जरासी सावधानी : ज़िन्दगी मै ना रहें परेशानी

Dr.Sameer Ghotavadekar

       ( ABCDE…of Anaesthesia practice)

Dear friends,

This is in support & extension to the discussion about machine check and safe anaesthesia on our Facebook forum.

In India,institutional practice is concentrated in metros, where operation theaters are well equipped and properly managed by dedicated staff. Actually, more than 75 % of our colleagues are practicing in small to medium sized nursing homes.  Every day most of them leave their houses early in the morning (with their "dabba batli") running around from one clinic to another, knocking down patients so that surgeons can operate peacefully. 

These frequently changing ( some times absolutely unfamilier ) working environments add to the traffic and profession related stress. These circumstances are extremely vulnerable to serious human errors and life threatning accidents. Therefor,during this cross country tour one should not forget basic checks in  every setup before starting a case how so ever familiar the setup may be.  Just one mishap and career is ruined especially in this era of breaking news on electronic media.

Recent brainstorming inputs on our Facebook forum  from our colleagues from India &  different parts of the world stimulated me to go through the different international preanaesthesia safety check guidelines. WHO and WFSA (World Federartion of Societies of anaesthesiologists) have worked in depth in this area and developed useful guidelines.

In 2009 ,WHO has published the Guidelines for safe surgery under their "Safe surgery Save life campaign.”  Though extensive and supported with tons of references, it is a document worth referring.

The international task force for anaesthesia safety, in 2010, updated their previously  developed 'Standards'  which are adopted  & published by  WFSA  in their  document " International Standards for a Safe Practice of Anesthesia 2010.”

Most of their recommendations give very clear message about what should be done, where  & how.

Points described & recommended in above documents, ideally, are expected to be meticulously followed, but during our cross country tour, it is not always possible.

Therefore, I have made a tailor made checklist suitable to our practice.

Airway:

Appropriate sized Airways & masks,Ambu bag with oxygen tubing, Intubation tray i.e. Functioning laryngoscope, endotracheal tubes. One should also have a bougie in case of unanticipated difficult intubation. Functioning suction with appropriate sized suction catheter. Functioning Operation table.

Breathing:

Oxygen - ensure enough supply even if case is in local or regional anaesthesia. Appropriate  & functioning ventilation circuit .(Because you never know when you will have to go in for GA or in worst case resuscitation.)

Circulation:

Appropriate sized venous canulas, availability of i.v. fluids.

Drugs :

Emergency resuscitation drugs: Atropine, Adrenaline, Sodium Bicarbonate, Calcium Chloride, Aminophylline, Amiodarone,Dopamine,Steroid,Antihistamines etc.

Anaesthesia Drugs: Adequate amount of drugs needed to continue anesthesia for at least 50% more time than surgeon has predicted

Equipments:

Pulse oximeter,B.P.Apparatus,CO2 monitor,ECG monitor, Suction machine,Anesthesia machine.          The equipment check guidelines are elaborately listed in the document of Anesthesia Patient Safety Foundation. ( fig.2 ,fig.3)

File:  

Check for patient related factors which may put us in trouble. Take a thorough history about previous illnesses, surgeries, allergies, lab reports and other relevant investigations. During examination,airway should be meticulously evaluated and if necessary, difficult intubation tray should be made available.(fig.1) If needed by virtue of patient's condition and limitation of small setup one should be frank to tell surgeon & patient about conducting the case in an institutional setup with ICU back up. Most important point is to obtain/confirm existence of valid consent. 

Glucose:

Be sure that your own glucose level is normal i.e.you are physically and mentally fresh to conduct the case. Physical and mental fatigue can take a toll on decision making especially in unexpected emergency situations.

Humor:

Say hallo to surgeon and crack  a joke!! This is to ensure  that surgeon and anesthetist are in a good mood & comfortable working with each other. Uneasiness in operating room atmosphere again may affect performance of both surgeon and anesthetist.

Incentive : ????? 

After Amir Khan's program on Doctors, I have deleted this point from my checklist. But it is important for us, because surgeon and management might not have seen Amir Khan's program and might cancel the case if the patient has not paid the advance.This will waste the drugs, and disposables.

These are few thing I could recollect that we should go through but suggestions and additions are most welcome for safety of anesthetist and patient.( there are still 17 alphabets remaining.  )

 Refrences :

Proposed New Anaesthesia Checklist Sign In

International Standards for a Safe Practice of Anaesthesia 2010

New Guidelines Available for Pre-Anesthesia Checkout

Fig.1

Fig.2

fig.3

                                                                                                 Dr.Sameer Ghotavadekar
                                                                                                                                 Consultant Cardiac Anaesthetist

                                                                                                                                 Ruby Hall Clinic ,Pune.
                                                                                                                                 Maharashatra,India.
                                                                                                                                 sameer.ghotavadekar@gmail.com

Tips & Tricks

Dear friends !!                                           

During our successful career we have seen many ups and downs, many acute and panic moments. We have worked in many adverse surroundings and difficult situations.  To avoid complications we all must have modified our practices by doing some simple tricks suitable to the situation.These tricks are not given in any textbooks and  may not be practically applicable in all situations.   You are quite  successful & happy   with your improvisation but doubt that  the tricks will be accepted in a  formal scientific platform. If you believe that they are  worth sharing, please forward it to interactive anesthesia forum so that other colleagues who  probably  are in similar situation may benefit from it  .

Let us help each other to make our practice safe and better .

We are attaching few such examples .





Smart use of Used Ventilator tubing to organize the cabels of monitor and tranducer cords.
Avoids many accidents ,gives more space. 

Fig 1.

A Simple Arm Positioning Aid  for Fracture Table Cases 

Problem:

When positioning a patient on the fracture table for open reduction/internal fixation of a femoral neck fracture, it is commonly necessary to secure the arms over the chest in a crossed fashion to avoid contact with the fluoroscope. Most hip fracture patients are elderly, and are at risk for skin abrasions if tape is used for this purpose. Wrapping sheets around the patient to secure the arms can prevent access to the peripheral intravenous site, and may not adequately restrain the arms during manipulation of the lower extremities by the surgical team.

There has been succefully used  a soft foam donut-style headrest to gently but securely restrain the patient's arms across the chest. This method is well tolerated by a conscious patient with a regional block. It allows unobstructed access to hands and arms for peripheral venous or arterial line manipulation, and permits the use of a standard safety belt to hold the patient on the table.

To use a foam doughnut headrest for this purpose, first insert the patient's left arm into the hole and advance the headrest above the elbow until it is around the distal third of the humerus. Position that arm across the chest with the left hand lying over the right biceps area. Then cross the right forearm over the left forearm so the left wrist rests in the antecubital area of the right arm, and insert the right hand and wrist into the hole. The circular insert from the foam headrest may then be placed between the arms to pad one from the other. Of course, right and left arm positions may be switched as dictated by line placement or convenience. The final arrangement is shown in figure 1.

Please forward your inputs  on    interactiveanaesthesia@gmail.com 

( Do not forget to include your name,email address and institute.We are creating a page called TIPS &TRICKS .Your inputs will be included both in the main page and in the TIPS & TRICKS section.)

Have a Nice Day

                                                                                                  Interactive anaesthesia