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1. HAZARDS
OF OPERATION ROOM
Dr Nisar Ahmed Arain
Assistant professor
Anesthesia/Critical care/ER

2. DEFINATION OF HAZARD
HAZARD ???
-It is asituation that posesalevelof threat to life
health,property, orenvironment
-A hazarddoesnotexistwhenit isnothappening
-Anesthesiaandsurgeryareconductedintechnologically
intenseenvironment…….itispotentiallyHazardous

3. MOST COMMON HAZARDS IN OR
---FiresandExplosion
---StaticElectricity
---ElectricalHazards
---RadiationInjury
---Air Pollutionand
---PowerFailure

4. FIRES and EXPLOSION
--Bothof thesecancausedeath or
injury to the patient.
--Onlyoccurifwehave3 things:
---sparkor ahotsurface,
---flammablesubstanceand
---sourceof oxygen

5. SOURCES OF SPARKS OR HEAT
---Static electricity
--Faulty electrical switchesandapparatus
e.g. saws, plaster cutters and drills
--Foreign matter, e.g. dirt or greasein the
oxygen or nitrous oxide cylinders
--Diathermy
--Openflames
--- Flammablesubstances:Includes ether, ethyl
chloride andsolution in sprits.Theaddition
ofoxygenincreasedflammability

6. STATIC
ELECTRICITY 1
--Electricity present in the atmosphere
--Occurs if two materials which conduct electricity
poorly are brought into contact and then separated.
--If there is friction or movement between the two, a
spark is produced and a spark, of course, can produce
an explosion

7. STATIC ELECTRICITY - 2
-Ex woolen fabrics, non conducting rubber
and synthetic materials such as nylon.
-Should be avoided in the OR, using graphite
impregnated yellow coded rubber instead.

8. -Conductor floor (Concrete or conductive rubber
or plastic, placed on floors)
-Avoid wool, plastic, and nylon fabrics and wear
cotton or other anti-static outer clothes instead.
-Wear aprons of conductive rubber
-Wear antistatic boots or conductive canvas over
shoes.
-Maintain Humidity of 60% static sparks are more
frequent when the air is dry.
OTHER PRECAUTIONS
TO REDUCE STATIC ELECTRICITY 1

9. OTHER PRECAUTIONS TO REDUCE
STATIC ELECTRICITY 2
-Ventilation – Anesthetic gases are heavier than
air and tend to collect at ground level
-Regular inspection of electric switches and
apparatus is required
-Smokes and open flames must be forbidden
immediately
-Fire fighting equipment must be available in the
operation rooms

10. ELECTRICITY HAZARDS 1
-Theymayoccurwhenpatientsare:
-Incontact with faulty electrically-operated
medical equipment
-Accidentally connected to electric circuits by
spillageof blood orsaline
-Dependent on electrical equipment to replace
or support vital organfunctions
-Exposedto fire orexplosions
-Undergoing treatment whensafelevels of
electrical energyareexceeded.

11. Electrical hazards
2
Electric Shock
--When the body becomes part of an electrical
circuit with significant current.
--Wiring defects, faulty equipment components
and deteriorated insulation
--Lack of maintenance and misuse are the usual
causes

12. ELECTRICAL HAZARDS 3
MACRO-SHOCK
-Most common
-Occurs when the body conducts an electric current
which does not pass directly through the “Heart”
- Mild sensory stimulation @5 to 10 mA
-@50 to 60 mA – muscular contraction
-@100 mA – breathing becomes extremely difficult
-Somewhere above this level respiratory paralysis
cardiac arrest and severe burning occurs

13. ELECTRICAL HAZARDS 4
MICRO SHOCK
--When very tiny currents, such as
100 micro ampere, are intentionally
passed directly through heart muscle
e.g.
1-Cardiac catheterization
2-Carbon monoxide measurement

14. ELECTRICAL HAZARDS 5
High Frequency Currents
--Above 50 hertz are less likely to produce
electric shock but can cause burns and
interference with other devices such as
pacemakers
--DC is less likely to cause VF than high
frequency AC (above 50 Hz) but can
cause Muscle contraction
--Nerve damage often occurs with high
voltage currents
--Short circuits may be involved by large
currents passing from either
a-Head to foot or
b-Arm to arm

15. ELECTRIC BURNS AND ELECTRICALLY INITIATED BURNS
-Three types
-Carbonization of skin (From burns at a very high
temperature of 1,000 degrees C
-Flame burns
-Direct heating of tissues produce coagulation and
necrosis at entry and exit points and associated
injury in muscle and BV.

16. ELECTROSURGICAL UNITS
-Diathermy are arranged so that current from
the active electrode flows through the patient
and back to the generator
-Don’t use electric blankets in conjunction with
electro - surgery

17. -RISKS
a-spontaneous miscarriage
b-congenital abnormalities and
c-Liver disorders
-Waste anesthetic gases escape from
a-Faulty valves
b-The ventilators
c-Poorly fitted components in the breathing circuit
d-Split anesthetic drugs
e-Expired gases from the spill valve of the anesthetic
breathing circuit drugs
f-Gases exhaled by the patient
AIR POLLUTION 1

18. REMEDIES
This pollution can be reduced by
-a-Regular thorough inspection of all anesthetic equipment
-b-Limit or avoid the use of inhalational gases and agents
e.g. circle system, TIVA, and RA
-c-An efficient scavenging system
-d-Closed circuits
-e-Anti spill devices

19. POWER FAILURE!!!

20. POWER FAILURE
-Critical areas employing electrically driven
equipment such as respirators (Ventilators)
and dialysis machines require standby
equipment (I.e. generators)

21. PART - 2

22. ANESTHESIA
RELATED
HAZARDS / RISKS

23. RISK
-Risk is the potential that a chosen action will
lead to a loss or an undesirable outcome
-Risk is a ubiquitous, natural part of life,
because everything we do, including doing
nothing, poses uncertain outcome
-Occasionally the term refer to the outcome
itself (e.g Death as a one risk of anesthesia)

24. ANESTHESIA RISK AND INJURIES
-Accident is an unplanned, unexpected, undesired event
-Because there are no standard methods for assigning
causality, yet no accurate estimates of the rate of adverse
out-come is available
- Errors related to AW mgt(measured gas temperature)
monitoring, and sudden cardiac arrest during SA
equipment failures, or nerve injuries

25. ADVERSE RESPIRATORY EVENTS
-The most serious Hazards in anesthesia
-Causes of Death and Brain Damage are
inadequate ventilation,
esophageal intubation, and
difficult ETI
-Cases in the first two causes were judged
to have been preventable if better
monitoring had been employed
-Anticipated difficult ETI-refer to better
institution or surgical AW
should be performed before anesthesia

26. FAILURE TO MONITORING
-An important contributor to anesthesia adverse events
-There are numerous ways in which pulse oximetry
Capnometry, and Automated blood pressure monitors
can give false information, leading to missed or incorrect
diagnoses

27. MEDICATION INDICATORS
-The most frequent error in anesthesia, and in
healthcare practice in general
-Similarity of drug names, containers, and label
colors

28. MEDICAL ERRORS
-Dosing errors related to the frequent need for individual
-Error in numerical calculations when drawing and mixing
drugs for bolus administration or IV infusion
-Wrong drugs (e.g among various insulin formulations)
-Flushing a catheter with a solution containing another
potent drug.
-confusion in the programming of infusion pumps

29. -RECONDATION
-Read the label carefully 3 times

30. ERRORS IN IAGNOSIS
Especially during the management of critical events

31. EQUIPMENT ERRORS AND FAILURES
-Current anesthesia machines and associated technology
incorporated substantial safety features
-Frequent and can occur in many ways, but rarely causes
injury directly
-Equipment associated injury: It is more likely to be from
misuse than from overt failure of a device

32. LACK OF STANDARD PRACTICE AND UNUSUAL SITUATIONS
-Accidental dislodgement of ETT during transportation
-Undiluted phenytoin by rapid IV infusion – refractory HN
arrythmias, and death.
-Undiluted K+ by rapid IV infusion – and Cardiac arrest
-Neostigmine given without an antimuscarinic cause
a systole / severe bradycardia and AV block, and can be
fatal.

33. LACK OF STANDARD PRACTICE AND UNUSUAL SITUATIONS
-Inadvertent IV injection of LA –neurologic and cardiac
toxicity, which can be fatal (specially with Bupivacaine)
-Air Embolism during the placement or removal of
central venous catheter
-Limb necrosis if the tourniquet is left on the patient
for a prolonged period

34. PART 3

35. SUMMARY OF RISK
MANAGEMENT
RISK IS UBIQUITOUS
Stratification prioritization and intervention
-RISK ASSESMENT

36. -WHAT IF YOU FAIL TO DO ALL THIS ???

37. ENHANCING PATIENTS SAFETY
-Avoidance, prevention and amelioration of
adverse outcomes or injuries
QUALITY OF CARE
-Extent to which health services for individuals
and populations increase likelihood of desired
health outcomes and are consistent with
current professional knowledge
-Patients safety is focused on prevention of injury
-Quality assurance generally deals with the
broader spectrum of quality, including the
success of treatments
-Risk management is focused on proactive patient
safely, based on the principle that prevention of
injuries via error reduction and system
improvements

38. -
-
PRACTICAL ELEMENTS 1
-Avoidance of unnecessary risk taking
-Almost unending anticipation of what might go wrong
-Projection of actions in anticipation of failure and, above all
MINDFULNESS
-Being patient cantered………..PATIENT IS ABOVE OUR EGO !!

39. PRACTICAL ELEMENTS 2
Maintaining vigilance
-The anesthesia provider must maintain alertness
and be aware of, compensate for, and counteract
the forces working against vigilance
-Fatigue and sleep deprivation are probably the
most common causes of lapses in vigilance

40. -Practice in a system of care
-Teamwork
-Preparation
-Monitoring
-Control for human factors, organized
arrangement of supplies and drugs,
esp. labeling and establishing and
adhering to local standards
PRACTICAL ELEMENTS 3

41. PRACTICAL ELEMENTS 4
-Care to keep IV cannula and monitoring cables orderly
lighting, and reducing clutter, noise, and distractions
-Infection control
-Antibiotic administration in the perioperative interval
reduces postoperative wound infection.
-Surgical wound infection rates are increased 3 – fold
by hypothermia

42. ANESTHESIA CRISIS MANAGEMENT
-Seek assistance early and quickly inform others
-Establish clarity of roles for each person involved in
mgt(measured gas temperature) of event(event manager
-Use effective communication processes
-Use resources effectively and identify what additional
resource(People, Supplies, Equipment, Transportation)
are available to manage situation

43. CRISSMANAGEMENT DURING ANESTHESIA
C1 Circulation Adequacy of peripheral circulation (rate, rhythm, and character of pulse).
If pulse is absent(CPR)
C2 Color Note saturation. Examine for evidence of central cyanosis,Pulseoximetry
O1 Oxygen Checkrotameter settings; ensure inspired mixture is not hypoxic.
O2 Oxygen
analyzer
Adjust inspired oxygen concentration to100%
Check that oxygen analyzer showsarising oxygen concentrationdistal
to common gas outlet.
V1 Ventilation Ventilate lungs by hand to assessbreathing circuit integrity, airway patency,
chest compliance, and air entry by “feel,” careful observation, and
auscultation.
Also inspect capnograph’s trace if available
V2 Vaporizer Checkall vaporizer filler ports, seating’s, and connections for liquid or gas
leaks during pressurization of thesystem.
Consider possibility of wrong agent being in vaporizer.

44. CRISSMANAGEMENTDURING ANESTHESIA
C1 Circulation Adequacyof peripheralcirculation(rate,rhythm,andcharacterof pulse).If pulse
isabsent(CPR)
C2 Color Note saturation.Examinefor evidenceof central cyanosis,Pulseoximetry
O1 Oxygen Checkrotameter settings;ensureinspiredmixtureisnot hypoxic.
O2 Oxygen
analyzer
Adjust inspired oxygenconcentration to100%
Checkthat oxygen analyzershowsarising oxygenconcentrationdistal
to common gas outlet.
V1 Ventilation Ventilate lungsbyhandto assessbreathing circuit integrity, airway patency,chest
compliance,andairentry by“feel,” carefulobservation, andauscultation.
Alsoinspect capnograph’strace ifavailable
V2 Vaporizer Checkallvaporizerfiller ports,seating’s,andconnectionsfor liquid or gasleaks
during pressurizationof thesystem.
Considerpossibilityof wrongagentbeinginvaporizer.

45. CRISISMANAGEMENTDURINGANESTHESIA(CONT…)
A Air way Check patency of non-intubated airway. Consider laryngospasm, FB,blood, gastric contents,
or nasopharyngealor bronchial secretions
B Breathing Assesspattern, adequacy, and distribution of ventilation. Consider, examine, and auscultate
for bronchospasm,pulmonary edema, lobar collapse, and pneumo- orhemothorax
C Circulatio n Repeat evaluation of peripheral perfusion, pulse, BP
, ECG, and filling pressures and any
possible obstruction to venousreturn, raisedintra thoracicpressure(e.g.,inadvertentPEEP)
D Drugs Review intended (unintended) drug or substance administered Consider whether problem
may be a consequence of an unexpected effect, a failure of administration, or wrong dose,
route, or mannerof administrationof drug

46. PART 4

47. -HAZARDS FOR ANESTHETISTS
-1-Fire and Explosions
-2-Electrical accidents
-3-Pollutions by anesthetic agents
-4-Radiations
-5-Infections
-6-Incompatibilities / allergies
-7-Stress
-8-Chemical dependence
OR

48. INFECTIONS
-Physical spread – HSV, CMV
-Blood borne – HIV, HBV, HCV
-Air borne - Mtb

49. INFECTIONS
-Blood born diseases through needle stick injuries-HIV 0.3%
HBV-3% HCV-30%
-32% HAD ATLEAST 1 NSI in the preceding 12M (only half of them
took treatment)
-More risk with hollow – core and large bore
-NSI more in nondominated hands
-NSI more during disposal of contaminated needles
-Anesthesiologists have risk for occupational infection during
30 years of exposure 0.045—4.5%

50. INFECTIONS - HIV
-Health care workers contribute 5% of total cases
-4% of emergency department patients are
unidentified cases
-Patients considered infective if both screening
(ELISA) and confirmatory (western blot, indirect
fluorescent ab) tests are positive

51. INFECTIONS - HIV
-54 reported cases of occupationally acquired HIV(1998)
-88% of them had H / NSI
-?Quantity of inoculums- (a case report: 100 to 200
micro ml of blood through IV produced HIV)
-Risk for the patients – 6 cases reported

52. INFECTIONS - HBV
-Non immunized HCW – higher risks
-17.8% of seropositive among anesthesiologists
-30% became positive after 11 years of exposure
-Disinfectants and gloves are not completely
protective viruses viable for >14 days in needles,
gloves, and surfaces

53. INFECTIONS - HCV
-No immunization available
-No specific treatment available
-Advice: serologic monitoring for
HCV and LFT3 – 6 Monthly

54. Management of occupational infections
SAFE PRACTICE
INFECTIONS
-Protective equipments
-Washing methods
-Disposal methods

55. -INFECTIONS – CDC RECOMMENDATIONS
Universal precautions – 1900
-Considering as all patients, blood and
body fluids are infective
Isolation precautions – 1996
-2 tier recommendations
1-Standard precautions:- To be followed
for handling all patients as infective
2-Transmission based precautions:-For
handling patients known to be /
suspected of being risks

56. INFECTIONS – CDC RECOMMENDATIONS
-Transmission based precautions
-Based on the properties of specific pathogens
-Airborne precautions {Measles, Varicella, TB} – to
prevent from small particles <5-micron meter by
specific filters, air handling devices, HEPA NEGATIVE
PRESURE ENVIRONMENT
-Droplet precautions {HBV, mycoplasma, streptococcal
pharyngitis, rubella} – to prevent from large particles
>5micron meters, keep distance >1 meter
-Contact precautions{HAV, HSV, Viral conjunctivitis}

57. INCOMPATIBILITIES / ALLERGIES
-Latex Allergy
-Type IV / Type I
-Risk groups
1-Spina bifida
2-Urogenital abnormalities
3-HCV
4-Rubber Factory workers

58. -LATEX ALLERGY
-MANAGEMENT
1-Identification of Risk groups
2-Use Latex free objects-latex
free environment
3-Tests RAST {Radio-allegro-sorbent test}
--SPT
--Sr histamine
--Urinary Histamine
--Sr IgE
--Sr. compliments
--Sr Typase
Screening
tests
Testsfor anaphylaxis

59. -LATEX ALLERGY
-Management – drug regimens
-Pre-operative protocol
1-Di phenhydramine -1mg/kg.po/iv,q 6hr at 13,7,1 hr
before surgery
2-Prednisolone – 1 mg/kg,po/iv,q 6hr at 13, 7 ,1 hr
before surgery or Hydrocortisone 4 mg/kg
3-Ranitidine – 2 mg / kg po, 1mg/kg iv, q 12 hr at 13, 1 hr
before surgery
-post –op protocol
1-drugs to be repeated for 12 hrs

60. STRESS
-Inevitable, universal phenomenon to which no
one is immune
-Job related stress are unavoidable but may be
controlled
-2Types – unavoidable and Avoidable
-Unavoidable-professional stress
-Avoidable-sleep related

61. STRESS
Unavoidable Stress
1-Professional stress
2-Co-worker relationships
3-Work load
4-Litigations
5-Peer review
6-Professional dis-satisfaction
7-Administrative responsibilities

62. STRESS
AVOIDABLE STRESS
-Sleep related-altered sleep pattern
sleep deprivation
-Coincide with natural sleep peaks
-Identification of sleep disturbances
-Regulations of working hours

63. CHEMICAL DEPENDENCE
-Self administration of drugs and suicidal rates are high among
anesthesiologists
ADDICTION
Compulsive continued use of drugs inspite of adverse, a chronic
relapsing condition resulting from long term effects of drugs on
Brain , due to molecular, structural, cellular, and functional
changes
DEPENDENCE
Physical / Psychological inability to control drug use
ABUSE
Use of drugs in detrimental way but not to the point of
addiction. A pre-Addiction level can easily quit a voluntary act.

64. CHEMICAL DEPENDENCE
CAUSES
-1-Stress
-2-Availabilities
-3-Curiosity for experimentation
-4-Drug potency
-Others-genetic pre-disposition

65. -CHEMICAL DEPENDENCE
MANAGEMENT
-1-Identification
-2-Intervention
-3-Referral
-4-Rehablitation