Educative in Anesthesia

1. GROUP ONE
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2. Outline
• Introduction
• General Considerations And Principles
• Anaesthesia for radiotherapy
• Computed Tomography (The General Principle, Anesthetic
Management
• Magnetic Resonance (The General Principle, Anesthetic Management
• Cardiac Catheterization
• Anaesthesia In Accident And Emergency Room
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3. INTRODUCTION
• Anesthesia outside the operating theatre suite is often challenging for
the anesthetist.
• Although the principles of remote site anesthesia are common to many
situations, each specialized environment poses its unique problems.
• In hospital the anesthetist must provide a service for patients with
standards of safety which are equal to those in the main operating
theatre department.
• Outside the hospital, this level of service may be more dependent on
location and available resources.
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4. General considerations and principles
1. Appropriate personnel.
Only senior experienced anaesthetists, who are also familiar with the particular
environment and its challenges, should normally administer anaesthesia outside
the operating room. Patients are often challenging, and additional skilled
anaesthetic help may not be readily available compared with an operating
theatre suite.
2. Equipment.
The remote clinical area may not have been designed with anaesthetic
requirements in mind and in general, conditions are less than optimal.
Nevertheless monitoring capabilities and anaesthetic equipment should meet the
minimum standard set by the Association of Anaesthetists as those used in the
operating department
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5. 3. Patient preparation.
Preparation of the patient may be inadequate because the patient is from a ward where
staff are unfamiliar with preoperative protocols, or patients may be unreliable, e.g.
those presenting for electroconvulsive therapy (ECT).
4. Assistance.
An anaesthetic assistant (e.g. operating department practitioner) should be present,
although this person may be unfamiliar with the environment. Maintenance of
anaesthetic equipment may be less than ideal.
5. Communication.
Communication between staff of other specialities and the anaesthetist may be poor.
This may lead to failure in recognizing each other’s requirements. Education
programmes for non-anaesthesia personnel regarding the care of anaesthetized
patients may be of benefit.
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6. . Recovery.
• Recovery facilities are often non-existent. Anaesthetists may have to
recover their own patients in the suite. Consequently, they must be
familiar with the location of recovery equipment including suction,
supplementary oxygen and resuscitation equipment.
• There should be a nominated lead anaesthetist responsible for remote
locations in which anaesthesia is administered in a hospital. This
individual should liaise with the relevant specialties (e.g. radiologists,
psychiatrists) to ensure that the environment, equipment and guidelines
are suitable for safe, appropriate and efficient patient care.
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7. Anaesthesia for radiotherapy Radiotherapy
Radiotherapy is used in the
management of a variety of
malignant diseases, some of which
occur in childhood. These include
the acute leukaemias, Wilms’
tumour, retinoblastoma and
central nervous system tumours.
High-dose X-rays are administered
by a linear accelerator, and all staff
must remain outside the room to
be protected from radiation
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8. Anaesthetic considerations
• ensure reliable i.v. access for a range of medications and blood
sampling.
• Agents such as ketamine are unsatisfactory because sudden
movements may occur, and excessive salivation may risk airway
compromise.
• No analgesia is required, and tracheal intubation is generally not
necessary. There is virtually no surgical stimulation, and patients may
be maintained at relatively light anaesthetic levels, allowing for rapid
emergence and recovery
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9. Magnetic RESONANCE
imaging
Magnetic resonance imaging
(MRI) is an imaging modality
that depends on magnetic
fields and radiofrequency
pulses to produce its images.
The imaging capabilities of MRI
are superior to those of CT for
examining intracranial, spinal,
and soft tissue lesions. It may
display images in the sagittal,
coronal, transverse or oblique
planes and has the advantage
that no ionizing radiation is
produced.
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10. Anaesthetic management
• Staff safety
• . Anaesthetists should also understand the consequences of
quenching the magnet and be aware of recommendations on
exposure and the need for ear protection
• All potentially hazardous articles should be removed (e.g. watches,
mobile telephones bleeps, pens and stethoscopes). Bank cards, credit
cards and other belongings containing electromagnetic strips become
demagnetised in the vicinity of the scanner, and personal computers,
pagers, mobile telephones and calculators may also be damaged.
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11. Patient safety.
Ferromagnetic objects within or attached to the patient pose a risk.
• Jewellery, hearing aids or drug patches should be removed.
• Absolute contraindications to MRI include implanted surgical devices
such as cochlear implants, intraocular metallic objects and metal vascular
clips.
• Pacemakers remain an absolute contraindication in most settings,
although MRI-conditional pacemakers have now been developed
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12. • Joint prostheses, artificial heart valves and sternal wires are generally
safe because of fibrous tissue fixation. Patients with large metal implants
should be monitored for implant heating.
• All patients should wear ear protection because noise levels may
exceed 85 dB.
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13. Equipment
• The magnetic effects of MRI impose restrictions on the selection of
anesthetic equipment. Any ferromagnetic object distorts the
magnetic field sufficiently to degrade the image. It is also likely to be
propelled towards the scanner and may cause a significant accident if
it makes contact with the patient or with staff. Equipment used in the
MRI scanner is designated ‘MR conditional’, ‘MR-safe’, or ‘MR-unsafe
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14. ANAESTHETIC CONCERNS
• 30% of Patients - Anxiety,
• 10% Severe Panic & Claustrophobia
• 14% require sedation.
• In most cases, sedation is usually provided by the Radiologist.
• Complex cases such as the Mentally Retarded, Obesity, Obstructive
Sleep Apnea, Raised ICP, Those Movement Disorders etc may need
anesthesia,
• Most children under 5 require sedation or General Anesthesia to
tolerate MR
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15. Anaesthesia Administration
• Induced outside MRI room
• Short-acting drugs for rapid recovery
• Sedation can be done however GA allows for a more rapid onset,
immobility guaranteed.
• Patient Transport and Safety
• Transport on MRI-appropriate trolleys
• Anaesthetist should ideally be in the control room, but in exceptional
circumstances be in the scanning room if well-protected
• If emergency arises, the anaesthetist needs to be aware of the procedure for
rapid removal of the patient into a save area.
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16. • ICU Patients and MRI
• Increasing need for MRI in ICU
• Careful planning and screening checklists necessary
• Infusion Management
• Non-essential infusions discontinued
• Essential infusions transferred to MRI-safe pumps
• Potential patient instability during transfer
• High vasopressor requirements may contraindicate
scanning
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17. • Equipment Precautions
• Secure tracheal tube valve spring away from scan area
• Remove pulmonary artery catheters with conductive wires and pacing
catheters
• Simple CVCs safe if disconnected from electrical connections
• Gadolinium Contrast Agent
• Generally safe with high therapeutic ratio
• Risk of nephrogenic systemic fibrosis in renal failure patients
• Caution in patients with GFR <30ml/min/1.73m², minimal contrast if
necessary, avoid repetition for 7 days
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18. Computed tomography
CT scans produce tomographic axial
slices of the body.
Images are created by computer
integration of radiation absorption
coefficients.
Brightness of areas on the image
corresponds to absorption values.
The gantry rotation produces axial
slices, or "cuts," typically at 7mm
intervals.
The circular scanning tunnel houses
the X-ray tube and detectors, with
the patient positioned in the center
during the scan.
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19. Anaesthetic management
• Computed tomography (CT) is non-invasive and painless for most adult
patients.
• Sedation or anesthesia is typically unnecessary, except for patients with
fears or anxieties.
• Some patients (pediatric, head trauma, or intoxicated) may require
sedation or general anesthesia to prevent movement.
• General anesthesia is preferred for patients with potential airway issues or
critical intracranial pressure (ICP).
• Airway management is crucial during CT scans, particularly when the
patient's head is inaccessible.
• Controlled ventilation is necessary for patients with high ICP, often using a
total intravenous technique with neuromuscular blockade.
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20. • Use of volatile anesthetic agents during scans is acceptable but may
require technique changes for patient transfer.
• Portable ventilators with end-tidal CO2 monitoring are preferable to
traditional breathing systems.
• Consider switching to piped oxygen supply for prolonged scans to
conserve oxygen.
• Ensure alarms and monitors have visual signals visible from the
control room if the anesthetist is observing the patient.
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21. Anaesthetic complications while in the CT
scanner include:
• kinking of the tracheal tube or disconnection of the breathing
system, particularly during positioning and movement of the gantry;
• hypothermia in paediatric patients;
• disconnection of drips and lines during transfer; and
• haemodynamic instability during movement on to the scanning table
(e.g. in the trauma setting)
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22. Anaesthesia in the Emergency Department
Anaesthetists’ involvement in the ED varies among hospitals,
depending on the skills of the resident ED medical staff. The following
clinical conditions usually require an anaesthetist to attend the ED:
• preoperative assessment and resuscitation before emergency
surgery (e.g. major trauma or ruptured aortic aneurysm);
• specialist airway management for a patient with respiratory failure or
acute airway compromise;
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23. Cardiac catheterization
• General anesthesia is essential for children due to their unique
physiological considerations.
• Congenital heart disease in children often presents with symptoms
like cyanosis, dyspnea, and failure to thrive.
• Diagnosis typically involves echocardiography, with cardiac
catheterization sometimes necessary for treatment planning.
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24. Anesthetic Techniques and Challenges
• An ideal anesthetic technique for pediatric congenital heart disease
aims to avoid myocardial depression, hypertension, and tachycardia.
• Techniques such as positive pressure ventilation and volatile agents
have limitations and may influence pulmonary hemodynamics.
• Monitoring ECG and invasive arterial pressure is crucial for rapid
assessment of arrhythmias and hypotension, especially with contrast
medium use.
• Polycythemia in cyanotic heart disease increases the risk of
thrombosis in children.
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25. • intensive care admission for a patient needing ventilatory and/or
other organ support;
• resuscitation as part of the cardiac arrest or trauma team;
• patients requiring specialist cannulation skills;
• anaesthesia for patients requiring procedures such as cardioversion
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26. Quality and safety in anaesthesia
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27. • Quality in healthcare is hard to define. One approach is based around
six goals: safety; effectiveness; patient focus; timeliness; efficiency;
and equity . Although errors and incidents are commonly discussed in
relation to safety, the same fundamental principles apply to all
aspects of healthcare quality
Introduction
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28. Aims of a high-quality healthcare system
1. Safe Prevention of injuries to patients from the care that
is intended to help them
2. Effective Provision of services based on scientific knowledge
to all who could benefit, and refraining from
providing services to those not likely to benefit.
3. Patient-centred Providing care that is respectful of and responsive
to individual patient preferences, needs and values,
and ensuring that patient values guide all clinical
decisions.
4.Timely Reducing waits and sometimes harmful delays for
both those who receive care and those who give it.
5. Efficient Avoiding waste, including waste of equipment,
supplies, ideas and energy.
6. Equitable Providing care that does not vary in quality because
of personal characteristics such as gender, ethnicity,
geographic location and socioeconomic status
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29. MEDICAL RECORDS AND DOCUMENTATION
•Definition
• An orderly written document encompassing the patient's
identification data, health history, physical examination findings,
surgical procedures, and hospital course.
• When complete, it should contain sufficient data to justify the
investigation, diagnosis, treatment, length of hospital stay, result
of care, future course of action.
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30. Benefits to Patient
• Document the history of a patient
• Avoids repetition of diagnosis & treatment
• Assists in the continuity of care in the event of future illness
• Serves an evidence to support or to refute the legal questions that arise
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31. • Benefits to Hospital
• Provides the management with statistical information necessary for
decision-making regarding the utilization of resources
• Furnishes documentary evidence for purposes of evaluation of hospital
care in terms of quantity, quality, and adequacy (medical audit)
• Protects the hospital in the event of legal action
Benefits to Public Health Authorities
• Gives morbidity & mortality statistics
• Helps PH Authorities to plan the prevention and social measures to meet
the needs of the community
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32. Medical Education & Research
• Since recorded observations and case studies are the basis of all
clinical research, medical records become invaluable in all research
and teaching programs
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33. Characteristics of Good MR
• Complete: sufficient data to identify the patient, justify diagnosis, and
warrant treatment and outcome
• Adequate: all necessary forms and all relevant clinical information
• Accurate: capable of quantitative analysis
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34. REVIEWING MEDICAL RECORDS- BASICS
• Biodata
• Name(s) of Surgeon/ Physician
• Dates and Time periods of appointment/ admissions
• History:
Presenting condition & concurrent medical
Anesthetic
Family
Drug
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35. Allergies
Smoking
Alcohol
OSA
• Review the information obtained from clinical examination that
confirms good health or otherwise and this should complement the
patient’s history and allows the anesthetist to focus further on
features of relevance.
Other Consult/ Investigations
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36. Peri-operative anesthesia audit
• A perioperative anesthesia audit is a systematic review and evaluation
of anesthesia practices and outcomes in the perioperative period,
which includes the preoperative, intraoperative, and postoperative
phases of patient care. The goal of such an audit is to assess the quality
of anesthesia care provided to patients undergoing surgery or other
invasive procedures and to identify areas for improvement.
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37. STEPS
1. Define the audit objectives: Determine the specific goals and
objectives of the audit, such as assessing adherence to anesthesia
guidelines, evaluating patient outcomes, or identifying opportunities
for process improvement.
2. Select audit criteria: Decide on the specific criteria or standards
against which the anesthesia practice will be evaluated. These criteria
may include factors such as preoperative assessment, anesthesia
technique, intraoperative monitoring, postoperative pain management,
and complications
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38. 3. Collect data: Gather relevant data from patient records, anesthesia
charts, electronic medical records, and other sources. The data
collected may include patient demographics, preoperative
assessments, anesthesia techniques used, intraoperative monitoring
data, postoperative pain scores, and any complications or adverse
events.
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39. 4. Analyze data: Analyze the collected data to assess adherence to the
audit criteria and identify any deviations or areas of concern. This
analysis may involve statistical methods, such as calculating compliance
rates or comparing outcomes against established benchmarks.
5. Interpret findings: Interpret the audit findings to understand the
implications for patient safety and quality of care. Identify any trends,
patterns, or specific areas where improvements can be made.
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40. 6. Develop recommendations: Based on the audit findings, develop
recommendations for improving anesthesia practices and patient care.
These recommendations should be practical, evidence-based, and
address the identified areas for improvement.
7. Implement changes: Work with relevant stakeholders, such as
anesthesia providers, surgeons, nurses, and hospital administrators, to
implement the recommended changes in anesthesia practices. This
may involve updating protocols, providing additional training or
education, or making changes in equipment or resources.
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41. 8. Monitor outcomes: Continuously monitor and evaluate the impact
of the implemented changes on anesthesia practices and patient
outcomes. This may involve conducting follow-up audits or tracking
specific quality indicators over time.
By conducting perioperative anesthesia audits, healthcare
organizations can identify opportunities for improvement, enhance
patient safety, and optimize perioperative care delivery. It is important
to involve a multidisciplinary team of healthcare professionals in the
audit process to ensure comprehensive evaluation and implementation
of changes.
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42. CRITICAL INCIDENT REPORTING IN ANAESTHESIA:
A critical incident in anaesthesia is defined as any untoward and
preventable mishap associated with the administration of general or
regional anaesthesia, and which leads to or could have led to an
undesirable patient outcome
•Near miss: an event that has the potential to lead to a substantial
negative outcome if left to progress
•Never event: serious, largely preventable patient safety incidents that
should not occur if relevant preventive measures have been put in
place
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43. Causes Of Critical Incidents
• Contributory factors: patient, surgery or anaesthesia
• Anaesthesia-related critical incidents may be due to human
errors, equipment errors, or pharmacological factors.
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44. Human Errors
•Due to active or latent failures
•Active failures: unsafe acts or omissions performed by front-end workers i.e.
anaesthetists, surgeons, nurses
— Slips: wrong label/syringe
— Cognitive failure: memory lapses, ignorance, misreading a situation
— Violations: deviations from safe practices, procedures or standards
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45. Latent failures: decisions taken by senior management or clinicians,
which create the conditions in an organization for unsafe acts to occur
— Inadequate or inappropriate staffing
— Heavy workload
— Poor supervision
— Stressful environment
— Poor communication
— Poor maintenance of equipment
— Conflict of priorities (finance vs. clinical need)
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46. Drug Errors
•Definition: error in the prescription, dispensing, or administration of a
medication with the result that the patient fails to receive the correct
drug or the indicated proper drug dosage
•Drug errors could be inappropriate dosing, wrong sequence of
administration, administration of a drug different from what was
intended, or administration of a drug to which the patient is allergic to
•Commoner during general anaesthesia than during regional
anaesthesia because fewer drugs are used for regional than for general
anaesthesia
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47. Risk Factors for Drug Errors
• Inadequate total experience
• Inadequate familiarity with
equipment or device
• Poor communication with team
• Haste
• Inattention/carelessness
• Fatigue
• Failure to perform normal check
•Lack of supervision
• Inadequate familiarity with
surgery
• Inadequate familiarity with
anaesthetic technique
• Distraction
• Poor labeling of drugs
• Apprehension
• Demanding or difficult case
Emergency case
• Boredom
• Insufficient preparation
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48. Prevention of Drug Errors
• The label on any drug ampoule or syringe should be read carefully
before the drug is drawn up or injected.
• Legibility and contents of labels on ampoules and syringes should be
optimized according to agreed standards with respect to font, size,
colour and information.
• Syringes should always be labelled
• Double checking of ampoules, syringes and equipment before starting
the procedure
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49. • Labels should be checked specifically with the help of a second person or a device like
bar code reader before administration
• Error during administration should be reported and reviewed
• Management of inventory should focus on minimising the risk of drug error
• Look-alike packaging and presentation of the drug should be avoided where possible
• Drug should be presented in prefilled syringes rather than ampoules
• Drugs should be drawn up and labelled by the anaesthesia provider himself/herself
• Colour coding by class of drugs should be according to an agreed national or
international standard
• Coding of syringe according to position or size
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50. Incident Reporting Systems
• The main reason for reporting incidents to improve patient safety is
the belief that safety can be improved by learning from incidents and
near misses, rather than pretending that they have not happened
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51. Barriers and Enablers to Incident Reporting
• Under-reporting, in particular by doctors, remains a significant
problem
• Unfamiliarity with the process
• Cultural issues: fear of punitive action, legal ramifications, workplace
discrimination
•Poor reporting practices by doctors: only bad doctors make mistakes
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52. ANAESTHESIA RESEARCH
Anesthesia research encompasses a wide range of studies focusing:
• on improving techniques,
• safety and outcomes related to anesthesia administration.
• drug interactions,
• patient monitoring,
• pain management,
• long-term effects of anesthesia.
It's a critical field that constantly evolves to enhance patient care and
surgical procedures.
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53. • 1. Patient Safety Measures: Research focuses on identifying and
implementing safety measures to prevent adverse events during
anesthesia. This includes studying protocols for preoperative patient
assessment, medication safety, infection control, and prevention of
perioperative complications.
• 2. Anesthesia Monitoring: Studies are conducted to evaluate the
effectiveness and reliability of various monitoring techniques used
during anesthesia, such as blood pressure monitoring, pulse oximetry,
capnography, and depth of anesthesia monitoring
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54. • 3. Medication Safety: Research investigates strategies to improve
medication safety in anesthesia, including proper drug selection,
dosage calculation, drug administration techniques, and monitoring for
potential drug interactions or adverse drug reactions.
4. Team Communication and Collaboration: Research examines
communication and teamwork among anesthesia providers, surgeons,
nurses, and other healthcare professionals in the perioperative setting.
The focus is on identifying effective communication strategies,
enhancing interdisciplinary collaboration, and reducing errors caused
by communication breakdown
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55. • 5. Simulation Training: Simulation-based training is used to improve
anesthesia providers' skills, decision-making, and crisis management
abilities. Research explores the use of simulation in anesthesia
education and training, including the development of realistic
scenarios, assessment of performance, and the impact of simulation
on patient outcomes.
• 6. Quality Improvement Initiatives: Research investigates quality
improvement initiatives in anesthesia, such as the implementation of
clinical guidelines, protocols, and checklists. These initiatives aim to
standardize practice, reduce practice variation, and improve patient
outcomes by incorporating evidence-based practices into routine
care.
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56. • 7. Adverse Event Reporting and Analysis: Studies focus on the analysis
of adverse events and near misses in anesthesia, aiming to identify
contributing factors, patterns, and opportunities for improvement. This
includes the development of reporting systems, analysis of root causes,
and implementation of strategies to prevent similar events in the future.
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57. • 8. Technology and Innovation: Research explores the use of new
technologies, such as electronic health records, decision-support
systems, and telemedicine, to enhance patient safety and improve
anesthesia care delivery. This includes evaluating the benefits,
challenges, and the impact of technology on anesthesia practice and
patient outcomes.
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58. • These are just a few examples of the research areas in quality and
safety in anesthesia. Ongoing research in this field is crucial to
advancing patient safety, optimizing anesthesia practices, and
improving the overall quality of care in the perioperative setting
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59. References
1.Textbook for Anaesthesia 7th Edition
Author: Alan R. Aitkenhead, Lain Moppett, Jonathan Thompson
Publisher: Churchill Livingston
2.Synopsis of Anaesthesia 13th Edition
Author: Nicolar J. H Davis, Jeremy N. Cashman
Publisher: Butterworth Heinemann
3.Millers Anaesthesia 8th Edition
Author: Ronald D. Miller, Neal H. Coheir, Lars I. Eriksson
Publisher: Elsevier
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60. Group members
1. MAVIS NOI SOAK/2022/R025
2. EMMANEL KURU AYAABA SOAK/2022/R021
3. PHILEMON ASHANTE AHIABLE SOAK/2022/R004
4. FRANCIS YEBOAH SOAK/2022/R041
5. FELIX TENGAN SOAK/2022/R038
6. SAMUEL K DAMOAH SOAK/2022/R015
7. YAMINU IDDRISU SOAK/2022/R020
8. BARIKISU MAHAMUD SOAK/2022/R022
9. PRINCE OBENG SOAK/2022/R026
10. JOACHIM KWAKU ASARE SOAK/2022/R010
11. COMFORT BAMFOAH AKOSUAH SOAK/2022/R013
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