Title: Audit of use of end-tidal carbon dioxide monitoring for rapid sequence induction and patient transfer in non-theatre situation
Sangram Patil1
Madhu Gowda2
1. Specialist Registrar in Anaesthetics, Morriston Hospital Swansea, SA6
6PU, UK.
2. SHO in ITU, Morriston Hospital Swansea, SA6 6PU, UK.
Introduction:
End tidal carbon dioxide monitoring gives indication of successful expiration. Therefore it is recommended in anaesthetic and other airway management scenarios. Various specialist societies, including Royal College of Anaesthetists, AAGBI, and Intensive Care Society, have recommended use of end tidal carbon dioxide as a basic standard for rapid sequence induction and patient transfers in or out of hospital. There is evidence which suggest that monitoring end tidal carbon dioxide helps improving patient safety and quality of care.
Objective:
To know the practice with regards to end tidal carbon dioxide monitoring in our department and give recommendations for improvement in practice. For this to be audited to do a survey of use of etCO2 monitoring amongst trainees in our department.
Method:
A simple form was distributed amongst trainees and they were requested to questions and also given choice to express the factors related to etCO2 monitoring the end of the survey. The survey consisted of five simple questions. Out of 30 forms distributed- 21 forms were received back.
Results:
Did you use end tidal carbon dioxide monitor in A & E the last time you intubated patient?
Yes 8 No 12 Never attended intubation in A &
Did you use end tidal carbon dioxide monitor the last time you transferred the intubated patient inside the hospital?
Yes 9 No 12 Never attended intubation in A & E 0
Did you use end tidal carbon dioxide monitor the last time you transferred the intubated patient outside the hospital?
Yes 10 No 2 Never attended intubation in A & E 9
Are you aware of any national/local recommendations for etCO2 monitoring during patient transfer?
Yes 9 No 11
If you answered no to questions 1 2 3 Why didn't you use the etCO2 monitor in these situation?
a. etCO2 monitor not available at all - 3
b. etCO2 monitor was not provided even after your request- 7
c. you don’t think etCO2 monitor is required in above situations-1
d. you are not sure whether it is necessary to use etCO2 monitor in above situations- 4
e. Any other reasons- free comments-
capnograph was available only after repeated requests
Most of the A & E staff are unaware of where capnograph connectors are kept
There is usually delay in getting the capnograph in A & E
You never get it if you don’t ask for it.
Very useful audit!
Discussion:
Difficult or failed intubation is a serious problem. This can lead to potential oxygenation problems and is associated with significant mortality and morbidity.1
Difficult airway society (DAS) has recommended capnograph as a method to detect tracheal intubation as a monitoring for all routine intubations (2).
Rapid sequence induction (RSI) is increasingly used by emergency physicians in the emergency department. A feared complication of the technique is the inability to intubate and subsequently ventilate the patient (3). During RSI clinical assessment of proper placement of endotracheal tube, including direct visualization, auscultation, chest rise and tube condensation, cannot always confirm proper placement of the endotracheal tube. (4)
Unintentional hyperventilation occurs during the intrahospital transport (5). The standard of care and monitoring during transport should be at least as good as that at the referring hospital or base unit (6). The minimum standards required for all patients are:
_ Continuous presence of appropriately trained staff
_ ECG
_ Non-invasive blood pressure
_ Arterial oxygen saturation (SaO2)
_ End tidal carbon dioxide (EtCO2) in ventilated patients
_ Temperature (preferably core and peripheral).
These guidelines apply to the transport of critically ill adult patients in the UK outside of the normal critical care environment. They apply both to patients transferred between hospitals.
Royal college of anaesthetists of UK also has recommended the use of end tidal carbon dioxide for patient transfer (7). The association of Anaesthetists of great Briton and Ireland (AAGBI) has given guidelines for anaesthetizing patient (8), which obviously are also valid for rapid sequence induction (as this involves anaesthetizing the patient). The Association has recommended etCO2 monitoring as a basic requirement for anaesthetizing any patient.
Recommendations:
Awareness of what is end tidal carbon dioxide monitoring is necessary. This can only be achieved through more teaching and training directed towards nursing staff in casualty department. This will ensure that they know what is being requested in emergency situation.
Availability of etCO2 monitoring device on casualty and intensive care department. All the nursing staff should be aware of where these sampling connectors are stored.
Teaching and training of junior doctors who actually use the monitoring. The teaching sessions/study day on airway management in emergency situation can help raise awareness. Training in patient transfer (formal courses are available) may be helpful for novice doctors.
Reaudit the practice again and look for any positive changes in quality of clinical care with regards to use of end tidal carbon dioxide monitoring for rapid sequence induction and patient transfer.
References:
1. Caplan RA, Posner KL, Ward RJ. Adverse respiratory events in
anaesthesia: a closed claims analysis. Anesthesiology 1990; 72; 828-33.
2. Difficult airway society (DAS) guidelines.
3. S D Carley, C Gwinnutt, J Butler. Rapid sequence induction in the
emergency department: a strategy for failure. Emerg Med J 2002; 19:109-
113
4. Pearson S. The airway pipeline: How do you know where your ETT is?
Air Med J 22:42 - 46, 2003.
5. Tobias JD, Lynch A, Garrett J. Pediatric Emerg Care. 1996 Aug;
12(4):249-51.
6. The intensive care society (UK) guidelines.
7. Royal college of anaesthetists of UK guidelines.
8. The Association of Anaesthetists of great Briton and Ireland guidelines.
Friday, January 18, 2008
Monday, May 22, 2006
AUDIT ON USE OF ANITIBIOTICS FOR SURGICAL PROPHYLAXIS
INTRODUCTION
Surgical Antibiotic Prophylaxis reduces the likelihood of infection where:
Inoculum of infecting bacteria likely to be high.
Procedure may result in infection from small inoculum
The idea behind prophylaxis is not to protect against post operatively acquired infection.
In most cases single I.V dose at induction is adequate.
The audit is based on evidence obtained from national and local guidelines and evidence based literature prepared by our micro department
OBJECTIVES
To ascertain current practice in most surgical specialities.
To find whether we use appropriate antibiotic.
If so , appropriate dose or doses given at appropriate time.
To come to a consensus among specialities regarding this and re-audit in 2 months time.
METHODS
The audit was performed from 22nd of Feb – 15th of Mar.
All surgical patients both elective and emergency were included.
Totally 80 patients were followed up prospectively and data was obtained from anaesthetic and prescription charts.
The pharmacist was also involved in obtaining data.
DATA INTERPRETATION
PERCENTAGE OF CASES IN EACH SPECIALITY
FINDINGS
PROPHYLAXIS GIVEN
DOSES GIVEN
(within appropriate prophylaxis GROUP)
NUMBER OF DOSES GIVEN
(within appropriate prophylaxis GROUP)
GIVEN AT APPROPRIATE TIME
(within appropriate prophylaxis GROUP)
OVERALL “INAPPROPRIATE” ANTIBIOTICS
“INAPPROPRIATE” ANTIBIOTICS WITHIN SPECIALITIES
REASON WHY“INAPPROPRIATE”
Urology and General Surgery contributed the most towards the overall percentage of “inappropriate” use of antibiotics.
However vascular and General Surgery contributed the most individually.
Though the number of Orthopaedic cases that were followed up were high, 90% of cases received appropriate antibiotics.
Most of the cases in Urology and General Surgery were “inappropriate” because the patients received treatment rather than prophylaxis.
The patients who received “inappropriate” antibiotics underwent the following procedures:
We also observed that each surgical consultant had their own choice of antibiotics which at times were “inappropriate”.
This resulted in some of the anaesthetists giving “inappropriate” antibiotics as prophylaxis.
NO CURENT RECOMMENDATIONS
SUMMARY
Based on the findings we observed that almost 60% of patients received appropriate antibiotic prophylaxis.
Guidelines are not available for more than 20% of cases audited.
Potential implications for the patient and the trust are to provide high level prophylaxis while minimising production of resistant microbes.
We welcome evidence based suggestions from all the staff involved in use of antibiotics following which guidelines can be revised for better practice in future.
INTRODUCTION
Surgical Antibiotic Prophylaxis reduces the likelihood of infection where:
Inoculum of infecting bacteria likely to be high.
Procedure may result in infection from small inoculum
The idea behind prophylaxis is not to protect against post operatively acquired infection.
In most cases single I.V dose at induction is adequate.
The audit is based on evidence obtained from national and local guidelines and evidence based literature prepared by our micro department
OBJECTIVES
To ascertain current practice in most surgical specialities.
To find whether we use appropriate antibiotic.
If so , appropriate dose or doses given at appropriate time.
To come to a consensus among specialities regarding this and re-audit in 2 months time.
METHODS
The audit was performed from 22nd of Feb – 15th of Mar.
All surgical patients both elective and emergency were included.
Totally 80 patients were followed up prospectively and data was obtained from anaesthetic and prescription charts.
The pharmacist was also involved in obtaining data.
DATA INTERPRETATION
PERCENTAGE OF CASES IN EACH SPECIALITY
FINDINGS
PROPHYLAXIS GIVEN
DOSES GIVEN
(within appropriate prophylaxis GROUP)
NUMBER OF DOSES GIVEN
(within appropriate prophylaxis GROUP)
GIVEN AT APPROPRIATE TIME
(within appropriate prophylaxis GROUP)
OVERALL “INAPPROPRIATE” ANTIBIOTICS
“INAPPROPRIATE” ANTIBIOTICS WITHIN SPECIALITIES
REASON WHY“INAPPROPRIATE”
Urology and General Surgery contributed the most towards the overall percentage of “inappropriate” use of antibiotics.
However vascular and General Surgery contributed the most individually.
Though the number of Orthopaedic cases that were followed up were high, 90% of cases received appropriate antibiotics.
Most of the cases in Urology and General Surgery were “inappropriate” because the patients received treatment rather than prophylaxis.
The patients who received “inappropriate” antibiotics underwent the following procedures:
We also observed that each surgical consultant had their own choice of antibiotics which at times were “inappropriate”.
This resulted in some of the anaesthetists giving “inappropriate” antibiotics as prophylaxis.
NO CURENT RECOMMENDATIONS
SUMMARY
Based on the findings we observed that almost 60% of patients received appropriate antibiotic prophylaxis.
Guidelines are not available for more than 20% of cases audited.
Potential implications for the patient and the trust are to provide high level prophylaxis while minimising production of resistant microbes.
We welcome evidence based suggestions from all the staff involved in use of antibiotics following which guidelines can be revised for better practice in future.
Lparoscopic Surgery
DR Raghvendra Kulkarni.
Introduction
In recent years, laparoscopic surgery has become common clinical practice. Initially, the use of laparoscopic procedures was confined to the obstetric and gynaecological department where it was used for laparoscopic sterilization and short diagnostic procedures. Thus, it was usually carried out on young and healthy females.
New intra-abdominal laparoscopic surgical techniques have been developed, performed and advocated for older patients when they may have coexisting cardiac and pulmonary disease. These laparoscopic procedures may involve changes in patient position and require a longer period of intra-abdominal carbon dioxide insufflation.
The major problems during laparoscopic surgery are related to the cardiopulmonary effect of pneumoperitoneum, systemic carbon dioxide absorption, extraperitoneal gas insufflation, venous gas embolism, unintentional injuries to intra-abdominal structures and patient positioning.
An appraisal of the potential problems is essential for optimal anaesthetic care of patients undergoing laparoscopic surgery. Appropriate anaesthetic techniques and monitoring facilitate surgery and allow early detection and reduction of complications. The need for rapid recovery and a short hospital stay impose additional demands on the anaesthetist for skilful practice.
Anaesthesia
Anaesthetic management
Anaesthetic management of patients undergoing laparoscopic surgery must accommodate surgical requirements and allow for physiological changes during surgery. Monitoring devices are available for the early detection of complications. Recovery from anaesthesia should be rapid with minimal residual effects. The possibility of the procedures being converted to open laparotomy needs to be considered.
Pre-anaesthetic assessment
Medical contraindications to laparoscopic surgery are relative. Successful laparoscopic surgery has been performed on anticoagulated, pregnant and morbidly obese patients.
Premedication is usually not necessary except in anxious patients for whom anxiolytics, such as the benzodiazepines, may be prescribed. Atropine can be used for premedication to prevent vagally mediated bradyarrhythmias but may cause undesirable mouth drying and increase the likelihood of tachyarrhythmias. It is, therefore, more appropriate to give the drug intravenously only when necessary.
Anaesthetic techniques
The choice of anaesthetic technique for upper abdominal laparoscopic surgery is mostly limited to general anaesthesia with muscle paralysis, tracheal intubation and intermittent positive pressure ventilation (IPPV) .
At induction of anaesthesia it is important to avoid stomach inflation during ventilation as this increases the risk of gastric injury during trocar insertion. Tracheal intubation and IPPV ensure airway protection and control of pulmonary ventilation to maintain normocarbia. Ventilation with a large tidal volume of 12-15 ml/kg prevents progressive alveolar atelectasis and hypoxaemia and allows for more effective alveolar ventilation and carbon dioxide elimination.
The use of nitrous oxide during laparoscopic surgery is controversial because of concerns about its ability to produce bowel distension during surgery and the increase in postoperative nausea. Nitrous oxide is about 30 times more soluble than nitrogen. Thus, a closed air-containing space may accumulate nitrous oxide more rapidly than it can eliminate nitrogen.
Eger and Saidman observed an increase of more than 200% in intestinal lumen size after 4 hours of breathing nitrous oxide. Lomie and Harper reported a reduction in postoperative vomiting from 49% to 17% when nitrous oxide was omitted in a prospective randomized study of 87 patients undergoing gynaecological laparoscopic surgery. In contrast, in an extensive randomized and blinded prospective study, Muir et al. Found no association between the use of nitrous oxide and the subsequent development of postoperative nausea and vomiting.
Halothane increases the incidence of arrhythmia during laparoscopic surgery, especially in the presence of hypercarbia. Isoflurane is the preferred volatile anaesthetic agent as it has less arrhythmogenic and myocardial depressant effects.
Regional anaesthesia
Epidural anaesthesia has been used for outpatient gynaecological laparoscopic procedures to reduce complications and shorten recovery time after anaesthesia. Local or regional anaesthetic techniques have not been reported for laparoscopic cholecystectomy or other upper abdominal surgical procedures except in patients with cystic fibrosis. A high epidural block (T2-T4 levels) is required to abolish the discomfort of surgical stimulation of the upper gastrointestinal structures. The high block produces myocardial depression and reduction in venous return, aggravating the haemodynamic effects of tension pneumoperitoneum.
Monitoring
The electrocardiogram, noninvasive arterial pressure monitor, airway pressure monitor, pulse oximeter, end-tidal carbon dioxide concentration monitor, peripheral nerve stimulation and body temperature probe are routinely used. A urinary catheter is usually placed to minimize the risk of bladder injury and improve surgical exposure. The urine output should be monitored in patients with compromised cardiopulmonary function.
End-tidal carbon dioxide is most commonly used as a noninvasive substitute for PaCO2 (tension of carbon dioxide in arterial blood) in evaluating the adequacy of ventilation during laparoscopic surgery because the gradient between PaCO2 and PECO2 (tension of CO2 in expired air) in healthy patients under general anaesthesia is between 2 mmHg and 9 mmHg. However, for patients with compromised cardiopulmonary function, the gradient between PaCO2 and PECO2 may become large and unpredictable so direct estimation of PaCO2 by arterial blood gas analysis may be necessary to detect hypercarbia. A PECO2 monitor is also valuable for early detection of venous gas embolism.
An airway pressure monitor is mandatory for anaesthetized patients receiving IPPV. A high airway pressure alarm can aid detection of excessive elevation in intra-abdominal pressure.
Nerve stimulation ensures adequate muscle paralysis which reduces the intra-abdominal pressure necessary for abdominal distension. This also prevents sudden patient movement during surgery that can lead to accidental injuries of intra-abdominal structures by laparoscopic instruments.
Postoperative course
Laparoscopic surgery is a relatively new surgical technique, with the advantages of shortening hospital stays, allowing a more rapid return to normal activities and lessening pain.
Nausea and vomiting are particularly troublesome after laparoscopic surgery; over 50% of patients require antiemetics, so prophylactic antiemetics may be given routinely. The use of non-steroidal anti-inflammatory drugs for postoperative analgesia has been described to minimize emesis after laparoscopic cholecystectomy . Pain following laparoscopic surgery consists of early transient vagal abdominal and shoulder discomfort due to peritoneal irritation by residual carbon dioxide. Patients can also experience deep-seated pain related to trauma at the surgical site.
Pain from the puncture wounds of the trocars is generally mild because the wounds are small and are produced without the cutting of muscle fibres. Pulmonary function is better presented following laparoscopic surgery; forced vital capacity is reduced by 27% after laparoscopic surgery and by 48% after operation.
DR Raghvendra Kulkarni.
Introduction
In recent years, laparoscopic surgery has become common clinical practice. Initially, the use of laparoscopic procedures was confined to the obstetric and gynaecological department where it was used for laparoscopic sterilization and short diagnostic procedures. Thus, it was usually carried out on young and healthy females.
New intra-abdominal laparoscopic surgical techniques have been developed, performed and advocated for older patients when they may have coexisting cardiac and pulmonary disease. These laparoscopic procedures may involve changes in patient position and require a longer period of intra-abdominal carbon dioxide insufflation.
The major problems during laparoscopic surgery are related to the cardiopulmonary effect of pneumoperitoneum, systemic carbon dioxide absorption, extraperitoneal gas insufflation, venous gas embolism, unintentional injuries to intra-abdominal structures and patient positioning.
An appraisal of the potential problems is essential for optimal anaesthetic care of patients undergoing laparoscopic surgery. Appropriate anaesthetic techniques and monitoring facilitate surgery and allow early detection and reduction of complications. The need for rapid recovery and a short hospital stay impose additional demands on the anaesthetist for skilful practice.
Anaesthesia
Anaesthetic management
Anaesthetic management of patients undergoing laparoscopic surgery must accommodate surgical requirements and allow for physiological changes during surgery. Monitoring devices are available for the early detection of complications. Recovery from anaesthesia should be rapid with minimal residual effects. The possibility of the procedures being converted to open laparotomy needs to be considered.
Pre-anaesthetic assessment
Medical contraindications to laparoscopic surgery are relative. Successful laparoscopic surgery has been performed on anticoagulated, pregnant and morbidly obese patients.
Premedication is usually not necessary except in anxious patients for whom anxiolytics, such as the benzodiazepines, may be prescribed. Atropine can be used for premedication to prevent vagally mediated bradyarrhythmias but may cause undesirable mouth drying and increase the likelihood of tachyarrhythmias. It is, therefore, more appropriate to give the drug intravenously only when necessary.
Anaesthetic techniques
The choice of anaesthetic technique for upper abdominal laparoscopic surgery is mostly limited to general anaesthesia with muscle paralysis, tracheal intubation and intermittent positive pressure ventilation (IPPV) .
At induction of anaesthesia it is important to avoid stomach inflation during ventilation as this increases the risk of gastric injury during trocar insertion. Tracheal intubation and IPPV ensure airway protection and control of pulmonary ventilation to maintain normocarbia. Ventilation with a large tidal volume of 12-15 ml/kg prevents progressive alveolar atelectasis and hypoxaemia and allows for more effective alveolar ventilation and carbon dioxide elimination.
The use of nitrous oxide during laparoscopic surgery is controversial because of concerns about its ability to produce bowel distension during surgery and the increase in postoperative nausea. Nitrous oxide is about 30 times more soluble than nitrogen. Thus, a closed air-containing space may accumulate nitrous oxide more rapidly than it can eliminate nitrogen.
Eger and Saidman observed an increase of more than 200% in intestinal lumen size after 4 hours of breathing nitrous oxide. Lomie and Harper reported a reduction in postoperative vomiting from 49% to 17% when nitrous oxide was omitted in a prospective randomized study of 87 patients undergoing gynaecological laparoscopic surgery. In contrast, in an extensive randomized and blinded prospective study, Muir et al. Found no association between the use of nitrous oxide and the subsequent development of postoperative nausea and vomiting.
Halothane increases the incidence of arrhythmia during laparoscopic surgery, especially in the presence of hypercarbia. Isoflurane is the preferred volatile anaesthetic agent as it has less arrhythmogenic and myocardial depressant effects.
Regional anaesthesia
Epidural anaesthesia has been used for outpatient gynaecological laparoscopic procedures to reduce complications and shorten recovery time after anaesthesia. Local or regional anaesthetic techniques have not been reported for laparoscopic cholecystectomy or other upper abdominal surgical procedures except in patients with cystic fibrosis. A high epidural block (T2-T4 levels) is required to abolish the discomfort of surgical stimulation of the upper gastrointestinal structures. The high block produces myocardial depression and reduction in venous return, aggravating the haemodynamic effects of tension pneumoperitoneum.
Monitoring
The electrocardiogram, noninvasive arterial pressure monitor, airway pressure monitor, pulse oximeter, end-tidal carbon dioxide concentration monitor, peripheral nerve stimulation and body temperature probe are routinely used. A urinary catheter is usually placed to minimize the risk of bladder injury and improve surgical exposure. The urine output should be monitored in patients with compromised cardiopulmonary function.
End-tidal carbon dioxide is most commonly used as a noninvasive substitute for PaCO2 (tension of carbon dioxide in arterial blood) in evaluating the adequacy of ventilation during laparoscopic surgery because the gradient between PaCO2 and PECO2 (tension of CO2 in expired air) in healthy patients under general anaesthesia is between 2 mmHg and 9 mmHg. However, for patients with compromised cardiopulmonary function, the gradient between PaCO2 and PECO2 may become large and unpredictable so direct estimation of PaCO2 by arterial blood gas analysis may be necessary to detect hypercarbia. A PECO2 monitor is also valuable for early detection of venous gas embolism.
An airway pressure monitor is mandatory for anaesthetized patients receiving IPPV. A high airway pressure alarm can aid detection of excessive elevation in intra-abdominal pressure.
Nerve stimulation ensures adequate muscle paralysis which reduces the intra-abdominal pressure necessary for abdominal distension. This also prevents sudden patient movement during surgery that can lead to accidental injuries of intra-abdominal structures by laparoscopic instruments.
Postoperative course
Laparoscopic surgery is a relatively new surgical technique, with the advantages of shortening hospital stays, allowing a more rapid return to normal activities and lessening pain.
Nausea and vomiting are particularly troublesome after laparoscopic surgery; over 50% of patients require antiemetics, so prophylactic antiemetics may be given routinely. The use of non-steroidal anti-inflammatory drugs for postoperative analgesia has been described to minimize emesis after laparoscopic cholecystectomy . Pain following laparoscopic surgery consists of early transient vagal abdominal and shoulder discomfort due to peritoneal irritation by residual carbon dioxide. Patients can also experience deep-seated pain related to trauma at the surgical site.
Pain from the puncture wounds of the trocars is generally mild because the wounds are small and are produced without the cutting of muscle fibres. Pulmonary function is better presented following laparoscopic surgery; forced vital capacity is reduced by 27% after laparoscopic surgery and by 48% after operation.
Do we waste drugs in theatres?
Aim of audit
Anaesthetic expenses, a small part of hospital expenses.
But, it definitely is an expense.
To find out whether we waste any drugs.
If yes, what are the things we waste?
Methods
A simple audit form, to be filled in by ODPs/ Anaesthetic nurses.
Duration- one month- April, 2005.
Data
Total 32 sessions reported.
Week days- 31, Week ends- 1.
Sessions- Morning 13, Noon 12, Evening 6, Night 1.
Scheduled 21, CEPOD 2, trauma 3, Emergency 6.
Main OT 26, Obstetrics 5.
Results…
Out of 32 sessions-
No wastage 10 sessions.
Wastage on 22 sessions.
The list of drugs opened but not used at all.
Atropine 11, Ephedrine 15.
Thiopentone 5, Propofol 5.
Lignocaine 4.
Antibiotics 1.
Suxamethonium 4, NMDR 3.
Morphine 3, Fentanyl 1.
Midazolam 1.
Phenylephrine 1.
Total…
Percentage…
Timing wise
Conclusion…
Difficult to draw conclusion.
But we definitely waste drugs.
It involves expensive drugs including propofol, NMDR, Morphine, fentanyl.
May be over reported positive finding.
May be just a tip of an iceberg.
Recommendations
Communication- in theatre, recovery?
Labelling
Drawing up of drugs- Morphine, Fentanyl- just before use.
Muscle relaxants, especially NMDRs just before use (more safe!).
Atropine/ ephedrine/ Suxamethonium- pre-filled syringes?
Have you got any solutions? - Discussion.
THANKS
Aim of audit
Anaesthetic expenses, a small part of hospital expenses.
But, it definitely is an expense.
To find out whether we waste any drugs.
If yes, what are the things we waste?
Methods
A simple audit form, to be filled in by ODPs/ Anaesthetic nurses.
Duration- one month- April, 2005.
Data
Total 32 sessions reported.
Week days- 31, Week ends- 1.
Sessions- Morning 13, Noon 12, Evening 6, Night 1.
Scheduled 21, CEPOD 2, trauma 3, Emergency 6.
Main OT 26, Obstetrics 5.
Results…
Out of 32 sessions-
No wastage 10 sessions.
Wastage on 22 sessions.
The list of drugs opened but not used at all.
Atropine 11, Ephedrine 15.
Thiopentone 5, Propofol 5.
Lignocaine 4.
Antibiotics 1.
Suxamethonium 4, NMDR 3.
Morphine 3, Fentanyl 1.
Midazolam 1.
Phenylephrine 1.
Total…
Percentage…
Timing wise
Conclusion…
Difficult to draw conclusion.
But we definitely waste drugs.
It involves expensive drugs including propofol, NMDR, Morphine, fentanyl.
May be over reported positive finding.
May be just a tip of an iceberg.
Recommendations
Communication- in theatre, recovery?
Labelling
Drawing up of drugs- Morphine, Fentanyl- just before use.
Muscle relaxants, especially NMDRs just before use (more safe!).
Atropine/ ephedrine/ Suxamethonium- pre-filled syringes?
Have you got any solutions? - Discussion.
THANKS
A study of use of Low Flow Anaesthesia in our department at NHH.
Some background-
Former reservations against low flow anaesthesia are not justified any longer.
Definitions-
Metabolic flow = 250 ml/minMinimal flow = 250-500 ml/minLow flow = 500-1000 ml/minMedium flow = 1-2 l/minHigh flow = 2-4 l/min, Very high flow = > 4 l/min
LFA- recommended by authorities.
Advantages
Apart from other advantages of LFA, there is definite reduction in cost with the use of low flows.
According to 1994 study at Northwick Park Hospital, there was a proportional decrease in cost of inhalational agents used with reduction in flow rates.
Method of audit
A simple questionnaire, 5 questions.
Definition
What flow rates?
Why?
Which inhalational agents?
Nitrous oxide?
Results
Definition-
What Flow rates?
Why these flows?
Which agents?
N2O
Definition of LFA
Individual flows
Reasons for not using LFA
Inhalational Agents
Inhalational agents.
Awareness & Usage.
Summary
Third of us do definitely know and use LFA.
In general, more than half of us are not very familiar with the concept.
Those who think they use LFA- 40% of them don’t use LFA actually.
Third of us don’t understand the concept, 25% are not comfortable with it.
Recommendations
Use low flow, its definitely better than higher flow.
More teaching.
More training, discussions.
? Trainees.
Re-audit.
ALFA website.
THANK YOU.
Some background-
Former reservations against low flow anaesthesia are not justified any longer.
Definitions-
Metabolic flow = 250 ml/minMinimal flow = 250-500 ml/minLow flow = 500-1000 ml/minMedium flow = 1-2 l/minHigh flow = 2-4 l/min, Very high flow = > 4 l/min
LFA- recommended by authorities.
Advantages
Apart from other advantages of LFA, there is definite reduction in cost with the use of low flows.
According to 1994 study at Northwick Park Hospital, there was a proportional decrease in cost of inhalational agents used with reduction in flow rates.
Method of audit
A simple questionnaire, 5 questions.
Definition
What flow rates?
Why?
Which inhalational agents?
Nitrous oxide?
Results
Definition-
What Flow rates?
Why these flows?
Which agents?
N2O
Definition of LFA
Individual flows
Reasons for not using LFA
Inhalational Agents
Inhalational agents.
Awareness & Usage.
Summary
Third of us do definitely know and use LFA.
In general, more than half of us are not very familiar with the concept.
Those who think they use LFA- 40% of them don’t use LFA actually.
Third of us don’t understand the concept, 25% are not comfortable with it.
Recommendations
Use low flow, its definitely better than higher flow.
More teaching.
More training, discussions.
? Trainees.
Re-audit.
ALFA website.
THANK YOU.
Control of blood sugar level on our unit
Why control blood glucose?
•Van Den Berghe study, Belgium, 2001, (110mg/dl).
•Van Den Berghe study, Belgium, 2003, high insulin therapy- mortality.
•BHF, Dr Finney, Oct. 2003, JAMA, for Insulin therapy.
•Laver et al, 2004, (Royal United Hosp, Bath), first paper in UK on protocols for BM control.
Methods
•Aim- To check how we were doing on our HDU/ ITU.
•Maximum and minimum blood sugar and insulin doses used over 24 hours.
•Mixed medical & surgical cases.
•Data collected over Sep-Oct. 2004.
Data
•152 audited*
•Diabetic-24
•Non diabetic-128
•145 fed/7 not fed
•Insulin- 112,
•DM- 21
Non DM- 89.
Maximum blood sugar levels
Minimum blood sugar levels
Percentage of patients, max. sugars.
Insulin therapy*
High dose Insulin therapy
High dose insulin*
Conclusions
•>10 BM- Not bad ( esp. for non DM).
•4-8 BM- Just under 50 % of total, all Non DM.
•Main bulk outside this range- BM 8-10, (50% DM, 23% Non DM).
•>10 BM- 50% DM lie above 10.
•We have a scope for improvement in BM 8-10 group.
•Further scope for control of even higher BM level groups, with insulin dose adjustments.
Recommendations
•For us- We can look at BM as if its a vital parameter, during daily ward rounds*.
•For nurses- Regular reinforcement of the protocols for BM control.
•Recheck the outcome after implementing these suggestions.
Why control blood glucose?
•Van Den Berghe study, Belgium, 2001, (110mg/dl).
•Van Den Berghe study, Belgium, 2003, high insulin therapy- mortality.
•BHF, Dr Finney, Oct. 2003, JAMA, for Insulin therapy.
•Laver et al, 2004, (Royal United Hosp, Bath), first paper in UK on protocols for BM control.
Methods
•Aim- To check how we were doing on our HDU/ ITU.
•Maximum and minimum blood sugar and insulin doses used over 24 hours.
•Mixed medical & surgical cases.
•Data collected over Sep-Oct. 2004.
Data
•152 audited*
•Diabetic-24
•Non diabetic-128
•145 fed/7 not fed
•Insulin- 112,
•DM- 21
Non DM- 89.
Maximum blood sugar levels
Minimum blood sugar levels
Percentage of patients, max. sugars.
Insulin therapy*
High dose Insulin therapy
High dose insulin*
Conclusions
•>10 BM- Not bad ( esp. for non DM).
•4-8 BM- Just under 50 % of total, all Non DM.
•Main bulk outside this range- BM 8-10, (50% DM, 23% Non DM).
•>10 BM- 50% DM lie above 10.
•We have a scope for improvement in BM 8-10 group.
•Further scope for control of even higher BM level groups, with insulin dose adjustments.
Recommendations
•For us- We can look at BM as if its a vital parameter, during daily ward rounds*.
•For nurses- Regular reinforcement of the protocols for BM control.
•Recheck the outcome after implementing these suggestions.
Audit of compliance with NICE guidelines for preoperative tests
What does NICE say?
Patients
ASA 1
ASA 2
ASA 3
ASA 4
Surgery
Grade 1
Grade 2
Grade 3
Grade 4
Who need what?
Grade 1 surgery
ASA 1 < 16 yrs; grade 1 surgery.
ASA 1 <80> 80 yrs will need ECG. Age 40- 80 consider if indicated.
ASA 2 will only need relevant tests for their condition.
ASA 3 will need FBC and other relevant tests.
Grade 2 surgery
ASA 1 <16 year- nil
ASA 2- FBC in above 60 and ECG in above 80 yrs.
ASA 3 >16 will need ECG and renal functions; other tests as indicated.
Grade 3 surgery
ASA 1; <16 yrs- consider FBC, renal functions, urine analysis.
ASA 1, >16 yrs- FBC for all ECG and renal functions in >60 yrs. Others.
ASA 2; > 16 yrs- ECG, FBC, renal functions.
ASA 3; > 16 yrs- ECG, FBC, renal functions.
Grade 4 surgery
ASA 1; < 16 yrs- consider FBC, Urine, renal functions.
ASA 1; > 16 yrs-FBC, renal functions, ECG for >60 yrs.
ASA 2; >16 yrs-ECG, FBC, renal functions.
ASA 3- ECG > 40, FBC, renal functions, others.
This audit
Simple
Forms
Elective cases
25 forms collected
Data
Appropriate investigations
ASA 1- 2/6
ASA 2- 4/10
ASA 3- 4/8
ASA 4- 1/1
Inappropriate investigations
ASA 1- 4/6
ASA 2- 6/10
ASA 3- 4/8
ASA 4- 0/1
Summary
Juniors in surgery
Pre-assessment nurses
Local guidelines for the trust
Inappropriate use of tests
Tip of iceberg
Recommendations
More teaching in this field
Induction of juniors at the start of job
Ward nurses
NICE guideline cards
Charts on the walls
Re-audit
Thank you
What does NICE say?
Patients
ASA 1
ASA 2
ASA 3
ASA 4
Surgery
Grade 1
Grade 2
Grade 3
Grade 4
Who need what?
Grade 1 surgery
ASA 1 < 16 yrs; grade 1 surgery.
ASA 1 <80> 80 yrs will need ECG. Age 40- 80 consider if indicated.
ASA 2 will only need relevant tests for their condition.
ASA 3 will need FBC and other relevant tests.
Grade 2 surgery
ASA 1 <16 year- nil
ASA 2- FBC in above 60 and ECG in above 80 yrs.
ASA 3 >16 will need ECG and renal functions; other tests as indicated.
Grade 3 surgery
ASA 1; <16 yrs- consider FBC, renal functions, urine analysis.
ASA 1, >16 yrs- FBC for all ECG and renal functions in >60 yrs. Others.
ASA 2; > 16 yrs- ECG, FBC, renal functions.
ASA 3; > 16 yrs- ECG, FBC, renal functions.
Grade 4 surgery
ASA 1; < 16 yrs- consider FBC, Urine, renal functions.
ASA 1; > 16 yrs-FBC, renal functions, ECG for >60 yrs.
ASA 2; >16 yrs-ECG, FBC, renal functions.
ASA 3- ECG > 40, FBC, renal functions, others.
This audit
Simple
Forms
Elective cases
25 forms collected
Data
Appropriate investigations
ASA 1- 2/6
ASA 2- 4/10
ASA 3- 4/8
ASA 4- 1/1
Inappropriate investigations
ASA 1- 4/6
ASA 2- 6/10
ASA 3- 4/8
ASA 4- 0/1
Summary
Juniors in surgery
Pre-assessment nurses
Local guidelines for the trust
Inappropriate use of tests
Tip of iceberg
Recommendations
More teaching in this field
Induction of juniors at the start of job
Ward nurses
NICE guideline cards
Charts on the walls
Re-audit
Thank you
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