Criticare - A special feature on Anaesthesiology

Ensuring safe anaesthesia practice

Shardul Nautiyal - Mumbai

At a time when the number of medico-legal cases against anaesthesiologists are alarming, safe anaesthesia practice is assuming significance. Indian hospitals are well-equipped for safe anaesthesia practice, opine experts. “Safe anaesthesia practice in major Indian hospitals can be compared to hospitals in the west,” says Dr Kailash Kothari, anaesthesiologist, Swastik Hospital.

Experts say that large corporate hospitals and specialised nursing homes, particularly in urban areas are 90 per cent well-equipped for administering of safe anaesthesia. Safe anaesthesia accounts for 60 to 70 per cent in private practice and 30 to 40 per cent in institutional practice. So, how does one achieve safe anaesthesia practice? Government of India has not laid down guidelines for anaesthesia practice,” informs Dr R P Gehdoo, professor, department of anaesthesiology, Tata Memorial Hospital. Hence, anaesthetists follow the guidelines laid down by American Society of Anaesthesiologists (ASA).

According to Dr Smita Sharma, anaesthesiologist, Bombay Hospital, safe anaesthesia practice can be achieved with thorough pre-operative assessment of the patient, pre-operative drill of anaesthesia equipment and checklisting of the drugs.

Other key elements to arrive at safe anaesthesia are proper utilisation of monitoring available, correct interpretation of the figures, constant vigilance througout the surgery. “An extra five to ten minutes should be reserved for monitoring the patient at the end of anaesthesia. The key to safe anaesthesia practice is high level of anticipation for the complications of anaesthesia,” adds Dr Sharma.

Other aspects to be considered in safe anaesthesia practice are electrical injury, skin injury, infection and various hazards inherent in the OT. Training of OT staff is also a crucial aspect to protect patients from these hazards.

Various newer technologies for monitoring include new mass spectography (real time analysis and data display), Raman photospectrometer, automatic non-invasive sphygmomanometers with appropriate alarms are contribute towards safe anaesthesia. While some advanced techniques may not be routinely available in anaesthesia set-ups, they are extremely important. These include sophisticated monitors , such as expired and inspired level of anaesthesia agent, electro-encephalograph (EEG), sensory-evoked potential and motor evoked potential. These techniques are instrumental in fine-tuning anaesthesia. The hurdles in safe anaesthesia practice are newer drugs, which are expensive and not always available in mofuzil and outstations. The lack of proper facility has prevented many small nursing homes from undertaking risky surgeries. According to Dr S R Gupte, senior anaesthesiologist, Breach Candy, “Due to financial constraints, there are very little monitoring equipment in the nursing homes and smaller hospitals. There is no uniformity in the equipment available and many times the available equipment is not in working order.” Major corporate hospitals, with their modern monitoring equipment are reasonably safer, he adds.

It has been found that mishap in peripheral hospitals during administering anaesthesia practice is because of the “compromises” made. “The peripheral centres do not have standard machines, monitors and necessary equipment like resuscitation drugs and equipment. They even lack the basic equipment like anaesthesia machine,” informs Dr Gehdoo. In private hospitals, infection caused because of re-use of equipment is another hurdle in safe anaesthesia practice. “Anaesthesia circuits, endotracheal tubes and many other equipment are reused. Though it is not acceptable, it is practised due to economic constraints,” says Dr Kothari.

The North East Mumbai Anaesthesia Association (NEMAA) has laid guidelines for minimum level of monitoring to be provided by the hospital. Though the situation is improving since the past few years, experts mourn the lack of a regulatory body. “Government in association with anaesthesia societies should monitor the level of care provided by healthcare institutions,” opines Dr Kothari.

Guidelines by American Society of anaesthesiologists

• The patient should be seen by anaesthesia personnel couple of days before the operation so that the anaesthetist can understand patient’s inherent problems like asthma, diabetes etc. Patient has to be stabilised and anaesthesia has to be planned accordingly.
• Which drugs has to continued and which drugs need to be stopped is determined two days prior to the pre-anaesthesia evaluation. Minimum four to six hours of fasting prior to anaesthesia is recommended.
• Written consent is the main prerequisite to avoid any medico-legal complications.
• Before anaesthesia is started one must check the anaesthesia machine (Boyle machine), which includes source of gases, anaesthesia drugs, resuscitating or emergency drugs, necessary anaesthesia equipment, suction units. n In intra-operative order, the patient has to be given necessary fluid balance, which is monitored by input/output chart. Intra-operative monitoring has to be continued and blood loss have to be measured and replaced accordingly.
• In the post operative order, after checking the normal vital signs, patient can be awakened from the anaesthesia depending on the type of surgery and shifted to the recovery room with machine to support respiration through the ventilator.
• After operation, patient need to be observed after minimum four to six hours of surgery in the recovery room.

shardul@expresshealthcaremgmt.com