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Jerey J. Schwartz, MD
Associate Professor
Department of Anesthesiology
Yale University School of Medicine
New Haven, CT
Kinza Sentissi, MD
Resident
Department of Anesthesiology
Brigham and Women’s Hospital
Boston, MA
Shahzad Shae, MD
Instructor in Anaesthesia
Department of Anesthesia, Critical Care and Pain
Medicine
Beth Israel Deaconess Medical Center
Harvard Medical School
Boston, MA
Aali Shah, MD
Assistant Professor of Clinical Anesthesia
Indiana University School of Medicine
Indianapolis, IN
Deepak Sharma, MBBS, MD, DM
Departments of Anesthesiology & Pain Medicine
and Neurological Surgery
University of Washington
Seattle, WA
Andrew Shaw, MB, FRCA, FFICM, FCCM
Professor and Executive Vice Chair
Department of Anesthesiology
Vanderbilt University School of Medicine
Nashville, TN
Kara Siegrist, MD
Anesthesiology Resident
Vanderbilt University Medical Center
Nashville, TN
Bantayehu Sileshi, MD
Department of Anesthesiology
Vanderbilt University Medical Center
Nashville, TN
Julia Sobol, MD
Assistant Professor of Anesthesiology
Columbia University Medical Center
NewYork- Presbyterian Hospital
New York, NY
Alissa Sodickson, MD
Sta Anesthesiologist
Department of Anesthesiology, Perioperative
and Pain Medicine
Brigham and Women’s Hospital
Boston, MA
Andrew F. Stasic, MD
Associate Professor of Clinical Anesthesia
Indiana University School of Medicine
Indianapolis, IN
Jing Tao, MD
Assistant Professor
Department of Anesthesiology
Yale University School of Medicine
New Haven, CT
Paloma Toledo, MD, MPH
Center for Healthcare Studies
Northwestern University, Feinberg School of Medicine
Chicago, IL
Muoi Trinh, MD, MPH
Assistant Professor of Anesthesiology
Department of Anesthesiology
Icahn School of Medicine at Mount Sinai
New York, NY
Agnieszka Trzcinka, MD
Instructor of Anesthesia
Department of Anesthesiology, Perioperative
and Pain Medicine
Brigham and Women’s Hospital
Harvard Medical School
Boston, MA
Gebhard Wagener, MD
Associate Professor
Department of Anesthesiology
Columbia University College of Physicians and Surgeons
New York, NY
XX CONTRIBUTORS
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xxi
Cynthia Wang, MD
Assistant Professor
Department of Anesthesiology and Pain
Management
University of Texas Southwestern Medical Center
Dallas, TX
Scott C. Watkins, MD
Assistant Professor of Anesthesiology
Department of Anesthesiology
Division of Pediatric Anesthesia
Vanderbilt University Medical Center
Nashville, TN
Sheena M. Weaver, MD
Assistant Professor of Clinical
Anesthesiology
Department of Anesthesiology
Division of Critical Care Medicine
Vanderbilt University Medical Center
Nashville, TN
Christopher Allen- John Webb, MD
Clinical Instructor of Anesthesiology
Regional Anesthesiology Fellow
Department of Anesthesiology, Perioperative,
and Pain Medicine
Stanford University
Stanford, CA
Paul David Weyker, MD
Critical Care Fellow
Department of Anesthesia and
Perioperative Care
University of California, San Francisco
San Francisco, CA
Peggy White, MD
Assistant Professor of Anesthesiology
Department of Anesthesiology
University of Florida
Gainesville, FL
Cristina Wood, MD, MS
Assistant Professor
Department of Anesthesiology
University of Colorado School of Medicine
Aurora, CO
Stephanie Yacoubian, MD
Sta Anesthesiologist
Department of Anesthesiology, Perioperative
and Pain Medicine
Brigham and Women’s Hospital
Boston, MA
Natacha Zamor, MD
Sta Anesthesiologist
Signature Healthcare
Brockton, MA
Jamie M. Zorn, MD
Obstetric Anesthesiology Fellow
Department of Anesthesiology
University of Pittsburgh School of Medicine
Magee- Womens Hospital of the University of Pittsburgh
Medical Center
Pittsburgh, PA
CONTRIBUTORS XXI
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ADVANCED PERIOPERATIVE CRISIS
MANAGEMENT
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1
PART I.
CRISIS RESOURCE MANAGEMENT
NONTECHNICAL SKILLS OF TEAM PERFORMANCE
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1.
A CRITICAL THINKING APPROACH TO THE UNSTABLE PATIENT
Mark E. Nunnally, Arna Banerjee, and Matthew D. McEvoy
INTRODUCTION
deliberately practice managing these situations, and reect
on their performance.11 Although emphasis is placed on
Several factors unfairly shape the medical community’s
approach to crisis. First, almost all assertions about adequacy of care are inuenced by hindsight bias.
1,2
Second,
there is a common misperception that choices are obvious
in real time, and that there are simple routes to success and
failure.3 Such factors underscore the truth that clinicians do
not think enough about how to think about crises.
Cardiac arrest under anesthesia is rare, and outcomes
are better in the perioperative arena than in other settings,
particularly out of hospital arrest. Modern estimates of incidence range from 5.64 to 7.1 per 10,000.5 Encountering
a rare event interrupts routine care and can lead to errors
in patient care and result in injury to the patients or sentinel events.6 With such a low frequency, it becomes
challenging to maintain competence in these areas, and
practitioners must master skills in crisis management independent of direct practice. is chapter focuses on two such
approaches. e rst is learning to recognize deterioration
early enough to reverse it and avoid arrest. e second is
practicing simulated crises.
Recognizing crisis and taking evasive action are dicult skills. e rareness of cardiac arrest is confounded by
the multiple sources of failure, further rarefying infrequent
events. However, the practice of anesthesiology deals with
rare complications routinely. Dicult mask ventilation
combined with dicult laryngoscopy might occur at a frequency of 4 in 1000,7 while malignant hyperthermia occurs
in about 0.18 in100,000.8 In order to be prepared for rescue, low- frequency events need to be regarded as routine.
medical knowledge and learning technical skills, critical
incident reporting and observational studies show that
nontechnical skills such as dynamic decision- making and
teamwork are a major determinant of success in crisis management.12 To manage a crisis a clinician must rst detect
the problem and then take necessary steps to correct it. is
involves a constant loop of observation and recognition of
the crisis, dynamic decision- making, and therapeutic action
followed by reevaluation.
Strategies used in Cockpit/ Crew Resource Management
(CRM) have been adopted by the healthcare industry to aid
in this process and promote safety. ese include the use of
checklists and cognitive aids, established protocols for crisis management, and formal training in dynamic decisionmaking, resource management, and teamwork. Studies
have shown that acquisition of these skills requires specic
education.13 Simulation- based curricula have been developed to integrate these strategies and teach these skills.
16
Teamwork training programs have also been developed,
14-
of which TeamSTEPPS, Veterans Aairs Medical team
training program, and CRM are a few. e Eective
Management of Anesthetic Crises course is a standardized 2.5- day simulation- based course and is a component
of training for Fellowship of Australian and New Zealand
College of Anesthetists.
17
ere is growing knowledge that to successfully manage
a crisis a clinician requires both technical and nontechnical
skills. Nontechnical skills complement technical skills and
contribute to safe and ecient task performance. ey do
not relate to medical knowledge and can be broadly divided
IS THIS A PROBLEM?
into two categories— cognitive skills (resource utilization,
planning, decision- making, situation awareness) and interpersonal skills (team work, leadership, communication).18
Even the astute and experienced clinician can make errors
during crisis situations,9 as shown by closed claims analysis and simulated studies.10 To attain expertise, clinicians
need to be exposed to these rare challenging situations,
Simulation- based curricula have been developed and used
eectively to teach and practice these skills.
19
Human factors literature shows that cognitive functions
can fail during stress. Cognitive aids (posters, owcharts,
3
4
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checklists, mnemonics) can aid clinicians during crisis situations and help them recall key actions.20 Simulated training sessions may be helpful in educating clinicians on the
use and implementation of these aids.21 Mnemonics and
protocols have also been developed to aid specically during crisis.
22
But, does this training translate into clinical practice?
Studies have shown that rst- year residents perform better
than third- year residents aer simulation- based education
in critical care medicine.23 In a review of a small number
of studies using simulation- based learning, authors found
that CRM skills learned in the simulation center are
transferred to the clinical setting and this improves clinical outcome and may even show a decrease in mortality.24
Simulation- trained residents also responded to cardiac
arrest events with greater compliance to American Heart
Association protocols than more experienced team leaders
not trained with simulation.25 More studies are required
to see whether simulation- based CRM training improves
patient outcome.
quite right may be the best way for experts to see an arrest
before it happens— this likely means that there is a deep
level of pattern recognition/ perturbation to which one
should pay attention in routine processes of care, always
asking why a patient may be deviating from responding to
ongoing management as expected.
When crisis, or pending crisis, is recognized, clinicians
must act quickly and decisively. Creating and narrowing a
dierential diagnosis and formulating a stepwise approach
to management lets a clinician take decisive action in the
short space of time before arrest occurs. A classic strategy, promoted by Lawrence D. H. Wood, involves asking
three crucial questions of the patient’s circulation.28 e
rst question asks whether the cardiac output is too high
or too low. is question splits the dierential diagnoses
into high- and low- cardiac output shock states. e second
asks whether the heart is too full or too empty. Intravenous
uid resuscitation is frequently a solution to intraoperative shock, but there are times when resuscitation might be
harmful. e nal question addresses “what doesn’t t?”
Rarely is crisis the result of a single random event. Shock
PRINCIPLES FOR DEVELOPING A CRITICAL
THINKING APPROACH
can unmask other problems. An astute clinician should
always be thinking of concomitant problems or alternative
explanations.
Crisis rarely occurs out of the blue, but it seems that way in
real time. e evolution of arrest is oen presaged by subtle
abnormalities. Although these abnormalities take time to
evolve, oen they are not clinically apparent until shortly
before crisis, and they do not cross a detectable threshold
until late in their evolution.26 Combinations of more subtle
signs may be apparent earlier, but detection of these requires
expertise and is confounded by xation bias,27 when there is
a natural tendency to focus on one feature to the exclusion
of others. is is one reason why someone new to a crisis
situation may see things those involved in the process over
time will not.
How does a clinician best recognize and treat instability? Traditionally this emphasizes vital signs, which
oer reasonable sensitivity but poor specicity until crisis is imminent. A systolic blood pressure of 95 mmHg in
an adult could be benign or a marker of pending arrest.
Another approach is to look at markers of perfusion as a
way to assess the adequacy of the circulation. Urine output, serum lactate, assessment of tissue oxygenation, as with
near- infrared spectroscopy (NIRS) or other tissue- specic
probes, or central or mixed- venous hemoglobin oxygen
saturations are indirect variables for the assessment of the
circulation. Finally, understanding that experts may unconsciously recognize patterns, any sense that something is not
SOME PRACTICAL STEPS
As noted above, persistent vigilance and practice are two
key components to being prepared when a perioperative
crisis occurs. A mental model that may help when such an
event does occur should, as noted above, start with circulation. While there are a number of major categories in which
emergencies can occur (as denoted in the sections of this
book), the nal common pathway for all crises involves the
circulatory system. As such, starting with an evaluation of
hemodynamics and then moving to other systems is logical, particularly for the novice, but also for the expert— any
of whom can be prone to mental errors under stress. us,
when a patient becomes unstable, we suggest that clinicians
as the following questions:
1. Is there a pulse? [If no, start CPR and follow
appropriate ACLS management guidelines, with noted
alterations based on specic diagnosis (e.g., LAST)]
2. Is the origin of the instability:
a. Pump— need for inotropic support?
b. Pipes— need for increased/ reduced aerload?
4 PART I. CRISIS RESOURCE MANAGEMENT
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c. Preload— need for additional preload/ volume?
d. Voltage— arrhythmia causing disturbance?
e. Vessels— coronary ischemia/ infarction?
f. Valves— severe valvular disease causing problem?
3. If answers to all of the above are “no,” then the issue is
not directly of cardiac origin and the clinician can move
to sequentially assessing other organ systems:
a. Pulmonary— oxygenation, ventilation, mechanics,
airway control?
b. Neurologic— global or focal issue? peripheral or
central?
c. Metabolic/ Endocrine— past medical history? recent
lab values?
d. Toxins— medication administration history, and so
forth.
4. Keep in mind that cardiac instability is always the
nal common pathway and that this sequence should
be iteratively pursued until a denitive diagnosis
is reached, the problem averted, and the patient is
stabilized.
As you approach subsequent chapters in this text, we
encourage continued use of this paradigm to consider how
to place each specic diagnosis and treatment within one’s
overall mental model for approaching the unstable patient.
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