Perioperative Deathsafe anaesthesia practice

Dr.Mushtaq AhmadConsultant anesthetist

BVH,Bahawalpur

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ANESTHETIC DEATH

“Anaesthetic death” is often defined as the death of a patient who has had an anaesthetic, within 24 hours of the procedure. This is irrespective of the contribution of anaesthesia to the cause of death.

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The recent studies defined mortality associated with anesthesia as a death under anesthesia or as a result of anesthesia and death within 24hrs of an anesthetic procedure.

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Perioperative Death

It is potentially the most stressful event we experience as

anesthetists.

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My

is only on anesthetic death.

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Can be classified further into 4 groups according to the cause of the death

Journal of clinical pathology 1999 52 640-652 Roger. D. Start et al

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Directly caused by the disease for which anesthesia was being performed eg: aneurysmal rupture during aneurysmal repair

Caused by a disease other than for which anesthesia was being performed eg: CAD patient dying in a whipples resection

Resulting from a mishap of the surgery eg: rebleeding in Tonsillar surgeries

Resulting from a mishap of anesthesia eg: slipped ETT in cleft lip and palate surgery

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Incidence High in the developing countries High with emergency and complex surgeries High with age High with inadequate preop preparation Inappropriate postop care Lack of supervision

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Timing of perioperative mortality

Majority occurs in the postoperative(51%)Intraoperative(37%)and during induction(9%) of

anesthesia

Percentage

PostoperativeIntraoperativeInduction

Safe Anaesthesia practice

IF WE KNOW THE CAUSE OF A COMPLICATION

HUMAN ERROR

COMMUNICATION FAILURE

EQUIPMENT FAILURE

COEXISTING DISEASES

INEVITABLE COMLICATIONS

CAUSES OF COMPLICATIONS

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What is complication? Unexpected &

unwanted events 10% of all

anesthetics Death 5/million

anesthetics i-e 0.0005% in UK

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HUMAN ERRORPoor monitoringEquipment malfunctionOrganizational failurePoor trainingFatigueInadequate experiencePoor preparation of pt

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Prevention of human error

Good organization

Effective monitoring

Vigilance Action plans &

drills rehearsed previously

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COMMUNICATION FAILURE

Poor working relationship

Poor working condition Prevention

Team training & simulation-based training

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EQUIPMENT FAILURE Failure of

Breathing system Airway devices Gas supplies

Malfunction Infusion pumps

Prevention Ensure availability

& correct function of life saving & critical important equipments

alternative devices ..if primary device fail

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COEXISTING DISEASES

• Pt in fine balance of pathology & compensatory physiology

HTN,DM,IHD,ASTHAMA

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INEVITABLE COMPLICATIONS

Despite excellent surgical & anesthetic practice

Not always necessary to place the blame for a complication on a healthcare provider

Complications of anaesthesia

Major Complications Minor complicationsCardiac arrest Peioperative MIAspiration Anaphylaxis Drug overdose/ toxicity Awareness Convulsion Nerve palsiesOrgan injury- Malignant hyperthermia

Airway obstruction Post op Nausea / vomitingSore throat Persistent sedation Haemodynamic instability Pneumonia Delirium Shivering Organ dysfunction- kidney/liverCognitive defect

1. RESPIRATORY2. CARDIOVASCULAR3. NEUROROLOGICAL4. TEPERATURE5. DRUG REACTIONS6. REGIONAL ANESTHESIA7. INJURY

COMPLICATIONS

1. Respiratory obstruction2. Laryngospasm3. Bronchospasm4. Complications associated with tracheal

intubation5. Hiccup6. Hypoxaemia7. Apnoea8. Hypercapnia9. Hypocapnia10. Pneumothorax11. atelactasis

RESPIRATORY

1. Hypertension2. Hypotension3. Hypovolaemia4. Haemorrhage5. Disturbance of HR & Rhythm6. Myocardial ischemia7. Embolus

CARDIOVASCULAR

SPINALEPIDURALPERIPHERAL NERVE BLOCK

REGIONAL ANESTHESIA

Cutaneous & muscularPeripheral nerve During airway managementOpthalmicThermal & electrical Vascular tourniquets

INJURY

1. Drug overdose/ adverse reaction2. Rhythm disturbances3. Peri-op MI4. Airway obstruction5. High spinal 6. Lack of vigilance 7. Bleeding 8. Over-dosage of inhalation agent9. Aspiration 10. Technical problem in anaesthesia system

10 common causes of cardiac arrest under anaesthesia

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1. Preoperative assessment, investigation and counselling of the patient

2. Preoperative checking of equipment and the assurance of backup equipment

3. The availability of an appropriately trained Assistant4. Preoperative consultation with more experienced

personnel, where necessary, regarding the Most appropriate anaesthetic technique

5. The use of appropriate monitoring techniques

AVOIDANCE OF COMPLICATIONS

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EXPERIENCE

Anesthetist’s responsibility to ensure HAS HE /SHE ADEQUATE TRAINING

FOR THE TASK PRESENTED ?IF NO

SENIOR ASSISTANCE HELP MUST BE SOUGHT

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RECORD KEEPING Vital sign & treatment

Trends in vital sign Early intervension

safer sharing of care between anesthetists Handover long cases Better team work

After the event investigations & learning,thus reducing complications

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REDUNDENT SYSTEMS Availability of at least two working

laryngoscopes Maintenance of 2 or more IV line if

blood loss expected Monitoring of expired volatile agent

conc . Alongwith depth of anesthesia monitorsMinimizes risk of awareness

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MONITORING

ASA & AAGBI have set minimum standard of intraoperative monitoring

Automatically activated alarm…. Values set by anesthetists

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SUMMARYProphylactic measures

Improve the preoperative assessment Provide preoperative preparations Improve the monitoring standards Provide balanced anesthesia Provide adequate post operative care Provide adequate supervision Proper auditing of critical incidents

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It should have been prevented by above

measures

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It had happened

GENERAL MANAGEMENTRECORD KEEPING

MANAGEMENT OF COMPLICATIONS

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GENERAL MANAGEMENT

Provision of high FiO2 Assurance of adequate cardiac output

Cessation of perfusion …more rapid damage of organs than low level of oxygenation

Brain & heart most sensitive Liver & kidneys …potentially at risk

1. Continual vigilance and

monitoring

2. Recognition of the evolution

of a problem

3. Creation of a list of differential

diagnoses

GENERAL MANAGEMENT

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4. Choice of a working diagnosis, which is either the most likely or the most

dangerous possibility

5. Treatment of the working

diagnosis

6. Assessment of the response of the problem to the

treatment administered

7. Refinement of the list of differential diagnoses,

especially if the response has not been as expected

8. Confirmation or elimination of the choice of

working diagnosis; if the response to treatment has

been unexpected then replacement with a more likely working diagnosis is

indicated

9. Go to step 5 and repeat until the problem is resolved

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RECORD KEEPING & DOCUMENTATION

Trends in pt physiological data apparent only when charted

Generation of new DD of a problem with help of data

Data of an incident & complication important in preventing future repetition through education in department

Detailed record available to defend the practitioner

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Put every moment in black and white

The more detail, the better

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Documentations after the event

Prepare the accurate records Don’t alter the original notes Amendments and additions are recorded

separately Preoperative visit details are included Consent form and relevant investigation

reports are collected

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Documentation checklist When the patient was first seen by whom?

What was prescribed?

Investigation reports

Plan of anesthesia

Critical incidents

Remedial measures

Senior Help sought

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Dealing with the deceased

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Handling the relatives

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Be empathetic

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Communicating with relatives

Quiet comfortable room to sit Help from a senior Surgical and nursing colleague are

included Explain the serious complications Tried remedial measures detailed Answer all immediate questions

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Tug of war begins here

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Before Peri operative death

Surgeons and anesthesiologists

team up for a common goal

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After on table death

They usually fight and blame each other

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THANKS