risk assessment Flashcards
1st anesthetic
1846 (ether)
1st death from anesthesia
(chloroform) 1848
1st study
(John Snow, chloroform) 1858
•50 deaths; healthy pts, minor procedures
•Risk (noun)
- Hazard, danger, exposure to peril
- 1:1000
•Risk (verb)
•To expose to the chance of injury or loss
Perioperative Risk
•Technical/Systems (periop risk)
- Information data systems
- Appropriateness of postoperative monitoring
- Specialized nurses/equipment
- Staffing patterns
•Anesthetic Management- risk
Technical difficulties with airway management
- Risks of positioning
- Choices of anesthetic
- Postoperative extubation
Pain management
Medical Factors
- Do not depend on practice location or anesthetic technique
- Patient medical condition
- Well described for some factors/not for others
Perioperative Risks of surgery itself
- Severity of surgical procedure
- Well based in research
Goals of Risk Assessment
Accurately assess potential risk
- Emergent
- Elective
- “Grey-zone”
Identify modifiable risk factors
- Coronary revascularization prior to non-cardiac surgery
- CEA prior to……
History of Risk Assessment
•ASA 1941
Calculation of overall operative risk “useless”
- Too much variety in patients health
- Varying severity of planned procedure
- Varying familiarity of hospitals with procedure
ASA Physical Status
1 Healthy patient without medical problems
2 Mild, well-controlled systemic disease
3 Severe systemic disease (not incapacitating)
4 Severe systemic disease (constant threat to life)
5 Moribund (not expected to live 24 hours regardless of procedure)
6 Organ donor
ASA Physical Status Examples
- 1 Healthy, non-smoker, minimal alcohol
- 2 smoker, pregnancy, obesity (BMI<30), well controlled DM, mild lung dz
- 3 poorly controlled DM, HTN, COPD, alcoholism, CAD, >3mo hx MI/CVA
- 4 <3mo hx of MI/CVA, ESRD on dialysis, DIC
- 5 Ruptured thoracic aneurysm, massive trauma, MODS
- E: emergency
John Hopkins Risk System
- 1 Minimally invasive; little to no blood loss; office setting. Minimal risk
- 2 Minimally/moderate invasive; blood loss <500ml. Mild risk
- 3 Moderate/significantly invasive; blood loss 500-1500ml; Moderate risk
- 4 Highly invasive; blood loss >1500ml; Major risk
- 5 Highly invasive; blood loss >1500ml; Critical risk; ICU postop
Limitations of risk systems
- ASA doesn’t consider operative procedure
- John Hopkins doesn’t consider physical health; estimates difficulty
- Neither considers anesthetic difficulty
Maternal Mortality:
anesthetic implications
- More difficult airway
- Emergency induction
- Suboptimal preparation/examination
- Failed regional/contraindicated regional
- Poor residency training
Jehovah’s Witnesses
•Blood/blood products outlawed in 1945
“That ye abstain from meats offered to idols, and from blood, and from things strangled, and from fornicaton: from which if ye keep yourselves, ye shall do well.” Acts 15:29
•Guidelines
Private conversation
What if you were dying?
Court order?
In an emergency?
Perioperative blood work?
Blood components
focused risk assessment examples
inadequate mask ventilation
acute renal failure in normal CrCl
Pediatric Mortality
Greatest risk
- Very young
- Non-pediatric facilities- less eqiupment- not more risk
Pediatric Anesthetic Implications
- Tongue large
- Glottis anterior
- Less pulmonary reserve
- Neonatal hearts non-compliant
Breastfeeding risks
Past- any drug gave mom appeared in breast milk; pump and dump 24 hrs
Current- safe to breastfeed immediately
-Safe pain meds
- Protein bound? Colostrum doesn’t have much protein (won’t hang on to drugs
- Volume of distribution? Really large Vd in mom so not so much for breast milk
- Colostrum/breast milk: Colostrum doesn’t have much protein (won’t hang on to drugs
Improving safety
- APSF October 1985
- Standards
Unanimous decision to choose
Intraoperative Monitoring
•Guidelines
Followed in most cases….tailored to individual
Difficult airway algorithm
Surgical time-out
Use of blood components
