary theraphy to consider?

Antihistamine – iv chlorpheniramine 10-20 Antihistamine – iv chlorpheniramine 10-20 mg slow bolusmg slow bolus

Corticosteroid – iv hydrocort 100-200 mg Corticosteroid – iv hydrocort 100-200 mg BronchodilatorsBronchodilators Consider bicarb ( 0.5-1.0 mmol/kg )Consider bicarb ( 0.5-1.0 mmol/kg )

How would you investigate this patient for How would you investigate this patient for suspected anaphylaxis?suspected anaphylaxis?

Serum tryptaseSerum tryptase Urine methylhistamineUrine methylhistamine Skin prick testSkin prick test

Why do the testsWhy do the tests

Full explaination to patient / spause Full explaination to patient / spause -give medic-alert bracelet-give medic-alert bracelet Record in the case note - ? red colourRecord in the case note - ? red colour Inform GPInform GP

CASE 2CASE 2

As the medical officer oncall for emergency OT, As the medical officer oncall for emergency OT, you are anaesthetising a young lady, who came you are anaesthetising a young lady, who came for twisted ovarian cyst. As she well fasted and for twisted ovarian cyst. As she well fasted and ASA 1, no obvious features of difficult airway, ASA 1, no obvious features of difficult airway, you choose modified RSI using rocuronium of 1 you choose modified RSI using rocuronium of 1 mg per kg. initially ventilation was uneventful. mg per kg. initially ventilation was uneventful. Laryngoscopy revealed CL III and not improved Laryngoscopy revealed CL III and not improved with manipulation. After 3with manipulation. After 3rdrd attemp still cannot attemp still cannot intubate and pt start to desaturate intubate and pt start to desaturate

What will you do?What will you do?

Call for expert / senior helpCall for expert / senior help ventilate with 100%via a face maskventilate with 100%via a face mask Ensure optimal intubating / ventilating positionEnsure optimal intubating / ventilating position May use oropharyngeal / nasopharyngeal airwayMay use oropharyngeal / nasopharyngeal airway Do not attemp >4 intubation and >2 LMA insertionDo not attemp >4 intubation and >2 LMA insertion

If able to ventilateIf able to ventilate ConsiderConsider

Wake up the patientWake up the patient -defer surgery-defer surgery -RA-RA -tracheostomy under LA-tracheostomy under LA -awake FOI-awake FOI OR anaesthesia with mask ventilation – if OR anaesthesia with mask ventilation – if

appropriateappropriate

If successfully intubated/LMAIf successfully intubated/LMA

Proceed with surgeryProceed with surgery If LMA /ILMA – can attemp intubation If LMA /ILMA – can attemp intubation OR wake up patientOR wake up patient -defer surgery-defer surgery -RA-RA

Difficult / unable to ventilateDifficult / unable to ventilate

Airway obstructed? Try LMAAirway obstructed? Try LMA IF failed – surgical airwayIF failed – surgical airway -needle OR surgical cricothyrodotomy-needle OR surgical cricothyrodotomy -transtracheal jet ventilation-transtracheal jet ventilation

Other helpful gadgets Other helpful gadgets

Glidescope with glidescope styletGlidescope with glidescope stylet Airtract, KingVisionAirtract, KingVision C tractC tract C maxC max Bonefill semirigid fibrescopeBonefill semirigid fibrescope TrachlightTrachlight CombitubeCombitube

Extubation of difficult airwayExtubation of difficult airway

When to extubateWhen to extubate Where to extubateWhere to extubate Deep extubation?Deep extubation? Leak testLeak test Exchange catheterExchange catheter

Clear documentation and post op visitClear documentation and post op visit

CASE 3CASE 3

A 33 year old lady is planned for A 33 year old lady is planned for laparoscopic cystectomy under GA. laparoscopic cystectomy under GA. Induction and intubation done uneventfully. Induction and intubation done uneventfully. ETT anchored at level 20 cm. 5 minutes ETT anchored at level 20 cm. 5 minutes after abdomen inflated with CO2 gas, SPO2 after abdomen inflated with CO2 gas, SPO2 dropped and ventilator alarm activated - dropped and ventilator alarm activated - high pressurehigh pressure

What is yr ddxWhat is yr ddx

-bronchospasm-bronchospasm -ETT problem-ETT problem -Breathing system / ventilator problem-Breathing system / ventilator problem

Immediate actionImmediate action

-FIO2 100%-FIO2 100% -manually ventilate to assess compliance-manually ventilate to assess compliance

Is it truly bronchospasmIs it truly bronchospasm

Quick inspection of breathing systemQuick inspection of breathing system ETTETT Auscultation Auscultation

Severe bronchospasmSevere bronchospasm

O2 100%O2 100% Bronchodilator ( via ETT or parenteral )Bronchodilator ( via ETT or parenteral ) -via ETT 4-8 puff terbutaline or salbutamol-via ETT 4-8 puff terbutaline or salbutamol -cont nebulizer – salbutamol-cont nebulizer – salbutamol -s/c bricanyl 0.25 mg -s/c bricanyl 0.25 mg -or bricanyl infusion ( 3mg/50cc )-or bricanyl infusion ( 3mg/50cc )

Corticosetroid – hydrocort 200mgCorticosetroid – hydrocort 200mg Ipratropium bromide – MDI / NebsIpratropium bromide – MDI / Nebs Iv adrenalin 10mcg may be considered if Iv adrenalin 10mcg may be considered if

anaphylaxis cannot be excludedanaphylaxis cannot be excluded Mg sulfate Mg sulfate Iv ketamine Iv ketamine Iv lignocaine 1.5-2 mg/kgIv lignocaine 1.5-2 mg/kg Aminophylline Aminophylline

Simultaneously, consider looking for the cause Simultaneously, consider looking for the cause of bronchospasm – and treat accordinglyof bronchospasm – and treat accordingly

Watch for cardiac arrythmiasWatch for cardiac arrythmias ABG if indicatedABG if indicated ?CXR if suspected pneumothorax?CXR if suspected pneumothorax May consider ICU ventilator if difficult ventilationMay consider ICU ventilator if difficult ventilation Discuss with surgeon if bronchospasm not Discuss with surgeon if bronchospasm not

resolvedresolved

CASE 4CASE 4

You are the anaesthetist oncall for delivery You are the anaesthetist oncall for delivery suit. You are called urgently to a delivery suit. You are called urgently to a delivery room where a women in the second stage of room where a women in the second stage of labour has collapsed. Just prior to this she labour has collapsed. Just prior to this she became extremely breathless and went became extremely breathless and went blue, according to the midwife. She is now blue, according to the midwife. She is now not breathingnot breathing

DRSABCDRSABC

Call for immediate help from a senior Call for immediate help from a senior obstetrician and anaestetistobstetrician and anaestetist

If not breathing / no pulse – CPR and get If not breathing / no pulse – CPR and get defibirillatordefibirillator

Establish AIRWAY – early intubationEstablish AIRWAY – early intubation Establish BREATHING – 100% O2Establish BREATHING – 100% O2 CIRCULATION – large bore branula, GXM, CIRCULATION – large bore branula, GXM,

blood Ix, blood sugarblood Ix, blood sugar

Commence fluid resuscitationCommence fluid resuscitation Left lateral tilt / uterine displacementLeft lateral tilt / uterine displacement After 5mins, consider LSCS – to aid After 5mins, consider LSCS – to aid

resuscitationresuscitation

There is no evident of blood loss. What is There is no evident of blood loss. What is the DDxthe DDx

The causes of sudden cardiovascular collapse in The causes of sudden cardiovascular collapse in pregnancy arepregnancy are

-AFE-AFE -pulmonary thrombo-embolism-pulmonary thrombo-embolism -venous air embolism-venous air embolism Occult haemorrhageOccult haemorrhage ICBICB Drug toxicityDrug toxicity MIMI SepsisSepsis

Rare 1:20,000 but devastatingRare 1:20,000 but devastating 50% died first hour, 85% overall mortality50% died first hour, 85% overall mortality Usually complicated with Usually complicated with -APO-APO -DIC-DIC -uterine atony-uterine atony -Xtreme hypoxia - shunts-Xtreme hypoxia - shunts

Further Mx Further Mx -ICU-ICU -supportive-supportive

CASE 5CASE 5LA toxicityLA toxicity