HSNZ NOV 2013

1. HSNZ NOV 2013

2. Crisis: A time of great danger or trouble whose outcome decides whether possible bad consequences will follow.

4. Other professions like ours: • Aviation • Spaceflight • Nuclear power and chemical manufacturing • Military Command – Fighter Pilots in combat • Fire fighting

5. Complex and Dynamic • Event driven and dynamic • Complex and tightly coupled • Uncertain • Risky

6. Dynamism Time pressure Intensity Complexity Uncertainty Risk What makes Anesthesia different from other specialties?

7. The stress of anesthesia

8. Anesthesiology, by its nature, involves crises The combination of complexity and dynamism makes crises much more likely to occur and more difficult to deal with.

9. Up to our elbows… • Anesthesia involves direct physical involvement in the tasks of patient care including: - performance of invasive procedures - administration of rapidly acting, potentially lethal medications - operation of increasingly complex devices

10. During crises, knowledge is not enough.. • Management of the environment, the equipment and the patient care team • This involves aspects of cognitive and social psychology, sociology and anthropology

11. Old View • Adequate Training + Qualified Trainee = Ability to handle Crisis Situations

12. New View • Each individual is affected by multiple factors…. • Individual strengths and vulnerabilities • Distractions, biases, errors • Environment, Equipment • Physiologic factors such as fatigue, emotional stress, illness

13. It happened all of a sudden… • Crisis perceived as sudden in onset and rapid in development • In retrospect one can usually identify an evolution from underlying triggering events

14. Gaba DM, Fish KJ, Howard SK: Crisis Management in Anesthesia 1994

15. Triggering events may initiate a problem. A problem is an abnormal situation that requires attention but is unlikely by itself to cause harm. Problems can evolve and if not detected or corrected can lead to adverse outcomes.

16. Adverse Outcome…

17. The events that trigger problems do not occur at random • They emerge from three sets of underlying conditions: • Latent errors • Predisposing factors • Psychological precursors

18. 1. Latent Errors: …errors whose adverse consequences may lie dormant within the system for a long time, only becoming evident when they combine with other factors to breach the system’s defenses, most likely spawned by those whose activities are removed in space and time from direct control: designers, adminstrators, managers.

19. 2. Predisposing Factors: • The external environment constitutes predisposing factors. • In aviation this is weather. In anesthesia these are the patient’s underlying diseases and the nature of the surgery

20. 3. Psychological Precursors • Can predispose the surgeon or anesthesia provider to commit unsafe acts that may trigger a problem • “Performance Shaping Factors” including fatigue, boredom, illness, drugs, environment (noise, illumination)

22. Vigilance… • Both Aviation and Anesthesia are describe as…”99% boredom and 1% Sheer Terror….”

23. 99% Boredom….

24. 1% Sheer Terror

25. Interesting Parallels • Preop Evaluation • Machine/Equipment check • Induction • Deepening Anesthesia • Intraop • Lightening Anesthesia • Emergence • Preflight • Aircraft and preflight checklist • Take Off • Gaining Altitude • Cruise Altitude • Descent • Landing

26. Dials, Knobs and Alarms

27. “Cruising, Stormy and Crashing”

28. Similar Environments… • High Stress Potential • Work hours and Performance • Equipment Dependent • Production Pressures • Communication and Team Approach • Multiple Tasking • Accident Evolution

29. Vigilance… • …Ability of observers to remain alert to stimuli for prolonged periods of time… • Warm J, Presentation at the panel on vigilance, 1992 ASA annual meeting

30. Team • …a distinguishable set of two or more people who interact dynamically, independently, and adaptively toward a common and valued goal/objective/mission, who have each been assigned specific roles or functions to perform and who have a limited life-span of membership

31. Simulators

32. Simulation Training • Allows practice in situations that rarely occur in real life • Safe environment for practicing crises situations • Mandatory training in Netherlands, Belgium, Sweden and Germany • Allows safe environment for research

33. Making Things Safer • Since the early 1980s, the Anesthesia Patient Safety Foundation (APSF) has been instrumental in reducing the number of anesthesia-related deaths from 1 in 10,000 to about 1 in 200,000. Technological advances -- such as pulse oximeters, capnometers, and oxygen regulators have been key factors. Also, simulators are now used in anesthesia for practice and training. Online CME sponsored by Massachusetts Medical Society, file:///C:/Documents%20and%20Settings/Christopher/Desktop/New%20Folder/New%20Folder/Online%20CME%20%20A%20Success%20Story%20in%20Safety.htm

34. CASE 1 • You are anaesthetising a young women for an appendicectomy. She is clinically moderately dehydrated due to poor oral intake and vomiting. Shortly after intubation, her bp dropped to 70/40. immediaetly put on 1 pint colloid run fast. But, instead of bp pick up, now her bp is unrecordable, she became flushed, and her lungs are very difficult to ventilate

35. What are your differential diagnosis? • What are your immediate actions?

36. Stop administration of suspected agent/s • Maintain airway/give 100% O2 • Lay patient flat and keep leg elevated • Give adrenalin • -im at a dose of 0.5-1.0 mg repeated every 15 min if required • -iv at a dose of 0.1 mg for hypotention or cardiovascular collapsed – titrated up to 0.5-1.0 mg as required • Give iv fluid – crystalloid or colloid

37. Other secodarytheraphy to consider? • Antihistamine – iv chlorpheniramine 10-20 mg slow bolus • Corticosteroid – iv hydrocort 100-200 mg • Bronchodilators • Consider bicarb ( 0.5-1.0 mmol/kg )

38. How would you investigate this patient for suspected anaphylaxis? • Serum tryptase • Urine methylhistamine • Skin prick test

39. Why do the tests • Full explaination to patient / spause • -give medic-alert bracelet • Record in the case note - ? red colour • Inform GP

40. CASE 2 • As the medical officer oncall for emergency OT, you are anaesthetising a young lady, who came for twisted ovarian cyst. As she well fasted and ASA 1, no obvious features of difficult airway, you choose modified RSI using rocuronium of 1 mg per kg. initially ventilation was uneventful. Laryngoscopy revealed CL III and not improved with manipulation. After 3rdattemp still cannot intubate and pt start to desaturate

41. What will you do? • Call for expert / senior help • ventilate with 100%via a face mask • Ensure optimal intubating / ventilating position • May use oropharyngeal / nasopharyngeal airway • Do not attemp >4 intubation and >2 LMA insertion

42. If able to ventilate • Consider • Wake up the patient • -defer surgery • -RA • -tracheostomy under LA • -awake FOI • OR anaesthesia with mask ventilation – if appropriate

43. If successfully intubated/LMA • Proceed with surgery • If LMA /ILMA – can attemp intubation • OR wake up patient • -defer surgery • -RA

44. Difficult / unable to ventilate • Airway obstructed? Try LMA • IF failed – surgical airway • -needle OR surgical cricothyrodotomy • -transtracheal jet ventilation

45. Other helpful gadgets • Glidescope with glidescopestylet • Airtract, KingVision • C tract • C max • Bonefillsemirigidfibrescope • Trachlight • Combitube

46. Extubation of difficult airway • When to extubate • Where to extubate • Deep extubation? • Leak test • Exchange catheter • Clear documentation and post op visit

47. CASE 3 • A 33 year old lady is planned for laparoscopic cystectomy under GA. Induction and intubation done uneventfully. ETT anchored at level 20 cm. 5 minutes after abdomen inflated with CO2 gas, SPO2 dropped and ventilator alarm activated - high pressure

48. What is yr ddx • -bronchospasm • -ETT problem • -Breathing system / ventilator problem

49. Immediate action • -FIO2 100% • -manually ventilate to assess compliance

50. Is it truly bronchospasm • Quick inspection of breathing system • ETT • Auscultation