1. SAFE ANAESTHESIA PRACTICE Dr.J.Edward Johnson

2. What do you mean by that ? Safety of the Anaesthetist ? Safety of the Surgeon ? Safety of the Patient ?

3. SAFE ANAESTHESIA PRACTICE Protocals Crisis Management Tips and Tricks for Anaesthesia

4. PROTOCALS

5. International Standards for a Safe Practice of Anaesthesia 2010 Developed by the International Task Force on Anaesthesia Safety Adopted by the World Federation of Societies of Anaesthesiologists (WFSA)

6. International Standards for a Safe Practice of Anaesthesia 2010 The goal always in any setting is to practice to the highest possible standards

7. "HIGHLY RECOMMENDED" Minimum standards that would be expected in all anaesthesia care for elective surgical procedures “Mandatory" standards

8. Peri-anaesthetic care and monitoring standards Pre-anaesthetic care Pre-anaesthesia checks Monitoring during anaesthesia

9. Pre-anaesthesia checks PRE ANAESTHETIC CHECK LIST Patient name ________________ Number ___________ Date of Birth ­__/__/__ Procedure____________________________________ Site_______ Check patient risk factors (if yes - circle and annotate) Check resourcesPresent and Functioning ASA 1 2 3 4 5 E Airway Mallampati (pictures) Aspiration risk? Allergies? Abnormal investigations? Medications? Co-morbidities? NNNNNNNNNN Airway Masks Airways Laryngoscopes (working) Tubes Bougies Breathing Leaks (a FGF of 300 ml/minute maintains a pressure of > 30 cm H 2 O) ------------------

10. Check patient risk factors (if yes - circle and annotate) Check resourcesPresent and Functioning ASA 1 2 3 4 5 E Airway Mallampati (pictures) Aspiration risk? Allergies? Abnormal investigations? Medications? Co-morbidities? Soda lime (colour - if present) Circle system (2-bag test if present) Suction Drugs and Devices Oxygen cylinder (full and off) Vaporisers (full and seated) Drips (IV secure) Drugs (lebeled - TIVA connected) Blood / fluids available Monitors - alarms on Humidifiers, warmers and thermometers Emergency Assistant Adrenaline Suxamethonium Self inflating bag Tilting table ------------------------------------

12. Monitoring during anaesthesia Oxygenation Airway and ventilation Circulation Temperature Neuromuscular function Depth of anaesthesia Audible signals and alarms

13. HIGHLY RECOMMENDED RECOMMENDEDSUGGESTED Oxygenation Oxygen supply : Oxygenation of the patient : - Supplemental oxygen -Un interrupted supply - V isual examination, - Adequate illumination - P ulse oximetry - Inspired oxygen concentration - Oxygen supply failure alarm -Hypoxic Guard- - Airway and ventilation - Observation - Auscultation - T he reservoir bag - Precordial, - Pretracheal, or -Oesophageal stethoscope - C apnography - Continuous measurement of the inspiratory and/or expired gas volumes, and of the concentration of volatile agents Circulation Cardiac rate and rhythm : Tissue perfusion : Blood pressure : -Palpation of the pulse - Auscultation of the heart sounds - P ulse oximetry - C linical examination - P ulse oximetry - At least every 5 mts - Electrocardiograph - Defibrillator - C apnography - NIBP - IABP

14. HIGHLY RECOMMENDEDRECOMMENDEDSUGGESTED Temperature - At frequent intervals - Continual electronic temperature measurement Neuromuscular function - Peripheral nerve stimulator Depth of anaesthesia - Degree of unconsciousness (clinical observation) - Continuous measurement of the inspiratory and/or expired gas volumes, and of the concentration of volatile agents - BIS Monitor Audible signals and alarms Available audible signals (pulse tone of the pulse oximeter) and audible alarms (with appropriately set limit values) should be activated at all times and loud enough to be heard throughout the operating room

15. Crisis Management during anaesthesia Crisis Management during anaesthesia

16. Crisis Management Crisis Management Crisis Management Manual developed by Australian Patient Safety Foundation Qual Saf Health Care 2005;14 Working groups from several countries including the USA, UK and Australia after analysing incident reports from the 4000 Australian Incident Monitoring Study (AIMS) reports and designed Core Algorithm & 24 Sub-Algorithms

17. Crisis Management Manual ‘‘Core’’ algorithm - COVER ABCD – A SWIFT CHECK Crisis management algorithm ‘‘COVER ABCD’’

19. Sub Algorithm – Crisis Management

20. Crisis management manual Ref. Crisis management during anaesthesia: the development of an Anaesthetic Crisis Management Manual http://qualitysafety.bmj.com/content/14/3/e1.full.html Anaesthesia Crisis Management Manual http://www.apsf.com.au/crisis_management/Crisis_Management_Sta rt.htm This article cites 42 articles, 30 of which can be accessed free at: http://qualitysafety.bmj.com/content/14/3/e1.full.html#ref-list-1

21. Where Safety Starts ? Patient Facilities, Equipment, and Medications Anaesthetist’s Skill Surgeon’s Skill

22. Survival Depends....... Survival Depends....... Facilities, Equipment, and Medications Quantity and Quality Anaesthetist Skill HELP Referal 10% 20% 60% 10%

23. Where Safety Starts ? Where Safety Starts ? Patient - Optimized patient (CVS, RS, Renal, Liver) ASA risk Well controlled Hypertension Well controlled Diabetes Haemodynamically stabilsed

24. Medication Medication All drugs should be clearly labelled The label on both ampoule and syringe should be read carefully before the drug is drawn up or injected Ideally drugs should be drawn up and labelled by the anaesthetist who administers them.

25. Anaesthetist Skill Anaesthetist Skill Learn one or two alternate method of Airway skill Practice it in routine cases

26. Post Crisis

27. Counseling Counseling Pre operative counseling - Possible complication - Remote complication Post operative counseling - The Swiss Foundation for Patient Safety has published guidelines describing the actions to take after an adverse event has occurred.

28. Recommendations for senior staff members A severe medical error is an emergency Confidence between the senior staff and the involved professional Involved professionals need a professional and objective discussion with, as well as emotional support from, peers in their department Seniors should offer support for the disclosing conversation with the patient and/or the relatives A professional work-up of that case based on facts is important for analysis and learning out of medical error. Ex..

29. Recommendations for colleagues Be aware that such an adverse event could happen to you also Offer time to discuss the case with your colleague. Listen to what your colleague wants to tell and support him/her with your professional expertise Address any culture of blame either directly from within the team or by any other colleagues

30. Recommendations for healthcare professionals directly involved in an adverse event Do not suppress any feelings of emotion you may encounter after your involvement in a medical error Talk through what has happened with a dependable colleague or senior member of staff. This is not weakness. This represents appropriate professional behaviour Take part in a formal debriefing session. Try to draw conclusions and learn from this event. Ex.. If possible talk to your patient/their relatives and engage with them in open disclosure conversations If you experience any uncertainties regarding the management of future cases seek support from colleagues or seniors

31. Tips and Tricks for Anaesthesia

32. Facilities and Equipments Macintosh Magill Miller Polio Mc Coy (GEB) Endotracheal Tube Introducer (LMA ) Airways Igel

33. Infra - glottic Invasive Airways CricothyrotomyTracheostomy

34. Unanticipated Difficult Airway

35. Techniques to decrease hypotension with neuraxial anesthesia for cesarean delivery. Leg wrapping Prehydration or co-load with intravenous colloid solution Co-load with crystalloid intravenous solution Lower dose intrathecal local anesthesia supplemented with opioid Maternal left uterine displacement positioning Consider epidural instead of spinal anesthesia Phenylephrine infusion with rapid crystalloid co-load Phenylephrine infusion with low-dose intrathecal bupivacaine Phenylephrine infusion or boluses titrated to maintain a consistent heart rate Expert Review of Obstetrics & Gynecology Katherine W Arendt; Jochen D Muehlschlegel; Lawrence C Tsen

36. OBESE - AIRWAY

37. AIRWAY CORRECTION Build a BIG RAMPPPP

38. Perianesthetic Management of Laryngospasm

40. The Laryngospasm Notch Technique

42. Unorthodox method: not generally accepted, better than nothing

43. Emergency Airway Emergency Airway

44. SAFE ANAESTHESIA PRACTICE

45. Thank you