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ORIGINAL ARTICLE

Crisis management during anaesthesia: the development ofan anaesthetic crisis management manual

W B Runciman, M T Kluger, R W Morris, A D Paix, L M Watterson, R K Webb. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

See end of article forauthors affiliations. . . . . . . . . . . . . . . . . . . . . . .

Correspondence to:Professor W B Runciman,President, AustralianPatient Safety Foundation,GPO Box 400, Adelaide,

South Australia 5001,Australia; [email protected]

Accepted 10 January 2005. . . . . . . . . . . . . . . . . . . . . . .

Qual Saf Health Care 2005;14:e1 (http://www.qshc.com/cgi/content/full/14/3/e1). doi: 10.1136/qshc.2002.004101

Background: All anaesthetists have to handle life threatening crises with little or no warning. However,some cognitive strategies and work practices that are appropriate for speed and efficiency under normalcircumstances may become maladaptive in a crisis. It was judged in a previous study that the use of astructured core algorithm (based on the mnemonic COVER ABCDA SWIFT CHECK) would diagnoseand correct the problem in 60% of cases and provide a functional diagnosis in virtually all of the remaining40%. It was recommended that specific sub-algorithms be developed for managing the problemsunderlying the remaining 40% of crises and assembled in an easy-to-use manual. Sub-algorithms weretherefore developed for these problems so that they could be checked for applicability and validity againstthe first 4000 anaesthesia incidents reported to the Australian Incident Monitoring Study (AIMS).Methods: The need for 24 specific sub-algorithms was identified. Teams of practising anaesthetists wereassembled and sets of incidents relevant to each sub-algorithm were identified from the first 4000 reportedto AIMS. Based largely on successful strategies identified in these reports, a set of 24 specific sub-

algorithms was developed for trial against the 4000 AIMS reports and assembled into an easy-to-usemanual. A process was developed for applying each component of the core algorithm COVER at one offour levels (scan-check-alert/ready-emergency) according to the degree of perceived urgency, andincorporated into the manual. The manual was disseminated at a World Congress and feedback wasobtained.Results: Each of the 24 specific crisis management sub-algorithms was tested against the relevant incidentsamong the first 4000 reported to AIMS and compared with the actual management by the anaesthetist atthe time. It was judged that, if the core algorithm had been correctly applied, the appropriate sub-algorithm would have been resolved better and/or faster in one in eight of all incidents, and would havebeen unlikely to have caused harm to any patient. The descriptions of the validation of each of the 24 sub-algorithms constitute the remaining 24 papers in this set. Feedback from five meetings each attended by60100 anaesthetists was then collated and is included.Conclusion: The 24 sub-algorithms developed form the basis for developing a rational evidence-basedapproach to crisis management during anaesthesia. The COVER component has been found to besatisfactory in real life resuscitation situations and the sub-algorithms have been used successfully for

several years. It would now be desirable for carefully designed simulator based studies, using naivetrainees at the start of their training, to systematically examine the merits and demerits of various aspects ofthe sub-algorithms. It would seem prudent that these sub-algorithms be regarded, for the moment, asdecision aids to support and back up clinicians natural responses to a crisis when all is not progressing asexpected.

All anaesthetists have to manage life threatening crises

which may arise with little or no warning.14 Indeed,

with a risky procedure in a sick patient, much of the

working day may be spent preventing and heading off

potential crises. Anaesthetists manage the vast majority of

these complex problems promptly and efficiently with skilled

pattern recognition and frequently practised clinical routines.

However, high profile cases documented in the lay press fromaround the world indicate that these patterns of response do

not always lead to the resolution of problems.5 Attention has

been focused worldwide on the safety of health care and the

ways in which it may be enhanced. Working groups from

several countries including the USA,6 UK,7 and Australia8

have produced documents outlining plans for improving the

safety of health care. This set of 25 articles outlines a

structured approach for when things are going wrong during

anaesthesia.932 Prevention is, of course, better than cure.

However, prevention (for example, appropriate preoperative

assessment, checking and planning) is not the intent of this

set of articles.

As indicated above, situations do arise during which

patient safety is compromised when the usual measures

have been or are being taken. This is the context in which an

incident report may be submitted. The Australian Incident

Monitoring Study (AIMS) was started in 1988.33 In 1993 a

symposium issue reviewing the first 2000 incidents was

published in the journal Anaesthesia and Intensive Care.34 The

symposium consisted of 30 papers looking at various aspectsof anaesthetic incidents. These included clinical crises and

adverse events (such as anaphylaxis, difficult intubation,

cardiac arrest, the wrong drug problem), assessments of the

applications and limitations of physiological monitors (for

example, the pulse oximeter, the electrocardiograph, the

capnograph), and an evaluation of the factors involved in the

generation and resolution of these incidents. In seven out of

every eight incidents which arose when patients were

breathing gas from an anaesthetic machine, the anaesthetists

involved recognised the problem and responded appropri-

ately.4 However, in one out of every eight it was considered by

an AIMS panel of reviewers that the application of a simple

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learned routine, properly applied, would have expedited the

diagnosis and/or led to an appropriate response more

rapidlyand often more effectively.4 This is because pre-

viously learned and intuitive strategies and work practices

which have evolved for speed and efficiency under normal

working conditions may fail to adjust in a crisis.35 Use of such

pre-compiled responses is consistent with the rapid

phase learned responses to some crises in aviation, nuclear

plant operation, community rescue organisations, and

military command, many of which are routinely tested in

simulation situations.

2

These findings suggested that there is a place for defaulting

to a simple structured routine when the anaesthetist is

uneasy that all may not be what it seems to be, when the

situation is deteriorating, or when an adverse outcome seems

likely. It is well recognised within the field of human error

and safety that the use of simple succinct guidelines and

protocols reduces the burden on the individuals involved and

allows their limited available cognitive resource to be used for

essential immediate tasks.36 37 Some of the principles under-

lying this structured approach have been dealt with in a

companion paper.35

THE COVERABCD A SWIFT CHECK COREAL GO RI TH M

After considering a number of alternatives, it was generallyagreed after a series of three meetings, each attended by 60

100 anaesthetists, that a core algorithm should form the

basis for the management of any crisis in which the

anaesthetist was uncertain of the exact cause or which was

not going exactly as expected.4 A common starting sequence

for all crises was thought to be essential because it was

recognised that it is very difficult to recover from a mind

set that a particular problem is being faced when, in fact,

the problem is a different one requiring a completely different

solution.

Such a core algorithm was devised based on the mnemonic

COVER ABCDA SWIFT CHECK which is suitable for use

when any patient is undergoing general or regional anaes-thesia. The original version, which was available on two sides

of a single laminated sheet, is shown in tables 1 and 2. When

the manual which resulted from this set of 25 articles was

compiled, more detailed instructions were made available

about aspects of this core algorithm (see figs 1 and 2). The

use of the traditional cardiac arrest mnemonic ABCD was

considered but it was thought that it would miss some

dangerous problems related to the surgery, the use of the

anaesthetic machine, and ancillary equipment which would

require immediate resolution; this is discussed in the last

section of this paper.

The initial component, COVERwhich addresses problems

arising from circulatory compromise, the gas supply, the

anaesthetic machine, the breathing circuit, the ventilator and

the endotracheal tubehas been validated against the 1301relevant incidents under general anaesthesia amongst the

first 2000 reported to AIMS.4 It was found that just under

Table 1 Crisis management algorithm memorise and practise: an explanation of eachcue in the mnemonic COVER ABCD

C1 Circulation Establish adequacy of peripheral circulation (rate, rhythm and character of pulse). Ifpulseless, institute cardiopulmonary resuscitation (CPR). The core algorithm must stillbe completed as soon as possible.

C2 Colour Note saturation. Examine for evidence of central cyanosis. Pulse oximetry is superiorto clinical detection and is recommended. Test probe on own finger, if necessary,whilst proceeding with O1 and O2.

O1 Oxygen Check rotameter settings, ensure inspired mixture is not hypoxic.O2 Oxygen analyser Adjust inspired oxygen concentration to 100% and note that only the oxygen

flowmeter is operating. Check that the oxygen analyser shows a rising oxygenconcentration distal to the common gas outlet.

V1 Ventilation Ventilate the lungs by hand to assess breathing circuit integrity, airway patency, chestcompliance and air entry by feel and careful observation and auscultation. Alsoinspect capnography trace.

V2 Vaporiser Note settings and levels of agents. Check all vaporiser filler ports, seatings andconnections for liquid or gas leaks during pressurisation of the system. Consider thepossibility of the wrong agent being in the vaporiser.

E1 Endotracheal tube Systematically check the endotracheal tube (if in use). Ensure that it is patent with noleaks or kinks or obstructions (see suggested protocol in Anaesth Intensive Care1993;21:615). Check capnograph for tracheal placement and oximeter for possibleendobronchial position. If necessary, adjust, deflate cuff, pass a catheter, or removeand replace.

E2 Elimination Eliminate the anaesthetic machine and ventilate with self-inflating (e.g. Air Viva) bagwith 100% oxygen (fro m alternative source if necessary). Retain gas monitor samplingport (but be aware of possible problems).

R1 Review monitors Review all monitors in use (preferably oxygen analyser, capnograph, oximeter, bloodpressure, electrocardiograph (ECG), temperature and neuromuscular junctionmonitor). For proper use, the algorithm requires all monitors to have been correctlysited, checked and calibrated.

R2 Review equipment Review all other equipment in contact with or relevant to the patient (e.g. diathermy,humidifiers, heating blankets, endoscopes, probes, prostheses, retractors and other

appliances).A Airway Check patency of the unintubated airway. Consider laryngospasm or presence of

foreign body, blood, gastric contents, nasopharyngeal or bronchial secretions.B Breathing Assess pattern, adequacy and distribution of ventilation. Consider, examine and

auscultate for bronchospasm, pulmonary oedema, lobar collapse and pneumo- orhaemothorax.

C Circulation Repeat evaluation of peripheral perfusion, pulse, blood pressure, ECG and fillingpressures (where possible) and any possible obstruction to venous return, raisedintrathoracic pressure (e.g. inadvertent PEEP) or direct interference to (e.g. stimulationby central line) or tamponade of the heart. Note any trends on records.

D Drugs Review intended (and consider possible unintended) drug or substance administration.Consider whether the problem may be due to unexpected effect, a failure ofadministration or wrong dose, route or manner of administration of an intended orwrong drug. Review all possible routes of drug administration.

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60% of these problems had arisen from these sources and

that COVER, correctly applied, would have provided a

functional diagnosis and an appropriate response in virtuallyall the cases in 4060 seconds.4 Subsequent users and many

case presentations at audits have confirmed that COVER can

be rapidly performed and is reliable.

If the remainder of the algorithm had been used (ABCDA

SWIFT CHECK), it was considered that, correctly applied, a

functional diagnosis would have been obtained in 99% of

these incidents. However, unlike the COVER component, the

ABCDA SWIFT CHECK component is largely a diagnostic

checklist. The anaesthetist would still have to handle the 40%

of problems remaining after COVERthat is, those arising

from the patient or from patient/doctor/procedure/drug

interactions. To do this the anaesthetist may work from first

principles, employ pattern recognition and learned sequences

or, failing this, apply one of a set of prescribed sub-

algorithms. Experience from audits of anaesthetic practiceand ongoing review of AIMS forms has confirmed that it

would be desirable for there to be a basic set of structured

sub-algorithms to handle the problems arising from these

sources when the problem is not immediately resolved, as on

many occasions the management described constitutes a

considerable departure from what would generally be

regarded as currently accepted practice. The development of

the 24 sub-algorithms deemed necessary is described in the

other articles in this series as shown in table 3.932

How this was done is presented below. However, first, the

issue of how to use the COVER component of the core

algorithm is discussed in more detail.

HOW TO USE COVERAn important issue to arise from discussions about the core

algorithm was the question as to when and how it should beinvoked. The majority of potential incidents are recognised

early in their evolution and are headed off by appropriate

responses on the part of the anaesthetist. Of those events that

actually moved an anaesthetist to fill in an incident report,

seven out of eight were correctly recognised and promptly

handled; for these, pattern recognition was clearly successful

and the use of COVER was unnecessary, and would

potentially have been more time consuming and disruptive

than the initial response.

How should the anaesthetist recognise when the situation

justifies invoking the full set of actions required by COVER?4

It is obvious, for example, that it is not worth getting rid of

the anaesthetic machine when the saturation falls from 98%

to 94% over 10 minutes. However, it is equally obvious that

COVER should be invoked in full if a patient is suddenlyfound pulseless and cyanosed with slow wide QRS complexes

on the electrocardiogram.

SCAREA solution to this problem lies in grading the application of

each component of COVER into four levels represented by the

mnemonic SCARE, depending on the degree of perceived

urgency (Scan-Check-Alert/Ready-Emergency). These are

shown in figs 36.

The various levels of each component of COVER should be

used in combinations deemed appropriate for the situation.

This provides great flexibility and appropriateness of response

Table 2 A SWIFT CHECK (the checklist arising from the mnemonic need not bememorised but should be immediately available in the operating theatre)

Condition Comments

A Air embolus Hypotension, hypocarbiaA Ana phylaxis Hypo tensio n, broncho spas m, u rti cariaA Air in pleura Pneumothorax, any unexpected circulatory or respiratory deteriorationA Awareness Consider dilut ion of anaesthet ic gases, resistant pat ient S Surgeon/situation Vagal stimulation, caval compression, bleeding, direct myocardial

stimulationS Sepsis H ypot en sion, desat urat ion, acidosis, hy perdynamic c ircu la tion

W W ound T rauma, b leeding, t amponade, pneumoth orax, problems due t oretractorsW Water intoxicat ion E lectrolyte disturbance, f luid overloadI Infarct M yocardia l c on duct ion or rhy thm problem, hy potension, poor c ardiac

outputI Insufflat ion Vagal tone, reduced venous return, pulmonary venous or paradoxical

arterial gas embolismF Fat syndrome Desaturation and/or hypotension, especially after induction and in the

lithotomy position including distended abdomen for any causeF Ful l bladder May cause marked haemodynamic changes and/or sympathet ic

stimulationT T rauma C on sider spina l injury, undiagn osed sub- or d iaphragmatic injury,

ruptured viscusT Tourniquet down Local anaesthet ic toxicity or unseen bleedingC Catheter/IV cannula/chest drain

problemsLeaks, failure to deliver, wrong drug or label, obstructed, wrongconnected, wrong rate

C Cement Haemodynamic change with methylmethacrylateH Hyperthermia (hypothermia) Tachycardia and hypercarbia/ECG changes, (poor perfusion, ECG

changes)H Hypoglycaemia Consider inappropriate or inadvertent insulin preoperatively, fasting and

beta blockers, hepatic compromise and beta blockersE Embolus Fat, thrombus, amniotic f luid; hypotension, hypocarbia, ECG changesE Endocrine Hyperthyroid or hypothyroid/adrenal medul lar or cortex/pituitary/

diabetes/5-HTC Check Right patient, right operation, right surgeonC C heck C ase n ot es, preoperat ive s ta tus, preoperat ive drugs, preoperat ive

diseasesK K+ Potassium and any other electrolyte abnormality (hyper or hypo),

ECG changes, CNS signsK K eep Ke ep the pati ent asleep unti l a new anae sthetic machine can be

obtained (e.g. diazepam, ketamine)

If the problem has not been solved, direct the available resources to its solution. Get skilled and experienced help. Workfrom first principles.

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while still reducing the cognitive load for the anaesthetist. It

can be argued that COVER is no longer an algorithm when

different actions can be taken, depending on circumstances,

and that it should more properly be called a cognitive aid,

encouraging the use of various pre-compiled responses.

However, for the sake of simplicity, we will continue to use

the term algorithm for this set of articles.The use of the SCAN level every 5 minutes during each

case (fig 3) and of the CHECK level at regular intervals (fig 4)

also overcomes the problem of regular formal training being

required for the effective use of the core crisis management

algorithm. Commercial jet airline pilots are required to

undertake simulator sessions and be accredited every

3 months. However, to introduce this for every practising

anaesthetist, whilst desirable, is not feasible at the moment,

especially in developing countries.

In general, the slower and less serious the deviations from

normal and the more monitoring and other information

available, the less likely it will be that the EMERGENCY

mode of COVER will need to be used. However, in

circumstances in which the situation is obscure or not readily

apparent due to opaque or non-specific signs, or is progress-

ing rapidly, there should be no hesitation in invoking the

algorithm to the full. In contexts in which no monitors are

available, it is likely that the full application of the

EMERGENCY mode of COVER would be much morefrequently invoked.39

For those who have practised using COVER in this way,

appropriate responses may rapidly be achieved while the

anaesthetist is confident that the majority of possible

contingencies have been accounted for. This knowledge is

valuable for trainees who have not yet fully developed their

pattern recognition and clinical response routines, for any

anaesthetist who encounters a novel situation, when all is

not going well, or when there is likely to be an adverse

outcome. In this last context, the anaesthetist can proceed

with handling the problem to the best of his or her ability,

taking some comfort in the knowledge that any independent

T h e m n e m o n i c s e r v e s a s a r e m i n d e r t o a l w a y s c y c l e s y s t e m a t i c a l l y

t h r o u g h a b a s i c s e r i e s o f t h o u g h t s a n d a c t i o n s , t h e i n t e n s i t y o f w h i c h

w i l l d e p e n d o n t h e c i r c u m s t a n c e s . T h i s s e r i e s o f t h o u g h t s a n d

a c t i o n s i s :

C

O

V

E

R

A

B

C

D

A

S W I F T C H E C K o f p a t i e n t , s u r g e o n , p r o c e s s , a n d r e s p o n s e s .

T h e f o u r l e v e l s o f i n t e n s i t y f o r e a c h o f t h e s e c o m p o n e n t s a r e

r e p r e s e n t e d b y a n o t h e r m n e m o n i c - S C A R E ( S C A N , C H E C K ,

A L E R T / R E A D Y , E M E R G E N C Y ) a n d c o m p r i s e p a g e s 4 t o 1 1 * o f t h i s

m a n u a l .

T h e S C A N s e q u e n c e s h o u l d b e f o l l o w e d e v e r y 5 m i n u t e s o f a n y

a n a e s t h e t i c , o r m o r e o f t e n i f n e c e s s a r y . T h i s o v e r c o m e s t h e n e e d f o r

s p e c i a l t r a i n i n g s e s s i o n s , a s t h e s e q u e n c e r a p i d l y b e c o m e s s e c o n d

n a t u r e a n d c a n u s u a l l y b e c o m p l e t e d i n 4 0 - 6 0 s e c o n d s . T h e C H E C K

s e q u e n c e s h o u l d b e u s e d w h e n e v e r a l l i s n o t g o i n g a c c o r d i n g t o

p l a n , a n d s h o u l d a l s o b e p r a c t i s e d r e g u l a r l y .

D o n o t h e s i t a t e t o m o v e o n t o t h e A L E R T / R E A D Y a n d E M E R G E N C Y

s e q u e n c e s i f y o u a r e w o r r i e d , i f e v e n t s a r e m o v i n g q u i c k l y , o r i f i t

s e e m s t h a t a n a d v e r s e o u t c o m e i s p o s s i b l e . T h e s e s h o u l d a l s o b e

p r a c t i s e d f r o m t i m e t o t i m e .

* P a g e r e f e r e n c e s r e f e r t o t h e C r i s i s M a n a g e m e n t M a n u a l .

3 8

W H E N A N D H O W T O U S E T H I S M A N U A L

T h e m a n u a l i s b a s e d o n t h e m n e m o n i c C O V E R A B C D A S W I F T

C H E C K a n d i s d e s i g n e d f o r u s e w h e n a n y p a t i e n t i s u n d e r g o i n g

g e n e r a l o r r e g i o n a l a n a e s t h e s i a . T h e s e q u e n c e b e c o m e s A B C O V E R

C D A S W I F T C H E C K w h e n t h e p a t i e n t i s b r e a t h i n g s p o n t a n e o u s l y ,

a n d s o m e c o m p o n e n t s b e c o m e r e d u n d a n t i n c e r t a i n c i r c u m s t a n c e s ;

e x a m p l e s a r e g i v e n a t t h e e n d o f t h i s s e c t i o n .

D e p e n d i n g o n t h e c i r c u m s t a n c e s , c o m p o n e n t s o f e a c h l e v e l o f

S C A R E m a y b e a s s e m b l e d a s a p p r o p r i a t e , a s l o n g a s t h e s e q u e n c e

o f C O V E R i s a l w a y s a d h e r e d t o . F o r e x a m p l e , w i t h s u d d e n , s e v e r e

h y p e r t e n s i o n , i f t h e f i r s t f o u r c o m p o n e n t s o f C O V E R ( C i r c u l a t i o n ,

C o l o u r , O x y g e n , O x y g e n A n a l y s e r ) a r e s t a b l e a n d n o r m a l a t t h e

S C A N l e v e l , n o f u r t h e r a c t i o n i s r e q u i r e d f o r t h e s e . H o w e v e r , i t

w o u l d b e d e s i r a b l e t o u s e t h e C H E C K l e v e l f o r t h e V e n t i l a t i o n ,

V a p o r i s e r , R e v i e w m o n i t o r s , a n d R e v i e w e q u i p m e n t c o m p o n e n t s o f

C O V E R , f o r t h e C ( C i r c u l a t i o n ) a n d D ( D r u g s ) c o m p o n e n t s o f A B C D ,

f o r t h e A ( f o r A w a r e n e s s ) a n d f o r S W I F T C H E C K ( e s p e c i a l l y w i t h

r e s p e c t t o w h a t t h e s u r g e o n i s d o i n g ) . H y p e r t e n s i o n a n d a w a r e n e s s

a r e t w o c i r c u m s t a n c e s i n w h i c h t h e c o n c e n t r a t i o n o f v o l a t i l e a g e n t

m a y b e i n c r e a s e d - f o r m o s t c r i s e s i t i s l e f t a l o n e a t t h e S C A N a n d

C H E C K l e v e l s a n d t u r n e d o f f a t t h e R E A D Y / A L E R T a n d E M E R G E N C Y

l e v e l s .

O n t h e o t h e r h a n d , i f , f o r e x a m p l e , i t i s s u d d e n l y n o t i c e d t h a t t h e

p a t i e n t i s p u l s e l e s s a n d b l u e , t h e f u l l E M E R G E N C Y s e q u e n c e o f

C O V E R s h o u l d b e c a r r i e d o u t i m m e d i a t e l y w i t h p r o g r e s s i o n t o a n y

a p p r o p r i a t e s u b - a l g o r i t h m s .

I t i s i m p o r t a n t t h a t t h e b a s i c C O V E R A B C D s e q u e n c e i s f o l l o w e d

b e f o r e b e c o m i n g f o c u s e d o n a n y p a r t i c u l a r s u b - a l g o r i t h m ; a m a j o r

p r o b l e m i s l o c k i n g o n t o a d i a g n o s i s w h i c h m a y n o t b e c o r r e c t .

W h e n a s s i s t a n c e i s c a l l e d f o r , o n e p e r s o n s h o u l d r e p e a t e d l y c y c l e

t h r o u g h t h e C O V E R A B C D s e q u e n c e a n d c o n s i d e r o t h e r p o s s i b i l i t i e s ,

w h i l s t t h e s t e p s i n a n y r e l e v a n t s u b - a l g o r i t h m s a r e f o l l o w e d . S o m e

s u b - a l g o r i t h m s r e p e a t c o m p o n e n t s o f C O V E R ( e . g . g i v e 1 0 0 %

o x y g e n ) , u s u a l l y w h e n t h e e n t i r e s e q u e n c e d o e s n o t n e c e s s a r i l y

h a v e t o b e f o l l o w e d i n f u l l a t t h e o u t s e t , w h e r e a s o t h e r s s t a r t b y

i n s t r u c t i n g a n a e s t h e s i o l o g i s t s t o e n s u r e t h a t t h e f u l l C O V E R s e q u e n c e

h a s b e e n c o m p l e t e d b e f o r e s t a r t i n g t h e s u b - a l g o r i t h m ( e . g . t h a t f o r

p e r s i s t e n t d e s a t u r a t i o n , o r a i r e m b o l i s m ) .

A l t h o u g h t h e s t a n d a r d C O V E R A B C D A S W I F T C H E C K s e q u e n c e

s h o u l d a l w a y s b e f o l l o w e d , s o m e c o m p o n e n t s b e c o m e l e s s

i m p o r t a n t o r r e d u n d a n t u n d e r p a r t i c u l a r c i r c u m s t a n c e s : f o r

i n t u b a t e d , v e n t i l a t e d p a t i e n t s t h e A a n d B a f t e r C O V E R b e c o m e

r e d u n d a n t ; f o r p a t i e n t s b r e a t h i n g s p o n t a n e o u s l y v i a a m a s k , A a n d

B p r e c e d e C O V E R , a s i n d i c a t e d a t t h e s t a r t o f t h i s s e c t i o n , a n d V f o r

V e n t i l a t i o n b e c o m e s r e d u n d a n t ; f o r a p a t i e n t b e i n g v e n t i l a t e d v i a a

l a r y n g e a l m a s k , B b e c o m e s r e d u n d a n t ; a n d f o r a p a t i e n t b r e a t h i n g

s p o n t a n e o u s l y a n d r e c e i v i n g o x y g e n f r o m a s o u r c e i n d e p e n d e n t o f

a n a n a e s t h e t i c m a c h i n e ( e . g . f r o m a w a l l m o u n t e d f l o w m e t e r d u r i n g

r e g i o n a l o r i n t r a v e n o u s a n a e s t h e s i a ) , t h e V a n d E o f C O V E R

b e c o m e r e d u n d a n t .

C i r c u l a t i o n , C a p n o g r a p h , a n d C o l o u r ( s a t u r a t i o n )

O x y g e n s u p p l y a n d O x y g e n a n a l y s e r

V e n t i l a t i o n ( i n t u b a t e d p a t i e n t ) a n d V a p o r i s e r s

E n d o t r a c h e a l t u b e a n d E l i m i n a t e m a c h i n e

R e v i e w m o n i t o r s a n d R e v i e w e q u i p m e n t

A i r w a y ( w i t h f a c e o r l a r y n g e a l m a s k )

B r e a t h i n g ( w i t h s p o n t a n e o u s v e n t i l a t i o n )

C i r c u l a t i o n ( i n m o r e d e t a i l t h a n a b o v e )

D r u g s ( c o n s i d e r a l l g i v e n o r n o t g i v e n )

B e A w a r e o f A i r a n d A l l e r g y - p a g e 4 *

Figure 1 Introduction to the Crisis Management Manual.


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5/12

retrospective review must find that the appropriate responses

had been made for over 99% of the spectrum of problems

reported to AIMS.

The SCARE algorithms have been incorporated into the

Crisis Management Manual developed from this set of 25

articles.38 There has been considerable feedback that the use

of this SCARE-based graded response has proved to be quite

satisfactory for those who have decided to use the manual as

it is. However, the concept of using such a highly structured

graded response does not have universal acceptance. Someprefer to remember the COVER algorithm only for emergency

use when pattern recognition appears to have failed. Also,

while the SCAN routine of the COVER mnemonic is perfectly

satisfactory, some clinicians prefer their own SCAN routine

based on local circumstances and their own equipment setup.

It is recognised that complexity can cause errors13 and that

reducing choice, reducing the number of steps required, and

ensuring that the duration of execution is as short as possible

all assist in reducing the complexity of a system. However,

this should not be at the cost of ensuring safety. There is a

trade-off between relying on pattern recognition and using

the highly structured approach represented in the Crisis

Management Manual by the SCARE sequence. The challenge

is to cover all contingencies while retaining as simple a set of

responses as possible. It is likely that COVER will be refined

with more use; there are advantages to defaulting to a

standard sequence of actions when people have to work in

teams in a crisis.36

ABCDA SWIFT CHECKThe rationale for the use of sub-algorithms for the ABCDA

SWIFT CHECK portion of the mnemonic is the same as that

which underpins the use of the core algorithm for the first

part (COVER). Complex problems may be manifested by non-

specific cues in circumstances in which a minor transgression

or a delay in taking corrective measures might have serious

consequences. For example, of 179 incidents first detected by

oximetry and thus having manifested as desaturation, just

under three quarters (represented by nine clinical situa-

tions including dangerous problems requiring rapid resolu-

tion such as hypoxic gas mixture and undetected oesophageal

intubation) were handled by COVER.4 3 9 4 0 However, over one

quarter fell into the ABCDA SWIFT CHECK portion of the

algorithm. These were represented by 12 clinical situations,

some of which had relatively rare or obscure causes but

required rapid diagnosis and a prompt responsefor

example, anaphylaxis, air embolism, tension pneumothorax,

pulmonary oedema. In some of these cases the correctdiagnosis was missed for a prolonged time. With such an

array of possibilities it is too time consuming to work from

first principles. In such circumstances, if the problem is not

resolved immediately by actions based on pattern recogni-

tion, the use of a carefully validated prescribed algorithm is

safer and more reliable than trying to work out what the

problem is, and what to do about it, from first principles.

Early on, a number of anaesthetists commented that they

found the use of A SWIFT CHECK as a mnemonic, as shown

in table 2, to be contrived and unhelpful. It was therefore

replaced as follows. Firstly, the sentence Be Aware of Air

and Allergy was suggested as a reminder for what the As in

S O M E F I N A L T I P S

R E M E M B E R : A l w a y s g o t h r o u g h C O V E R A B C D f o r v e n t i l a t e d

p a t i e n t s a n d A B C O V E R C D f o r s p o n t a n e o u s l y b r e a t h i n g p a t i e n t s

f o l l o w e d i n e a c h i n s t a n c e b y A S W I F T C H E C K . I t w i l l b e o b v i o u s i n

a n y p a r t i c u l a r c i r c u m s t a n c e w h i c h c o m p o n e n t s b e c o m e r e d u n d a n t .

R E M E M B E R : R e q u e s t a s s i s t a n c e e a r l y o n , a l l o c a t e t a s k s a n d

c a l m l y c o o r d i n a t e a c t i v i t i e s , r e p e a t e d l y c y c l i n g t h r o u g h C O V E R a s

w e l l a s a n y s u b - a l g o r i t h m / s t h o u g h t t o b e a p p r o p r i a t e .

R E G I O N A L A N A E S T H E S I A

T h e r e a r e t w o d i f f e r e n c e s w i t h r e g i o n a l a n a e s t h e s i a .

1 A t t h e A f o r A w a r e n e s s s t a g e o f A S W I F T C H E C K : i f t h e p a t i e n t

i s s e d a t e d o r c o n s c i o u s , t a l k t o t h e p a t i e n t , a n d , i f c o n c e r n e d ,

a s k h o w t h e y a r e f e e l i n g .

2 A t t h e C H E C K l e v e l o f A S W I F T C H E C K : c h e c k t h e q u a l i t y a n d

e x t e n t o f a n y b l o c k , a n d c o r r e l a t e t h e e s t i m a t e d e x t e n t o f

s y m p a t h e t i c b l o c k a d e w i t h a n y c a r d i o v a s c u l a r s e q u e l a e .

A B B R E V I A T I O N S :

M o n i t o r s

E T C O

2

F I O

2

S p O

2

B P

E C G

C i r c u l a t i o n

V F

V T

A i r w a y

E T T

L M A

B r e a t h i n g

I P P V

P E E P

C P A P

A R D S

L A Y O U T O F T H E M A N U A L : T h e i m m e d i a t e s e q u e n c e s o f

t h o u g h t s a n d a c t i o n s a r e s h o w n o n t h e r i g h t h a n d p a g e s .

R e f e r e n c e s t o o n g o i n g c a r e a n d f u r t h e r d e t a i l s a r e o n t h e r e v e r s e

s i d e s o f t h e s e p a g e s . T h i s w i l l a l l o w s i n g l e p a g e s t o b e r e p l a c e d a s

s u b - a l g o r i t h m s a r e u p d a t e d .

E n d t i d a l c a r b o n d i o x i d e c o n c e n t r a t i o n

O x y g e n f r a c t i o n o f t h e i n s p i r e d g a s

P u l s e o x i m e t e r s a t u r a t i o n r e a d o u t

B l o o d p r e s s u r e

E l e c t r o c a r d i o g r a m

V e n t r i c u l a r f i b r i l l a t i o n

V e n t r i c u l a r t a c h y c a r d i a

E n d o t r a c h e a l t u b e

L a r y n g e a l m a s k a i r w a y

I n t e r m i t t e n t p o s i t i v e p r e s s u r e v e n t i l a t i o n

P o s i t i v e a n d e x p i r a t o r y p r e s s u r e

C o n t i n u o u s p o s i t i v e a i r w a y p r e s s u r e

A d u l t r e s p i r a t o r y d i s t r e s s s y n d r o m e .

Figure 2 Final instructions and abbreviations for the CrisisManagement Manual.

Table 3 Papers in Crisis Management series

A Obstruction of th e natural airway9

A Laryngospasm10

A Regurgitation, vomiting and aspi ration11

A Difficult intubation12

B Desaturation13

B Bronchospasm14

B Pulmonary oedema15

C Bradycardia16

C Tachycardia17

C Hypotension18

C Hypertension19

C Myocardial ischaemia20

C Cardiac arrest21

D Problems associated with drug administration during anaesthesia22

A Awareness23

A Embolism24

A Pneumothorax25

A Anaphylaxis and allergy26

* Vascular access problems27

* Trauma: development of a sub-algorithm28

* Sepsis29

* Water intoxication30

* Crisis management during regional anaesthesia31

* Recovering from a crisis32

The 24 sub-algorithms are described in this set of articles. These arerepresented by ABCD (A - Airway; B - Breathing; C - Circulation; D -Drugs), A(the four As be Aware of Air (embolism or in the pleura) and

Allergy), SWIFT CHECK(*miscellaneous problems such as vascular access

problems, trauma, sepsis, water intoxication, problems arising duringregional anaesthesia, and recovering from a crisis). Additional problemssuch as endocrine, electrolyte and metabolic problems (includingmalignant hyperthermia) are also dealt with in the manual.


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6/12

ASWIFT CHECK stand for (Michael Burt, personal commu-

nication). Each A in this sentence acts as a reminder for two

things: Awareness in the patient and as an exhortation to the

anaesthetist to be Aware; Air for Air (and other) embolism

and for Air in the pleural space (pneumothorax); and Allergy

to act as a reminder for Allergic reactions and Anaphylaxis

(see table 3).

Secondly, it was suggested that the SWIFT CHECK should

now be taken simply as a reminder for a swift check during

the normal 5 minute scan of the surgeons, assistants,

nurses and orderlies activities and of the operative site, a

quick consideration of the pattern of physiological change

revealed by the monitors, and a mental review of the

patients history and preoperative status.4 The conditions

listed under SWIFT CHECK in table 2 have been dealt with in

some of the companion papers (see asterisks in table 3) and

in some additional algorithms in the Crisis Management

Manual.38

T h e c o l u m n o n t h e l e f t l i s t s , i n t h e o r d e r o f t h e m n e m o n i c ,

w h a t s h o u l d b e s c a n n e d . T h i s w i l l c o m p r i s e a f a c i n g p a g e

o f t h e m a n u a l . N o t e s c o r r e s p o n d i n g t o t h e n u m b e r s i n

p a r e n t h e s e s w i l l b e o n t h e r e v e r s e s i d e .

S C A N a s n e e d e d , o r e v e r y 5 m i n u t e s

C i r c u l a t i o n : N o t e t h e r a t e , r h y t h m a n d v o l u m e o f t h e p u l s e a n d n o t e

t h e e n d t i d a l c a r b o n d i o x i d e c o n c e n t r a t i o n ( E T C O

2

) ( 1 ) * .

C o l o u r : N o t e t h e c o l o u r o f t h e p a t i e n t s m u c o u s m e m b r a n e s a n d

b l o o d a n d n o t e t h e s a t u r a t i o n r e a d i n g o f t h e o x i m e t e r ( S p O

2

) .

O x y g e n : N o t e t h e r o t a m e t e r s e t t i n g s a n d t h a t t h e b o b b i n s a r e

s p i n n i n g a n d c a l c u l a t e t h e i n s p i r e d o x y g e n f r a c t i o n ( F I O

2

) ( 2 ) .

O x y g e n A n a l y s e r : N o t e t h a t t h e r e a d o u t m a t c h e s t h a t e x p e c t e d i n

t h e i n s p i r a t o r y l i m b o f t h e b r e a t h i n g c i r c u i t . C a l i b r a t e i f n e c e s s a r y .

V e n t i l a t i o n : N o t e t h e p a t i e n t s c h e s t m o v e m e n t s . C o r r e l a t e t h e s e

w i t h t h e c a p n o g r a p h , b r e a t h i n g c i r c u i t p r e s s u r e s a n d t i d a l v o l u m e s .

V a p o r i s e r s : N o t e t h e v a p o r i s e r s e t t i n g s o n a l l v a p o r i s e r s a n d t h e

v o l a t i l e a g e n t l i q u i d l e v e l o n t h e v a p o r i s e r i n u s e .

E n d o t r a c h e a l t u b e o r l a r y n g e a l m a s k a i r w a y : N o t e i t s p o s i t i o n

( d i s t a n c e m a r k e r a t t h e l i p s ) , i t s o r i e n t a t i o n a n d i t s s e c u r i t y ( 3 ) .

E l i m i n a t e : N o t e t h a t , i n a c r i s i s , y o u m a y n e e d t o r e m o v e m a c h i n e ,

c i r c u i t , f i l t e r , E T T a n d i t s c o n n e c t i o n s , e . g . t h e c a t h e t e r m o u n t .

R e v i e w m o n i t o r s : N o t e m o n i t o r s i n u s e a n d r e v i e w a l l r e a d i n g s ,

w a v e f o r m s a n d a l a r m s e t t i n g s . U p d a t e t h e a n a e s t h e t i c r e c o r d ( 4 ) .

R e v i e w e q u i p m e n t : N o t e a l l e q u i p m e n t i n u s e , e s p e c i a l l y i t e m s i n

c o n t a c t w i t h t h e p a t i e n t . R e v i e w i t s s a f e t y a n d f u n c t i o n ( 5 ) .

A i r w a y : N o t e t h e p o s i t i o n o f t h e h e a d a n d n e c k , a n d t h e p o s i t i o n ,

p a t e n c y a n d s e c u r i t y o f a n y a r t i f i c i a l a i r w a y s o r m a s k s ( 6 ) .

B r e a t h i n g : N o t e c h e s t a n d a b d o m i n a l m o v e m e n t s a n d c o r r e l a t e

t h e s e w i t h t h e r e s p i r a t o r y r a t e a n d p a t t e r n o f s p o n t a n e o u s

v e n t i l a t i o n .

C i r c u l a t i o n : N o t e t r e n d s i n a l l c a r d i o v a s c u l a r p a r a m e t e r s a n d

c o r r e l a t e t h e s e w i t h e s t i m a t e d b l o o d o r o t h e r f l u i d l o s e s ( 7 ) .

D r u g s : N o t e d r u g s t h a t h a v e b e e n g i v e n a n d c o r r e l a t e d o s e s w i t h

e f f e c t s . N o t e c o r r e c t f u n c t i o n o f a l l I V l i n e s a n d i n f u s i o n s ( 8 ) .

A : B e A w a r e o f A i r a n d A l l e r g y . B e A w a r e y o u r s e l f , t h i n k o f

p o s s i b l e A w a r e n e s s i n t h e p a t i e n t , a n d o f A i r ( o r o t h e r ) e m b o l i s m ,

A i r i n t h e p l e u r a ( p n e u m o t h o r a x ) , A l l e r g y o r A n a p h y l a x i s ( 9 ) .

S W I F T C H E C K : N o t e w h a t t h e s u r g e o n a n d o t h e r p e r s o n n e l a r e

d o i n g , c h e c k t h e p a t i e n t s p o s i t i o n o n t h e t a b l e a n d t h a t t h e

p h y s i o l o g i c a l r e s p o n s e s m a t c h t h e c i r c u m s t a n c e s .

* N u m b e r s i n b r a c k e t s r e f e r t o n o t e s o f t h e C r i s i s M a n a g e m e n t

M a n u a l

3 8

a s s h o w n i n t h e s e c o n d c o l u m n o f t h i s f i g u r e .

C o r r e s p o n d i n g n o t e s t o b e s h o w n o n t h e r e v e r s e s i d e

S C A N

( 1 )

( 2 )

( 3 )

( 4 )

( 5 )

( 6 )

( 7 )

( 8 )

( 9 )

C i r c u l a t i o n : N o t e t h e v o l u m e o f t h e p u l s e . T h e E T C O

2

i s u s e d

h e r e a s a n i n d e x o f v e n o u s r e t u r n a n d c a r d i a c o u t p u t .

O x y g e n : I f t h e s o u r c e i s n o t v i a a n a n a e s t h e t i c m a c h i n e ( e . g .

d i r e c t s u p p l y f r o m w a l l o u t l e t , c y l i n d e r o r o x y g e n c o n c e n t r a t o r ) ,

c h e c k t h e f l o w m e t e r a n d t h e i n t e g r i t y o f s u p p l y f r o m s o u r c e t o

p a t i e n t .

E n d o t r a c h e a l t u b e : A t i n s e r t i o n n o t e a n d c h a r t t h e d i s t a n c e

m a r k e r a t t h e t e e t h o r g u m s w h e n t h e t i p i s 3 c m ( i n a n a d u l t )

p a s t t h e v o c a l c o r d s . C h e c k t h i s d i s t a n c e a g a i n s t t h e c h a r t e d

v a l u e , e s p e c i a l l y a f t e r t h e p a t i e n t h a s b e e n m o v e d , t h e s u r g e o n

i s w o r k i n g n e a r t h e t u b e , o r h a m m e r i n g o r m a n i p u l a t i o n h a s

t a k e n p l a c e . I f a n L M A i s i n u s e , d i s t a n c e c h e c k s d o n o t a p p l y .

R e v i e w M o n i t o r s : N o t e t h a t a l l s e n s o r s a r e c o r r e c t l y p l a c e d ,

z e r o e d a n d l e v e l l e d w h e r e a p p r o p r i a t e , a n d n o t e t h a t t h e y h a v e

b e e n c a l i b r a t e d , i f t h i s i s p o s s i b l e a n d p r a c t i c a l . N o t e t h a t a l a r m

a n d a l e r t s e t t i n g s a r e a p p r o p r i a t e a n d a r e t u r n e d o n .

R e v i e w E q u i p m e n t : R e v i e w a l l e q u i p m e n t i n u s e b y y o u r s e l f

a n d t h e s u r g i c a l t e a m i n c l u d i n g d i a t h e r m y , e n d o s c o p e s ,

p r o b e s , r e t r a c t o r s , h e a t i n g b l a n k e t s , h u m i d i f i e r s e t c . E n s u r e t h a t

n o p h y s i c a l , t h e r m a l o r c h e m i c a l d a m a g e c a n b e d o n e t o t h e

p a t i e n t , a n d t h a t t h e e q u i p m e n t i s f u n c t i o n i n g a s e x p e c t e d .

A i r w a y : N o t e a n y i n a p p r o p r i a t e u s e o r p a t t e r n o f t h e a c c e s s o r y

m u s c l e s o f r e s p i r a t i o n , a n y e x c e s s i v e r e t r a c t i o n o f t h e t r a c h e a o r

t h y r o i d , a n d a n y u n c o o r d i n a t e d o r p a r a d o x i c a l m o v e m e n t s o f

t h e c h e s t o r a b d o m e n i n r e l a t i o n t o r e s p i r a t o r y e f f o r t s .

C i r c u l a t i o n : I n e s t i m a t i n g b l o o d o r o t h e r f l u i d l o s s , s u c t i o n

b o t t l e c o n t e n t s , s w a b s , d r a p e s a n d f l o o r s h o u l d b e c h e c k e d .

R e m e m b e r t h a t b l o o d c a n p o o l u n d e r t h e p a t i e n t o n t h e t a b l e ,

a n d t h a t c o n s i d e r a b l e b l e e d i n g c a n t a k e p l a c e i n t o t i s s u e s p a c e s

a n d b o d y c a v i t i e s . N o t e t h a t v e n o u s r e t u r n c a n b e s u b s t a n t i a l l y

i n f l u e n c e d b y r e t r a c t i o n , p r e s s u r e b y t h e s u r g e o n , b y t h e g r a v i d

u t e r u s l y i n g o n t h e i n f e r i o r v e n a c a v a , o r b y m a n i p u l a t i o n o f t h e

h e a r t , l u n g s o r g r e a t v e s s e l s . A l s o , r e m e m b e r t h a t t r a c t i o n ,

e s p e c i a l l y o n t h e e y e m u s c l e s a n d p e r i t o n e u m , c a n c a u s e v a g a l

s t i m u l a t i o n .

D r u g s : N o t e t h a t a l l s y r i n g e s o r i n f u s i o n s h a v e b e e n l a b e l l e d i n

a s t a n d a r d i s e d m a n n e r w i t h t h e g e n e r i c n a m e o f t h e d r u g ( o r

f l u i d ) a n d t h e d o s e ( i n m g / m l ) , a n d t h a t t h e a m p o u l e s f r o m

w h i c h t h e i n g r e d i e n t s h a v e b e e n t a k e n a r e a v a i l a b l e f o r

c h e c k i n g . N o t e t h a t a l l I V l i n e s a r e s e c u r e , a n d , i f p o s s i b l e ,

v i s i b l e f r o m s o u r c e t o p a t i e n t e n t r y s i t e .

A : A l w a y s c o n s i d e r t h e s e p o s s i b i l i t i e s ; e a c h m a d e u p a b o u t

1 % o f A I M S r e p o r t s .

Figure 3 Items which, in the order of the mnemonic, should be SCANNED.


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7/12

DEVELOPMENT OF THE SUB-ALGORITHMSFollowing analysis of the first 2000 reports as described in the

1993 symposium issue,34 the need for a number of specific

sub-algorithms was identified to assist the anaesthetist in

treating the remaining 40% of the incidents that were not

corrected by the COVER core algorithm. Volunteer anaes-

thetists were given sets of incident reports from the first 4000

AIMS reports that dealt with the specific clinical problems

shown in table 3. These sets were generated by using the key

word section on the AIMS form. For incidents that involved

large numbers of reports (such as airway obstruction and

desaturation), at least two anaesthetists were involved in the

initial data analysis while for those where there were fewer

reports (such as water intoxication) one investigator initially

reviewed the data. As the majority of reported cases were

clearly dealt with well, the reporting anaesthetists described

actions played an important role in creating the crisis

management sub-algorithms. Each sub-algorithm was


w h a t s h o u l d b e c h e c k e d . T h i s w i l l c o m p r i s e a f a c i n g p a g e

o f t h e m a n u a l . N o t e s c o r r e s p o n d i n g t o t h e n u m b e r s i n

p a r e n t h e s e s w i l l b e o n t h e r e v e r s e s i d e .

C H E C K : w h e n e v e r y o u a r e w o r r i e d

C i r c u l a t i o n : P a l p a t e a p u l s e . C o r r e l a t e r a t e , r h y t h m a n d v o l u m e w i t h

t h e o x i m e t e r a n d E C G . C h e c k c a p i l l a r y r e f i l l a n d E T C O

2

t r a c e ( 1 ) .

C o l o u r : I f s u s p i c i o u s t r y t h e p u l s e o x i m e t e r o n y o u r s e l f . T a k e a r t e r i a l

b l o o d f o r a l a b c h e c k o n s a t u r a t i o n o r b l o o d g a s e s .

O x y g e n : B r i e f l y i n c r e a s e t h e o x y g e n f l o w r a t e a n d c a l c u l a t e t h e n e w

e x p e c t e d F I O

2

i n t h e b r e a t h i n g c i r c u i t .

O x y g e n A n a l y s e r : C h e c k t h a t t h e c h a n g e s i n t h e F I O

2

a r e i n l i n e w i t h

t h e c a l c u l a t e d c h a n g e s i n F I O

2

i n t h e b r e a t h i n g c i r c u i t .

V e n t i l a t i o n : V e n t i l a t e b y h a n d . C h e c k c i r c u i t , s c a v e n g i n g , v a l v e s a n d

v i s i b l e m o v i n g v e n t i l a t o r p a r t s .

V a p o r i s e r s : C h e c k t h e v a p o r i s e r ( s ) a r e c o r r e c t l y s e a t e d a n d s e t ,

l o c k e d i n a n d c o n n e c t e d a n d t h a t t h e r e a r e n o g a s o r l i q u i d l e a k s .

E n d o t r a c h e a l t u b e o r l a r y n g e a l m a s k a i r w a y : C h e c k p o s i t i o n ,

o r i e n t a t i o n a n d p a t e n c y . I f E T t u b e i s i n u s e e x c l u d e e n d o b r o n c h i a l

i n t u b a t i o n ( 2 ) .

E l i m i n a t e : C h e c k t h a t a n i n d e p e n d e n t m e a n s o f v e n t i l a t i n g t h e

p a t i e n t ( e . g . s e l f - i n f l a t i n g b a g ) a n d a n a l t e r n a t e s u p p l y o f o x y g e n

a r e a v a i l a b l e .

R e v i e w m o n i t o r s : C h e c k a l l m o n i t o r s i n u s e a n d c o m p a r e c u r r e n t

m o n i t o r v a l u e s w i t h t h o s e o n t h e a n a e s t h e t i c r e c o r d ( 3 ) .

R e v i e w e q u i p m e n t : C h e c k t h a t a l l e q u i p m e n t i n c o n t a c t w i t h o r

r e l e v a n t t o t h e p a t i e n t i s s a f e a n d f u n c t i o n i n g c o r r e c t l y .

A i r w a y : O b s e r v e , p a l p a t e a n d a u s c u l t a t e t h e n e c k . I f s u s p i c i o u s o f

a i r w a y o b s t r u c t i o n , p l a n d i r e c t p h a r y n g o s c o p y .

B r e a t h i n g : P a l p a t e a n d a u s c u l t a t e t h e c h e s t w h i l s t r e p e a t i n g S C A N .

R e v i e w t h e E T C O

2

i f a c a p n o g r a p h i s i n u s e .

C i r c u l a t i o n : C r o s s c h e c k a n y a b n o r m a l B P r e a d i n g s w h e r e p o s s i b l e .

C h e c k t h e z e r o a n d s c a l e s o f t r a n s d u c e r s .

D r u g s : C h e c k a l l a m p o u l e s , s y r i n g e s , l a b e l s , i n f u s i o n a p p a r a t u s ,

c o n n e c t i o n s & c a n n u l a e f r o m f l u i d s o u r c e t o v e i n ( 4 ) .

A : S p e c i f i c a l l y c o n s i d e r t h e p o s s i b i l i t y o f A w a r e n e s s ( 5 ) , A i r ( o r

o t h e r ) e m b o l i s m ( 6 ) , A i r i n p l e u r a ( p n e u m o t h o r a x ) ( 7 ) , A l l e r g y o r

A n a p h y l a x i s ( 8 ) . S e e t h e r e l e v a n t s u b - a l g o r i t h m s f o r s i g n s a n d h i g h

r i s k s i t u a t i o n s .

S W I F T C H E C K : C o r r e l a t e t h e m o n i t o r e d p a r a m e t e r s w i t h t h e

c l i n i c a l s i t u a t i o n a n d r i s k f a c t o r s . S p e c i f i c a l l y q u e s t i o n t h e s u r g e o n

a b o u t w h a t i s b e i n g d o n e , a n d c h e c k t h e p r e - o p e r a t i v e a s s e s s m e n t ,

m e d i c a l r e c o r d a n d w a r d d r u g c h a r t .

C o r r e s p o n d i n g n o t e s t o b e s h o w n o n t h e r e v e r s e s i d e

C H E C K

( 1 )

( 2 )

( 3 )

( 4 )

( 5 )

( 6 )

( 7 )

( 8 )

C i r c u l a t i o n : I f p o s s i b l e , m a n u a l l y c h e c k a p u l s e o t h e r t h a n t h e

o n e b e i n g s e n s e d b y t h e o x i m e t e r . B e w a r e - s o m e o x i m e t e r s

a u t o m a t i c a l l y i n c r e a s e t h e s i z e o f t h e p l e t h y s m o g r a p h t r a c e , i f i t s

v o l u m e i s s m a l l .

E n d o t r a c h e a l t u b e : E n d o b r o n c h i a l i n t u b a t i o n m u s t a l w a y s b e

e x c l u d e d . P a l p a t i o n o f t h e p i l o t b a l l o o n w h i l e s q u e e z i n g t h e c u f f

i n t h e t r a c h e a a b o v e t h e s t e r n a l n o t c h w i l l c o n f i r m i t s p o s i t i o n ,

a n d s l i g h t w i t h d r a w a l m a y a l s o r e s o l v e d e s a t u r a t i o n .

P a t e n c y : V e n t i l a t e t h e t u b e d i r e c t l y ( r e m o v e c i r c u i t , f i l t e r ,

c o n n e c t i o n s ) w i t h a s e p a r a t e s y s t e m ( s e e E l i m i n a t e ) . T h e t i p o f

t h e t u b e m a y h a v e m o v e d , t h e l u m e n b e c o m e o b s t r u c t e d o r t h e

c u f f h e r n i a t e d i n t o t h e l u m e n o r o v e r t h e e n d o f t h e t u b e . I f t h e r e

i s a n y s u s p i c i o n o f r e g u r g i t a t i o n , a s p i r a t i o n o r o b s t r u c t i o n o f a

t u b e , p e r f o r m d i r e c t l a r y n g o s c o p y , s u c k o u t t h e p h a r y n x , a d j u s t

t h e t u b e s p o s i t i o n , c o n s i d e r a d j u s t i n g t h e c u f f a n d p a s s a

s u c t i o n c a t h e t e r t h r o u g h t h e t u b e . D o n ' t f o r g e t s w a b s o r p a c k s .

R e v i e w m o n i t o r s : A l w a y s a t t e m p t t o c o n f i r m c o r r e c t s i t i n g ,

c a l i b r a t i o n , a l a r m s e t t i n g s a n d f u n c t i o n :

O x i m e t e r : C h e c k t h e p r o b e o n y o u r s e l f , t r y a n o t h e r s i t e , t r y

a n o t h e r p r o b e , t r y a n o t h e r o x i m e t e r .

C a p n o g r a p h : B r e a t h e i n t o t h e s e n s o r y o u r s e l f a n d c h e c k t h a t

t h e E T

C O

2

r e a d s 5 % o r 4 0 m m H g . R e m e m b e r , a s u d d e n f a l l i n

E T C O

2

m a y b e d u e t o e n t r a i n m e n t o f r o o m a i r b e t w e e n t h e g a s

s a m p l i n g s i t e a n d t h e c a p n o g r a p h .

B l o o d p r e s s u r e : C o n f i r m a u t o m a t e d n o n i n v a s i v e b l o o d

p r e s s u r e m e a s u r e m e n t s m a n u a l l y b e f o r e a c t i n g . C h e c k z e r o a n d

c a l i b r a t i o n o f d i r e c t m e a s u r e m e n t s .

E C G : C h e c k t h e r i g h t l e a d s a r e i n u s e , t h a t w a v e f o r m s a r e

c a l i b r a t e d a n d t h a t t h e m o n i t o r i s i n d i a g n o s t i c m o d e b e f o r e

a s s e s s i n g S T s e g m e n t s .

D r u g s : C o n s i d e r w h e t h e r t h e p r o b l e m m i g h t b e t h e r e s u l t o f

f a i l u r e o f d r u g d e l i v e r y o r t h e w r o n g d r u g , w r o n g d o s e , w r o n g

r o u t e , o r w r o n g t i m e o f a d m i n i s t r a t i o n b e i n g u s e d .

A w a r e n e s s : C o n s i d e r p r e v i o u s d r u g / a l c o h o l u s e . L o o k f o r s i g n s

o f s y m p a t h e t i c a c t i v i t y . C h e c k t h e a n a e s t h e t i c i s a c t u a l l y b e i n g

d e l i v e r e d . I f i n d o u b t , d e e p e n a n a e s t h e s i a .

A i r ( a n d o t h e r ) e m b o l i s m : A l w a y s c o n s i d e r w i t h a f a l l i n

E T C O

2

d e s a t u r a t i o n , h y p o t e n s i o n a n d / o r a s u d d e n c h a n g e i n

E C G r a t e o r c o n f i g u r a t i o n , e s p e c i a l l y i n a r i s k y s i t u a t i o n .

A i r i n p l e u r a ( p n e u m o t h o r a x ) : I f c a r d i o - r e s p i r a t o r y

c o m p r o m i s e r e m a i n s u n d i a g n o s e d a f t e r C O V E R A B C D , e x p o s e

t h e c h e s t a n d a b d o m e n , a n d c a r e f u l l y c o m p a r e l e f t a n d r i g h t

s i d e s , u s i n g i n s p e c t i o n , p a l p a t i o n a n d a u s c u l t a t i o n .

A l l e r g y o r a n a p h y l a x i s : L o o k f o r h y p o t e n s i o n , a f a l l i n E T C O

2

b r o n c h o s p a s m , d e s a t u r a t i o n a n d s k i n s i g n s .

Figure 4 Items which, in the order of the mnemonic, should be CHECKED.


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8/12

developed by those who had reviewed the reports and by at

least one other specialist with a clinical interest in that area.

Once a sub-algorithm had been created, the relevant analysts

again reviewed each of the reports in the relevant set. The

potential value of using a structured approachthat is, the

application of COVER ABCDA SWIFT CHECK to the

diagnosis and initial management of each problemfollowed

by the application of the sub-algorithm for that specific

problem was assessed in the light of each of the relevant

AIMS reports from the first 4000. This was done by

comparing the potential effectiveness of the structured

approach for each incident with that of the actual manage-

ment, as recorded in each report. A judgement was made by

the reviewers as to whether the sub-algorithm, properly

applied, would have led to a better or quicker resolution of

the problem, and specific consideration was also given to

whether use of the sub-algorithm could have caused a

problem. Other relevant aspects of the incidents were


w h a t s h o u l d b e d o n e i n t h e A L E R T / R E A D Y p h a s e . T h i s w i l l

c o m p r i s e a f a c i n g p a g e o f t h e m a n u a l . N o t e s c o r r e s p o n d i n g

t o t h e n u m b e r s i n p a r e n t h e s e s w i l l b e o n t h e r e v e r s e s i d e .

A L E R T / R E A D Y C a l l f o r h e l p / t r o l l e y s ( 1 , 2 )

C i r c u l a t i o n : I f t h e r e i s a n i m p e n d i n g a r r e s t a l l o c a t e t h e

c i r c u l a t i o n t a s k ( 1 ) a n d a s k f o r t h e a r r e s t t r o l l e y t o b e f e t c h e d .

C o l o u r : I f t h e o x i m e t e r i s s u s p e c t , r e s i t e o r r e p l a c e i t a n d / o r d o a n

a r t e r i a l b l o o d g a s . C o n s i d e r i n s e r t i n g a n a r t e r i a l l i n e .

O x y g e n : I f a d e q u a t e s a t u r a t i o n c a n n o t b e c o n f i r m e d , a d m i n i s t e r

1 0 0 % o x y g e n . P l a n h o w t o p r o v i d e a n a l g e s i a a n d a n a e s t h e s i a .

O x y g e n A n a l y s e r : C o n f i r m t h a t t h e g a s i n t h e i n s p i r e d l i m b o f t h e

b r e a t h i n g c i r c u i t i s 1 0 0 % o x y g e n .

V e n t i l a t i o n : A l l o c a t e t h e a i r w a y a n d b r e a t h i n g t a s k ( 1 ) .

V e n t i l a t e w i t h a s e l f - i n f l a t i n g b a g . S e e b r e a t h i n g b e l o w .

V a p o r i s e r s : T u r n t h e v a p o r i s e r o f f i f t h e r e i s c a r d i o r e s p i r a t o r y

c o m p r o m i s e . P l a n h o w t o p r o v i d e a n a l g e s i a a n d a n a e s t h e s i a .

E n d o t r a c h e a l t u b e o r l a r y n g e a l m a s k a i r w a y : A l l o c a t e t h e

e q u i p m e n t t a s k ( 1 ) . I f s u s p i c i o u s , p r e p a r e t o r e m o v e a n d

c h a n g e t h e t u b e o r L M A .

E l i m i n a t e : P r e p a r e a n d c h e c k t h e c o r r e c t f u n c t i o n o f a n a l t e r n a t e

b r e a t h i n g s y s t e m a n d s e p a r a t e o x y g e n s o u r c e .

R e v i e w m o n i t o r s : R e c h e c k , c o r r e l a t e a n d r e c o r d a l l r e a d o u t s a n d

t r e n d s . C a l l f o r a d d i t i o n a l m o n i t o r s a s n e c e s s a r y .

R e v i e w e q u i p m e n t : R e m o v e o r r e p l a c e s u s p e c t e q u i p m e n t . B r i n g i n

a d d i t i o n a l e m e r g e n c y e q u i p m e n t a s a p p r o p r i a t e .

A i r w a y : A d j u s t h e a d a n d n e c k , a t t e m p t g e n t l e c h i n l i f t . P r e p a r e f o r

p h a r y n g o s c o p y ; i f s u s p i c i o u s , g o t o a i r w a y o b s t r u c t i o n .

B r e a t h i n g : E x p o s e t h e c h e s t a n d a b d o m e n . R e p e a t S C A N a n d

C H E C K w h i l s t c o m p a r i n g L a n d R s i d e s . C o n s i d e r c a u s e s .

C i r c u l a t i o n : C h e c k I V a c c e s s . S e c u r e a d d i t i o n a l a c c e s s ( v e n o u s a n d

a r t e r i a l ) a s n e c e s s a r y . P r e p a r e t o t r a n s f u s e .

D r u g s : A l l o c a t e t h e d r u g s t a s k ( 1 ) . C h e c k a l l d r u g s a n d

i n f u s i o n s a n d t h e e n t i r e I V a p p a r a t u s . D r a w u p , c h e c k a n d l a b e l

d r u g s t h a t m a y b e n e e d e d .

A : D e c i d e w h e t h e r A w a r e n e s s , A i r ( o r o t h e r ) e m b o l i s m , A i r i n p l e u r a

( p n e u m o t h o r a x ) , A l l e r g y a n d A n a p h y l a x i s a r e p o s s i b l e c a u s e s o f t h e

p r o b l e m , a n d a c t a c c o r d i n g l y ( s e e a l g o r i t h m s ) .

S W I F T C H E C K : M a k e a n o t h e r a s s e s s m e n t o f t h e g e n e r a l s i t u a t i o n ,

o f t h e p a t i e n t , o f t h e a c t i v i t i e s o f t h e s u r g e o n a n d o t h e r p e r s o n n e l ,

a n d o f t h e p o s s i b l e e f f e c t s o f t h e o p e r a t i o n a n d / o r a n y d r u g s o r

i n f u s i o n s .

C o r r e s p o n d i n g n o t e s t o b e s h o w n o n t h e r e v e r s e s i d e .

A L E R T / R E A D Y

( 1 ) C a l l f o r H e l p - A l l o c a t e T a s k s

T A S K S : A i r w a y ( A ) , B r e a t h i n g ( B ) , C i r c u l a t i o n ( C ) , D r u g s ( D ) ,

E q u i p m e n t ( E ) .

P E R S O N 1 : I n i t i a l l y t h e a n a e s t h e s i o l o g i s t - t o l o o k a f t e r A , B , o v e r a l l

c o o r d i n a t i o n a n d c y c l i n g t h r o u g h C O V E R a n d t h e a p p r o p r i a t e

a l g o r i t h m / s . W h e n s k i l l e d a s s i s t a n c e i s a v a i l a b l e t h e

a n a e s t h e s i o l o g i s t m a y d e l e g a t e A , B , a n d c o n c e n t r a t e o n

c o o r d i n a t i n g a c t i v i t i e s a n d c h e c k i n g a l g o r i t h m s .

P E R S O N 2 : T h e a n a e s t h e t i c a s s i s t a n t . T h i s p e r s o n s h o u l d b e

p r i m a r i l y r e s p o n s i b l e f o r D , E , a l t h o u g h m a y b e d e p l o y e d b y t h e

a n a e s t h e s i o l o g i s t t o o t h e r t a s k s .

P E R S O N 3 : T h i s p e r s o n s h o u l d l o o k a f t e r C . I f t h e r e i s a c a r d i a c

a r r e s t , t h i s p e r s o n s h o u l d b e r e s p o n s i b l e f o r E C M .

P E R S O N 4 : T o b e d e p l o y e d b y t h e a n a e s t h e s i o l o g i s t . I f t h e r e i s a

c a r d i a c a r r e s t , t h i s s h o u l d b e t h e s e c o n d p e r s o n l o o k i n g a f t e r C ,

e n s u r i n g g o o d i n t r a v e n o u s a c c e s s , i n j e c t i o n o f i n t r a v e n o u s d r u g s ,

a n d e n s u r i n g t h e y a r e f l u s h e d t h r o u g h .

P E R S O N 5 : T h i s p e r s o n a n d a n y o t h e r a v a i l a b l e p e r s o n s h o u l d b e

d e p l o y e d b y t h e a n a e s t h e s i o l o g i s t . I t i s m o s t i m p o r t a n t t h a t e a c h

p e r s o n b e g i v e n a s p e c i f i c t a s k , e . g . C a n y o u i n d e p e n d e n t l y a s s e s s

t h e s i t u a t i o n , g o t h r o u g h C O V E R a n d s u b - a l g o r i t h m s X a n d Y , a n d

c h e c k t h a t a l l i s g o i n g t o p l a n ? O R P l e a s e h e l p t h e a n a e s t h e t i c

a s s i s t a n t g e t t i n g d r u g Z r e a d y , O R P l e a s e h e l p P e r s o n 3 ( o r 4 ) g e t

t h e d e f i b r i l l a t o r r e a d y .

( 2 ) E m e r g e n c y E q u i p m e n t a n d D r u g T r o l l e y s

S t a n d a r d s e t s o f e q u i p m e n t a n d d r u g s s h o u l d b e a v a i l a b l e o n

t r o l l e y s w h i c h c a n b e b r o u g h t i n , o r i n d r a w e r s o n t h e a n a e s t h e t i c

m a c h i n e . T h e f o l l o w i n g s h o u l d b e a v a i l a b l e :

A i r w a y E q u i p m e n t I ( S t a n d a r d )

A i r w a y E q u i p m e n t I I ( D i f f i c u l t i n t u b a t i o n )

B r e a t h i n g E q u i p m e n t I ( S t a n d a r d )

B r e a t h i n g E q u i p m e n t I I ( P l e u r a l d r a i n a g e / b r o n c h o s c o p y )

C i r c u l a t o r y E q u i p m e n t I ( S t a n d a r d )

C i r c u l a t o r y E q u i p m e n t I I ( C a r d i a c a r r e s t )

D r u g s - E m e r g e n c y I ( S t a n d a r d )

D r u g s - E m e r g e n c y I I ( F o r u n u s u a l p r o b l e m s )

E q u i p m e n t E x t r a s I ( S p a r e s e t o f m o n i t o r s )

E q u i p m e n t E x t r a s I I ( F o r u n u s u a l p r o b l e m s )

Figure 5 Items which, in the order of the mnemonic, should be done in the ALERT/READY phase.


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manual there are easy-to-use tabs down the right hand sides

of the pages to allow the anaesthetist immediate access to

sub-algorithms for problems with non-specific cues such as

desaturation, but which also allow direct access to sub-

algorithms for specific problems such as anaphylaxis or air

embolism, when these are immediately recognised. There are

also tabs at the tops of the first few pages for rapid access to

the SCARE sequences.

An electronic copy of the algorithms in the manual was

made available on the internet.38 Unlike paper manuals, these

web based manuals are more flexible a nd allow rapid updatesto all users. With the more frequent use of personal

computers and hand held devices, it was felt that this would

be a beneficial medium in which to house the manual. To this

end, an electronic software form of the manual has been

developed using hypertext documentation that can be used

on a personal computer or a hand held personal desk

assistant (e.g. Palm PilotTM). The program uses frames with

resizable boxes and scroll bars on the sides. Underlined text

expands into full text boxes and, within the crisis algorithm

itself, collapsible headings and hyperlinks and pop-up boxes

are used to fully describe each of the sub-algorithms. The

personal computer program is of most use as a teaching tool,

while the ease of use and instant availability of a hand held

device allows the manual to be instantly accessible during

times of a crisis. This version is currently being used by some

trainee anaesthetists in New Zealand (Charles Bradfield,personal communication).

COMMENTS ON THE CRISIS MANAGEMENTMANUALSince the publication of the core algorithm, five meetings on

crisis management have been held: one at Noosa in

Queensland in June 1993; one at Toukley in New South

Wales in March 1994; and two 2 day meetings in association

with Annual Scientific Meetings of the Australian Society of

Anaesthetists, one in Fiji in November 1994 and one in

Melbourne in October 1995. Finally, the electronic version

was demonstrated at the 2001 Annual Scientific Meeting of

the Australian Society of Anaesthetists in Canberra. The 2001

Canberra meeting was especially important as it was the first

meeting for several years following dissemination of the draft

manual. At all of these meetings the sub-algorithms

presented in this issue were presented, discussed, and

refined. It was recognised that the methods used for

validating the algorithms were intrinsically limited and

subject to hindsight bias. Prospective validation using

simulation would be ideal but will require a large scale,

carefully designed study.

It was agreed by all that the algorithms should only be

used when the usual responses based on pattern recognition

do not appear to have been successful. Also, right from the

start it was agreed that the use of the traditional cardiac

arrest mnemonic ABCD was too limited for more complex

problems which arise because of the interposition of artificial

gas supplies, anaesthetic machines (with additional hazards

such as vaporisers), artificial airways, and various breathingcircuits with failure prone components such as one-way

valves and arrangements for carbon dioxide absorption. For

example, hypoxic gas mixtures (especially 100% nitrous

oxide), potentially fatal vapour concentrations, and circuit

over-pressures must be excluded almost immediately or

severe patient harm or death may ensue rapidly. A number of

additional important points were raised at the various

meetings.

Firstly, it is important to recognise that the AIMS reports

simply constitute a body of information arising from

occasions when anaesthetists were sufficiently interested or

concerned by an event to report it and the surrounding

circumstances as an incident. It is known that common or

mundane events are under-reportedfor example, circuit

disconnections and leaks are under-reported but are never-

theless the most frequently reported incidentswhereas very

dramatic and unusual events are more likely to be reported

for example, anaphylactic reactions or air embolism.41 42

The relative frequencies with which various types of

incident are reported thus provide some hybrid reflection of

the relative frequency with which they occur and the degree

of interest or alarm they engender. Although reporting such

comparative frequencies may produce considerable unease inclassical epidemiologists, it does have practical relevance to a

body of anaesthetists who are provided with a prioritised

catalogue of events sequenced according to their perceived

relative importance by fellow practitioners.39 Half of New

Zealand anaesthetists who responded to a survey (57%

response rate) felt that AIMS had changed their practice.43

The second issue addressed was whether the AIMS data

are relevant to crises that actually have adverse outcomes.

Data from anaesthetic deaths which were substantially

attributed to anaesthetic management and which occurred

within 48 hours of anaesthesia in the UK (790 deaths) and

New South Wales (172 deaths) indicate that the AIMS data

are relevant.39 44 In 80% of the deaths on the same day the

first sign of disaster was a life threatening crisis. Of all these

crises leading to death, three quarters are in the AIMS top

10 and nearly all the remainder are in the next 10.39 There is

also a striking similarity between the presenting signs in the

UK and New South Wales studies (table 4);44 the non-

specificity of these signs confirms that a structured approach

would be desirable as there was a large number of causes of

the underlying problems.

In the UK study 30% of deaths were in patients who were

ASA grade 14 and in the New South Wales study 40% of

deaths were in patients regarded as being fair risks. The

conclusions that AIMS crises are relevant for validating crisis

management algorithms, that many crises which result in

death start with non-specific signs, and that problems may

arise in low or moderate risk patients all support the routine

use of a structured algorithm. Studies from elsewhere have

confirmed that there is a strong association between initial

process events and poor outcomes.45 46

The third problem which arose for discussion was that,

even if structured algorithms are available, poor team work

may compromise their execution. Again, the ideal is that

practising anaesthetists should undergo regular simulation

sessions in which they play various roles in crisis situations

that is, the equivalent of cockpit resource management

sessions in the aviation industry.4749 However, in reality this

will not be possible for all anaesthetists in the near future.

Experience from attending real crises and from observing

Australian anaesthetists in simulated crisis situationsfor

example, during the crisis management simulation session in

Toukley, New South Wales in March 1994confirms that

teamwork is often poor. The use of a crisis management

Table 4 Comparison of mode of presentation of 360NCEPOD* and 138 NSW** crises44

Incident NCEPOD NSW

Hypotension 33% 43%Cardiac arrest 24% 25%Arrhythmia 19% 24%Cyanosis 7% 6%Pulmonary oedema 3% 3%

*Data from the National Confidential Enquiry into Perioperative Deaths(UK).**Data from the New South Wales Special Committee InvestigatingDeaths under Anaesthesia (Australia).


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manual allows a coordinating person (usually an anaesthe-

tist) to allocate tasks for individual members of the operating

room team. In this way, tasks will be prioritised and it will be

ensured that the essential basic tasks are carried out in the

correct sequence and in an expeditious manner. The value of

a crew resource management approach cannot be over-

emphasised and its introduction into clinical practice needs

to be widely supported.2 49 Better communication was cited

by over two-thirds of operating room nurses and doctors as

the most important intervention required to improve safety,49

underlining the importance of moving towards formal teamtraining using simulators.

This may be based on the use of crisis management

algorithms which, in the future, may be available as part of

the software of integrated monitoring devices and clinical

decision support systems. The first step was producing Palm

and PC-based versions of this crisis management manual.

The introduction of such an approach into commercial

monitoring systems has gained interest by some manufac-

turers and is well recognised as being an effective way of

applying information of this sort.50 51

Fourthly, the use of COVER ABCDA SWIFT CHECK and

the sub-algorithms does not guarantee a good outcome

merely that an appropriate sequence of actions will have been

carried out in the vast majority of cases. In some instances

something will have been done (such as a wrong drug given)

or something will have occurred (such as pulmonary

embolism) that has consequences that the anaesthetist

cannot reverse or even control. Also, it is inevitable that the

core algorithm and sub-algorithms will not always be

correctly applied. However, if this is the case, as long as these

are available in an easy-to-access form, others called to assist

in the management of an escalating crisis will have a fresh

chance of resolving the problem.

The sub-algorithms have been designed to be a simple set

of instructions that can be followed in an emergency. It is

inevitable that these algorithms will differ from accepted

practice in some regions and do not represent the only

acceptable course of action. However, it is suggested that they

be followed in crises when pattern recognition has failed, at

least in the first instance, as they have been designed to

represent appropriate courses of action in the vast majority ofcircumstances. If this structured approach proves to be

unhelpful, the anaesthetist can always revert to problem

solving from first principles. The relevant sub-algorithm

should also be examined following resolution of an incident

to ensure that the reason for the crisis has not been missed

and to facilitate appropriate ongoing care and management.

Although the structured approach advocated may not be the

best for every situation, it will be consistent, is unlikely to

harm the patient, will assist in the diagnosis of the problem

in 99% of cases, and will be better than the current clinical

management by the average clinician in at least one in eight

incidents.

Finally, crisis management is not complete until the

consequences for the patient, his or her friends and relatives,

all medical (and other) staff involved, and the implicationsfor the institution, practice or system have been dealt with.52

An approach to this is outlined in the final paper in this set of

articles32 and forms the last section of the Crisis Management

Manual.38 An open disclosure standard has now been

developed by the Australian Council for Safety and Quality in

Health Care which supplements the approach advocated in

this last section of the manual.53

The sub-algorithms presented in this set of 24 articles were

developed as an adjunct for the practising clinician to use in

the resolution of incidents that occur during anaesthesia.

They are didactic but are open to debate, discussion, and

criticism. They form the basis of what we believe to be a

useful step in developing a rational evidence-based approach

to crisis management during anaesthesia. However, much

remains to be done. The COVER component has been found

to be satisfactory in real life resuscitation situations.54

Carefully designed simulator based studies, using nave

trainees right at the start of training, could evaluate the

approach advocated here against possible alternatives, and

could systematically examine the merits and demerits of

various aspects of the sub-algorithms and how they are

presented. The extent to which pre-compiled responses

should be required to be usedas in aviation and by the

policies of some hospitals with respect to the use of cardiac

arrest protocolsis likely to be the subject of lively debate as

medical practice receives increased scrutiny. Due to the

complexities of clinical medicine, however, it would seem

prudent, for the foreseeable future, that the core algorithm

and sub-algorithms described in this set of articles be

regarded as decision aids to support and back up a

clinicians natural responses to a crisis when all is notprogressing as expected.55

AC KN OW LE DG EM EN TSThe authors would like to thank all the anaesthetists in Australia and

New Zealand who contributed to the 4000 incident reports upon

which this and the other 24 papers in the Crisis Management Series

are based. The coordinators of the project also thank Liz Brown for

preparing the draft of the original Crisis Management Manual;

Loretta Smyth for typing; Monika Bullock RN for earlier coding and

classifying of data; Dr Charles Bradfield for the electronic version of

the algorithms; Dr Klee Benveniste for literature research; and Drs

Klee Benveniste, Michal Kluger, John Williamson and Andrew Paix

for editing and checking manuscripts.

Key messages

N This paper forms the introduction to a set of 24 articlesthat outline a structured approach for use when thingsgo wrong during anaesthesia. Prevention is not theintent of this set of articles as the focus is on crisismanagement.

N From three meetings involving 60100 anaesthetists itwas agreed that a core crisis management algo-rithm was needed when either cause or response totreatment during an anaesthesia crisis was notapparent.

N From the study of the first 4000 incidents reported toAIMS, a need for 24 specific sub-algorithms wasidentified based on successful strategies identified inthe reports.

N Using the application of the previously reported corealgorithm, the 24 sub-algorithms were assembled in auser friendly manual for trial against the 4000 incidentreports.

N The trial showed that this structured approach wouldaid in diagnosis in 99% of crises and would providebetter management than that of the average clinician,

without patient harm, in one in eight of the situations.N Poor teamwork may compromise the execution of a

structured algorithm.

N These algorithms will differ from accepted practicein some regions and do not represent the onlyacceptable course of action.

N Such structured approaches lend themselves readily tosimulation training in anaesthesia, resuscitation, andintensive care.


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Authors affiliations. . . . . . . . . . . . . . . . . . . . .

W B Runciman, Professor and Head, Department of Anaesthesia andIntensive Care, University of Adelaide and Royal Adelaide Hospital,

Adelaide, South Australia, AustraliaM T Kluger, Senior Staff Specialist, Department of Anaesthesiology andPerioperative Medicine, North Shore Hospital, Auckland, New ZealandR W Morris, Director, Research and Development, Sydney MedicalSimulation Centre, Royal North Shore Hospital, St Leonards, New South

Wales, AustraliaA D Paix, Consultant Anaesthetist, Princess Royal University Hospital,Orpington, Kent, UK

L M Watterson, Senior Staff Specialist and Director, Sydney MedicalSimulation Centre, Royal North Shore Hospital, St Leonards, New SouthWales, AustraliaR K Webb, Senior Staff Specialist, Department of Anaesthesia andIntensive Care, The Townsville Hospital, Douglas, Queensland, Australia

This study was coordinated by The Australian Patient Safety Foundation,GPO Box 400, Adelaide, South Australia 5001, Australia.

REFERENCES1 Runciman WB. Crisis management. Anaesth Intensive Care 1988;16:868.2 Gaba D, Fish K, Howard S. Crisis management in anesthesiology. New York:

Churchill Livingstone, 1994.3 Fisher MMcD, ed. The anaesthetic crisis. Best Pract Res Clin Anaesthesiol

1993;7:199515.4 Runciman WB, Webb RK, Klepper ID, et al. Crisis management: validation of

an algorithm by analysis of 2000 incident reports. Anaesth Intensive Care1993;21:57992.

5 Merry A, McCall Smith A. Errors, medicine and the law. Cambridge:Cambridge University Press, 2001:1922.6 Kohn LT, Corrigan JM, Donaldson MS, eds. To err is human: building a safer

health system. Washington, DC: National Academy Press, 1999.7 Department of Health. An organisation with a memory. Report of an expert

group on learning from adverse events in the NHS, chaired by the ChiefMedical Officer. London: The Stationery Office, 2000.

8 Runciman WB, Moller J. Iatrogenic injury in Australia. Adelaide: AustralianPatient Safety Foundation, 2001.

9 Visvanathan T, Kluger MT, Webb RK, et al. Crisis management duringanaesthesia: obstruction of the natural airway. Qual Saf Health Care2005;14:e2.

10 Visvanathan T, Kluger MT, Webb RK, et al. Crisis management duringanaesthesia: laryngospasm. Qual Saf Health Care 2005;14:e3.

11 Kluger MT, Visvanathan T, Myburgh JA, et al. Crisis management duringanaesthesia: regurgitation, vomiting, and aspiration. Qual Saf Health Care2005;14:e4.

12 Paix AD, Williamson JA, Runciman WB. Crisis management duringanaesthesia: difficult intubation. Qual Saf Health Care2005;14:e5.

13 Szekely SM, Runciman WB, Webb RK, et al. Crisis management during

anaesthesia: desaturation. Qual Saf Health Care2005;14:e6.14 Westhorpe RN, Ludbrook GL, Helps SC. Crisis management duringanaesthesia: bronchospasm. Qual Saf Health Care 2005;14:e7.

15 Chapman MJ, Myburgh JA, Kluger MT, et al. Crisis management duringanaesthesia: pulmonary oedema. Qual Saf Health Care2005;14:e8.

16 Watterson LM, Morris RW, Westhorpe RN, et al. Crisis management duringanaesthesia: bradycardia. Qual Saf Health Care2005;14:e9.

17 Watterson LM, Morris RW, Williamson JA, et al. Crisis management duringanaesthesia: tachycardia. Qual Saf Health Care 2005;14:e10.

18 Morris RW, Watterson LM, Westhorpe RN, et al. Crisis management duringanaesthesia: hypotension. Qual Saf Health Care2005;14:e11.

19 Paix AD, Runciman WB, Horan BF, et al. Crisis management duringanaesthesia: hypertension. Qual Saf Health Care2005;14:e12.

20 Ludbrook GL, Webb RK, Currie M, et al. Crisis management duringanaesthesia: myocardial ischaemia and infarction. Qual Saf Health Care2005;14:e13.

21 Runciman WB, Morris RW, Watterson LM, et al. Crisis management duringanaesthesia: cardiac arrest. Qual Saf Health Care 2005;14:e14.

22 Paix AD, Bullock MF, Runciman WB, et al. Crisis management duringanaesthesia: problems associated with drug administration during

anaesthesia. Qual Saf Health Care2005;14:e15.

23 Osborne GA, Bacon AK, Runciman WB, et al. Crisis management duringanaesthesia: awareness. Qual Saf Health Care 2005;14:e16.

24 Williamson JA, Helps SC, Westhorpe RN, et al. Crisis management duringanaesthesia: embolism. Qual Saf Health Care 2005;14:e17.

25 Bacon AK, P

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