42. CRISIS IN ANAESTHESIA

A crisis rarely occurs during an anaesthetic. Mishaps that do occur include hypotension, hypovolaemia, hypoventilation, hypoxia, airway obstruction, aspiration, drug overdose, equipment failure, inadequate preparation, inexperience, inadequate vigilance and inadequate treatment of anaesthetic problems.

A life-theatening crisis may appear to occur suddenly during an anaesthetic but usually they develop over time with one or more problems becoming more severe until the patient is at risk. Problems may happen with the patient (e.g. myocardial ischaemia), surgery (e.g. blood loss), anaesthesia (e.g. endotracheal tube disconnection) and with equipment (e.g. anaesthetic machine). A good anaesthetist can detect and correct a problem early to prevent it from becoming a crisis.

Prevention

The anaesthetist may prevent a crisis during an anaesthetic by always doing a complete preoperative assessment of each patient, planning the anaesthetic and checking all equipment. If the anaesthetist is uncertain how to anaesthetise a patient or believes that it is unsafe to anaesthetise a patient they must discuss their concerns with other anaesthetists and the surgeon before giving the anaesthetic. In some cases the patient may be too ill to safely have an anaesthetic.

Crisis Management

The anaesthetist must have a plan to treat any crisis. Remember that common problems happen commonly but rare problems may also be life theatening.

With any anaesthetic crisis the anaesthetist must take command. They should call for help early rather than late. The anaesthetist must use all the available people in theatre. In an emergency anaesthetists cannot do everything themselves. They must decide what needs to be done and who needs to do it. They must communicate well. In a crisis the anaesthetist should state their commands clearly and directly to a person. That person should repeat what the anaesthetist has asked, to make sure that they have clearly heard what the anaesthetist needs.

During a crisis the anaesthetist must repeatedly assess and re-evaluate the crisis. They must ask themselves did my action have an effect, is the problem getting better or worse, are there side-effects from my actions, are there any new problems and was my first diagnosis correct?

Recognise the problem early

Call for help

Start immediate treatment

Re – evaluate

Diagnose the underlying cause

Begin definitive treatment

Errors of Crisis Management

The anaesthetist must avoid errors of crisis management. It is easy to believe that everything will be all right and take no action despite a problem occurring. It is also easy to believe that your first diagnosis is correct and fail to reassess the crisis, and change your diagnosis even when the problem is becoming worse. Finally, it is easy to be hesitant to start treatment even though you know there is a problem.

The anaesthetist must also be aware of his or her own attitude to a crisis. Some attitudes can make a crisis worse. They must not be antiauthority and believe that policies are for someone else. They should follow the rules, the rules are usually right. They should not be impulsive, think first. They must not be arrogant and overconfident. A crisis can happen to anyone. Taking chances is foolish. Plan. The anaesthetist must not be timid. When a crisis happens they must act.

 IN EVERY CRISIS