Safe Anaesthesia practice- Current Trends
Dr Surjya Prasad Upadhyay
Specialist 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 complications
Cardiac arrest Airway obstruction
Peioperative MI Post op Nausea / vomiting
Aspiration Sore throat
Anaphylaxis Persistent sedation
Drug overdose/ toxicity Haemodynamic instability
Awareness Pneumonia
Convulsion Delirium
Nerve palsies Shivering
Organ injury- Organ dysfunction- kidney/liver
Malignant hyperthermia 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
GA Vs RTA
2013: WHO released “Global Status report on road safety;
RTA mortality 18 per 100,000 people/year
Mortality From GA: 1 in 300,000
So, A patients has HIGHER chances of dying from RTA than
from exposure to General Anaesthesia.
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 ?
Patient
Surgeon’s Skill
Facilities, Equipment, and Medications Anaesthetist’s Skill
.......Survival Depends
Referal
10%
HELP 10%
20%
Anaesthetist Skill
60%
Facilities, resources; Equipment,
and Medications Quantity and Quality
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 RECOMMENDED
Minimum standards that would be expected in
all anaesthesia care for elective surgical
procedures
“Mandatory" standards
Mandatory standard
Pre-anaesthesia checks/ Care
Safe Conduct of anaesthesia
Monitoring during anaesthesia
Post Anaesthesia Care
Pre-anaesthesia checks
Check patient risk factors
ASA 1 2 3 4 5 6 E
Airway
Mallampati
Aspiration risk?
Allergies?
Abnormal investigations?
Medications?
Co-morbidities?
Formulate anaesthetic plan
Pre operative Counseling
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
Medication
Human error: most common
All drugs should be clearly labelled; cross check before
administering
Unanticipated Difficult Airway
Post-anaesthesia Care
Facilities and personnels
Monitoring
Pain relief
Discharged criteria
Documentation: Legal aspects
Post Crisis
Avoid blame culture
Develop Help Culture
Post 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: All Trauma patients;
formula milk- 6 hrs Pregnant Patient in labour:
Considered to be full stomach
Breast milk: 4 hrs
Clear fluid: 2 hrs
Adult Obese
Diabetic
Heavy meal: 8 hrs Pt with GERD
Hiatus Hernia
Light meal 6 hrs Considered to be high risk for aspiration:
Clear fluid: 2 hrs 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
Thank you
