Crisis Management in Anesthesiology, 2nd Edition

398 Pages·09.212 MB·English

by  David Gaba, Kevin Fish, Steven Howard, Amanda Burden

Crisis Management in
Anesthesiology
SECOND EDITION
Crisis Management
in Anesthesiology
DAVID M. GABA, MD
Associate Dean for Immersive and Simulation-based Learning
Professor
Department of Anesthesiology, Perioperative and Pain Medicine
Stanford University School of Medicine
Stanford, California
Staff Anesthesiologist
Veterans Affairs Palo Alto Health Care System
Palo Alto, California
KEVIN J. FISH, MSC, MB CHB
Professor Emeritus
Department of Anesthesiology, Perioperative and Pain Medicine
Stanford University School of Medicine
Stanford, California
Per Diem Staff Anesthesiologist
Anesthesiology and Perioperative Care Service
Veterans Affairs Palo Alto Health Care System
Palo Alto, California
STEVEN K. HOWARD, MD
Associate Professor
Department of Anesthesiology, Perioperative and Pain Medicine
Stanford University School of Medicine
Stanford, California
Staff Anesthesiologist
Anesthesiology and Perioperative Care Service
Veterans Affairs Palo Alto Health Care System
Palo Alto, California
AMANDA R. BURDEN, MD
Associate Professor of Anesthesiology
Director, Simulation Program
Cooper Medical School of Rowan University
Cooper University Hospital
Camden, New Jersey
1600 John F. Kennedy Blvd.
Ste. 1800
Philadelphia, PA 19103-2899
CRISIS MANAGEMENT IN ANESTHESIOLOGY, SECOND EDITION ISBN: 978-0-443-06537-8
Copyright © 2015 by Saunders, an imprint of Elsevier Inc.
Copyright © 1994 by Churchill Livingstone Inc., an imprint of Elsevier Inc.
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Notices
Knowledge and best practice in this field are constantly changing. As new research and experience broaden our
understanding, changes in research methods, professional practices, or medical treatment may become necessary.
Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using
any information, methods, compounds, or experiments described herein. In using such information or methods
they should be mindful of their own safety and the safety of others, including parties for whom they have a
professional responsibility.
With respect to any drug or pharmaceutical products identified, readers are advised to check the most current
information provided (i) on procedures featured or (ii) by the manufacturer of each product to be administered, to
verify the recommended dose or formula, the method and duration of administration, and contraindications. It is the
responsibility of practitioners, relying on their own experience and knowledge of their patients, to make diagnoses, to
determine dosages and the best treatment for each individual patient, and to take all appropriate safety precautions.
To the fullest extent of the law, neither the publisher nor the authors, contributors, or editors assume any liability
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from any use or operation of any methods, products, instructions, or ideas contained in the material herein.
Library of Congress Cataloging-in-Publication Data
Crisis management in anesthesiology / [edited by] David M. Gaba, Kevin J. Fish, Steven K. Howard, Amanda R. Burden.
– Second edition.
p. ; cm.
Preceded by Crisis management in anesthesiology / David M. Gaba, Kevin J. Fish, Steven K. Howard ; with contribu-
tions by Emily Ratner, Robert S. Holzman. 1994.
Includes bibliographical references and index.
ISBN 978-0-443-06537-8 (pbk. : alk. paper)
I. Gaba, David M., editor. II. Fish, Kevin J., editor. III. Howard, Steven K., editor. IV. Burden, Amanda R., editor. V.
Gaba, David M. Crisis management in anesthesiology. Preceded by (work):
[DNLM: 1. Anesthesiology–methods. 2. Anesthesia–adverse effects. 3. Decision Making. 4. Emergencies. WO 200]
RD82.5
617.9'6041–dc23
2014027627
Executive Content Strategist: William R. Schmitt
Content Development Specialist: Angela Rufino
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Printed in the United States of America
Last digit is the print number: 9 8 7 6 5 4 3 2 1
Contributors
Gregory H. Botz, MD, FCCM Ruth M. Fanning, MB, MRCPI,
Distinguished Teaching Professor FFARCSI
Professor of Anesthesiology and Critical Clinical Assistant Professor
Care Co-Director, Evolve Simulation Program
The University of Texas MD Anderson Department of Anesthesiology,
Cancer Center Perioperative and Pain Medicine
Houston, Texas Stanford University School of Medicine
Adjunct Clinical Associate Professor Stanford, California
Department of Anesthesiology,
Kevin J. Fish, MSc, MB ChB
Perioperative and Pain Medicine
Professor Emeritus
Stanford University School of Medicine
Department of Anesthesiology, Perioperative
Stanford, California
and Pain Medicine
Amanda R. Burden, MD Stanford University School of Medicine
Associate Professor of Anesthesiology Stanford, California
Director, Simulation Program Per Diem Staff Anesthesiologist
Cooper Medical School of Rowan University Anesthesiology and Perioperative Care
Cooper University Hospital Service
Camden, New Jersey Veterans Affairs Palo Alto Health Care
System
Johannes Dorfling, MB ChB
Palo Alto, California
Assistant Professor
Department of Anesthesiology David M. Gaba, MD
University of Kentucky College of Medicine Associate Dean for Immersive and
Lexington, Kentucky Simulation-based Learning
Professor
Jeremy S. Dority, MD
Department of Anesthesiology, Perioperative
Assistant Professor
and Pain Medicine
Department of Anesthesiology
Stanford University School of Medicine
University of Kentucky College of Medicine
Stanford, California
Lexington, Kentucky
Staff Anesthesiologist
Jan Ehrenwerth, MD Veterans Affairs Palo Alto Health Care
System
Professor of Anesthesiology
Palo Alto, California
Yale University School of Medicine
Attending Anesthesiologist
Sara Goldhaber-Fiebert, MD
Yale − New Haven Hospital
Clinical Assistant Professor
New Haven, Connecticut
Co-Director, Evolve Simulation Program
James B. Eisenkraft, MD Department of Anesthesiology,
Professor of Anesthesiology Perioperative and Pain Medicine
Icahn School of Medicine at Mount Sinai Stanford University School of Medicine
New York, New York Stanford, California
v
vi Contributors
T. Kyle Harrison, MD Geoffrey K. Lighthall, MD, PhD
Staff Physician Associate Professor
Anesthesiology and Perioperative Care Department of Anesthesiology,
Service Perioperative and Pain Medicine
Veterans Affairs Palo Alto Health Care Stanford University School of Medicine
System Stanford, California
Palo Alto, California Staff Anesthesiologist and Intensivist
Clinical Associate Professor Anesthesiology and Perioperative Care Service
Department of Anesthesiology, Veterans Affairs Palo Alto Health Care System
Perioperative and Pain Medicine Palo Alto, California
Stanford University School of Medicine
Erin White Pukenas, MD, FAAP
Stanford, California
Assistant Professor of Anesthesiology
Gillian Hilton, MB ChB, FRCA Associate Director
Clinical Assistant Professor Division of Pediatric Anesthesiology
Department of Anesthesiology, Director, Elizabeth Blackwell Advisory
Perioperative and Pain Medicine College
Stanford University School of Medicine Cooper Medical School of Rowan
Stanford, California University
Cooper University Hospital
Steven K. Howard, MD
Camden, New Jersey
Associate Professor
Department of Anesthesiology, Perioperative Johannes Steyn, MD
and Pain Medicine Department of Anesthesiology
Stanford University School of Medicine University of Kentucky College of
Stanford, California Medicine
Staff Anesthesiologist Lexington, Kentucky
Anesthesiology and Perioperative Care Service
Veterans Affairs Palo Alto Health Care System Ankeet Udani, MD
Palo Alto, California Clinical Instructor
Department of Anesthesiology, Perioperative
Calvin Kuan, MD, FAAP and Pain Medicine
Clinical Associate Professor Stanford University School of Medicine
Pediatric Cardiac Anesthesia Stanford, California
Lucile Packard Children’s Hospital Assistant Professor of Anesthesiology
Department of Anesthesiology, Duke University School of Medicine
Perioperative and Pain Medicine Durham, North Carolina
Stanford University School of Medicine
Stanford, California
Attending Physician
Pediatric Intensive Care Unit
Children’s Hospital and Research Center
Oakland
Oakland, California
Foreword to the Second Edition
When we wrote the Foreword to the first edition of this book, I didn’t know that it would
become a classic. It is still widely read in the anesthesiology and simulation communities.
I also didn’t know that it would take more than 20 years to update it to a second edition. To the
credit of the authors, there was so much novel, excellent material in the first edition that much
of the original work has held up well through the ensuing years. Thus what was written in the
Foreword to the first edition still holds true. Unfortunately, I’m writing this second Foreword
alone; our friend and patient safety visionary, Ellison (Jeep) C. Pierce, Jr., MD, passed away
in 2011. Jeep set us on a great course. It is universally acknowledged that the profession of
anesthesiology has made huge strides in reducing adverse events and risk.
But the battle is far from over; in fact, it’s never over. That’s why this second edition is as
important as the first. We are reminded in many ways that anesthesia safety improvements are
always under siege, both in the moment and in general; there are so many ways that things can
go wrong. Some readers will be reminded while others will learn, perhaps for the first time,
about the kinds of things that have to be done to achieve the vision of the Anesthesia Patient
Safety Foundation: “that no patient is harmed by anesthesia.”
Many things have changed in the past 20 years that make a new edition of this pioneer-
ing text necessary. Some of the concepts first presented in this book are accepted but still
not well practiced (e.g., the importance of good hand-offs). Other ideas aren’t adequately
understood or implemented (e.g., debriefing following simulation scenarios). I’ll come back
to this later, because I believe it’s the most essential teaching approach to make simulation
effective. Finally, after 20 years, the compilation of information about the original 80-plus
anesthesia crises needs some updating. There are 99 in this edition; all of the old ones, some
under new names, and several new ones for situations that weren’t recognized or appreciated
20 years ago (perioperative visual loss) or responses that weren’t available (treatment for local
anesthetic systemic toxicity). For more detail on what’s new in this edition, see the Preface.
Patient safety in anesthesia and all of health care has changed dramatically in 20 years.
I can’t even begin to document all that encompasses here. This book introduced some of the
most important concepts and interventions, including Crisis Resource Management (CRM),
which the Stanford University anesthesia team adapted from aviation, and the rest of health
care soon emulated. The acronym is now commonly heard in patient safety conversations. But
CRM is not only a better approach in managing a crisis. It’s a new way of thinking—giving
teamwork a higher priority over the individual team member and focusing on what’s best for
the patient. Although CRM and teamwork principles are now widely taught, they are still not
sufficiently practiced. I have confidence that will come in time.
One reason for my confidence is that the use of simulation for training in CRM in
anesthesia has also caught on. It also was initially introduced by those who wrote the first
edition of this book. And simulation, like CRM in general, has since been adopted in various
ways throughout the health care industry, primarily as an educational tool and specifically
as a highly effective patient safety enhancer. All anesthesiologists certified after 2000 are
required to enroll in Maintenance of Certification in Anesthesiology (MOCA), to remain
board certified. One of the most innovative, challenging, and probably effective elements is
the requirement that all anesthesiologists first certified after 2007 attend 1 day of simulation-
based CRM training. I suspect that as anesthesiologists come to understand the value of the
vii
viii Foreword to the Second Edition
simulation experience they will gladly accept even more frequent training, whether required
or not. Given what I’ve witnessed over 20 years in simulation, I hope they do. Simulation-
based training of complete operating room teams is just starting to catch on as well.
I also feel positive about the continuing improvements in patient safety to which CRM
and simulation principles contribute. There is now a robust patient safety movement. People
talk about safety as if it were second nature. Anesthesiology is heralded as the safety- conscious
specialty. And it is. It got the ball rolling and others have taken safety in new directions.
Anesthesia is safer. The training, personnel selection, technology, drugs, and most important,
better attitudes, have made that so.
It is also worth noting that all these patient safety elements are now understood to be
part of the larger concept of high reliability organizations (HRO). HRO is another idea intro-
duced into anesthesia and health care by David M. Gaba and his colleagues in the late 1980s.
HRO wasn’t fully developed when the first edition of this book was published. It is now
more fully appreciated and applied. Likewise, the term “production pressure” wasn’t widely
used 20 years ago but is now frequently mentioned in discussions about anesthesia practice
and adverse events. These are concepts adapted to anesthesia and health care by the authors
of this book. We also learn more in this edition about the influence of fatigue and other
performance-shaping factors, all of which have been studied more intensely since the first
edition. The concept of cognitive aids for managing crises more effectively is also new in the
past 20 years. Soon that concept will surely be widely introduced in the form of emergency
manuals that will be as routine for use in anesthesia emergencies as they are in aviation, the
field from which the idea is adapted.
From my perspective (perhaps a biased one), simulation (and its manifestations) is the
single most important new concept that has been expanded upon in this edition. The idea of
practicing for emergencies seems obvious, although some are likely still waiting for the ran-
domized controlled trials and detailed cost benefit analysis. Aviation, wisely and fortunately
for its passengers, did not bother to wait to achieve the impossible before it embraced the
training approach as a fundamental aspect of its overall approach to safety. That decision
surely accounts for the remarkable safety record of commercial aviation.
Simulation was a nascent concept in 1994. The field of anesthesia pioneered its adoption.
The use of simulation is now embedded in anesthesia training. Its use will continue to grow as
a vital part of CRM training and in all aspects of anesthesia care. For that to be done well and
for simulation to contribute to the more fundamental culture change that has yet to transpire in
perioperative care, truly effective methods of debriefing must be widely adopted. Many forms
of debriefing are now described in what for me is the most critical new chapter of this book.
What isn’t yet completely understood or accepted is that the use of simulation with effective
debriefing will do more than improve CRM, especially when used with intact perioperative
teams. Simulation has the potential to improve the often dysfunctional relationships among
those teams, relationships that are “latent errors” in the chain that leads to critical events.
Those relationships and interactions can be greatly improved by better understanding of cross-
disciplinary needs, by open discussion of each person’s contribution to adverse events, and
most important, to greater and more transparent self-reflection on personal behavior and team
interaction. This can only come about via debriefings that are conducted with mutual respect
between teacher and students, or facilitators and participants, and creating a safe environment
in which to conduct those conversations.
Creating a psychologically safe environment and truly effective debriefings is easier said
than done, but it is more important than some would think. Although learning is often seen
as a cognitive task, it also involves matters of identity (Will I be a good doctor? Am I a good
nurse?) and emotion (Do I feel threatened? Do I feel included?).
Foreword to the Second Edition ix
Concepts addressed in the debriefing chapter help to illustrate how that can happen. Not
all of those concepts are founded in identified pedagogy; that is one area where simulation
and all of patient safety still can improve by borrowing from the theory and research of the
social sciences. Where that has been done most for debriefing science is in the application
of concepts from action science, the work of Argyris and others, and that leads to the idea
of “debriefing with good judgment.” (Admittedly I am biased since the derivative work was
developed by our simulation group at Massachusetts General Hospital.) The principle is rela-
tively simple but powerful—foster in teacher and learner a true spirit of curiosity, inquiry,
and then self-reflection about the reasons for their actions. Most importantly, debriefing helps
develop in us a respect for all individuals with whom we work, to assume they are doing their
best. When they err or are less than perfect, we give them the benefit of the doubt and work
to understand the reasons for their actions. It is by fostering this spirit of respect and inquiry
that simulation can have its greatest impact on patient safety.
Every anesthesia provider needs to study, not just read, this new edition, even if you read
the first edition. Also, distilled instructions of key elements of the cases covered in this book
need to be included in manuals made available for emergencies (although that, too, needs
further study on how best to use them). If I were your patient, I would ask if you had studied
these principles. If you hadn’t, I might ask for another health care provider into whose hands
I would want to entrust my life.
Jeffrey B. Cooper, PhD
Professor of Anaesthesia
Harvard Medical School
Executive Director, Center for Medical Simulation
Department of Anesthesia, Critical Care and Pain Medicine
Massachusetts General Hospital
Boston, Massachusetts