handling crisis in or

Handling Crisis in OR

Lok Tsz KiAPN (OT/SURG)

HKCH

Operating Room Critical Event

1. Air Embolism

2. Anaphylaxis

3. Bradycardia – Unstable

4. Cardiac Arrest

5. Failed Airway

6. Fire

7. Haemorrhage

8. Malignant Hyperthermia

9. Local Anaesthetic Toxicity

Debriefing after event

Suspected Events

1. Air Embolism -Decreased end-tidal CO2, decreased oxygen saturation, hypotension, tachycardia, ECG changes

Œ Call for help and get the resuscitation trolley

Who is the leader?

Inform the surgeon

Nitrous oxide stopped? FiO2 increased to 100%

‘ Stop source of air entry

•Wound filled with irrigation or cover in saline soaked swabs

•Surgical site lowered the level of the heart if possible

•Entry point search (including open venous lines)

Consider: • Left side down once source

controlled • Additional monitoring • Fluid bolus • Inotropes - adrenaline +/-

infusion

Additional Considerations: Aspiration air from CVP line

Discontinuation operation

Arrange supportive care in

ICU

Critical CHANGES

? ASYSTOLE/PEA develops

? VT/VF develops

2. Anaphylaxis -Hypotension, bronchospasm, high peak-airway pressures, decreased or lack of breath sounds, tachycardia, urticaria


Who is the “hands-off” leader?

FiO2 increased to 100% and consider turning off volatile agent

Adrenaline bolus - 50-100mcg and repeated as required

Potential causative agents removed?

‘ Airway established/secured?

’ IV access adequate?

“ IV Fluids bolus

Consider:

Consider additional lines and investigations

Arterial line / Central line

ABG, electrolytes, FBC, Coagulation Screen

Consider antihistamine/steroids

Dexamethasone / Hydrocortisone

Arrange post-operative cares in HDU/ICU

-If bradycardia occurs: invariably heralds

cardiovascular collapse

-Other that may be implemented:

• Blood products

-Referral for allergy testing

Common CAUSATIVE AGENTS

Chlorhexidine

Latex

Antibiotics

Colloids

Neuromuscular blockers

DRUG DOSES and treatments

Adrenaline Bolus: 50-100mcg IV

Infusion: 5mg in 50ml

NS, run at 3-30ml/hr

Noradrenaline Infusion: 4mg in 40ml

NS, run at 3-30ml/hr

Vasopressin Bolus: 1-2 units IV

Infusion: 2units/hr

Salbutamol Bolus: 250mcg IV

Infusion: 5-

25mcg/min

Glucagon 1-5mg over 5 min

Critical CHANGES

? ASYSTOLE/PEA develops

? VT/VF develops

Adrenaline +/- Noradrenaline infusion

Vasopressin

Salbutamol - if resistant bronchospasm

Glucagon – for beta blocker reversal

3. Bradycardia – Unstable -HR <50bpm with hypotension, acutely altered mental state, shock, ischaemic ECG, acute heart failure


Who is the leader?

Turn FiO2 to 100% and consider turning off volatile agent

Give atropine 0.6mg IV (may repeat up to 3mg)

Stop surgical stimulation (if laparoscopy, desufflate)

‘If atropine ineffective •Start adrenaline infusion

- or -•Start transcutaneous pacing

’ Confirm pulse present - if PEA develops

Consider:

Urgent cardiology consultation

Myocardial infarction

Drug induced causes eg. β/Ca2+

channel blockers, digoxin, LA toxicity

Critical CHANGES

If PEA develops? ASYSTOLE/ PEA

If LA toxicity? LA TOXICITY

During RESUSCITATION

Airway Assess and secure

Circulat

ion

Confirm IV access, IV fluids

wide open

TRANSCUTANEOUS PACING instructions

-Select MANUAL ON on defibrillator

-Apply electrodes and pads & connect

to defibrillator

-Press PACER

-Adjust RATE to 80/min – can adjust

once established

-Press START

-Adjust OUTPUT (mA) until electrical

capture

-Pacer spikes aligned with QRS

complex; normally 65-100mA.

-Set final milliamperes to 10mA

above this level.

-Confirm mechanical capture - cardiac

output


Adrenaline Infusion: 3-30ml/hr

(5mg in 50mls)

Atropine 0.6mg IV (Max. 3

doses)

OVERDOSE treatments

Beta blocker:

Glucagon

2-4mg IV push

Ca channel blocker:

CaCl2

1g IV

Digoxin:

digoxin immune FAB

10 vials

Transvenous pacing if transcutaneous pacing is ineffective.

4a. Cardiac Arrest :Asystole/PEA-Non-shockable pulseless cardiac arrest


Who is the leader?

Ž Say “CPR”

Start CPR and assessment cycle

Perform CPR •“Hard and fast” compressions 100/min

•Minimal interruptions

•8 breaths/min, do not overinflate Ø Give adrenaline

•Repeat every second cycle Ø Assess every 2 minutes

•Change CPR provider

•Check rhythm; if rhythm is organized, then check pulse

-VF/VT → resume CPR – defibrillation – assessment cycle

-Asystole/PEA → resume CPR and assessment cycle

Critical CHANGES

If VF/VT develops

During CPR

Airway: Assess and secure

Circulation: Confirm IV access, IV fluids

wide open

Assign roles:

Chest compressions, Airway,

Vascular access, Documentation,

Drugs


Adrenaline 1mg IV, repeat every 2nd

cycle

TOXIN treatment

Local anaesthetic :

Intralipid

-1.5ml/kg IV bolus

-Repeat 1-2 times in

persistent asystole

-Start infusion 0.25-

0.5ml/kg for 60mins for

refractory hypotension

Beta-blocker :

Glucagon

2-4mg IV

Ca channel blocker :

Calcium Chloride

1g IV

HYPERKALAEMIA treatment

Calcium Chloride 1g IV

Insulin 10 u actrapid in 50 ml of

50% dextrose

Sodium bicarbonate 0.5-1mmol/kg slow IV

Reversible clauses: 5Hʼs & 5Tʼs

Hypovolaemia Tension pneumothorax

Hypoxia Tamponade, cardiac

Hyper/

hypokalaemia

Toxins (beta blocker ,Ca2+

channel blocker, local

anaesthetic)

Hypothermia Thrombosis (pulmonary)

Hydrogen ion Thrombosis (coronary)

4b. Cardiac Arrest – VF/VT -Shockable pulseless cardiac arrest

Call for help and the resuscitation trolley

Who is the leader?

� Say “Start CPR and shock patient as soon as defibrillator arrives”

FiO2 100% and stop volatile anaesthetics

Start CPR – defibrillation – assessment cycle -Perform CPR

“Hard and fast” compressions 100/min

Minimal interruptions

-Defibrillate

Shock at 120-200J (Biphasic), 360J (Monophasic)

Resume CPR immediately after shock

-Give adrenaline

Repeat every 2nd cycle

Consider amiodarone (ANTIARRHYTHMICS) after 3rd cycle Ø Assess every 2 minutes

-Change CPR compression provider -Treat reversible causes, consider reading out 5Hʼs & 5Tʼs -Check rhythm; if organised, check pulse

•VF/VT → resume CPR – defibrillation – assessment cycle •Asystole/PEA → resume CPR and assessment cycle

During CPR

-Airway Assess and secure

-Circulation Confirm IV access, IV fluids

wide open

-Assign roles :

Chest compressions, Airway,

Vascular access, Documentation,

Drugs

Reversible clauses: 5Hʼs & 5Tʼs

Hypovolaemia Tension pneumothorax

Hypoxia Tamponade, cardiac

Hyper/

hypokalaemia

Toxins (beta blocker ,Ca2+

channel blocker, local

anaesthetic)

Hypothermia Thrombosis (pulmonary)

Hydrogen ion Thrombosis (coronary)


Adrenaline 1mg IV, repeat

every 2nd cycle

Amiodarone Bolus: 300mg IV

after 3rd cycle

Infusion: 900mg IV

over 24 hours

Magnesium Bolus: 2g IV for

torsades de pointes

DEFIBRILLATOR instructions

Select ENERGY 120-200J on defibrillator according to manufactor’s

recommendation

Apply pads to chest & connect to defibrillator

Consider SYNC shock if VT

Press CHARGE

Say “Stand Clear” and press SHOCK

Synchronised Cardioversion:

• Requires defibrillator ECG to be attached to the patient

• Pads will not discharge immediately as QRS complex needs to be detected

• Keep the SYNC button pressed until shock delivered

TACHYCARDIA RHYTHMS where synchronisation indicated:

• Atrial fibrillation

• Mono-morphic VT

• Other SVT, atrial flutter

5. Failed Airway -2 unsuccessful intubation attempts by an airway expert with

adequate muscle relaxation

Œ Call for help and consider calling for surgical/ENT assistance

Get difficult intubation trolley and the Glidescope

Who is the leader?

Bag-mask ventilate with 100% O2

“The top priority is oxygenation”‘ Is ventilation adequate?

NOT ADEQUATE Remains NOT ADEQUATE

Ø Optimise Ventilation • Reposition patient

• Oral airway/nasal airway

• Two-handed mask

Ø Check equipment • Using 100% O2

• Capnography

• Circuit

Ø Check ventilation

Place laryngeal mask airway

(LMA/iLMA)

If unsuccessful, attempt intubation

using video laryngoscope

Prepare for surgical airway Ø Paralysis

adequate?

Consider

• Urgency of surgery

• Aspiration risk

• Airway swelling

• Obstetrics - fetal status

Ventilation still NOT ADEQUATE

Implement surgical airway (Tracheostomy)/Cricothyrotomy

If ventilation status changes

awakening patient

OR

alternative approaches

to secure airway

Alternative approaches to secure airway

• Operation using LMA, face mask

• Video laryngoscope

• LMA as conduit to intubation

• Return to spontaneous ventilation

• Different blades

• Intubating stylet

• Fiberoptic intubation

• Retrograde intubation

• Blind oral or nasal intubation

6. Fire -Surgical fire: Evidence of fire (smoke, odour, flash) on patient

or drapes, or in patient's airway

-Environmental fire: Evidence of fire (smoke, odour, flash) in OT/surrounding areaŒ

Call for help

Who is the leader?

Extinguish of fire / Evacuation

For AIRWAY fire

Attempt to extinguish fire •Shut off medical gases •Disconnect ventilator •Remove ETT and flammable material from airway •Pour saline into airway After fire extinguished 1. Re-establish ventilation using self-inflating bag with room air management plan • Re-establish ventilation • Avoid NO2 and minimize FIO2 2. Confirm no secondary fire 3. Equipment•Check surgical field, drapes and towels materials/devices for review •Assess airway for injury or foreign body •Assess ETT integrity (fragments may be left in airway) •Consider bronchoscopy Assess patient status and devise ongoing plan Save involved materials/devices for review

For NON-AIRWAY fire

•• Follow Fire Diaster Plan and department protocol

7. Haemorrhage-Acute massive bleeding

Œ Call for help

Who will be the leader?

Open IV fluids and assess for adequate IV access

FiO2 100%

Inform blood bank

-If shocked & uncontrolled bleeding → massive transfusion protocol

-If controlled bleeding → ask for 4 units RBC / according to anaesthetists'order

-If no group and screen → ask for unmatched blood (O negative)

‘ Request rapid infuser or fluid warmer and pressure bags

’ Discuss management plan among surgical, anaesthesia and nursing teams

“ Keep patient warm

” Send ABG or venous blood sample, repeat regularly

TRANSFUSION Goals

MAP >50 but do not normalize until surgical control

Fibrinogen >2.0g/L

Red blood Cells >70g/L

Platelets >50 x 109/L

Adverse effect of massive blood transfusion and treatments

Hypocalcemia Calcium Chloride 10% 10ml IV. Repeat as required

Hyperkalemia Insulin

10u actrapid in 50 ml 50%

Dextrose

AcidosisSodium bicarbonate

0.5-1 mmol/kg IV to maintain

ph>7.2

ANTIFIBRINOLYTIC Tranexamic acid

1g IV over 10min then 1g over 8

hrs

8. Malignant Hyperthermia -In presence of triggering agent: unexpected increase in end-

tidal CO2, unexplained tachycardia/tachypnoea. Prolonged masseter muscle spasm after succinylcholine. Hyperthermia is a late sign.

Call for help and notify surgeon

Who will be the leader?

Get Malignant Hyperthermia (MH) Box

Assign task cards to individuals

ŽSay “Dantrolene administration is the priority”

Turn off volatile agent and remove triggering agents

Hyperventilate with 100% oxygen and high fresh gas flows (>15L/min)

Add vapour-clean filters. Do not change machine.

‘ Commence non triggering anaesthesia

’ Dantrolene administration in progress?

“ Lines and investigations (ABG) in progress?

” Patient cooling: Cold IV fluids running + ice pad + cold irrigation

Simultaneously treat life threatening effects:

Hyperthermia / Acidosis / Hyperkalaemia / Arrhythmias

9. Local Anaesthetic Toxicity -Sudden alteration in mental status, Numbness of tongue,tonic-

clonic seizure, cardiovascular arrhythmias or collapse

Œ Stop injecting the local anaesthetic

Call for help (Crash call)Resuscitation trolley

Intralipid

Who is the leader?

FiO2 increased to 100% and secure airway

‘ Control seizures with midazolam or propofol

’ Assess cardiovascular status Circulatory arrest

Start CPR – defibrillation – assessment cycle

Administer Intralipid

Manage arrhythmias

If not in circulatory arrest

Treat hypotension, bradycardia, tachyarrhythmias

Consider Intralipid


Adrenaline1mg IV, repeat

every 2nd cycle

Amiodarone Bolus: 300mg IV

after 3rd cycle

Infusion: 900mg

IV over 24 hours

Atropine Bolus: 0.6mg IV

Intralipid 1.5ml/kg IV bolus

X Propofol is not a

substitute for

intralipid

X Avoid using

lignocaine

Debriefing after a critical incident - Reflection of facts and processes, sharing emotions, learning experience, reporting Who is the “debriefer” – the chair of the meeting?

State the confidentiality of the meeting

Identify and introduce each member of the team

•Say “All should have an opportunity to contribute.”

Invite sharing of emotional reactions

•Recognise and acknowledge stress

Clarifying what happened

•Try to establish what happened during the incident response

What are the learning points and any changes for the future?

•Consider review of structure/processes

•Consider review of policy/guidelines

•Further education

Discuss reporting/investigation of the event

Reporting Channel

Conclude by restating confidentiality of the debriefing

Thank you

handling crisis in or

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