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

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

4. In the World 234 million operations are performed per year
Reported complications is nearly % (mostly surgical-related adverse events)
Mortality related to operations is %
≅ 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

5. 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

6. 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
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) /

7. MMR
USA (SOAP 2011, ): 7 – /
UK (CMACE ) – /
Turkey (2011 – 2013) /

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

9. Maternal mortality and anesthesia
Obesity a significant contributor to maternal death (CMACE 2011,
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

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

11. 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

12. 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!

13. 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

14. 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

15. 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%)

16. 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

17. 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:
Roshan Fernando, SOAP 43 rd 2011, Nevada

18. 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

20. 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

21. 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

22. 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

23. 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

24. 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!

25. 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

26. 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…

27. 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

28. 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

29. 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

30. 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

31. 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 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.

32. 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

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

34. AIRWAY CORRECTION
Build a BIG RAMPPPP

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

36. Unanticipated Difficult Airway

37. Anesth Analg 2014

38. Anesth Analg 2014

40.  

41. Pharmacological Treatment of LAST 

42. 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

43. EXCELLENT TEAM WORK FOR OBSTETRIC PATIENT SAFETY!!!!

44. THANK YOU