2.7 Safety and Quality in Anaesthesia Practice
SQ_1.7 Describe the likely presentation of and steps to take in the event of: • Failure of pipeline gas supply • Anaesthesia machine and ventilator malfunction • Breathing circuit malfunctions such as stuck valves and massive leaks
Likely Presentation and Steps to Take in Specific Anaesthetic Emergencies
1. Failure of Pipeline Gas Supply
Likely Presentation:
Low or absent gas supply pressure alarms.
Sudden depletion of pipeline-delivered oxygen, nitrous oxide, or air.
Falling oxygen concentrations in the delivered gas mixture.
Steps to Take:
Immediate Action:
Open the oxygen cylinder on the back of the anaesthesia machine and disconnect the pipeline oxygen to prevent contamination from a faulty pipeline.
Ensure adequate oxygen flow using the cylinder.
Assess Patient Safety:
Manually ventilate the patient if required.
Monitor oxygen saturation (SpO₂), end-tidal CO₂ (EtCO₂), and other vital parameters closely.
Switch to Backup Systems:
Use portable oxygen cylinders or self-inflating bag-valve-mask devices if necessary.
Alert relevant personnel (engineering, biomedical staff) to investigate and rectify the pipeline issue.
Conserve Resources:
Minimize oxygen wastage; avoid high fresh gas flows unless clinically indicated.
2. Anaesthesia Machine and Ventilator Malfunction
Likely Presentation:
Inability to achieve adequate ventilation or oxygenation.
Alarms indicating failure of components (e.g., ventilator or gas flow).
Disconnection or cessation of monitored parameters (e.g., airway pressure or tidal volume).
Steps to Take:
Immediate Action:
Disconnect the patient from the malfunctioning machine and begin manual ventilation with a self-inflating bag-valve-mask system.
Ensure delivery of 100% oxygen during manual ventilation.
Check the Machine:
Inspect for obvious issues such as disconnections, leaks, or stuck valves.
Attempt to reset or bypass the faulty ventilator if possible.
Monitor Patient:
Continue monitoring vital signs and ventilatory parameters closely.
Switch to Backup Equipment:
Use an alternative anaesthesia machine or transport ventilator.
Escalate to biomedical engineers for immediate repair.
3. Breathing Circuit Malfunctions
(e.g., Stuck Valves and Massive Leaks)
Likely Presentation:
Increased airway pressures or high resistance to ventilation (stuck valves).
Sudden loss of airway pressure, inability to ventilate, or noise of escaping gas (massive leaks).
Reduced tidal volumes or altered EtCO₂ readings.
Steps to Take:
Immediate Action:
Disconnect the patient from the circuit and provide manual ventilation with a self-inflating bag and 100% oxygen.
Inspect and Isolate the Problem:
Check all components of the breathing circuit (e.g., connections, valves, hoses, reservoir bag) for obstructions, stuck parts, or disconnections.
Replace faulty components where possible.
Assess Patient:
Ensure effective ventilation and oxygenation during troubleshooting.
Monitor for hypoxia, hypercapnia, or hemodynamic instability.
Replace Equipment:
Switch to a new circuit or spare equipment if available.
Escalate to senior anaesthetic staff and technical support for further assistance.
In all scenarios, ensuring adequate oxygenation and ventilation is the immediate priority. Communication with the surgical team and escalating issues to senior staff and technical support are vital steps for comprehensive management.
SQ_1.10 Describe the short- and long-term hazards of anaesthetic gas pollution, factors for agent choice and the methods of scavenging anaesthetic gases. Refer to ANZCA professional document: PS64(G) Position statement on environmental sustainability in anaesthesia and pain medicine practice 2019
1. Short-Term Hazards of Anaesthetic Gas Pollution
Health Effects on Operating Room Staff:
Headaches, fatigue, and nausea from acute exposure to waste anaesthetic gases.
Potential irritation of eyes, nose, and throat due to unscavenged gases.
Reduced Cognitive Function:
Short-term cognitive or motor impairments, impacting staff performance and safety.
2. Long-Term Hazards of Anaesthetic Gas Pollution
Occupational Health Risks:
Chronic exposure associated with reproductive health issues, such as reduced fertility and spontaneous miscarriage in exposed staff.
Increased risk of long-term neurological conditions, including memory impairment.
Environmental Impact:
Anaesthetic agents such as desflurane and nitrous oxide contribute significantly to greenhouse gas emissions due to their long atmospheric lifetimes and high global warming potential (GWP).
Desflurane has a GWP over 2,500 times that of carbon dioxide, and nitrous oxide contributes significantly to ozone depletion.
3. Factors for Choosing an Anaesthetic Agent
Environmental Considerations:
Avoid high-GWP agents like desflurane and nitrous oxide where clinically appropriate.
Favor low-impact alternatives such as sevoflurane or total intravenous anaesthesia (TIVA), which have significantly lower carbon footprints.
Clinical Factors:
Tailor agent choice to the patient's clinical needs, including specific comorbidities, surgical requirements, and pharmacokinetics of the drug.
Flow Rates:
Practice low-flow anaesthesia (<1 L/min) to reduce agent use without compromising safety.
Alternatives to Inhalational Anaesthesia:
Use regional anaesthesia or TIVA to minimize reliance on volatile agents and mitigate environmental and occupational risks.
4. Methods of Scavenging Anaesthetic Gases
Active Scavenging Systems (ASS):
Most effective and widely used system in modern operating rooms.
Connects the anaesthetic machine to a central vacuum system, actively removing waste gases from the patient circuit.
Passive Scavenging Systems:
Relies on ventilation to remove waste gases, using ducts or exhaust points to direct gases outside the operating theatre.
Less efficient compared to active systems but still reduces occupational exposure.
Charcoal Absorption Systems:
Utilizes activated charcoal filters to adsorb halogenated agents, offering portability for remote or resource-limited settings.
Effective for halogenated gases but does not absorb nitrous oxide.
Room Ventilation:
Maintain at least 15 air changes per hour in operating theatres to dilute and remove residual anaesthetic gases.
Maintenance of Equipment:
Regular servicing and leak testing of anaesthetic machines to minimize unintentional gas leaks.
Education and Monitoring:
Train staff in proper use of scavenging systems and monitor ambient air quality to ensure compliance with safety standards.
5. Key Recommendations (ANZCA PS64(G)):
Environmental Responsibility:
Promote the use of sustainable anaesthetic practices, such as favoring low-GWP agents and reducing unnecessary anaesthetic gas use.
Clinical and Environmental Balance:
Consider both patient outcomes and environmental sustainability when selecting anaesthetic techniques and agents.
Research and Advocacy:
Support innovation and research into sustainable anaesthesia practices, including alternative agents and technologies.
Conclusion
Effective management of anaesthetic gas pollution requires a combination of choosing appropriate agents, implementing robust scavenging methods, and adopting sustainable practices. By considering both environmental impact and patient safety, clinicians can optimize perioperative care while minimizing harm to staff and the planet.
SQ_1.11 Outline the generic steps to take in the event of: • An operating room fire • Electrical power failure in the operating suite
Operating Room Fire
1. Recognize the Fire
Identify the source (e.g., drapes, equipment, airway, alcohol-based prep solutions).
Announce loudly, “FIRE IN THE OPERATING ROOM.”
2. Respond Immediately
Stop the Procedure:
Cease surgery, stop ventilation, and halt delivery of supplemental oxygen.
Switch to room air or reduce oxygen concentration, if safe.
Remove Flammable Material:
Remove drapes, alcohol-soaked materials, or burning equipment.
Extinguish the Fire:
Use a sterile saline or water solution to douse flames on the patient.
Use a fire extinguisher for equipment or room fires:
CO₂ extinguisher for electrical fires.
Avoid extinguishers that could harm the patient unless necessary.
3. Evacuate if Necessary
Move the patient to a safe area if the fire cannot be controlled.
4. Manage Patient Injuries
Assess and treat thermal injuries (e.g., burns, airway damage).
Ensure adequate oxygenation and ventilation, especially if the airway was involved.
5. Post-Incident Actions
Shut off gases to the room.
Report the incident and preserve equipment for investigation.
Conduct a debrief with the team to review the response and improve protocols.
Electrical Power Failure in the Operating Suite
1. Recognize the Failure
Confirm that the power outage is affecting the operating suite.
Identify whether emergency backup systems (e.g., generators, battery backups) are functioning.
2. Maintain Patient Safety
Airway and Ventilation:
Switch to manual ventilation using a self-inflating bag (Ambu bag).
Ensure that oxygen supply remains active.
Monitoring:
Use portable or battery-powered monitors for vital signs.
Ensure adequate lighting using headlamps or mobile lights.
Surgical Equipment:
If using diathermy or powered surgical instruments, pause until power is restored or alternative equipment is available.
3. Stabilize the Situation
Notify the operating suite team and hospital engineering department.
Assess which systems are operational (e.g., suction, oxygen delivery, battery life of devices).
Prioritize critical devices and conserve battery power where possible.
4. Decide on Continuing or Abandoning the Procedure
Minor Procedures: Safely conclude if feasible without risking patient harm.
Major Procedures: If safe, stabilize the patient and prepare for transfer to a functional operating room or recovery area.
5. Post-Incident Actions
Conduct a detailed review of the event.
Ensure proper documentation and reporting.
Arrange equipment checks and staff training on power failure protocols.
Both scenarios emphasize rapid assessment, effective communication, and ensuring patient safety while addressing the crisis.
SQ_1.12 Describe the prevention and management of injuries sustained during anaesthetic care
Prevention and Management of Injuries Sustained During Anaesthetic Care
Anaesthetic care carries inherent risks of injury to patients due to the use of invasive devices, positioning, drug administration, and other perioperative factors. Preventative measures, early recognition, and effective management are key to minimizing morbidity and improving outcomes.
1. Prevention of Injuries
A. Airway-Related Injuries
Prevention:
Use appropriate airway assessment to anticipate difficulties (e.g., Mallampati score, thyromental distance).
Choose suitable airway devices and techniques.
Use lubricated and properly sized equipment to minimize trauma.
Limit attempts at intubation and ensure gentle technique.
Examples of Injuries:
Dental trauma, laryngeal or tracheal injuries, and aspiration.
B. Positioning Injuries
Prevention:
Conduct preoperative assessments to identify patients at high risk (e.g., neuropathy, arthritis).
Use padding and positioning aids to protect pressure points (e.g., elbows, heels).
Avoid hyperextension or excessive flexion of joints and maintain physiological alignment.
Examples of Injuries:
Nerve injuries (e.g., ulnar neuropathy, brachial plexus injury), pressure sores, compartment syndrome.
C. Eye Injuries
Prevention:
Tape eyelids shut to prevent corneal exposure during general anaesthesia.
Avoid direct pressure on the eyes, particularly in prone positions.
Ensure careful handling of the face and airway devices to prevent trauma to the orbit or eye.
Maintain adequate lubrication of the eyes to prevent drying and corneal abrasions.
Examples of Injuries:
Corneal abrasions, chemical injuries (from prep solutions), and perioperative vision loss due to ischemic optic neuropathy.
D. Medication-Related Injuries
Prevention:
Double-check drug doses, labels, and compatibility.
Use infusion pumps for accurate dosing of vasoactive and anaesthetic agents.
Maintain vigilance for potential allergic reactions or side effects.
Examples of Injuries:
Hypotension, anaphylaxis, and local anesthetic toxicity.
E. Thermal and Electrical Injuries
Prevention:
Monitor temperature closely to avoid hypo- or hyperthermia.
Use grounding pads appropriately to prevent electrical burns.
Examples of Injuries:
Burns from warming devices or electrosurgical units.
2. Management of Injuries
A. Immediate Response
Recognize Early Signs:
Continuous monitoring of vital signs and clinical examination.
Prompt identification of injuries such as hypoxia, nerve deficits, drug reactions, or eye pain.
Stabilize the Patient:
Prioritize ABCs (Airway, Breathing, Circulation).
Administer appropriate medications or interventions (e.g., adrenaline for anaphylaxis).
B. Injury-Specific Management
Airway Injuries:
Manage dental trauma by stabilizing or replacing teeth and referring to a dentist.
Treat airway swelling with corticosteroids, nebulized adrenaline, or securing a definitive airway if necessary.
Nerve Injuries:
Initiate physical therapy for rehabilitation.
Consider imaging or neurologist referral for persistent deficits.
Pressure Injuries:
Implement wound care and offload pressure.
Use specialized dressings or surgical intervention for severe cases.
Eye Injuries:
Treat corneal abrasions with topical lubricants or antibiotics.
Avoid eye patching, which can promote infection.
For chemical injuries, irrigate immediately with copious sterile saline and consult an ophthalmologist.
Investigate vision loss urgently with imaging and specialist referral.
Medication Reactions:
Stop the offending agent and administer antidotes if available (e.g., intralipid for local anesthetic toxicity).
Provide supportive care, such as fluid resuscitation or vasopressors.
C. Documentation and Reporting
Record the nature of the injury, management steps, and patient outcomes.
Report to institutional quality improvement teams for analysis and prevention of future incidents.
D. Post-Injury Follow-Up
Provide ongoing care and monitoring of recovery.
Offer psychological support if needed (e.g., counseling for significant injuries).
3. Systems-Level Prevention
Regular staff training on injury prevention and management.
Standardized protocols for drug administration, positioning, and equipment checks.
Root cause analysis of adverse events to improve processes and minimize recurrence.
By implementing comprehensive prevention and management strategies, anaesthetic providers can ensure safer patient care and reduce the incidence of perioperative injuries.
SQ_1.16 Outline the general principles related to staffing and facilities for the post anaesthesia care unit. Refer to ANZCA professional document: PS04(A) Position statement on the post-anaesthesia care unit 2020
General Principles Related to Staffing and Facilities for the Post-Anaesthesia Care Unit (PACU)
Based on the ANZCA PS04(A) Position Statement on the Post-Anaesthesia Care Unit 2020, the following outlines the principles ensuring the safe and efficient operation of a PACU:
1. Staffing
A. General Requirements
The PACU must be staffed at all times by nurses trained in post-anaesthesia care.
Junior or less experienced nurses should be supervised by a registered nurse certified in post-anaesthesia care.
B. Nurse-to-Patient Ratios
One-to-One Observation: All patients require continuous observation until they regain airway control, hemodynamic stability, and purposeful communication.
Higher Acuity Patients: A two-to-one ratio may be necessary during the initial reception of critically ill or unstable patients, or those requiring airway support.
C. Leadership and Supervision
A registered nurse certified in post-anaesthesia care should oversee the PACU.
Anaesthetists must remain available during the patient’s recovery period to address complications or authorize discharge.
D. Multidisciplinary Collaboration
PACU staffing must facilitate immediate access to anaesthetists and other specialists when necessary.
2. Facilities
A. Location and Layout
The PACU should be:
Close to Operating Theatres: Ensures rapid transfer and access to care.
Designed for Visibility: Layout must enable clear line-of-sight nursing care for all patients.
Spacious: Minimum 9 m² per bed/trolley, allowing sufficient space for equipment and staff during emergencies.
Separate areas for paediatric, obstetric, and infectious patients should be available where relevant.
B. Equipment
Each bed space must have:
Monitoring Devices:
Pulse oximeter, blood pressure monitor, and ECG.
Capnography for patients with endotracheal tubes.
Airway Management:
Oxygen delivery systems, suction, and intubation equipment.
Emergency Equipment:
Defibrillator, manual ventilation devices, and emergency drug trolleys for anaphylaxis, cardiac arrest, or malignant hyperthermia.
Other Essentials:
Intravenous equipment, warming devices, temperature monitoring, and point-of-care testing tools (e.g., glucose meters).
C. Medications
The PACU should have immediate access to drugs for:
Pain management.
Postoperative nausea and vomiting.
Cardiovascular, respiratory, and neurological emergencies.
3. Patient Management Protocols
A. Handover Process
Anaesthetists must provide a detailed verbal and written handover, including:
Patient identification.
Anaesthesia details (e.g., drugs, airway management).
Surgical events and anticipated postoperative complications.
PACU staff must explicitly accept responsibility for the patient before the anaesthetist departs.
B. Observation and Monitoring
Continuous monitoring of airway, respiratory, cardiovascular function, and level of consciousness is mandatory.
Additional procedure-specific assessments (e.g., neurological or vascular observations) should be performed as required.
C. Discharge Criteria
Patients must meet established criteria before discharge, including:
Stable cardiovascular and respiratory status.
Effective pain control.
Normothermia and no active bleeding.
Recovery of consciousness and motor/sensory function.
D. Emergency Response
An effective emergency call system must be in place to summon immediate assistance.
4. Design and Infrastructure
A. Patient Comfort and Privacy
Respect patient dignity by providing curtained or private areas when possible.
Separate paediatric areas must allow for parental presence and adequate space for carers.
B. Infection Control
Facilities should support the isolation of infectious patients if necessary.
Conclusion
The safe operation of a PACU requires well-trained staff, appropriate infrastructure, and standardized protocols. These principles ensure optimal patient care during the vulnerable recovery phase following anaesthesia.
SQ_1.18 Demonstrate knowledge of criteria for safe discharge of patients from the post anaesthesia care unit
Criteria for Safe Discharge from the Post-Anaesthesia Care Unit (PACU)
Discharge from the PACU requires ensuring patients meet specific physiological and safety benchmarks to minimize risks of complications after leaving the recovery area. The criteria focus on airway, breathing, circulation, pain control, and overall readiness.
1. Key Discharge Criteria
A. Airway and Breathing
Airway Patency:
Patient maintains a clear airway without assistance.
No signs of obstruction (e.g., stridor or snoring).
Adequate Ventilation:
Stable respiratory rate within the normal range.
Oxygen saturation ≥ 92% on room air or baseline oxygen requirement.
Absence of significant respiratory distress (e.g., tachypnea or accessory muscle use).
B. Circulation
Hemodynamic Stability:
Blood pressure and heart rate within 20% of preoperative baseline.
No significant arrhythmias or signs of shock.
Peripheral Perfusion:
Warm extremities and capillary refill < 2 seconds.
C. Neurological Status
Consciousness:
Fully awake, or at baseline mental status for sedated or elderly patients.
Responsive to verbal stimuli and able to follow simple commands.
Motor and Sensory Function:
Recovery of motor and sensory function after regional or neuraxial anaesthesia.
D. Pain Management
Adequate Pain Control:
Pain level tolerable or controlled with oral or IV analgesics.
Pain relief that does not impair breathing or hemodynamic stability.
E. Nausea and Vomiting
Minimal or Controlled Symptoms:
Patient can tolerate oral fluids without persistent nausea or vomiting.
F. Temperature Regulation
Normothermia:
Core temperature ≥ 36°C, or return to baseline.
Absence of shivering or hypothermia-related complications.
G. Surgical Site
Stable Wound Status:
Dressings intact with no excessive bleeding or discharge.
2. Additional Considerations
A. Criteria for Specialized Groups
Paediatrics:
Comfort with parents and ability to maintain hydration.
Adequate return to baseline activity level.
Obstetrics:
Monitoring for uterine tone and bleeding.
B. Specific Anaesthetic Techniques
Regional Anaesthesia:
Recovery of sensation and motor function.
Monitoring for complications like hematoma or hypotension.
General Anaesthesia:
Full recovery from sedation with adequate protective reflexes.
3. Discharge Documentation
Complete documentation of PACU course, including vital signs, medications, and any complications.
Handover to the next team, including recovery status and specific instructions.
4. Scoring Systems to Assist Decision-Making
A. Modified Aldrete Score
Evaluates activity, respiration, circulation, consciousness, and oxygen saturation.
Score ≥ 9 typically indicates readiness for discharge.
B. Post-Anaesthetic Discharge Scoring System (PADSS)
Includes pain, mobility, hydration, and surgical site criteria for ambulatory patients.
5. Criteria for Admission to Higher Care
Persistent hemodynamic instability.
Need for advanced airway or respiratory support.
Uncontrolled pain or bleeding.
Neurological compromise.
6. Communication with Patients and Families
Provide clear discharge instructions, including:
Pain management and medication guidelines.
When to seek medical help (e.g., for bleeding, respiratory issues).
Arrangements for safe transport home if applicable.
Conclusion
Safe discharge from the PACU relies on meeting specific physiological and functional benchmarks tailored to the individual patient. Structured assessment using tools like the Aldrete Score ensures readiness while reducing the risk of adverse events.
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