Imagine it’s your first month in anaesthesia. 30mins into an elective laparoscopic cholecystectomy your consultant goes for a tea break and leaves you in theatre alone with the patient. The patient’s saturations suddenly fall to 90% just as the BP comes back at 70/30! What do you do?
This is obviously a challenging situation for anyone regardless of experience! You may have all the challenges of keeping the patient safe whilst trying to solve a difficult problem, not knowing whether to call the consultant and manage the surgeon’s expectations as well!
Calling For Assistance
It is vitally important to realise that you should ALWAYS CALL FOR HELP even if you think you know what to do. As you gain more experience you realise that you call for help for 2 reasons – brains or hands or both. In your training years assistance is particularly useful as you may not know what you don’t know and the process of getting help is as much for the patient as for your learning.
In summary, call for help:
- to see how a crisis is managed
- to receive feedback on your own crisis management (while still being supervised)
- to gain insight to things you may not have even considered yet
- to mobilise extra hands to manage a crisis
The difficulty of teaching crisis management in anaesthesia
Teaching crisis management can really be challenging due to multiple factors, each crisis can be substantially different and can also be managed well by different methods. An expert may manage the same issue very differently based on the magnitude of the problem, the number and experience of staff, equipment, environment, patient factors and the type of surgery. With this in mind I have tried to outline a safe and reproducible framework to get you started on your road to effective crisis management as a new trainee.
The 3 phases of crisis management
Phase 1 – Safety
Aim: To mobilise help and perform low risk high yield actions to rapidly stablise the patient and buy some time.
Phase 2 – Diagnosis
Aim: to provide insight into how most experts in anaesthesia rapidly solve diagnostic dilemmas with a probability gambit whilst avoiding fixation errors by systematically ruling out lethal and other diverse causes
Phase 3 – Treatment
Aim: to provide a list of the differentials and essential treatment strategies for each. This resource can be referred to at any time like a checklist.
Phase 1 – safety
- Check the pulse
- Scan patient, surgery, monitors
- Check reading/transducer/monitors
- Call for Help
- Stop Surgery
- First line treatment
- Airway and breathing: Increase oxygen, switch to hand ventilation
- Circulatory issues: fluid, ephedrine or metaraminol
- Optimise anaesthetic depth
- FINALLY Assess and Treat
a) Check the pulse
Aim: I want to know immediately if my patient has arrested
I can rapidly check this with a good sats prob trace and ECG rhythm. If these are not available, or there’s interference with the sats trace then a finger on the carotid pulse is a useful indication of output.
Tip: to get skilled at anything, just do it more often. Check the pulse of every patient to increase your proficiency
b) Scan patient, surgery and monitors
Aim: To identify and rule out obvious problems by taking a look at the whole situation.
Just like the ‘general inspection’ you perform before any patient assessment, this step is to take in as much info from the room as possible to get an overall feel. You can identify an resolve many problems with this one step.
Lets go through some common examples:
- The surgeon may have just performed the first incision and that is the obvious temporal cause of the tachycardia or hypertension.
- The severe bradycardia has occurred just as the surgeon inflates the abdomen for pneumoperitoneum during a lap chole. Deflating the abdomen will often resolve this immediately.
- The high ventilating pressures are due to the paralysis wearing off and inspection of the patient under the drapes shows that they are tense and clenching down on the endotracheal tube (ETT).
- The O2 sats are falling and you notice a green liquid at the mouth of the patient revealing the patient has potentially is aspirated gastric contents
- The monitor alarms for tachycardia – scanning the rest of the screen give you the likely diagnosis…. A low BP might indicate hypovolaemia whereas a simultaneous high BP indicates pain or light anaesthesia.
c) Check the reading
Aim: Measurement error is a common occurrence; so checking your reading is absolutely vital to ensure you are managing a real problem.
No measurement device is perfect and often prone to error. Common examples include
- The sats probe reads <90%. You change the probe to an ear probe and the sats are 99%. The sats probe depends on good blood flow, and the ability to detect wavelengths of blood in the finger. Errors will occur due to a patient being peripherally shut down, nail polish or movement artifact.
- The blood pressure reads 250 on the intra-arterial BP monitor. You find that the transducer has fallen down to grossly overestimate the reading.
- The monitor alarms ‘asystole’! Due to your patient’s barrel chest, the ECG has trouble detecting the QRS complexes.
- The end tidal CO2 is alarming. On closer inspection, the patient is taking irregular breaths causing some lower CO2 readings to alarm.
d) Call for Help
Aim: rapidly mobilise assistance while continuing with your basic management.
The first 3 steps can often solve the problem, confirm the problem or confirm there is no problem quite rapidly. Therefore you call for help appropriately, without a false alarm and without delay.
e) Stop the surgery
Aim: To stop a potential trigger/cause of the problem
There will be a number of problems/crises that are directly the result of what the surgeon is doing. The most common issue that surgery causes is pain causing tachycardia and hypertension. In some patients (patients with coronary artery disease, severe aortic stenosis or intracranial pathology) these deviations of BP and HR could cause serious harm. So while not a true crisis, simply checking the reading and asking the surgeon to stop can give you time to give more analgesia.
Other situations the surgeon may be the true cause of a serious complication like severe bradycardia/asystole. This rarely happens in ophthalmic surgery (oculocardiac reflex) and instituting pneumoperitoeum (vagal/bezold-Jarisch reflex). Cessation of retraction on the globe may be all that’s required to reverse the problem. Likewise deflation of penumoperitoneum may be a vital step prior to giving atropine. Another common situation is a patient may become apnoeic during a gastroscopy. An airway is very difficult to manage when you are sharing it with another specialist , and you may need to ask them to urgently remove the gastroscope.
f) First line treatment
Aim: To stop or slow down a patient’s deterioration while waiting for help to arrive
The primary survey is a systematic way of assessing and treating the patients vital organs prior to establishing a diagnosis. In anaesthesia we have the luxury of a reasonably controlled situation where a patient already has an advanced airway (ETT or LMA), an anaesthesia machine to ventilate, BP and heart rate monitoring and iv access. This means our ability to assess and treat ABCs is potentially very rapid!
If the issue is airway or breathing, for example desaturation, apnoea, high ventilation pressures you can often temporize or stabilise the situation with just 4 manoeuvres:
- Increase the oxygen to 100%
- To increase oxygen reserves to keep patient safe.
- Increase gas flows (4-6L/min)
- To increase delivery of oxygen
- Use the manual ventilation circuit with the APL valve at 30-70
- To help increase pressure to deliver breaths
- To gain an appreciation of lung compliance which may help diagnose the issue. High pressures = bronchospasm/sputum plug or kink in ETT. Low pressures = dislodged ETT, disconnection of circuit.
- Auscultate the lungs
- To diagnose multiple causes euch as bronchospasm, aspiration, pulmonary oedema, endobronchial intubation, pneumothorax, sputum plugging
If the issue is circulatory, for example hypotension is a common intraoperative problem, you can stabilise the situation with just 2 manoeuvres:
- Increase fluid rate.
- Give 0.5mg or metaraminol if BP low and HR above 60bpm
- Give 3-6mg ephedrine if BP low and HR below 60bpm
g) Optimise anaesthetic depth
Aim: To rapidly solve issue by targeting depth of anaesthesia
There is a saying that you have far more issues if the patient is ‘light’ than if they’re deep. This essentially means that the problems that occur with too much anaesthesia are easier to solve that with too little anaesthesia.
For example a patient with too much anaesthesia can be
- Rendered apnoeic (not an issue as advanced airways are able to ventilate and oxygenate patients effectively).
- Hypotensive (this is easily treated with fluid and vasopressor)
NB: this is not a one size fits all rule, and an elderly or very sick patient does need careful titration of anesthesia.
A patient with too little anaesthesia may
- React and move causing difficulty with ventilation
- Suffer laryngospasm
Additionally, a patient may be suffering severe hypotension due to potential blood loss or anaphylaxis. In this case optimal anaesthesia depth means something different. I would substantially decrease my anaesthesia dose to prioritise BP over depth of anaesthesia. Practically this means turn off volatile or propofol infusion while stabilising the situation with fluid and metaraminol (or adrenaline if severe).
f) Assess and treat
Aim: To simultaneously provide supportive care, institute a sequence of diagnostic and treatment steps.
By this time you would have done some very useful things to help stabilise and potentially diagnose the problem already. With the assistance of your supervising anaesthetist you will now be able to observe the strategy for diagnosis and treatment.
Below I will outline what I believe is the most efficient and thorough strategy for diagnosis and how you can combine this with sequential treatments.
Phase 2 – diagnosis
In the initial phase it is vitally important to provide supportive measures as outlined above. This ‘buys’ time to then diagnose and treat the particular issue.
Human physiology can be so complex, that combining the complex effects of anaesthesia and surgery can make diagnosis extremely difficult. There are numerous causes for each altered sign and symptom and going through a review of systems or an exhaustive checklist could cause delays in diagnosis.
As you develop more expertise in your practice you will use your experience to get an overall impression of the situation. Most experts in the field will be able to make a reasonably accurate probability gambit. This method allows you to get to a solution very quickly, which will resolve the situation most of the time.
However, it is very important that we do not miss potentially lethal diagnoses. So I believe that considering the unique lethal diagnoses for a particular patient, surgery and set of signs and symptoms and systematically ruling out these will keep your patient safe from pathology that could cause harm in the immediate future.
If you are unable to satisfactorily diagnose the patient in these first 2 steps it is important to have a systematic method of ruling out the long list of other differentials.
Below I have provided a list of tables with common issues and lists of common differentials.
The phrasing I use in my mind is as follows.
I think it is most likely _____
The serious differentials I must rule out are____
My systematic differentials include _____
For example
24yo male is having an appendicectomy. The BP is 60mmHg post induction.
I think it is most likely that this may be hypotension post anaesthesia in a volume deplete patient.
The serious differentials I must exclude are anaphylaxis, sepsis and lap port injury
*Practically I check for a rash, auscultate and manually ventilate the lungs to check for wheeze and decreased compliance, check the temperature and likelihood of sepsis, and check the port camera screen for untoward signs of blood loss*
My systematic differentials include (see the hypotension table below).
During the ABCs of Anaesthesia Boot Camp we will go through many more examples. At this stage consider the situations that may arise perioperatively and structure diagnostic steps using the framework above.
Phase 3 – treatment
I have outlined suggested treatments for the numerous problems you might face in the theatre environment. As you gain more experience and seniority you will gain more comfort in managing these cases by yourself.
At a junior level I would use this as a guide and always defer to your supervisor for definitive management steps. Ideally you could store these tables on your smartphone and refer to them as needed to help checklist a solution, refresh your memory and eventually tailor specific management.
Hypoxaemia
| Cause | Management | |
| FiO2 | O2 not connected Diffusion hypoxaemia |
Increase oxygen |
| Hypoventilation | Low minute ventilation All failure to breath causes (CNS, muscle) All stridor causes |
Ensure adequate MV Check ETCO2 Assist ventilation |
| Hypoventilation | Low minute ventilation All failure to breath causes (CNS, muscle) All stridor causes |
Ensure adequate MV Check ETCO2 Assist ventilation |
| VQ mismatch | Bronchospasm Aspiration, atelectasis/collapse/consolidation/mucous APO/NPPO PE Pneumothorax Anaphylaxis |
Salbutamol/Atrovent/ ↑Volatile Recruitment/↑PEEP Suction catheter LMNOP Needle decompression/ICC |
| Diffusion | Pre-existing resp disease COAD |
|
| Cardiac | Low cardiac output state Congenital heart disease |
Optimise CVS |
High ventilating pressures
| Cause | Management | |
| Machine | Flow valves | Inspect Use Laedel Bag |
| Circuit | Kink in tubing | Inspect Use Laedel Bag |
| HME | Obstruction from secretions | Check/replace |
| ETT | Kink Secretions Cuff herniation |
Inspect Can you pass bougie/suction catheter? |
| Patient | Inadequate paralysis Bronchospasm Sputum plug Pneumothorax Pneumoperitoneum APO |
Salbutamol/atrovent/volatile/steroid Suction catheterNeedle decompression/ICC Muscle relaxant, position,↓pressure Lasix, morphine, nitrates, oxygen, Positive pressure (LMNOP) |
Tachycardia
| Cause | Management | |
| Physiological | Resp: O2, CO2/pH, all lung path (pneumothorax, aspiration, bronchospasm)
CVS: blood loss, hypovolaemia, tamponade, MI, vasodilation and ↓BP, anemia CNS: rebleed, strokes Metabolic/endo: temp, thyroid, phaeo, BSLs, MH, sepsis |
Optimise O2 and CO2
Give volume, check surgery, Hb
CT Specific treatments |
| Pharm | Anaesthesia depth Drug error, reaction, withdrawal, illicit use |
Volatile, propofol Cease drug Supportive treatments |
| Pain | Somatic – wound Visceral – full bladder Anxiety |
Analgesia IDC for long cases, ensure not blocked |
| Surgical | Bleeding Incision, tourniquet Brainstem manipulation Pneumoperitoneum |
Treat and prevent further blood loss Tolerate if all else ruled out |
| Bblocker Esmolol 0.25-0.5mg/kg bolus Follow with metoprolol 1mg bolus q15min |
Bradycardia
| Cause | Management | |
| Pharm | Metaraminol BB, CCB, amiodarone, digoxin Anticholinesterase Redose sux |
Cease drug |
| Vagal | Traction on viscera/pleura/peritoneum Baroreceptor – CEA, ↑ICP-Cushings, Metaraminol OC reflex Bezold Jarisch reflex Laryngeal |
Cease stimulus |
| CVS | AMI | Meds Glycopyrrolate 0.2mg Atropine 0.4mg Ephedrine 6-10mg Adrenaline 20-50mcg |
| Pacing |
Failure to Breathe
| Cause | Management | |
| CNS | All failure to emerge causes Phys, pharm, neuro and other |
See Delayed emergence |
| Muscle function | CNS – upper motor neurone Lower motor neurone Neuromuscular junction (NMBD, myasthenia) Lung Chest wall (obesity, burns) Pain |
Ultimately will need assisted ventilation if other causes not reversed |
Hypertension
| Cause | Management | |
| Pre-existing | ||
| Physiological | Resp: O2, CO2/pH, APO CVS: CNS: autonomic hyperreflexia, ICP Metabolic/endo: temp, thyroid, phaeo, BSL, MH, sepsis |
Optimise O2 and CO2 Give volume, check surgery, Hb CTSpecific treatments |
| Pharm | Anaesthesia depth Analgesia Drug error, reaction, withdrawal, illicit use |
Volatile, propofol Fentanyl, alfentanil, N20 Stop drug and supportive treatments |
| Pain | Somatic – wound Visceral – bladder full? SNS – tourniquet |
Somatic – wound IDC for long cases, ensure not blocked |
| Surgical | Incision, tourniquet Pneumoperitoneum |
Treat and prevent further blood loss Tolerate if all else ruled out |
| ↑ Anaesthetic agents Hydralazine 5mg Phentolamine 0.5mg Bblocker GTN/SNP |
Hypotension
| Cause | Management | |
| Preload | Hypovolaemia, haemorrhage, Venodilation, Increased ITP |
Volume Check surgical field/drains/suction/PPV Hb |
| Rate | Too fast, too slow | ECG/ monitor – atropine/ALS guidelines |
| Rhythm | Non sinus, too fast or too slow | ECG/ monitor – ALS guidelines |
| Afterload | ↑in AS, HOCM ↓vasodilation, sepsis, anaphylaxis, all anaesthetic and many cardiac drugs |
Associated signs
Metaraminol/Norad Specific treatments |
| Obstructive | Tamponade PE Tension pneumothorax |
General treatments ↓Anaesthetic agents Metaraminol 0.5mg Ephedrine 3-6mg Adrenaline Atropine |
Hypercapnoea
| Cause | Management | |
| Making too much | MH Thyrotoxicosis Sepsis Exogenous from Pneumoperitoneum |
Temp/cool/dantrolene/cease volatile + others Supportive/propranolol/hydrocort/fluids/cooling/propylthiouracil Specific sepsis treatments |
| Exhaling too little | Hypoventilation
Dead space |
Increase MV Decrease pneumoperitoneum or perform open surgery Fluids resus |
| Rebreathing | Exhausted soda lime Low flow (esp Mapleson) |
Replace Soda lime Increase flows |
Stridor
| Cause | Management | |
| Lumen | Foreign body – denture, throat pack, phlegm, blood ↓airway tone – OSA, snorer, obesity, anaesthesia laryngospasm – blood, smoker, URTI, RLN palsy, hypoCa |
Hx – suction, laryngoscopy + Magill’s forceps Airway manoeuvres, Guedels, NPA, invasive CPAP +O2, Prop, Sux |
| Wall | Bronchospasm, oedema Tracheomalacia (invasive ca) |
Salbutamol/atrovent/adrenaline/ Hydrocortisone Intubate |
| Extrinsic | Exhausted soda lime Low flow (esp Mapleson) |
Drain, release sutures Intubate |
Hypercapnoea
| Cause | Management | |
| Making too much | MH Thyrotoxicosis Sepsis Exogenous from Pneumoperitoneum |
Temp/cool/dantrolene/cease volatile + others Supportive/propranolol/hydrocort/fluids/cooling/propylthiouracil Specific sepsis treatments |
| Exhaling too little | Hypoventilation
Dead space |
Increase MV Decrease pneumoperitoneum or perform open surgery Fluids resus |
| Rebreathing | Exhausted soda lime Low flow (esp Mapleson) |
Replace Soda lime
Increase flows |
Stridor
| Cause | Management | |
| Lumen | Foreign body – denture, throat pack, phlegm, blood ↓airway tone – OSA, snorer, obesity, anaesthesia laryngospasm – blood, smoker, URTI, RLN palsy, hypoCa |
Hx – suction, laryngoscopy + Magill’s forceps Airway manoeuvres, Guedels, NPA, invasive CPAP +O2, Prop, Sux |
| Wall | Bronchospasm, oedema Tracheomalacia (invasive ca) |
Salbutamol/atrovent/adrenaline/ Hydrocortisone Intubate |
| Extrinsic | Exhausted soda lime Low flow (esp Mapleson) |
Drain, release sutures Intubate |
Delayed Emergence/ Decreased conscious state
| Cause | Management | |
| Physiological | O2, CO2, pH, temp, BP Na, BSL |
Check monitors ABG/VBG |
| Pharm | NMBD, opioids, BZDs, volatiles, prop, neuroleptics, antipsychotics Prior drug intoxication Local anaesthetic CNS spread |
Check etVol, drugs given NMM/sugammadex Naloxone/flumazenil Past history |
| Neuro | Stroke, CVA, Tumour Seizure, post ictal Myopathy Psychosomatic |
CT (Difficult diagnoses) |
| Other | Thyroid | Past history TFT |
The Complexity of Anaesthesia
Due to the nature of our profession, a number of normal occurrences in an anaesthetised patient are also the signs of severe reactions. So it is vital to understand
- What criteria are needed to diagnose a problem
- When to start treating for a lethal problem
For example, the common presentation of anaphylaxis is hypotension to 70mmHg, bronchospasm and a rash. However the induction of anaesthesia can cause these very signs due to the nature of the medications.
- Propofol causes hypotension routinely through veno and vasodilation.
- Introducing a endotracheal tube into the trachea often causes bronchospasm as does some of our histamine releasing drugs (see ABCS guide to medications)
- Rashes are also a very common and relatively benign side effect of anaesthesia medications and antibiotics.
So the challenge is to know when to ‘label’ this as an anaphylaxis emergency. One rule I use is that if I have to give 5 doses of metaraminol with limited effect, this triggers a decision to ask myself is this anaphylaxis? I then ask myself what is the harm of treating this as anaphylaxis?
If this was the 24yo male who is otherwise well, there is very little harm of giving 1000ml of fluid and carefully titrating 20-50micrograms of adrenaline iv whilst ventilating with 100% oxygen.
My suspicion is always raised and my threshold lowered if the patient exhibits multiple signs in the context of giving an anaphylactogenic medication like a muscle relaxant or an antibiotic. This means that I may start treating this as anaphylaxis quicker and with less of a BP drop.
Think of all the other common situations caused by anaesthesia and surgery that might mask potentially serious disease.
During your rotation you will commonly see desaturations, high ventilating pressures, tachycardia, bradycardia, hypertension to name a few.
What are these potentially signs of?
