1. The document discusses optimizing teamwork through developing shared mental models, mutual trust, closed-loop communication, and other behaviors and coordinating mechanisms that enable effective teamwork. 2. It presents a model of the "Big Five" behaviors and coordinating mechanisms required for effective teamwork, including team leadership, team orientation, mutual performance monitoring, backup behavior, and adaptability. 3. The document provides guidelines for the immediate management of anaphylaxis during anesthesia, including securing the airway, administering IV fluids and drugs like adrenaline, and establishing an adrenaline infusion if needed. It outlines treatment approaches based on the severity of the reaction and the patient's age.

1. Optimising Teamwork
A/Prof Stuart Marshall
@hypoxicchicken
Slideshare.net/StuartMarshall15

3. Non-Technical Skills
Cognitive
Social
Personal resource

5. Shared Mental Models
Mutual
Trust
Closed Loop
Communication
Effective Teamwork
Team
Leadership
Team
Orientation
Mutual
Performance
Monitoring
Adaptability
Backup
Behaviour
Adapted from Salas, Sims and Burke, 2005. “Is there a ‘Big Five’ in Teamwork.” Model represents the ‘Big
Five’ behaviours (green) and the Co-ordinating Mechanisms (blue) required for Effective Teamwork (yellow).
The ‘Big Five’ of Effective Teamwork Model

6. Team members
Stress inoculation
Guided error
Speaking up

7. Cross training

8. Team self-correction
Translational simulation

13. Anaphylaxis during Anaesthesia
Immediate Management
Draft Anaphylaxis Management Guidelines 2012 v6
Danger and Diagnosis
Response to stimulusDR
AB
B
Secure Airway
Breathing - 100% oxygen
C Circulation: CPR if no pulse
Give IV fluid bolus
D
Drugs: Adrenaline
IV Bolus, repeat if needed
Prepare Infusion
Unresponsive hypotension or bronchospasm
Cease triggers including latex and colloid
Stop procedure. Use minimal volatile if GA
Call for Help and Anaphylaxis box
Assign a designated Leader and Scribe
Assign a Reader of this card
If no pulse give 1mg Adrenaline IV
(Paed 10 mcg/kg) and follow ALS protocol
IV Fluid: 20mls/kg bolus repeat as required
(Colloid if not in use at time of reaction)
IV Adrenaline BOLUSES
Draw up 1mg in 10ml
Adrenaline (1:10,000) = 100mcg/ml
Give dose below every 1-2 minutes prn:
Grade 2 – Moderate
Hypotension or
Bronchospasm
Grade 3 - Severe
Hypotension or
Bronchospasm
Adult 5-20 mcg
= 0.05 - 0.2 ml
Adult 100-200 mcg
= 1 - 2 ml
Child 1 - 5 mcg/kg
= 0.01 - 0.05 ml/kg
Child 5 - 10 mcg/kg
= 0.05 - 0.1 ml/kg
No IV access or haemodynamic monitoring:
IM Adrenaline
1:1000 (1mg/ml) into lateral thigh
Adult = 0.5ml (500mcg)
<12 years = 0.3ml (300mcg)
<6 years = 0.15ml (150mcg)
Intubation: airway oedema or compromise
Confirm FiO2 is 100%
S Send for help and
organise team
Adrenaline INFUSION If requiring repeated doses of Adrenaline prepare and start infusion:
Adult 0.05 to 0.4 mcg/kg/min Child 0.1 to 5 mcg/kg/min
Infusion Preparation (3mg/50mls or 6mg in 100mls = 60mcg/ml) Infusion Rate (1ml/hour = 1mcg/min)
If NOT RESPONDING see ‘Refractory Management’
Anaphylaxis during Anaesthesia
Immediate Management
Unresponsive hypotension or bronchospasm
Stop procedure. Cease triggers including latex and colloid. Use minimal volatile if GA
Call for Help and Anaphylaxis box
Assign a designated Leader and Scribe. Assign a Reader of this card
Give 1mg Adrenaline IV
(Paed 10 mcg/kg) and follow ALS protocol
Intubation: airway oedema or compromise
100% Oxygen and Confirm FiO2 is 100%
If NOT RESPONDING see ‘Refractory Management’
CARDIAC ARREST?
AIRWAY COMPROMISED?
HYPOTENSIVE? IV Fluid: 20mls/kg bolus repeat as required
(Colloid if not in use at time of reaction)
BOLUS ADRENALINE
IV or IM (if no IV access or haemodynamic monitoring
ADULT WITH MODERATE
HYPOTENSION/BRONCHOSPASM
iv. 5-20 mcg (0.05 – 0.2ml of
1:10,000 adrenaline 1mg/10ml)
OR im 500mcg into lateral
thigh
ADULT WITH SEVERE
HYPOTENSION/BRONCHOSPASM
CHILD WITH MODERATE/SEVERE
HYPOTENSION/BRONCHOSPASM
iv. 100-200 mcg (1 – 2ml of
1:10,000 adrenaline 1mg/10ml)
OR im 500mcg into lateral
thigh
iv. 1-10 mcg/kg (0.01 –0.1ml/kg
of 1:10,000 adrenaline)
OR im 150mcg (300mcg if over
12 years old) into lateral thigh
YES
YES
YES
NO
NO
NO
Repeat doses of Adrenaline 1-2 minutes prn. Consider starting an infusion (3mg/50mls or 6mg/100mls)
Adult 0.05-0.4mcg/kg/min Child 0.1-5mcg/kg/min (1ml/hour = 1mcg/min)

14. Marshall et al Anaesth. 2016
Kolawole et al Anaes. Int. Care 2017

16. Marshall, Mehra Anaesth. 2014

18. Teams
Change outcomes
Can be trained
Can be supported

19. References
• Salas E, DiazGranados D, Klein C, Shawn-
Burke C, Stagl KC, Goodwin GF Does team
training improve team performance? A meta-
analysis. Human Factors 2008; 50: 903-33.
• Schmutz J, Manser T Do team processes really
have an effect on clinical performance? A
systematic literature review. British Journal of
Anaesthesia 2013; 110: 529-44.
• Salas, E., D. Sims, and C. Burke, Is There A
"Big Five" In Teamwork? Small Group
Research, 2005. 36(5): p. 555-599.
• ANZAAG. Anaphylaxis management
guidelineswww.anzaag.com/Mgmt%20Resourc
es.aspx
• Marshall SD, Torrie J, Schnittker R. Human
Factors. In: Riley R, ed. EMAC course
participant manual. Melbourne, Australia:
Australian and New Zealand College of
Anaesthetists, 2017.
• Draycott T, Sibanda T, Owen L, Akande V, Winter
C, Reading S Does training in obstetric
emergencies improve neonatal outcome? .
BJOG: An International Journal of Obstetrics and
Gynaecology 2006; 113: 177-82.
• Marshall SD, Sanderson P, McIntosh C, Kolawole
H The effect of two cognitive aid designs on team
functioning during intra-operative anaphylaxis
emergencies: a multi-centre simulation study.
Anaesthesia 2016; 71: 389-404.
• Kolawole H, Marshall SD, Crilly H, Kerridge RK,
Roessler P ANZAAG/ANZCA Perioperative
Anaphylaxis Management Guidelines. Anaesth
Intensive Care 2017; 45: 151-8.
• Marshall SD, Mehra R The effects of a displayed
cognitive aid on non-technical skills in a
simulated 'can't intubate, can't oxygenate' crisis.
Anaesthesia 2014; 69: 669-77.

20. Photo acknowledgements
• Slides 1, 8, 11 and 18
NASA photo archives
(spaceflight.nasa.gov)
• Slides 3, 8 Photo Piron
Guillaume
(unsplash.com)
• Slide 6: Inoculation of a
child for typhoid, Texas
1943 John Vachon
• Slide 7 RhondaK on
unsplash.com
• Slides 14, 16 With
written permission of
research participants
• Slides 13, 15 Courtesy
ANZAAG and ANZCA