1. National Hospital for Neurology & Neurosurgery,
Phases of Anaesthesia
Jeremy Radcliffe
National Hospital for Neurology & Neurosurgery,
UCLH, London

2. Commendation Local coordinators and reporting clinicians
Patients’ descriptions, which allowed NAP5 interpretation
RCoA Bulletin 87, September 2014 p.28 ; ‘Introductory remarks’

3. 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

4. Expectations
‘Classic’ ?

5. 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’ ….

6. Expectations Studies and Publications focus on ‘Maintenance’ phase %
Induction Maintenance Emergence
50% 36% 18%
( n = (58i:12t) ) %
Gender (F)
ASA 1,
Emerg/Urgent 50~ (survey)
Overweight (42)
NMB recorded (45)

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

8. 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%

9. Causation
Induction
The ‘Gap’: Airway,

10. 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.’

11. Experience
% Induction Maintenance Emergence Distress Experience paralysis pain 49 (both 37) tactile 34 Preventable Poor care quality

12. Recommendations
Distilled: 23
Research implications noted: 15

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

14. 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.