Mike Sury APA Linkman Meeting 2014

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Presentation transcript:

Mike Sury APA Linkman Meeting 2014 NAP5 & AAGA Mike Sury APA Linkman Meeting 2014

AAGA is recall of an experience Is it from Direct questioning? Spontaneous reporting?

The incidence of AAGA in adults 0.1 - 0.2%, mainly related to paralysis 15% get PTSD Avidan et al. 2008 Avidan et al. 2011 Myles et al. 2004 Sandin et al. 2000 Sebel et al. 2004 Wennervirta et al. 2002

NAP5 Spontaneous reports A procedure managed by an anaesthetist First reports only A procedure managed by an anaesthetist In and out of theatres the patent complains

How many reports? Of 300 reports A = certain B = probable C = sedation 141 were class A or B A = certain B = probable C = sedation D = ICU E = unassessable F = unlikely G = other SO = statement only

Classification: experience NAP5 The 5th National Audit Project ■ ■ ■ ■ ■

NAP5 activity survey Denominator Important details Who What Which When

Intended Conscious level (LOC) GA 2,766,600 76.9% Sedation (of any level) 308,800 8.6% Awake 523,100 14.5%

Main procedure

Intended LOC

2.8m GA cases per year (overall incidence of AAGA reports = 1:20,000)

Incidence: depends on circumstances NAP5 The 5th National Audit Project ■ ■ ■ ■ ■

Vignettes: Unassessable or Statement Only

If 0.74% is the true rate of AAGA, there should be approximately 3,700 children per year in the UK with recall of events during general anaesthesia. ? Missing reports

NAP5 The 5th National Audit Project NAP5 Executive Summary The largest AAGA study ever undertaken Of 300 reports 141 classified as “certain/probable” or “possible” AAGA Wide range of experiences/sensations 50% reported distress linked to paralysis. psychological sequelae pronounced and long lasting in 41% NAP5 The 5th National Audit Project

Common/Important situations Induction Transfer Emergence Cardiovascular collapse Syringe swops TIVA

Induction 50% of reports Causative/contributory factors were: thiopental obesity, rapid sequence induction (RSI), prolonged airway management

drug omission on transfer (‘Mind the gap’)

Emergence 18% almost all experienced distressing residual paralysis from unmonitored blockade

Cardiovascular instability Do not turn anaesthesia off Except…………

Accidental paralysis from drug error 10% of reports identical effects. “organisational factors” NAP5 The 5th National Audit Project

NAP5 The 5th National Audit Project TIVA Transfers to ICU/Radiology poor & non-standard techniques ? monitoring NAP5 The 5th National Audit Project

Preventable? 2/3 were Or were they? 7% had no obvious explanation

Minimising the psychological consequences of AAGA Before “if you waken you might not be able to move ………. this is reversible, I will look after you …..” Reconfirm intended conscious level During Reassure the patient if you think they are awake

Managing AAGA: suggested pathway NAP5 The 5th National Audit Project ■ ■ ■ ■ ■

NAP5 The 5th National Audit Project NAP5: Recommendations N = 64 TIVA and EEG – both need training with pragmatic protocols SOPs (Who checklist, what to say to patients, how to manage AAGA) NAP5 The 5th National Audit Project