National Hospital for Neurology & Neurosurgery,

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Presentation transcript:

National Hospital for Neurology & Neurosurgery, 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’

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

Expectations ‘Classic’ ?

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’ ….

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)

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

Causation / mechanism Induction Maintenance Emergence The ‘Gap’: Airway, Vaporiser, Transfer Underdosing: Planned and Unplanned Management of Induction: Opioid omitted, RSI, Thiopentone, dose titration Maintenance The Gap? Uncertain (25%) Emergence NMB too long or too late = perceived residual paralysis No nerve stimulator use recorded in 88%

Causation Induction The ‘Gap’: Airway,

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.’

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

Recommendations Distilled: 23 Research implications noted: 15

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

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.