Qual Saf Health Care
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Anaesthetists may experience difficulty with intubation unexpectedly which may be associated with difficulty in ventilating the patient. If not well managed, there may be serious consequences for the patient. A simple structured approach to this problem was developed to assist the anaesthetist in this difficult situation. ⋯ The data confirm previously reported failures to predict difficult intubation with existing preoperative clinical tests and suggest an ongoing need to teach a pre-learned strategy to deal with difficult intubation and any associated problem with ventilation. An easy-to-follow structured approach to these problems is outlined. It is recommended that skilled assistance be obtained (preferably another anaesthetist) when difficulty is expected or the patient's cardiorespiratory reserve is low. Patients should be assessed postoperatively to exclude any sequelae and to inform them of the difficulties encountered. These should be clearly documented and appropriate steps taken to warn future anaesthetists.
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Qual Saf Health Care · Jun 2005
Crisis management during anaesthesia: problems associated with drug administration during anaesthesia.
Modern anaesthetic practice relies upon the administration of a wide range of potent drugs given by a variety of routes, at times in haste or under conditions of stress. Problems associated with drug administration make up the largest group of incidents reported during anaesthesia, with outcomes including major morbidity and death. It was decided to examine the role of a structured approach to the diagnosis and management of drug problems under anaesthesia. ⋯ It was judged that the use of the COVER-ABCD algorithm during the course of an anaesthetic, properly applied, would prevent many drug related incidents from occurring. The sub-algorithm presented here provides a systematic framework for detecting the causes of drug related incidents.
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Hypotension is commonly encountered in association with anaesthesia and surgery. Uncorrected and sustained it puts the brain, heart, kidneys, and the fetus in pregnancy at risk of permanent or even fatal damage. Its recognition and correction is time critical, especially in patients with pre-existing disease that compromises organ perfusion. ⋯ Pattern recognition in most cases enables anaesthetists to determine the cause and manage hypotension. However, an algorithm based approach is likely to improve the management of a small proportion of atypical but potentially life threatening cases. While an algorithm based approach will facilitate crisis management, the frequency of co-existing abnormalities in other vital signs means that all cases of hypotension cannot be dealt with using a single algorithm. Diagnosis, in particular, may potentially be assisted by cross referencing to the specific sub-algorithms for these.
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Embolism with gas, thrombus, fat, amniotic fluid, or particulate matter may occur suddenly and unexpectedly during anaesthesia, posing a diagnostic and management problem for the anaesthetist. ⋯ The potential value of an explicit structured approach to the diagnosis and management of embolism was assessed in the light of AIMS reports. It was considered that, correctly applied, it potentially would have led to earlier recognition of the problem and/or better management in over 40% of cases.
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Desaturation occurs for many reasons under anaesthesia, some rare and obscure, and many potentially life threatening. The rapidity with which the cause is determined and appropriate management is instituted varies considerably between anaesthetists. ⋯ Desaturation may have many causes, some of which are obscure, and failure to respond promptly may place the patient at risk. In the face of persistent desaturation, management should consist of hand ventilation with 100% oxygen, completion of COVER ABCD-A SWIFT CHECK, and a return to a supine posture. Blood gases, chest radiography, and bronchoscopy may be required where desaturation is persistent and/or no apparent causes can be found.