NAP studies Flashcards by Sara Bellas

what did NAP 1 look at ?

the supervisory role of the consultant

link between patient outcome and level of supervision

emphysis on needing
- clear protocols/ guidelines on level of supervision in different setings
- more training opportunities
- supervisor / consultants more available

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what did NAP 2 look at?

M&M meetings
- highlighted importance in patient safety and outcome
- training into how to conduct an M&M
- increase regularity of M&M
- adviced joint specialty m&ms - with surgeons - no blame and teaching around topics.

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what did NAP 3 look at

major complications after neuroaxial blockade
assessed 700,000 cases
equal spinal and epidural
just under half obstetric

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What was the rate of permanent injury and paraplegia / death in neuraxial blocks

permanent nerve damage = 1 in 50,000
paraplegia / death = 1 in 140,000

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What was found to have higher risk epidurals or spinals?

epidurals

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Which group had lower rates of complications with neuraxial blocks

children
obstetric

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What was suggested by the NAP3 study

improved detection of complications - training on signs/ symptoms, carebundles, available acess to scanning fascilities
improved management - alogorithms available / training
prevention - assessing those at higher risk, strict asepsis

Key to dealing with complications is early detection with proper monitoring

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How many deaths were reported by NAP 3

1 in 140,000

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What are the complications and rates of these with epidurals

1 in 20 - fail
1 in 50 - hypotension
1 in 150 - PDPH / headache
1 in 2000 - temporary nerve damage
1 in 15000 - permanent
1 in 50, 000 - epidural abscess
1 in 100,000 - meningitis
1 in 140,000= permananet paralysis (NAP 3)

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how common are vertebral canal haematomas after CNB?

0.85 in 100,000

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Which nerves and modalities are least / most sensitive to local anaesthetic

B fibres - sympathetic - most
C fibres
A d
Ag - touch
Aa - motor and proprioception

Aa and Ab are quite resistant - hence still feel pressure in C section

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What factors affect the spread of local

Baricity
Patient position
Dose – volume
Pregnancy = reduced volume

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Limitations of NAP 3

looked mainly at permananet / serious complications rather than minor

didnt differentiate if complications were due to dangerous nature of epi/spinal or high risk factors

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Which complications had most significant prognosis

vertebral canal haematoma - spinal cord ischaemia

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give examples of short acting and longer acting local anaesthetic agents

shortest - procaine
medium - lidocaine , prilocaine
long - levo/bupivacaine , ropivacaine (longest)

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adjuncts that can be used in neuraxial anaesthesia..

diamorphine, fentanyl, morphine
clonidine, dexmedetomidine
bicarb - increases speed of onset
adrenaline - prolong duration of block

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What did NAP 4 look at

major airway complications - where they occur (ED/ITU/ theatre), what stage of anaesthesia, what they are associated with.

what airway devices are used in anaesthesia

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What did NAP 4 find to be a cause of complications - i.e. factors invovled

lack of airway assessment
lack of airway plan
lack of planning for failure
remote locations
obesity
inappropriate SGA devices in those high risk reflux

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according to NAP 4 What were obese patients more at risk of

aspiration
obstruction on emergence
difficult intubation

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What was the biggest cause of death in airway management

Aspiration
Partly from inappropriate use of SGA in those with multiple risk factors requiring RSI

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When did majority of airway complications occurs

majority at induction
but over 1/3 at extubation - quite significant
due to obstruction and post op pulmonary oedema

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Methods for avoiding complications at extubation

bite block
suctioning
pre oxygenate
reversal NMBA
only extubate when fully awake

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What was the no trace, wrong place campaign

teaching and emphysis on confirming placement of ET tube by sustained exhaled CO2 - consistent presence of CO2 over 6 breaths or more

hence capnography should be employed in all areas – arrests, ED, ITU etc

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Where did the majority of SERIOUS airway problems occur and why

most complications occured in theatree
but only 1/3 of the SERIOUS complications occured in theatre

serious complications more likely in ED / ITU
due to…
- unstable patients
- lack of good airway assessment and identifying high risk
- unfamiliar environment
- untrained / skilled staff
- lack of equiptment / capno

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What was found to be the biggest difference in patient outcomes? nap 4

capnography use

Recommendations by NAP 4

use checklists use capnography training - tracheostomy algorithm, CICO, no trace, wrong place extubation stuff - suction, bite block ITU patients have an emergency re-intubation plan

What was the major airway complication seen on ITU

displaced / blocked tracheostomy tubes and unable to successfully reintubate

Number of cases in NAP 4 - deaths and brain damage

38 deaths 8 brain damage 184 cases in total

What did NAP 4 find relating to trauma and why

more failed intubations / difficult airways / complications/ requiring surgical airway because - MILS / RSI - unfamiliar environment - pressure of trauma situation - facial injuries and distorted anatomy - unstable pt

how did NAP4 change front of neck practice?

= needle cricothyroidotomy is worse than scalpel method

what did NAP 5 look at ?

incidence of awareness under anaesthesia

incidence rates in NAP 5

1 in 19000 = overall awareness 1 in 8000 - using NMBA 1 in 136,000 - not paralysed

How long did awareness events last

less than 5 mins

What complication was found in those experiencing awareness

PTSD and depression Around half the patients in the study reported distress including pain/paralysis and this was associated with long term psychological outcomes

Which types of surgery were more at risk of awareness

cardiothoracic emergency Obstetrics

What patient factor was found to be a risk factor for awareness

females obesity difficult airway

What anaesthetic factors increase risk of awareness

junior anaesthetist out of hours Thio RSI TIVA NMBA

When was awareness mostly reported

induction and emergence - 2/3

Recommendations by NAP 5 / AABGI on awareness

use of BIS reversal of NMBA and TOF monitoring training inform patients of risk of awareness at pre op identify those at high risk

causes of accidental awareness when using TIVA

**failure to deliver intended dose** * equiptment failure e.g. cannula disconnection/ tissues, pump failure. * human error - wrong dose / drug selected or wrong patient info input **poor understanding of underlying mechanism** - lack of training in TIVA - using fixed dose infusion instead of TCI - switching from volatile to TIVA in transfer and not allowing IV to build up before volatile switched off.

What did NAP 6 look at

- Anaphylaxis incidence and causes related to anaesthesia and surgery

what is the incidence of perioperative anaphylaxis

1 in 10,000 - 10 deaths and 40 cardiac arrests

What are the most common causes of anaphylaxis

- Antibiotics = 47% - Muscle relaxants = 33% - Chlorhexidine - Patent blue dye

Survival rate for periop anaphylaxis

> 96% 1/3 had harm - long term anxiety of op, myocardial injury , PTSD

How does anaphylaxis most commonly present

hypotension - always present and 46% of time first feature bronchospasm - 18% tahcycardia hypoxia

Which patient group is most at risk of cardiac arrest secondary to anaphylaxis?

- Elderly - cardiac disease - Obese - Increasing ASA - ACEi or B blocker use

Which antibiotic was particularly high risk

- Teicoplanin - (co-amoxiclav 2nd)

Which NMBA has highest anaphylaxis incidence

succinylcholine - mostly presents as bronchospasm

How does atracurium anaphylaxis present

hypotension

What is the usual type of cardiac arrest seen in anaphylaxis

PEA often with bradycardia

Recommendations by NAP 6

better training - national and regional allergy department lead better anaphylaxis kits and guidelines available start compressions if SBP < 50mmHg better identification of true penicillin allergy to avoid teicoplanin

How often were complications in anaesthesia arising

1 in 18 1/3 CVS in nature 1/4 - airway and breathing e..g laryngospams, failed airway, breathing issues more commonly in urgent situations, extremes of age

Patient risk factors for complications / poor outcome

frailty obese high ASA male

Surgical factors for complication

urgent out of hours complex / long duration type - vascular, lower limb ortho, lower GI, interventional cardiology (obstetrics lower riks)

What was the incidence for cardiac arrest

1 in 3000

What was the survival rate of cardiac arrest

75% - much higher than other hospital arrests 44% discharged

Most common causes of perioperative cardiac arrest

haemorrhage bradyarrhythmias cardiac ischaemia

What were the majority of rhythms in cardiac arrest

non shockable - PEA

What rhythm had best and worst outcomes

bradyarrhythmias - best PEA - worst

When were arrests mostly occurring

- 40% during surgery - 26% during induction

Potential contributing factors to cardiac arrests in anaesthesia...

lack of risk scoring lack of adjustment of anaesthesia in high risk -e.g. smaller dose, slower induction lack of supervision lack of appropriate monitoring in transfer 6 cases of oesophageal intubation more complex / elderly population plus higher BMI

what were the risk factors for airway complications

- obesity - infants - out of hours - H&N surgery

Recommendations by NAP 7

routine use of risk scores - NELA / SORT discussions of DNAR with families in those high risk training - QRH handbook, local guidelines / protocols, especially in at risk groups - children/ elderly guidelines on how to manage specific populations e..g frailty / hypovolaemia adequate monitoring in transfer Standardisation of resus equipment available in all areas in low flow states - give small bolus of adrenaline debreif for staff

what will NAP 8 report on

major complications of regional anaesthesia and perioperative nerve injury

NAP studies Flashcards

(64 cards)