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Educative in Anesthesia

1. ANESTHESIA OUTSIDE THE OPERATING THEATRE & QUALITY AND SAFETY IN ANAESTHESIA GROUP ONE 4/27/2024 2:29 PM 1

2. Outline Introduction General Considerations And Principles Anaesthesia for radiotherapy Computed Tomography ( The General Principle, Anesthetic Management Magnetic Resonance (The General Principle, Anesthetic Management Cardiac Catheterization Anaesthesia In Accident And Emergency Room 4/27/2024 2:29 PM 2

3. INTRODUCTION Anesthesia outside the operating theatre suite is often challenging for the anesthetist. Although the principles of remote site anesthesia are common to many situations, each specialized environment poses its unique problems. In hospital the anesthetist must provide a service for patients with standards of safety which are equal to those in the main operating theatre department. Outside the hospital, this level of service may be more dependent on location and available resources. 4/27/2024 2:29 PM 3

4. General considerations and principles 1. Appropriate personnel . Only senior experienced anaesthetists , who are also familiar with the particular environment and its challenges, should normally administer anaesthesia outside the operating room. Patients are often challenging, and additional skilled anaesthetic help may not be readily available compared with an operating theatre suite. Equipment. The remote clinical area may not have been designed with anaesthetic requirements in mind and in general, conditions are less than optimal. Nevertheless monitoring capabilities and anaesthetic equipment should meet the minimum standard set by the Association of Anaesthetists as those used in the operating department 4/27/2024 2:29 PM 4

5. Patient preparation. Preparation of the patient may be inadequate because the patient is from a ward where staff are unfamiliar with preoperative protocols, or patients may be unreliable, e.g. those presenting for electroconvulsive therapy (ECT). 4. Assistance. An anaesthetic assistant (e.g. operating department practitioner) should be present, although this person may be unfamiliar with the environment. Maintenance of anaesthetic equipment may be less than ideal. 5. Communication. Communication between staff of other specialities and the anaesthetist may be poor. This may lead to failure in recognizing each other’s requirements. Education programmes for non- anaesthesia personnel regarding the care of anaesthetized patients may be of benefit. 4/27/2024 2:29 PM 5

6. . Recovery . Recovery facilities are often non-existent. Anaesthetists may have to recover their own patients in the suite. Consequently, they must be familiar with the location of recovery equipment including suction, supplementary oxygen and resuscitation equipment. There should be a nominated lead anaesthetist responsible for remote locations in which anaesthesia is administered in a hospital. This individual should liaise with the relevant specialties (e.g. radiologists, psychiatrists) to ensure that the environment, equipment and guidelines are suitable for safe, appropriate and efficient patient care. 4/27/2024 2:29 PM 6

7. Anaesthesia for radiotherapy Radiotherapy Radiotherapy is used in the management of a variety of malignant diseases, some of which occur in childhood. These include the acute leukaemias , Wilms’ tumour , retinoblastoma and central nervous system tumours . High-dose X-rays are administered by a linear accelerator, and all staff must remain outside the room to be protected from radiation 4/27/2024 2:29 PM 7

8. Anaesthetic considerations ensure reliable i.v. access for a range of medications and blood sampling. Agents such as ketamine are unsatisfactory because sudden movements may occur, and excessive salivation may risk airway compromise. No analgesia is required, and tracheal intubation is generally not necessary. There is virtually no surgical stimulation, and patients may be maintained at relatively light anaesthetic levels, allowing for rapid emergence and recovery 4/27/2024 2:29 PM 8

9. Magnetic RESONANCE imaging Magnetic resonance imaging (MRI) is an imaging modality that depends on magnetic fields and radiofrequency pulses to produce its images. The imaging capabilities of MRI are superior to those of CT for examining intracranial, spinal, and soft tissue lesions. It may display images in the sagittal, coronal, transverse or oblique planes and has the advantage that no ionizing radiation is produced. 4/27/2024 2:29 PM 9

10. Anaesthetic management Staff safety . Anaesthetists should also understand the consequences of quenching the magnet and be aware of recommendations on exposure and the need for ear protection All potentially hazardous articles should be removed (e.g. watches, mobile telephones bleeps, pens and stethoscopes). Bank cards, credit cards and other belongings containing electromagnetic strips become demagnetised in the vicinity of the scanner, and personal computers, pagers, mobile telephones and calculators may also be damaged. 4/27/2024 2:29 PM 10

11. Patient safety. Ferromagnetic objects within or attached to the patient pose a risk. • Jewellery , hearing aids or drug patches should be removed. • Absolute contraindications to MRI include implanted surgical devices such as cochlear implants, intraocular metallic objects and metal vascular clips. • Pacemakers remain an absolute contraindication in most settings, although MRI-conditional pacemakers have now been developed 4/27/2024 2:29 PM 11

12. • Joint prostheses, artificial heart valves and sternal wires are generally safe because of fibrous tissue fixation. Patients with large metal implants should be monitored for implant heating. • All patients should wear ear protection because noise levels may exceed 85 dB. 4/27/2024 2:29 PM 12

13. Equipment The magnetic effects of MRI impose restrictions on the selection of anesthetic equipment. Any ferromagnetic object distorts the magnetic field sufficiently to degrade the image. It is also likely to be propelled towards the scanner and may cause a significant accident if it makes contact with the patient or with staff. Equipment used in the MRI scanner is designated ‘MR conditional’, ‘MR-safe’, or ‘MR-unsafe 4/27/2024 2:29 PM 13

14. ANAESTHETIC CONCERNS 30% of Patients - Anxiety, 10% Severe Panic & Claustrophobia 14% require sedation. In most cases, sedation is usually provided by the Radiologist. Complex cases such as the Mentally Retarded, Obesity, Obstructive Sleep Apnea, Raised ICP, Those Movement Disorders etc may need anesthesia, Most children under 5 require sedation or General Anesthesia to tolerate MR 4/27/2024 2:29 PM 14

15. Anaesthesia Administration Induced outside MRI room Short-acting drugs for rapid recovery Sedation can be done however GA allows for a more rapid onset, immobility guaranteed. Patient Transport and Safety Transport on MRI-appropriate trolleys Anaesthetist should ideally be in the control room, but in exceptional circumstances be in the scanning room if well-protected If emergency arises, the anaesthetist needs to be aware of the procedure for rapid removal of the patient into a save area. 4/27/2024 2:29 PM 15

16. ICU Patients and MRI Increasing need for MRI in ICU Careful planning and screening checklists necessary Infusion Management Non-essential infusions discontinued Essential infusions transferred to MRI-safe pumps Potential patient instability during transfer High vasopressor requirements may contraindicate scanning 4/27/2024 2:29 PM 16

17. Equipment Precautions Secure tracheal tube valve spring away from scan area Remove pulmonary artery catheters with conductive wires and pacing catheters Simple CVCs safe if disconnected from electrical connections Gadolinium Contrast Agent Generally safe with high therapeutic ratio Risk of nephrogenic systemic fibrosis in renal failure patients Caution in patients with GFR <30ml/min/1.73m², minimal contrast if necessary, avoid repetition for 7 days 4/27/2024 2:29 PM 17

18. Computed tomography CT scans produce tomographic axial slices of the body. Images are created by computer integration of radiation absorption coefficients. Brightness of areas on the image corresponds to absorption values. The gantry rotation produces axial slices, or "cuts," typically at 7mm intervals. The circular scanning tunnel houses the X-ray tube and detectors, with the patient positioned in the center during the scan. 4/27/2024 2:29 PM 18

19. Anaesthetic management Computed tomography (CT) is non-invasive and painless for most adult patients. Sedation or anesthesia is typically unnecessary, except for patients with fears or anxieties. Some patients (pediatric, head trauma, or intoxicated) may require sedation or general anesthesia to prevent movement. General anesthesia is preferred for patients with potential airway issues or critical intracranial pressure (ICP). Airway management is crucial during CT scans, particularly when the patient's head is inaccessible. Controlled ventilation is necessary for patients with high ICP, often using a total intravenous technique with neuromuscular blockade. 4/27/2024 2:29 PM 19

20. Use of volatile anesthetic agents during scans is acceptable but may require technique changes for patient transfer. Portable ventilators with end-tidal CO2 monitoring are preferable to traditional breathing systems. Consider switching to piped oxygen supply for prolonged scans to conserve oxygen. Ensure alarms and monitors have visual signals visible from the control room if the anesthetist is observing the patient. 4/27/2024 2:29 PM 20

21. Anaesthetic complications while in the CT scanner include: kinking of the tracheal tube or disconnection of the breathing system, particularly during positioning and movement of the gantry; hypothermia in paediatric patients; disconnection of drips and lines during transfer; and haemodynamic instability during movement on to the scanning table (e.g. in the trauma setting) 4/27/2024 2:29 PM 21

22. Anaesthesia in the Emergency Department Anaesthetists’ involvement in the ED varies among hospitals, depending on the skills of the resident ED medical staff. The following clinical conditions usually require an anaesthetist to attend the ED: • preoperative assessment and resuscitation before emergency surgery (e.g. major trauma or ruptured aortic aneurysm); • specialist airway management for a patient with respiratory failure or acute airway compromise; 4/27/2024 2:29 PM 22

23. Cardiac catheterization General anesthesia is essential for children due to their unique physiological considerations. Congenital heart disease in children often presents with symptoms like cyanosis, dyspnea, and failure to thrive. Diagnosis typically involves echocardiography, with cardiac catheterization sometimes necessary for treatment planning. 4/27/2024 2:29 PM 23

24. Anesthetic Techniques and Challenges An ideal anesthetic technique for pediatric congenital heart disease aims to avoid myocardial depression, hypertension, and tachycardia. Techniques such as positive pressure ventilation and volatile agents have limitations and may influence pulmonary hemodynamics. Monitoring ECG and invasive arterial pressure is crucial for rapid assessment of arrhythmias and hypotension, especially with contrast medium use. Polycythemia in cyanotic heart disease increases the risk of thrombosis in children. 4/27/2024 2:29 PM 24

25. • intensive care admission for a patient needing ventilatory and/or other organ support; • resuscitation as part of the cardiac arrest or trauma team; • patients requiring specialist cannulation skills; • anaesthesia for patients requiring procedures such as cardioversion 4/27/2024 2:29 PM 25

26. Quality and safety in anaesthesia 4/27/2024 2:29 PM 26

27. Quality in healthcare is hard to define. One approach is based around six goals: safety; effectiveness; patient focus; timeliness; efficiency; and equity . Although errors and incidents are commonly discussed in relation to safety, the same fundamental principles apply to all aspects of healthcare quality Introduction 4/27/2024 2:29 PM 27

28. Aims of a high-quality healthcare system 1. Safe Prevention of injuries to patients from the care that is intended to help them 2. Effective Provision of services based on scientific knowledge to all who could benefit, and refraining from providing services to those not likely to benefit. 3. Patient- centred Providing care that is respectful of and responsive to individual patient preferences, needs and values, and ensuring that patient values guide all clinical decisions. 4.Timely Reducing waits and sometimes harmful delays for both those who receive care and those who give it. 5. Efficient Avoiding waste, including waste of equipment, supplies, ideas and energy. 6. Equitable Providing care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location and socioeconomic status 4/27/2024 2:29 PM 28

29. MEDICAL RECORDS AND DOCUMENTATION Definition An orderly written document encompassing the patient's identification data, health history, physical examination findings, surgical procedures, and hospital course. When complete, it should contain sufficient data to justify the investigation, diagnosis, treatment, length of hospital stay, result of care, future course of action. 4/27/2024 2:29 PM 29

30. Benefits to Patient Document the history of a patient Avoids repetition of diagnosis & treatment Assists in the continuity of care in the event of future illness Serves an evidence to support or to refute the legal questions that arise 4/27/2024 2:29 PM 30

31. Benefits to Hospital Provides the management with statistical information necessary for decision-making regarding the utilization of resources Furnishes documentary evidence for purposes of evaluation of hospital care in terms of quantity, quality, and adequacy (medical audit) Protects the hospital in the event of legal action Benefits to Public Health Authorities Gives morbidity & mortality statistics Helps PH Authorities to plan the prevention and social measures to meet the needs of the community 4/27/2024 2:29 PM 31

32. Medical Education & Research Since recorded observations and case studies are the basis of all clinical research, medical records become invaluable in all research and teaching programs 4/27/2024 2:29 PM 32

33. Characteristics of Good MR Complete : sufficient data to identify the patient, justify diagnosis, and warrant treatment and outcome Adequate : all necessary forms and all relevant clinical information Accurate : capable of quantitative analysis 4/27/2024 2:29 PM 33

34. REVIEWING MEDICAL RECORDS- BASICS Biodata Name(s) of Surgeon/ Physician Dates and Time periods of appointment/ admissions History: Presenting condition & concurrent medical Anesthetic Family Drug 4/27/2024 2:29 PM 34

35. Allergies Smoking Alcohol OSA Review the information obtained from clinical examination that confirms good health or otherwise and this should complement the patient’s history and allows the anesthetist to focus further on features of relevance. Other Consult/ Investigations 4/27/2024 2:29 PM 35

36. Peri-operative anesthesia audit A perioperative anesthesia audit is a systematic review and evaluation of anesthesia practices and outcomes in the perioperative period, which includes the preoperative, intraoperative, and postoperative phases of patient care. The goal of such an audit is to assess the quality of anesthesia care provided to patients undergoing surgery or other invasive procedures and to identify areas for improvement. 4/27/2024 2:29 PM 36

37. STEPS 1. Define the audit objectives: Determine the specific goals and objectives of the audit, such as assessing adherence to anesthesia guidelines, evaluating patient outcomes, or identifying opportunities for process improvement. 2 . Select audit criteria: Decide on the specific criteria or standards against which the anesthesia practice will be evaluated. These criteria may include factors such as preoperative assessment, anesthesia technique, intraoperative monitoring, postoperative pain management, and complications 4/27/2024 2:29 PM 37

38. 3. Collect data: Gather relevant data from patient records, anesthesia charts, electronic medical records, and other sources. The data collected may include patient demographics, preoperative assessments, anesthesia techniques used, intraoperative monitoring data, postoperative pain scores, and any complications or adverse events. 4/27/2024 2:29 PM 38

39. 4. Analyze data: Analyze the collected data to assess adherence to the audit criteria and identify any deviations or areas of concern. This analysis may involve statistical methods, such as calculating compliance rates or comparing outcomes against established benchmarks. 5. Interpret findings: Interpret the audit findings to understand the implications for patient safety and quality of care. Identify any trends, patterns, or specific areas where improvements can be made. 4/27/2024 2:29 PM 39

40. 6. Develop recommendations: Based on the audit findings, develop recommendations for improving anesthesia practices and patient care. These recommendations should be practical, evidence-based, and address the identified areas for improvement. 7. Implement changes : Work with relevant stakeholders, such as anesthesia providers, surgeons, nurses, and hospital administrators, to implement the recommended changes in anesthesia practices. This may involve updating protocols, providing additional training or education, or making changes in equipment or resources. 4/27/2024 2:29 PM 40

41. 8. Monitor outcomes: Continuously monitor and evaluate the impact of the implemented changes on anesthesia practices and patient outcomes. This may involve conducting follow-up audits or tracking specific quality indicators over time. By conducting perioperative anesthesia audits, healthcare organizations can identify opportunities for improvement, enhance patient safety, and optimize perioperative care delivery. It is important to involve a multidisciplinary team of healthcare professionals in the audit process to ensure comprehensive evaluation and implementation of changes. 4/27/2024 2:29 PM 41

42. CRITICAL INCIDENT REPORTING IN ANAESTHESIA: A critical incident in anaesthesia is defined as any untoward and preventable mishap associated with the administration of general or regional anaesthesia , and which leads to or could have led to an undesirable patient outcome • Near miss : an event that has the potential to lead to a substantial negative outcome if left to progress • Never event : serious, largely preventable patient safety incidents that should not occur if relevant preventive measures have been put in place 4/27/2024 2:29 PM 42

43. Causes Of Critical Incidents • Contributory factors: patient, surgery or anaesthesia • Anaesthesia -related critical incidents may be due to human errors, equipment errors, or pharmacological factors. 4/27/2024 2:29 PM 43

44. Human Errors •Due to active or latent failures • Active failures : unsafe acts or omissions performed by front-end workers i.e. anaesthetists , surgeons, nurses — Slips: wrong label/syringe — Cognitive failure: memory lapses, ignorance, misreading a situation — Violations: deviations from safe practices, procedures or standards 4/27/2024 2:29 PM 44

45. Latent failures : decisions taken by senior management or clinicians, which create the conditions in an organization for unsafe acts to occur — Inadequate or inappropriate staffing — Heavy workload — Poor supervision — Stressful environment — Poor communication — Poor maintenance of equipment — Conflict of priorities (finance vs. clinical need) 4/27/2024 2:29 PM 45

46. Drug Errors •Definition: error in the prescription, dispensing, or administration of a medication with the result that the patient fails to receive the correct drug or the indicated proper drug dosage •Drug errors could be inappropriate dosing, wrong sequence of administration, administration of a drug different from what was intended, or administration of a drug to which the patient is allergic to •Commoner during general anaesthesia than during regional anaesthesia because fewer drugs are used for regional than for general anaesthesia 4/27/2024 2:29 PM 46

47. Risk Factors for Drug Errors • Inadequate total experience • Inadequate familiarity with equipment or device • Poor communication with team • Haste • Inattention/carelessness • Fatigue • Failure to perform normal check •Lack of supervision • Inadequate familiarity with surgery • Inadequate familiarity with anaesthetic technique • Distraction • Poor labeling of drugs • Apprehension • Demanding or difficult case Emergency case • Boredom • Insufficient preparation 4/27/2024 2:29 PM 47

48. Prevention of Drug Errors The label on any drug ampoule or syringe should be read carefully before the drug is drawn up or injected. Legibility and contents of labels on ampoules and syringes should be optimized according to agreed standards with respect to font, size, colour and information. Syringes should always be labelled Double checking of ampoules, syringes and equipment before starting the procedure 4/27/2024 2:29 PM 48

49. Labels should be checked specifically with the help of a second person or a device like bar code reader before administration Error during administration should be reported and reviewed Management of inventory should focus on minimising the risk of drug error Look-alike packaging and presentation of the drug should be avoided where possible Drug should be presented in prefilled syringes rather than ampoules Drugs should be drawn up and labelled by the anaesthesia provider himself/herself Colour coding by class of drugs should be according to an agreed national or international standard Coding of syringe according to position or size 4/27/2024 2:29 PM 49

50. Incident Reporting Systems • The main reason for reporting incidents to improve patient safety is the belief that safety can be improved by learning from incidents and near misses, rather than pretending that they have not happened 4/27/2024 2:29 PM 50

51. Barriers and Enablers to Incident Reporting • Under-reporting, in particular by doctors, remains a significant problem • Unfamiliarity with the process • Cultural issues: fear of punitive action, legal ramifications, workplace discrimination •Poor reporting practices by doctors: only bad doctors make mistakes 4/27/2024 2:29 PM 51

52. ANAESTHESIA RESEARCH Anesthesia research encompasses a wide range of studies focusing: on improving techniques, safety and outcomes related to anesthesia administration. drug interactions, patient monitoring, pain management, long-term effects of anesthesia. It's a critical field that constantly evolves to enhance patient care and surgical procedures. 4/27/2024 2:29 PM 52

53. 1. Patient Safety Measures: Research focuses on identifying and implementing safety measures to prevent adverse events during anesthesia. This includes studying protocols for preoperative patient assessment, medication safety, infection control, and prevention of perioperative complications. 2. Anesthesia Monitoring: Studies are conducted to evaluate the effectiveness and reliability of various monitoring techniques used during anesthesia, such as blood pressure monitoring, pulse oximetry, capnography , and depth of anesthesia monitoring 4/27/2024 2:29 PM 53

54. 3. Medication Safety : Research investigates strategies to improve medication safety in anesthesia, including proper drug selection, dosage calculation, drug administration techniques, and monitoring for potential drug interactions or adverse drug reactions. 4. Team Communication and Collaboration : Research examines communication and teamwork among anesthesia providers, surgeons, nurses, and other healthcare professionals in the perioperative setting. The focus is on identifying effective communication strategies, enhancing interdisciplinary collaboration, and reducing errors caused by communication breakdown 4/27/2024 2:29 PM 54

55. 5. Simulation Training : Simulation-based training is used to improve anesthesia providers' skills, decision-making, and crisis management abilities. Research explores the use of simulation in anesthesia education and training, including the development of realistic scenarios, assessment of performance, and the impact of simulation on patient outcomes. 6. Quality Improvement Initiatives: Research investigates quality improvement initiatives in anesthesia, such as the implementation of clinical guidelines, protocols, and checklists. These initiatives aim to standardize practice, reduce practice variation, and improve patient outcomes by incorporating evidence-based practices into routine care. 4/27/2024 2:29 PM 55

56. 7. Adverse Event Reporting and Analysis : Studies focus on the analysis of adverse events and near misses in anesthesia, aiming to identify contributing factors, patterns, and opportunities for improvement. This includes the development of reporting systems, analysis of root causes, and implementation of strategies to prevent similar events in the future. 4/27/2024 2:29 PM 56

57. 8. Technology and Innovation: Research explores the use of new technologies, such as electronic health records, decision-support systems, and telemedicine, to enhance patient safety and improve anesthesia care delivery. This includes evaluating the benefits, challenges, and the impact of technology on anesthesia practice and patient outcomes. 4/27/2024 2:29 PM 57

58. These are just a few examples of the research areas in quality and safety in anesthesia. Ongoing research in this field is crucial to advancing patient safety, optimizing anesthesia practices, and improving the overall quality of care in the perioperative setting 4/27/2024 2:29 PM 58

59. References 1.Textbook for Anaesthesia 7 th Edition Author: Alan R. Aitkenhead , Lain Moppett , Jonathan Thompson Publisher: Churchill Livingston   2. Synopsis of Anaesthesia 13 th Edition Author: Nicolar J. H Davis, Jeremy N. Cashman Publisher: Butterworth Heinemann   3. Millers Anaesthesia 8 th Edition Author: Ronald D. Miller, Neal H. Coheir, Lars I. Eriksson Publisher: Elsevier 4/27/2024 2:29 PM 59

60. Group members MAVIS NOI SOAK/2022/R025 EMMANEL KURU AYAABA SOAK/2022/R021 PHILEMON ASHANTE AHIABLE SOAK/2022/R004 FRANCIS YEBOAH SOAK/2022/R041 FELIX TENGAN SOAK/2022/R038 SAMUEL K DAMOAH SOAK/2022/R015 YAMINU IDDRISU SOAK/2022/R020 BARIKISU MAHAMUD SOAK/2022/R022 PRINCE OBENG SOAK/2022/R026 JOACHIM KWAKU ASARE SOAK/2022/R010 COMFORT BAMFOAH AKOSUAH SOAK/2022/R013 4/27/2024 2:29 PM 60