OR HAZARD & ANESTHESIA AWARENESS Flashcards
WHAT IS ONE OF THE BIGGEST PATIENT FEARS
INTEROPERATIVE AWARENESS
MEMORY:EXPLICIT
CONSCIOUS MEMORY
CONSCIOUS RECOLLECTION OF PREVIOUS EXPERIENCES: EQUIVALENT TO REMEMBERING.
AWARENESS DURING ANESTHESIA DESCRIBES CONSCIOUS RECALL (EXPLICIT MEMORY) OF INTRAOPERATIVE EVENTS
MEMORY IMPLICIT
UNCONSCIOUS
PATIENTS CAN RESPOND TO TO COMMANDS AND LACK CONSCIOUS RECALL OF INTRAOPERATIVE EVENTS (IMPLICIT MEMORY)
INTERVIEWING PATIENTS, CAN THEIR MEMORY BE DELAYED?
MEMORY FORMATION FOR INTRAOPERATIVE AWARENESS MAY BE DELAYED BEYOND IMMEDIATE RECOVERY PERIOD
HOW MANY AWARENESS CASES WERE IDENTIFIED PRIOR TO LEAVING THE HOSPITAL
1/3 OF CASES
WHAT ARE SOME FACTORS THAT WOULD INHIBIT PATIENTS FROM READILY VOLUNTEERING INFORMATION
PATIENT MAY NOT VOLUNTARILY REPORT AWARENESS D/T EMBARRASSMENT OR WAS NOT DISTURBED BY THE EXPERIENCE
HOW DO WE ASK IF THEY EXPERIENCED AWARENESS
WHAT IS THE LAST THING THEY REMEMBER, WHAT DO THEY REMEMBER?
QUESTIONS TO EVALUATE AWARENESS (5)
WHAT WAS THE LAST THING YOU REMEMBER BEFORE GOING TO SLEEP?
WHAT IS THE FIRST THING YOU REMEMBER AFTER YOUR OPERATION?
CAN YOU REMEMBER ANYTHING IN BETWEEN?
CAN YOU REMEMBER IF YOU HAD ANY DREAMS DURING YOUR PROCEDURE?
WHAT AS THE WORST THING ABOUT YOUR PROCEDURE?
INCIDENCE OF AWARENESS IN SWEDEN
PROSPECTIVE STUDIES IN SWEDEN: 12,000 PATIENTS = 0.18% (18/10,000) HAD AWARENESS UNDER GENERAL WHERE NMBD WERE USED
- 10% (10/10,000) ABSENT NMD
- 13% (13/10,000) OVERALL INCIDENCE
INCIDENCE IN U.S. OF AWARENESS
1/1000 PATIENTS HAVE AWARENESS
PATIENTS WITH COEXISTING MORBIDITIES TEND TO HAVE MORE FREQUENT INCIDENCE OF AWARENESS.
RISK FOR OPERATIVE AWARENESS GREATER FOR OB AND CARDIAC ANESTHESIA WHERE ANESTHESIA MAY BE LIGHT
3 MAJOR CAUSES OF AWARENESS
LIGHT ANESTHESIA
INCREASED PATIENT ANESTHESIA REQUIREMENTS
ANESTHETIC DELIVERY PROBLEMS
LIGHT ANESTHESIA-
name two surges that have light anesthesia
why might doses be reduced
REDUCED ANESTHESIA USUALLY DUE HEMODYNAMIC INTOLERANCE OF ANESTHETIC DRUGS
OB OR CARDIAC SURGERIES
REDUCED ANESTHETIC DOSES MAY BE NECESSARY FOR OPTIMAL PHYSIOLOGY AND SAFETY IN HYPOVOLEMIC PATIENTS OR THOSE WITH LIMITED CARDIAC RESERVE
Which asa range have more frequent incidence of awareness
ASA 3-5 UNDER GOING MAJOR SURGERY HAVE MORE FREQUENT INCIDENCE OF AWARENESS.
INCREASED PATIENT ANESTHESIA REQUIREMENTS- DRUGS
ABUSE OF ETOH; OPIOIDS; AMPHETAMINES AND COCAINE MAY REQUIRE INCREASE ANESTHETIC DOSING
DO GENETICS PLAY A ROLE IN INCREASE PATIENT ANESTHESIA REQUIREMENTS
GENETICS MAY PLAY A ROLE
LIKELY TO HAVE AWARENESS (4)
IMPAIRED CARDIOVASCULAR STATUS
UNDERGOING EMERGENCY SURGERY
RECEIVE SMALLER DOSES OF VOLATILE ANESTHETICS
TECHNICAL DIFFICULTIES
WHAT MAC DOSE IS USED TO PREVENT CONSCIOUS RECALL
A 0.7 MAC OR ABOVE PREVENT CONSCIOUS RECALL
WHAT CAN MASK AWARENESS FOR THE ANESTHESIA PROVIDER
NMBD
WHEN IS ANESTHETIC AWARENESS LESS LIKELY TO OCCUR USING WHAT DRUG?
VOLATILE ANESTHETICS
WHAT DRUGS ARE THEIR INCREASED AWARENESS
NITROUS AND INTRAVENOUSLY ADMINISTERED ANESTHETICS
ANESTHETIC DELIVER PROBLEMS (3)
EQUIPMENT PROBLEMS WITH VAPORIZERS
IV DEVICES NOT WORKING
ANESTHESIA MACHINE PROBLEMS
THESE ISSUES ARE USUALLY LESS COMMON REASONS FOR AWARENESS
PSYCHOLOGICAL SEQUELAE- WHAT CAN AWARENESS MANIFEST INTO?
~ 1/3 PATIENTS EXPERIENCING AWARENESS WILL MANIFEST IN LATE PSYCHOLOGICAL SEQUELAE
WHAT DO MOST PATIENTS OFTEN RECALL
LIGHTS, SOUND, FEELINGS OF HELPLESSNESS, FEAR, ANXIETY
IS PAIN A COMMON AWARENESS COMPLAINT?
IT IS LESS COMMON BUT MAY OCCUR WHEN NMBD ARE GIVEN
TELL ME ABOUT AWARENESS AND PTSD
CAN DEVELOP PTSD INTERFERING WITH INTERPERSONAL RELATIONSHIPS AND DAILY LIVING
CAN REGIONAL ANESTHESIA AND MAC CREATE PHYSOLGICAL ISSUES
PSYCHOLOGICAL ISSUES MAY BE PRESENT DURING REGIONAL ANESTHESIA AND MAC
ACUTE EMOTIONAL REACTION TO AWARENESS CAN DO WHAT?
AN ACUTE EMOTIONAL REACTION TO THE EXPERIENCE SIGNIFICANTLY PREDICTED THE DEVELOPMENT OF LATE PSYCHOLOGICAL SEQUELA
SIDE EFFECTS OF AWARENESS
FLASHBACKS, ANXIETY, NERVOUSNESS, LONELINESS, NIGHTMARES, FEAR, PANIC ATTACKS
TREATMENT FOR AWARENESS
EARLY PSYCHOTHERAPEUTIC THERAPY MAY REDUCE POTENTIAL OF ACUTE AND LONG TERM PSYCHOLOGICAL SEQUELAE.
AS ANESTHESIA PROVIDERS HOW DO WE APPROACH PATIENTS FEELINGS IN REGARD TO AWARENESS
AN EXPLANATION OR VALIDATION OF THE AWARENESS MAY EFFECT PRESENCE AND DURATION OF PSYCHOLOGICAL CONSEQUENCES.
WHAT REPORTING IS THERE FOR AWARNESS
A REGISTRY EXIST WHERE PATIENTS CAN REPORT EXPERIENCES AND OTHERS CAN LEARN MORE ABOUT PATIENTS’ EXPERIENCES
HOW TO DO PREP PATIENTS FOR SURGERY AND THEIR CONCERNS FOR AWARENESS
IMPORTANT TO TALK TO YOUR PATIENTS ABOUT THE ANESTHESIA PROCEDURE
LET THEM KNOW WHAT TO EXPECT. LISTEN TO FEARS AND ANSWER QUESTIONS
LET THEM KNOW WHAT TO EXPECT WITH A MAC CASE OR A REGIONAL WITH SEDATION (MAC).
ALWAYS LET THEM KNOW THEY WILL GET PAIN MEDICINE AND N/V MEDS WHILE ASLEEP AND CAN HAVE MORE IF NEEDED WHEN AWAKE IN PACU
BIS (BISPECTRAL INDEX SYSTEM):
MAY SEE IN MANY OR’s TODAY. MYLES ET AL. PERFORMED RCT n= 2500 pts. AT HIGH RISK FOR AWARENESS. IMPORTANT TO REALIZE THAT IF ONE ADDITIONAL PT HAD HAD RECALL IN THE BIS GROUP, IT WOULD HAVE NO LONGER BEEN SIGNIFICANT. THEREFORE, THERE IS NO REAL “GOLD STANDARD” FOR AWARENESS.
MORE BIS STUDIES
EKMAN ET AL. : PROSPECTIVE COHORT STUDY: n= 5027 PTS COMPARED WITH HISTORICAL GROUP n= 7826. BIS WAS USED TO GUIDE ANESTHESIA ADMINISTRATION. DEMONSTRATED ONCE AGAIN IF 1 MORE IN BIS GROUP AND 1 LESS IN THE HISTORICAL GROUP REPORTED AWARENESS, THE DIFFERENCE WOULD NOT BE STATISTICALLY SIGNIFICANT. MAY HAVE HAD A HAWTHORNE EFFECT
MORE BIS STUDIES
AVIDAN ET AL.: RANDOMLY ASSIGNED PATIENTS TO BIS (n = 967) OR ETCO2 GROUP (n = 974) FOUND NOT DIFFERENCE IN THE INCIDENCE OF DEFINITE AWARENESS IN BOTH GROUPS (2 EACH).
SEBEL ET AL.: PROSPECTIVE NONRANDOM COHORT (n = 19,575). BIS WAS MONITORED IN 38% OF THE PATIENTS AND NO DIFFERENCE IN AWARENESS INCIDENCE WAS FOUND.
AWARENESS PREVENTION PREMEDICATION
BENZO (ANTEGRADE AMNESIA)
AWARENESS PREVENTION INDUCTION DRUGS?
ADEQUATE DOSES OF DRUGS FOR INDUCTION
AWARENESS PREVENTION WHAT MED SHOULD WE AVOID UNLESS NECESSARY
AVOID MUSCLE PARALYSIS UNLESS NECESSARY
VOLATILE GASES SHOULD BE AT LEAST WHAT MAC
0.7
ANESTHESIA AWARENESS DOES NOT NECESSARILY =
LAW SUIT
1 OUT OF HOW MANY INJURIES RESULTED IN MALPRACTICE CLAIMS
1 OUT OF 25 INJURIES FROM NEGLIGENT CARE RESULTS IN MALPRACTICE CLAIMS AND FEWER CLAIMS WHEN STANDARD OF CARE WAS DELIVERED.
HOW MANY YEARS LATER CAN SOMEONE MAKE A CLAIM FOR AWARENESS
UP TO 10 YEARS
CLOSED CLAIMS DATA
DATABASE CAPTURES CLAIMS FROM LIABILITY INSURERS WHICH COVER 1/3 OF U.S. ANESTHESIOLOGIST
FACTORS INFLUENCE PATIENT SUITS (3)
POOR COMMUNICATION
UNMET EXPECTATIONS
FINANCIAL PRESSURES ON PATIENT
WHEN DO ELECTRICAL SHOCKS OCCUR
OCCURS WHEN A PERSON BECOMES PART OF OR COMPLETES AN ELECTRICAL CIRCUIT.
WHAT DOES THE BOVIE HAVE THE POTENTIAL TO INTERFERE WITH
PULSE OX AND PACEMAKERS
WHAT CAN A BOVIE CAUSE INTERFERENCE WITH
EKG MONITORING
WHAT IS THE CONCERN WITH BOVIE AND ANESTHETICS AGENTS
HASTENED END OF EXPLOSIVE ANESTHETICS AGENTS
WHO INVENTED THE BOVIE
1926 W.T. BOVIE
WHAT CARDIAC RHYTHM DOES THE BOVIE HAVE THE POTENTIAL TO CAUSE
V-FIB WITH A STRAY WHEN FIRST ACTIVATED OF 50-60 HZ RANGE
3 COMPONENTS OF A FIRE
IGNITION SOURCE
(SURGEON, BOVIE)
FUEL
(NURSE, PREP)
ANESTHESIA
(OXIDIZER/02)
TOXICANTS
PRODUCTS OF COMBUSTION
LESS OBVIOUS BUT POTENTIALLY MORE DEADLY RISK
INJURIOUS PRODUCTS FROM BURNING MATERIALS SUCH AS PLASTICS AND OTHER MATERIAL
C02
AMMONIA
HYDROGEN CHLORIDE
CYANIDE
INJURIES FROM TOXICANTS
AIRWAY TISSUE
LUNG TISSUE
ASPHYXIA
WHAT IS THE CONCERN REGARDING OR FIRES AND SPRINKLER DETECTION
OR FIRES CAN PRODUCE LARGE AMOUNTS OF SMOKE BEFORE SPRINKLERS DETECT FIRE BY HEAT ACTIVATION THEREFORE EVACUATION ASAP NEEDS TO BE PRIORITY
TYPE 1 OR FIRE
IN or ON THE PATIENT IS THE MOST COMMON
TYPE 1 HIGH RISK PROCEDURES
HIGH RISK PROCEDURES IN WHICH AN IGNITION SOURCE IS USED IN AN OXIDIZER-RICH ENVIRONMENT ET FIRES OROPHARYNX DURING T&A FIRES IN BREATHING CIRCUIT FIRES DURING LAPAROSCOPY
FIRES ON PATIENTS: WHAT body parts do they involve
HEAD AND NECK OF PATIENT
WHAT TYPE OF ANESTHESIA ARE WE MOST CONCERNED WITH PATIENTS CATCHING FIRE
REGIONAL OR MAC WHEN PATIENT IS RECEIVING HIGH FLOWS OF SUPPLEMENTAL 02
WHAT ARE ITEMS THAT CAN BE READILY IGNITED AND PRODUCE SEVERE BURNS
SURGICAL TOWELS, DRAPES AND BODY HAIR CAN BE READILY IGNITED AND PRODUCE SEVERE BURNS
WHAT IS THE MAIN CONCERN WITH OXYGEN RICH ATMOSPHERES AND FIRE
OXYGEN RICH ATMOSPHERES LOWER THE TEMPERATURE AT WHICH A FUEL WILL IGNITE
THESE FIRES WILL BURN MORE VIGOROUSLY AND SPREAD FASTER
FIRE CASE: KATZ & CAMPBELL (2005): FIRE DURING THORACOTOMY. DRY LAP CAUGHT FIRE B/C 100% 02 PRESENT IN THORACIC CAVITY WHILE USING ELECTROCAUTERY.
KATZ & CAMPBELL (2005): FIRE DURING THORACOTOMY. DRY LAP CAUGHT FIRE B/C 100% 02 PRESENT IN THORACIC CAVITY WHILE USING ELECTROCAUTERY.
WHAT PULMONARY CASES ARE THE MOST CONCERN FOR FIRE
CASES INVOLVING STRIPPING OF THE PLEURA OR RESECTION OF PULMONARY BLEBS, CAN EASILY RESULT IN HIGH CONCENTRATIONS OF O2 IN THE CAVITY WHEN LUNG IS REINFLATED DUE TO GAS LEAKAGE
SOLUTION TO PREVENT FIRE WHEN SURGEON NEEDS LUNG INFLATED
IF SURGEON NEEDS LUNG INFLATED, DO IT WITH CPAP WITH AIR INSTEAD OF O2
SOLUTION TO PREVENT FIRE IN 02 RICH ENVIRONMENTS
WET LAPS IN 02 RICH ENVIRONMENTS
TYPE 2 FIRE
REMOTE FROM PATIENT
EXAMPLES OF TYPE 2 FIRES
PIECE OF EQUIPMENT
CO2 ABSORBER
ALL MATERIALS BURN IN A HIGH O2 ENRICHED ENVIRONMENT: THE HIGHER THE CONCENTRATION OF O2 THE MORE READILY MATERIALS CATCH FIRE:
COTTON HUCK TOWEL: 21% 02 - ignition mean?
21% 02: IGNITION MEAN 12 SECONDS
COTTON HUCK TOWEL: at 95% 02 ignition mean
95% IGNITION MEAN 0.1 SECONDS
ENDOTRACHEAL TUBE FIRE
DEVASTATING
O2 AND OR N2O WILL PRODUCE A BLOWTORCH TYPE OF FLAME
RESULTS IN SEVERE INJURY TO TRACHEA, LUNGS, AND SURROUNDING TISSUES.
UNCUFFED ETT FOR CHILD HAVING A T&A
WHAT IS THE FIRE CONCERNS?
SURGEON USES LASER TO CAUTERIZE TONSIL BED
WHAT COULD HAPPEN?
WHAT CAN YOU DO TO PREVENT OR DECREASE THE RISK?
WHAT PRECENT OF SURGICAL FIRES ARE 02 ENRICHED.
MAJORITY OF OR FIRES OCCUR WITH MAC DURING HEAD AND NECK SURGERY
75% OF SURGICAL FIRES ARE O2 ENRICHED
IDEA TO USE <30% O2 IF POSSIBLE. IF NOT CAN ADD ROOM AIR TO REDUCE CONCENTRATION OR CONSIDER LMA/ETT
WHAT IS THE FIRE RISK FOR SURGICAL PREPS
SOME NEWER SURGICAL PREPS CONTRIBUTE TO FIRES
HOW DO THESE PREP COMES PACKAGED?
WHAT OTHER THINGS CONCERN US?
THESE SOLUTIONS TYPICALLY COME PRE-PACKAGED WITH A PAINTING STICK APPLICATOR WITH A SPONGE ON THE END (ex. DuraPrep)
IODOPHOR MIXED WITH 74% ISOPROPYL ALCOHOL THUS HIGHLY FLAMMABLE. 4-5 MINUTES TO DRY COMPLETELY!
BEWARE OF POOLS OF SURGICAL PREP
WHAT ISSUE MAY ARISE WITH A LONG DRYING TIME?
IS SEVO FLAMMABLE
SEVOFLURANE IS VOLATILE (AT ROOM TEMP LIQUID VOLATIZES INTO A VAPOR) BUT CONSIDERED “NONFLAMMABLE”
TELL ME WHEN SEVO AND NITROUS SERVES AS FUEL
HOWEVER SEVO IS NONFLAMMABLE IN AIR BUT CAN SERVE AS FUEL AT CONCENTRATIONS AS LOW AS 11% O2 AND 10% NITROUS OXIDE
WHAT CHEMICAL REACTION DOES SEVO UNDERGO
SEVO CAN UNDERGO EXOTHERMIC CHEMICAL REACTION WITH DESICCATED CO2 ABSORBER (SODA LIME OR BARALYME)
MANUFACTURERS OF SEVO SUGGEST REGARDING CO2 ABSORBERS
AVOID DESICCATED CO2 ABSORBENTS; MONITOR TEMP OF ABSORBERS AND INSPIRED SEVO CONCENTRA TION. SUDDEN UNEXPECTED INFLUX OF SEVO INHALATION REMOVE CIRCUIT AND ASSESS FOR THERMAL OR CHEMICAL INJURIES
WHAT TYPE OF ABSORBENTS MUST WE USE
USE ABSORBENTS THAT DO NOT CONTAIN STRONG ALKALI. EXAMPLE AMSORB CONTAINS CALCIUM HYDROXIDE AND CALCIUM CHLORIDE AND NO STRONG ALKALI.
AMSORB
UNREACTIVE WITH CURRENTLY USED VOLATILE ANESTHETICS
DOES NOT PRODUCE CARBON MONOXIDE OR COMPOUND A
WILL NOT INTERACT WITH SEVO AND UDERGO AN EXOTHERMIC CHEMICAL REACTION
WHAT DO I DO? FOR AIRWAY FIRE
FRESH GAS DELIVERY MUST BE STOPPED: ACCOMPLISHED BY TURNING OFF FLOWMETERS, DISCONNECTING THE CIRCUIT FROM MACHINE, OR DISCONNECTING THE CIRCUIT FROM THE ETT
REMOVE ETT
M/M (P. 24) SAYS THE ORDER IS NOT AS IMPORTANT AS THE FACT THAT BOTH ARE DONE IMMEDIATELY IF NOT AT THE SAME TIME. WHAT DO YOU THINK?
STERILE WATER OR SALINE INTO AIRWAY TO EXTINGUISH ANY BURNING EMBERS
RESUME VENTILATION OF PATIENT WITH AIR (PREFERABLY)
AVOID O2 AND NITROUS
EXAMINE TUBE FOR MISSING PIECES
AIRWAY RE-ESTABLISHED
CONSIDER BRONCHOSCOPE
TREAT FOR SMOKE INHALATION AND POSSIBLE TRANSFER TO BURN CENTER
closed claim project found 2.6% of awareness during ga were
demographic?
asa?
age?
class of procedure?
female
asa 1 or 2
elective procedure
less than 60 yrs
how do you supply ungrounded power to the OR
use of an isolation transformer
is there a direct electrical connection between the power supplied form the utility company on primary side and the power induced by the transformer on the ungrounded side or secondary side?
no direct connection
is power isolated from the ground in the OR
why is that
Yes
faulty equipment into an ips
no shock hazard- just converts the isolated power to conventional grounded power.
line isolation monitor what is it monitoring
monitors the integrity of the IPS (isolation transformer)
if a faulty piece of equipment is plugged in- the IPS becomes grounded- what detects that
Line isolation monitor
what is the LIM set to alarm at
2-5mA
when one faulty piece of equipment is plugged in is it a dangerous situation?
means its not totally isolated from the ground anymore - - it requires a second fault to be dangerous. a second piece of equipment that is faulty would then create a dangerous shock.
if several piece of equipment have a leak it can cause the LIM to go off.
