Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_938_Библиотеки_им_академика_М_И_Перельмана
.pdf
25 Fundamentals ofManaging theOperative Catastrophe
https://t.me/med1917
327
thyrotomy. Cummings Otolaryngology denes a
cricothyrotomy as “the establishment of a surgical opening into the airway through the cricothyroid membrane (CTM) and placement of a
tube for ventilation” [19]. The importance of
understanding the diagnosis and management of
a difcult airway and emergent treatment is critical to the practicing surgeon, as operative
catastrophes related to inadequate airway and
ventilation have continuously been found to be
some of the leading causes of serious and lifethreatening intraoperative and perioperative
complications [1, 20, 21].
25.3.2.2 Clinical/Diagnosis
ASA practice guidelines acknowledge the variation of denitions of “difcult airway” in the literature and dene this term as “the clinical
situation in which a conventionally trained anesthesiologist experiences difculty with facemask
ventilation of the upper airway, difculty with
tracheal intubation, or both.” They provide a
description of a “failed intubation” as “placement of the endotracheal tube fails after multiple
attempts.” Similarly, one could think of a “failed
airway” as the failure to achieve a controlled airway after multiple attempts by an airway expert
(or an experienced anesthesiologist). Failed airway, resulting from an inability to intubate and
ventilate, has been estimated to occur in the
range of 0.01–2 per 10,000 patients with difcult
endotracheal intubation ranging between 5 and
35 per 10,000 patients and difcult mask ventilation at an incidence of about 5% [19]. A failed
airway can quickly lead to anoxic brain injury
and death. The surgeon and operating room team
are encouraged to be prepared to quickly and
accurately diagnose and address this situation
and provide a mechanism for adequate ventilation and oxygenation when less invasive techniques have failed. A key piece of information in
the management of a failed airway is whether the
patient is able to receive adequate ventilation
(such as bag-mask ventilation) while further
decisions are being made (ranging from awakening the patient to considering alternative
approaches to securing the airway). Below, we
will describe and illustrate the necessary steps
for management of a failed airway including creating a surgical airway via a cricothyrotomy
while understanding that other invasive techniques may also be considered by the team (e.g.,
needle cricothyroidotomy).
25.3.2.3 Treatment
In a failed airway scenario, immediately calling
for help, designating a crisis manager/leader, and
requesting a difcult airway cart and video laryngoscope are all essential steps. If ventilation is
inadequate and an experienced anesthesiologist
has failed to achieve a controlled airway after
multiple attempts, the surgeon should communicate with the team and prepare for the possibility
that a surgical airway will be urgently needed.
While the anesthesiologist continues to attempt
to optimize ventilation, possibly through placement of a laryngeal mask airway, alternative
supraglottic devices, or other approaches, the surgeon should begin to consider what is available to
prep the neck (such as the prep solution available
for the surgical case) and how to obtain supplies
needed for an urgent surgical airway. Cummings
describes a modied “rapid ve-step technique”
which is “simple to learn and faster in obtaining a
surgical airway.” This technique is comprised of
(1) Identifying landmarks and stabilizing the airway, (2) making a vertical skin incision, (3) making a horizontal incision through the cricothyroid
membrane, (4) inserting a clamp to spread and
elevate the airway, and (5) inserting a tracheostomy tube or small endotracheal tube. The
Manual of Emergency Airway Management provides detailed illustrations of the technique used
for an emergency cricothyrotomy (Figs. 25.1,
25.2, 25.3, 25.4, 25.5, 25.6, 25.7) [22]. (Used
with permission from Walls RM, Murphy MF,
editors. Manual of emergency airway management; Fourth Edition. Philadelphia: Lippincott
Williams & Wilkins; 2013).
While ventilation status may change over the
course of treatment, which alters the acuity of the
situation, a surgeon who communicates well and is
prepared for the possibility of a surgical airway can
be a life-saving member of this critical scenario.
328
https://t.me/med1917
I. Franco et al.
a
b
Fig. 25.1 (a) Surface anatomy of the airway. (b) The
thumb and long nger immobilize the superior cornua of
the larynx; the index nger is used to palpate the cricothyroid membrane. (Used with permission from Walls RM,
Murphy MF, editors. Manual of emergency airway management; Fourth Edition. Philadelphia: Lippincott
Williams & Wilkins; 2013)
25.3.3 Intraoperative Emergencies
Where theDiagnosis
Is Unclear
25.3.3.1 Hypotension andHypoxemia
Introduction
Hypotension and hypoxemia present a particularly difcult situation for operating room
teams due to their broad differential and subsequent difculty for accurate and efcient diagnosis and treatment. In these situations, clinical
judgment relative to the patient’s history, phys-
Fig. 25.2 With the index nger moved to the side but
continued rm immobilization of the larynx, a vertical
midline skin incision is made, down to the depth of the
laryngeal structures. (Used with permission from Walls
RM, Murphy MF, editors. Manual of emergency airway
management; Fourth Edition. Philadelphia: Lippincott
Williams & Wilkins; 2013)
ical exam ndings, anesthetics given, and operating room course is key to adequate assessment
and optimal treatment. When faced with situations where the diagnosis is unclear, especially
when multiple abnormalities in signs and
symptoms are observed, it is important to
understand the abnormality representing the
primary problem as this will prevent unnecessary or invasive procedures that can cause harm
to the patient or delay of appropriate treatment.
Within the incident reports for 4000 cases of
the Australian Incident Monitoring Study
(AIMS), 438 reports included the words “hypotension,” “cardiovascular collapse,” or “cardiac
arrest” (~11%), and 706 contained the word
“desaturation” (~18%) [23, 24]. In both hypotension and hypoxemia, there were multiple
potential causes for the observed abnormality,
with other associated signs and symptoms. The
use of a structured algorithm was considered to
have resulted in a better and/or more prompt
resolution in 6% of hypotension cases and 15%
of hypoxemic cases. It is known that both of
these operative catastrophes have the potential
to result in irreversible damage to organs leading to a high degree of morbidity and mortality.
Thus, this time-critical need for efcient and
25 Fundamentals ofManaging theOperative Catastrophe
https://t.me/med1917
329
a
Fig. 25.3 With the skin incised, the index nger can now
directly palpate the cricothyroid membrane. (Used with
permission from Walls RM, Murphy MF, editors. Manual
of emergency airway management; Fourth Edition.
Philadelphia: Lippincott Williams & Wilkins; 2013)
effective treatment highlights the importance
for the surgeon to have a structured set of key
steps to guide the differential diagnosis and
treatment management considerations inherent
to unclear/sustained hypotension/hypoxemia.
Clinical/Diagnosis andTreatment
Due to the broad differential for these common
scenarios, we present this section in the format of
crisis checklists that have been adopted by
aninstitution. Figures 25.8 and 25.9 are examples
b
Fig. 25.4 (a) A horizontal membrane incision is made
near the inferior edge of the cricothyroid membrane. The
index nger may be swung aside or may remain in the
wound, palpating the inferior edge of the thyroid cartilage, to guide the scalpel to the membrane. (b) A low cricothyroid incision avoids the superior cricothyroid
vessels, which run transversely near the top of the membrane. (Used with permission from Walls RM, Murphy
MF, editors. Manual of emergency airway management;
Fourth Edition. Philadelphia: Lippincott Williams &
Wilkins; 2013)
330
a
b
c
https://t.me/med1917
Fig. 25.5 (a) The tracheal hook is oriented
transversely during insertion. (b, c) After insertion,
cephalad traction is applied to the inferior margin of
the thyroid cartilage. (Used with permission from
Walls RM, Murphy MF, editors. Manual of emergency
airway management; Fourth Edition. Philadelphia:
Lippincott Williams & Wilkins; 2013)
I. Franco et al.
25 Fundamentals ofManaging theOperative Catastrophe
https://t.me/med1917
331
a
b
a
b
Fig. 25.6 (a) The Trousseau dilator is inserted a short
distance into the incision. (b) In this orientation, the dilator enlarges the opening vertically, the crucial dimension.
(Used with permission from Walls RM, Murphy MF, editors. Manual of emergency airway management; Fourth
Edition. Philadelphia: Lippincott Williams & Wilkins;
2013)
from (the crisis checklists for structured
approaches in the setting of hypotension and
hypoxemia (the crisis checklists in their native
format are available at www.projectcheck.org/
crisis). In both cases, one can see that there are
many causes to consider. There can be benet of
a team running through these causes together and
attempting to narrow the differential, similar to
how one would run though the “H’s and T’s” in
cardiac arrest”.
c
Fig. 25.7 (a) Insertion of the tracheostomy tube. (b)
Rotation of the Trousseau dilator to orient the blades longitudinally in the airway facilitates passage of the tracheostomy tube. (c) Tracheostomy tube fully inserted,
instruments removed. (Used with permission from Walls
RM, Murphy MF, editors. Manual of emergency airway
management; Fourth Edition. Philadelphia: Lippincott
Williams & Wilkins; 2013)
332
Hypotension
Une
lies with the reader. Revised July 2013 (072413.1)
9
9
https://t.me/med1917
xplained drop in blood pressure refractory to initial treatment
I. Franco et al.
START
1
Call for help and a code cartConsider actions...
Ask: “who will be the crisis manager?”
2
Check...
Pulse
Blood pressure
Equipment
Heart rate
If BRADYCARDIA, go to
Rhythm
If VF / VT, go to
If PEA, go to
3
Run IV fluids wide open
4
Give vasopressors and titrate to response
MILD hypotension:
Give ephedrine or phenylephrine
SIGNIFICANT/REFRACTORY hypotension:
Give epinephrine bolus, consider starting
epinephrine infusion
5
6
All reasonable precautions have been taken to verify the information contained in this publication. The responsibility for the interpretation and use of the materials
to 100% and
Turn FiO
2
turn down volatile anesthetics
Inspect surgical field for bleeding
If BLEEDING, go to
CHKLST 3
CHKLST 5
CHKLST 4
CHKLST 8
7
Place patient in
Trendelenberg position
Obtain additional IV access
Place arterial line
8
Consider causes...
Operative field
Mechanical or surgical manipulation
:Insufflation during laparoscopy
Retraction
Vagal stimulation
Vascular compression
Unaccounted blood loss
Blood in suction canister
Bloody sponges
Blood on the floor
Internal bleeding
Drugs / Allergy
Anaphylaxis go to
Recent drugs given
Dose error
Drugs used on the field
(i.e., Intravascular injection of local
anesthetic drugs)
Wrong drug
CHKLST 2
DRUG DOSES and treatments
Ephedrine: 5 − 25 mg IV, repeat as needed
Phenylephrine:
Epinephrine
Breathing
Increased PEEP
Hypoventilation
Hypoxia go to
Persistent hyoerventilation
Pneumothorax
Pulmonary edema
Circulation
Air embolism go to
Bradycardia go to
Malignant hyperthermia go to
Tachycardia go to
Bone cementing (methylmethacrylate effect)
Myocardial ischemia
Emboli ( pulmonary, fat, septic, amniotic,CO2)
Severe sepsis
Tamponade
100 − 500 mcg IV,repeat as needed
BOLUS: 5 − 10 mcg IV
INFUSION: 0.1 − 10 mcg/kg/min IV
CHKLST 10
CHKLST 1
CHKLST 3
CHKLST 11
CHKLST 12
Fig. 25.8 Crisis checklist for hypotension. In Ariadne
Labs. Operating Room Crisis Checklists. With permission. A version from the Brigham and Women’s Hospital
25.3.4 Other Emergencies
As noted above, the goal of this chapter was to
familiarize the surgeon with some common operative catastrophes that every surgeon should
know. However, we hope that this chapter also
encourages the reader to obtain familiarity with
other operative emergencies that simply could
not be covered due to the space constraints.
Hemorrhage, for example, is an operating room
emergency that crosses many different disciplines (surgery, obstetrics, anesthesia, nursing,
hematology, and potentially trauma, vascular,
interventional radiology, and other specialties)
and is often presented with dedicated chapters in
and of themselves. For this specic emergency,
we provide Fig.25.10, which is an example of
the hemorrhage emergency manual entry from
is also available at: www.projectcheck.org/crisis. Image
compressed to meet publication requirements. For native
version, see URL provided. Accessed April 23, 2017
the Stanford Cognitive Aid Group (available at
www.emergencymanuals.org).
In the suggested reading section, we refer to
some essential resources for emergency cognitive
aids specic to the O.R. environment. For example, for malignant hyperthermia, an exceptionally
rare but life-threatening event, there exist a crisis
checklist [
13], a critical event checklist geared to
the pediatric population [http://www.pedsanes-
thesia.org/wp-content/uploads/2017/03/Critical_
Event_Checklists.pdf], an emergency manual
entry [25], posters from the Malignant
Hyperthermia Association of the United States
(MHAUS) [http://www.mhaus.org/healthcare-
professionals/managing-a-crisis], and other
resources (www.emergencymanuals.org). We
strongly encourage the reader to use these
resources to familiarize themselves with opera-
Hypoxia
Une
lies with the reader. Revised July 2013 (072413.1)
25 Fundamentals ofManaging theOperative Catastrophe
https://t.me/med1917
xplained oxygen desaturation
TART
1
Call for help and a code cart
Ask: “Who will be the crisis manager?"
2
Turn FiO
Hand - ventilate to assess
3
Listen
4
Check...
5
Consider actions to assess possible
6
breathing issue...
All reasonable precautions have been taken to verify the information contained in this publication. The responsibility for the interpretation and use of the materials
to 100% at high gas flows
2
Confirm inspired
on gas analyzer
Confirm presence of end-tidal CO
changes in capnogram morphology
to breath sounds
Blood pressure,PIP, pulse
ET tube position
Pulse oximeter placement
Circuit integrity: look for disconnection,
kinks,holes
Draw blood gas
Suction (to clear secretions, mucus plug)
Remove circuit and use ambu-bag
Bronchoscopy
FiO
= 100%
2
Compliance
2
and
Consider causes...
7
Is Airway / Breathing issue suspected?
NO airway issue suspected
Circulation
• Embolism
– Pulmonary embolus
– Air embolism-Venous go to CHKLST 1
– Other emboli (fat, septic, CO
• Heart disease
– Congestive heart failure
– Coronary heart disease
– Myocardial ischemia
– Cardiac lamponade
Corgenital anatomical defect
• Severe sepsis
• If hypoxia associated with hypotension,
go to CHKLST9
Drugs / Allergy
• Recent drugs given
• Dose error / allergy/ anaphylaxis
• Dyes and abnormal hemoglobin
(e.g., methemoglobinemia, methylene blue)
2
, amniotic fluid)
YES airway issue suspected
Airway/ Breathing
• Aspiration
• Atelectasis
• Bronchospasm
• Hypoventilation
• Obesity/positioning
• Pnmumothorax
• Pulnonary Edema
• Right mainstem intubation
• Ventilator settings,
leading to auto-peep
Additional DIAGNO STIC TESTS
• Fiberoptic bronchoscope
• Chest xray
• Electrocardiogram
• Transesophageal echocardiogram
333
Fig. 25.9 Crisis checklist for hypoxemia. In Ariadne
Labs. Operating Room Crisis Checklists. With permission. A version from the Brigham and Women’s Hospital
tive catastrophes that they are likely to encounter
over the course of their practice. The practice patterns of the surgeon and institution are relevant
considerations (i.e., certain catastrophes may be
more common for the orthopedic surgeon, otolaryngologist, gynecological surgeon, pediatric surgeon, and others).
25.4 Current Controversies/
Future Directions
At present, there are no guidelines mandating
crisis checklists or emergency manuals be available or used during patient care [26]. This point
is amplied by existing cultural perceptions
which attribute the use of cognitive aids to less
clinical competence and overall skills by healthcare providers. A survey done at the University
of California, San Francisco, found that one
is also available at: www.projectcheck.org/crisis. Image
compressed to meet publication requirements. For native
version, see URL provided. Accessed April 23, 2017
potential reason for providers to not use checklists was the “perception of them being less
skilled because they needed to use a ‘cheat
sheet.’” Survey results showed 17% of providers
felt uncomfortable using a checklist in front of
their team members and only 45% of providers
feeling comfortable [27]. Additionally, those
reporting uncomfortable feelings were more
likely to have fewer years of experience.
Addressing these issues necessitates cultural
shifts and implementation from leaders within
the eld to foster a culture that embraces the use
of checklists and emergency manuals. To this
end the Emergency Manuals Implementation
Collaborative (EMIC) was formed to encourage
the use of manuals and address barriers to implementation and dissemination by providing free
access to multiple versions of emergency aids at
www.emergencymanuals.org. Ultimately, these
tools must be readily available to be used in cri-
334
https://t.me/med1917
I. Franco et al.
Fig. 25.10 (a, b) Emergency manual entry for hemor-
rhage. Used with permission from Stanford Anesthesia
Cognitive Aid Group. Emergency Manual: Cognitive aids
for perioperative critical events. See http://
emergencymanual.stanford.edu for latest version. Image
compressed to meet publication requirements. For native
version, see URL provided. Creative Commons
BY-NC-ND. 2016 (Version 3) (http://creativecommons.
org/licenses/by-nc-nd/3.0/legalcode) (see Footnote 1)
25 Fundamentals ofManaging theOperative Catastrophe
https://t.me/med1917
335
Fig. 25.10 (continued)
336
https://t.me/med1917
sis situations and implementation is a key step in
ensuring availability and appropriate use. This
requires both an awareness of availability and
training with the use of crisis checklist and emergency manuals [28].
An additional point of controversy in the use
of crisis checklists/emergency manuals suggests
that the doctors’ use of a cognitive aid may cause
providers to become reliant on these cognitive
aids, to the point where clinical judgment is no
longer used and xation on one particular course
of action can lead to a lack of exibility and delay
in appropriate care [29]. As we have stated
throughout this chapter, all clinical signs and
symptoms associated with the operative catastrophe must be interpreted in the context of patient
history, physical exam, and current patient presentation, such that clinical judgment continues
to be a primary driver of ultimate decisionmaking. In this setting, cognitive aids are implemented as an additional tool in the surgeon’s
armory, utilized in situations where high stress or
high stakes may limit memory and recall of key
steps and negatively impact team dynamics.
As with anything else in medicine, there is no
“one solution ts all” approach. The recommendations presented in this chapter must be taken in
context with the culture and resources of individual institutions and adapted for best use, prior
to the occurrence of such events. Surgeons play a
unique role in coordinating and executing care
for patients in the operating room, as they are
tasked with the responsibility of not only the
knowledge, clinical expertise, and technical skills
to treat patients but must also serve a leadership
role in managing and maintaining successful
team dynamics, incorporating effective communication skills, assigning appropriate task management, maintaining situational awareness, and
ensuring successful team decision-making [30].
Take-Home Points
• Operative catastrophes are rare events
that require time-sensitive diagnostic
and management decisions to be
recalled by even the most experienced
I. Franco et al.
clinicians under highly stressful
conditions.
Under stressful circumstances that come
•
from rare life-threatening events, failure
to adhere to best practices can be common when relying on memory alone. In
these cases, cognitive aids can serve as
an additional tool in the surgeon’s
armory, utilized in situations where high
stress or high stakes may limit memory
and recall of key steps and negatively
impact team dynamics.
•
Clinical judgment relative to the
patient’s history, physical exam ndings, anesthetics given, and operating
room course is key to adequate assessment and optimal treatment.
• In any operative catastrophe, the rst
steps should include calling for help,
designating a crisis leader/checklist
reader, and requesting additional
resources needed.
• Crisis checklists and emergency manuals should be adapted to reect the most
up-to-date guidelines available and consistently be evaluated for effectiveness
of content, design, and implementation,
ensuring that these tools meet the needs
of the institution and practicing
providers.
As such, we present the topics in this chapter to
equip the surgeon with evidence-based guidelines and tools to successfully address operative
catastrophes and feel prepared to lead teams in
these high-stress and high-stakes situations.
Acknowledgment This work is supported by grants from
the University of Pennsylvania, McCabe Fund, and Bach
Fund. The authors would like to thank Maryann Henry,
CRNA, MS, and Carlene McLaughlin, CRNA, MSN,
PhD, for their review of the work and their efforts to
advance the principles of crisis management and patient
safety. The views expressed in this article are those of the
authors and do not necessarily represent the ofcial views
of supporting entities.
Соседние файлы в папке Библиотека им академика М.И. Перельмана