Emergencies in Anaesthesia (Emergencies in...)
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For emergency surgery compromises may have to be made for some aspects of preoperative preparation and balanced against the risks of delayed surgery . A six year old boy was referred from a private clinic with complaints of abdominal swelling, abdominal pain and fever of one week duration and vomiting of five days duration and black tarry stools.
The abdominal swelling was generalised. Abdominal pain at the onset was at the lower abdomen and of sudden onset and progressively became. Constipation was noticed the day abdominal distension started.
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Vomitus initially consisted of recently ingested feeds and later consisted of clear fluids when patient could not eat. There was difficulty in breathing as the abdomen continued to distend. Fever was higher grade and continuous. At the onset of the illness, the patient was given some unknown drugs bought over the counter a patent medicine dealer shop and was given some herbal concoctions by the aunty.
Anesthetic problems and emergency
There was no improvement hence he was taken to a private clinic that referred the patient to the children emergency room of a Nigerian teaching hospital. On examination, the child was clinically ill looking, wasted with prominent ribs and zymotic arch, in respiratory distress evidenced by flaring alae nasi, subcostal and intercostal recession, in obvious painful distress, dehydrated evidenced by sunken eye balls dry buccal mucosa.
He was immediately placed on oxygen by nasal prongs. Nasogastric tube was insitu draining brown coloured bolus fluid, weight 14 kg, febrile temperature The abdomen was uniformly enlarged, moves with respiratory with dilated umbilical vein, everted umbilicus, generalised tenderness, abdominal gait 40 cm. Rectal examination findings are poor anal hygiene, intact anal sphincter, tender and empty rectum, examining finger was stained with dark stool.
Temperomandibular joint was mobile with malampathi I. Abdominal ultrasounds scan showed bowel wall thickness measuring about 6 mm with bowel dilatation and slow peristalsis. Abdominal x-ray showed free peritoneal fluid, pneumoperitoneum and floating dilated bowel. Nasogastric tube drain reservoir drained 1.
The patient was placed on full strength dextrose to alternate with 4. Anaesthesia was induced with halothane and maintained with halothane, oxygen and pentazocine. Anaesthesia was monitored with pulse oximeter, blood loss, respiratory rate, precordial stethoscope and urine output.
Surgical findings were necrosis of the distal ileum extending to the caecum with the appendix buried in the inflammation, massive feculent exudate, fibrinous exudate, and multiple paracolic lymphadenopathies. Faecal effluent of 1. Left hemicolectomy was done with ileocolic anastomosis. The peritoneum was irrigated and drain left in position.
Blood loss was mls. Patient received blood transfusion in the course of surgery. Anaesthesia was reversed by putting dialling off halothane and received oxygen by facemask initially and later by intranasal prongs for the next 24 hours. Intravenous analgesic, antibiotics and fluids was continued until bowel sounds returned.
The patient was discharged home on the tenth postoperative day in good condition on oral haematinics, analgesics, antibiotics and high protein diet. The health seeking behaviour in developing countries including Nigeria is poor as everyone seems to have knowledge about illness because when complaints are made that even the layman prescribes drugs he does not know anything about the its pharmacology. Drugs can also be purchased from drug vendors who parade the streets without any licenced to dispense drugs.
The patient was a minor and therefore cannot make decisions for himself. There are four cardinal features of acute intestinal obstruction are pain, vomiting, distension and constipation [,5]. Which was present in the patient late manifestations which may be encountered included dehydrated, oliguria, hypovolaemia, shock, pyrexia, septisaemia, respiratory embarrassment and peritonitis . Abdominal pain is the primary and first symptom and occurs suddenly and is usually severe and bowel sounds are absent [1,5].
Dehydration is seen moat commonly in small bowel obstruction due to repeated vomiting and fluid sequestration. This results in dry skin and tongue, poor venous filling and sunken eyes with oliguria.
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The blood urea level and haematocrit rise give a secondary polycythaemia . This patient was dehydrated, ill looking, in respiratory and painful distress and septisaemia. Pyrexia is the presence of obstruction may include the onset of ischaemia, intestinal perforation, inflammation associated in the obstructing disease. Full Name Comment goes here. Are you sure you want to Yes No. Be the first to like this.
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Anesthetic problems and emergency 1. Every anesthetic procedure has the potential to cause the death of the animal Anesthetic Problems and Emergencies Chapter 12 2. Oxygen Delivery Methods Use of an Ambu Bag Cardiac Compressions In both aviation and anesthesiology, some emergencies may develop abruptly, whereas others may evolve over time. Major anesthesia societies have adopted the use of checklists. The American Society of Regional Anesthesia and Pain Medicine published a practice advisory on local anesthetic systemic toxicity in , which included a checklist on the treatment of LAST.
A study using high-fidelity simulations of medical management tasks demonstrated that when the LAST checklist was utilized, there was better treatment, including proper ACLS protocol and more appropriate use of intralipid. Interestingly, there was higher knowledge retention 2 months later in the checklist group.
This checklist has since been revised, illustrating that checklists are dynamic tools that require modification based both on local institutional differences and on temporal changes in clinical evidence. The Society for Pediatric Anesthesia SPA developed a cognitive aid for pediatric critical events that consists of 27 checklists. Lack of familiarity with the format led to frustration with use. Anesthesia trainees preferred paper over an electronic version, because of concern regarding technology barriers. The authors concluded that more simulation-based training with the use of cognitive aids is needed to make them more usable, as suggested by the conceptual framework for emergency manuals implementation.
The Society for Obstetric Anesthesia and Perinatology developed a consensus statement on the management of cardiac arrest in pregnancy, which recommends that a checklist emphasizing key tasks be immediately available. In a simulation-based study of malignant hyperthermia and maternal cardiac arrest scenarios, the use of a checklist reader was more likely to lead to completion of all critical steps during an emergency than when no reader was utilized. There has been little work investigating the best methods to incorporate crisis checklists and emergency manuals into everyday practice; many questions remain unanswered: 1 What is the optimal format for organizing them?
From simulation-based trials, we believe that there is sufficient collective evidence to conclude that using a well-designed cognitive aid will lead to substantially fewer missed critical steps than would working from memory alone in crisis situations. Nonetheless, preparing for crises still requires training to attain competence in managing the event and effectively using a cognitive aid.
The first several steps in responding to an emergency may need to be done immediately, without the use of a cognitive aid. The next priorities are understanding effective checklist implementation and how best to use them in clinical practice. Like many healthcare innovations, these tools will not implement themselves, nor jump off the walls during crises.
Changing human behavior, particularly of entire groups and systems, is challenging. Four factors have been suggested as being important for successful implementation of emergency manuals: create or modify an existing tool , familiarize, use, and integrate. In contrast, the Expert Recommendations for Implementing Change group developed a detailed compilation of 73 specific implementation strategies, actively vetted in multiple rounds by an expert group of clinician implementers and implementation researchers.
Emergency Manuals Implementation Collaborative. The implementation sciences promote the role of leadership buy-in. Leaders of multiple efforts to develop and implement cognitive aids formed the Emergency Manuals Implementation Collaborative EMIC to publicly share resources and further research on effectiveness and how best to implement and use emergency manuals.
EMIC fosters the dissemination and effective use of emergency manuals to enhance patient safety with a primary focus on perioperative crises through shared principles throughout healthcare fields. The primary goals of EMIC are to encourage the use of emergency manuals in clinical practice and to build a community to share tools, overcome barriers, and facilitate implementation of emergency manuals. Although there is no clear evidence at this point that one design is better than another, operating room providers should consider use of cognitive aids for emergencies in their clinical practice in preference to not using any tool.
The results of local use should be monitored and be subject to a process of continuous improvement. Published resources for training include curricula and videos on why and how to use emergency manuals. Cognitive aids have been demonstrated to work to counter the effects of stress, ineffective teamwork, and inability to recall all evidence-based actions required for the optimal response in rare events. Our hope is that effective training and implementation strategies will lead to a perioperative culture that trains for and encourages appropriately using cognitive aids in conjunction with good teamwork and judgment and thus further reduces preventable perioperative adverse events.
Despite the widespread dissemination of tools more than , downloads of Stanford, Ariadne, and SPA tools combined and multiple early-adopter implementing institutions, more research is needed to further assess the impact of implementation strategies and clinical use of emergency manuals. The authors thank Lizzie Edmondson, B.
The authors also thank Steven K. Howard, M. The authors declare no competing interests. National Transportation Safety Board: Crew neglected pre-flight check in crash that killed 7. Accessed October 8, Runway overrun during rejected takeoff. Accessed May 25, A nesthesiology ; 84 —75 [Article] [PubMed].
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