Anesthesia without risk does not exist, and this is a reality that every practice needs to deal with. Whether the patient is at a higher risk because of disease, perilous surgery or human error, it is important to minimize that danger. Here are four tips to help you reduce risk during anesthesia.
- Risk management is paramount during anesthesia
- Many tools are available for the clinicians
- Lack of preparation before anesthesia puts the patient’s life in danger
- Teamwork is essential to decrease risk during anesthesia
- Quality of care is the prerequisite and the result of risk management
1 – Use Appropriate Tools
Use appropriate tools
Various groups have created tools for anesthesia. The AAHA (American Animal Hospital Association) veterinary anesthesia guidelines address myths and misconceptions, such as endotracheal intubation in cats or the use of drugs for specific breeds. The AAHA also published guidelines for pain management in small animals. The ACVAA (American College of Veterinary Anaesthesia and Analgesia) published guidelines for small animal monitoring during anesthesia. All of these guidelines can be accessed on the associations’ websites. The ASA physical status is an indicator of the overall health status of the patient and helps determine the impact of anesthesia on the overall health of the patient. This is only useful if determined before anesthesia begins. Textbooks can also be very useful resources when preparing for anesthesia.
Develop your own tools
Checklists are useful as risk management tools. High-risks institutions (aviation, nuclear industry, etc.) use checklists to decrease risk. The World Health Organization (WHO) developed a checklist to reduce risk during anesthesia and surgery. All those checklists have been shown to be very useful to decrease risk and to improve the efficiency of a team dealing with unexpected events. Although known by most, checklists are actually rarely used in veterinary practices. Despite what people may think, checklists are a proven tool to improve both efficiency and time management. However, for them to be useful, they need to be developed by and for the team that will use them. In veterinary practices, the following checklists could be used: anesthesia record, physical exam sheet, list of equipment needed for specific procedures, step-by-step checklists to verify anesthesia units or surgery room, etc.
Consult with the veterinary community
Veterinary anesthetists can be contacted if you have any questions regarding basic or advanced anesthesia. Remember, it is always better to call before complications arise.
2 – Be Ready
Prepare your day ahead of time
Prepare the day’s schedule, make sure the equipment (anesthesia machine and monitoring device) is ready and functional. Machines should be checked every morning and before use. The monitoring devices should be checked and ready to be used before anesthesia begins.
Prepare your team
Make sure everyone knows what needs to be done. It is important that the team (technicians and veterinarians) knows the anesthetic drugs they are going to use, including their normal efficiency and side effects. This will help them to detect abnormal responses and manage side effects better. Make sure the team stays focused. Falling into a routine and habits is easy. Important steps will be forgotten, voluntarily or not. As long as everything goes well, nobody notices. However, the day a patient suffers, medical errors will be costly for the patient and the team. It is always important to treat each patient as if it were your own.
3 – Work as a Team
Communication is vital for teamwork. Every member should communicate with each other. It is important that each member knows what the others are doing. Assuming is the best way to get into troubles. Ideally, everything should be recorded on the medical record for future use. It is also necessary to have a strategy to avoid complications. This should include knowing what resources (people and equipment) are available.
Know your roles
Each individual in the team has a role to play. Technicians are the front line. Usually, they welcome the clients, are in charge of the technical parts of anesthesia (catheter, intubation, etc.), monitor anesthesia, and prepare all the equipment used. Their role is to be a filter between the patient and the veterinarian. Among all information they get from the patient, they have to detect what is abnormal and keep the veterinarian informed. Veterinarians are responsible for all procedures and medical decisions. They choose anesthesia protocols and appropriate treatments if complications arise. In most cases, veterinarians do the surgery while the patient is monitored by a technician. Owners are also part of the team. It is important to listen to them carefully. Some may have heard or read on the Internet that their pet is more at risk. Even though it’s often wrong, it is always worth listening and reassuring owners, and it may allow your team to pick up a problem beforehand. The most important things to ask is the source of the information, and if an animal of the same lineage has a history of complications during anesthesia.
Plan your workload
It is recommended to have one trained person dedicated to anesthesia. For healthy patients and minor procedures, the minimum is having one person available to check the patient’s health status at least every 5 minutes. For patients at risk (ASA 3 or more), a person dedicated solely to monitoring anesthesia should remain continuously with the patient. If you plan to induce a patient while a surgery is in progress and while a patient wakes up, 2 to 3 people are needed, excluding the surgical team.
Establish treatment strategies beforehand
Basic complications (mild to moderate hypothermia, inappropriate anesthesia depth, mild hypotension, etc.) can be dealt with by technicians without asking the veterinarian. However, even if the complications seem mild and benign, the veterinarian should be told. For more complex difficulties, the veterinarian should be the one deciding the treatment strategy. It is, however, essential that technicians are comfortable implementing any treatments. A team that knows what to do will decrease the risk. In case of mortality or unusual complications, and especially if it is the results of an error, it is important to understand what happened to avoid making the same errors again. Discussing the case with the people that were involved, without blaming anybody, is probably the best way to do this. Everyone makes mistakes; it is just important not to make them twice.
4 – Aim at the Best Possible Quality of Care
Quality of care is both the prerequisite and the result of risk management. The purpose of this text is not to review veterinary anesthesia; therefore, only some aspects are detailed here. It is important to change our way of assessing the quality of care during anesthesia. Mortality (or lack thereof) should not be the endpoint when evaluating anesthesia success. Complications rate (hypotension, hypothermia, prolonged recovery, etc.) should now be used as proper indicators of quality of care.
The use of monitoring devices is crucial in risk management. Monitoring of vital parameters will allow reacting before complications become deadly. Monitoring must be done for all patients as soon as the level of sedation allows it. Do not wait to be in surgery to begin monitoring. The earlier a problem is detected, the better the chance of correcting it and preventing long-term complications. The use of anesthesia record has been reviewed by the OMVQ (Ordre des Médecins Vétérinaires du Québec) in a practical guide published in Veterinarius. The anesthesia record is recommended by the OMVQ and must include, at least, a free and informed consent, a protocol sheet and an anesthesia record sheet detailing the patient’s condition during the procedure. The ACVAA made similar recommendations but added that recording of vital signs should be done at least every 5 minutes. Common monitoring devices include pulse oximetry, capnography, Doppler flow detector (or other blood pressure monitoring devices), and ECG. These various devices, their advantages, and disadvantages are detailed in other texts on the website. Pain should be evaluated before, immediately after, and regularly after the procedure. Pain should be considered as the fourth clinical signs. Poorly managed pain can have an impact on the patient’s health. The evaluation of pain is difficult, but tools exist.
Adapt to the patient
Choosing a protocol tailored to the patient needs will avoid many complications. This protocol should be chosen after a thorough physical exam and the results of the appropriate ancillary tests. The behavior of the patient is a determining factor when selecting sedative dosage. The use of “premix” is debatable, and it is, therefore, important to remember that dosage needs to be adjusted to the particular needs of each patient, which cannot be done when using a premix. Having premix available should not be used as an excuse to avoid adapting the protocol to each patient.
To ensure the best chance for the patient, it is important to offer the ideal plan, even if it requires to refer the case to referral centers. The owner is entitled to refuse, but the patient should always benefit from the best possible care.
Using these tips will help you reduce risk during anesthesia. The relationship between these 4 tips and risk management is illustrated in Figure 1. Applying basic rules will improve the quality of care and improving efficiency. Your team will be more comfortable and will adapt more easily to a complex or unexpected event.