Wht profits do u think gain? What risks? How we manage? Risk assessment?
Use a water blanket instead.
It is especially important, then, that in a hospital, particularly in a hospitaloperating theatre, we provide the cleanest air possible for patients and particularly for staff. The patients spend only a short time in the operating theatre whereas the nursing and medical staffs spend many hours each day in this atmosphere and are at risk for health problems.
(better notice the unexpected in the making and halt its development).
18.104.22.168 Practice in a system of care: Anesthetists must identify and integrate into the larger system of care in which they operate. Safe care depends on the effective work of many others working as a team, and understanding their constraints and processes can go far toward creating an environment of safety.
especially identify who will manage the event
Needle stick injury
OPEN WOUNDS SUSECTIBLE TO INF
High efficiency particulate arrestance
Serine c palitoyl tranferase
Operation room hazards AND PATIENT SAFETY
BY ABAYNEH BELIHUN
DEPARTMENT OF ANESTHESIOLOGY
• Hazard: a situation that poses a level of threat to life,
health, property, or environment.
• A hazard does not exist when it is not happening.
• Anesthesia and surgery are conducted in technologically
intense envt……potentially hazardous.
The most common hazards in OR
• Fires and Explosion
• Static Electricity
• Electrical Hazards
• Radiation Injury
• Air Pollution and
• Power Failure
• Both of these can cause death or injury to the patient.
• Only occur if we have 3 things:
– spark or a hot surface,
– flammable substance and
– source of oxygen
Sources of sparks or heat
– Static electricity
– Faulty electrical switches and apparatus, e.g. saws, plaster cutters and
– Foreign matter, e.g. dirt or grease in the oxygen or nitrous oxide
– Open flames.
• Flammable substances: Includes ether, ethyl chloride and solution in
sprits. The addition of oxygen increased flammability.
Static electricity 1
• Electricity present in the atm.
• Occurs if two materials which conduct
electricity poorly are brought into contact and
• If there is friction or movement between the
two, a spark is produced and a spark, of course,
can produce an explosion.
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.
OTHER PRECAUTIONS TO REDUCE STATIC ELECTRICITY 1
• 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 anti-static boots or conductive canvas
• Maintain humidity of 60%. Static sparks are more
frequent when the air is dry.
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 switch &
• Firefighting equipment should always be
• Smoking and open flames must be forbidden
Electrical hazards 1
• They may occur when patients are:
– In contact with faulty electrically-operated medical
– Accidentally connected to electric circuits by spillage of
blood or saline
– Dependent on electrical equipment to replace or support
vital organ functions
– Exposed to fire or explosions
– Undergoing treatment when safe levels of electrical energy
Electrical hazards 2
• When the body actually 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
Electrical hazards 3
• 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 60mA- muscular contraction
• @100mA- breathing becomes extremely difficult.
• Somewhere above this level respiratory paralysis,
cardiac arrest and severe burning occur.
Electrical hazards 4
• When very tiny currents, such as 100µA, are
intentionally passed directly thru heart muscle
– e.g. direct cardiac catheterization, CO measmt
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 50Hz) but can cause muscle contraction.
• Nerve damage often occurs with high currents.
• The SC may be involved by large currents passing from
head to foot or from arm to arm.
Electrical burns and electrically initiated burns
• Three types
– Carbonization of skin (from burns at very high
temperatures of 1,000°C)
– Flame burns
– Direct heating of tissues produce coagulation and
necrosis at entry and exit points and associated
injury in muscle and BV.
• 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
Air pollution 1
– Spontaneous miscarriage,
– Congenital abnormalities and
– Liver disorders.
• Waste anesthetic gases escape from:
– Faulty valves
– The ventilator
– Poorly fitted components in the breathing circuit
– Spilt anesthetic drugs
– Expired gases from the spill valve of the anesthetic breathing system
– Gases exhaled by the patient
• This pollution can be reduced by
– Regular thorough inspection of all anesthetic equipment
– Limit or avoid the use of inhalational gases and agents e.g., circle
system, TIVA and RA
– An efficient scavenging system.
– Closed circuits
– Anti spill devices
• 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 one risk of anesthesia).
Anesthesia risk and accidents
• Accident is an unplanned, unexpected, and undesired event
• Because there are no standard methods for assigning causality
yet, no accurate estimates of the rate of adverse out-come
• Errors related to AW mgt, monitoring, and sudden cardiac
arrest during SA, equipment failures, or nerve injuries.
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 2 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.
Failure to monitoring
• An important contributor to anesthesia adverse
• There are numerous ways in which pulse oximetry,
capnometry, and automated blood pressure
monitors can give false information, leading to
missed or incorrect diagnoses.
• The most frequent error in anesthesia, and in
healthcare practice in general.
• Similarity of drug names, containers, and label colors
• 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 drug (e.g., among various insulin formulations)
• Flushing a catheter with a solution containing another
• Confusion in the programming of infusion pumps
• Read the label carefully 3 times!
Errors in diagnosis
• Especially during the management of critical
Equipment errors and failures
• Current anesthesia machines and associated
technology incorporate 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.
lack of standard practice and unusual situations
• Accidental dislodgement of ETT during transportation
• Undiluted phenytoin by rapid IV infusion - refractory HN,
arrhythmias, and death.
• Undiluted K+ by rapid IV infusion - VF and cardiac arrest.
• Neostigmine given without an antimuscarinic cause
asystole/severe bradycardia and AV block, and can be fatal.
lack of standard practice and unusual situations
• Inadvertent IV injection of LA- neurologic and
cardiac toxicity, which can be fatal (especially
• 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
Summary of Risk Management
RISK IS UBIQUITOUS
Enhancing patient safety
11/23/2015 OR Hazard and strategies to enhence PS 35
• 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
• Patient safety is focused on prevention of injury.
• Quality assurance generally deals with the broader
spectrum of quality, including the success of
• Risk management is focused on proactive patient
safety, based on the principle that prevention of
injuries via error reduction and system
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,
• Being patient centered……..PATIENT IS ABOVE OUR EGO!
Practical elements 2
• 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.
Practical elements 3
• Practice in a system of care
• Control for human factors: organized arrangement
of supplies and drugs, esp labeling, and
establishing and adhering to local standards.
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
Anesthesia crisis management
11/23/2015 OR Hazard and strategies to enhence PS 41
• Seek assistance early and quickly inform others
• Establish clarity of roles for each person involved in mgt. of event
• Use effective communication processes
• Use resources effectively and identify what additional resource
(people, supplies, equipment, transportation) are available to
11/23/2015 OR Hazard and strategies to enhence PS 42
CRISS MANAGEMENT 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 Check rotameter settings; ensure inspired mixture is not hypoxic.
Adjust inspired oxygen concentration to 100%
Check that oxygen analyzer shows a rising oxygen concentration distal
to common gas outlet.
V1 Ventilation Ventilate lungs by hand to assess breathing circuit integrity, airway
patency, chest compliance, and air entry by “feel,” careful observation,
Also inspect capnograph’s trace if available
V2 Vaporizer Check all vaporizer filler ports, seating’s, and connections for liquid or
gas leaks during pressurization of the system.
Consider possibility of wrong agent being in vaporizer.
CRISIS MANAGEMENT DURING ANESTHESIA (CONT…)
E1 ETT check ET tube (if in use) Ensure no leaks or kinks or obstructions.
Check capnograp, oximeter for possible
E2 Elimination Eliminate anesthetic machine and ventilate with self-inflating
(e.g., Ambu) bag with 100%
Oxygen analyzer, capnograph, oximeter, blood pressure, ECG,
temperature and NMJ monitor)
R2 Review all
Review all other equipment in contact with or relevant to patient
(e.g., diathermy, humidifiers, heating blankets, endoscopes,
probes, prostheses, retractors…
CRISIS MANAGEMENT DURING ANESTHESIA (CONT…)
A Air way Check patency of non-intubated airway. Consider laryngospasm,
FB, blood, gastric contents, or nasopharyngeal or bronchial
B Breathing Assess pattern, adequacy, and distribution of ventilation. Consider,
examine, and auscultate for bronchospasm, pulmonary edema,
lobar collapse, and pneumo- or hemothorax
Repeat evaluation of peripheral perfusion, pulse, BP, ECG, and
filling pressures and any possible obstruction to venous return,
raised intra thoracic pressure (e.g., inadvertent PEEP)
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 manner of administration of drug
HAZARDS FOR ANASTHETISTS
• Fire & explosions
• Electrical accidents
• Pollutions by anesthetic agents
• Incompatibilities / allergies
• Chemical dependence
• Blood borne diseases thro’ Needle stick injuries- HIV:0.3%,
• 32% had at least 1 NSI in the preceding 12M.(only half of them
• More risk with hollow-core & large bore
• NSI more in non dominated hands
• NSI more during disposal of contaminated needles.
• Anesthesiologists have risk for occupational infection during
30years of exposure-0.045-4.5%
• Health care workers contribute 5% of total
• 4% of emergency department pts are
• Pts considered infective if both screening
(ELISA) & confirmatory (western blot, indirect
fluorescent ab) tests are positive.
• 54 reported cases of occupationally acquired
• 88% of them had H/O NSI
• ? Quantity of inoculums- ( a case report :100-200µml of blood
thro” i.v. produced HIV).
• Risk for the pts- 6 cases reported.
• Non immunized HCW- higher risks
• 17.8% 0f seropositive among anesthesiologist
• 30% became positive after 11 years of exposure
• Disinfectants & gloves are not completely protective-
viruses viable for >14 days in needles, gloves, & surfaces.
• No immunization available
• No specific treatment available
• Advice: serologic monitoring for HCV & LFT 3-
Management of occupational infections.
1. Protective equipments
2. Washing methods
3. Disposal methods
Infections - CDC recommendations
-considering as all pts, blood & body fluids are
-2 tier recommendations
1. Standard precautions -to be followed for handling all pts
2. Transmission based precautions -for handling pts known
to be / suspected of being risks.
Infections -CDC recommendations
Transmission based precautions
• Based on properties of specific pathogens
• Airborne precautions [measles, varicella, Tb] -to prevent from
small particles<5µm by specific filters air handling devices.-
HEPA, Negative pressure environment
• Droplet precautions [HBV, mycoplasma, streptococcal
pharyngitis, rubella]-to prevent from large particles>5µm, keep
• Contact precautions [HAV, HSV, viral conjunctivitis]
Incompatibilities / Allergies
• Type IV/ type I
• Risk groups :
1. Spina bifida,
2. Urogenital abnormalities ,
4. Rubber factory workers.
1. Identification of risk groups
2. Use latex free objects-latex free environment
3. Tests: RAST[radio-allergo-sorbent test]
Tests for anaphylaxis
• Preoperative protocol:
1. Dipenhydramine -1mg/kg,po/iv,q 6hr at 13,7,1hr before
2. Prednisolone -1mg/kg,po/iv,q 6hr at 13,7,1hr before
surgery or hydro cortisone 4g/kg
3. Ranitidine - 2mg/kg po, 1mg/kg iv,q 12hr at 13,1hr
• Postop protocol
-drugs to be repeated for 12hrs
• Inevitable, universal phenomenon to which no
one is immune
• Job related stress are unavoidable but may be
• 2 types-Unavoidable & Avoidable
• Unavoidable-professional stress
• Avoidable-sleep related
• Professional Stress
• Co-worker relationships
• Work load
• Peer review
• Professional dissatisfaction
• Administrative responsibilities
• Sleep related-altered sleep pattern, sleep
• Coincide with natural sleep peaks
• Identification of sleep disturbances
• Regulations of working hours
Self administration of drugs & suicide rates are high among
• 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, & functional changes.
• Dependence: physical / psychological inability to control drug
• Abuse :use of drugs in detrimental way but not to the point of
addiction. a pre addiction level, can easily quit. a voluntary act.
• Curiosity for experimentation
• Drug potency
• Others-genetic predisposition
11/23/2015 OR Hazard and strategies to enhence PS 64
• Safe anesthesia –third edition
• Ronald D Miller and Manuel C Pardo, Jr
• Airway management in emergencies, George Kovacs and J. Adam
• Clinical Anesthesiology, 4th Edition, G. Edward Morgan, Jr., Maged S.
Mikhail, Michael J. Murray
• Clinical Anesthesia, 5th Edition by Barash, Paul G.; Cullen, Bruce F.;
Stoelting, Robert K. 2006
• Miller’s Anesthesia, 7th edition by Ronald D. Miller, 2010
• Decontamination of medical equipment, update in anesthesia
content number 7, 1997