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