Incidents relating to paediatric regional anaesthesia in the first 8000 cases reported to webAIRS.

Regional anaesthesia is an essential tool in the armamentarium for paediatric anaesthesia. While largely safe and effective, a range of serious yet preventable adverse events can occur. Incidence and risk factors have been described, but few detailed case series exist relating to paediatric regional anaesthesia. Across Australia and New Zealand, a web-based anaesthesia incident reporting system enables voluntary reporting of detailed anaesthesia-related events in adults and children. From this database, all reports involving paediatric regional anaesthesia (age less than 17 years) were retrieved. Perioperative events and their outcomes were reviewed and analysed. When offered, the reported contributing or alleviating factors relating to the case and its management were noted. This paper provides a summary of these reports alongside an evidence review to support safe practice. Of 8000 reported incidents, 26 related to paediatric regional anaesthesia were identified. There were no deaths or reports of permanent harm. Nine reports of local anaesthetic systemic toxicity were included, seven equipment and technical issues, six errors in which regional anaesthesia made an indirect contribution and four logistical and communication issues. Most incidents involved single-shot techniques or a neuraxial approach. Common themes included variable local anaesthetic dosing, cognitive overload, inadequate preparation and communication breakdown. Neonates, infants and medically complex children were disproportionately represented, highlighting their inherent risk profile. A range of preventable incidents are reported relating to patient, systems and human factors, demonstrating several areas for improvement. Risk stratification, application of existing dosing and administration guidelines, and effective teamwork and communication are encouraged to ensure safe regional anaesthesia in the paediatric population.

Hypercarbia and high-flow nasal oxygen use during anaesthesia - risking a failure to thrive?

Prevention of arterial oxygen desaturation during anaesthesia with high-flow nasal oxygen (HFNO) has gained greater acceptance for a widening range of procedures. However, during HFNO use there remains the potential for development of significant anaesthesia-associated apnoea or hypoventilation and the possibility of hypercarbia, with harmful cardiovascular or neurological sequelae. The aim of this study was to determine whether any HFNO-related hypercarbia adverse incidents had been reported on webAIRS, an online database of adverse anaesthesia-related incidents. Two relevant reports were identified of complications due to marked hypercarbia during HFNO use to maintain oxygenation. In both reports, HFNO and total intravenous anaesthesia were used during endoscopic procedures through the upper airway. In both, the extent of hypoventilation went undetected during HFNO use. An ensuing cardiac arrest was reported in one report, ascribed to acute hypercarbia-induced exacerbation of the patient's pre-existing pulmonary hypertension. In the other report, hypercarbia led to a prolonged duration of decreased level of consciousness post procedure, requiring ventilatory support. During the search, an additional 11 reports of postoperative hypercarbia-associated sedation were identified, unrelated to HFNO. In these additional reports an extended duration of severe acute hypercarbia led to sedation or loss of consciousness, consistent with the known effects of hypercarbia on consciousness. These 13 reports highlight the potential dangers of unrecognised and untreated hypercarbia, even if adequate oxygenation is maintained.

Adult perioperative cardiac arrest: An overview of 684 cases reported to webAIRS.

There were 684 perioperative cardiac arrests reported to webAIRS between September 2009 and March 2022. The majority involved patients older than 60 years, classified as American Society of Anesthesiologists Physical Status 3 to 5, undergoing an emergency or major procedure. The most common precipitants included airway events, cardiovascular events, massive blood loss. medication issues, and sepsis. The highest mortality rate was 54% of the 46 cases in the miscellaneous category (this included 34 cases of severe sepsis, which had a mortality of 65%). This was followed by cardiovascular precipitants (n = 424) in which there were 147 deaths (35% mortality): these precipitants included blood loss (53%), embolism (61%) and myocardial infarction (70%). Airway and breathing events accounted for 25% and anaphylaxis 8%. A specialist anaesthetist attended the majority of these cardiac arrests. As webAIRS is a voluntary database, it is not possible to determine the incidence of perioperative cardiac arrest and only descriptive information on factors associated with cardiac arrest can be obtained. Nevertheless, the large number of reports includes a wide range of cases, precipitants, demographics and outcomes, providing ample opportunity to learn from these events. The data also provide rich scope for further research into further initiatives to prevent cardiac arrest in the perioperative period, and to improve outcomes, should a cardiac arrest occur.

Perioperative corneal abrasions: A report of 42 cases from the webAIRS database.

Corneal abrasions are an uncommon complication of anaesthesia. The aim of this study was to identify potential risk factors, treatment and outcomes associated with corneal abrasions reported to the web-based anaesthesia incident reporting system (webAIRS), a voluntary de-identified anaesthesia incident reporting system in Australia and New Zealand, from 2009 to 2021. There were 43 such cases of corneal abrasions reported to webAIRS over this period. The most common postoperative finding was a painful eye. Common features included older patients, individuals with pre-existing eye conditions, general anaesthesia and procedures longer than 60 minutes. Most cases were treated with a combination of lubricating eye drops or aqueous antibiotic eye drops. The findings indicate that patients who sustain a perioperative corneal abrasion can be reassured that in many cases it will heal within 48 hours, but they should seek earlier review if symptoms persist or deteriorate. None of the cases in this series resulted in permanent harm. Well established eye protective measures are important to utilise throughout the perioperative period, including the time until the patient has recovered in the post-anaesthesia care unit.

Updated guideline on equipment to manage difficult airways: Australian and New Zealand College of Anaesthetists.

The Australian and New Zealand College of Anaesthetists (ANZCA) recently reviewed and updated the guideline on equipment to manage a difficult airway. An ANZCA-established document development group, which included representatives from the Australasian College for Emergency Medicine and the College of Intensive Care Medicine of Australia and New Zealand, performed the review, which is based on expert consensus, an extensive literature review, and bi-nationwide consultation. The guideline (PG56(A) 2021, https://www.anzca.edu.au/getattachment/02fe1a4c-14f0-4ad1-8337-c281d26bfa17/PS56-Guideline-on-equipment-to-manage-difficult-airways) is accompanied by a detailed background paper (PG56(A)BP 2021, https://www.anzca.edu.au/getattachment/9ef4cd97-2f02-47fe-a63a-9f74fa7c68ac/PG56(A)BP-Guideline-on-equipment-to-manage-difficult-airways-Background-Paper), from which the current recommendations are reproduced on behalf of, and with the permission of, ANZCA. The updated 2021 guideline replaces the 2012 version and aims to provide an updated, objective, informed, transparent, and evidence-based review of equipment to manage difficult airways.

A cross-sectional overview of the second 4000 incidents reported to webAIRS, a de-identified web-based anaesthesia incident reporting system in Australia and New Zealand.

This cross-sectional overview of the second 4000 incidents reported to webAIRS has findings that are very similar to the previous overview of the first 4000 incidents. The distribution of patient age, body mass index and American Society of Anesthesiologists physical status was similar, as was anaesthetist gender, grade, location and time of day of incidents. About 35% of incidents occurred during non-elective procedures (vs. 33% in the first 4000 incidents). The proportion of incidents in the various main categories was also similar, with respiratory/airway being most common, followed by cardiovascular, medication-related and medical device or equipment-related incidents. Together these categories made up about 78% of all incidents in both overviews. The immediate outcome was comparable with reports of harm in about a quarter of incidents and a similar rate of deaths (4.7% vs. 4.2%). However, the proportion of patients who had received total intravenous anaesthesia was higher (17.6% vs. 7.7%) and the proportion of patients who received combined intravenous and inhalational anaesthesia was lower (52.3% vs. 58.4%), as was the proportion receiving local anaesthesia alone (1.6% vs. 6.7%). There was a small increase in the number of incidents resulting in unplanned admission to a high dependency or intensive care unit (18.1% vs. 13.5%). It is not clear whether these differences represent trends or random observations. About 48% of incidents were considered preventable by the reporters (vs. 52% in the first 4000). These findings support continued emphasis on human and system factors to promote and improve patient safety in anaesthesia care.

A proposed system for standardization of colour-coding stages of escalating criticality in clinical incidents.

PURPOSE OF REVIEW: This article proposes a standardized framework for colour-coding states of criticality in clinical situations and their respective escalated responses. RECENT FINDINGS: The first level is a green zone representing a 'safe' space (to proceed), where any hazards are controlled, latent or undetectable. The second is an amber zone, where hazards are known to be present, but one can proceed with caution and increased vigilance, and where defences are used to prevent escalation to a crisis. In the red phase -- a state of crisis -- a hazard is realized, clear and present. This is a time to decide what actions are required to mitigate the threat. Next, a blue phase refers to a life-threatening emergency, where the system is unstable, harm is evident and compounding upon itself, and immediate rescue action is needed to avert an irreversible outcome. Finally, dark grey represents the aftermath, where the situation has either stabilized or progressed to its final outcome, a time to reflect and learn. SUMMARY: A standardized colour-coding system for assessing and responding to escalating levels of criticality has implications for clinical practice and adverse event reporting systems.

2021 Update on airway management from the Anaesthesia Continuing Education Airway Management Special Interest Group.

Airway Management is the key for anaesthetists dealing with patients undergoing diagnostic procedures and surgical interventions. The present coronavirus pandemic underpins even more how important safe airway management is. It also highlights the need to apply stringent precautions to avoid infection and ongoing transmission to patients, anaesthetists and other healthcare workers (HCWs). In light of this extraordinary global situation the aim of this article is to update the reader on the varied aspects of the ever-changing tasks anaesthetists are involved in and highlight the equipment, devices and techniques that have evolved in response to changing technology and unique patient and surgical requirements.

LMA® Gastro™: A paediatric experience.

The laryngeal mask airway, the LMA® Gastro™ (Teleflex Medical, Athlone, Ireland), is a novel airway device which permits upper gastrointestinal (GI) endoscopy to be performed via a dedicated large calibre oesophageal lumen. It has been validated in adult studies, but to our knowledge, there have been no data published regarding its use in a paediatric population. Following a brief education programme, the LMA Gastro was introduced on a trial basis at our institution and made freely available. Over a four-month period, our pre-existing endoscopy audit framework captured data on a total of 55 patients who had the LMA Gastro device chosen as the primary airway for elective upper GI endoscopy. These data were collected prospectively by the treating anaesthetist and included a range of airway and endoscopy outcomes. Of the 55 patients, the LMA Gastro provided an adequate airway in 52 (94.5%). Forty-six (88.5%) were sited on first attempt, and 50 (96.2%) insertions were rated 'easy' by the anaesthetist. Aside from three insertion failures, there were no airway events. The endoscopy success rate was 100% in the 52 patients who had an LMA Gastro airway successfully inserted. First-pass oesophageal access was achieved in 51 (98%) cases, and 100% of insertions were rated 'easy' by the gastroenterologist. Despite our relative inexperience with it, the device had a high success rate for airway maintenance and oesophageal access in our paediatric patient population. In our institution, the LMA Gastro provided a useful airway option in older children undergoing elective upper GI endoscopy.

Difficult and failed intubation in the first 4000 incidents reported on webAIRS.

A review of the first 4000 reports to the webAIRS anaesthesia incident reporting database was performed to analyse cases reported as difficult or failed intubation. Patient, task, caregiver and system factors were evaluated. Among the 4000 reports, there were 170 incidents of difficult or failed intubation. Difficult or failed intubation incidents were most common in the 40-59 years age group. More than half of cases were not predicted. A total of 40% involved patients with a body mass index >30 kg/m2 and 41% involved emergency cases. A third of the reports described multiple intubation attempts. Of the reports, 18% mentioned equipment problems including endotracheal tube cuff rupture, laryngoscope light failure, dysfunctional capnography and delays with availability of additional equipment to assist with intubation. Immediate outcomes included 40 cases of oxygen desaturation below 85%; of these cases, four required cardiopulmonary resuscitation. The majority of the incidents resulted in no harm or minor harm (45%). However, 12% suffered moderate harm, 3.5% severe harm and there were three deaths (although only one related to the airway incident). Despite advances and significant developments in airway management strategies, difficult and failed intubation still occurs. Although not all incidents are predictable, nor are all preventable, the information provided by this analysis might assist with future planning, preparation and management of difficult intubation.

A prospective six-month audit of airway incidents during anaesthesia in twelve tertiary level hospitals across Australia and New Zealand.

This audit of airway incidents was conducted over six months in 12 tertiary level hospitals across Australia and New Zealand. During that time, 131,233 patients had airway management and 111 reports were submitted (incidence 0.08%). The airway incidents included a combination of difficult airway management (83), oxygen desaturation (58), aspiration (19), regurgitation (14), laryngospasm (16), airway bleeding (10), bronchospasm (5) and dental injury (4), which gave a total of 209 events in 111 reports. Most incidents occurred during general anaesthesia (GA; 83.8%) and normal working hours (81.1%). Forty-three percent were associated with head and neck surgery and 12.6% with upper abdominal procedures. Of these patients, 52% required further medical treatment or additional procedures and 16.2% required unplanned admission to an intensive care unit or a high dependency unit. A total of 31.5% of patients suffered from temporary harm and 1.8% from permanent harm. There was one death. The factors associated with a high relative risk (RR) of an airway incident included American Society of Anesthesiologists Physical Status (ASA PS) (ASA PS 2 versus 1, RR 1.75; ASA PS 3 versus 1, RR 3.56; ASA PS 4 versus 1, RR 6.1), and emergency surgery (RR 2.16 compared with elective). Sedation and monitored anaesthesia care were associated with lower RRs (RR 0.49 and RR 0.73 versus GA, respectively). Inadequate airway assessment, poor judgement and poor planning appeared to be contributors to these events. Future teaching and research should focus on these areas to further improve airway management and patient safety.

The Bowtie diagram: a simple tool for analysis and planning in anesthesia.

PURPOSE OF REVIEW: The purpose is to show the advantages of a Bowtie diagram as a versatile tool for displaying and understanding the evolvement and management of critical incidents. RECENT FINDINGS: The Bowtie diagram has been used recently in anesthesia to depict critical incidents having been used in high-risk industries for several decades. This diagram displays the progression from latent factors to potential harm in five steps. SUMMARY: The Bowtie diagram combines the features of a fault tree and an event tree with the adverse event, known as the Top Event separating the two sections. The fault tree is similar in concept to a Swiss Cheese diagram and the event tree similar in concept to an emergency management algorithm. Preventive barriers and escalation measures are used to detect and trap abnormal states. If these fail, the event proceeds to a crisis, leading to the Top Event, a time for making decisions. A recovery state follows, which depicts an emergency state mandating immediate life or limb-saving management to recover from the crisis. Finally, in the aftermath state, a time for reflection and learning, ultimate outcomes are shown in the right-hand column. VIDEO ABSTRACT: The Bowtie Diagram. Designed and created by Yasmin Endlich, Martin D. Culwick and Stavros N. Prineas, http://links.lww.com/COAN/A68.