acid: anaesthetic critical incident drills trainee …...03a_unexpected hypoxia you are 15 minutes...

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ACID: Anaesthetic Critical Incident Drills

Trainee Package !

Key Basic Plan for Management of Critical Incidents- Look, Listen, Feel:

Adequate Oxygen Delivery

Adequate FGF Check FiO2

Connections Bag / Bellows Moving

Clear Airway

Airway position, Airway noise

Adjuncts, LMA / ETT Clear

Capnograph Trace

Check Breathing

Rate, Symmetry, SpO2

Exp tidal volume, EtCO2 Airway pressure

Check Circulation

Rate, Rhythm Perfusion

BP

Check Depth

Anaesthesia Analgesia

Consider Surgical Problem

Call for HELP if problem not resolving quickly

01A_Unexpected increase in peak airway pressure You are 30 minutes in to anaesthetic maintenance of a 35 year old female undergoing elective gynaecological exploratory laparoscopy under general anaesthetic. Her history includes cigarette smoking and she is otherwise fit and healthy. Since moving to the head down position, the peak airway pressure has gone up to 39cmH2O from 15cmH2O following induction. The uneventful induction was with Propofol 200mg, Rocuronium 30mg and Morphine 5mg. She has a size 8 ETT in situ, being ventilated with Oxygen, Air and Sevoflurane. You have 4 minutes to manage this problem.

Management of increased airway pressure- Look, Listen, Feel:


Adequate FGF Check FiO2 Connections

Bag / Bellows Moving

FiO2 1.0 Confirm pPeak

Clear Airway



Capnograph Trace

Isolate equipment

Suction catheter

for patency

Attach AmbuBag

direct to ETT

Easy to ventilate = EQUIPMENT PROBLEM

Check Breathing



Patient problem:

Reconnect Equipment

Check muscle relaxation

Check Endobronchial

ETT

Neutral position

Release abdo gas

Broncho-dilators

Check Circulation


BP

Check Depth




02A_Progressive fall in minute volume You are 30 minutes in to anaesthetic maintenance of a 59 year old male undergoing elective repair of umbilical hernia under general anaesthetic. He has acid reflux but is otherwise fit and healthy. The uneventful rapid sequence induction was with Thiopentone 450mg, Fentanyl 100mcg and Suxamethonium 100mg, followed by 5mg Morphine and Vecuronium 6mg. He has a size 8 ETT in situ, being ventilated with Oxygen, Air and Sevoflurane. His expired minute volume on the monitor has reduced from 5L to 2L over the past 5 minutes. You have 2 minutes to manage this problem.

Management of Fall in MV - Look, Listen, Feel:




Check for leak FGF Connections ETT Cuff Capnograph

and tubing

Clear Airway

Airway position, Airway noise Adjuncts, LMA / ETT Clear

Capnograph Trace

Check Breathing



Check Circulation


BP

Check Depth


If spont breathing

Assist ventilation



03A_Unexpected hypoxia You are 15 minutes in to anaesthetic maintenance of a fit and healthy 35 year old male undergoing elective repair of inguinal hernia under general anaesthetic. The SpO2 has been gradually dropping since moving from the anaesthetic room in to theatre and is now 90%. The uneventful induction was with Propofol 200mg and Fentanyl 200mcg followed by an Ultrasound guided ilioinguinal field block with 10ml 0.25% levobupivacaine. He has a size 4 LMA in situ, breathing Oxygen, Air and Sevoflurane. You have 3 minutes to manage this problem.

Management of Unexpected Hypoxia- Look, Listen, Feel:



Connections:Leak Bag / Bellows Moving

FiO2 1.0 Ensure SpO2

accurate

Is it a Perfusion Problem?

Clear Airway



Capnograph Trace

Clear tongue

obstruction

Reposition airway device

Suction catheter

for patency Clear FB /

Kink

Check Breathing


Exp tidal volume, EtCO2

Airway pressure

No movement: Drugs

Asymmetrical: Endobronchial / Pneumothorax

Resp Depressant

Vent settings

Clear lower • Suction • Bronchodilation • Diuretic/PEEP

Check Circulation

Rate, Rhythm

Perfusion

BP

If unstable is it due to hypoxia?

Check ABG

Check Depth

Anaesthesia

Analgesia



04A_Fall in EtCO2 You are 10 minutes in to anaesthetic maintenance of a 75 year old male undergoing urgent DHS for fractured hip sustained within the last 24 hours. He has hypertension and peripheral vascular disease and he is on Aspirin, Ramipril and Bendrofluazide. The uneventful induction was with Propofol 150mg, Fentanyl 100mcg and Vecuronium 6mg, followed by 5mg Morphine and fascia iliaca block with 30ml 0.25% Levobupivacaine. He has a size 8 ETT in situ, being ventilated with Oxygen, Air and Sevoflurane. His EtCO2 was 5.8 following intubation and has gradually reduced to 3.1. You have 3 minutes to manage this problem.

Management of Fall in EtCO2 - Look, Listen, Feel:




Sudden Fall: Disconnection / No lung blood supply

Clear Airway


Capnograph Trace

Check Breathing



Check Circulation


BP

Exclude / Manage �Cardiac Output

Check Depth


Check anaesthesia level

Check analgesia level

Adjust ventilation



05A_Rise in EtCO2 You are 20 minutes in to anaesthetic maintenance of a 17 year old male undergoing emergency exploration of testicle for presumed torsion. He is otherwise fit and healthy. The uneventful rapid sequence induction was with Thiopentone 500mg and Suxamethonium 100mg, followed by Rocuronium 20mg, He has a size 8 ETT in situ, being ventilated with Oxygen, Air and Sevoflurane. His EtCO2 has gradually risen from 4.1 following induction to 6.9 kPa currently. You have 3 minutes to manage this problem.

Management of Rise in EtCO2 - Look, Listen, Feel:




High FiCO2 = Use other drill

Clear Airway


Capnograph Trace

SV with �MV Clear Airway

Assist Ventilation

Consider Depth

Check Breathing



IPPV with �MV Increase MV

Check Circulation


BP

Check Depth


SV with �MV or IPPV with NormMV

="↑CO2"Produc-on

Consider Depth

Consider Uncommon



06A_Rise in FiCO2 You are 10 minutes in to anaesthetic maintenance of an unfasted 25 year old male undergoing emergency reduction of ankle dislocation under general anaesthetic. He is otherwise fit and healthy. The uneventful rapid sequence induction was with Thiopentone 500mg and Suxamethonium 100mg, followed by Fentanyl 50mcg. He has a size 8 ETT in situ, being ventilated with Oxygen, Air and Sevoflurane via a Bain circuit in the anaesthetic room. There is now FiCO2 appearing in the circuit. You have 3 minutes to manage this problem.

Management of Rise in FiCO2 - Look, Listen, Feel:




Check FGF for circuit

Clear Airway


Capnograph Trace

Check Breathing



Airway pressure

Remove Dead Space

�RR: Check anaesthesia &

analgesia Check muscle

relaxation

Check Circulation

Rate, Rhythm

Perfusion

BP

Check Depth

Anaesthesia

Analgesia Circle System CO2 Absorber

(consider ↑FGF) One Way Valves +

Connections

Aux Outlet / Ambubag +

TIVA

Communicate problem with surgeon and request to stop surgery


07B_Cardiac and / or respiratory arrest You are 30 minutes in to anaesthetic maintenance of an elderly female undergoing emergency DHS for fractured hip under general anaesthetic. The uneventful induction was with Propofol 100mg and Fentanyl 100mcg followed by Vecuronium 4mg and fascia iliaca block with 30ml 0.25% Levobupivacaine. She has a size 8 ETT in situ, being ventilated with Oxygen, Air and Sevoflurane. She has developed ventricular fibrillation. You have 3 minutes to manage this problem.

Management of Cardiac Arrest - Look, Listen, Feel:

Call for HELP: Your theatre, Next door theatre, Your senior, 2222. START CHEST COMPRESSIONS 30:2



Connections

FiO2 1.0 Consider turning Volatile / TIVA off

Clear Airway


Capnograph Trace

Breathing



Ventilate patient

Circulation Follow ALS algorithm 2 min Cycles

Adrenaline 1mg after 3rd

Shock

Reversible Causes

Hypoxia Hypovolaemia

Hypo / Hyperkalaemia Hypothermia

Tamponade Toxins

Tension Pneumothorax Thrombosis

Remember Intralipid

Remember anaesthesia once

ROSC

3 Stacked shocks in Cardiac Catheter Lab and Post Op Cardiac

Surgery


08B_Unexpected Hypotension You are 20 minutes in to anaesthetic maintenance of an elderly female undergoing elective umbilical hernia repair. She is usually hypertensive on a beta-blocker and diuretic. She has been fasting all day and is last on your list. The uneventful induction was with Propofol 150mg and Fentanyl 100mcg followed by Vecuronium 4mg and Morphine 5mg. She has a size 8 ETT in situ, being ventilated with Oxygen, Air and Sevoflurane. Her BP was 120/80 following induction but is now 70/30. You have 3 minutes to manage this problem.

Management of Unexpected Hypotension - Look, Listen, Feel:




HR >100 non-sinus = Use Arrhythmia

Drill

Clear Airway


Capnograph Trace

Check Breathing



Exclude High Intrathoracic

Pressure

Check Circulation


↑frequency BP checking

HR <60: Give anticholinergic

HR >100 sinus: Treat as

Hypovolaemia Fluid bolus Head

down Vasopressor /

Intrope

Check Depth


Consider Surgical Problem: Pressure on vena cava, Blood loss


09B_Unexpected Hypertension You are 10 minutes in to anaesthetic maintenance of a 28 year old fit and healthy male undergoing elective nasal septoplasty. The uneventful induction was with Propofol 200mg and Fentanyl 50mcg followed by Vecuronium 4mg. He has a size 8 ETT in situ, being ventilated with Oxygen, Air and Sevoflurane. His BP was 120/80 following induction but is now 160/90. You have 3 minutes to manage this problem.

Management of Unexpected Hypertension - Look, Listen, Feel:




Recheck BP and begin review

↑Depth Anaesthesia

↓Surgical Stimulus

Clear Airway


Capnograph Trace

Check Breathing



Exclude Hypoxia & Hypercarbia

Check Circulation



Fluids: distended bladder, renal failure,

TURP

Check Depth


Consider drug error

Consider drug interaction

Consider medical causes (ICP, Thyroid,

Phaeo, MH)

Consider Surgical Problem: administered vasopressor? / surgical tourniquet time?


10B_Sinus Tachycardia You are 20 minutes in to anaesthetic maintenance of a 21 year old fit and healthy male undergoing emergency laparoscopy for presumed appendicitis. He is usually fit and healthy. The uneventful rapid sequence induction was with Thiopentone 450mg, Fentanyl 100mcg and Suxamethonium 100mg, followed by Vecuronium 4mg and Morphine 10mg. He has a size 8 ETT in situ, being ventilated with Oxygen, Air and Sevoflurane. His heart rate pre-induction was 90 but it has gradually risen to 115. You have 3 minutes to manage this problem.

Management of Sinus Tachycardia - Look, Listen, Feel:




Recheck BP & Begin

Review

↑BP = Use ↑BP Drill

Clear Airway


Capnograph Trace

Check Breathing



Check Circulation



Check Depth


Look for specific cause

Hypovolaemia Sepsis, Drug interaction, Pneumothorax,

Embolism, Cardiac Disease, Unusual conditions (MH, Phaeo, thyroid)



11B_Arrhythmias You are 20 minutes in to anaesthetic maintenance of a 29 year old female undergoing elective laparoscopy for investigation of pelvic pain. She has a history of SVT twice in the past 8 years but is on no medication. She is otherwise fit and healthy. The uneventful induction was with Propofol 180mg, Fentanyl 100mcg followed by Rocuronium 30mg. She has a size 8 ETT in situ, being ventilated with Oxygen, Air and Sevoflurane. She has a narrow complex tachycardia at a rate of 170 which developed suddenly from an initial heart rate of 60. You have 3 minutes to manage this problem.

Management of Arrhythmias - Look, Listen, Feel:




Treat the patient, not the

arrhythmia Recheck

Pulse

No Pulse = Start chest compressions and Use

Cardiac Arrest Algorthm

Clear Airway


Capnograph Trace

Check Breathing



Exclude Hypoxia &

Hypercarbia

Check Circulation



Consider Invasive

Monitoring

If Cardiac Output compromised: Use ALS algorithms (consider

intervention criteria)

Check Depth


Depth of anaesthesia

↓Surgical Stimulus



12B_Convulsions You are 10 minutes in to anaesthetic maintenance of a 54 year old female undergoing elective hysteroscopy for postmenopausal bleeding. She has a history of epilepsy and is on 300mg Carbamazepine twice daily and has self-terminating seizures about once every two months. She is otherwise fit and healthy. The uneventful induction was with Propofol 180mg and Fentanyl 50mcg. She has a size 4 LMA in situ, spontaneously breathing Oxygen, Air and Sevoflurane. She has just begun to have a generalized seizure. You have 3 minutes to manage this problem.

Management of Convulsions - Look, Listen, Feel:


Adequate FGF Check FiO2 Connections

Bag / Bellows Moving

FiO2 1.0 Prevent injury

Notify Surgeon

Clear Airway


Capnograph Trace

May need to stop seizure to manage

airway

Check Breathing



Airway pressure

Assist Breathing

Check Circulation


BP

Check Depth


Check BM

Stop Seizure: Induction Agent Benzodiazapine MgSO4 (Eclampsia) Dextrose (Hypo)

Look for treatable cause: Hypoxaemia, LA Toxicity, Drugs (NB

social history), Sepsis, Pyrexia, Intrinsic CNS, Metabolic



acid: anaesthetic critical incident drills trainee …...03a_unexpected hypoxia you are 15 minutes...

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