causes and prevention and managements of anesthesia complications

2. Perioperative Death
safe anaesthesia practice
Dr.Mushtaq Ahmad
Consultant anesthetist
BVH,Bahawalpur

3. 3

4. ANESTHETIC DEATH
“Anaesthetic death” is often
defined as the death of a patient
who has had an anaesthetic,
within 24 hours of the procedure.
This is irrespective of the
contribution of anaesthesia to the
cause of death.
4

5. The recent studies defined
mortality associated with
anesthesia as a death under
anesthesia or as a result of
anesthesia and death within
24hrs of an anesthetic procedure.
5

6. Perioperative Death
It is potentially the most stressful
event we experience as
anesthetists.
6

7. My
is only on anesthetic death.
7

8. Can be classified further
into 4 groups according
to the cause of the death
Journal of clinical pathology 1999 52 640-652
Roger. D. Start et al
8

9. Directly caused by the disease for which
anesthesia was being performed eg:
aneurysmal rupture during aneurysmal repair
Caused by a disease other than for which
anesthesia was being performed eg: CAD
patient dying in a whipples resection
Resulting from a mishap of the surgery eg:
rebleeding in Tonsillar surgeries
Resulting from a mishap of anesthesia eg:
slipped ETT in cleft lip and palate surgery
9

10. Incidence
 High in the developing countries
 High with emergency and complex surgeries
 High with age
 High with inadequate preop preparation
 Inappropriate postop care
 Lack of supervision
10

11. Timing of perioperative mortality
Majority occurs in the postoperative(51%)
Intraoperative(37%)and during induction(9%) of
anesthesia
11
Percentage
Postoperative
Intraoperative
Induction

12. Safe Anaesthesia practice
IF WE KNOW THE
CAUSE OF A
COMPLICATION
THEN WE CAN
AVOID THE
COMPLICATION

13. HUMAN ERROR
COMMUNICATION FAILURE
EQUIPMENT FAILURE
COEXISTING DISEASES
INEVITABLE COMLICATIONS
CAUSES OF COMPLICATIONS

14. What is complication?
 Unexpected &
unwanted events
 10% of all
anesthetics
 Death 5/million
anesthetics i-e
0.0005% in UK
14

15. HUMAN ERROR
Poor monitoring
Equipment malfunction
Organizational failure
Poor training
Fatigue
Inadequate experience
Poor preparation of pt
15

16. Prevention of human
error
 Good
organization
 Effective
monitoring
 Vigilance
 Action plans &
drills rehearsed
previously
16

17. COMMUNICATION
FAILURE
 Poor working
relationship
 Poor working condition
 Prevention
 Team training &
simulation-based
training
17

18. EQUIPMENT FAILURE
 Failure of
 Breathing system
 Airway devices
 Gas supplies
 Malfunction
 Infusion pumps
 Prevention
 Ensure availability
& correct function of
life saving & critical
important
equipments
 alternative devices
..if primary device fail
18

19. COEXISTING DISEASES
• Pt in fine
balance of
pathology &
compensatory
physiology
HTN,DM,IHD,ASTHAMA
SURGERY/ANESTHESIA
SUDDEN WORSENING
OF APPARENTLY
STABLE PATHOLOGY
19

20. INEVITABLE
COMPLICATIONS
 Despite excellent
surgical & anesthetic
practice
 Not always
necessary to place
the blame for a
complication on a
healthcare provider
20

21. Complications of anaesthesia
Major Complications Minor complications
Cardiac 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

22. 1. RESPIRATORY
2. CARDIOVASCULAR
3. NEUROROLOGICAL
4. TEPERATURE
5. DRUG REACTIONS
6. REGIONAL ANESTHESIA
7. INJURY
COMPLICATIONS

23. 1. Respiratory obstruction
2. Laryngospasm
3. Bronchospasm
4. Complications associated with tracheal intubation
5. Hiccup
6. Hypoxaemia
7. Apnoea
8. Hypercapnia
9. Hypocapnia
10. Pneumothorax
11. atelactasis
RESPIRATORY

24. 1. Hypertension
2. Hypotension
3. Hypovolaemia
4. Haemorrhage
5. Disturbance of HR & Rhythm
6. Myocardial ischemia
7. Embolus
CARDIOVASCULAR

25. SPINAL
EPIDURAL
PERIPHERAL NERVE BLOCK
REGIONAL ANESTHESIA

26.  Cutaneous & muscular
 Peripheral nerve
 During airway management
 Opthalmic
 Thermal & electrical
 Vascular
 tourniquets
INJURY

27. 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
10 common causes of cardiac
arrest under anaesthesia

28. 28

29. 1. Preoperative assessment, investigation and counselling
of the patient
2. Preoperative checking of equipment and the assurance
of backup equipment
3. The availability of an appropriately trained Assistant
4. Preoperative consultation with more experienced
personnel, where necessary, regarding the Most
appropriate anaesthetic technique
5. The use of appropriate monitoring techniques
AVOIDANCE OF COMPLICATIONS

30. EXPERIENCE
 Anesthetist’s responsibility to ensure
 HAS HE /SHE ADEQUATE TRAINING
FOR THE TASK PRESENTED ?
IF NO
SENIOR ASSISTANCE HELP
MUST BE SOUGHT
30

31. RECORD KEEPING
 Vital sign & treatment
 Trends in vital sign
 Early intervension
 safer sharing of care between
anesthetists
 Handover long cases
 Better team work
 After the event investigations &
learning,thus reducing
complications
31

32. REDUNDENT SYSTEMS
 Availability of at least two working
laryngoscopes
 Maintenance of 2 or more IV line if
blood loss expected
 Monitoring of expired volatile agent
conc . Alongwith depth of anesthesia
monitors
 Minimizes risk of awareness
32

33. MONITORING
ASA & AAGBI have set minimum
standard of intraoperative
monitoring
Automatically activated alarm….
Values set by anesthetists
33

34. SUMMARY
Prophylactic measures
 Improve the preoperative assessment
 Provide preoperative preparations
 Improve the monitoring standards
 Provide balanced anesthesia
 Provide adequate post operative care
 Provide adequate supervision
 Proper auditing of critical incidents
34

35. It should have been
prevented by above
measures
35

36. It had happened
36

37. GENERAL
MANAGEMENT
RECORD
KEEPING
MANAGEMENT OF COMPLICATIONS

38. GENERAL
MANAGEMENT
 Provision of high FiO2
 Assurance of adequate cardiac output
 Cessation of perfusion …more rapid
damage of organs than low level of
oxygenation
 Brain & heart most sensitive
 Liver & kidneys …potentially at risk
38

39. 1. Continual
vigilance and
monitoring
2. Recognition
of the evolution
of a problem
3. Creation of a
list of differential
diagnoses
GENERAL MANAGEMENT

40. 4. Choice of a
working diagnosis,
which is either the
most likely or the most
dangerous possibility
5. Treatment of
the working
diagnosis
6. Assessment of the
response of the
problem to the
treatment
administered
40

41. 7. Refinement of the list
of differential diagnoses,
especially if the response
has not been as expected
8. Confirmation or elimination of
the choice of working diagnosis; if
the response to treatment has
been unexpected then
replacement with a more likely
working diagnosis is indicated
9. Go to step 5 and
repeat until the problem is
resolved

42. RECORD KEEPING &
DOCUMENTATION
 Trends in pt physiological data apparent only
when charted
 Generation of new DD of a problem with help
of data
 Data of an incident & complication important in
preventing future repetition through education
in department
 Detailed record available to defend the
practitioner
42

43. Put every moment in
black and white
The more detail, the better
43

44. Documentations after the
event
 Prepare the accurate records
 Don’t alter the original notes
 Amendments and additions are recorded
separately
 Preoperative visit details are included
 Consent form and relevant investigation
reports are collected
44

45. Documentation checklist
When the patient was first seen by whom?
What was prescribed?
Investigation reports
Plan of anesthesia
Critical incidents
Remedial measures
Senior Help sought
45

46. Dealing
with the
deceased
46

47. Handling the relatives
47

48. Be empathetic
48

49. Communicating with
relatives
 Quiet comfortable room to sit
 Help from a senior
 Surgical and nursing colleague are
included
 Explain the serious complications
 Tried remedial measures detailed
 Answer all immediate questions
49

50. Tug of war begins here
50

51. Before Peri operative
death
Surgeons and
anesthesiologists
team up for a
common goal
51

52. After on table death
They usually fight and
blame each other
52

53. THANKS
53