Safety in Anesthesia Dr Lin Cao Department of Anesthesia, 2 nd affiliated hospital, Sun Yat-Sen University
Anesthetists are responsible for patient safety during operations
Anesthesiology is a high-risk specialty as compared with other specialties in medicine
The risk of anesthesia
Anesthesia may contribute to death in about 1 per 10,000 anesthetics.
Many other patients suffer serious and costly nonfatal injuries such as permanent neurologic damage (paraplegia and vegetative).
Now we can see anesthesia event can cause severe results
So we should find out factors threatening patient safety in the operation room and search for strategies to deal with them
There are many factors threatening patient safety in the operation rooms
Strategies: pre-use checkout
Underlying diseases: hyperthyroidism-thyroid storm, diabetes-ketoacidosis or hyperosmolar coma
Allergic reaction to some drug
Anesthetist and Surgeon
Human factors affecting performance such as :fatigue, noise, boredom, long hours, hunger, tension
Causes for Accidents
There is rarely a single cause for an accident.
System failures are the main reason for accidents
check anesthetic machine
A backup O2 tank
Never shut down audible alarms (very important)
Emergency ventilation equipment
Human error is a strong contributor
Deviations from accepted anesthesia practices.
A lapse in vigilance and no attention to detail
Vigilance and attention to detail are essential for a safely conducted anesthetic.
Vigilance lets anesthetists find abnormal signs as early as possible
Vigilance allows the anesthetist to remain aware of surrounding events and signals while performing other tasks.
II. General safety strategies
A. Prepare a preoperative plan
Preoperative visit to the patient to let us know the patient’s condition in detail
Make an anesthesia plan to let us know clearly how to perform the anesthesia and how to deal with possible crisis
Check anesthesia machine ,monitors and other devices
Prepare the workspace to make us work more conveniently and efficiently. Arrange equipment and appropriate monitors in a way that facilitates this. So we can clearly observe the patient and easily manipulate all devices
Check backup equipment
Know the location of emergency supplies and equipment
Label all medications
B. Develop situational awareness
Use a systematic approach to scanning the machine, monitors, patient, surgical field, and surroundings.
If one vital sign is anomalous, quickly assess the others while repeating the measurement and observing what is happening on the surgical field.
C. Verify observations
Assess covarying variables
Review it with a second person.
D. Implement compensatory responses
If something wrong happens urgently, first implementing time-buying measures. e.g., increase the fraction of inspired oxygen when oxygen saturation falls; administer intravenous fluids or vasopressors when hypotension occurs).
Then search out any correctable primary cause and treat it appropriately
E. Prepare for crisis
If there is any critical events happened (cardiac arrest, malignant hyperthermia or difficult intubation), call for help early (WHY), then use accepted protocols for emergencies and resuscitation (e.g., advanced cardiac life support, malignant hyperthermia protocols).
F. Enhance teamwork; communicate
To enhance teamwork and communication, address surgeons and nurses early in the case by knowing names. Make requests and delegate tasks clearly and specifically by name (e.g., “Jack, do task X and tell me when task X is completed.”).
G. Compensate for stressors
Anesthetist is a stressful job. If you feel very tired, ask for a relief.
Reduce various stressors: noise, fatigue, interpersonal tension, etc. optimize the work environment .
H. Recognize and address production pressures
Patient safety must remain the highest priority
In big hospitals, anesthetists have a great deal of workload. There are many operations everyday. Anytime we can’t sacrifice patient safety in order to emphasize production. If there is no adequate preoperative evaluation, preparation, or monitoring, it is unsafe to anesthetize the patient. You must address concerns explicitly to surgeons and cancel the operation.
I. Learn from close calls
Every mistake is an opportunity to learn and improve.
Analysis and feedback of adverse events to identify and assess system problems
III. Crucial errors to know and avoid
A. Airway errors
As we know, patients receiving general anesthesia have no spontaneous respiration due to use of muscular relaxants, their respiration is controlled by machine via endo-tracheal tube. So we must ensure oxygen supply and avoid accidental extubation during sugeries(esp a prone surgery) and transport. Once it happens, the result is severe. It can cause severe hypoxia and directly threaten the patient life.
How to avoid
Check the system and guarantee it to function well
Verify an endotracheal tube by auscultating for breath sounds bilaterally and by detecting end-tidal CO 2
Fix the tube solidly
Closely observe vital signs
Verify an endotracheal tube
B. Medication errors
Administration of undiluted potassium by rapid intravenous infusion can cause ventricular fibrillation and cardiac arrest.
Neostigmine given without an antimuscarinic drug can cause asystole, severe bradycardia and atrioventricular block and can be fatal.
Succinylcholine can cause severe hyperkalemia and dysrhythmias, may trigger malignant hyperthermia.
Medications to which a patient is allergic can cause anaphylaxis.
Administering the wrong blood can cause an incompatibility reaction that can be fatal.
How to avoid
Be Familiar with the medication you use, know clearly its indications and contraindications.
Administrate the medication strictly according to instructions.
Know the patient’s history of allergy
Cross-check blood type
C. Procedure errors
Inadvertent intravascular injection of local anesthetics during a nerve block can cause neurologic and cardiac toxicity, which can be fatal (especially with bupivacaine).
Avoidable epidural hematomas may develop when spinal or epidural anesthetics are performed in patients who have coagulopathies.
Air embolisms may occur during the placement or removal of central venous catheters and may cause significant hemodynamic instability. ( decumbens position can avoid it )
How to avoid
Adequate preoperative evaluation of patients
Manipulation according to standards and guidelines.
IV. Quality assurance
The aim is improving the quality of care and minimizing the risk of injury from anesthesia.
Any adverse events should be reported truthfully, discussed, analyzed to identify causes and assess system problems. So we can learn from them and develop patterns to prevent recurrence.
B. Standards and guidelines
Anesthesists should be aware of their institution's safety policies and procedures. These should include those for monitoring, response to an adverse event, handoff checklist, resuscitation protocols, perioperative testing, and any special procedures or practices for the use of drugs, equipment, and supplies.
C. Safety training
Anesthesia providers should obtain training in safety to learn and maintain basic skills. Simulation techniques should be used. In reality, for one doctor, the opportunity to confront a critical event is rare, the best way to learn critical-event management skills is using simulator. After training on simulator repeatedly, when crisis happens, you can manage it efficiently.
V. Standards and protocols
Standards for basic anesthetic monitoring
1. Qualified anesthesia personnel shall be present in the room throughout the course of all general anesthetics, regional anesthetics, and monitored anesthesia care.
2. Continually evaluate the patient's respiration ,circulation and temperature.
2.1 Respiratory monitor
an oxygen analyzer
continual end-tidal carbon dioxide analysis must be used with tracheal intubation
some form of monitoring with an audible alarm must be used during mechanical ventilation
2.2 Cardiacvascular monitor
blood pressure and heart rate at least every 5 min
one or more of the following
palpation of a pulse
auscultation of heart sounds
CVP and arterial blood pressure
2.3 Temperature monitor
when clinically significant changes in body temperature are intended, anticipated, or suspected
Periodic breaks should be given to the primary individuals providing anesthesia.
The following information should be clearly presented
a. Prior clinical details
The patient's diagnosis, surgery, allergies, past medical and surgical history, relevant medications, and any pertinent normal or abnormal laboratory values or studies.
b. Intraoperative management
Status of surgery, airway assessment and management techniques, anesthetic plan and current status, current vital signs with an explanation for any apparent abnormalities or trends, intravenous access and monitoring, blood loss and volume status assessment, anticipated need for additional medications (e.g., narcotics, muscle relaxation or reversal, antiemetics),
Guidelines for action after an adverse anesthesia event
The anesthesiologist involved in an adverse event should do the following:
a. Provide for continuing care of the patient.
b. Notify the anesthesia operating room administrator as soon as possible. If a resident or certified registered nurse anesthetist was involved in the event, (s)he should notify the attending staff.
c. Not discard supplies or tamper with equipment.
d. Document events in the patient record (including the serial number of the anesthesia machine).
e. Not alter the record.
f. Stay involved with the follow-up care.
g. Contact consultants as needed.
h. Submit a follow-up report to the department quality assurance committee.
i. Document continuing care in the patient's record.
The objectives are to limit patient injury from a specific adverse event associated with anesthesia and to ensure that the causes of the event are identified so that a recurrence can be prevented.