Crisis management Flashcards

Question

Approximately what proportion of cases of AAGA in NAP5 occurred during emergence or extubation?

Answer 1

approx 1/3

Answer 2

Early identification & supportive intervention at the time & after can optimise long term psychological consequences (pts experiencing AAGA are at risk of adverse psych consequences incl PTSD) MITIGATION of intra-op distress If awareness suspected intra-op, the anaesthetist should speak to the patient & provide reassurance that the anaesthetist knows pt may be aware & is addressing it, eg "I realise you are awake & cannot move. This is because of the effect of one of the drugs given to you. Don't worry; you are quite safe I am helping you with your breathing, though this may feel strange, and I am giving you some anaesthetic drugs so that you will become unconscious very soon". MEETING listen, be sympathetic & promise to investigate the cause of why the experience may have happened to help prevent it happening again to them or another pt express regret that the event happened (this does not constitute an admission of liability) consult with clinical psychologist ANALYSIS At the meeting it's important for the pt & anaesthetist to either verify or exclude a diagnosis of AAGA (eg. how plausible is the account)- classify as per NAP 5 categories (eg. probably or unlikely). analyse chart/comments. Grade degree of evidence. NAP provides standardised & structured grading of: classification (probability), degree of supporting evidence, immediate experience as per Michigan classification & longer-term impact. Info analysed by a small group with appropriate training, providing an unbiased opinion re: classification, impact & likely causality. SUPPORT Seek signs of impact early. Review within 24hrs, ideally in person. aim to detect the 4 cardinal signs of impact: (i) flashbacks (ii) nightmares (iii) any new anxiety state (iv) symptoms of depression early referral to psychologist or psychiatrist is advised if early symptoms are concerning or approach uncertain. If pt was mistaken (eg. thought that immediate postop events were intra-operative), address gently with care & understanding. further equivalent follow-up at 2/52, even if true AAGA unlikely, NAP5 showed that pt interpretation is important & impact of unpleasant periop experiences may be severe & they may still need psychological support. If PTSD-type reactions occur, should be treated either with trauma-focused CBT or eye-movement desensitisation & reprocessing. If none of the 4 cardinal signs of impact, pt encouraged to make contact later if concerns. Consideration of open disclosure, M&M/QI processes if unexpected error, WebAIRS to encourage the process of learning from events.

Answer 3

declare crisis & call for help + MH box while simultaneously: -stopping volatile & removing vaporiser -hyperventilating (flow >10L/min) with 100% O2 -dantrolene IV 2.5mg/kg 10-15 minutely until crisis over (may need to mobilise supplies- 20mg vial mixed with 60mL sterile water) -don't waste time changing circuit but change to TIVA, apply activated charcoal filters if available to both limbs of circuit -actively cool if temp >38.5degC- intra-abdo lavage with saline @ 4degC, cool IV fluids, cool sponging & ice packs, lower OT temp -insertion of art line+/-CVC -treat hyperkalemia, acidosis (consider 8.4% NaHCO3 if hyperK), arrhythmias (amiodarone, lignocaine, metoprolol) -aim UO >2mL/kg/hr (each vial dantrolene contains 3g mannitol) -monitor ABGs, electrolytes, abc, CK, clotting profile, myoglobin. temp & prepare for ICU

Answer 4

CCBs- may cause CV collapse & marked hyperkalemia

Answer 5

-thyrotoxic crisis, MH, phaeochromocytoma, carcinoid -thyroid storm characterised by biochemical hyperthyroidism + severe life-threatening signs & symptoms (hyperthermia, cardiac dysfunction, altered mentation) -cerebral haemorrhage from extreme HTN -myocardial ischaemia from incr demand > supply -high-output cardiac failure with high afterload (may need inotropic support); 25% Intra-op mortality 20-30% -C (so stop manipulation of thyroid gland) AT (100% O2, propranolol (1mg IV over 1 minute, repeat dose every 2 mins up to 3-6mg, onset 2-5mins peaks @ 10 mins, DOA 3hrs), esmolol (0.5mg/kg IV loading over 60 seconds, onset within 5 mins & duration 10-30mins; then can do IV infusion 50-100microg/kg/min), vasodilators) -Urgently consult endocrine supportive: IV hydration & glucose supplementation, cool to normothermia, Rx metabolic abnormalities (esp acidosis) specific measures to limit free thyroid hormone: thionamide (eg. PTU 1mg over 10 mins, can repeat every few hrs), hydrocortisone, sodium/potassium iodide (should wait at least 1 hr after PTU to prevent the iodine being used as substrate for new thyroid hormone synthesis) (remember it's a hypermetabolic state that can put the pt into heart failure); treat arrhythmias but avoid amiodarone ICU monitoring as high mortality Thyroid storm can occur during surgery & in the first 18hrs postop in hyperthyroid pts (low incidence in pts who receive preop antithyroid Rx)

Answer 6

Intra-op seizure rare under GA, may occur in high risk pts for neurosurgery. Difficult to Dx under GA (esp if muscle relaxants used- HTN, tachy, incr EtCO2, dilated pupils). Declare, inform surgeons, 100% O2, deepen anaes (reduce CMRO2), correct precipitating factors (hypoglycaemia, hypoxaemia, hypercapnia, hyponatremia) Stabilise & support airway & breathing, 100% O2 (RSI w intubation if airway, breathing or oxygenation can't be maintained or if seizure prolonged). Continuous cardiorespiratory monitoring & pulse ox IV or IO access (ideally @ least 2 lines) Labs for glucose, Ca++, Na+, Mg++, LFTs, CBC, toxicology, anti-seizure medication levels Manage reversible causes: hypoglycaemia, metabolic/electrolyte abnormalities, fever/infection, incr ICP If persists >5mins, midaz 5-10mg (0.1mg/kg) over 2-5mins (or 10mg IM or IN); diazepam is 0.15mg/kg IV max 10mg, lorazepam 0.1mg/kg or 4mg fixed dose, max rate 2mg/min. along with AED- phenytoin 15mg/kg, or keppra 60mg/kg IV or IO over 15 mins if seizure persists at 10-15mins, further dose benzodiazepine emergency consult neurologist, portable EEG, ICU If seizure persists despite appropriate Rx at 15-30mins, could give an additional ASM not given previously (eg. fosphenytoin 20mgPE/kg IV(max cumulative dose 30mgPE/kg), valproate 40mg/kg max 3000mg at 10mg/min, keppra 60mg/kg) prepare for ICU transfer, prepare for RSI/mech ventilation; refractory if continues beyond 30mins. (requires RSI I&V, CV monitoring, continuous EEG, vasopressors as indicated). Commence continuous infusion for seizure control, either: midazolam (preferred) 0.2mg/kg bolus loading then 0.1mg/kg/hr up-titrate to seizure freedom to max 3mg/kg/hr, continue for 24hrs before tapering OR Props 1-2mg/kg loading over 5mins, repeat 0.5-2mg/kg until seizure stops, then infuse 20mcg/kg/min & titrate to achieve seizure freedom (max rate 200mcg/kg/min). if seizures persist after 45-60mins, change to midaz or pentobarbital. if seizures stop, continue infusion 24hrs before tapering. Pentobarbital 5mg/kg bolus over 10 mins, max rate 50mg/min. additional 5mg/kg boluses if seizures continue. infusion at 1mg/kg/hr, titrate up until seizure freedom. max dose 5mg/kg/hr. if seizures stop, continue inf 24hrs before tapering. maintain therapeutic anti-seizure medication levels If resolves, place L) lat w 100% O2 if seizure terminated & airway patent; continue close monitoring until fully recovered. consult neurology for full neurol Ax, continuous EEG monitoring & neuroimaging if return to responsiveness delayed by >1hr, do any additional diagnostics as needed.

Answer 7

NAP4: over 50% of airway related deaths in anaes were a consequence of aspiration Vital to thoroughly assess, plan to limit risk gastric contents apparent in oropharynx, tube high airway pressure hypercapnia or hypoxaemia wheeze Mx depends on timing; if during pre-O2 w FiO2 100%, immediate head down, L) lateral, suction call for help, delegate (prepare for intubation) ensure paralysis & intubate w VL (only cric if not actively vomiting)suction as go once tube placed, suction in tube prior to PPV, then ventilate w 100% O2 if particulate matter, inspect lungs w FoB If occurs during procedure w SGA, communicate to the room; stop surgical stimulation, call for help, delegate (intubation setup for RSI, diff airway trolley w FoB). If pt maintaining SpO2, suction around, FoB down SGA to look for particulate matter, railroad cuffed ETT into SGA, secure airway for remainder of case (either wake up or proceed depending on urgency). **ACM: immediately place down L) lat, remove airway & suction pharynx, intubate *ONLY proceed w OT if emergency empty stomach before emergence once extubated, pt doesn't require ICU after period of obsn 2hrs if no desat <95%, asymptomatic & no evidence consol on CXR Need ICU if particulate matter or indicator of severe aspiration (eg. desaturation, wheeze) no role for steriods or ABx preventative; only ABx if pneumonia

Answer 8

recognition: rapid ascending sympathetic, sensory & motor block w brady, hypoT, dyspnoea & difficulty swallowing/phonation may progress to unconsciousness (brainstem hypoperfusion or anaesthesia) & resp depression if large dose intrathecal (vs accidental spread from epidural), first sign may be unconsciousness or rsp depression generally signs within mins, may be up to 40mins w change of position ABC secure airway if needed (LOC= maternal collapse, resus trolley, RSI w cric); sedation & ventilation until block wears off, may take hours. If urgent LSCS required, to OT w paeds in attendance (expecting an anaesthetised baby as induction to delivery longer than expected) 100% O2 IVT, vasopressors (metaraminol, ephedrine)+/- inotropes (glyco 200-600microg, atropine 200-500microg); if no response of circulation, consider Adr w dilution max [] 10microg/mL sit up monitor FHR if obs await regression open disclosure, full debrief offered to the woman & family during admission & opportunity for follow-up risk management/Q&S report & consideration of contributing factors/future risk mitigation

Answer 9

dose based on the amount used in the 24hrs prior to ceasing PCA & equianalgesic dosing (unlike for initial oral doses, don't use age-based dosing since pts opioid requirements are known). As acute pain varies day to day, allow 0.5-1.5x the last 24hrs dose charted as range; divide the 24hr dose by 6 for 4-hourly.