Safe Anaesthesia practice- Current Trends

Dr Surjya Prasad UpadhyaySpecialist Anaesthesiology

NM hospital DIP

Safety? Whose safety?

Anesthesia is an area in which very impressive improvements in safety have been made. The Institute of Medicine; (National Academy of Medicine)

How safe is surgery and anesthesia?

1 death per 5,000 anesthetics administered during the 1970s, to 1 death per 200,000-300,000 in 1999.

Today’s surgical patients are sicker and aged than ever.

5% of all surgical patients die within one year of surgery.

Surgical Patients over 65 years, 10% die within one year of surgery.

Dr. Jeana Havidich; 2014 ASA Convention:

3.2 million anaesthesia case data: 2010-2013.

Complication rate: decreased from 11.8 percent to 4.8 percent

Evening or holiday procedures: no increase in complications

Healthier patients having elective daytime surgery: highest minor

complications

Serious complications highest in pt >50 years

Complications of anaesthesia

Major Complications Minor complicationsCardiac arrest

Peioperative MI

Aspiration

Anaphylaxis

Drug overdose/ toxicity

Awareness

Convulsion

Nerve palsies

Organ injury-

Malignant hyperthermia

Airway obstruction

Post op Nausea / vomiting

Sore throat

Persistent sedation

Haemodynamic instability

Pneumonia

Delirium

Shivering

Organ dysfunction- kidney/liver

Cognitive defect

10 common causes of cardiac arrest under anaesthesia

1. Drug overdose/ adverse reaction

2. Rhythm disturbances

3. Peri-op MI

4. Airway obstruction

5. High spinal

6. Lack of vigilance

7. Bleeding

8. Over-dosage of inhalation agent

9. Aspiration

10.Technical problem in anaesthesia system

Anaesthesiology: A High risk Speciality

Anaesthesiology is a high-risk speciality as compared with other specialities in medicine

Anaesthesia Vs Aviation industry The safety of airline travel-highest:

Increased in air traffic density; More take-offs and landings with

less separation between aircraft.

Practice of anesthesiology similar like aviation:

Take off and landing: similar to induction and recovery

Increased No of Surgical patient; diverse age group;

Increasing co-morbidities; complex surgical procedure.

Fatal accident/ complications still happened.

Lets look at the mortality from Anaesthesia

In 1950: 3.7 in 1000 anaesthetics 1980: 1 in 10,000 anaesthetics 2000: 1 in 300,000- anaesthetics

Mortality: GA Vs RTA Now Lets Compare the Mortality from GA with an

event that anyone, anywhere on this Mother earth can face

So, A patients has HIGHER chances of dying from RTA than from exposure to General Anaesthesia.

2013: WHO released “Global Status report on road safety;

RTA mortality 18 per 100,000 people/year

Mortality From GA: 1 in 300,000

GA Vs RTA

What makes anaesthesia safe ?

What makes anaesthesia safe ? Monitoring equipments

Safer drugs, equipment

Advanced in airway management

Anaesthetist skill and knowledge

Guideline and protocol: EBM

Surgical skill

Factors influencing risk of Anaesthesia?

Patient status: age, co-morbidities

Procedure –: urgency, invasive

Facility: resources, equipment, monitoring

Skill/ expertise- anaesthetist, surgeon

Readiness, fatigue of the physicians

Where Safety Starts ?Where Safety Starts ?

Patient

Facilities, Equipment, and Medications Anaesthetist’s Skill

Surgeon’s Skill

Survival DependsSurvival Depends..............

Facilities, resources; Equipment, and Medications Quantity and Quality

Anaesthetist Skill

HELP

Referal

10%

20%

60%

10%

Safe Anaesthesia Practice

Protocol

Crisis management / guideline

Training / skill development/ updation- CPD activities

Evidence based medicine; Transforming evidence into practice

The goal is to provide highest standard of care and safety in any setting

International Task Force on Anaesthesia Safety And Approved by World Federation of Societies of Anaesthesiologists (WFSA)

HIGHLY RECOMMENDEDHIGHLY RECOMMENDED

Minimum standards that would be expected in all anaesthesia care for elective surgical procedures

“Mandatory" standards

Mandatory standardMandatory standard

Pre-anaesthesia checks/ Care

Safe Conduct of anaesthesia

Monitoring during anaesthesia

Post Anaesthesia Care

Pre-anaesthesia checksPre-anaesthesia checksCheck patient risk factors

ASA 1 2 3 4 5 6 EAirwayMallampati Aspiration risk?Allergies?Abnormal investigations?Medications?Co-morbidities?Formulate anaesthetic plan

Pre operativePre operative CounselingCounseling

Associated risk - Possible complication - Remote complication

Anaesthesia plan:

- GA

- Regional

Postop care

- Pain management

- post-op monitoring/ care

Check resources? Before starting Anaesthesia

Choice of Anaesthesia Judged by type of patient / procedure/ facility Chose the Simplest and safest technique Variety of options available

- LA

-LA + Sedation

-Regional +/- sedation

- GA with LMA/i-gel

- GA with ETT

- GA + Regional combination Try to minimise the multiple combinations

Standard monitoring recommended by ASA

MedicationMedication Human error: most common All drugs should be clearly labelled; cross check before

administering

Unanticipated Difficult Airway Unanticipated Difficult Airway

Post-anaesthesia Care

Facilities and personnels Monitoring Pain relief Discharged criteria

Documentation: Legal aspects

Post CrisisPost Crisis

Avoid blame cultureDevelop Help Culture

Post Crisis: Recommendations for colleaguesPost Crisis: Recommendations for colleagues

Be aware that such an adverse event could happen to you also

Discuss with your colleague or seniors. This is not weakness. This represents appropriate professional behaviour

Listen to what your colleague wants to tell and support him/her with your professional expertise

A professional work-up of that case based on fact is important for analysis and learning out of medical error.

Senior/ colleague should offer support in discussing and briefing with patient/relative after an medical error.

Changing definition of Anaesthesia

Word anaesthesia was coined from two greek words: “an” meaning without and “aesthesis” meaning sensation.

Traditionally the goal of anaesthesia were described as Amnesia, analgesia, and muscle relaxant.

More recently, Anaesthesia can be considered as a science of reflex management.

Aims of General Anaesthesia In real there are Only 2 aims of GA

1. Narcosis: unrousable unconsciousness

2. Reflex Depression:

Reflexes may Motor : Movement, coughing Autonomic reflexes Cardiovascular: BP, HR changes Neuro-endocrine: Cortisol, vasopressin

ANAESTHESIA“A Modern Concept”

Reflex depression: Main aim of general anaesthesia Consciousness and reflex depression act in different level. Reflex depression has nothing to do with consciousness Amnesia and muscle relaxation are desirable but not mandatory

for GA.

Genera Anaesthesia can thus be defined as:

A reversible iatrogenic state characterised by unrousable unconsciousness and reflex depression.

Present Global scenario Anaesthesiologist no more confined to operative room only Perioperative physician Emergency / ICU care / trauma Pain physician Palliative care provider Evidence based practice of some perioperative issues and

Current trends in Anaesthesia perioperative care

Reducing aspiration risk (fasting guideline)

Infant and children: formula milk- 6 hrs Breast milk: 4 hrs Clear fluid: 2 hrs

Adult Heavy meal: 8 hrs Light meal 6 hrs Clear fluid: 2 hrs

All Trauma patients;Pregnant Patient in labour:

Considered to be full stomach

Obese Diabetic

Pt with GERDHiatus Hernia

Considered to be high risk for aspiration:Gastroprophylaxis even in full fasted state

Restrictive Vs liberal fluid

Rational use of Blood

Postoperative pain Multimodal Analgesia

Preemptive/ preventive analgesia

Avoidance of Opioids

Greater use of regional Anaesthesia technique

Regular analgesic- No SOS or PRN dosing for pain

Individualised treatment

Identify problematic patient; formulate a pain management plan

Why Opioid free analgesia? PONV-- delay start of feeds

Bladder/ bowel function

Sedation: delayed mobilisation; discharge Respiratory: Obstructive breathing, Silent aspiration, Postoperative

pulmonary complications.

Immuno - suppressant effects- would infection. Cancer recurrence/ metastasis Persistent post-op pain into chronic pain

Hypothermia:peri-operative morbidity/mortality

Consequences of hypothermia

Shivering/oxygen requirement increased: myocardial oxygen supply /

demand

Infection: Directly depress immune function, Vasoconstriction-

reduced tissue oxygen- predispose to infection

Delay would healing

Bleeding / transfusion: Depressed platelet and coagulation

Depressed Cardiac function and risk for arrythmias

Delay recovery from anaesthesia

Oxygen therapy (hyperoxia) No evidence that hyperoxia reduces surgical infection

AVOID trial: Air Vs oxygen in MI; Harm by excess oxygen

Pao2 independent predictor of mortality after stroke in ventilated pt. (Crit Care Med. 2014 Feb;42(2):387-96.)

Hyperoxia; not good for pulmonary physiology:

Targeting normal SPO2 by giving high oxygen in ARDS- worse

outcome. (Ann Am Thorac Soc. 2014 Nov;11(9):1449-53)

Routine supplementation of oxygen in postop: may be more harmful

than benefit

Postoperative infection: Anaesthetic role

Antibiotic prophylaxis Hand hygiene Aseptic precaution for invasive procedure Glycemic control Avoidance of hypothermia Fluid and blood product Oxygen- avoiding hypoxia / hyperoxia Regional anaesthesia technique

Anaesthesia Future prospective

Surgical revenue: major portion of hospital revenue:

Perioperative Physician / leader: perioperative coordinator

Anaesthesiologist: identify and correct perioperative risk;

improve outcome and pt satisfaction

Surgeon: focus on new and more specialised technical

procedure

Uncontrolled pain- patients' dissatisfaction in hospitals.

As anesthesiology, we know pain and how to treat it.

Safety first Unless Safe Anaesthesia is provided--> Safe Surgery will not

be Possible and -->Safety of Patient cannot be ensured.

So, Safe Anaesthesia-->Safe surgery-->Safe Patient

SAFE ANAESTHESIA PRACTICE SAFE ANAESTHESIA PRACTICE

Thank youThank you