Below is an attempt at a comprehensive framework for intraoperative anaesthetic crisis management.
REFLEX
‘This is a crisis situation’
+/- exclude/confirm cardiac arrest by palpating the carotid pulse
+/- commence cardiopulmonary resuscitation as per ALS guidelines
I would immediately
- Review monitoring & clinical signs to determine severity & aetiology
- Communicate the problem to the team
- Instruct a nurse to call for help
- Send someone to retrieve [resource]
TARGETED MANAGEMENT
My immediate management would be to
- Increase inspired oxygen to 100%
- I would remove [trigger/source] and [deepen/lighten] anaesthesia
- Institute immediate management of [intervention]
I would treat the most likely cause [cause]
- However I would consider a broader differential according to [diagnostic model]
- I would manage [cause] as per [relevant guideline]
- The mainstay of treatment is [intervention]
I would simultaneously assess and manage the patient in a systematic fashion
- [Airway management]
- [Breathing management]
- [Circulation management], [invasive monitoring]
- [Disability management], [anaesthesia management]
- [Environmental management]
SUPPORTIVE CARE
Further supportive management would include [supportive management]
Once the patient has clinically stabilised, I would
- Discuss with the surgeon the appropriateness of continuing/deferring surgery
- +/- liaise with ICU for ongoing post-resuscitative care
- Ensure investigation & confirmation of the aetiology
- Ensure investigation & management of complications
FOLLOW-UP
Subsequent follow-up would involve
- Accurate documentation
- Review & medical care as appropriate +/- follow-up testing
- Disclosure of events to the patient/NOK
- Debrief of the team
- I would notify the relevant institutional & national morbidity/mortality pathways
- +/- contact medical defence organisation