PRACTICAL APPROACHES TO CRISIS MANAGEMENT IN OBSTETRIC ANESTHESIA Berrin Günaydın, MD, PhD Gazi University School of Medicine Department of Obstetric Anesthesia, Ankara, Turkey www.berringunaydin.com

OUTLINE Maternal Mortality Checklists Charts Crisis Management Surgical Safety Checklist Obstetric Anesthesia Safety Checklist Charts Early Obstetric Warning Scoring System Crisis Management

In the World 234 million operations are performed per year Reported complications is nearly 3 - 16% (mostly surgical-related adverse events) Mortality related to operations is 0.4 - 0.9% ≅ 1 million deaths occur during operations per year but some are preventable in all countries * inadequate anaesthetic safety practices * poor communication among team members human error

Human error and substandard care is around 55-70 % (CMACE 2011) Communication problems (including women of ethnic minority, recently arrived immigrants, refugees ) LACK of knowledge, experience, and skills LACK of preparing obstetric patients properly for anaesthesia and operation LACK of vital sign monitoring… Predelivery, during delivery and after delivery Emergency posses the highest risk!!!!!! LACK of recognition is responsible from Clinical Crisis LACK of recognition Clinical Crisis

Maternal Mortality Rate (MMR) (Number of woman who died from pregnancy related causes within 42 days postpartum / the number of livebirths in that year) X 100 000 Pregnancy Associated Deaths Death of a woman within 1 year postpartum from any cause Non-pregnancy related Pregnancy related (direct or indirect) Pakistan (1990 – 2010) 541.2-376.4 / 100 000

MMR USA (SOAP 2011, 1996-2006): 7 – 13. 3 / 100 000 UK (CMACE 2006-2008) 13.95 – 11.39 / 100 000 Turkey (2011 – 2013) 15.6 - 15.9 / 100 000

Main reasons for maternal mortality Peripartum hemorhage (PH) Tromboembolism & Amniotic fluid embolism Sepsis Preeclampsia ANESTHESIA Anesthesia-related maternal death rare but may happen

Maternal mortality and anesthesia Obesity a significant contributor to maternal death (CMACE 2011, www.thl.fi) WHO guidelines- the pre-pregnant BMI >30 General Anesthesia Difficult airway/aspiration/respiratory problems Neuraxial Anesthesia high spinal: airway problem hemodynamic problem Anaesthesia related complications are the 7th leading cause of maternal deaths in USA and UK

For Safe Anaesthesia Practice Checklists & Charts Crisis Management Tips & Tricks for Anaesthesia

Checklists to improve maternal safety Surgical Safety Checklist Before induction of anaesthesia Before skin incision Before patient leaves the operating room WHO perioperative Safety Checklist Patient safety checklists; -reduce deaths and complications according to evidence-based scientific data -inexpensive! -simple and quick to use! Therefore WE NEED…. Before induction of anaesthesia (with at least nurses and anaesthetist) The patient identity procedure, consent? The operating site? The anaesthesia machine, medication? Before skin incision ( with nurses, anaesthetist and surgeon)Confirm all team members by name and role Confirm the patient`s name, procedure and where the incision will be Has antibiotic prophylaxis been given within the last 60 minutes? Before patient leaves operating room (with nurses, anaesthetist and surgeon)Nurse verbally confirms: The name of the procedure Completion of instruments, sponges and needle counts etc. Specimen labelling (read aloud including patient name) Whether there are any equipment problems to be addressed Surgeon, Anaesthetist and Nurse: What are the key concerns for recovery and management of this patient? Pulse oximeter on the patient? Does the patient have: Known allergy? Difficult airway? Aspiration risk? (eating, drinking, G-I-disease etc.)? Risk of blood loss > 500 ml? Iv-access? Fluids planned? Blood? all steps should be checked verbally with the appropiate team member (a single person lead= the checklist coordinator) to ensure the key actions have been performed

Obstetric Safety Checklists & Charts Therefore WE NEED…. Before induction of anaesthesia (with at least nurses and anaesthetist) The patient identity procedure, consent? The operating site? The anaesthesia machine, medication? Before skin incision ( with nurses, anaesthetist and surgeon)Confirm all team members by name and role Confirm the patient`s name, procedure and where the incision will be Has antibiotic prophylaxis been given within the last 60 minutes? Before patient leaves operating room (with nurses, anaesthetist and surgeon)Nurse verbally confirms: The name of the procedure Completion of instruments, sponges and needle counts etc. Specimen labelling (read aloud including patient name) Whether there are any equipment problems to be addressed Surgeon, Anaesthetist and Nurse: What are the key concerns for recovery and management of this patient? Pulse oximeter on the patient? Does the patient have: Known allergy? Difficult airway? Aspiration risk? (eating, drinking, G-I-disease etc.)? Risk of blood loss > 500 ml? Iv-access? Fluids planned? Blood? Alerts the presence of risk factors that place the mother in an increased risk of complication Maternal safety Save the mother for the baby!

Vital signs monitoring…on maternity ward..delivery suite…? Early Warning Scoring (EWS) chart is used in the general adult population “Therefore, need for use of a national modified early obstetric warning score(MEOWS) chart in all pregnant or postpartum women who become unwell and require either obstetric or gynaecology services. This will help in the more timely recognition, treatment and referral of women who have, or are developing, a critical illness during or after pregnancy.” Regional Obstetric Early Warning Score Chart Track and Trigger Adapted from BHSCT EWS chart 2013 Gillian Morrow, Intrapartum Midwifery Practice Educator, BHSCT

Who needs an observation by Chart? All women whose clinical condition requires close observation; admitted early pregnancy, antenatal or postnatal All post operative cases – in recovery and following transfer from theatre Any woman giving cause for concern (medical or obstetric causes) During/Following APH/PPH/Eclampsia Suspected infection High-risk women in delivery suite

identifies a very sick obstetric patient MEOWS identifies a very sick obstetric patient (currently used as high risk women) 89% sensitive and 79% specific (+) predictive value 39% (95%CI 32-46%) (-) predictive value 98% (95%CI 96-99%)

MEOWS has a value in structuring the surveillance of hospitalised women with established risk of morbidity However, lack of evidence based information limits its widespread routine use. There is still need for further research for its validation

Blood Pressure (graphic trend using arrows & dotted line) MEOWS includes Respiratory Rate Oxygen Saturation Temperature Heart rate Blood Pressure (graphic trend using arrows & dotted line) Neuro Response Pain Score Nausea Taenzer AH et al Anesthesiology 2011; 115: 421-31 Roshan Fernando, SOAP 43 rd 2011, Nevada

Completing the MEOWS Chart ALL relevant sections must be completed Top section to include woman’s details Date Frequency of Obs Time (24 hr clock) Signature at bottom section – to correlate with signature list in maternity case notes

Action Protocol Continue observations as before White Only Continue observations as before Inform Midwife/Nurse in Charge Recheck observations in 1 hr or more frequently if clinically indicated) Single Yellow Inform Midwife/Nurse in Charge Immediately contact the on-call obstetric SHO/Reg to review the woman within 30 minutes (min) Recheck observations in 30 min (or more frequently if clinically indicated) ≥ 2 Yellow or 1 Red

Action Protocol Inform Midwife/Nurse in Charge Immediately contact the on-call obstetric SHO/Reg to review the woman within 20 mins Recheck observations in 15 min (or more frequently if clinically indicated) 2 Red Inform Midwife/Nurse in Charge Immediately contact the on-call obstetric Reg using SBAR to review the woman within 20 min Discuss with Obstetric Consultant/Tutor Recheck observations in 15 min (or more frequently if clinically indicated) Consider calling other specialties or Emergency Obstetric Team as appropriate > 2 Red

Action Protocol for Early Pregnancy, Antenatal and Postnatal Regional OEWS Chart 2013 Action Protocol for Early Pregnancy, Antenatal and Postnatal The colour trigger (yellow and red) is simple and visual. A numerical score is more complex Red is the colour denoting serious patient condition requiring urgent action Yellow is the colour suggesting that the patient condition is worsening requiring escalation of treatment

If the parturient becomes a patient… Communication & Consultation is a MUST in maternity health station maternity clinic in the hospital maternity ward delivery suite operating room Awareness might be provided about emergency and unpredictability of labour and delivery with more educational programs

The unpredictable nature of labour & delivery is a typical obstetric anesthesia emergency!!!!! NO time to prepare the patient (demographic and physiologic data) NO information of medical & obstetric history NO information of the course of labour & delivery NO identification of common warning signs NO blood products available LACK of additional personal, staff more unexperienced…(out-off-office- hours) … BAD communication You have to be prepared!

High risk parturients are increasing!!! Ageing of pregnant women increasing, too!! Cardiac disease Obesity Psychic problems (suicidal attempt), other lifestyle-related risk factors (drugs, alcohol, smoking, violation etc.) Operative deliveries induce problems to next pregnancy like placenta accreta (massive bleeding) Other pregnancy-related problems

Morbidly obese parturients… BMI increases (BMI >40> 50 > 60) More airway/ventilation problems! Oxygenation! Unstable hemodynamics! Difficulties in iv-access Problems in anesthesia techniques (either regional or general) Big mother!!! Big baby!!!!! Induction of labour fails leading to operative delivery!!! Morbidly obese parturients…are commonly more problematic…

More operative deliveries The rate of CS increases!!!!!!!!! PH increases because of increased incidence of placental patology (e.g. placenta accreta) due to rise in CS rate (from 21 % in 1997 to 35 % in 2010 and increasing further!!!!) The parturients may prefer CS vs VD More arest of labor More complications of the normal course of labor More induction of labor MORE RISK PARTURIENTS

Operative deliveries and anesthesia choices Regional anaesthesia is used commonly in obstetrics Spinals are for CS Nordic Countries: > 90 % Gazi University in Turkey ≅85 % Gunaydin & Kaya. Anesth Pain Intensive Care 2013;17:51-4. Junior anaesthesiologists are less likely to be skilled/experienced in general anesthesia (GA) for CS

Definition of Crisis A sudden change in the course of a patient’s disease An unstable condition requiring action often described as ‘critical events’ Anesthesiologist mandate : Ensure safe resolution of a crisis in the perioperative arena

WHY is crisis management difficult? Challenges of the OR environment Dynamic Complex and uncertain Risky Time pressure Poorly defined problems Incomplete feedback Crisis Management Manual developed by Australian Patient Safety Foundation Qual Saf Health Care 2005;14

COVER ABCD SWIFT CHECK of patient, surgeon, process, and responses. The four levels of intensity for each of these components are represented by another mnemonic: SCARE SCAN CHECK ALERT READY EMERGENCY Circulation, Capnograph, and Colour (saturation) Oxygen supply and Oxygen analyser Ventilation (intubated patient) and Vaporisers Endotracheal tube and Eliminate machine Review monitors and Review equipment  Airway (with face or laryngeal mask)  Breathing (with spontaneous ventilation)  Circulation (in more detail than above)  Drugs (consider all given or not given) A Be Aware of Air and Allergy and comprise - pages 6 to 13 of this manual. The SCAN sequence should be followed every 5 minutes of any anaesthetic, or more often if necessary. This overcomes the need for special training sessions, as the sequence rapidly becomes second nature and can usually be completed in 40-60 seconds. The CHECK sequence should be used whenever all is not going according to plan, and should also be practised regularly. Do not hesitate to move on to the ALERT/READY and EMERGENCY sequences if you are worried, if events are moving quickly, or if it seems that an adverse outcome is possible. These should also be practised from time to time.

Sub Algorithm – Crisis Management Obstruction of the natural airway Laryngospasm Regurgitation, vomiting and aspiration Difficult intubation B Desaturation Bronchospasm Pulmonary oedema C Bradycardia Tachycardia Hypotension Hypertension Myocardial ischaemia Cardiac arrest D Problems associated with drug administration during anaesthesia Awareness Embolism Pneumothorax Anaphylaxis and allergy * Vascular access problems Trauma: development of a sub-algorithm Sepsis Water intoxication Crisis management during regional anaesthesia Recovering from a crisis Sub Algorithm – Crisis Management

Crisis Management for Obstetric Anesthesia Difficult Airway (Anticipated or unanticipated) Maternal Cardiac Arrest Local Anesthetic Systemic Toxicity (LAST)

AIRWAY CORRECTION Build a BIG RAMPPPP

Equipments Macintosh Airways Magill Igel Miller Cricothyrotomy Polio (LMA ) Igel Miller Cricothyrotomy Polio Endotracheal Tube Introducer Mc Coy Tracheostomy

Unanticipated Difficult Airway

Anesth Analg 2014

Anesth Analg 2014

 

Pharmacological Treatment of LAST 

Back to Basics GOOD COMMUNICATION+TEAMWORK GOOD clinical knowledge of pregnancy GOOD practice and skills among doctors, midwives, nurses, and other heath care professionals may reduce potentially avoidable maternal morbidity & mortality At first, recognize the crucial importance of patient medical and obstetric history and risk status Then, consult the obstetrician, pediatrician and anesthesiologist GOOD COMMUNICATION+TEAMWORK

EXCELLENT TEAM WORK FOR OBSTETRIC PATIENT SAFETY!!!!

THANK YOU