Critical Incident in Anesthesia - Essay Example

Critical Incident in Anesthesia: Analysis Critical Incident Scenario This is the story of a 55-year-old female who was suffering from myelopathy secondary to cervical spondylosis. This patient presented to the hospital with severe disease and was investigated. She was found to have cervical myelopathy at C4-C5 level, and apart from pain, she had paresthesias and beginning of paresis. It was decided that an elective surgery will be done on her. Accordingly anterior cervical decompression and fusion at C4-C5 levels will be done. A detailed preoperative history revealed no history of allergy, no history of asthma, no previous surgeries, and she had never been subjected to any anesthetics. On the day of surgery, she was brought to the operating room, and there, she was induced for anesthesia with Fentanyl, Remifentanyl, Propofol, and Rocuronium. Once she was induced, she was endotracheally intubated with a size 7 cuffed endotracheal tube. Just few following this, she developed tachycardia, precipitous fall in blood pressure, and erythema in the exposed parts of her body. She was immediately diagnosed to be having anaphylactic reactions to Rocuronium, and in a rapid response, she was first put in high-pressure ventilation. All anesthetic agents were stopped; the fluid was increased to a high volume rate. Chlorpheniramine 20 mg was injected through the intravenous line, and she was put on 100% oxygen. This is obviously a critical incident in the setting of anesthesia, and this author is going to analyze this scenario based on her experiences and from the point of view of her perspectives as an anesthetic nurse. Critical Incident Anesthesia is a system and discipline where complex and dynamic events are the rules. It is a discipline which involves interaction between anesthesiologists and their assistants such as nurses, machine and monitors, and the environment comprising of operating room, hospitals, surgeons, and nurses happen continuously. Since by definition, anesthesia puts patients in a critical condition where extremely high dependency nursing is the requirement, in most of the cases, the anesthesia team including the assistant nurses need to be extremely vigilant. Any failure, event, incident, and error involving any component of this stated system may lead to harm of the patient. Fortunately, anesthesia is a procedure with high technological expertise, and thus recognition of an incident that is critical in nature would lead to appropriate and timely intervention leading to better outcome. However, if it is not done or monitored so a preventive measure is not implemented in the right time, devastating situations may arise, and in may cases these critical incidents may lead to even death of the patient. Nurse who serves as an assistant in the anesthesia team has many things to impart to this end, and knowledge about the possibility and management of such situations is necessary in order to avoid and successfully intervene in such incidents. The theoretical model of critical incident analysis, therefore, will be used to analyse this incident (Balas MC, Scott LD, Rogers AE., 2004). Critical incidents indicate undesirable incidents, and if they occur during the course of anesthesia, such as this, they would be termed as critical incidents during anesthesia. As evident from the history here, the severity of the incident would affect the outcome of the patient. The effects of such incidents may vary from full recovery, damage, increased hospital stay due to complications, or even death in the worst cases. Anaphylactic Shock In this case, the anesthesiologist suspected anaphylactic shock. Anaphylactic shock, the most severe type of distributive shock, occurs when the body has an extreme hypersensitivity reaction to an antigen. Death from anaphylactic shock may occur in minutes. It occurs most commonly from insect stings, antibiotics, many drugs, shellfish, peanuts, anesthetics, contrast dye, and blood products. The signs and symptoms are similar to those seen in hypovolemic shock. Additionally, patients may have symptoms specific to allergic reactions, including urticaria, pruritus, wheezing, laryngeal edema, angioedema, and severe bronchospasm. If conscious, patients may be extremely apprehensive and short of breath, and they may complain of a metallic taste. However, when sedated, the symptomatic presentation would depend upon the state of sedation. If the patient is intubated and on ventilator, that indicates that the patient is breathing on the ventilation, not on her own. Anaphylaxis is a dramatic, acute atopic reaction marked by the sudden onset of rapidly progressive urticaria and respiratory distress. A severe reaction may initiate vascular collapse, leading to systemic shock and, possibly, death (Abbas, A.K., and Lichtman, A.H., 2004). Allergy These are essentially allergic disorders. Allergy is defined and characterized by a harmful reaction to extrinsic materials or allergens, allergic disorders include allergic rhinitis, anaphylaxis, asthma, atopic dermatitis, blood transfusion reaction, latex allergy, and urticaria and angioedema. An anaphylactic reaction requires previous sensitization or exposure to the specific antigen. After initial exposure to an antigen, the immune system responds by producing specific immunoglobulin antibodies in the lymph nodes. Helper T cells enhance the process. These antibodies, IgE then bind to membrane receptors located on mast cells found throughout connective tissue, typically near small blood vessels and basophils. When the body reencounters the antigen, the IgE antibodies, or cross-linked IgE receptors, recognize the antigen as foreign. This activates a series of cellular reactions that trigger degranulation and the release of chemical mediators such as histamine, prostaglandins, and platelet-activating factor from mast cell stores. IgG or IgM enters into the reaction and activates the release of complement factors (Abbas, A.K., and Lichtman, A.H., 2004). Nursing Management In such patients, a preoperative check list of utmost importance. In this specific case there was no previous history of prior surgery, previous anesthesia, and previous administration of the drug Rocuronium. The anesthesiologist suspected anaphylactic reactions to this drug. Thus preoperative check list may appear irrelevant, and intraoperative monitoring takes the mainstay. Despite that the importance of preoperative check list cannot be undermined. Check list gives the nurse in a single view a clear guideline about do's and don'ts, and an appropriate strategy can be devised even before taking the patient into the operating room. At the least, this would allow the anesthesia team to be alerted beforehand and would stimulate preparedness in case of an adverse event such as this (Meurier CE., 2000). Routine Monitoring in the Operating Theater Monitoring is considered mandatory and routine in anesthesia care, so that these are now termed as monitored anesthesia care. In this case, and in fact, in all cases, a system of mandatory, detailed, and careful monitoring can save many critical incidents. When the patient is anesthetised, the patient has not voice to verbalise her complaints and distress. In such situations aberrations of any parameters specially respiratory and hemodynamic parameters would hint to a problem. The anesthesia team must be vigilant about these indicators, and state-of-the-art monitoring systems are available that can monitor the very important breathing, hemodynamic, and cardiovascular functions. In this case, the main manifestation of the anaphylactic shock would be through appearance of bronchospasm and shock. A monitoring of pulmonary function and cardiovascular function would indicate those at the earliest, and intervention directed to those functions would be then indicated as urgently as possible. Indeed, one of the more commonly associated roles of monitoring devices is to alert the anesthetist of changes in patient's conditions. However, an additional goal of "monitoring" relates to regulation and control: the anesthetist uses information gleaned from the monitors to modify therapeutic interventions, and then uses the monitors again to gauge the effect of these interventions, and so on in a continual feedback-control loop. Blood pressure is the vital sign that is the major determinant of left ventricular afterload. Accurate, reliable, and timely measurement of arterial blood pressure is crucial for the responsible care of those undergoing surgical procedures. ABP can be measured accurately with invasive and noninvasive methods. Arterial waveform monitors can detect specific waveform patterns and may provide useful diagnostic information in several pathologic states. Central venous pressure (CVP) provides an indicator of intravascular volume, and the waveform details can provide additional information about specific cardiac pathology and dysrhythmias. Monitoring is the continuous, or nearly continuous, evaluation of the physiologic function of a patient in real time to guide diagnosis and management decisions, including when to make therapeutic interventions and assessment of those interventions. Hypoxemia results from decreased delivery of oxygen from the atmosphere to the arterial blood, and hypoxia refers to decreased delivery of oxygen to the tissues. Arterial blood gases refer to measurements of PCO2 and PO2. The measurement of pH is also included with blood gases. Continuous pulse oximetry is the standard of care in the operating room. In this patient, as anaphylaxis would cause a shock due to extensive extracellular space fluid sequestration, the haemodynamics will be altered, and in the monitors, it would be indicated by a drop in the blood pressure and an enhancement in the heart rate and a drop in the CVP. Since this condition leads to bronchospasm, it would also lead to deficit in oxygen exchange, and hence that would be manifested as an increase in the rate of breathing with change in breath sound depth with generalized rhonchi throughout the lungs. Auscultation would reveal that, but there is a high likelihood of this being undetected. However, respiratory monitoring would reveal them in this patient. Since the patient is intubated, the ventilatory parameters monitored would indicate them. Pulse oximetry would also reflect a deficit in oxygenation (Longnecker, DE., Brown, DL., Newman, MF., and Zapol, WM., 2008). Intubation Untreated anaphylaxis can cause respiratory obstruction, systemic vascular collapse, and death minutes to hours after the first symptoms. The role of nurse here is to note the details of the incident and theoretically correlate them with their academic learning, so she can extend appropriate assistance to the anesthesiologist in order to manage the case. Fortunately, this patient was intubated before the onset of anaphylaxis; otherwise, management of her acute respiratory symptoms would have been very problematic. The reason for this would be evident from the following reasons. Immediately after exposure, the patient may complain of a feeling of impending doom or fright and exhibit apprehension, restlessness, cyanosis, cool and clammy skin, erythema, edema, tachypnea, weakness, sweating, sneezing, dyspnea, nasal pruritus, and urticaria. He may impress you as being extremely anxious. Symptoms are not available in this patient since is anesthetised. In an anesthetised patient, a high degree of suspicion is necessary, and it is to be remembered that a very rapid intervention is the key to save the patient. The sooner signs and symptoms appear after exposure to the antigen, the more severe the anaphylaxis. On inspection, the patient's skin may display well-circumscribed, discrete cutaneous wheals with erythematous, raised, serpiginous borders and blanched centers. They may coalesce to form giant hives. Introduction of the endotracheal tube becomes very difficult since these patients usually have angioedema. Angioedema may cause the patient to complain of a lump in his throat, or the nurse may hear hoarseness or stridor, although in an intubated patient on ventilator, such findings are difficult to demonstrate. Wheezing, dyspnea, and complaints of chest tightness suggest bronchial obstruction. They are early signs of impending, potentially fatal respiratory failure. Thus, intubation and increased ventilatory rates are one of the methods of management to bring the respiratory parameters back. Acid-base balance is explained by the Henderson-Hasselbalch equation. Point-of-care analyzers are available to measure blood gases and pH. These analyzers also can make other important useful measurements at the bedside, including levels of electrolytes, glucose, lactate, urea nitrogen, and hematocrit, and clotting studies. Arterial blood gases primarily reflect lung function, whereas venous blood gases reflect the adequacy of tissue oxygenation and tissue carbon dioxide clearance. A low mixed venous PO2 level, Read More