Aneasthesia Pearls December 2012

Crisis Management during Anaesthesia
Crisis Management Algorithm
C1 Circulation Establish adequacy of peripheral circulation ((rate, rhythm and character of pulse) – CPR
C2 Colour Note saturation. Pulse oximetry – Test probe on own finger
O1 Oxygen Check rotameter
Ensure inspired mixture is not hypoxic
O2 Oxygen analyser Adjust inspired oxygen concentration to 100%
Check that the oxygen analyser shows a rising oxygen concentration
V1 Ventilation Ventilate the lungs by hand
To assess circuit integrity, airway patency, chest compliance and air entry by ‘‘feel’’ and auscultation. (Capnography)
V2 Vaporiser Note settings and levels of agents
Gas leaks during pressurisation
Consider the possibility of the wrong agent
E1 Endotracheal tube Check the endotracheal tube (leaks or kinks or obstructions)
E2 Elimination Eliminate the anaesthetic machine and ventilate with self-inflating  bag
R1 Review monitors Review all monitors in use
R2 Review equipment Review all other equipment in contact with or relevant to the patient (e.g. diathermy, humidifiers, heating blankets, endoscopes, probes, prostheses, retractors and other appliances).
A Airway Check patency of the unintubated airway
(Consider laryngospasm or presence of foreign body, blood, gastric contents, nasopharyngeal or bronchial secretions)
B Breathing Assess pattern, adequacy and distribution of ventilation
C Circulation Repeat evaluation of peripheral perfusion, pulse, blood pressure, ECG and  and any possible obstruction to venous return, raised
intrathoracic pressure or tamponade of the heart
D Drugs Review drug or substance administration
Wrong drug, Wrong dose
All anaesthetists have to handle life threatening crises with little or no warning. However, some cognitive strategies and work practices that are appropriate for speed and efficiency under normal circumstances may become maladaptive in a crisis. So, they have designed a Crisis Management Manual which can be adapted in all crisis situations.
The ‘‘core’’ algorithm (based on the mnemonic COVER ABCD–A SWIFT CHECK) would diagnose and correct the problem in 60% of cases and provide a functional diagnosis in virtually all of the remaining 40%. For managing the problems underlying the remaining 40% of crises 24 specific Sub-algorithms were therefore developed.
COVER should be applied into four levels represented by the mnemonic ‘‘SCARE’’, depending on the degree of perceived urgency (Scan-Check-Alert/Ready-Emergency).
This manual is based on the mnemonic COVER ABCD–A SWIFT CHECK) and is designed for use when any patient is undergoing general or regional anaesthesia. Every Anaesthetists should read this manual at least once before starting their practice.
C Circulation, Capnography and Colour (saturation)
O Oxygen supply and Oxygen analyser
V   Ventilation (intubated person), Vapourisers
E Entotracheal tube and Eliminate of machine.
R Review monitors and Review equipments
A Airway (with face and laryngeal masks)
B Breathing (with spontaneous ventilation)
C Circulation( in more details than above)
D Drugs ( consider all given and not given)
1. Crisis management during anaesthesia: the development of an anaesthetic crisis management manual
2. Anaesthesia Crisis Management Manual
3. This article cites 42 articles, 30 of which can be accessed free.
In Crisis Management the Patient Survival Depends……….
The safe practice of Anaesthesia starts with the patient. A well pre-operatively optimized patient, the availability of modern facilities, equipments and medication in good quality and quantity at time of crisis and the skill of the attending Anaesthetist are all collectively determines the final outcome of the crisis. So the patient safety is in our hand.
Survival Depends
Cleft Palate – Remember 5 points
Difficult airway and other associated abnormalities
South RAE tube and throat pack
Nasal airways post op – Repair can cause upper airway obstruction in patients who were breathing though the cleft. Plus tongue can swell with gag
Arm splints and respiratory monitoring post op
For cleft lip use infraorbital nerve blocks via the mouth  :
Intraoral route – The nerve is accessed through the sub-sulcal area in the buccal mucosa at the junction of premolars 1 and 2.
Palpate infraorbital foramen with index finger and use to guide needle and retract the cheek with the thumb. Insert the needle into the mucobuccal fold at junction of premolars 1 and 2. Direct the needle parallel to the long axis of premolar 2, palpating its location as the needle is advanced until it is adjacent to the infraorbital foramen. 0.5 to 1ml of local is usually enough.
Cleft Palate
For neonates anatomy is different: Halfway between the midpoint of palpebral fissure and the angle of the mouth.  Bosenberg. BJA 1995; 74: 506-508.
neonates anatomy
Dose: For infants scheduled for cleft lip repairs, use 0.5mL of local anesthetic solution for each side, for older children and adolescents; use 1.5 mL to 2 mL of local anesthetic solution.
1. Peripheral Nerve Blocks For Children; NYSORA.
Ultrasound for Epidurals…
Ultrasound has recently been utilized to facilitate lumbar spinals and epidurals. Spinal ultrasound is especially challenging, because the structures we need to image are protected by a very complex, articulated encasement of bones, which affords very limited acoustic windows for the ultrasound beam. In addition, the structures we want to visualize are located even deeper than we are accustomed to when we use ultrasound for peripheral nerve blocks or central lines. For these reasons, the ultrasound probe used for spinals and epidurals must be a low frequency, curved probe (2-5 mHz). The low frequency ultrasound beam penetrates deeper, but loses in image resolution.
There are two acoustic windows that are effective for lumbar spine sonographic assessment: one seen on the transverse approach, and the other seen on the longitudinal paramedian approach. The information from each of these two scanning planes supplements the other.3
Despite widespread enthusiasm for using lumbar ultrasound in obstetrics, there are some who believe it is expensive and time-consuming, with undetermined risks and uncertain benefits.
Indeed, obstetric anesthesiologists have managed to do this with great success without using imaging techniques. There is a long learning curve associated with lumbar ultrasound and it is unclear from the literature if the success rates associated with its use are superior to clinical skill alone6.
1. Chris’s tips in beautifully illustrated form of Ultra sound for Epidurals 
2. Ultrasound for the Guidance of Epidural Analgesia,
3. Ultrasound-Facilitated Epidurals and Spinals in Obstetrics.
4. Ultrasound Guided Epidural Anaesthesia.
5. “Using Ultrasound on Epidurals”
6. Lumbar ultrasound: useful gadget or time-consuming gimmick?
Postoperative Airway Complications after Cleft Palate Repair
Postoperative Airway Complications after Cleft Palate Repair
Airway complications after Cleft Palate repair range from episodes of mild stridor (noisy, snoring-like breathing resulting from obstruction in the naso- or oropharynx) to complete loss of the airway requiring re-intubation.
Anaesthetic or surgical complications:
  • Retained throat pack
  • Bleeding or blood clots in the airway
  • Laryngospasm
  • Reduction in pharyngeal tone due to the residual effects of volatile agents
  • Respiratory depression due to opioid analgesia
  • Laryngeal oedema secondary to difficult intubation
  • Tongue oedema secondary to prolonged insertion of the mouth gag
Perioperative Strategies to Minimise Airway Complications after Palate Surgery
  • Regional Anaesthetic Techniques: Infraorbital nerve blocks are effective for cleft lip repair and obviate the need for opioids.
  • Dexamethasone: Dexamethasone 0.25mg/kg may be given perioperatively to reduce upper airway oedema and problems at extubation.
  • Elective Nasopharyngeal Airway Insertion: A nasopharyngeal airway (NPA) may be inserted electively at the end of surgery to prevent problems with postoperative airway obstruction. The NPA is placed at the end of surgery when the child is still anaesthetised. The tip of the NPA should protrude from behind the soft palate, but be placed above the epiglottis to avoid laryngeal irritation when the child is awake.
  • Tongue Suture: A tongue suture may be employed following cleft palate surgery to relieve airway obstruction in the postoperative period.
  • Management of extubation: At the end of the procedure the pharynx should be inspected for blood clots and to check haemostasis. Particular care should be taken to remove throat packs. Extubation should only occur once the child is fully awake and protective airway reflexes have returned.
Nasopharyngeal Airway Size
Age of Child (months) Internal Diameter (mm)
0-3 2.5 – 3.0
6 3.5 – 4.0
Crown Heel Length (cm) 30 35 40 45 50 55 60 65 70
Length of NPA (cm) 3.5 4 5 5.5 6.5 7 8 9 9.5
Postoperative Airway Complications after Cleft Palate Repair, Anaesthesia Tutorial of the Week – 237
Guidelines for insertion of Nasopharyngeal airway (NPA)
Great Ormond Street guidelines on preparation and management of nasopharyngeal airways

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