UiA 33 Final Replacement Web 2

Available at: www.wfsahq.
org/resources/update-in-anaesthesia
Update in
Anaesthesia Education for anaesthesia providers worldwide
Volume 33 January 2019
Editor-in-chief: Alan Jay Schwartz ISSN 1353-4882
Associate editors: Christina Lundgren and Victoria Howell
• SAFE-T Summit 2018

–– Global challenge for patient safety
–– Global surgery, obstetrics and anaesthesia metamorphosis
–– Surgical capacity indicators
–– Implications for the WFSA
–– Progress and challenges in global surgical and anaesthesia
care and safety
–– Surgical and anaesthesia capacity and safety: European
Society of Anaesthesiologists’ perspective
–– NGO perspective
–– Anaesthesia Patient Safety Foundation (APSF) perspective
–– WFSA SAFE-T Summit: overview and commentary
• ATOTW Clinical Safety
–– WHO Surgical Safety Checklist
–– Patient Safety Update: Infusion safety, preoperative
assessment, bone cement implantation syndrome
–– Patient Safety Update: Central neuraxial blockade, drug errors
and ‘never events’
• The Vital Anaesthesia Simulation Training (VAST) course
• Long-term venous access devices
• Successful management of malignant hyperthermia without
dantrolene in paediatric anaesthesia
• In Memory – Professor Michael Rosen
The Journal of the World Federation of Societies of Anaesthesiologists

NEW UPDATE TEAM
Editor-in-chief
Alan Jay Schwartz (USA)
Associate Editors
Christina Lundgren (SA)
Victoria Howell (UK)
Emeritus Editor-in-chief
Bruce McCormick (UK)
Editorial Board of Update in Anaesthesia

Douglas Bacon (USA)
Gustavo Elena (Argentina)
Martin Chobli (Benin)
Dr Aboudoul-Fataou Ouro-Bang’na Maman (Togo)
Dr David Pescod (Australia)
Dr Jeanette Thirlwell (Australia)
Dr Isabeau Walker (UK)
SS Harsoor (India)
Kazuyoshi Hirota (Japan)
Zhanggang Xue (China)
Jing Zhao (China)
Typeset by Prepress Projects Ltd, Perth, UK
Printed by COS Printers Pte Ltd, Singapore
© World Federation of Societies of Anaesthesiologists 2019. This issue may be freely reproduced for the purposes of private research and
study and extracts (or indeed, the full report) may be included in professional journals provided that suitable acknowledgement is made and
the reproduction is not associated with any form of advertising. Applications for commercial reproduction should be addressed to: World
Federation of Societies of Anaesthesiologists, Dean Bradley House, 52 Horseferry Rd, London SW1P 2AF, UK.
Disclaimer
The WFSA takes all reasonable care to ensure that the information contained in Update in Anaesthesia is accurate. We cannot be
held responsible for any errors or omissions and take no responsibility for the consequences of error or for any loss or damage
which may arise from reliance on information contained.
Update in
Anaesthesia
Update on Update!
This issue of Update in Anaesthesia is the first publica- reprinted for your review. These tutorials are most
tion facilitated by me as your new editor-in-chief. I am pertinent to the topics presented at the SAFE-T
thrilled to bring you, as my first issue of your journal, Summit 2018. Please join me in thanking ATOTW
a collection of safety articles. Safe anaesthesia patient editor-in-chief, Maytinee Lilaonitkul, for sharing these
care is our primary goal! Recognising this imperative, important safety tutorials.
the World Federation of Societies of Anaesthesiologists
Editorial
(WFSA), in collaboration with the Anaesthesia Section Completing this issue of Update in Anaesthesia are
of the Royal Society of Medicine (anaesthesia@rsm. three original manuscripts. The topics discussed in
ac.uk), jointly organised and conducted the SAFE-T these submissions, that is, utilisation of simulation to
(Safe Anaesthesia for Everybody – Today) Summit teach management of critical events, vascular access
2018. techniques and care of a patient with malignant
hyperthermia in a low-resource environment, provide
The SAFE-T Summit 2018 provided an opportunity important safety considerations.
for anaesthetists, surgeons, obstetricians and allied
health providers to focus on the principles of safe This issue of Update in Anaesthesia launches a new
surgery and all that enables this to be possible, phase of your journal’s existence. I look forward to
especially safe anaesthesia care. This issue of Update bringing you more themed issues that will focus on
in Anaesthesia brings you nine articles that cover some important anaesthesia patient care issues. I am eager
of the important topics considered at the SAFE-T to bring you more original articles to showcase your
Summit 2018. scholarly work, be it case reports, review articles or
original research. Enjoy and learn from reading this
To complement the articles from the summit, three and future issues of Update in Anaesthesia. I hope
previously published safety-focused articles from you will share your ideas and manuscripts with me at
Anaesthesia Tutorial of the Week (ATOTW) have been schwartza@email.chop.edu.
Alan Jay Schwartz, MD MSEd
Department of Anesthesiology and Critical Care Medicine

The Children’s Hospital of Philadelphia
Philadelphia, PA 19104-4399, USA
Professor of Clinical Anesthesiology and Critical Care

Perelman School of Medicine
University of Pennsylvania
Correspondence: schwartza@email.chop.edu
The WFSA would like to thank Baxter

for their financial support of this
edition of Update in Anaesthesia
© World Federation of Societies of Anaesthesiologists 2019. This issue may be freely reproduced for the purposes of private research and study and extracts (or indeed, the full report)
may be included in professional journals provided that suitable acknowledgement is made and the reproduction is not associated with any form of advertising. Applications for
commercial reproduction should be addressed to: World Federation of Societies of Anaesthesiologists, Dean Bradley House, 52 Horseferry Rd, London SW1P 2AF, UK. 1
Update in
Anaesthesia
SAFE-T Summit 2018 Reports
The global challenge for patient safety: scope

and definition
Tore Laerdal
Correspondence: Tore.Laerdal@laerdal.com
Patient safety is normally defined as omission of categories each claim about 5 million lives per year if
harm during medical care in hospital. Relative to the 1.3 million fresh stillbirths are also included. What
global challenge, a wider scope is needed, including lessons can be learned from fighting these categories
the primary care sector and coverage of care, or of death that are relevant to the global challenge of
lack thereof, as well as quality of care. There are no patient safety? (Figure 1).
global statistics on deaths caused by medical error.
Estimates vary greatly. A review of US-based studies1
indicates that the number of deaths in US hospitals LESSONS FROM FIGHTING SUDDEN
alone may be between 200,000 and 400,000 per CARDIAC DEATHS
year. Extrapolating these numbers may give a global
estimate of 3–5 million deaths per year. However, the Today, 60 years after the introduction of cardiopul-
death toll is likely to be much larger than this estimate. monary resuscitation (CPR), in-hospital survival
In low- and middle-income countries (LMICs), where from SCA in the USA is about 25%, representing
82% of the global population lives, most medical care 50,000 survivors among 200,000 patients.3 More
takes place in primary care institutions and is delivered recent studies have shown that the quality of CPR
by non-physicians. Many deaths that may have a root delivered greatly impacts patient outcome. Whereas
cause in lack of access to care and poor patient safety poor CPR has marginal clinical impact, high-quality
end up being classified in other categories. Given the CPR may enhance the chances of patient survival by
magnitude of the problem, it may appear as a paradox three to four times.4 Therefore, the American Heart
that patient safety is not referred to specifically in any Association (AHA)5 recently declared that ‘Poor
of the 17 sub-goals of the United Nations (UN) Sus- quality CPR should be considered to be a preventable
tainable Development Goal (SDG) 3, to secure health harm’. Evidence now shows that what is increasingly
and well-being for all.2 One explanation may be the referred to as ‘low-dose, high-frequency training’6 is
misclassification of patient safety issues and another significantly more effective for the acquisition and
may be patient safety’s vaguely defined nomenclature, maintenance of CPR skills than traditional 2-yearly
measurement indicators and reporting requirements. certification.
What is not measured tends to get less attention. In
comparison, two other categories of death, death from To secure more efficient in-hospital resuscitation
sudden cardiac arrest (SCA; under 70 years of age) practice, the AHA and Laerdal have developed the
and maternal/newborn death, are more clearly defined Resuscitation Quality Improvement (RQI) Program,
and part of SDG3, with goals set for reduction by which enables practitioners to refresh their skills in
Tore Laerdal MSc 2030 of one-third and two-thirds, respectively. These low doses every month in the workplace. They can
Executive Director do this during a short break and do not need to be
Laerdal Foundation absent for up to a day, as is the case with traditional
Stavanger CPR training methods. Since its introduction,
Norway approximately 300 hospitals in the USA have adopted
and the RQI Program, enrolling and improving the
Chairperson competency of over 300,000 healthcare providers.
Laerdal Medical
At the 6th World Summit on Patient Safety held in
Orpington
UK
London in February 2018, the AHA presented a 2025
and commitment to help save 50,000 more lives each year
Chairperson by widespread adoption of the RQI Program across
Laerdal Global Health Figure 1. Scope and magnitude of the patient safety US hospitals, combined with strategies to prevent
Stavanger challenge relative to sudden cardiac and maternal/ cardiac arrest and implementation of practices known
Norway newborn deaths. to improve survival.
2 www.wfsahq.org/resources/update-in-anaesthesia
Update in Anaesthesia ■ Volume 33 ■ January 2019
Out-of-hospital survival from SCA is estimated to average around

10% in high-income countries (HICs) and to be as low as 1% in Box 1. The 10 best practice steps for increasing survival
LMICs. However, there is a 10-fold or more difference in survival from out-of-hospital cardiac arrest
from the worst- to the best-performing emergency medical systems
1. Cardiac arrest registry
(EMSs), even between and within HICs.7 What might explain
2. Telephone CPR for more and better CPR
such differences when all systems have access to the same science
3. High-performance EMS CPR
and use similar education curricula and equipment? This question
4. Rapid dispatch
was first addressed in 1990 at an expert meeting at Utstein Abbey
5. CPR performance data
outside Stavanger, Norway. The meeting resulted in widely endorsed
6. First-responder automated external defibrillator (AED)
recommendations on reporting outcome data. Without good
programmes
measurement, it is difficult to improve. The Utstein Formula for
7. Smart technologies to expand CPR and public access
Survival8 stipulates that the chances of survival may be expressed as
defibrillation (PAD)
the product of three factors: medical science, educational efficiency
8. CPR/AED training in schools and the community
and local implementation (Figure 2). There are strong reasons to
9. Accountability
believe that the last two factors in this formula are the weakest and
10. Work towards a culture of excellence
where most additional impact could be achieved. Without effective
education and implementation, there will be little impact of advances
in medical research.
LESSONS FROM FIGHTING MATERNAL/NEWBORN
At another Utstein meeting in 2015, experts from around the world DEATHS
made a call to establish a Global Resuscitation Alliance, with an
objective of helping increase survival from cardiac arrest by 50% In total, 800 babies and 80 mothers die at birth every day, nearly
by 2020 by adherence to 10 suggested steps for best practice in the all in LMICs. Over 80% of these deaths could be prevented by
community (Box 1). A report published in 2018, Acting on the Call,9 well-trained and equipped birth attendants. Asphyxia is the leading
details 27 case examples on progress, giving hope that the goal of 50% cause of early newborn death, officially claiming 700,000 lives every
increased survival may be realistically achievable. This is supported by year. In addition, some 1.3 million babies classified as ‘fresh stillbirths’
strong case examples from Japan and Denmark, with both showing have a heartbeat during labour. Many of these could be resuscitated
an impressive tripling in survival over the past 10 years by leveraging and would likely more correctly be classified as being asphyxiated.
national registries for measuring all out-of-hospital cardiac arrests On top of this, a million babies survive with brain damage as a result
(OHCAs) as a basis for systematic improvement plans. of a compromised oxygen supply during labour.
A meeting convened in Singapore in August 2017 concluded that Some 10 years ago, Laerdal had the privilege of partnering with
the same 10 steps were also relevant for developing EMSs in LMICs, the American Academy of Pediatrics to develop the Helping Babies
but they needed to be applied in a local context. Factors that the Breathe (HBB) programme10 to address this challenge. Today, more
individual EMS service may influence include strong local leadership, than 500,000 birth attendants in over 80 LMICs have been trained
efficient training, quality improvement and establishing a culture of by this programme. Studies in Tanzania, Nepal, Uganda and Ghana11
excellence. Factors that represent additional challenges in LMICs show that, when well implemented, this programme can reduce early
include restricted healthcare budgets, cultural attitudes to helping infant mortality by as much as 50% and fresh stillbirths by 25%.
strangers, ignorance of lifesaving techniques among bystanders The HBB programme makes lifesaving easier to learn and remember
and poorly developed emergency dispatch systems and ambulance through use of a simple action plan, using a traffic light colour-coding
services. Addressing such factors may often require a longer term system. Ten per cent of babies, in both HICs and LMICs, are born
perspective. in the yellow colour zone, needing help to start breathing to move
to the green zone. The traffic light stays yellow for only 1 minute,
the ‘golden minute’. If the right help is not given, the light will shift
to red and the baby is likely to die. In rich countries, babies get this
help; in poor countries, where close to 90% of all babies are born,
more than half of the cases do not receive the necessary help.
The course uses scenario-based training in pairs. A low-cost, culturally

adapted newborn simulator includes three simple squeeze bulbs
enabling realistic training in addressing the three essential questions:
Is the baby crying? Is the baby breathing normally? Does the baby
have a heartbeat? Thus, the course makes use of two of the main
Figure 2. The Utstein Formula for Survival. recommendations in the landmark To Err is Human report by the
US Institute of Medicine:12 train in teams those who work in teams CONCLUSION

and use simulation whenever possible.
Three lessons that pertain to the global challenge of patient safety
Birth attendants must also be prepared to handle mothers at risk: can be learned from fighting sudden cardiac arrest and maternal/
100,000 mothers are dying on the day of birth. Encouraged by the newborn deaths:
success of the HBB programme, Jhpiego (https://www.jhpiego.
org), an affiliate of Johns Hopkins University, Baltimore, USA, 1. more clearly defined nomenclature and criteria for data report-
and partners have developed with Laerdal the Helping Mothers ing may help increase awareness of the problems and provide a
Survive programme.13 These partners include the International required basis for measuring and reporting patient safety;
Confederation of Midwives, the International Pediatric Association 2. strong local leadership, regular refresher training and quality
and International Federation of Gynaecology and Obstetrics. improvement are essential for programme success;
3. partnerships play a key role in implementing and sustaining
A realistic and affordable simulator has also been developed to patient safety programmes.
facilitate hands-on training in the control of bleeding after birth,
the leading cause of maternal death. It is worn by the instructor like
an apron and includes a blood tank and a uterus that can be made REFERENCES
to contract. Having the facilitator and students in turn act as the
delivering mother also facilitates training in patient communication 1. James, JT. A new, evidence-based estimate of patient harms
and respectful care, two important dimensions of patient safety. The associated with hospital care. J Patient Saf 2013; 9: 122–8.
same educational methodology has been used to develop six more 2. World Health Organization. SDG 3: Ensure Healthy Lives and Promote
educational programmes. Together, these programmes address over Wellbeing For All at All Ages. Available at http://www.who.int/sdg/
80% of the causes of deaths for both mothers and newborns through targets/en/ (accessed 23 October 2018).
the continuum of care, from pregnancy through the first 4 weeks
3. Chan PS. Public Health Burden of In-hospital Cardiac Arrest.
of life. Commissioned by the Institute of Medicine Committee on the
Treatment of Cardiac Arrest: Current Status and Future Directions.
An Utstein meeting in 2015 established 10 steps for best practice 30 June 2015. Available at http://www.nationalacademies.org/
implementation of these programmes14 (Box 2). hmd/~/media/Files/Report%20Files/2015/GWTG.pdf (accessed 23
October 2018).
The SAFE (Safer Anaesthesia From Education) (https://www.aagbi.
4. Gallagher EJ, Lombardi G, Gennis P. Effectiveness of bystander
org/international/safer-anaesthesia-from-education) programme,15 cardiopulmonary resuscitation and survival following out-of-
introduced by the World Federation of Societies of Anaesthesiologists hospital cardiac arrest. J Am Med Assoc 1995; 274: 1922–5.
(WFSA) in collaboration with the Association of Anaesthetists of
Great Britain & Ireland (AAGBI) in 2013, utilises many of the 5. Meaney P, Bobrow B, Mancini M, Christenson J, de Caen AR, Bhanji
same educational principles. This course in obstetric and paediatric F et al. Cardiopulmonary resuscitation quality: improving cardiac
resuscitation outcomes both inside and outside the hospital.
anaesthesia has already reached over 3000 anaesthesia providers in
A consensus statement from the American Heart Association.
30 low-resource countries. Circulation 2013; 128: 417–35.
6. Sasson C, Rogers MAM, Dahl J, Kellerman AL. Predictors of survival
Box 2. The 10 best practice steps for implementation of from out-of-hosptial cardiac arrest: a systematic review and meta-
the HBB and Helping Mothers Survive programmes analysis. Circ Cardiovasc Qual Outcomes 2010; 3: 63–81.
7. Jhpiego. Low Dose, High Frequency: A Learning Approach to Improve
1. Secure Ministry of Health buy-in
Health Workforce Competence, Confidence, and Performance.
2. Form a working group for planning, training and Available at https://hms.jhpiego.org/wp-content/uploads/2016/08/
monitoring LDHF_briefer.pdf (accessed 23 October 2018).
3. Develop a national roll-out plan, for pre-service and in-
service training, in both the public and the private sectors 8. Søreide E, Morrison L, Hillman K, Monsieurs K, Sunde K, Zideman D
4. Provide learning materials and equipment at the time of et al. The formula for survival in resuscitation. Resuscitation 2013; 84:
1487–93.
training
5. Identify and support local leaders and champions 9. Global Resuscitation Alliance. Improving Survival from Out-of-
6. Establish low-dose, high-frequency refresher training hospital Cardiac Arrest: Acting on the Call. Available at http://www.
7. Establish facility-level quality improvement teams globalresuscitationalliance.org/wp-content/pdf/acting_on_the_
8. Monitor performance call.pdf (accessed 23 October 2018).
9. Establish a system for reporting and feedback 10. American Academy of Pediatrics. Helping Babies Breathe. Available
10. Engage healthcare professionals, families and the broader at https://www.aap.org/en-us/advocacy-and-policy/aap-health-
community initiatives/helping-babies-survive/Pages/Helping-Babies-Breathe.
aspx (accessed 23 October 2018).
11. American Academy of Pediatrics. Scientific Articles. Available at 14. Ersdal HL, Singhal N, Msemo G, Ashish KC, Data S, Moyo NT et al.
https://www.aap.org/en-us/advocacy-and-policy/aap-health- Successful implementation of Helping Babies Breathe and Helping
initiatives/helping-babies-survive/Pages/Scientific-Articles.aspx Mothers Survive programs – an Unstein formula for newborn and
(accessed 23 October 2018). maternal survival. PLOS ONE 2017; 12: e0178073.
12. Kohn LT, Corrigan J, Donaldson MS. To Err is Human: Building a Safer 15. Association of Anaesthetists of Great Britain & Ireland. SAFE.
Health System. National Academies Press, Washington, DC; 2000. Available at https://www.aagbi.org/international/safer-anaesthesia-
from-education (accessed 23 October 2018).
13. Jhpiego. Helping Mothers Survive. Available at https://hms.jhpiego.
org/ (accessed 23 October 2018).
Update in
Anaesthesia
A global surgery, obstetrics and anaesthesia

metamorphosis
Isabelle Citron and John G Meara
Correspondence: John.Meara@childrens.harvard.edu
NEGLECTED NO MORE
Just 3 years ago it was inconceivable to imagine the

trajectory that the ‘Global Surgery’ movement would
take. Three years ago, surgery was the ‘neglected
stepchild’ of global health, too fragmented and nebu-
lous to take part in the global health discourse and
existing almost exclusively as missions or site-to-site
partnerships.1 In 2013, The Lancet commissioned an
investigation into the state of surgical care worldwide.
By the end of 2015, this report, a collaboration
including over 110 countries, was published (Lancet
2015; 386: 569–624).2 The Disease Control Priorities,
third edition, had dedicated its entire first volume
to highlighting the cost-effectiveness of surgery.3
The World Health Assembly had passed resolution
68.15 to include emergency and essential surgery and
Figure 1. The next steps for the global surgery
anaesthesia care as a component of Universal Health
movement and their relationships.
Coverage (http://apps.who.int/gb/ebwha/pdf_files/
EB135/B135_3-en.pdf ).4 In addition, the World
Bank – through its president Jim Kim– called for time- cycle of three co-dependent elements: data, NSOAPs
bound targets for global surgery and by April 2016 the and funding (Figure 1).
World Bank had accepted four surgical indicators in its
World Development Indicators (WDIs) dataset (Table
1).5–7 Two years after the launch in 2017, the first DATA-DRIVEN ADVOCACY
National Surgical, Obstetric and Anaesthesia Plans
(NSOAPs) were launched by Zambia and Ethiopia.8,9 Much of the success of the last 3 years can be attributed
By early 2018, a second worldwide wave of WDI to data and, more precisely, data-driven advocacy.
collection had been completed, four countries had The Lancet Commission on Global Surgery and its
Isabelle Citron BmBCh, completed NSOAPs and many more are in progress.10 associated publications generated over 50 original
MPH What is needed next for global surgery, obstetrics and articles and over the last 5 years publications in global
Program in Global Surgery
anaesthesia is not a simple linear process; rather, it is a surgery and anaesthesia have increased fourfold. It
and Social Change
Department of Global
Health and Social Medicine Table 1. World Development Indicators for surgery
Harvard Medical School No. Indicator Definition
Boston, MA
1 SAO density Physician surgery, anaesthesia and obstetric providers per 100,000 population
USA
2 Procedure density Procedures performed in an operating room per 100,000 population

John G Meara MD, DMD,
MBA 3 Impoverishing expenditure Direct out-of-pocket payments for surgical, obstetric and anaesthesia care that
Department of Plastic and drive people below a poverty threshold
Oral Surgery 4 Catastrophic expenditure Direct out-of-pocket payments for surgical, obstetric and anaesthesia care
Boston Children’s Hospital exceeding 10% of total income
Boston, MA
USA SAO, surgery, anaesthesia and obstetrics.
is precisely because of this work on consensus building and data there is a clear definition of how these indicators should be collected,
generation that the World Bank accepted four surgical/anaesthesia surgical indicator collection will be hardwired into each country’s
indicators (see Table 1). By endorsing these surgical metrics as monitoring and evaluation strategy. Going forward, countries that
WDIs, the World Bank creates a framework for countries to collect have completed their NSOAPs will serve as international leaders and
and transparently report progress, as Jim Kim challenged the global experts to mentor and guide other countries through the process.
health community to do in 2014. Once collected, data can be used To facilitate this process, engagement will be required from strong
to advocate for improved access and quality of surgery, obstetric regional advocates such as the WHO Regional Offices, the African
and anaesthesia care by shining a light on the current poor situation Union and the Southern African Development Community. These
of surgery, obstetrics and anaesthesia worldwide, tracking progress regional actors can provide technical support, financing, international
made and creating evidence for policies that work to improve surgical advocacy and data collection.
outcomes. As the world moves towards results-based financing and
impact investing, the goal is clearly to have high-quality data attract
funding to improve surgery, obstetric and anaesthesia care and assess FINANCE THE CHANGE
what does and does not work.
Writing and costing an NSOAP is only the first step; a critical
Despite these benefits, the global surgery community is at risk of mass of the activities need to be funded concurrently or the
losing this great opportunity afforded by the World Bank. To date, co-dependent cogs of the system will not turn. The unreliable drip
although there are data on up to 71 countries for some indicators, of location- and disease-specific funding will not achieve the goals
this has been achieved through externally driven efforts. No countries of strengthening health systems and Universal Health Coverage,
are systematically collecting and reporting the WDIs on a national which covers emergency and essential surgery and obstetric and
scale.11 The most logical solution is to integrate WDI collection into anaesthesia care. Innovative ways of blending diverse sources of
existing international tools and collection mechanisms. Examples funding for NSOAPs will be needed. First, countries will need to
include the integration of surgery-themed questions into some of mobilise domestic funding for NSOAP implementation and for
the world’s largest assessment tools such as the Demographic Health healthcare more broadly, as, for example, was pledged by the African
Survey or the Harmonized Health Facilities Assessment, developed Union in the Abuja Declaration.17 Estimates have shown that 85%
with the World Health Organization (WHO) and to be launched of funding for Universal Health Coverage can be met with domestic
in the next year.12,13 resources.18 However, this financing will need to be augmented by
other sources, especially in the initial stages.19 Much of the financing
required for NSOAP implementation is also needed for the majority
NSOAPS PREPARE THE PATH of other health interventions, including reliable supply chains, water,
electricity, blood banks and oxygen to name but a few. By ensuring
‘If you don’t know where you are going, any road will get you there’.14 that NSOAPs are written to complement, coordinate and not
For decades, national, regional and global health planning ignored duplicate other funded policies and initiatives, the additional price
surgical care delivery. If global surgery was a ‘neglected stepchild’, tag associated with the NSOAP will co-fund other programme and
then anaesthesia was its ‘invisible friend’. The solution to this lack development sectors. Finally, as well as looking to external funding,
of data collection involves NSOAPs, uniting all three communities, the coordinated expansion of surgery, anaesthesia and obstetrics
that are fully integrated into national, regional and global health creates a unique opportunity to create shared value that will expand
strategies. Regular reporting of indicators is possible and in fact the markets and create health equity concurrently.20 By creating systems
norm for many health programmes. Take, for example, maternal and that consistently deliver surgery, anaesthesia and obstetrics, NSOAPs
child health, for which 90% of countries report their annual maternal create a consistent market for surgical devices and supplies and
mortality rates.15 Through the establishment of NSOAPs, a country therefore a strong business case for industry investment.
lays out a comprehensive strategy for improvement of surgery,
anaesthesia and obstetric care across all six building blocks of the No matter what the mechanism, all funders require data. The
health system: workforce, infrastructure, service delivery, information collection of data, notably the WDIs, will create the data that
management, finance and governance.16 The creation of the plan investors and donors require in order to make a case for investment,
itself mobilises the surgery, anaesthesia and obstetric community in calculate the proposed return on investment and measure the real
a country, brings a new prioritisation of surgery, obstetric and anaes- impact that investment is having on population outcomes.
thesia care and incentivises the collection of the indicators to serve
as a baseline against which to measure progress and direct activities.
Perhaps most importantly, the NSOAP lays out the mechanisms, data CONCLUSION
flows and governance systems responsible for collecting, collating and
escalating data. In isolation, the World Bank request to collect the Data create evidence to show that improvement is needed.
surgical WDIs, as has been seen, is an insufficient incentive. However, NSOAPs build the roadmap for the process. Funding allows for
if these form part of a more comprehensive effort to elevate surgery, the metamorphosis from plan to implementation and, coming full
anaesthesia and obstetric care cohesively on the national agenda, and circle, data prove the impact of that investment and monitor progress
development – the Zambian experience. Bull Am Coll Surg 2017;

towards Universal Health Coverage and realisation of the Sustainable
102: 28–35.
Development Goals. None of this will be possible unless all of the
communities involved – anaesthesia, surgery and obstetrics – work in 10. Albutt K, Citron I, Sonderman K, Nthele M, Bekele A, Maongezi S et
partnership, realising that the ‘elephant in the room’ is social change al. National Surgical Obstetric and Anaesthesia Planning: Process and
and health equity. Consensus Recommendations. Harvard Medical School Center for
Global Health Delivery–Dubai, Dubai, United Arab Emirates; 2018.
11. The Lancet Commission on Global Surgery. Data for the Sustainable
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Surgical Care and Anaesthesia as a Component of Universal Health
Coverage. Report by the Secretariat. Provisional Agenda Item 5.1. 16 14. Carroll L, 1832–1898. L. Alice’s Adventures in Wonderland, 2nd edn.
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62–77.
national surgical, obstetric, and anesthesia strategic plan
Update in
Anaesthesia

Surgical capacity indicators in 2018 and beyond
Thomas G Weiser
Correspondence: thomas.weiser@ed.ac.uk
In the early part of the 20th century, Ernest Codman of of the burden could be averted with a basic package
the Massachusetts General Hospital described his ‘end of surgery.
results system’ that sought to identify poor outcomes
and learn from them. It was the first formal ‘morbidity At the same time as Debas was engaged in this
and mortality’ programme and for his efforts he was work, the World Health Organization (WHO) was
forced from the staff and out of his position. Modern launching its Safe Surgery Saves Lives programme.5 As
forms of measurement have taken hold despite this part of this effort, surgical surveillance was identified
early resistance, but realisation of the size and scale as a priority. The programme developed a working
of this global undertaking is only just beginning. As group to focus on surgical metrics, the results of which
we move to an era of Sustainable Development Goals identified six specific indicators that might help inform
(SDGs), Universal Health Coverage (UHC) and surgical capacity, provision and outcomes: number of
the integration of surgical services as an ‘indivisible, operating theatres, number of accredited surgeons,
indispensable part of health care’, the importance of number of accredited anaesthesia professionals,
surgical surveillance has taken on increased urgency.1 number of operations, day of surgery death ratio
The global surgical, anaesthetic and surgical nursing and postoperative in-hospital death ratio.6 These
community will not know the effect of care we provide were based on four primary guiding principles: that
and the advocacy we are engaged in if we neglect to the proposed measures be simple, widely applicable
attend to an understanding of capacity and outcomes and relevant to public health imperatives and that
of that care. unintended negative consequences of measurement
were minimised.
Surgical surveillance should aim to understand some
essential components of care: the capacity to deliver Early work from the WHO described the volume
surgical services, access to those services, the clinical of surgery occurring globally. In 2004, 234 million
needs of the population, the biological and functional operations were estimated to have taken place; in 2012,
outcomes of care and, in a nod to the SDGs and UHC, that number rose to 313 million, with massive growth
the economic outcomes of care. Although frequently noted in the poorest countries.7,8 This was followed
neglected, surveillance should also seek to understand by estimates of the distribution of operating rooms
the quality of care and compliance with best practices worldwide, and the resourcing of such infrastructure
and current standards of care. as a crude measure of safe capacity.9 Almost nothing
was known about the provider landscape or mortality
In 2006, Debas and colleagues outlined the impor- following surgery.
tance of surgical care and its cost-effectiveness in the
second edition of Disease Control Priorities.2 This was With the recent Lancet Commission on Global Sur-
a remarkable body of work because, for the first time, gery, an updated set of indicators has been identified; it
an effort had been made to make a public health and includes measures of timely access, volume of surgical
economic argument for the value of surgical care in delivery, human resources for surgical and anaesthetic
treating disease. Using disability-adjusted life-years care, postoperative mortality and impoverishing and
(DALYs), an econometric measure of the value of catastrophic expenditure.1 However, 3 years following
healthy years of life, the authors noted that there were the publication of the Commission report, the global
high-value services such as caesarean delivery, hernia surgical and anaesthesia community is still struggling
repair, treatment of club foot and other congenital to deliver information on these basic indicators. A
Thomas G Weiser MD, MPH,
defects, and cataracts. DALYs resulting from diseases recent assessment by Commission members identified
FACS
amenable to surgical correction or treatment were enduring gaps in information, with few countries Visiting Professor of Surgery
estimated to account for 12% of all disease burden. By able to report accurately on surgical access, volume University of Edinburgh
the time the third edition of Disease Control Priorities of surgery or postoperative mortality.10 Definitions and Royal Infirmary of
was released, surgical burden was more accurately were variable, limiting their utility for comparative Edinburgh
noted to be responsible for at least 18% of all disease purposes. There was almost no information on Edinburgh
burden, and perhaps as much as 30%;3,4 indeed, 6% impoverishment as a result of paying for surgical care. UK
3. Debas HT, Donkor P, Gawande A, Jamison DT, Kruk ME, Mock CN

Of the indicators, only the surgical and anaesthetic workforce density
(editors). Essential Surgery. Disease Control Priorities. Volume 1, 3rd
indicator was fairly complete, as recent work has demonstrated.11,12 edn. World Bank, Washington, DC; 2015.
Although enthusiasm is high amongst the global surgical and 4. Bickler SN, Weiser TG, Kassebaum N, Higashi H, Chang DC,
anaesthetic community, many threats remain. First, there is a lack Barendregt JJ et al. Global burden of surgical conditions. In Debas
of leadership at the highest level, particularly among convening and HT, Donkor P, Gawande A, Jamison DT, Kruk ME, Mock CN (editors).
Essential Surgery. Disease Control Priorities. Volume 1, 3rd edn. World
normalising bodies such as the WHO or the World Bank. The World
Bank, Washington, DC; 2015.
Bank has expressed interest in the work and has provided a venue for
distributing information that has been collected to date, but has not 5. World Health Organization. WHO Guidelines for Safe Surgery. WHO,
provided further structure or ongoing funding to enable or encourage Geneva; 2009.
sustainable data collection. This has led to a lack of collaboration and 6. Weiser TG, Makary MA, Haynes AB, Dziekan G, Berry WR, Gawande
coordination aside from individual efforts and relationships between AA. Standardised metrics for global surgical surveillance. Lancet
like-minded individuals working to fill the knowledge gap. A lack of 2009; 374: 1113–17.
funding severely impedes the work, as data collection takes effort,
7. Weiser TG, Regenbogen SE, Thompson KD, Haynes AB, Lipsitz SR,
time and human resources. Few inroads have been made to engage Berry WR, Gawande AA. An estimation of the global volume of
the public to support, indeed insist on, such efforts. Finally, the surgery: a modelling strategy based on available data. Lancet 2008;
potential perverse negative effects of data collection and reporting 372: 139–44.
cannot be underestimated or overstated. Countries that have no
incentives to understand what is happening or report truthfully on 8. Weiser TG, Haynes AB, Molina G, Lipsitz SR, Esquivel MM, Uribe-Leitz
T et al. Size and distribution of the global volume of surgery in 2012.
surgical services likewise have little interest in or appetite for data
Bull World Health Organ 2016; 94: 201–9F.
collection that will undoubtedly tap scant resources with marginal
benefit and almost no clear direction for improvement. 9. Funk LM, Weiser TG, Berry WR, Lipsitz SR, Merry AF, Enright AC et al.
Global operating theatre distribution and pulse oximetry supply: an
Given recent advances in open source data, crowdsourcing of estimation from reported data. Lancet 2010; 376: 1055–61.
information and connectivity, and enthusiasm by medical students, 10. Holmer H, Bekele A, Hagander L, Harrison EM, Kamali P, Ng-Kamstra
policymakers, economists and the surgical and anaesthetic JS et al. Evaluating the collection, comparability and findings of
community more broadly, a number of opportunities have arisen. six global surgery indicators [published online ahead of print 20
The first is the potential for real-time, user-generated, interactive December 2018]. BJS 2018. https://doi.org/10.1002/bjs.11061
data that can allow for end-user interfaces and exploration.13,14 The 11. Holmer H, Lantz A, Kunjumen T, Finlayson F, Hoyler M, Siyam A
second is the use of geospatial data, many of which are open access, et al. Global distribution of surgeons, anaesthesiologists, and
to explore resources, opportunities and barriers to care.15,16 Although obstetricians. Lancet Glob Health 2015; 3(Suppl. 2): S9–11.
the challenges remain substantial, the ability of our community
12. Kempthorne P, Morriss WW, Mellin-Olsen J, Gore-Booth J. The
to engage public health professionals, policymakers, economists,
WFSA Global Anesthesia Workforce Survey. Anesth Analg 2017; 125:
ministries, leaders at the highest level and the general public will 981–90.
ensure that surgical and anaesthesia care is no longer ignored as the
‘neglected stepchild of public health’.17 13. GlobalSurg Collaborative. Surgical site infection after
gastrointestinal surgery in high-income, middle-income, and low-
income countries: a prospective, international, multicentre cohort
study. Lancet Infect Dis 2018; 18: 516–25.
REFERENCES
14. GlobalSurg Collaborative. GlobalSurg. Available at http://www.
1. Meara JG, Leather AJ, Hagander L, Alkire BC, Alonso N, Ameh EA globalsurg.org (accessed 1 May 2018).
et al. Global Surgery 2030: evidence and solutions for achieving
15. Stewart BT, Tansley G, Gyedu A, Ofosu A, Donkor P, Appiah-Denkyira
health, welfare, and economic development. Lancet 2015; 386:
et al. Mapping population-level spatial access to essential surgical
569–624.
care in Ghana using availability of bellwether procedures. JAMA
2. Debas HT, Gosselin R, McCord C, Thind A. Surgery. In Jamison DT, Surg 2016; 151: e161239.
Breman JG, Measham AR, Alleyne G, Claeson M, Evans DB et al.
16. Esquivel MM, Uribe-Leitz T, Makasa E, Lishimpi K, Mwaba P, Bowman
(editors). Disease Control Priorities in Developing Countries, 2nd edn.
K, Weiser TG. Mapping disparities in access to safe, timely, and
International Bank for Reconstruction and Development/World
essential surgical care in Zambia. JAMA Surg 2016; 151: 1064–9.
Bank, Washington, DC; 2006.
17. Farmer PE, Kim JY. Surgery and global health: a view from beyond
the OR. World J Surg 2008; 32: 533–6.
Update in
Anaesthesia

The SAFE-T Summit 2018: implications for the
WFSA Safety and Quality of Practice Committee
Fauzia Anis Khan
Correspondence: fauzia.khan@aku.edu
The inaugural SAFE-T (Safe Anaesthesia for Every- need to standardise the definitions used. This requires
body – Today) Summit took place in London at the collaboration and interaction between the WFSA and
Royal Society of Medicine on 13 April 2018. There other stakeholders.
were presentations by eminent speakers on topics of
safe anaesthesia and surgery. Central to the discussion The SQP Committee of the WFSA is also designing
was the patient safety agenda following the Lancet a Morbidity and Mortality Tool Kit for LMICs. This
Commission on Global Surgery 2015 initiative. The toolkit will be aimed at anaesthesiologists working in
World Health Organization (WHO) defines patient secondary and non-teaching institutions where there
safety as the absence of harm to a patient during the is a lack of systems to analyse such events and bring
process of healthcare and reduction of risk of unneces- improvements in patient safety. A needs assessment
sary harm associated with healthcare to an acceptable survey is currently being conducted in five LMICs in
minimum.1 Although the Lancet Commission has this respect. A future goal for the SQP Committee
given directions for National Surgical, Obstetric and may be to have a web link where anonymous reports
Anaesthesia Plans (NSOAPs), defined bellwether of such events can be collected from LMICs to provide
procedures and provided core indicators, major information on the nature and magnitude of the
challenges still exist, especially from the perspective problem. At present, publications on major morbidity
of low- and middle-income countries (LMICs). Safe and mortality are lacking from LMICs.
anaesthesia and surgery is still a distant dream for
many.2 This commentary will focus on some of the key
messages with implications for the World Federation Specialist workforce density and work
of Societies of Anaesthesiologists (WFSA) Safety and assessment tool
Quality of Practice (SQP) Committee. The function Information on infrastructure is one of the building
of the WFSA SQP Committee is to provide the blocks required for NSOAPs. This information is
highest standards of safety and quality in anaesthesia essential to collect data on core indicators. The WFSA’s
internationally. contribution to this has been the World Anaesthesiol-
ogy Workforce Map. This live interactive map provides
information on the physician-based anaesthesia
CORE INDICATORS FOR SAFETY workforce per 100,000 population and is accessible
on the WFSA website.5 The map is also accompanied
Meara and colleagues 3 have recommended five by an article on the global anaesthesia workforce.6
indicators for monitoring universal access to An Anaesthesia Facility Assessment Tool (AFAT),
healthcare. These are access to timely essential surgery, which is currently undergoing pilot assessment, was
specialist surgical workforce density, surgical volume, also introduced by WFSA secretary Professor Adrian
perioperative mortality rate (POMR) and protection Gelb. The purpose of this tool is to create a dataset that
against impoverishing expenditure. can be modified at a country level to help maintain Fauzia Anis Khan MBBS,
standards for the safe practice of anaesthesia. FRCA
Chair
Perioperative mortality Safety and Quality of
Perioperative mortality has declined over the last few ANAESTHETIC EQUIPMENT Practice Committee
World Federation
decades but it is still significantly higher in LMICs.4
of Societies of
One of the problems seen with the collection of data An Ad-Hoc Anaesthetic Equipment Committee was Anaesthesiologists
on this indicator is lack of standard definitions, which formed by the WFSA in 2017, bringing together and
have ranged from in-hospital deaths to deaths 30 days global expertise in anaesthetic equipment and varied Professor of Anaesthesiology
postoperatively. As mentioned by presenters at the operating requirements to advance patient safety Aga Khan University
summit, at present no data have been provided for and access to safe anaesthesia. The Committee is Karachi
this indicator from some countries. There is therefore a currently being chaired by Dr Philippe Mavoungou. Pakistan
At the SAFE-T summit he highlighted the issues of affordability and College of Obstetricians and Gynaecologists, Anesthesia Patient
quality of equipment in LMICs. Some of the issues discussed related Safety Foundation, King’s Centre for Global Health and Health
to poorly organised tenders and on-site maintenance, healthcare Partnerships and International Federation of Perioperative Nurses,
budgets not being a priority, short-term guarantees and no policy were represented at this first WFSA SAFE-T summit. Synergistic
for disposables. He advocated the reliability of energy sources such partnerships between these organisations will benefit patient safety.
as solar energy with use of back-up batteries, the reliability of oxygen
sources, modular and non-modular compact monitoring, robust One such example of collaboration and strategic partnership is the
syringe pumps, portable ultrasound systems, cheap and easily reusable recently published combined WHO–WFSA International Standards
devices, local logistic organisation and communication for remote for a Safe Practice of Anaesthesia.9
expertise, and long-term warrantees.
The SQP Committee is also working towards collecting information
Pulse oximetry is an example of how concerns about patient safety from all major organisations working on patient safety and to follow
were married to technology, resulting in the development of robust up on collaboration between the WFSA with these organisations for
inexpensive equipment for LMIC settings (https://www.lifebox.org). the common goal of patient safety.
There is a further need to strengthen the WFSA’s relationship with
industry and to impress on manufacturers the need for such robust,
inexpensive and reliable equipment for millions of patients. REFERENCES
The WHO has also published the WHO Compendium of Innovative 1. World Health Organization. Patient Safety. Available at http://www.
Health Technologies for Low-Resource Settings.7 Another piece of equip- who.int/patientsafety/en/ (accessed 11 May 2018).
ment described and of interest to anaesthesiologists is an anaesthesia 2. Divatia JV. Safe anaesthesia for all Indians. A distant dream? Indian J
machine with a low-pressure pneumatic ventilator. Anaesth 2017; 61: 531–3.
3. Meara JG, Leather AJ, Hagander L, Alkire BC, Alonso N, Ameh EA et
The SQP Committee works in close collaboration with the Equip-
al. Global Surgery 2030: evidence and solutions for achieving health
ment Committee. Two members of the SQP Committee are also welfare and economic development. Lancet 2015; 386: 569–624.
members of the Equipment Committee.
4. Bainbridge D, Martin J, Arango M, Cheng D; Evidence-based
Peri-operative Clinical Outcomes Research (EPiCOR) Group.
MEDICATION SAFETY Perioperative and anesthetic related mortality in developed and
developing countries: a systematic review and meta-analysis.
Lancet 2012; 380: 1075–81.
Shortages of anaesthetic medications are an issue for LMICs and have
expanded to become a worldwide concern. Some of the European 5. World Federation of Societies of Anaesthesiologists. World
Board of Anaesthesiology recommendations were presented by Dr Anaesthesiology Workforce. Available at http://www.wfsahq.org/
David Whitaker at the SAFE-T summit. These simple and universally workforce-map (accessed 12 May 2018).
applicable measures relate to drug preparation and administration, 6. Kempthorne P, Morris WW, Mellin-Olsen J, Gore-Booth J. The WFSA
proper drug labelling, minimising manipulation of medication in Workforce Survey. Anesth Analg 2017; 125: 981–90.
clinical areas and preventing incorrect medication administration
7. World Health Organization. WHO Compendium of Innovative
scenarios.8 The European Board of Anaesthesiology recommendations Health Technologies for Low-resource Settings, 2016–2017. Geneva:
can be endorsed for universal application worldwide. World Health Organization; 2018. Available at: http://www.who.
int/medical_devices/publications/compendium_2016_2017/en/
Members of the SQP Committee are also currently involved in (accessed 12 May 2018).
another WFSA project on anaesthesia medication safety guidelines.
8. Whitaker D, Brattebø G, Trenkler S, Vanags I, Petrini F, Aykac Z et al.
The European Board of Anaesthesiology recommendations for safe
medication practice: first update. Eur J Anaesthesiol 2017; 34: 4–7.
COLLABORATIONS, COORDINATION AND INTERACTIONS
BETWEEN SAFETY STAKEHOLDERS 9. Gelb AW, Morriss WW, Johnson W, Merry AF, Abayadeera A, Belil
N et al. World Health Organization–World Federation of Societies
Patient safety is a universal agenda and is a priority for many of Anaesthesiologists. (WHO-WFSA) International Standards for a
Safe Practice of Anaesthesia [published online ahead of print 7 May
international organisations. Several of these organisations, that is,
2018]. Can J Anesth 2018. doi: 10.1007/s12630-018-1111-5.
the WFSA, WHO, World Bank, Royal College of Surgeons, Royal
Update in
Anaesthesia

Progress and challenges in global surgical and
anaesthesia care and safety: proceedings of the
SAFE-T Summit 2018
Kerry A Vaughan and Walter D Johnson
Correspondence: johnsonw@who.int
Surgical and anaesthesia care are undeniably critical to Safety is intimately linked to strengthening SAO care
strengthening healthcare systems worldwide and they across numerous linked domains, from anaesthesia
are steadily gaining support from the World Health risks, surgical disease burden, morbidity and mortality
Organization (WHO). Former Director-General to outcomes, SAO workforce and even pain manage-
Halfdan Mahler remarked in his address to the World ment. Strict adherence to global safety standards for
Congress of the International College of Surgeons anaesthesia and surgery is critical, as surgical disease
in 1980 that surgical (and anaesthetic and obstetric) accounts for 30% of the global disease burden.5
resources should be scrutinised according to social Unsafe perioperative practices in anaesthesia are
justice principles.1 His vision of social justice in the linked not only to surgical outcomes, but also to
realm of surgery and anaesthesia remained in the maternal mortality worldwide.7 Risks associated with
background of global public health, but began to anaesthesia are significantly disparate across countries
gain momentum in the 21st century. World Health and settings, with the vast majority of risk found in
Assembly (WHA; the decision-making body of low- and middle-income countries (LMICs). The
WHO) resolution 68.15 on strengthening emergency risk of perioperative mortality from anaesthesia in
and essential surgical care and anaesthesia as a LMICs remains high at around 5–10%; this compares
component of Universal Health Coverage (UHC), with 0.0005% (1 in 200,000 cases) in high-income
the Lancet Commission on Global Surgery (LCoGS)2 countries as a result of improvements in anaesthesia
and Essential Surgery. Disease Control Priorities,3 which safety and practice.8 Inadequate anaesthesia workforce
lay out the health economic case for surgical care and density, training and support also hinder operative care
anaesthesia, were all launched in 2015. They serve as in LMICs. Whereas in high-income countries such
key rallying points for advancing surgical, anaesthesia as the UK or USA there is one trained anaesthesia
and obstetric (SAO) care. provider per 4000–5000 persons, in LMICs there are
much lower ratios, such as one provider per 3.6 million
The scale of the global disease burden of surgical people in Afghanistan.8–11 Safety in pain management Kerry A Vaughan MD
conditions was underestimated prior to the LCoGS, and administration of pain medications is also critical Program in Global Surgery
which demonstrated that 5 billion people were from an anaesthesia perspective, for acute and chronic and Social Change
lacking timely access to safe and affordable surgery pain in all populations. Harvard Medical School
and anaesthesia.4 This disparity is aggravated by a Boston, MA
severe lack of funding: whereas infectious diseases Safety is inextricably linked to continued global USA
(HIV/AIDS, tuberculosis and malaria) have a US$5 healthcare improvements, as well as strengthening and
Department of
billion annual global budget to address 3 million surgical and anaesthesia care. Good health and
Neurosurgery and Penn
deaths annually, avertable surgical deaths total 16.9 well-being is one of the pillars of the United Nations Global Surgery Group
million annually and have a US$0 global budget.5 (UN) Sustainable Development Goals also launched University of Pennsylvania
Furthermore, avertable surgical deaths are expected in 2015 (i.e. SDG3), the successors to the UN Mil- Philadelphia, PA
to increase significantly over the next few years lennium Development Goals.12 At least nine of the 13 USA
with the projected rise in global deaths due to non- SDG3 targets are directly or indirectly addressed by
communicable diseases (NCDs); demand for surgical improving anaesthesia and surgical safety standards
Walter D Johnson MD, MPH,
care and anaesthesia increases in parallel with increases and practices worldwide, including SDG3.8 on
MBA
in NCDs. Cancer, ischaemic heart disease and UHC and a direct link to WHA resolution 68.15.13 Lead
cerebrovascular disease are the three most common Furthermore, SAO care is also linked to many of Emergency and Essential
killers globally and will likely remain so in the coming the other 17 SDGs. These strengthening efforts are Surgical Care Programme
years.6 Deaths from road traffic accidents, among other addressed through all levels of healthcare, from access World Health Organization
injuries, are also projected to increase, of which many to essential medicines to health systems integration. Geneva
may be averted by surgery and anaesthesia. Stronger SAO care cannot be accomplished without Switzerland
simultaneously addressing safety concerns and disparity via advocacy, NSOAP creation is led by the Ministry of Health, with support
resource development, service access and delivery, data collection from local and international stakeholders and technical assistance
and analysis, and workforce training and competence. Baseline data from the WHO and international partners. The Republic of Zambia
collection on surgical and anaesthesia care is part of the core of WHA has completed its strategic plan and has begun country-wide
resolution 68.15, which directly mentions safety as a focus of these implementation, as have Senegal and Tanzania. Ethiopia has also
efforts. Although this initial resolution called for a one-time report developed a pathway for scaling up SAO care through its SaLTS
on implementation progress in 2017, WHA Decision Point 70.22 plan, currently undergoing implementation.21 Smaller scale efforts to
was adopted in 2017, mandating continued biennial progress reports improve safety in these domains have been launched in Madagascar,
on implementation from the WHO Secretariat.14 Uganda, Vietnam, Brazil and India, among others.
Progress in SAO care advocacy has occurred, including on the The NSOAP process has garnered international attention, with
global stage through the WHO. The six major indicators on safety, requests from many Member States, leading to an NSOAP workshop
accessibility and economic burden of surgical and anaesthesia in March 2018 that was developed by the WHO and the Program
management of disease published by the LCoGS were successfully in Global Surgery and Social Change (PGSSC) from Harvard
incorporated into the 2015 WHO 100 Core Health Indicators:15 University. As multiple Member States begin work on this process,
postoperative mortality, surgical volume, 2-hour access to services, collaboration across multiple Ministries of Health and a consortium
SAO workforce density and risk of impoverishing and catastrophic of partners will be important in improving national and global SAO
health expenditures related to surgical and anaesthesia care. All but care.
one of these, catastrophic health expenditure, was preserved in the
2018 WHO Indicators.16 The planning phase should include special consideration of the safety
of vulnerable populations, including obstetric and paediatric patients
Recent safety-focused SAO efforts from the WHO include safety and those who are injured. Children are particularly susceptible
checklists, the creation of collaborative safety standards, international to unsafe practices, as the same challenges facing the surgical and
safe anaesthesia guidelines, surgical site infection guidelines and anaesthesia care of the adult patient are even more pronounced, such
promoting safe essential medicines and their use. Checklists for as fewer paediatric-trained providers, as well as there being additional
trauma care, surgical safety and safe childbirth have been developed paediatric-specific challenges. Children under 15 years make up on
by the WHO and globally disseminated to help all health systems average 43% of the total population in sub-Saharan Africa (with this
implement and provide safer services, thus ideally improving SAO figure being as high as 50% in some countries) and 26% of the total
outcomes.17–19 The WHO and the World Federation of Societies of world population, which places additional stress on already limited
Anaesthesiologists (WFSA) published International Standards for a paediatric surgical and anaesthesia resources in LMICs.22 Adult
Safe Practice of Anaesthesia in May 2018 as minimum safety standards surgeons may choose to not operate on these children because of
for all anaesthesia providers and settings.20 Multiple campaigns on safe the higher risks, unfamiliarity with unique pathologies and children’s
administration practices for essential medicines, such as ketamine, inability to pay for services. Strategic alliances, such as the Global
narcotics and antibiotics, have been launched, in part with the WHO, Initiative for Children’s Surgery, include all paediatric surgical and
to promote the safe and judicious usage of these agents without anaesthesia services to support care for this vulnerable population.
causing patient harm. The current WHO Patient Safety Campaign
is on medication safety. Safety must also be considered for surgical Patients with traumatic injuries represent another vulnerable popula-
and anaesthesia providers, that is, safety from infectious diseases such tion and highlight safety disparities, both in healthcare as well as in
as Ebola, as well as harm from local natural and man-made events. prevention. These are often treatable and remain most prevalent and
most severe in LMICs. Of the disease burden that could be averted
Five academic and medical institutions around the world have by surgical and anaesthesia system scaling up at first-level LMIC
become official WHO collaborating centres for surgery and hospitals, 68% would be related to injuries.23 Safety through injury
anaesthesia. Centres from all WHO regions have joined efforts to prevention is also critical, as only 7% of the world’s population has
strengthen surgical and anaesthesia care, with the goal of creating not adequate legal protection from the five major risk factors for road
only bidirectional relationships with the WHO, but also international traffic accidents: speed, drink driving, helmets, seatbelts and child
collaborative networks. Resolution 68.15 has been advanced at the restraints.24
country level by the WHO and collaborating centre partnerships with
Ministries of Health in the form of National Surgical, Obstetric and The incoming leadership at the WHO has developed the 13th
Anaesthesia Plans (NSOAPs). Such plans are intended to improve General Programme of Work, a 5-year strategic plan outlining WHO
national SAO care and safety by an iterative process of planning, a priorities.25 Its main focus includes promoting health, keeping the
national surgical forum for feedback, and implementation, with the world safe and serving the vulnerable. These broad priorities are
NSOAP fully embedded within the national health policy, strategy supported by specific ‘triple billion goals’ to improve access for an
or plan. additional 1 billion people to UHC, better protection from health
12. United Nations General Assembly. Resolution 70/1. Transforming our

emergencies and better health. Scaling up safe surgical and anaesthesia
World: The 2030 Agenda for Sustainable Development. United Nations,
care are critical to achieving these priorities and goals, as healthcare New York; 2015.
safety affects everyone’s health.
13. World Health Organization, Sixty-eighth World Health Assembly.
WHA68.15. Strengthening Emergency and Essential Surgical Care and
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Geneva; 2015.
1. Mahler H. Address to the XXII Biennial World Congress of the 14. World Health Organization, Seventieth World Health Assembly.
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et al. Global Surgery 2030: evidence and solutions for achieving
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(editors). Essential Surgery. Disease Control Priorities. Volume 1, 3rd Available at http://www.who.int/emergencycare/publications/
edn. World Bank, Washington, DC; 2015. trauma-care-checklist.pdf (accessed 10 May 2018).
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Navaratnarajah R et al. Anaesthesia-related maternal mortality in 21. World Health Organization, Program in Global Surgery and
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Anaesthesia Plans. WHO, Geneva; 2017.
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C, Atcheson CLH (editors). The Role of Anesthesiology in Global 2018).
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Update in
Anaesthesia
Transforming surgical and anaesthesia capacity

and safety – the path to success: the European
Society of Anaesthesiologists’ perspective
Stefan De Hert
Correspondence: stefan.dehert@esahq.org
Following the production of international standards Interestingly, monitoring standards seemed to have
for safe practice of anaesthesia by the World Federation been very well implemented in the majority of
of Societies of Anaesthesiologists (WFSA) in 1992, countries; however, the World Health Organization
which were revised in 2008 and 2010,1 the European (WHO) guidelines and organisation of patient safety
Society of Anaesthesiologists (ESA) and European teaching and training facilities were significantly less
Board of Anaesthesiology (EBA) launched the well implemented in the various national practices.
Helsinki Declaration on Patient Safety in Anaes- These data indicated that there is still a huge amount
thesiology (https://www.esahq.org/patient-safety/ of work to be done to get all different aspects of
patient-safety/helsinki-declaration/full-declaration).2 perioperative patient safety implemented in our daily
This declaration emphasises the role of anaesthesiology clinical practice.3–5
in promoting safe perioperative care and underscores
the fact that perioperative patient safety is a core topic What are the main challenges for Europe in organising
of interest for the society. The ESA promotes this by similar efficient and effective high-level standards for
providing access via the website to the Patient Safety patient safety in all of its member countries? Although
Starter Kit (https://www.esahq.org/patient-safety/ many problems will be similar to those in other places
patient-safety/patient-safety-starter-kit). The ESA worldwide, Europe faces a major challenge because of
Patient Safety and Quality Committee is very active its specific political composition of a conglomerate
in organising European Patient Safety and Quality of individual nations with specific languages and
Courses and Masterclasses and in promoting the healthcare system organisation. Indeed, the European
Patient Safety Expert Network. The interest of Union consists of 28 member countries in which 24
patient safety extends far beyond Europe as can be different languages are spoken. As a mirror of this, the
observed on the Helsinki Declaration map (https:// ESA, with its approximately 9000 active members and
www.esahq.org/~/media/ESA/Files/Downloads/ more than 35,000 associate members, encompasses
Resources-PatientSafety-MapHelsinkiDeclaration/ more than 40 different nationalities.
Resources-PatientSafety-Map%20Helsinki%20
Declaration.ashx). Many countries all over the world A 2012 report from the European Commission inves-
have signed this Declaration. For instance, Australia tigated the topic of Europeans and their languages
and New Zealand have supported the Declaration (http://ec.europa.eu/commfrontoffice/publicopinion/
since 2010; Canada and the USA since 2010 and archives/ebs/ebs_386_en.pdf ). Some interesting
2014, respectively; Latin America since 2012; and observations were made. First, in accordance with the
China and Japan since 2015. Many other countries population, the most widely spoken mother tongue
have followed. In other words, there is a worldwide seems to be German (16%), followed by Italian and
major interest in the problem of perioperative patient English (13% each), French (12%) and then Spanish
safety. and Polish (8% each). Interestingly, at a national level
English is the most widely spoken foreign language
However, signing a declaration is one thing; another in 19 of the 25 Member States where it is not the
Stefan De Hert MD, PhD issue is to really implement the principles of that official language. The five most widely spoken foreign
President
declaration in our daily clinical practice. In 2012, the languages are English (38%), French (12%), German
European Society of
Anaesthesiologists
ESA launched a survey among its council members (11%), Spanish (7%) and Russian (5%). It is to be
and and national anaesthesiology societies interrogating underscored that just over half of Europeans (54%) are
Professor of Anaesthesiology how three main aspects of the Helsinki Declaration able to hold a conversation in at least one additional
Ghent University Hospital were implemented in their national daily practices. language, one-quarter (25%) are able to speak at least
Ghent The response rate was impressive, with more than two additional languages and only one in 10 (10%) are
Belgium 90% of the member countries providing feedback. conversant in at least three languages. It is obvious that
the issue of diversity of language creates a huge challenge in terms of The Helsinki Declaration calls for routine measurement of safety
implementing common European initiatives such as patient safety in all anaesthesia departments. Because no generally accepted and
directives in individual national daily practices. sufficiently evidence-based set of anaesthesia quality/safety indicators
exists,10,11 the ESA Patient Safety and Quality Committee has started
Other problems are related to the differences in financial and the ESA Quality Indicators Project (EQUIP). EQUIP is surveying
human resources in the various European countries and the different national anaesthesia societies to establish an overview of anaesthesia
organisation of the healthcare systems, all of which can influence quality indices used in Europe. This approach is complementing
standard of care. In 2012, the European Surgical Outcomes Study formal research about quality indices by describing commonly and
(EuSOS) group published the results of 7-day mortality after successfully used indices, the suitability of quality indices in routine
surgery in Europe.6 Astonishingly, a mean of 4% 7-day mortality practice of different countries in Europe and common obstacles to
was observed, ranging from 1.2% to as much as 21.5% depending and requirements needed for implementation of quality indices.
on the country. This excess mortality seemed to be related to what
the authors referred to as ‘failure to rescue’. In other words, patients A major challenge is consistent implementation of the Helsinki
died because of lack of identification and prompt treatment of adverse Declaration principles such as patient safety programmes across
perioperative events. This failure to rescue seemed to be related to a Europe. To meet this challenge, the ESA has started the Helsinki
lack of adequate resources, suggesting a direct relationship between Declaration Follow Up (HD-FU) Project. This research project is
improved patient outcome, patient safety and available human and designed to better understand the local and regional/national differ-
financial resources. ences in anaesthesia departments that help or hinder implementation
of the Helsinki Declaration requirements. Based on the results,
This problem deserves further attention. One of the basic principles strategies will be developed that improve implementation and
of the European Union is free movement of students, patients and adaption nationwide.
doctors across borders. If one takes a closer look at the monthly
salaries for board-certified anaesthesiologists in Europe, a greater Patient safety is a concern of every person and society dealing with
than 10-fold difference can be observed between low-income and patient care. The ESA is committed to close cooperation with all
high-income countries.7 The result is a brain drain of board-certified anaesthesiology and other specialist societies involved in perioperative
anaesthesiologists from low-income (mainly Eastern and Southern patient care. A good example of such cooperation is the International
Europe) to high-income countries (North-western Europe).8 The Forum on Perioperative Safety and Quality. This is a meeting jointly
consequence is a lack of trained and skilled professionals in those organised by the ESA and the American Society of Anaesthesiologists
areas suffering from the brain drain.9 at their yearly scientific meeting. After a successful meeting in Boston
last autumn, we organised a new edition of this symposium in
How is the ESA dealing with all of these challenges? Several projects Copenhagen on 1 June in conjunction with Euroanaesthesia 2018,
are ongoing. Yearly, two or three guidelines are produced on various which took place on 2–4 June. The Keynote Lecture, delivered
topics in anaesthesiology and intensive care, critical emergency by Professor Charles Vincent (Oxford, UK), was entitled ‘Safer
medicine, pain and perioperative medicine. These guidelines are healthcare: strategies for the real world’. By attending meetings such
meant to provide recommendations for standard of care, which as this, anaesthesiologists can take the opportunity to meet colleagues
should help to bring practices all over Europe to the same level. and gain new knowledge about fatigue risk management and about
In addition, they may help local care providers convince hospital the role of simulation for improving patient outcomes.
administrations and healthcare officials about the specific needs to
achieve these European standards of care. Finally, caregivers are not the only stakeholders when thinking about
perioperative patient safety. Our industry partners and the different
The European Diploma in Anaesthesiology and Intensive Care patient societies and movements are also important key players. In
(EDAIC) undoubtedly contributes to setting a universal high the end, major advances in patient safety can be achieved only when
standard with regard to the knowledge and skills of anaesthesiologists all stakeholders work together to achieve a safer patient environment.
worldwide. Programmes such as ‘mentor/mentee’ and ‘train abroad-
return home’ aim to allow professionals in low-income countries to
develop their skills with the help of foreign colleagues/centres with REFERENCES
specific expertise.
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10. Haller G, Stoelwinder J, Myles PS, McNeil J. Quality and safety
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Update in
Anaesthesia

The NGO perspective: SAFE operating theatre
Mona Guckian Fisher
Correspondence: mona@guckianfisher.com
Universal access to safe, timely, affordable surgical There are numerous NGOs, charities and individuals
and anaesthetic care is a basic human right, yet involved in delivering support across the globe. In
more than 4 million people worldwide lack access to 2010 the first SAFE course (Safer Anaesthesia from
quality health services. This is mostly explained by a Education) was developed in obstetric anaesthesia fol-
human resource shortage compounded by the fact lowed by paediatric anaesthesia by the Association of
that the skills, competencies and clinical experience of Anaesthetists of Great Britain & Ireland (AAGBI) and
providers are often poorly suited to the health needs the World Federation of Societies of Anaesthesiologists
of the populations being served. (WFSA). This has now been successfully delivered in
a number of countries: 59 courses have been run and
Nurses play a pivotal role, caring and supporting more than 2000 delegates have been trained.
patients throughout the continuum of life. As a
professional group they advocate for health promotion The SAFE OR programme was developed col-
and support and education of patients and the public laboratively, with an initial aim to bring practitioners
on the prevention of illness and injury, providing care to a level of practice whereby they could deliver
and assisting in cure and rehabilitation across global vigilant and competent anaesthesia. This educational
communities. No other healthcare professional has programme has been extended to include the other
such a broad and far-reaching role. Nurses are teachers, team disciplines of surgery, and more recently nursing,
advocates, caregivers, critical thinkers and innovators. to produce multidisciplinary service delivery teams
This honourable profession puts nurses at the heart offering a carefully balanced mix of clinicians to
and soul of the healthcare system in every country. address the full training needs identified.
The Nursing Now campaign (https://nigelcrisp.com/ These courses have shown that, although education
nursing-now/), run in collaboration with the World can be developed for individual specialties, there is
Health Organization (WHO) and International much more to gain from training the whole team
Council of Nurses (ICN), aims to raise the status working in the operating room. Through this concept,
and profile of nursing, empowering nurses to take the SAFE OR course was developed, with partners
their place at the heart of tackling 21st-century health in the Royal College of Surgeons (RCS), Association
challenges. The campaign launched globally on 27 for Perioperative Practice (AfPP) and now the Royal
February 2018 with events worldwide and runs until College of Obstetricians and Gynaecologists (RCOG).
the end of 2020.
The perioperative setting is a unique practice
Safety is a challenge inside and outside the operating environment. Provision of safe and effective care in
theatre; recent visits to developing countries provide all areas of a surgical services suite requires a complex
evidence on additional challenges in infrastructure, organisational structure, utilising a diverse skill mix
where the potential for care in the surgical setting is from numerous personnel. In addition, within this
clearly indicated. There are high-rise buildings with multifaceted setting, various members of the surgical
scaffolding made from sticks where construction team may have conflicting goals and objectives.
workers are at serious risk of injury whilst working Because this environment is so complex and intense
at height. It is indeed difficult to observe this, in at times, effective leadership and communication skills Mona Guckian Fisher RGN,
contrast to our first-world regulated safety systems. are crucial in order to bring these diverse workers LLM, BSc (Hons), OHND,
If the old adage ‘prevention is better than cure’ still together to provide safe care and achieve positive DipHSWW, CMIOSH, Dip
holds good, then there are opportunities for collegiate patient outcomes, including prevention of (1) surgical Perioperative Nursing, Dip
Counselling
non-governmental organisations (NGOs) to assist us site infections, (2) medication errors, (3) wrong-site
President
in the prevention and safety trajectory. surgery and (4) other preventable complications International Federation of
related to surgical intervention. Perioperative Nurses (IFPN)
Wherever we are in the world, the basic minimum and
perioperative team will consist of the anaesthetist, Nursing skills are essential for the delivery of most Immediate Past President
surgeon and registered nurse or, in the UK, registered healthcare, but are commonly ignored in the various Association for Perioperative
operating department practitioner. debates about increasing capacity. In surgical nursing, Practice (AfPP)
the small UK-based charity Friends of African Nursing (FoAN), Many of these nurses are well educated but are struggling with limited
established in 2002, has successfully delivered education and support resources, and many identify the need for support to set standards of
to 2000 nurses with an unbelievable minimal resource, mostly practice that can empower them and the entire team. This is where
achieved from coffee mornings and the dedicated altruism of a few team training cannot be surpassed.
perioperative nurses.
The NGO experience of surgeons, anaesthetists and nurses working
In 2017 and 2018 two self-funded perioperative nurses engaged on collaboratively as an integrated professional group, to educate inform
an educational tour of southern India and provided training sessions and empower, is a thrilling and worthwhile experience.
on patient safety, staff welfare, nursing leadership and empowerment
along with other aspects of clinical practice to over 1000 nurses. Changes that empower the nursing team from the NGO experience
During our work we have discovered similar lessons: the perioperative are simple to achieve, such as employing the safety checklist, com-
team is the essential ingredient that makes possible the objective of municating with colleagues, saying thank you, developing suitable
the NGOs working in these settings. standards and protocols, assuring correct patient identification,
asking for help, ensuring that consent is signed, assuring scrub nurse
The SAFE OR course is the first time that nurses have been engaged responsibility for patient and procedure identification, checking the
in a team education programme from the start of the writing to patient, building capacity for sharing knowledge, implementing
joining the courses. When Team ‘SAFE OR’ travelled to Addis a whiteboard count, improving nursing documentation, utilising
Ababa in Ethiopia in September 2017, nurses were part of a cohesive checklists for instruments, improving the process for preoperative
UK team working with Ethiopian colleagues, a powerful example assessment, resolving conflicts within the team, improving teamwork
of what can be achieved if cultural attitudes can be set aside in the with other professionals for the safety of the patient and generally
name of providing safe and timely perioperative patient care. Of the improving understanding and communication.
35 participants in Ethiopia who attended, 17 were nurses, a clear
indication of the investment that is needed for that professional
discipline. VALUE STATEMENT: ‘NURSES MAKE A DIFFERENCE’
We need to see a change in the way that the nursing profession is Managing the perioperative environment is not an easy task, but
viewed by surgeons, anaesthetists, community leaders, governments, effective leadership is critical to the success of the department.
the WHO and NGOs to create significant change in the perceived Effective leaders can create a working environment that promotes
value of the profession. The Nursing Now campaign aims to improve staff satisfaction and productivity, thereby contributing to the overall
the perceptions of nurses, enhance their influence and maximise success of the operating theatre. Conversely, ineffective leadership can
their contributions to ensure that everyone everywhere has access result in a loss of staff morale and productivity and ultimately have a
to health and healthcare. negative impact on the patient, the department and the organisation.
Collectively, nursing professionals need to ensure that they are visible, Success in the perioperative practice setting includes the provision
have input and value at the forefront of healthcare and are a part of of safe and effective patient care and achieving optimal outcomes.
these planned initiatives. There are hierarchical and cultural issues To realise these successes, this work environment requires strong,
to address and whole-team engagement is the only way to start to consistent, knowledgeable nurse leaders who are visible, inspire
tackle this important reality. It will take time and commitment but, others and can motivate the multidisciplinary team using effective
if built into every training package as an important part of the overall communication. We are all responsible for contributing to this
engagement, then we will begin to see and reap the benefits in terms outcome.
of team cohesiveness and patient outcomes.
Update in
Anaesthesia

Safe anaesthesia for everybody – today’s
initiative: the anaesthesia patient safety
perspective
Mark A Warner
Correspondence: warner@apsf.org
Anaesthesia patient safety must be a universal safety ideas between an increasing proportion of
mission. The Anesthesia Patient Safety Foundation the estimated 350,000 anaesthesia professionals
(APSF) applauds the World Federation of Societies of worldwide. The APSF will also use social media
Anaesthesiologists (WFSA) for its efforts to improve opportunities such as Facebook, Twitter, LinkedIn and
patient safety through initiatives such as SAFE-T unique blogs, especially those already well established,
(Safe Anaesthesia For Everybody – Today). The APSF to reach international anaesthesia professionals, to lead
will work closely with the WFSA and its national or participate in discussions of perioperative patient
anaesthesia organisations to provide support through safety issues. These, too, will be provided in multiple
education, research and advocacy. languages to support communication between the
diverse anaesthesia professionals globally.
The APSF’s vision statement is clear: ‘That no
patient shall be harmed by anesthesia’. Its primary The APSF has been a significant source of funding
mission remains to continually improve the safety of for perioperative patient safety research. More than
patients during anaesthetic care by encouraging and US$12 million have been provided to support
conducting: research on unique clinical safety issues, to develop
novel technologies and educational programmes and
• safety research and education; to support the early career development of future
• patient safety programmes and campaigns; anaesthesia patient safety scientists. Much of that
• national and international exchanges of informa- support has been directed at North American-based
tion and ideas. anaesthesia professionals. We are now seeking oppor-
tunities to expand support to aspiring anaesthesia
The APSF has primarily been US focused for the patient safety scientists and clinicians outside North
past several decades. This focus is changing to meet America. This expansion will require significant
our founding mission to increase the international financial support of the APSF and we are currently
exchange of patient safety ideas. For its 32 years working to attain it.
of publication, the APSF Newsletter has played an
important role in providing educational material on The APSF’s mission has not changed. When applying
anaesthesia patient safety and for sparking discussions the mission to today’s expectations of anaesthesia
through pro/con debates and letters to the editor. It professionals internationally, the APSF needs to
currently is the most widely distributed anaesthesia ensure that its activities span the extended range of Mark A Warner MD
publication in the world, reaching 125,000 anaesthesia perioperative care and involve collaboration with the President
professionals in print and another 50,000 electroni- full spectrum of colleagues in all fields and industries Anesthesia Patient Safety
Foundation
cally. That’s good – but it also is insufficient. that impact our patients’ care. As we all move forward,
and
the APSF will increase its focus on the full spectrum
Annenberg Professor
During 2018 and into the future, the APSF Newsletter of perioperative safety issues and increase its advocacy Department of
will be published in an increasing number of languages. for patient safety. There are important questions to be Anesthesiology and
These newsletter translations and also translated APSF answered and issues to be addressed. Perioperative Medicine
safety videos will appear on the APSF website (https:// Mayo Clinic
apsf.org) as they become available during 2018. These It’s the right thing to do for our patients . . . and for Rochester, MN
will support the exchange of perioperative patient our profession. USA
Update in
Anaesthesia
The WFSA SAFE-T Summit: overview and

commentary
Berend Mets and Alan Merry
Correspondence: a.merry@auckland.ac.nz
On launching the SAFE-T (Safe Anaesthesia for the benefit of effective training of people with minimal
Everyone – Today) campaign at the World Congress of or no prior qualifications has substantially outweighed
Anaesthesiologists in Hong Kong in September 2016, any potential for harm. Importantly, in Tanzania, this
the World Federation of Societies of Anaesthesiologists training was provided under the auspices of, but not
(WFSA) President and Board of Directors championed necessarily to, or even by, anaesthesiologists.
the concept of developing a series of SAFE-T Summits
that could advance the global patient safety agenda. As Dr Andy Leather turned to the messages of the Lancet
the co-conveners of this first SAFE-T Summit we are Commission and progress since its report. The poorest
pleased to provide a brief overview and commentary. one-third of the world’s population receive only 6.3%
of its surgical procedures. If global inequity in surgical
The objectives for the Summit were to update the dis- and anaesthetic care is to be addressed, clinicians will
cussion following the Lancet Commission on Global need to embrace the language of public (or popula-
Surgery (2015) (http://www.lancetglobalsurgery.org/), tion) health and the principles of health economics.
with a focus on: Conditions amenable to surgical care contribute to
one-third of the global burden of disease. Failures in
• indicators and metrics of surgical and anaesthesia access to this care, or in the safety of the care once
capacity and safety; accessed, have substantial, and indeed impoverishing,
• safety standards for equipment and medications; negative consequences at both individual and national
• gaining perspectives on the global safety situation levels. The Lancet Commission introduced the notion
from a broad range of stakeholders including of three bellwether procedures (surgery for caesarean
anaesthesiologists, surgeons, obstetricians, nurses, delivery, laparotomy and open fracture management)
governments, the World Health Organization as an indicator of the overall capability of a hospital.
(WHO), industry, patient safety societies and Importantly, these procedures are the very ones for
other interested organisations and individuals. which safe care is most needed, often urgently, by the
patients who currently cannot get it. These procedures
This first SAFE-T Summit was jointly hosted by can also be very difficult to perform safely, which
the WFSA and the Anaesthesia Section of the Royal makes the challenge of providing an adequately trained
Society of Medicine at its headquarters in London workforce very imposing.
on Friday, 13 April 2018. There were over 250
Berend Mets MBChB, PhD, participants. Here is our brief report on the entire Professor Justine Davies turned the discussion to
FRCA proceedings. the importance of data and why they matter. She
Chair asked ‘Whose data are they anyway?’, saying that their
Department of
In his opening keynote lecture, ‘The Global Challenge impact on the end user was critical. A key objective of
Anesthesiology and
Perioperative Medicine
for Patient Safety’, Dr Tore Laerdal reminded us that measurement is influence, through making problems
Pennsylvania State there will be 80 million deaths by the year 2030, and visible. Professor Davies illustrated this while at the
University that every second one of these will be avoidable. He same time introducing the important theme of gender
Hershey, PA discussed the relative roles of science, education and equity, describing the surprising finding that female
USA implementation in generating change. In practice, surgeons are more adversely affected by an unexpected
education and implementation are critical if the patient death whereas male surgeons receive more
benefits of science are to be realised. Tore emphasised benefit from an unexpectedly good result. She
Alan Merry MBChB, FAN-
ZCA, FFPMANZCA, FRCA
the importance of keeping things simple. The Helping discussed the potential for unintended consequences
Head Babies Breathe programme and bystander resuscitation of the use of metrics, using performance-based pay
School of Medicine (begun by Dr Peter Safar) provided great examples of as an example, and introduced the graphic phrase
University of Auckland this, with the graphic comment that ‘the community ‘Weapons of math destruction’. The goal should be
Auckland is the ultimate coronary care unit because the majority not so much hitting the target, as hitting the needs
New Zealand of heart attacks occur outside hospital’. In both cases, of our patients.
Characteristics of useful data would include: that capacity without safety is of little value, adding the often used
quotation that ‘Safety is not expensive, it is priceless’.
• availability;
• comparability; Professor Gelb introduced the third edition of the WHO–WFSA
• utility; International Standards for a Safe Practice of Anaesthesia, which for the
• feasibility. first time has been endorsed jointly by both the WHO and the WFSA
[Gelb AW, Morriss WW, Johnson W, Merry AF, Abayadeera A, Belil
A review of the availability of the core metrics from the Lancet N et al. World Health Organization–World Federation of Societies
Commission was somewhat sobering. The metrics for affordability of Anaesthesiologists (WHO-WFSA) International Standards for a
are not available from any country and the metric for perioperative Safe Practice of Anaesthesia [published online ahead of print 7 May
mortality is available only for 31 countries. Clearly, more work is 2018]. Can J Anesth 2018. doi: 10.1007/s12630-018-1111-5].
needed.
He also introduced the associated Anaesthesia Facility Assessment
Dr John Meara continued this theme, but with a strong emphasis Tool, which has been developed by the WFSA and his team at the
on the positive. In particular, the World Bank now publishes data University of California San Francisco (available at https://www.
on surgery and anaesthesia for the first time. This is a breakthrough wfsahq.org/resources/anaesthesia-facility-assessment-tool).
of the highest importance, but is vulnerable as a reversal of this
decision could readily occur. It is essential that the appropriate data Discussion in the subsequent panel included the notions that we
are provided to the World Bank on a regular basis if this is to continue. are ‘bombarded with information’, that we need to ‘keep it simple’,
that we should ‘target the finance ministers of the world’ and that it
Dr Meara introduced three words to capture the process of using data: is essential that data are sent to the World Bank to ensure that this
institution will continue including information on anaesthesia and
• acquire; surgery in its databases.
• curate;
• disseminate. Dr Atul Gawande provided ‘A Surgeon’s Public Health Perspec-
tive’. He started by reviewing classic studies showing that at least
Clearly it will be difficult for any one group to manage these processes half of adverse outcomes in surgery are preventable. The evidence
for all of the data relevant to surgery anaesthesia and obstetrics; hence, indicates that the most effective approaches to improving surgical
organisations will need to work together to this end. and anaesthesia safety lie less in training programmes or regulations
than in measures systematising care. A prime example of this is the
Dr Meara also described the National Surgical, Obstetric and WHO Safe Surgery Checklist (http://www.who.int/patientsafety/
Anaesthesia Plan (NSOAP) of Tanzania, which he estimated has a safesurgery/ss_checklist/en/) (also an output from the WHO’s Second
cost of US$1.70 per capita per year, representing astonishingly good Global Challenge). This is a process tool ‘to get people on the same
value for money. page’. However, its effectiveness in state and national populations
depends on how it is implemented. Top-down mandates alone have
A lasting image from Dr Meara’s lecture was that of an elephant: to been ineffective; when even modest bottom-up organisation and
move the elephant it is necessary to direct the rider, motivate the support of implementation teams has been provided, large reductions
elephant and shape the path. in mortality have been demonstrated.
Dr Tom Weiser opened with a reminder of the Second Global Dr Gawande discussed the next generation of system interventions
Challenge of the WHO: ‘Safe Surgery Saves Lives’. One of the for safer surgery and anaesthesia care, including team training,
outputs from this challenge is the definition of five metrics for coaching and the nation-wide simulation-based programme for
the measurement of surgery and anaesthesia globally. One of the training entire surgical teams currently being rolled out across New
objectives in developing these metrics is to avoid unintended Zealand. Another is the incorporation of patient-reported outcome
consequences. Dr Weiser presented a map of surgical volumes that, measures that ensure that the primary outcomes of surgery are
amongst other things, illustrated an extraordinary range for the actually achieved. For elective surgical patients, ‘it is not a sign of
highest density areas, from 12,000 to 36,000 operations per 100,000 success that you didn’t die’! Finally, he pointed out a still undeveloped
population. This illustrates the point well that the world faces not need: interventions to reduce unnecessary surgical interventions.
only overutilisation of healthcare but also underutilisation. Should He drew attention to the problem of inappropriate variation in
the available resource be distributed more equitably, everybody could healthcare, noting that rates of the most common operation in the
benefit from the redistribution. world, caesarean section, vary across the world from 2% to 80% of
deliveries, with the optimal rate for the safety of mothers and their
Professor Adrian Gelb defined ‘capacity’ (which also raises the babies measured at about 19%. The most unsafe operation is the one
question of the closely related concept of ‘capability’) and stressed that should not have been done at all, he pointed out.
This theme was continued by Professor Lesley Reagan. There are Emergency and Essential Surgical Care (GIEESC) at the WHO. Dr
213 million pregnancies a year worldwide, 75 million of which Johnson pointed out that all of the WHO Sustainable Development
are unplanned, and 303,000 maternal deaths, many of adolescent Goals are linked to access to safe surgery and anaesthesia, reiterating
girls. The ability of a young woman to control whether or not that he knew he was ‘preaching to the choir’ that there is a substantial
she becomes pregnant impacts her lifetime risk of dying and her challenge in getting the message beyond the converted to those who
chance of secondary school education, amongst many other things. have the capability of changing priorities for investment into global
In Chad, where there is little or no ability to do this, the lifetime health priorities. Addressing the challenges identified by the Lancet
chance of dying during pregnancy is one in eight. Professor Reagan Commission will depend on capturing the hearts and minds of those
pointed out that you can’t put your pregnancy on hold because your capable of the required investment.
country is having a civil war, noting Iraq as an example. In effect,
the determinants of maternal mortality are a matter of political will, Mona Guckian Fisher, President-Elect of the International Federa-
and in the words of Professor Mahmoud Fathalla, Secretary General tion of Perioperative Nurses (IFPN), followed with a timely reminder
of the United Nations (referring to Millennium Development Goal of the importance of registered nurses as part of the team in the care
5), ‘women are dying because societies have yet to make the decision of surgical patients in the operating room and on the wards. She
that their lives are worth saving’. The image of elephants returned noted that teamwork is key and that the Safe Surgery Checklist had
in the form of the elephants in the room, namely the global lack of been influential in helping nurses speak up when necessary. Mona
access to effective contraception and safe, legal abortion. These are highlighted the paradox that, although training and learning often
amongst the most important root causes of maternal deaths resulting occur in silos, we need to work in teams to ensure patient safety.
from the complications of unwanted pregnancy. Gender equity is a She finished by noting that nursing is a noble profession and has a
precondition to end poverty. The Leading Safe Choices Programme key role to play in addressing the challenges identified by the Lancet
(https://www.rcog.org.uk/leadingsafechoices) is a direct response to Commission.
these challenges.
Dr Mark Warner, President of the Anesthesia Patient Safety
The ensuing panel discussion included the (much-needed) progress Foundation (APSF), began with the original mission statement of
that has been made towards gender equity in medical graduates in that organisation: that ‘no patient shall be harmed from anaesthesia’.
high-income countries, but also the continuing dearth of women in Inspirational initiatives by the APSF include a new focus on global
senior leadership roles in healthcare and the related need to change health, including the translation of its newsletter (which is distributed
long-held hierarchical values in order to embrace the effective use of to over 150,000 readers) into eight languages, and a proposed grant
the Safe Surgery Checklist. In some low-income countries, the Safe initiative to develop new patient safety scientists in and beyond the
Surgery Checklist has opened the way for anaesthesia providers to USA.
have the confidence to discuss concerns about patients with surgeons.
Professor Alan Merry gave the final presentation of the conference,
Dr Philippe Mavoungou provided a thought-provoking discussion returning to the point that, in this context, the role of collecting
of equipment for use in low-income countries and the need for data is to drive improvement in outcomes for patients, globally. He
standards that ensure that such equipment is fit for purpose. Stan- argued that the six core metrics identified by the Lancet Commission
dards for low- and middle-income countries need to be enhanced, should form the cornerstone of a wider framework of indicators.
not reduced, in comparison with those for high-income countries. Substantial progress on measuring the professional workforce has
been made with the WFSA’s World Anaesthesiology Workforce Map
Dr David Whitaker discussed the WHO’s Third Global Challenge (https://www.wfsahq.org/workforce-map), which has the capacity to
for Patient Safety, ‘Medication Without Harm’. The primary themes support such a framework.
of this challenge are:
Returning to the ultimate objectives of surgery, he suggested includ-
• high-risk medications; ing high-level indicators of outcome, such as life expectancy and
• polypharmacy; patient-reported outcome measures, at the top of the framework to
• transitions of care. make the ultimate purpose of other indicators explicit. In relation
to the ‘three delays’ identified by the Lancet Commission, he showed
Clearly, medication safety is a central concern in anaesthesia. The some measures of access that could potentially be modified to reflect
importance of labelling, and the concept of ‘the Rainbow Tray™’ the impact of these delays. Donabedian’s triad of structure, process
were noted. A story of the persistent efforts to inject a medication and outcome could be applied across a modification of the Institute
intravenously, when it is intended for oral use, provided a graphic for Healthcare Improvement’s Triple Aim, such as that adopted in
illustration of the point that fools can be both persistent and very New Zealand, to emphasise equity and also value for money rather
ingenious in executing unsafe medication administration. than the reduction of expenditure on healthcare. Returning to the
core message of inappropriate variation in healthcare, he emphasised
‘The WHO Perspective’ was the title of the presentation by Dr the importance of doing ‘the right things’ in the first place (i.e.
Walter Johnson, a neurosurgeon who leads the Global Initiative for treatments that are evidence-based and valued by patients) and then
of ‘doing them right’ (i.e. safely). He drew attention to the corrosive Professors Alan Merry and Berend Mets closed the conference with
influence of corruption and advocated including measurements of a summary, concluding remarks and a heartfelt thank you to the
this into the framework, in effect to shine a light on this important Royal Society of Medicine and its anaesthesia section, the WFSA
contributor to inequity in health outcomes. Secretariat, industry sponsors and the speakers and participants for
contributing to the first ever WFSA SAFE-T Summit and expressed
a commitment to plan for another Summit the following year.
ATOTW Clinical Safety Republications
Update in
Anaesthesia
World Health Organization Surgical Safety
Checklist
Natasha Woodman
Edited by
Dr Isabeau Walker
Correspondence: atotw@wfsahq.org
Originally published as Anaesthesia Tutorial of the Week, 325, 5 February 2016, edited by Dr Isabeau
Walker
This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivitives 3.0

International License. To view this license, visit https://creativecommons.org/licenses/by-nc-nd/3.0/
QUESTIONS
Before continuing, try to answer the following questions. The answers can be found at the end of the
article, together with an explanation. Please answer True or False:
1. Regarding implementation of the WHO checklist:
a. Anaesthetists are responsible for implementing the checklist in theatre
b. Implementation of the checklist is an ideal student project
c. It is helpful to collect data, but it is important to only feed this back to the theatre team at the
end of the implementation process
d. Where an item cannot be completed in your facility due to lack of resources, remove that item
from the checklist
e. Staff are more likely to use the checklist if they understand how it improves patient safety
2. When conducting the WHO checklist:
a. Good communication is important – use clear questions and direct them to an individual
using their name
b. The WHO checklist is only for elective cases, not emergencies
Natasha Woodman
ST6 Anaesthetic Registrar c. It is important to maintain status and hierarchy during the checklist so that everyone knows
Great Ormond Street who is in charge
Hospital d. Antibiotics are usually given after skin incision
London e. Retained swabs, needles and instruments are an important recurring adverse event worldwide.
UK Use of standardised packs and lists of instruments helps the counting process
3. When briefing and debriefing:
Isabeau Walker a. These steps are added before and after each surgical case
Consultant Anaesthetist b. The briefing provides an opportunity for everyone to introduce himself or herself and identify
Great Ormond Street their role
Hospital c. Surgeons are usually very busy so they do not need to attend the pre-list briefing
London
d. The briefing takes too long for it to be used routinely
UK
e. There would be no reason to debrief a day that had run smoothly as there is nothing to learn
Update in Anaesthesia ■ Volume 33 ■ December 2018
incidents in 2013–2014. Over 3000 of these incidents were related

Key Points to treatment or procedure, or implementation of care and ongoing
monitoring/review.3 These figures, when extrapolated to the global
• Adverse events in surgery are an important problem
number of surgeries conducted, are alarming and provide clear
globally. Many are preventable.
motivation to make surgery safer.
• The WHO Surgical Safety Checklist has been shown to
reduce surgical complications and improve communica-
tion and teamwork in the operating theatre. HISTORY OF THE WHO SURGICAL SAFETY CHECKLIST
• Key components to successful implementation of the
checklist include senior administrative support, surgical In 2002 the World Health Assembly urged countries to improve the
buy-in, ensuring underlying processes of care are in place safety of health care and monitoring systems. They requested that
and the use of local champions. the WHO set global standards of care and provided support for
countries to improve patient safety. As a result, WHO Patient Safety
• Modification to suit local practice, training, stepwise was formed, and focussed its energy on campaigns named Global
implementation and real time feedback on performance Patient Safety Challenges. Following their first challenge, ‘Clean
improves uptake. Care is Safer Care’, WHO launched ‘Safe Surgery Saves Lives’ and
led by Professor Atul Gawande, published WHO Guidelines for Safe
Surgery.4 This set out 10 essential objectives for safe surgery from
INTRODUCTION which the Surgical Safety Checklist was derived (Figure 1)
In 2008 the World Health Organization (WHO) introduced a The aim of this ‘WHO checklist’ was to give teams a simple, efficient
surgical safety checklist applicable to all surgical teams to be used set of priority checks to improve effective teamwork and communica-
for every patient undergoing a surgical procedure. This tool has tion and encourage active consideration of patient safety for every
been implemented around the world, and encourages dialogue operation performed. WHO also wanted to ensure consistency in
within multidisciplinary teams and the use of routine safety checks patient safety in surgery and introduce (or maintain) a culture that
to minimize harm to our patients. values patient safety.5
In a pilot study of the WHO checklist implementation, Professor

Example case: Gawande’s team prospectively observed over 3000 patients prior to
An 18yr old girl, Ms X came to theatre for an urgent appendicectomy. the introduction of the checklist and nearly 4000 patients after check-
When the operating staff called to the ward for Ms X, her nurse was list implementation, and measured the rate of surgical complication
busy with another patient. Another nurse helpfully gathered the or mortality up to 30 days after surgery or until discharge.6 The study
notes and brought Ms X to the operating area. An anaesthetist, Dr included four hospitals in low- and middle-income countries and
A, had assessed Ms X on the previous shift and had given a brief four hospitals in high-income countries and found the overall rate
handover to the current anaesthetist, Dr B. Dr B was approaching of death prior to introduction of the checklist was 1.5% and after
the end of a busy 12-hour shift, with emergency cases on the priority checklist implementation fell to 0.8%. Inpatient complications were
list. Having anaesthetised Ms X, Dr B was about to give antibiotics also reduced, from 11% pre checklist to 7% after the checklist was
and noticed that the allergy box on the anaesthetic chart was left introduced. As a measure of adherence to the checklist, they identified
blank. She went to check the drug chart and saw Ms X had a severe 6 safety indicators, such as pre-incision antibiotics, swab counts
penicillin allergy. The nurse was unaware of this allergy, Ms X did and routine anaesthetic checks, and saw an increase in performance
not mention it before induction and Dr A had forgotten to hand it of these from 34.2% pre checklist to 56.7% post checklist. It is
over to Dr B. This was a near miss and could have been avoided if interesting that even with only 56% completing these 6 indicators,
the allergies had been checked before induction of anaesthesia during significant reductions in complications and death rates were seen. The
the ‘sign in’ part of the surgical safety checklist. checklist implementation team used team introductions, briefings
and debriefings as part of the safety routine, which has also been
formalised as part of the checklist strategy in the UK (see below).
ERRORS IN SURGERY: THE SIZE OF THE PROBLEM
By September 2014, the WHO team had identified 4132 institutions
The WHO have estimated that 234M operations are performed who had expressed an interest in using the checklist and 1790 institu-
annually around the globe.1 A systematic review including over tions who were actively using the checklist in at least one operating
74,000 patient records found a median incidence of in-hospital theatre.7 Seven years after introduction of the checklist, numerous
adverse events of 9.2% with approximately half of those events being studies have shown the benefit of the checklist, but observers, audits
operation or drug-related, and 43% deemed preventable.2 In England and trials have also reported common barriers to successful use of
and Wales, the National Reporting and Learning System (NRLS) this patient safety tool. Key to successful implementation across all
reported 10 526 patients died or came to severe harm secondary to cultures, economies and specialties seems to be engagement of the
This work by WFSA is licensed under a Creative Commons Attribution- NonCommercial-NoDerivitives 3.0 International License. To view this license, visit https://creativecommons.org/
licenses/by-nc-nd/3.0/ 27
Figure 1. WHO Surgical Safety Checklist. Reproduced with permission of the World Health Organization.
whole team, through understanding the relevance and power of this should be physically present during induction. Symptom-
tool in their setting. atic active reflux or a full stomach should also be handled
with a modified plan
h. Known allergies - all members of team need to be aware
CONSTITUENT PARTS OF THE CHECKLIST i. Anaesthesia safety checks complete (equipment, medica-
tions, emergency medications, patient’s anaesthetic risk)
There are three phases to the checklist: 2. Time out – after induction and before surgical incision, entire
team
1. Sign in – before induction of anaesthesia, ideally with surgeon a. Each team member introduces him/herself by name and
present, but not essential role
Verbally verify, review with the patient when possible: b. Pause to confirm correct operation for correct patient on
a. Patient identity correct site. Anaesthetist, nurse and surgeon should all
b. Procedure and site individually confirm agreement, plus the patient if awake
c. Consent for surgery c. Review anticipated critical events
d. Operative site is marked if appropriate (involving left or i. Surgical critical/unexpected steps, operative duration,
right distinction) anticipated blood loss
e. Pulse oximeter is on the patient and functioning ii. Anaesthetic patient specific concerns, for example,
Review between anaesthetist and checklist coordinator: intention to use blood products, co-morbidities
f. Patient’s risk of blood loss. If >500ml in adults or >7ml/kg iii. Nurses confirm sterility of instruments and discuss
in children, it is recommended to have at least 2 large bore equipment issues/concerns
intravenous lines or a central line before surgical incision d. Confirm prophylactic antibiotics where required, was
and fluids or blood available given within the 60 minutes prior to skin incision. If not
g. g. Airway difficulty or aspiration risk. Where a potentially given and required, administer prior to incision. If >60
high-risk airway is identified, at a minimum the approach minutes, consider re-dosing the patient
to anaesthesia should be adjusted accordingly, emergency e. Essential imaging displayed as appropriate
equipment must be accessible and a capable assistant
3. Sign out – during or immediately after wound closure, before and Wales to use the checklist. Patient Safety First reported that some
moving the patient out of the operating room, whilst surgeon elements of the checklist could be more effective if incorporated
still present into a briefing before the list starts. This is an opportunity to make
a. Confirm operation performed and recorded a plan for the list, amongst all the team members, to anticipate and
b. Check instrument, sponge/swab and needle counts are plan for any problems that can be foreseen. Any team member can
complete. Where numbers do not reconcile the team lead the briefing, ensuring that everyone has introduced himself or
should be alerted and take steps to investigate herself and clarified their role and responsibilities for the list. An
c. Check surgical specimens labelled correctly overview is taken of the list, highlighting any changes, equipment
d. Highlight equipment issues considerations, special requirements or safety concerns. All theatre
e. Verbalize plans or concerns for recovery and postopera- team members should be present for the briefing and debriefing.
tively, especially any specific risks
The debriefing naturally occurs at the end of the list, before any team
members have left the theatre or department. The purpose of this
IMPLEMENTING THE CHECKLIST debrief is to reflect on the list and share perspective on tasks that
went well and tasks that did not go well. This may include discussion
The WHO issued an implementation manual in support of the of teamwork, the theatre atmosphere, errors or near misses, and
checklist.5 This gives detail on how each step should be conducted. a retrospective look at the briefing and use of the surgical safety
The manual highlights the importance of leadership and institutional checklist throughout the day. It is important to register successes,
buy-in, and emphasizes that a department should practice using learning points, areas that require change or escalation and for this
the checklist before introduction and should modify it so that it to be conducted in a non-threatening, open environment. Patient
can be established within the normal operative workflow. Resources Safety
A single First
person should developed and
be responsible for promoted
checking the boxes onthe ‘Five
the list Steps
and this can betoanySafer Surgery’
healthcare
9
professional in
the operating team, often the circulating nurse. That nominated coordinator should prevent the team moving forward
to help with implementation of the checklist are available on the (Figure 2)
before each step has been addressed. Initially this could lead to tensions and resistance within
through consistently following the safety steps will the most common and avoidable risks be minimized.
the team, but only
WHO website: http://www.who.int/patientsafety/safesurgery/ Although facilities are encouraged to modify the checklist as needed, they are discouraged from removing safety steps
tools_resources/en/. Example videos from around the world can be simply because they cannot be accomplished. They also caution facilities from adding too many additional steps and
creating an unmanageable, complex checklist. In England and Wales, the National Patient Safety Agency (NPSA) issued
seen on the SafeSurg website: http://www.safesurg.org/videos.html. BARRIERS TO IMPLEMENTATION OF THE WHO
a patient safety alert in 2009. They launched a modified checklist for England and Wales with instructions to appoint a
clinical lead within each organisation, ensure the checklist was completed for every patient undergoing a surgical
CHECKLIST
8
procedure and that record of the checklist was entered into the patient notes . A guide to modification of the checklist is
available on the WHO website, as well as examples of modified checklists from around the world:
http://www.who.int/patientsafety/safesurgery/local_adaptation/en/
A single person should be responsible for checking the boxes on
the list and this can be any healthcare professional in the operating Common
Briefing themes that can hinder successful implementation of the
and debriefing
team, often the circulating nurse. That nominated coordinator checklist are listed in Figure 3. These barriers can be addressed to
The Patient Safety First Campaign was established to support implementation when the NPSA issued their alert
informing England and Wales to use the checklist. Patient Safety First reported that some elements of the checklist could
should prevent the team moving forward before each step has been improve implementation outcomes 9–11.
be more effective if incorporated into a briefing before the list starts. This is an opportunity to make a plan for the list,
amongst all the team members, to anticipate and plan for any problems that can be foreseen. Any team member can
addressed. Initially this could lead to tensions and resistance within lead the briefing, ensuring that everyone has introduced himself or herself and clarified their role and responsibilities for
the list. An overview is taken of the list, highlighting any changes, equipment considerations, special requirements or
the team, but only through consistently following the safety steps safety concerns. All theatre team members should be present for the briefing and debriefing.
will the most common and avoidable risks be minimized. The debriefing naturally occurs at the end of the list, before any team members have left the theatre or department. The
purpose of this debrief is to reflect on the list and share perspective on tasks that went well and tasks that did not go well.
This may include discussion of teamwork, the theatre atmosphere, errors or near misses, and a retrospective look at the
briefing and use of the surgical safety checklist throughout the day. It is important to register successes, learning points,
Although facilities are encouraged to modify the checklist as needed, areas that require change or escalation and for this to be conducted in a non-threatening, open environment. Patient
9
Safety First developed and promoted the ‘Five Steps to Safer Surgery’ (Figure 2)
they are discouraged from removing safety steps simply because they
Brieﬁng( Sign(in( Time(Out( Sign(Out( Sign(Out(
cannot be accomplished. They also caution facilities from adding
too many additional steps and creating an unmanageable, complex Start of list WHO Surgical Safety Checklist for each patient End of list
Figure 2. Five Steps to Safer Surgery.
checklist. In England and Wales, the National Patient Safety Agency Figure 2: Five Steps to Safer Surgery
(NPSA) issued a patient safety alert in 2009. They launched a modi- Barriers to implementation of the WHO checklist
fied checklist for England and Wales with instructions to appoint Common themes that can hinder successful implementation of the checklist are listed in Figure 3. These barriers can be
9-11
addressed to improve implementation outcomes .
a clinical lead within each organisation, ensure the checklist was
completed for every patient undergoing a surgical procedure and that Pragmatic challenges Attitudes
record of the checklist was entered into the patient notes.8 A guide • Duplication with existing checklists leading to • Denial that routine tasks can be forgotten
irritation and ‘checklist fatigue’ • Dismissive attitudes, lack of engagement
to modification of the checklist is available on the WHO website, • Time consuming, inconvenient • Hierarchy in the operating theatre discouraging
as well as examples of modified checklists from around the world: • Inappropriate timing open communication
• Poor communication • Embarrassment about introductions
http://www.who.int/patientsafety/safesurgery/local_adaptation/en/ • Unfamiliarity, confusion, who should prompt the • Lack of support from leaders or managers
items
• Absence of key team members
• Using the checklist as a ‘tick box exercise’
BRIEFING AND DEBRIEFING Resources Underlying processes of care

• Lack of resources such as marker pens, • Lack of antibiotic policies, protocols
antibiotics and pulse oximeters • No routine swab, needle or instrument counts
The Patient Safety First Campaign was established to support Figure 3: Table summarising barriers to checklist implementation
implementation when the NPSA issued their alert informing England Figure 3. Table summarising barriers to checklist implementation.
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th
ATOTW 325 – WHO Surgical Safety Checklist (5 Feb 2016) Page 4 of 9
TOP TIPS FOR SUCCESSFUL IMPLEMENTATION OF THE we are all fallible and omissions can occur in any facility under
WHO CHECKLIST anyone’s watch.
• It is important that the checklist is not mandated as a top-down
Implementation of the checklist can be a challenge, particularly chore for the staff, but that there is enthusiasm and engagement
when it is introduced as a new intervention, or top down within the workforce, giving them good reason to engage.
mandate, or when the benefits are not well understood. After By using evidence from experience of near misses or adverse
successful implementation, compliance can be one of the greatest incidents, leaders can encourage transparency and honesty, and
challenges, either in terms of use of the checklist or completeness encourage teams to see the value of these routine checks.
of the checks.11 Below are pointers that may help to introduce • In addition to leaders and champions, it is important to engage
the checklist and for it to be used effectively. These points are administrative staff. New resources may be needed or simply a
summarised below in Figure 4. supply of paper for checklists in each theatre. Administrative
support may also be required to ensure the antibiotic supply
chain is established and that the proper equipment is available,
Leadership including equipment to sterilise surgical instruments.
• Leaders in surgery, anaesthesia and nursing are very influential.
It is important for leaders to embrace patient safety as a priority
and to use the surgical safety checklist for their own cases. Senior Implementation of team and staff training
members of staff should act as local champions on the ‘shop floor’, • It is helpful to establish a local implementation team, with
to support junior staff when they want to speak up or challenge representatives from anaesthesia, surgery and nursing. This
an item, or simply to ask a question if they don’t understand team should meet on a regular basis to plan introduction of the
something. These champions should be approachable, accessible checklist.
and have skills in negotiation and persuasion. They need to create • The implementation team should lead staff training, with in situ
an honest, transparent culture and a baseline acceptance that demonstrations, videos and coaching when they start to use the
Figure 4. Diagram highlighting important steps in WHO checklist implementation.
checklist. Training should be multi-professional, incorporating ‘a moment of silence’ to gather everyone’s attention. In addition
the whole team. This helps to flatten the hierarchy in theatre, to being attentive, all members need to be present. It is helpful
and for many, it can be very revealing to see the world through for the sign out to be completed whilst the surgeon is closing the
the eyes of another. wound as this integrates the checklist into the surgical process
• In addition to teaching sessions, it is helpful to raise awareness, for and ensures the surgeon is still present in theatre.
instance through posters, newsletters or computer screen savers.
• The implementation team should consider whether to implement
the checklist in one area first or to introduce the checklist unit- Resources and documentation
wide. One example of effective implementation in Washington • Where an item cannot be completed, for instance due to lack
State described initially piloting the checklist in a small number of skin marker pens, pulse oximetry or antibiotics, checklist
of operating theatres. Due to the publication in newsletters of coordinators should not tick the item dishonestly. Use regular
‘poster child’ success, the other theatres were impatient to wait audit to document this need and feed this back to the department
for official rollout and the checklist spread spontaneously.12 on a regular basis. Contact your hospital administrator so that
• Where an item on the checklist is not a routine practice in your theatre resources can be improved.
facility, for instance, a team brief or de-brief, or preincision • Some facilities have found it useful to record the checklist
antibiotics or counting surgical instruments, focused training information on a whiteboard or laminated paper in theatre, to
in that area will be needed. These items can be introduced in a refer to during the case. With operating team members changing
stepwise approach, mastering one new item for a period, before frequently, staff names particularly may be easily forgotten and
adding a second new item. the team may find it helpful to display each staff member’s name.
• Retained swabs, needles or instruments are the most commonly • Where the checklist is not part of the computer system, give each
reported serious adverse events in surgery. Training should theatre a folder with multiple paper copies. Use of the checklist
incorporate the safety impact of such tasks so that staff are given should be documented in the patient record, for instance, on
reason to perform them and to recheck the patient if the count is the anaesthetic chart.
not correct. It will be difficult to complete a surgical instrument • Routine pre-anaesthesia safety checks and the use of a pulse
count if there is no standardised pack or formal instrument list. oximeter are part of the WHO Standards for Safe Surgery, also
Through generation of formal packs and lists, and routine count- the WFSA International Standards for the Safe Practice of Anaes-
ing out of equipment when it is placed on the surgical trolley, thesia 201013. The Lifebox Foundation has been established to
the hazards of retained swabs, needles and instruments can be facilitate access to pulse oximeters in low- and middle-income
reduced. All staff groups need to understand the importance of countries where these are not available (www.lifebox.org); if you
new checks added to practice, to avoid one group finding this a do not have access to a pulse oximeter, please contact Lifebox
disruptive, time consuming intervention. and make yourself known.
• Timely administration of antibiotics at least 15 but not more than
60 minutes before knife to skin (including in caesarean section)
is an effective intervention to reduce surgical site infection, and Data collection and feedback
anaesthetists can make an important contribution to reducing • Data is a powerful way to drive change in practice, and is an
this complication. It is important to establish local antibiotic essential component of any quality improvement project. This
protocols and to make sure that these are adhered to. can be an informal or formal process, paper based or electronic,
• It is useful to encourage teams to communicate clearly. Checks depending on your local situation. The Royal College of
need to be performed out loud for all of the operating team to Anaesthetists has published a useful introduction to quality
hear. Avoid leading questions (the antibiotics have been given improvement,14 and on-line courses are available through the
haven’t they?); rather use specific communication to a named Institute of Healthcare Improvement (IHI) (http://www.ihi.
individual (Question: Dr X: have you given the antibiotics? Dr org/Pages/default.aspx).
X Answer: Yes, the antibiotics have been given). • Data can be collected in the form of ‘process measures’ – for
instance, audit samples of the patient records on a weekly basis
to see if the checklist has been completed or if antibiotics have
Timing of briefing and surgical checks been given before knife to skin. Ask a member of the team to
• The ‘Five Steps to Safer Surgery’ helps to highlight issues at the observe in theatre to see if the checklist is being done, or to check
start of the day and enables early resolution to minimize negative whether all items on the checklist have been completed.
impact on theatre safety and throughput. If your facility is going • ‘Outcome measures’ such as surgical start times, reason for delays,
to adopt this approach, it is helpful to define a fixed time for the adverse events, near misses, and postoperative infections have
pre-list briefing to occur. This will avoid team members arriving been used to support the introduction of the checklist. Patient
casually at different times, and thus inefficiency and resentment stories are a powerful way to motivate teams.
whilst waiting for other team members. • The implementation team should feed this information back
• Staff need to free themselves up from distracting tasks when the to the theatre team on a regular basis, ideally as ‘run charts’. A
checks are being completed, ideally asking for ‘a surgical pause’ or run chart is a simple plot of frequency of event (% patients with
checklist completed, or antibiotics given) against time, so that d. False: Safety steps should not be removed where they
the theatre team can see how they are performing each week or cannot be achieved. Examples include using a functioning
month. Consider comparing one theatre to another – competi- pulse oximeter and administration of appropriate
tion is an effective driver for change. Use these results to stimulate prophylactic antibiotics. Engage the administrative staff in
discussion about why things work well, or to discover the barriers the hospital so that all the items can be checked. This may
that prevent success. also involve support from charities such as Lifebox.
• It is also important to present these data to the hospital e. True: Reporting and sharing stories of near misses or
administrative team (e.g. managers) so that recurring problems adverse incidents helps people to see how the checklist can
such as lack of resource or system issues can be addressed be useful. Run charts of checklist completion rate can help
promptly. On the other hand, making them aware of improve- people to see how they are doing with the ‘process’; audits
ment in patient outcomes will further incentivise management of outcomes such as wound infections are more difficult to
to endorse patient safety projects. do, but can inspire a team to use safety checklists.
2.
a. True
SUMMARY b. False: It is even more valuable to use the WHO checklist
in an emergency as simple safety checks can easily be
• Preventable harm occurs daily during surgery across the
forgotten in a pressurised, urgent environment.
world. The WHO checklist was introduced as one means
c. False: All staff members should feel able to raise ques-
of reducing harm and improving patient safety in the
tions and talk without fear or embarrassment. This can
operating theatre. With the benefit of hindsight, trials and
be encouraged by creating an open, non-hierarchal
audit, we have gained experience and identified the key
environment.
factors that enable successful use of the checklist. These
d. False: Antibiotics should be given 15- 60 minutes prior to
are senior multidisciplinary support, surgical buy-in,
the skin incision.
ensuring underlying processes of care are in place, and
e. True: ‘Counting’ surgical swabs and instruments is an
using local champions to enthuse and encourage staff.
important part of modern surgical nursing. It is easier if
• The checklist needs to become part of routine surgical there are standardised numbers of packs used (for instance,
culture, even more so in an emergency or at the end of swabs are put on the surgical trolley in packs of 5) and a
a long shift when simple tasks are easily forgotten. With standard list of instruments so that they can be checked off
consistent use, team members will become familiar with at the end of the operation.
the checks, less embarrassed about using them, more 3.
time efficient, and break down the barriers to success. a. False: The briefing is held before the start of the list and
And ultimately, patient harm will be reduced. debriefing at the end of the list rather than before and after
every case.
b. True
c. False: A pre-list briefing can be used to pre-empt or
ANSWERS trouble shoot equipment or safety issues and anticipate
challenges for the list. The whole team should be present
1. for pre-list briefing.
a. False: Implementation of the checklist is a team effort. d. False: The briefing should take around 10 minutes, but
The team should represent everyone who works in theatre will save delays throughout the day.
in order to get buy-in from all theatre personnel. e. False: When a list has run safely, efficiently and unevent-
b. False: Experienced members of the theatre team who fully, it is useful to look at the team behaviours during that
are committed to improving patient safety should lead list that contributed to success. By verbalising what went
the implementation process. Senior members of staff well the team can actively take those positive strategies
are very influential and need to be engaged; students into their next list.
are a very valuable resource and can help support the
implementation process if they have support of the leaders
in theatre. REFERENCES AND FURTHER READING
c. False: Real time mentorship in theatre and continual
feedback on progress of implementation is a powerful 1. Weiser TG, Regenbogen SE, Thompson KD, Haynes AB, Lipsitz
driver to influence change. It is useful to use regular SR, Berry WR et al. An estimation of the global volume of
observations and informal discussions on how things surgery: a modelling strategy based on available data. Lancet.
could be improved, rather than waiting until the end of an 2008;372(9633):139–44.
implementation period to evaluate the difficulties.
2. de Vries EN, Ramrattan MA, Smorenburg SM, Gouma DJ, 8. Agency NPSA. WHO Surgical Safety Checklist 2009 [cited
Boermeester MA. The incidence and nature of in-hospital adverse 2015 21st July]. Available from: http://www.nrls.npsa.nhs.uk/
events: a systematic review. Qual Saf Health Care. 2008;17(3):216– resources/?entryid45=59860.
23.
9. Agency NPSA. ‘How to Guide’ Five Steps to Safer Surgery 2010
3. National Reporting and Learning System. [cited 2015 21st July]. [cited 2015 25th July]. Available from: http://www.nrls.npsa.nhs.uk/
Available from: http://www.nrls.npsa.nhs.uk/resources/collections/ EasySiteWeb/getresource.axd?AssetID=93286
quarterly-data-summaries/?entryid45=135410.
10. Tang R, Ranmuthugala G, Cunningham F. Surgical safety checklists:
4. Organisation WHO. WHO guidelines for safe surgery: safe a review. ANZ J Surg. 2014;84(3):148–54.
surgery saves lives 2009 [cited 2015 21st July]. Available
11. Aveling EL, McCulloch P, Dixon-Woods M. A qualitative study
from: http://www.who.int/patientsafety/safesurgery/tools_
comparing experiences of the surgical safety checklist in
resources/9789241598552/en/.
hospitals in high-income and low-income countries. BMJ Open.
5. Organisation WHO. World alliance for patient safety: 2013;3(8):e003039.
Implementation manual surgical safety checklist 2008 [cited
12. Conley DM, Singer SJ, Edmondson L, Berry WR, Gawande AA.
2015 21st July]. First edition:Available from: http://www.who.int/
Effective surgical safety checklist implementation. J Am Coll Surg.
patientsafety/safesurgery/ss_checklist/en/.
2011;212(5):873–9.
6. Haynes AB, Weiser TG, Berry WR, Lipsitz SR, Breizat AH, Dellinger EP
13. Merry AF, Cooper JB, Soyannwo O, Wilson IH, Eichhorn JH.
et al. A surgical safety checklist to reduce morbidity and mortality in
International Standards for a Safe Practice of Anaesthesia 2010. Can
a global population. N Engl J Med. 2009;360(5):491–9.
J Anaesth. 2010;57(11):1027–34.
7. Centre for Geographic Analysis HU. Patient Safety: Surgical Safety
14. Quality Improvement in Anaesthesia: Royal College of
Web Map 2014 [cited 2015 21st July]. Available from: http://maps.
Anaesthetists; 2012 [cited 2015 3rd September] Available from:
cga.harvard.edu/surgical_safety/.
https://www.rcoa.ac.uk/content/search?cx=0093520064481594677
36%3Adf2oiygfg8q&cof=FORID%3A11&ie=ISO-8859–1&query=qua
lity+improvement+in+anaesthesia
Update in
Anaesthesia
Patient Safety Update: Infusion safety,
preoperative assessment, bone cement
implantation syndrome
Toby Reynolds and Queenie Lo
Edited by:
Isabeau Walker
Originally published as Anaesthesia Tutorial of the Week, 374, 6 March 2018, edited by Isabeau Walker
This work by WFSA is licensed under a Creative Commons Attribution-NonCommercial-NoDerivitives 4.0

An online test is available for self-directed Continuous Medical Education (CME). A certificate will be
awarded upon passing the test. Please refer to the accreditation policy here
Patient Safety Updates contain learning from incidents

KEY POINTS reported to the NHS England and Wales National
Reporting and Learning System (NRLS). The aim
• Drug infusion errors are preventable.
of SALG is to highlight potential or existing patient
System measures such as the use of a
safety issues from patient stories, and to encourage
preprogramed drug library on infusion
incident reporting for the purpose of learning.
pumps and a two-person drug checking
rule, can provide additional safety barrier.
Cases reported to the NRLS database that are
• Clear, effective communication is essential associated with severe harm or death are reviewed on
Toby Reynolds for patient safety a quarterly basis and form the basis of the SALG PSU.
Perioperative Medicine The text is changed very little from the reports of the
• Identify patients at risk of bone cement
Fellow clinicians involved – these are real stories. There are
implantation syndrome, ensure all theatre
Royal London Hospital often common themes within the cases that influence
UK team members are aware and plan
the learning points highlighted. The aim of this
accordingly
exercise is to learn from the experience of others, and
Queenie Lo in that way we can all improve the care of our patients.1
Patient Safety Fellow INTRODUCTION
Royal Marsden Hospital The cases reported are reproduced with permission
UK This tutorial is based on the Patient Safety Update from the Safe Anaesthesia Liaison Group, and were
(PSU) published by the Safe Anaesthesia Liaison originally published on the RCoA and AAGBI
Isabeau Walker
Group (SALG). SALG is a professional group websites. Further information, together with this
Consultant Anaesthetist with a core membership including representatives and previous Patient Safety Updates, is available
Great Ormond Street from the Royal College of Anaesthetists (RCoA), on the SALG website.2 The cases and much of the
Hospital the Association of Anaesthetists of Great Britain information contained in this tutorial is taken from
London & Ireland (AAGBI), and National Health Service the SALG Patient Safety Updates Oct 2016 – March
UK (NHS) England Patient Safety. SALG’s quarterly 2017. SALG has not reviewed this publication.
INFUSION SAFETY Vasoactive and analgesic drug infusions

The use of powerful agents or concentrated solutions in anaesthesia
“A patient remained hypotensive despite maximum such as sedatives, analgesics or inotropes exacerbates the problems
dose phenylephrine via peripheral cannula. A central associated with infusion errors. Errors associated with infusions
line was inserted by the anaesthetist and noradrenaline include:
(8mg/50mls) commenced by anaesthetist via syringe • Inadvertent bolus administration
pump . . . it was noted that around 15mls of 50ml syringe • Siphonage and free flow
had been given, and that rate had been set wrong and • Occlusion, and subsequent post-occlusion bolus delivery7
the patient had received 15–17mls bolus. The anaesthetist
was informed and the infusion was stopped immediately. Syringe-driver pumps, the most commonly used pumps for vasoactive
The patient became hypertensive and bradycardic, then drugs in anaesthesia practice, are usually programmed to depress a
hypotensive and lost output.” syringe plunger at a set rate of mm/hr, and thus putting in a syringe
with the wrong cross-sectional area will deliver the wrong volume in
“A patient underwent elective robotic assisted cystectomy. a given time. Although many pumps have safety systems designed to
The patient had pre-existing renal failure and developed automatically detect the type of syringe that has been loaded, these are
metabolic acidosis and hyperkalaemia during the surgery. not fool proof. Use of a pre-programmed drug library, as opposed
An IV infusion of lidocaine was used –approximately 1g to setting a generic administration rate in ml/hr, can help avoid errors
administered in total. The patient became agitated post in dose calculation, although this requires an institution to keep the
extubation, was transferred to ICU, and then had a tonic pump’s drug library up to date to avoid violation errors. Involving a
clonic seizure. The patient became bradycardic and aci- colleague as a second person to check the pump settings and dose
dotic requiring noradrenaline infusion to maintain blood calculations provides an additional safety barrier.
pressure. LA toxicity was diagnosed and treated with
intralipid. The patient improved rapidly within 20 minutes Of particular relevance for high potency infusions is the delivery of a
with resolution of the bradycardia and improvement in bolus dose as a result of a complete or partial occlusion of the infusion
acidosis, and the noradrenaline infusion was stopped.” line, or other interference with the depression of the syringe plunger.
Although the infusion fluid itself is incompressible, air bubbles in
Medication errors are the third most common patient safety incident the syringe and the elasticity of the infusion line tubing add a small
reported to the NRLS3 and medication-related incidents appear amount of compliance to the system that allows a brief period of
frequently in SALG Patient Safety Updates. The World Health continued drug infusion after occlusion of the line, which is then
Organization launched its Third Global Patient Safety Challenge, delivered to the patient as a bolus when the occlusion is removed. The
‘Medication without Harm’ in March 2017 to reduce the level of more distal the occlusion is to the pump and the higher the pump
severe avoidable medication harm related to medications by 50% over operating pressure, the greater the magnitude of this post-occlusion
5 years, globally.4 The initiative is designed for all healthcare profes- bolus. Clinicians investigating an incident of inadvertent hyperten-
sionals in all care settings. There are useful lessons for anaesthetic sion during noradrenaline administration noted accidental boluses of
practice in the WHO Patient Safety Curriculum Guide,5 including almost 1ml in a simulation study that added additional compliance
an emphasis on clear communication (such as encouragement to in the system, such as a piece of infusion tubing accidentally stuck
“state the obvious”), personal aide-memoires and routine use of between the plunger and the syringe driver.8
careful checks.
Finally, an extremely important source of error in anaesthesia is to
The Patient Safety Curriculum also describes the complex systems we forget to clear the drug line after the infusion has been completed
work in, and the importance of understanding the multiple system – for instance an extension used for a remifentanil or atracurium
factors that make it possible for error to occur (patient and provider infusion.
factors; task factors; technology and tool factors; team factors;
environmental factors; organizational factors). Human errors such
as slips, lapses, mistakes and violations interact with system factors Lidocaine infusions
such as inadequate communication, lack of checking procedures Perioperative use of intravenous lidocaine infusions for analgesia
and time pressures as well as suboptimal workplace and medication during and after surgery has gained popularity in recent years. Sci-
packaging design. entific literature suggests that lidocaine is a useful adjuvant analgesic
with predictable pharmacokinetics, but it is nonetheless a drug with
Violation of strict checking rules may be more common than we a narrow therapeutic range, with central nervous system (CNS)
care to think6 (do you check/double check the name and expiry date toxicity occurring only slightly above the therapeutic plasma level.
of every ampoule of every drug that you give?). We need to think
about the way that we work as individuals, as well as controlling The dose of intravenous lidocaine suitable for analgesia in the
the environment in which we work (rushed, noisy, multiple tasks perioperative period is 1–2 mg kg−1 as an initial slow bolus followed
undertaken at the same time), to help us to reduce errors. by a continuous infusion of 0.5–3 mg kg−1h−1. The free plasma
concentration of lidocaine is determined by the total dose and rate surgeon looked for but couldn’t find, most commonly imaging results,
of injection, but is also affected by the acid–base status, hypercapnia diagnostic test results and recent summaries of recent admissions.14
and hypoxia, low plasma protein levels, and diminished hepatic or
renal function. All these factors need to be taken into account when While it is hard for any individual clinician to change these system
calculating the dose to be given.9 factors, awareness of the problem is important as it can help limit
risks. Communication breakdown was found to be the second most
A recent review of 45 small randomized controlled trials suggested common contributing factor in a series of surgical error reports
that systemic perioperative lidocaine infusion was not associated analysed in the United States, after inexperience/ lack of competence.
with increased major adverse events, but noted that current data Importantly, miscommunication was reported as a contributing factor
were underpowered to definitively exclude this risk.10 twice as often where the surgeon also reported excessive workload.15
The authors of one review note that in their experience lidocaine A more detailed study of U.S. malpractice claims identified status
toxicity is almost always a result of an iatrogenic error in dose, asymmetry, ambiguity of roles and handovers as the three most
delivery, or infusion pump programming.9 In the case described here, common contributing factors to communication breakdowns that
the rapid response to intralipid therapy suggests that the plasma levels had led to injury to surgical patients.16
of lidocaine may have been toxic for this patient.
Communication tools can be used to minimise the risk of important
information being missed. The most obvious example of this is
COMMUNICATION AND PREOPERATIVE ASSESSMENT the WHO checklist, which has been shown to reduce death and
SAFETY complications in both high- and low-resource settings. Despite initial
misgivings, the WHO Checklist has now become an accepted part of
“A patient was undergoing eye examination under a operating theatre routine in many countries, and probably has had its
general anaesthetic. He suffered a sudden desaturation, greatest impact in improving adherence to routine safety checks, and
and required transfer to critical care, ventilated and by improving teamwork and communication.17,18 However, imposi-
sedated, and later required emergency placement of chest tion of checklists and formal communication tools will not eradicate
drain which drained large volumes of pleural fluid. A CT perioperative communication errors without effective implementa-
scan that was performed and reported prior to the eye tion – effective use of safety checks requires understanding of the
examination had demonstrated a large pleural effusion benefits, appropriate training and good surgical leadership.5,18,19
with mediastinal shift.” Teamwork training, structured reflection using simulated and real
clinical episodes and adoption of a systems approach may be useful.20
The ultimate responsibility for ensuring that a patient has been

assessed adequately prior to surgery rests with the anaesthetist who BONE CEMENT IMPLANTATION SYNDROME
will give the anaesthetic (AAGBI Preoperative Assessment and Patient
Preparation 2010)11. However, system factors may contribute to Bone cement implantation syndrome (BCIS) is a poorly understood
failings in preoperative assessment and preparation. Time is one phenomenon with no agreed standard definition currently. It is
important factor. Your organisation has a responsibility to make sure characterised by hypoxia and hypotension but has a wide spectrum
that you receive notification about elective lists in good time so that of clinical features that can occur with any surgical instrumentation
you can assess the patient without undue pressure. Although not of the femoral canal, ranging from transient desaturation and
specifically mentioned in the AAGBI guideline, it makes intuitive hypotension to pulmonary hypertension and cardiac arrhythmias. A
sense that the organisation should also provide space to see the sudden drop in end tidal CO2 may herald abrupt onset pulmonary
patient, and make sure that you have access to any relevant medical hypertension and a precipitous drop in cardiac output resulting in
records. cardiac arrest.21 BCIS is described in tutorial 351.22
Missing medical records and difficulty accessing relevant test results

was a common theme in a 2000 analysis of the Australian Incident “A patient was hypoxic and hypotensive after bone
Monitoring Study database. That study found that poor communica- cement was inserted. This resolved to some extent but the
tion contributed to 46 of 197 incidents related to preoperative assess- patient had to be intubated in recovery and taken to ICU.
ment, most commonly through missing records and organisational Following local case review, the department identified
system factors such as failure to communicate orders.12 Similarly, and reported some good practice points:
a qualitative interview study in the UK found that information • Identify high risk patients
transfer between surgeons, anaesthetists and preoperative assessment
teams was often poor, particularly regarding the results of specialist • Cement implantation syndrome was not discussed
assessments.13 Another study in surgical outpatient clinics in the UK within the surgical or anaesthetic consent process. This
found that 15% of patients had missing clinical information that the
should probably be done and documented in patients –– Maintain vigilance for signs of cardiorespiratory
who are high risk. compromise
–– Aim for a systolic blood pressure within 20% of pre-
• Communication between the surgical and anaesthetic induction value. Invasive blood pressure monitoring is
teams was good however the cementing was not indicated for patients at higher risk
discussed at the WHO check –– Prepare vasopressors in case of cardiovascular collapse
• The cement curfew did not take place formally, we just
discussed it around the time of cementing. Guidance The ‘Cement Curfew’ mentioned above refers to a protocol described
should be available in theatre on how exactly this by a team in Coventry in the UK, whereby team members are given
should be done to standardise this.” pre-assigned roles for the period of the operation when BCIS is most
likely and attention is focused on readying the patient for this possible
event, and monitoring for signs of a problem.
BCIS is associated with procedures that breach the femoral canal
such as intramedullary nailing and cemented and uncemented
hip implants. Frail patients undergoing cemented hip replacement SUMMARY
surgery following hip fracture are at particularly high risk. Interven-
• Drug infusions are a common source of preventable
tions which may reduce the likelihood or severity of bone cement
errors. Users should be familiar with pump programming
implantation syndrome include medullary lavage, good haemostasis
and the possibility of unintended boluses
before cement insertion and retrograde application of cement with
the cement gun.21 • Plasma lidocaine concentrations are related to the total
dose and infusion rate, but also to other factors such as
The AAGBI published a guideline on bone cement implantation acid base status and protein binding
syndrome in 2015, which provides a structured approach to manage-
• Communication breakdown is a common source of
ment of patients requiring cemented hemiarthroplasty following a
surgical and anaesthesia error
long bone fracture.23 In the above case, the local review panel noted
that some of the recommended steps had not been completed, such as • Bone cement implantation syndrome is characterised
identification of the at-risk patient and shared team understanding of by hypoxia and hypotension around the time of cement
the problem. Clinicians in Coventry recommend a ‘Cement Curfew’ implantation in the femoral canal, but can lead to
which teams might like to consider.24 cardiovascular collapse. It is important to identify patients
at risk and to plan accordingly, making all the theatre
The AAGBI guideline recommends the following steps to minimise team aware.
the impact of BCIS:
1. Identification of patients at high risk of cardiorespiratory This tutorial is estimated to take 1 hour to complete. Please record
compromise: time spent and report this to your accrediting body if you wish to
• Increasing age claim CME points.
• Significant cardiopulmonary disease
• Diuretics To take the online test accompanying this tutorial, please click here.
• Male sex
2. Preparation of team(s) and identification of roles in case of
severe reaction REFERENCES AND FURTHER READING
• Pre-operative multidisciplinary discussion
• Pre-list briefing and World Health Organisation (WHO) 1. Macintosh R. Deaths under anaesthetics (1949) BJA 21:107–36
Safe Surgery checklist ‘time-out’ (Reference) 2. Safe Ananesthesia Liaison Group. https://www.rcoa.ac.uk/
3. Specific intra-operative roles: node/25928 (accessed Nov 13, 2017)
• Surgeon
–– Inform the anaesthetist just before insertion of cement 3. NHS Improvement. National quarterly data on patient safety
incident reports: March 2017 http://bit.ly/2qY5MI6 (accessed Nov
–– Wash and dry the femoral canal
13, 2017)
–– Apply cement retrogradely using the cement gun with
a suction catheter and intramedullary plug in the 4. World Health Organisation. Medication Without Harm. http://www.
femoral shaft who.int/patientsafety/medication-safety/en/
• Anaesthetist 5. World Health Organisation. Patient Safety Curriculum Guide. http://
–– Ensure adequate resuscitation pre-and intra operatively www.who.int/patientsafety/education/mp_curriculum_guide/en/
–– Confirm to the surgeon that you are aware that he/she
is about to prepare/apply cement
6. Smith, A. F., Goodwin, D. S., Mort, M. and Pope, C. (2005), 16. Greenberg CC, Regenbogen SE et al. Patterns of communication
Anaesthetists’ violations of safety guidelines. Anaesthesia, 60: breakdowns resulting in injury to surgical patients. J Am Coll Surg.
201–202. doi:10.1111/j.1365–2044.2004.04092.x 2007; 204:533–540
7. Keay, S, Callander, C. The safe use of infusion devices, Continuing 17. Walker IA, Reshamwalla S, Wilson IH; Surgical safety checklists:
Education in Anaesthesia Critical Care & Pain. 2004; 4:81–85, https:// do they improve outcomes? BJA 2012;109;47–54 https://doi.
doi.org/10.1093/bjaceaccp/mkh022 org/10.1093/bja/aes175
8. Snijder, R, Knape, J et al. Hypertensive Crisis During Noradrenaline 18. Bergs J, Hellings J et al. Systematic review and meta-analysis of the
Syringe Exchange: A Case Report. A&A Case Reports: 2017; effect of the World Health Organisation surgical safety checklist
8:178–181 doi: 10.1213/XAA.0000000000000458 on postoperative complications. BJS 2014; 101:150–158. (http://
onlinelibrary.wiley.com/store/10.1002/bjs.9381/asset/bjs9381.pdf?v
9. Eipe N, Gupta S, Penning J. Intravenous lidocaine for acute pain:an
=1&t=jc66zl6c&s=56b34d8d1582c56fd7fe1cb834fb95e067be22e0)
evidence-based clinical update. BJA Education, 2016; 16 292–298.
doi: 10.1093/bjaed/mkw008 19. Bergs J, Lambrechts F et al. Barriers and facilitators related to the
implementation of surgical safety checklists: a systematic review of
10. Weibel S, Jokinen J et al. Efficacy and safety of intravenous lidocaine
the qualitative evidence. BMJ Qual Saf. Published on line July 2015
for postoperative analgesia and recovery after surgery: a systematic
(https://www.zorgneticuro.be/sites/default/files/general/BMJ%20
review with trial sequential analysis. BJA 2016; 118:770–783 https://
Qual%20Saf%202015%20Bergs.pdf )
doi.org/10.1093/bja/aew101
20. McCulloch P, Morgan L, New S et al. Combining systems and
11. Association of Anaesthetists of Great Britain and Ireland 2010
teamwork approaches to enhancing the effectiveness of safety
Pre-operative Assessment and Patient Preparation. The Role of the
improvement interventions in surgery: the safer delivery of surgical
Anaesthetist 2 (http://bit.ly/2q5RsfA).
services (S3) program. Annals Surg. 2017; 265: 90–96
12. Kluger MT, Tham EJ et al. Inadequate pre-operative evaluation and
21. Donaldson AJ, Thomson HE et al. Bone cement implantation
preparation: a review of 197 reports from the Australian Incident
syndrome, BJA 2009; 102: 12–22, https://doi.org/10.1093/bja/
Monitoring Study. Anaesthesia. 2000; 55: 1173–1178. doi:10.1046/
aen328
j.1365–2044.2000.01725.x
22. So D, Yu C and Doane MA. Tutorial 351 - Bone cement implantation
13. Nagpal K, Arora S et al. Failures in communication and information
syndrome. ATOTW 2017. (http://www.wfsahq.org/resources/
transfer across the surgical care pathway: interview study. BMJ Qual
anaesthesia-tutorial-of-the-week)
Saf 2012 [online first]. doi: 10.1136/bmjqs-2012–000886
23. Griffiths R et al. Guideline: reducing the risk from cemented
14. How safe are clinical systems? Health Foundation. 2011 (http://
hemiarthroplasty for hip fracture. Anaesthesia 2015; 70:623–626
www.health.org.uk/sites/health/files/HowSafeAreClinicalSystems_
fullversion.pdf ) 24. Scrase A, Horwood G, Sandys S. Coventry ‘‘Cement Curfew’’: team
training for crisis. Anaesthesia News 2014; 327:8 –9 https://www.
15. Gawande AA, Zinner MJ et al. Analysis of errors reported by
aagbi.org/sites/default/files/ANews_October_Web_0.pdf
surgeons at three teaching hospitals. Surgery 2003;133:614–21
Update in
Anaesthesia
Patient Safety Update: Central Neuraxial
Blockade, Drug Errors and ‘Never Events’
Dr T Reynolds
Edited by
Dr Isabeau Walker
Originally published as Anaesthesia Tutorial of the Week, 357, 11 July 2017, edited by Dr Isabeau Walker
This work by WFSA is licensed under a Creative Commons Attribution- NonCommercial-NoDerivitives 4.0
QUESTIONS
Before continuing, try to answer the following questions. The answers can be found at the end of the
article, together with an explanation. Please answer True or False:
1. Regarding safe central neuraxial blockade:
a. Meningitis is a rare but well-recognised complication of spinal anaesthesia
b. Chlorhexidine in alcohol is the best solution to use for skin antisepsis prior to performing a
central neuraxial block
c. Barrier precautions for performing an aseptic CNB include hand-washing, wearing a hat, mask,
sterile gloves and gown, and using a sterile drape
d. There is no need for the operator to wear a face-mask if they are just performing a spinal
injection
e. Spinal anaesthesia should be avoided in a patient with known bacteraemia
2. Concerning drug errors:
a. Rapid bolus administration of vancomycin, magnesium or amiodarone can lead to severe
hypotension or cardiac arrest
b. Good anaesthetists rarely make a drug error
c. Retained anaesthesia drugs in IV lines are only a risk in paediatric practice
d. Dangerous drugs such as concentrated potassium should be stored separately in the
operating theatre
e. Syringe swaps are an important cause of awareness with awake paralysis
T Reynolds
3. Concerning ‘never events’: Specialty trainee in
a. Never events are unfortunate, but have no reflection on the overall safety culture of the anaesthesia
organisation Broomfield Hospital
b. Surgical events rarely feature in descriptions of never events on a national scale UK
c. A ‘never event’ usually happens because one person doesn’t do their job properly
d. The most reliable way to prevent a surgical never event is the time out check immediately Dr Isabeau Walker
prior to skin incision Consultant Anaesthetist
e. All patients should have the surgical site marked if feasible, and the mark should remain visible Great Ormond Street
under the surgical drapes. Hospital
UK
This work by WFSA is licensed under a Creative Commons Attribution- NonCommercial-NoDerivitives 4.0 International License. To view this license,
visit https://creativecommons.org/licenses/by-nc-nd/4.0/ 39
CENTRAL NEURAXIAL BLOCKADE

KEY POINTS
Meningitis is a rare but well-recognised complication of CNB,
• Meningitis is a very rare but recognised complication
occurring in <1:200,000 cases. The Royal College of Anaesthetists’
of central neuraxial blockade, and is minimised by strict
third national audit project (NAP3) summarises the risks associated
aseptic technique
with epidural or spinal central neuraxial blockade (CNB), including
• Drug errors are common in anaesthesia practice. It is the risk of meningitis.2
our responsibility to adopt safety measures in our daily
practice and to comply with standard safety procedures Nasopharyngeal commensals are the most common causative bacteria
for meningitis after spinal anaesthesia, suggesting that the cause is
• ‘Surgical’ never events - wrong site surgery, retained
droplet contamination of the spinal needle by the operator. Culture
foreign object, wrong prosthesis- are the most common
of Strep. Salivarius in this case is in keeping with droplet spread from
category of never event in clinical practice, which usually
the operator’s airway.3 The most common causative agent in epidural
occur as a result of a cascade of errors. Standardisation of
anaesthesia is a skin commensal, suggesting suboptimal aseptic
operating department procedures may be an effective
technique, also an important cause of epidural abscess.2
way to reduce surgical never events.
Risk factors for development of meningitis after CNB

INTRODUCTION Patient risk factors:
This tutorial is based on the Patient Safety Update published by the • Immune compromise
Safe Anaesthesia Liaison Group (SALG). SALG is a professional • Prolonged insertion of a catheter.
group with a core membership including representatives from the
Royal College of Anaesthetists (RCoA), the Association of Anaesthe- Endogenous source of infection
tists of Great Britain & Ireland (AAGBI), and NHS England Patient
Safety. SALG’s quarterly Patient Safety Updates contain learning • Local skin sepsis
from incidents reported to the National Health Service England • Systemic sepsis
and Wales National Reporting and Learning System (NRLS). The
aim of SALG is to highlight potential or existing patient safety issues Exogenous source of infection
from patient stories, and to encourage incident reporting for the
purpose of learning. • Contaminated equipment
• Contaminated solutions
Cases reported to the NRLS database that are associated with severe
harm or death are reviewed on a quarterly basis and form the
basis of the SALG PSU. The text is changed very little from the Case Report
reports of the clinicians involved – these are real stories. There are
‘The patient had a spinal anaesthetic and had a polyp
often common themes within the cases that influence the learning
removed in theatre. The patient returned 2 days later for
points highlighted. The aim of this exercise to is learn from the
brachytherapy (radiotherapy), and had a repeat spinal
experience of others, and in that way we can all improve the care
anaesthetic… discharged later that day. The patient was
of our patients.
rushed to Accident & Emergency in the early hours of the
morning and ended up in ITU, intubated with suspected
The cases reported are reproduced with permission from the Safe
sepsis. Discharged 13 days later.
Anaesthesia Liaison Group, and were originally published on the
Royal College of Anaesthetists and the Association of Anaesthetists Reason stated for collapse was cerebromeningoence-
of Great Britain and Ireland websites. Further information, together palitis with Strep. Salivarius bacteraemia from the spinal
with this and previous Patient Safety Updates, is available on the anaesthetic.’
SALG website.1
The cases and much of the information contained in this tutorial is Full aseptic technique is recommended during preparation and siting
taken from the SALG Patient Safety Updates July-September 2016. of CNB. The Association of Anaesthetists of Great Britain & Ireland
SALG has not reviewed this publication. (AAGBI) and American Society of Anaesthesiologists (ASA) both
recommend the use of a surgical facemask by the operator during
spinal anaesthesia.4,5
The evidence-based practice advisory from the ASA highlights the everything and apologised to the patient as per duty of
prevention, diagnosis and management of infective complications candour an hour or two postop. I thought there had been
from CNB. There are few high-level studies, so most evidence is from no sequelae as she was fine at the time. Unfortunately the
observational studies and case reports, with recommendations based patient developed new neurological symptoms after the
on expert consensus opinion.5 The ASA Practice advisory makes the operation.’
following recommendations:
‘A patient was admitted to recovery. The 20G cannula
• Consider risks and benefits of CNB on a case-by-case basis, and used for induction with remifentanil and propofol at the
consider an alternative approach in patients at high-risk of an start of a case had not been flushed along with the other
infective complication (for instance, impaired immunity) cannula during the case. We were aware that there was a
• Avoid lumbar puncture in the presence of a known epidural risk of opioid remaining in the cannula so the cannula was
abscess. flushed by the anaesthetist. The patient stopped respond-
• Consider pre-procedure antibiotics in patients with known or ing and required assisted ventilation for 30 seconds.’
suspected to have on-going bacteraemia
• An aseptic technique must be used for all CNB insertions:
–– Sterile equipment must be used (e.g. needles, catheters, DRUG ERRORS
ultrasound cover)
–– Operator to wear surgical cap and face-mask to cover Drug errors are one of the most common types of error reported to
mouth and nose the NRLS and can arise for many reasons, including slips (failure of
–– Remove jewellery (rings, watches) attention) and lapses (failure of memory), as in the cases described
–– Wash hands here. The fifth Royal College of Anaesthetists’ national audit project
–– Use sterile gloves (NAP5), ‘Accidental Awareness During Anaesthesia in the United
–– Chlorhexidine in alcohol is recommended for skin Kingdom and Ireland’ found that syringe swaps and other drug errors
preparation with adequate drying time accounted for 1 in 8 of all definite and probable cases of awareness
–– Use a sterile occlusive dressing at the catheter insertion reported to the audit.6
site.
Vancomycin, clindamicin and levofloxacin are antibiotic drugs known
Chlorhexidine in alcohol is an effective skin antiseptic, but there to lead to hypotension and even cardiac arrest when given as a bolus.
are concerns about chemical arachnoiditis if the intrathecal space Vancomycin is a well-recognised cause of ‘red man syndrome’ due to
is contaminated with chlorhexidine, for instance by splashing histamine release after rapid IV administration. Rapid administration
chlorhexidine on the spinal needle. For this reason, the AAGBI of amiodarone, phenytoin, magnesium, and hypertonic solutions
recommends using low concentration chlorhexidine (0.5%) of mannitol and saline may also cause hypotension, which can be
in alcohol for skin antisepsis prior to performing CNB, with severe.7 Residual anaesthesia drug in IV lines is another drug error
meticulous care taken to avoid chlorhexidine from reaching the that has recently attracted attention; it is the responsibility of the
CSF4. Open containers containing chlorhexidine must NOT be anaesthetist to flush all IV lines at the end of each case.8
placed on the spinal trolley.
Anaesthetists are in the unique position in medicine of prescribing,
drawing up and administering multiple different drugs during a case,
Case Reports often in rapid succession, often in situations where there may be
many other distractions. Drug errors and near misses are common in
‘A trainee anaesthetist changed the propofol syringe
anaesthesia, estimated to occur in 1:133 -1:450 anaesthetics. Based
whilst the Consultant Anaesthetist took a comfort break
in these data, the average anaesthetist could be expected to make up
and forgot to restart the machine. The infusion pump
to seven drug errors per year, and possibly two drug errors resulting
failed to give an audible alarm and the anaesthetic levels
in serious harm to the patient during a career in anaesthesia. The
were not maintained, which was only discovered when
majority of drug errors are due to human error and preventable, so
the patient moved on the operating table.’
it is obvious that we all need to put measures into place to reduce
‘Just before knife to skin for insertion of haemodialysis our drug errors9–11.
access graft, I gave vancomycin intravenously over one
minute instead of over 60 minutes as advised. It had been The most common types of drug error in anaesthesia are9–11:
a year since I had last given vancomycin IV and I simply
forgot that it could not be given as a bolus. The patient • Incorrect dose (miscalculation, concentration or infusion rate)
became red, hypotensive (40/20 initially responding to • Substitution (syringe swap)
adrenaline). I knew immediately what I had done, cor- • Repetition (extra dose)
rected it, and surgery proceeded uneventfully. I explained • Omission (missed dose)
Uncommon potentially lethal drug errors include: appropriate induction for new staff, and teaching and supervision of
junior staff. Senior leadership is an important factor in achieving this.
• Wrong route errors (e.g. IV/epidural/intrathecal wrong route
errors)
• Miscalculation of dilution (or failure to dilute) SURGICAL NEVER EVENTS
• Mis-programming of infusion pumps
• Administering a drug to a patient with a known allergy
• Failure to flush a line after a drug has been administered Case Report
‘Patient being operated on in the prone position...despite
Stabile et al. published a very informative article concerning medica-
the WHO checklist the patient was shaved and then
tion safety in a USA Anaesthesia Patient Safety Foundation (APSF)
underwent an incision on the wrong hip... once recog-
newsletter.11 The APSF is an international campaigning organisation
nised the wound was closed and surgery was performed
aimed at anaesthesia safety research and education (http://www.
on the correct hip.’
apsf.org). They have also developed a video to support the APSF
advice concerning medication safety (http://www.apsf.org/resources/
med-safety/watch). There are some things that should never happen in health care,
particularly operation on the wrong site.
The following practices have been recommended to reduce drug
administration errors9–11: In the NHS, a ‘Never Event’ is defined as ‘a serious incident that
is wholly preventable as guidance or safety recommendations that
• Label all syringes, and discard unlabelled syringes provide strong systemic protective barriers are available at a national
• Read the label on any drug ampoule or syringe before a drug is level and should have been implemented by all healthcare providers.’
drawn up or injected
• Standardise syringe labels in your theatres/operating rooms, and Never events are unambiguous, serious events, usually preventable,
use class-specific colour codes according to international ISO and are thought to be indicative of a problem in the health system.
standards (or a bar-coding system)
• Organise your workplace - keep your workspace tidy, use Mandatory reporting is required, with root cause analysis conducted
standardised drug trays, separate similar or dangerous drugs, and for each incident in a proscribed time frame and dissemination of
remove dangerous drugs from the operating theatre. learning within the organisation and more widely. There may also
• Double check medications, particularly high-risk medications, be financial implications for the institution or individual clinician
prior to administration, ideally with a second person, or using in some healthcare settings.
bar-coding technology
• Use pre-filled syringes where possible Unfortunately, the most common never events in NHS practice are
• Cover all syringes with caps to maintain sterility ‘surgical’ never events: wrong site surgery, retained foreign object
• Use standardised ‘smart’ syringe pumps in your theatre/operating post procedure, wrong implant/prosthesis.
room, with pre-set alerts and alarms
• Use labelled ‘route specific’ administration sets (e.g. IV or Evidence suggests that never events in surgery generally occur as a
epidural), with colour codes (yellow epidural, red arterial), and result of a ‘cascade’ of errors, such as:12
remove injection ports e.g. from epidural lines.
• Include a review of drugs administered in your handover checks • Scheduling errors
• Discard all unused drugs at the end of each case • Incorrect consent
• Flush all IV lines at the end of the case, before handing the • Incorrect patient information
patient over to recovery • Failure of the time out procedures
• Incorrect marking procedure
All theatres/operating rooms should have dedicated support from the • Wrong site anaesthetic block
hospital pharmacy, including support for purchase and restocking of • Confusion due to prone position or incorrect positioning/
drugs. Purchase of look-alike drugs should be avoided, or if this is application of a tourniquet
unavoidable, the anaesthesia team should be alerted to the existence of • Multiple procedures on the same patient
look-like drugs, also to any change in appearance or concentration of • Incorrectly labelled specimen
commonly used drugs. Rarely used drugs and solutions (e.g. glucose,
heparin, hypertonic saline, sterile water, epidural solutions) should Other contributing factors to surgical never events have been
be stored separately from routinely used IV solutions. described:13,14
We should all aim to develop a culture of respect and compliance • Failure to follow standard procedures, bending or breaking the
relating to patient safety, with written policies for medication safety, rules
• Human factors ‘It is difficult enough to overcome the inertia natural to

• Chaotic workplace, rushing, interruptions most of us to write to the medical journals about our suc-
• Complexity of the case, perceived emergency cesses. Believe me, it takes considerable effort to prepare a
• Communication failures communication about one’s failures.’
• Lack of training
• Confirmation bias ‘A wise man learns from his mistakes, and I hope that we
• Channelled attention can go a step further and learn from the mistakes of the
• Over confidence other man.’
• Lack of vigilance Strict asepsis is important when undertaking CNB. Drug
• Failure to understand barriers errors are common in anaesthesia practice, and can be
• Inconsistent practices between teams reduced by careful arrangement of the workspace, adoption
• Staff unable to speak up of routine safety procedures such as labelling, checking, and
use of prefilled/pre-diluted medications, with separation of
In 2014 NHS England commissioned a Never Events Task Force ‘dangerous’ drugs from commonly used drugs. All IV lines
to address the problem of continuing surgical never events in the should be flushed at the end of surgery prior to transfer to
NHS (https://www.england.nhs.uk/patientsafety/never-events/ recovery area. Standardisation of operating room procedures
surgical/). The task force recommended improved education for and an understanding of why never events occur may be an
theatre staff to understand the evolution of never events, the opportunity to reduce serious incidents in surgical practice.
adoption of ‘standard operating procedures’ for operating practice,
and consistent reporting, dissemination and learning from never
events. The National Standards for Invasive Procedures (NatSSIPS) ANSWERS TO QUESTIONS
were published in 2015 (https://www.england.nhs.uk/patientsafety/
neverevents/natssips/), with a requirement for all NHS organisations 1. Regarding safe central neuraxial blockade:
to translate these national standards into local standard operating a. True: NAP3 estimated the incidence of meningitis as a
procedures. complication of CNB as fewer than 1:200,000
b. True: Chlorhexidine in alcohol is an effective antiseptic.
With respect to wrong site surgery, the least reliable safety check is The AAGBI guidelines recommend a 0.5% chlorhexidine
at the time out immediately prior to skin incision as ‘conformation solution as sufficient for antisepsis and less likely to cause
bias’ is very common. The most effective way to catch a wrong site neurotoxicity
error is for the surgeon to assess and mark the patient preoperatively, c. True: These are the barrier precautions recommended by
with repeat checks at multiple points. Relevant to the case described the AAGBI and the ASA guidelines
here, the procedural verification NatSSIP recommends: d. False: Nasopharyngeal commensals are the most
common causative bacteria for meningitis after spinal
For procedures during which the patient’s position may be anaesthesia, suggesting that the cause is droplet
changed, marking must be applied such that it is visible at all contamination of the spinal needle by the operator
times. When the patient’s position is changed during a procedure, e. True: ASA guidelines recommend that for patients at
the surgical site should be reverified and the surgical mark high risk of infectious complications, alternatives to
checked. neuraxial techniques should be considered, but that the
decision whether or not to use a neuraxial technique
The latest data from NHS Improvement for 2016/17 includes should be made on a case-by-case basis. The guidelines
380 never events, 78% of these surgical, including 156 wrong site recommend that antibiotics should be given before
surgeries, 95 retained foreign objects post procedure, and 45 wrong CNB when the patient has a known or suspected
implant/prosthesis. This is a slight improvement on the 2015/16 bacteraemia.
data – rather too soon to say, but maybe indicates that standardisation 2. Concerning drug errors:
of our operating procedures could be a way to reduce the incidence a. True: Rapid bolus injection of these drugs has been
of surgical never events.15 associated with hypotension and cardiovascular collapse
b. False: Drug errors are common in anaesthesia and the
average anaesthetist is likely to make up to seven errors
SUMMARY per year.
c. False: IV anaesthetic agents cause harm if not flushed
All anaesthetists should be encouraged to develop a culture
after IV administration in any patient. This is particularly
of incident reporting and analysis. The anaesthetists involved
true for potent agents such as remifentanil.
in the cases reported here are to be commended. In the
d. True: dangerous drugs such as concentrated potassium
words of Mackintosh:16
should be separated from routine IV drugs, and should
be stored separately.
e. True: Syringe swaps and other drug errors accounted 7. Westbrook JI et al. Errors in the administration of intravenous
for 1 in 8 of all definite and probable cases of awareness medications in hospital and the role of correct procedures and
reported to NAP5 nurse experience. BMJ Qual Saf 2011; 20:1027–1034. (http://
3. Regarding ‘never events’: qualitysafety.bmj.com/content/20/12/1027.full).
a. False: The occurrence of a never event may reflect an 8. Bowman S et al. Residual anaesthesia drugs in intravenous lines – a
underlying problem in the health system silent threat? Anaesthesia 2013; 68: 557–61 https://www.ncbi.nlm.
b. False: In the NHS, surgical never events are the most nih.gov/pubmed/23662748 (accessed 2nd April 2017).
common category of never event 9. Glavin RJ. Drug errors: consequences, mechanisms, and avoidance
c. False: A never event usually occurs due to a cascade of Brit J Anaesth 2010; 105: 76–82 https://www.ncbi.nlm.nih.gov/
errors involving multiple individuals pubmed/20507858 (accessed 2nd April 2017).
d. False: the most reliable way to prevent a surgical
10. Wahr JA et al. Medication safety in the operating room: literature
never event is for the surgeon to assess the patient
and expert-based recommendations Brit J Anaesth 2017; 118:
preoperatively and to mark the patient, and for the
32–43 https://www.ncbi.nlm.nih.gov/pubmed/28039240 (accessed
surgical site to be rechecked at multiple points. 2nd April 2017).
e. True: All patients should have the surgical site marked if
feasible, and the mark should remain visible under the 11. Stabile M et al. Medication Administration in Anaesthesia: Time for
surgical drapes. a paradigm shift. Anaesthesia Patient Safety Foundation Newsletter.
2007; 22 http://www.apsf.org/newsletters/html/2007/fall/02_
medical_administration.htm (accessed 2nd April 2017).
12. Clarke et al. Getting surgery right. Annals Surg 2007; 246: 395–405
REFERENCES AND FURTHER READING
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1959354/
(accessed 2nd April 2017).
1. Safe Anaesthesia Liaison Group https://www.rcoa.ac.uk/salg
(Accessed 2nd April 2017). 13. Neily J et al. Incorrect surgical procedures within and outside the
operating room. Arch Surg 2009 144: 1028–34 https://www.ncbi.
2. Major complications of central neuraxial blockade in the United
nlm.nih.gov/pubmed/19917939 (accessed 2nd April 2017).
Kingdom. The 3rd National Audit Project of the Royal College of
Anaesthetists January 2009 http://bit.ly/1VBcxb9 (Accessed 2nd 14. Thiels CA et al. Surgical never events: contributing human factors.
April 2017). Surgery 2015; 158: 515–521 https://www.ncbi.nlm.nih.gov/pmc/
articles/PMC4492832/ (accessed 2nd April 2017).
3. M Wilson et al. Clinical and Laboratory Features of Streptococcus
salivarius Meningitis: A Case Report and Literature Review. Clin Med 15. NHS England Never Events Data https://improvement.nhs.uk/
Res 2012; 10: 15–25. http://bit.ly/2iVlcID (Accessed 2nd April 2017). resources/never-events-data/ (accessed 2nd April2017).
4. AAGBI. Safety guideline: skin antisepsis for central neuraxial block. 16. Mackintosh RR. Deaths under Anaesthetics Br J Anaesth 1949;
Anaesthesia 2014; 69: 1279–1286 https://www.ncbi.nlm.nih.gov/ 21:107–136 https://www.ncbi.nlm.nih.gov/pubmed/18115864
pubmed/25187310 (Accessed 2nd April 2017). (accessed 2nd April 2017).
5. ASA. Practice Advisory for the Prevention, Diagnosis, and To take the online test accompanying this tutorial, please click on
Management of Infectious Complications Associated with Neuraxial this link.
Techniques Anaesthesiology 2010; 112:000–000 https://www.ncbi.
nlm.nih.gov/pubmed/20051824 (Accessed 2nd April 2017). This tutorial is estimated to take 1 hour to complete. Please record
6. RCOA/AAGBI. Accidental Awareness during General Anaesthesia time spent and report this to your accrediting body if you wish to
in the United Kingdom and Ireland. The 5th National Audit Project claim CME points.
of the Royal College of Anaesthetists and the Association of
Anaesthetists of Great Britain and Ireland. September 2014 http://
www.nationalauditprojects.org.uk/NAP5report (accessed 2nd April
2017).
Update in
Anaesthesia
Original Scholarly Publications

The Vital Anaesthesia Simulation Training
(VAST) course: immersive simulation designed
for low-resource settings
Adam Mossenson, Christian Mukwesi and Patricia Livingston
Correspondence: mossenson@gmail.com
KEY WORDS 5 billion of the world’s 7 billion people do not have

access to safe anaesthesia and surgical care.2 There is
Simulation, low-resource, non-technical skills a global shortage of trained anaesthesia providers,
with great disparities between high-resource and
low-resource countries.3 Non-physician anaesthetists
ABSTRACT (NPAs), who commonly receive 1–3 years of
post-secondary education, provide the majority of
There is a global shortage of trained anaesthesia anaesthesia in low-resource settings.4 NPAs often
providers, with great disparities between high-and work independently in challenging environments
low-resource countries. In low-resource settings, the and have few opportunities for ongoing professional
majority of anaesthesia providers work in relative development.4,5 Training initiatives that focus on
isolation, under extreme pressure and with few anaesthetic care in low-resource district hospitals are
opportunities for continuous professional develop- needed.2 Although the challenges in this setting are
ment. The Vital Anaesthesia Simulation Training amplified, the potential for impact is dramatic.6
(VAST) course was developed for anaesthesia providers
in this context and is a collaborative project between Non-technical skills (NTSs), such as communication,
partners in Rwanda and Canada. The VAST course team working and task coordination, are vital to
aims to maximise learning in a way that is simple, anaesthesia safety.7 Up to 70–80% of untoward events
practical and vivid. The main modality used is in healthcare are associated with errors in NTSs.8
immersive simulation, with clinical environments The Anaesthetists’ Non-Technical Skills (ANTS)
replicated through low-cost materials and a focus on framework9,10 describes behaviour markers for NTSs
a case mix that reflects practice at the district hospital in anaesthesia. Clinical simulation is often used to
level. The accompanying VAST facilitator course teach ANTS.10 Adam Mossenson, MBBS,
MPH
promotes sustainability, mentors future facilitators and
Department of Anaesthesia
is supported by intuitive materials and an opportunity In high-resource settings, simulation is crucial Pain Management and
to practise components of course delivery. The VAST in anaesthesia education and training in NTSs.11 Perioperative Medicine
course was piloted in early 2018 in Kigali, Rwanda. Prohibitive costs have been considered a barrier to Dalhousie University
The pilot course demonstrated feasible course delivery simulation-based education in low-resource settings. Halifax, NS
and a participant desire for widespread dissemination However, the emotional and conceptual responses to Canada
in Rwanda. After minor course revisions, the next step the simulated environment and psychological fidelity,
is a formal evaluation of the VAST course’s ability are more essential to learning than the simulator’s
Christian Mukwesi, MD,
to strengthen anaesthetists’ non-technical skills. The physical resemblance to real life.12 Consensus is MMed
VAST course holds potential as an exciting vehicle for mounting that relatively low-cost technology paired Rwanda Military Hospital
widespread application of simulation-based education with thoughtful scenario design can create effective Kigali City
in low-resource settings. simulation-based experiential learning.13,14 Low-cost Rwanda
equipment has been used successfully for simulation-
based training of ANTS in a low-resource setting.15
Patricia Livingston, MD,
INTRODUCTION
FRCPC, MEd
The VAST course was designed for anaesthesia Department of Anaesthesia,
Although the volume of surgery performed worldwide providers working in district hospitals in low- Pain Management and
is increasing,1 it is estimated that 143 million addi- resource settings. Creation of the VAST course Perioperative Medicine
tional operations are required to address emergency has been made possible through the longstanding Dalhousie University
and essential surgical conditions in low- and middle- relationship amongst the anaesthesia departments at Halifax, NS
income countries (LMICs).2 Estimates suggest that Dalhousie University, the University of Rwanda and Canada
the Canadian Anesthesiologists’ Society International Education of high- and low-resource countries. Feedback from the informal
Foundation (CASIEF). Foundational work in Rwanda includes steering committee was invaluable in eventual course design and
an ethnographic study of ANTS,16 development of the first content. The World Federation of Societies of Anaesthesiologists
simulation centre in East Africa17 and a feasibility study evaluating (WFSA) was also engaged during this consultation period, advising
ANTS improvement with low-cost simulation.15 Prior to course on how to maximise VAST’s utility alongside existing educational
development, a needs assessment was conducted amongst Rwandan programmes. A preliminary set of scenarios was developed. Pre-pilot
anaesthesia providers to gauge interest in a new simulation training testing, first with Canadian and then with Rwandan anaesthesia
course, desired content and potential barriers to and facilitators of residents, allowed for iterative refinement of materials and the VAST
course success. Insights generated informed course design; anaesthesia course’s simulation methodology. The University of Rwanda, the
providers wanted content to reflect their daily practice and to have a Rwanda Society of Anaesthesia and the WFSA were approached for
discussion forum for clinical practice challenges and solutions. The accreditation and endorsement of the VAST course prior to its pilot.
following is a description of the VAST course’s development, design
and pilot in Rwanda.
CONTENT
COLLABORATION To achieve a balance between breadth of content and feasibility of

delivery, the VAST course is limited to 3 days. The caseload, available
Starting from inception of the idea in mid-2017, the creation process resources and required clinical performance aim were designed to
for the VAST course has been consultative and collaborative. Broad reflect practice in a district hospital in a low-resource setting. The
goals were first established by the Dalhousie anaesthesia medical predominant learning methodology is simulation and, over the
director of global health, the Dalhousie anaesthesia global health course, 15 simulation scenarios and debriefings are conducted.
fellow and the leaders of the Rwanda Society of Anaesthesia. The Content includes anaesthesia and resuscitation for obstetrics,
ongoing development of the VAST course has been the principal paediatrics and trauma as well as safe general surgery and pre- and
project of the Dalhousie anaesthesia global health fellow (AM), sup- postoperative care. Targeted case-based discussions and skills stations
ported by co-authors (CM, PL) who have had extensive experience further explore NTSs, trauma primary survey, difficult airway
in simulation and NTS training in low-resource settings.15–17 Input management, neonatal resuscitation, pain management and complex
was sought from colleagues at the Scottish Centre for Simulation and decision making. Table 1 provides a course overview.
Clinical Human Factors (SCSCHF). Simulation principles advocated
by the SCSCHF are embedded in the VAST course scenario design A number of well-established programmes are directed at enhancing
and an adapted model of its debriefing framework is a pillar of core clinical knowledge [i.e. Safer Anaesthesia from Education
the VAST facilitator course. A Dalhousie University-based nurse (SAFE) course, Essential Pain Management, Primary Trauma Course,
(Michelle Murray RN, Skills Centre Coordinator, Skills Centre for Helping Babies Breathe]. From the outset, it was the intention for
Health Sciences, Halifax, NS, Canada) provided insight into scenario the VAST course to complement these courses. With permission,
mechanics, logistics and equipment. core resources from these programmes are referenced throughout the
VAST course, reinforcing consistent clinical frameworks. Establish-
The authors wanted content to accurately reflect practice in low- ment of an immersive simulation environment and a strong emphasis
resource settings. Early in development, a course overview and on NTSs is central to the VAST course’s value as a parallel training
sample scenarios were disseminated widely through the networks opportunity. All scenarios are followed by debriefing, which involves
of the CASIEF and Dalhousie University’s anaesthesia global health participant reflection and generation of learning points applicable
unit. This informal ‘steering committee’ comprised experts in the in the workplace. Participants can deploy deliberate practice – the
field of global health and simulation training from a broad range focused repetitive performance of a cognitive or psychomotor skill
Table 1. Course overview
Day 1 Day 2 Day 3
Introduction to simulation Obstetric case-based discussion Paedriatric case-based discussion
Facilitator-led scenario a
Obstetric preoperative assessment a
Paedriatric preoperative assessmenta
Clinical frameworks Caesarean section (C-section) under spinal Paedriatric laryngospasma
Non-technical skills anaesthesiaa Trauma primary surveyb
Emergency surgery preoperative assessment a General anaesthesia for C-sectiona Trauma – paedriatrica
Pre-anaesthesia preparationa Intrapartum haemorrhage a
Trauma – adulta
Unanticipated difficult intubation b Post-partum haemorrhagea Trauma – adult reassessmenta
Rapid sequence inductiona Postoperative sepsisa
No easy answers
Pain case-based discussion Morning handover in recoverya Commitment to change
Neonatal resuscitation b
a
Simulation scenario; bskill station.
– promoting a meaningful exploration and accelerated acquisition objectives mapped to ANTS elements and space for note
of NTSs.18 Learning is summarised daily through group reflection taking. Facilitators are encouraged to record specific actions or
and the course concludes with a commitment to change workshop. behaviours observed during the scenario on a Post-it® note and
then use these observations to trigger enquiry and discussion in
the debriefing. Appendix 2 provides example scenarios from the
DESIGN PRINCIPLES course. Additionally, there are extensive course resource materials
such as a course manual, presentations with presenter notes,
The design of the VAST course seeks to maximise learning and registration and evaluation templates, equipment checklists and
simultaneously promote practical delivery in low-resource settings. participant handbooks.
Design principles include: • Key themes. Although the clinical focus changes between
scenarios, consistent attention is drawn to the role of NTSs. A
• Preparation. A fundamental level of clinical knowledge and skills systematic approach to core clinical practices such as handover,
is required for participants to meaningfully engage in simulation. history taking, examination, pre-anaesthesia preparation and
Participants are sent pre-course preparatory reading materials crisis management is reinforced across scenarios. This is supported
and guiding questions to help ensure a common understanding through printed participant resources, posters and debriefing.
of core clinical concepts. During the course, key information The authors have also developed a simplified checklist for pre-
is reviewed in case-based discussions and skills stations prior anaesthesia preparation and early steps in crisis management. This
to application in simulation. This allows for greater emphasis aide-memoire is incorporated into VAST ID badges and its use
during debriefing on behaviours and use of NTSs rather than is encouraged throughout the course (Figure 1).
knowledge gaps. Participants are prepared for simulation through • Immersive. Psychological fidelity is promoted by creating a
an orientation session that includes principles of simulation, simulated environment that reflects clinical practice. Participants
personal safety and use of scenario equipment. Time is given wear theatre scrubs and are encouraged to behave as they
for orientation to the layout of equipment and for practice of normally would during clinical work. All scenarios have accom-
basic anaesthesia skills in the simulated environment. Following panying documentation with valuable clinical information (i.e.
orientation, participants observe a short demonstration scenario, observation charts, anaesthetic charts, consent forms, imaging).
with role-play by course facilitators. This preparation phase Pathology is created through simple moulage and printed photos
is designed to create a non-judgemental, supportive learning attached to either manikins or patient actors.
environment and optimise capacity for performance in scenarios. • Inter-professional. Dedicated roles are developed for non-
• Low cost. A vivid immersive simulation environment is created anaesthesia participants in the course. Many scenarios, such
with simple props, representative documentation and low-cost as trauma and perioperative resuscitation, can accommodate
technology. The VAST course utilises SimMon software on non-anaesthesia providers as the ‘lead participant’. Further, there
paired iPads, available at http://castleandersen.dk/apps/simmon/. are active roles for nurses, students, patients and relatives during
SimMon pairs any two iOS (Apple Inc., Cupertino, CA, USA) scenarios. This promotes exploration of a diverse set of themes
devices over Bluetooth to create a simple remotely controlled such as hierarchy, conflict management, consent, complaint
patient monitor. The facilitator can adjust variables such as resolution and burnout.
oxygen saturation, blood pressure and electrocardiogram on • Scalable. To provide an appropriate clinical challenge for
one device, with participants seeing parameter changes on the participants of varied experience, scenarios can be progressed
other, which functions as a patient monitor. Visual and audible from a ‘fundamental’ level to ‘intermediate’ and ‘advanced’
cues help to develop realism within a scenario. For example, stages at the discretion of the facilitator. For each level, desired
patient desaturation is associated with a tone change of the pulse actions are indicated.
oximeter. SimMon is an affordable and intuitive tool that requires • Accessible. Equipment and resources are limited to what meaning-
only a short period of practice prior to use. Other simulation fully contributes to simulation delivery. As such, the VAST
equipment is simple and robust; basic airway manikins are used course is readily transportable and can be delivered outside the
in scenarios when airway intervention is required. When airway confines of a dedicated simulation laboratory. This allows the
management is not required, participants role-play as patients course to be run in district hospitals, reducing transportation
and follow pre-scripted instructions. Appendix 1 details the costs for participants and increasing accessibility of continuing
equipment required to conduct a VAST course. professional development. Combined discussion sessions create a
• Reproducible. The VAST course aims to be an ‘off-the-shelf ’ forum for participants to learn from a broad range of colleagues
product. Detailed simulation materials outline predetermined whereas dividing into two simulation groups maintains individu-
learning objectives, allowing the facilitator to focus on simulation als’ engagement in scenarios.
delivery and debriefing. Each simulation scenario is formatted • Local governance. A local course director is responsible for the
in a consistent fashion including an overview, set-up instruc- selection of participants, course planning and liaison with
tions, briefing guidelines, a copy of participant briefing cards professional bodies and relevant authorities. External support is
and a scenario run sheet with facilitator notes. The debriefing provided as required.
page includes the debriefing framework as practised in the • Sustainable. The VAST facilitator course is conducted immedi-
VAST facilitator course, the scenario’s predetermined learning ately following the VAST course. The facilitator course begins
training programme, in a low-resource setting. Some revision of

course materials will occur, particularly to strengthen the focus on
NTSs, improve interactivity in the discussion sessions and expand the
scope of facilitator training. Participants expressed a desire for more
supporting resources. In the future, this will be addressed through the
development of the VAST course website (http://vastcourse.org) and
review of hard and soft copy materials provided. To simplify delivery
and test course mechanics, the pilot courses included only anaesthesia
providers. However, the VAST course is designed to accommodate
inter-professional participants. Future courses should endeavour to
include participants outside anaesthesia, that is, nursing, surgical
and medical colleagues. This will ultimately establish a richer and
more dynamic learning experience. The VAST facilitator course
will be expanded to a 2-day programme. In addition to increasing
the opportunity for practice in components of facilitation, trainee
facilitators will be tasked with the design and delivery of their own
simulation scenarios. This exercise helps build confidence with the
Figure 1. VAST course aide-memoire. The VAST course aide-
memoire is printed as a double-sided, 5 × 8.5cm plastic card.
internal workings of simulation.
The aide-memoire is looped on a ring-pull ID clip that is given to
all participants. This ID clip is worn throughout the course and
its use encouraged when appropriate. BP, blood pressure; ECG, FUTURE DIRECTIONS
electrocardiogram; ETT, endotracheal tube; HR, heart rate; IV,
intravenous; LMA, laryngeal mask airway. After the success of the pilot courses, there is enthusiasm for ongo-
ing delivery of the VAST course in Rwanda. Future delivery will
with an exploration of the theoretical principles of simulation incorporate Rwandan anaesthesia providers who have completed the
methodology. Trainee facilitators are then familiarised with VAST facilitator course, supported by international facilitators. In
the practical aspects of the VAST course including equipment, addition, planning for broader dissemination of the VAST course is
technology and the mechanics of conducting simulated scenarios. in progress, with the ongoing support of the CASIEF and WFSA.
Over time, trainee facilitators are mentored towards independent Courses will now aim to have an inter-professional participant
facilitation on subsequent courses. The goal of facilitator group, with each simulation group ideally comprising three or four
training is to develop a local network of simulation leaders both anaesthesia providers, two nurses and one or two doctors (surgeons or
for teaching the VAST course and more broadly to promote medical officers) from a non-anaesthesia background. A longitudinal
simulation-based education. study is also underway, formally evaluating the impact of the VAST
course on the development and retention of participants’ NTS.
Additionally, Dalhousie University and the University of Rwanda
COURSE PILOT IN RWANDA – JANUARY 2018 are extrapolating the VAST course into a ‘very VAST’ simulation
curriculum for first year anaesthesia trainees in Rwanda. Ongoing
The VAST course was piloted three times over 3 consecutive weeks in collaboration and affiliation is being sought with the CASIEF and
January 2018 in Kigali, Rwanda. In total, 40 participants completed WFSA to bolster delivery of the VAST course in Rwanda and to
the VAST course and 12 completed the VAST facilitator course. consider if the VAST course has a role in other low-resource settings.
The pilot courses represented the first time that the VAST course Although the current materials are in English, translation to other
had been conducted in its entirety. This created an opportunity to languages is planned.
test feasibility and gather information on the logistics of running a
3-day simulation programme on a modest budget in a low-resource
setting. In reviewing course feedback, participants appreciated the CONCLUSION
simulation format and case mix. They were consistently positive
about interactivity, the supportive learning environment, course Simulation-based education offers a dynamic and safe forum for
organisation, central themes and time management. There was a practical application of knowledge and skills. In debriefing, there is
strong desire to see the course disseminated throughout Rwanda opportunity to reflect on performance and contemplate meaningful
and that it be offered to other health professionals. learning outcomes. The successful piloting of the VAST course
reinforces the feasibility of offering simulation-based learning
outside the simulation laboratory. The next important step is to
LESSONS LEARNT evaluate programme efficacy for developing NTS. The VAST course
holds potential as an exciting vehicle for widespread application of
The key outcome from the pilot was demonstrated feasibility of simulation-based education in low-resource settings.
conducting the VAST course, a low-cost immersive simulation
APPENDIX 1: VAST COURSE EQUIPMENT LIST • Other than the laptop and projector, personnel and equipment
will need to be multiplied by the number of parallel simulation
The equipment list in Table 2 is for one simulation group: groups.
• Parallel simulation groups can be run in order to accommodate

more participants.
Table 2. VAST course equipment list
Category Detail
Personnel Simulation group size should be limited to seven participants:
• two facilitators are required for each simulation group
In addition to the facilitators, a simulation coordinator is recommended. Responsibilities include:
• set-up and changeover between scenarios
• checking equipment completeness and function
This role can be conducted by an additional facilitator or a simulation technician
General Laptop
Projector and cable for laptop
Whiteboard or large paper for debriefing
Markers
USB loaded with course materials and presentations
Printed materials:
• VAST course manual
• VAST course scenario documentation
• VAST facilitator course manual
• VAST course handbooks (for participants)
• VAST facilitator course handbooks (for trainee facilitators)
• supplementary resources:
–– equipment checklist
–– scenario documentation inventory
–– participant registration template
–– course timetable
–– evaluation forms
–– course certificates
Wall posters:
• SBAR for handover
• AMPLE for history
• A to E for examination
• ANTS framework
• WHO Surgical Safety Checklist
Blu Tack or tape for hanging posters
Post-it® notepad (4 × 6 inches)
Masking tape
Manikins Adult intubation trainer
Paediatric intubation trainer (age ≈ 3 years)
NeoNatalie
Monitors SimMon app loaded on two devices (iPad + iPad or iPad + iPhone) (https://itunes.apple.com/ca/app/simmon/
id364731597?mt=8)
Table 2. VAST course equipment list continued
Category Detail
Simulation set-up Organise equipment into four boxes:
• boxes 1, 2 and 3 are for use during all scenarios
• boxes 1, 2 and 3 should be located near the anaesthetic workstation
• box 4 contains extra equipment that is required only for certain scenarios
Box 1 – airway equipment:
• oral airway (3, 4, 5), nasal airway
• Yankauer sucker, laryngoscope, laryngoscope blade (Mac 3)
• ETT size 4, 5, 6, 7, 8, bougie, stylet
• LMA (size 3 – ideally second generation)
• tie, 20-ml syringe
Box 2 – breathing equipment:
• self-inflating bag (adult, paediatric, neonate)
• Mapleson F circuit (Ayres T-piece)
• mask (adult, paediatric, neonate)
• nasal prongs, O2 mask
• pulse oximeter probe (does not need to function)
Box 3 – circulation equipment and medications:
• IV cannulae (14, 16, 18, 20, 22G)
• IV fluids, tubing
• tourniquet, tape
• blood pressure cuff, stethoscope, ECG leads
• labelled empty syringes – ketamine, thiopentone, propofol, succinylcholine, rocuronium, morphine, fentanyl,
midazolam, adrenaline, atropine, ephedrine, ondansetron, antibiotic, oxytocin, ergometrine, carboprost,
labetalol, hydralazine, MgSO4, lignocaine, tetanus immunisation
• labelled empty tablet containers – misoprostol, nifedipine, methyldopa
Box 4 – extra equipment:
• surgical drape and clips × 2
• surgical gown × 2, gloves, hats
• pre-cut shirt and pants, reassembled with Velcro®
• sheets for gravid uterus
• wedge or sheets for lateral tilt
• ‘blood’-soaked pads (see VAST course manual for instructions on how to make fake blood)
• clean dressings for paediatric burns
• neonatal resuscitation equipment:
–– neonatal self-inflating bag, neonatal mask
–– suction (bulb or suction device)
–– cord clamp or tie
–– scissors
–– towel
Additional large equipment required:
• stretcher or operating room table
• pillow × 2
• sheet × 2
• small table × 2 (for surgical and anaesthesia equipment)
• IV pole × 2
AMPLE, Allergies, Medications, Past medical history, Last ate, Events; ECG, electrocardiogram; ETT, endotracheal tube; IV, intravenous; LMA, laryngeal mask airway;
SBAR, Situation, Background, Assessment, Recommendation; WHO, World Health Organization.
APPENDIX 2: EXAMPLE SCENARIOS
2.3 – SCENARIO
- C-section under spinal anaesthesia
Learning objectives
Identify the need for left uterine displacement during C-section under spinal anaesthesia
Recognise and treat post-spinal hypotension
Consider the differential diagnosis and management for persistent hypotension post-spinal
Scenario summary
Grace is a 21-year-old G1P0 who is in the operating theatre and has just been given spinal
anaesthesia for urgent C-section. She has been in labour for 18hrs, is 5cm dilated with poor
progression, signs of foetal distress and the surgeons are concerned regarding cephalopelvic
disproportion. The co-facilitator is an anaesthesia provider, wanting to take a quick break.
The scenario starts with handover between two anaesthesia providers. Routine care post-
spinal anaesthesia is required. Optional progression of the scenario to Int. hypotension and
nausea or Adv. persistent hypotension stages requires management of post spinal hypotension
and consideration of the differential diagnosis for persistent hypotension respectively.
SCENARIO SETUP
Location Operating theatre
Layout Patient on stretcher, surgical instruments on a small table
Patient
Type Human actor, wearing a patient gown
Details Grace, 21-year-old female
Position Sitting up, immediately post insertion of spinal
Equipment on Pulse oximeter, 16G IV line with fluids, BP cuff, ECG leads
Additional Patient gown, rolled blankets for gravid uterus
Other
Standard VAST equipment See VAST Course manual for standard equipment list
Wedge / sheets for left lateral tilt
Extra equipment Surgical equipment on tray for C-section - gowns, drape
Antibiotic syringe out on equipment table
Monitors 2 x iPads with SimMon
Prefilled pre-anaesthesia, observation, consent and intra-op
Documentation charts
Anaesthesia provider (co-facilitator)
Simulated patient
Cut out briefing notes Scrub nurse
Circulating nurse
Surgeons, medical students
2.3 – BRIEFING INSTRUCTIONS
Overview of roles
Lead participant Anaesthesia provider
Anaesthesia provider (co-facilitator)
Simulated patient
Present at start Scrub nurse
Circulating nurse
Surgeons, medical students
The co-facilitator will ‘leave’ the scenario after handover:
Additional - Cue the co-facilitator to re-enter if called for by the lead participant
or at any stage to help with crisis management following their ‘break’
Prepare the scenario

Isolate the lead participant outside the simulation room
Prepare the other participants in the simulation room:
- Allocate roles and briefing cards
- Allow time for reading and asking questions
- Arrange participants in the scenario according to their roles
-
Provide briefings:
- In the simulation room for ‘other participants’
- For the lead participant after the scenario is prepared and other participants briefed
Briefing in the simulation room

This is Grace, a 21-year-old female who is the operating theatre
She is having an urgent C-section for failure to progress
The spinal anaesthetic has just been placed
Briefing for the lead participant

You are an anaesthesia provider
You are going into the operating theatre to give a quick coffee break to one of your
colleagues who has been working solidly all morning
How to start the scenario

Cue the lead participant to enter the operating theatre to give the colleague a break
2.3 – COPY OF BRIEFING CARDS
2.3 – Anaesthesia provider (co-facilitator)

You are an anaesthesia provider and are in desperate need for a coffee break. You have just placed
the spinal anaesthetic and the Grace’s legs are starting to feel numb. As the lead participant enters,
lay Grace down flat, handover with SBAR and then leave the scenario:
S situation:
- This is Grace, a 21-year-old female, G1P0 having an emergency C-section for failure to
progress with signs of foetal distress
B background:
- Grace has no allergies, takes no regular medications, has no significant past medical history
- I have just placed the spinal (2.2mls 0.5% heavy bupivacaine)
- I have just given the antibiotics
A assessment:
- Grace has told me her legs are numb, so I think the spinal is working well
R recommendation:
- All her documentation is here, the nurses have my number if you need me, I just desperately
need to take a quick break
Extra notes:
- Wait to be cued by the facilitator before returning to the scenario
2.3 – Simulated patient

Your name is Grace. You are a 21-year-old female, G1P0 and about to have an urgent C-section:
- You have been in labour for 18hrs with failure to progress and signs of foetal distress
- You are otherwise well, have no past medical history, take no medications and have no
allergies
- The spinal anaesthetic has just been placed and your legs are feeling numb
Follow this instruction only if cued by the facilitator:
- One tap on your foot – complain of having nausea and wanting to vomit
- Two taps on your foot – complain of feeling terrible. You now have difficulty talking and
breathing, are feeling anxious and your heart is racing
2.3 – Scrub nurse

Act realistically in this role
- If tapped on the shoulder – tell anaesthesia the patient has a rash on her abdomen
2.3 – Circulating nurse

Act realistically in this role
- If tapped on the shoulder – comment to the anaesthesia provider, “When my sister was
pregnant, she was so much more comfortable on her side…will she be ok on her back?”
2.3 – Surgeons, medical student

You should be talking near the surgical equipment:
- After the patient is lying down, ask if it is ok to prep and drape
- Start the surgery and deliver the baby if time allows. The operation is going routinely
-
Give this information only if asked - there is a widespread rash over the patient’s abdomen
54
2.3 – SCENARIO SEQUENCE (10 minutes)
Stages Parameters Actions Transition triggers Additional notes

Uterine displacement or Post-spinal hypotension possible causes:
Initial vitals: Receive handover
A. Alert lateral tilt - Drug induced vasodilation / neuraxial blockade
Lay patient down
B. RR 20, SaO2 99% Prompts: - Aorto-caval compression
Position with L uterine displacement
C. HR 90, BP 100/56 1. 2nd set of vitals - High spinal
Fund. Scan monitoring and confirm readings
2. One tap circulating - Haemorrhage or hypovolaemia
2nd set of vitals: Confirm – IV and running fluids, vasopressor
nurse – “when my sister was - Anaphylaxis
A. Alert available, antibiotics given
pregnant, she was so much more - Vasovagal
B. RR 24, SaO2 98% Communicate with surgical team
comfortable on her side…will she - Drug overdose or toxicity
C. HR 98, BP 90/48 Prepare oxytocin for delivery
be ok on her back?” - Amniotic embolism
Option – If time allows, progress to intermediate stage – hypotension and nausea or progress to end
Reassure patient Recognise and treat Anaphylaxis grades:
hypotension Grade 1 – Mild (mucocutaneous signs only)
A. Alert – nauseated ++ Confirm sufficient uterine displacement
B. RR 25, SaO2 97% Prompts: Grade II – Moderate (multi-organ manifestations)
Int. Treat hypotension:
1. Change in vital signs Grade III – Life-threatening (severe hypotension
C. HR 115, BP 82/41 - Fluid bolus, vasopressor
2. One tap patient’s foot – or high airway pressure)
Recycle BP and reassess vital signs triggers nausea Grade IV – Cardiac arrest
Option – If time allows, progress to advanced stage – persistent hypotension or progress to end
Recognise the crisis, call for help, allocate tasks
Adrenaline (epinephrine) dosing in anaphylaxis:
Patient looks awful, sweaty Support A / B / C: Consider the differential - Initial dose:
- Assess airway diagnosis for hypotension o Grade II – 20mcg IV or 500mcg IM
A. Hoarse voice - Give O2, consider salbutamol o Grade III – 100mcg IV or 500mcg IM
Difficulty talking - Fluid bolus, vasopressor, adrenaline Prompts: o Grade IV – 1mg IV
B. RR 30, SaO2 86% Consider the differential diagnosis: 1. Two taps patient’s foot - Consider IM if no IV access or no monitoring
Adv. Difficulty breathing - Check block height – triggers breathing difficulty - Repeat adrenaline after 1-2 minutes if needed
Diffuse wheeze - Assess amount bleeding with surgeons 2. One tap scrub nurse – - Increase dose if no clinical improvement
C. HR 135, BP 70/32 - Assess for signs of anaphylaxis: comments on the widespread rash - Prepare an adrenaline infusion, titrate to effect
D. Responds to voice 3. Cue original anaesthesia
o Diagnose and treat anaphylaxis
Extremely anxious provider to return from break
Communicate with the team: Anaphylaxis guideline – www.anzaag.com
E. Widespread rash and ask what is happening
- Expedite the surgery
- Plan for ongoing management of the patient
A. Alert
End B. RR 22, SaO2 96% End the scenario when expected actions performed or 10 minutes has elapsed
C. HR 90, BP 110/56
www.wfsahq.org/resources/update-in-anaesthesia
Place Post-itâ note here
Broken underline = ANTS element

Management of persistent hypotension post-spinal
ANTS framework
SA = Situation awareness
Recognise and treat post-spinal hypotension
- Providing and maintaining standards – TM
TM = Task management
DM = Decision making
Learning objectives
TW = Team working
- Recognising and understanding – SA
All elements – TM, TW, SA, DM

- Gathering information – SA
Left uterine displacement
2.3 – DEBRIEFING (25 minutes)
Micro-teaching
-
Reactions
Messages
Analysis
Agenda
Home
Take
3.6 – SCENARIO
- Trauma – motorbike accident
Learning objectives
Prepare for the arrival of a trauma patient
Co-ordinate the completion of a primary survey
Institute immediate management for a compound fracture
Scenario summary
This scenario is set in the emergency department. Eric, a 27-year-old male motorbike driver
has been hit on his R side by a car travelling at low speed. He has extensive rib bruising and
an open R femur #. The scenario starts without a patient present. Participants are required
to prepare for the ambulance arrival. The ambulance officer (co-facilitator) enters and
provides handover. Coordination of primary survey and # management must be completed.
SCENARIO SETUP
Location Emergency department
Patient on a stretcher:
- Note – the scenario starts without a patient
Layout (Either cover the patient with a sheet, to have them ‘outside’ the scenario or
\
if the stretcher is on wheels, have it outside the room to be wheeled in)
Patient
Type Human actor
Details Eric, 27-year-old male
Position Supine on stretcher
Equipment on C-spine collar, pre-cut shirt and pants closed with Velcro
Photos of R chest injury, open R femur # under clothes
Additional Fake blood on pants
Other
Standard VAST equipment See VAST Course manual for standard equipment list
C-spine collar, photos of chest and leg injuries
Pre-cut shirt and pants closed with Velcro
Extra equipment Sheet to cover patient at start of scenario
Fake blood
Monitors 2 x iPads with SimMon
Documentation Blank observation, blank pre-anaesthesia chart
Ambulance officer (co-facilitator)
Simulated patient
Cut out briefing notes Nurse - A
Nurse - B
Radiographer
3.6 – BRIEFING INSTRUCTIONS
Overview of roles
Team approach, consisting of:
- Nurse - A
- Nurse - B
Lead participants - Anaesthesia provider
- Surgeon
- Medical officer
- Radiographer
All team members:
Present at start - The ambulance officer (co-facilitator) and patient are initially ‘outside’
the scenario. Cue them to enter after the first transition trigger.
Additional None available
Prepare the scenario

Isolate the patient and ambulance officer (co-facilitator) ‘outside’ the scenario:
- Allocate them their briefing cards, allow time for reading and asking questions
- Achieve this by either covering the patient with a sheet or if the stretcher has
wheels, the co-facilitator can wheel the patient in during the scenario
Prepare all participants in the simulation room:
- Inform them to ignore the patient covered by a sheet
- Allocate roles and briefing cards
- Allow time for reading and asking questions
- Confirm participants
-
Provide briefing:
- In the simulation room for all participants
-
Team briefing in the simulation room

You have been attending a farewell morning tea for a senior emergency department nurse
who is retiring:
- One of your colleagues received a phone call about a serious car versus motorbike
accident near the hospital
- The patient is being brought to the hospital by ambulance and will arrive very soon
- As a team, you need to go to the resuscitation bay to prepare for the patient’s arrival
How to start the scenario

You are about to enter the emergency department resuscitation bay:
- When you enter, you will have a short amount of time to get ready for the patient’s arrival
(Note - If the patient is in the simulation room covered by a sheet, inform the participants to ignore
anything in the room that is covered by a sheet)
3.6 – COPY OF BRIEFING CARDS
3.6 – Ambulance officer (co-facilitator)

You and the patient are initially ‘outside’ the scenario. When cued to enter the scenario,
either wheel the patient into the room or remove the sheet covering the patient.
Handover using SBAR:
S situation:
- 27-year-old male, motorbike driver hit by a car. Car travelling at low speed
- The accident occurred near the hospital, around 10 minutes ago
B background:
- No significant allergies, medications, past medical history
A assessment:
- He is in pain. We were so close, so I brought him here without delay for treatment
R recommendation:
- Can you take over his care?
Prompts:
1. One tap – you will be cued to give this prompt if there is not a clear team leader.
Ask the team “Who is in charge of the patient? I need to leave my paperwork with
someone.”
2. Two taps – tell the lead participant “I wanted to give antibiotics for his leg, but I didn’t
have time to get IV access”
3.6 – Simulated patient

Your name is Eric, A 27-year-old male. You have no significant past medical history, take no
medications and have no allergies. You last ate 2 hours ago (rice, beans and vegetables). You
were riding your motorbike and were hit on the R side by a car. You were wearing a helmet
and did not lose consciousness. You have severe pain in your R chest and R leg.
- If tapped once on the foot – complain, “Arrrrggghhhh…my leg hurts so much.
-
Please help me.”
3.6 – Nurse A
You are an experienced and capable nurse. Act realistically in this role
- If tapped once on the shoulder – ask the anaesthesia provider “Should I
prepare a fluid line for the patient?”
3.6 – Nurse B
You are an experienced and capable nurse. Act realistically in this role
- If tapped once on the shoulder – ask loudly “Please can just one person give me
instructions? It is very difficult to work with so many people making decisions!”
3.6 – Radiographer
You are a radiographer. Simulate conducting X-rays if requested by the team
3.6 – SCENARIO SEQUENCE (10 minutes)
Stages Parameters Actions Transition trigger Additional notes
Introductions amongst staff Prepare medications or equipment

Identify roles and capabilities prior to patient arrival
Fund. Pre-allocate tasks Prompts:
No patient
Prepare equipment and medications 1. Briefing to participants
Don personal protective equipment: 2. One tap nurse A – “Should I
- Gloves, eye wear, gowns prepare a fluid line for the patient?”
Components of the primary survey:

A. Alert and in pain ++ Receive handover
A. Assess airway patency, give oxygen
B. RR 28, SaO2 96% Conduct primary survey: Identify a team leader to co-ordinate Maintain C-spine precautions
R sided chest bruising - Prioritise A-E assessment the primary survey B. Look, feel, listen
Equal breath sounds - Recognise and treat life threats Give oxygen, attach pulse oximeter
Prompts:
C. HR 100, BP100/56 Co-ordinate activities: Note rib bruising
1. One tap co-facilitator – “Who is
Fund. Capillary refill 2 seconds - Identify a team leader C. Assess colour, perfusion, pulse
in charge of the patient? I need to leave my
Skin slightly cool - Use closed loop communication Attach BP cuff and check BP
paperwork with someone.”
D. AVPU - A, pupils equal - Use a systematic approach Establish IV access, blood for X-match
Moving all 4 limbs 2. One tap nurse B - “Please can just
- Share information one person give me instructions? It is very Request a CXR
E. Open right femur # Documentation difficult to work with so many people D. Assess AVPU, pupils and glucose
Temperature 36.1oC Communicate with patient making decisions!” E. Expose patient - note open femur #
Blood sugar 4.5mmol/L Maintain patient dignity Assess for external haemorrhage
Maintain patient dignity and temperature
Recognise the open #

Immediate management for open #:
Prompts: - Tetanus prophylaxis
Recognise and manage an open #
Fund. 1. One tap on the patient’s foot - Antibiotics
As above Begin secondary survey – “Arrrgggh, my leg hurts so much…” - Analgaesia
Plan for transfer for surgery 2. Two taps co-facilitator – “I - # reduction
wanted to give antibiotics for his leg, but I - Splinting and immobilisation
didn’t have time to get IV access”
commercial reproduction should be addressed to: World Federation of Societies of Anaesthesiologists, Dean Bradley House, 52 Horseferry Rd, London SW1P 2AF, UK.
End As above End the scenario when expected actions performed or 10 minutes have elapsed
59
60
3.6 – DEBRIEFING (25 minutes)
Reactions Learning objectives
Prepare for the arrival of a trauma patient

- Planning and preparing – TM
- Assessing capabilities – TW
- Anticipating – SA
Agenda
Co-ordinate the completion of a primary survey Place Post-itâ note here
- All elements – TM, TW, SA, DM
Immediate management of a compound fracture

- Gathering information – SA
Analysis
Micro-teaching
ANTS framework
TM = Task management
TW = Team working
Take
SA = Situation awareness
Home DM = Decision making
Messages
Broken underline = ANTS element
www.wfsahq.org/resources/update-in-anaesthesia
8. Flin R, O’Connor P, Crichton M. Safety at the Sharp End: A Guide to

DECLARATION
Non-Technical Skills. Ashgate Publishing, Farnham; 2017.
Financial and in-kind support was provided by the Dalhousie 9. Fletcher G, Flin R, McGeorge P, Glavin R, Maran N, Patey R.
University Anesthesia Office of Education and the Canadian Anaesthetists’ non-technical skills (ANTS): evaluation of a
Anesthesiologists’ Society International Education Foundation for behavioural marker system. Br J Anaesth 2003; 90: 580–8.
course materials and running costs of the pilot VAST courses, Kigali, 10. Flin R, Patey R, Glavin R, Maran N. Anaesthetists’ non-technical skills.
Rwanda, 2018. Br J Anaesth 2010; 105: 38–44.
11. Higham H, Baxendale B. To err is human: use of simulation to
enhance training and patient safety in anaesthesia. Br J Anaesth
REFERENCES 2017; 119: 106–14.
1. Weiser TG, Haynes AB, Molina G, Lipsitz SR, Esquivel MM, Uribe- 12. Maran NJ, Glavin RJ. Low- to high-fidelity simulation – a continuum
Leitz T et al. Estimate of the global volume of surgery in 2012: an of medical education? Med Educ 2003; 37: 22–8.
assessment supporting improved health outcomes. Lancet 2015; 13. Lorello GR, Cook DA, Johnson RL, Brydges R. Simulation-based
385 (Suppl. 2): S11. training in anaesthesiology: a systematic review and meta-analysis.
2. Meara JG, Leather AJ, Hagander L, Alkire BC, Alonso N, Ameh EA Br J Anaesth 2014; 112: 231–45.
et al. Global Surgery 2030: evidence and solutions for achieving 14. Gu Y, Witter T, Livingston P, Rao P, Varshney T, Kuca T, Dylan Bould M.
health, welfare, and economic development. Lancet 2015; 386: The effect of simulator fidelity on acquiring non-technical skills: a
569–624. randomized non-inferiority trial. Can J Anesth 2017; 64: 1182–93.
3. Kempthorne P, Morriss W, Mellin-Olsen M, Gore-Booth J. The WFSA 15. Skelton T, Nshimyumuremyi I, Mukwesi C, Whynot S, Zolpys L,
Global Anesthesia Workforce Survey. Anesth Anal 2017; 125: 981–90. Livingston P. Low-cost simulation to teach anesthetists’ non-
4. Hodges SC, Mijumbic C, Okello M, McCormick BA, Walker IA, Wilson technical skills in Rwanda. Anes Anal 2016; 123: 474–80.
IH. Anaesthesia services in developing countries: defining the 16. Livingston P, Zolpys L, Mukwesi C, Twagirumugabe T, Whynot
problems. Anaesthesia 2007; 62: 4–11. S, MacLeod A. Non-technical skills of anaesthesia providers in
5. Enright A. Review article. Safety aspects of anesthesia in under- Rwanda: an ethnography. Pan Afr Med J 2014; 19: 97.
resourced locations. Can J Anesth 2013; 60: 152–8. 17. Livingston P, Bailey J, Ntakiyiruta G, Mukwesi C, Whynot S, Brindley
6. LeBrun DG, Chackungai S, Chao TE, Knowlton LM, Linden AF, P. Development of a simulation and skills centre in East Africa: a
Notrica MR et al. Prioritizing essential surgery and safe anesthesia Rwandan-Canadian partnership. Pan Afr Med J 2014; 17: 315.
for the post-2015 development agenda: operative capacities of 78 18. Motola I, Devine LA, Chung HS, Sullivan JE, Issenberg SB. Simulation
district hospitals in 7 low- and middle-income countries. Surgery in healthcare education: a best evidence practical guide. AMEE
2014; 155: 365–73. Guide No. 82. Med Teach 2013; 35: e1511–30.
7. Gordon M, Derbyshire D, Baker P. Non-technical skills to enhance
patient safety. Med Educ 2012; 46: 1042–52.
Update in
Anaesthesia
Long-term venous access devices and

anaesthesiologists
Vibhavari Milind Naik, Keerthi S Rao, Basanth Kumar Rayani,
Maddirala Subrahmanyam and Rajeev Subramanyam
Correspondence: vibnaik@gmail.com
KEY WORDS former is used only in a special patient population

and the latter is considered an intermediate-term
Vascular access devices, implanted ports, port- access technique.1
a-cath, indwelling catheters, Hickman catheter,
complications, catheter-associated infections, catheter As an increasing number of patients are managed with
obstruction these devices, the anaesthesiologist needs to be well
versed in their care. Long-term venous access devices
have traditionally been placed by interventional
ABSTRACT radiologists, surgeons or oncologists. Anaesthesi-
ologists have the prerequisite skill set for placing
Vibhavari Milind Naik The use of long-term venous access devices is central lines. Long-term venous access requires some
Basavatarakam Indo- increasing. Anaesthesiologists frequently encounter modification of the placement procedures: tunnelling
American Cancer Hospital patients, within and outside the operating room, or creating a subcutaneous pocket for ports. Hence,
and Research Institute with long-term venous access. It is important that anaesthesiologists can become increasingly involved
Hyderabad anaesthesiologists are well informed about these in establishing these lines and maintaining their use
India devices, their indications, techniques for implantation in patient care. Anaesthesiologists can take the lead
and use, and maintenance. In this narrative review, we in forming a hospital-based ‘vascular access team’.
Keerthi S Rao discuss two commonly used long-term venous access This review describes the types of long-term venous
Rainbow Hospital for devices: implantable ports and tunnelled catheters. access devices and associated indications, placement
Women and Children We discuss the indications and contraindications, our techniques, precautions, anticipated complications
Hyderabad technique for placement, maintenance protocols and and maintenance care.
India anticipated complications associated with implanted
ports and tunnelled catheters. A goal of this review
Basanth Kumar Rayani is to encourage anaesthesiologists to become more TYPES OF LONG-TERM VENOUS ACCESS
Basavatarakam Indo- involved in placement and maintenance care of these DEVICES
American Cancer Hospital devices.
and Research Institute The two broad categories of long-term venous access
Hyderabad are ports and tunnelled catheters. Table 1 compares
India INTRODUCTION the characteristic features, advantages and disadvan-
tages of both. Use of multi-lumen catheters allows
Maddirala Subrahmanyam Long-term venous access is required for many patients simultaneous administration of non-compatible
Rainbow Hospital for who need prolonged intravenous therapy to more medications. The material of the catheter determines
Women and Children reliably provide chemotherapy, parenteral nutrition, its longevity and durability. Newer silicone and
Hyderabad antibiotics or fluid replacement therapies. Long-term polyurethane catheters are biocompatible and have a
India venous access is also indicated in patients needing high lower thrombogenic potential than polyethylene and
osmolar, irritant or vesicant drugs for an anticipated polyvinylchloride devices. Recent studies have revealed
Rajeev Subramanyam MD,
duration of more than 3 months, those requiring polyurethane catheters to be more durable but also
MS frequent blood draws and patients with poor venous more thrombogenic and susceptible to infections than
Children’s Hospital of access. Implanted port and tunnelled catheters are very silicone catheters.2 Antibiotic and antiseptic coatings
Philadelphia commonly used as long-term venous access devices. have been used on catheters in an attempt to reduce
Philadelphia, PA Dialysis catheters and peripherally inserted central catheter-related sepsis but there is not enough evidence
USA venous catheters are excluded from this review as the to support widespread practice.
Table 1. Basic features of and comparison between implanted ports and tunnelled catheters
Basic feature Implanted ports Tunnelled catheters

Characteristic for reducing infections Implanted into subcutaneous tissue pocket Tunnelled underneath the skin and has a
Dacron cuff
Number of lumens available Single- and dual-body devices Single-, double- or triple-lumen catheters
Advantages Lower infection risk, cosmetically appealing, Bigger lumen size allows better flows needed
can perform activities such as showering and for apheresis
swimming
Disadvantages More expensive, needs more technical expertise Needs more maintenance; home care such as
to place and remove flushing the line is needed
IMPLANTED PORTS catheter tips can be open- or close-ended with a valve. The valve
tip catheters were developed with the intention of reducing the
Since the first placement of an implanted port more than 25 years incidence of thrombosis, but recent literature does not show that
ago,3 there have been many modifications to the device structure and they provide any significant advantage.4 Ports are manufactured by
material. The port has a body, a catheter and a connector (Figure 1). multiple companies worldwide and there can be significant variation
The port body has a reservoir with a self-sealing silicone septum on its in the size, shape and material used (Table 2). Selection of the most
roof. The silicone septum can withstand more than 1000 punctures appropriate port depends on patient factors, treatment requirements
with a Huber tip needle. Huber tip needles are special non-coring and the clinician’s familiarity with the port (Table 3). Power-injectable
devices that cause minimal damage to the septum (Figure 2). Port devices and catheters were developed to safely tolerate higher pressures
and flows (300 psi or 5 ml/s flow) required for computed tomography
(CT) contrast procedures. Power-injectable ports are labelled ‘CT’,
which is visible on chest radiographs, for ease of differentiation from
regular ports.
Indications
Implanted ports are preferred for intermittent rather than continuous
therapy. They are commonly used in chemotherapy of solid organ
malignancies, intestinal failure, cystic fibrosis, sickle cell anaemias,
haemophilia and other genetic diseases.
Contraindications
Implanted ports are contraindicated if there is infection at the site
Figure 1. The parts of an implantable port: port body, connector,
of insertion, previous thrombosis of the selected vein or deranged
catheter and tip.
coagulation parameters and in septic or neutropenic patients. Port
placement can be considered in patients with a platelet count of
> 50,000/µl, an international normalised ratio of < 1.7 and a white
blood cell count of > 3000 cells/µl.6
Placement technique
Implanted ports are placed in the strict aseptic environment of the
operating theatre, with patients sedated or under general anaesthesia.
Routine antimicrobial prophylaxis is not recommended.7 The most
common site of port placement is the infra-clavicular area of the
chest wall. The catheter may be placed into the subclavian or internal
jugular vein under ultrasound guidance using the modified Seldinger
technique. The direction and location of the tip of the catheter should
be confirmed by fluoroscopy. The catheter is tunnelled under the skin
Figure 2. The structure inside the body of a port with a Huber needle up to the port pocket. The port is anchored to the pectoral fascia.
inserted. This disassembled port reservoir displays the Huber needle The port pocket is closed in two layers with absorbable sutures, after
piercing the silicone septum. securing haemostasis. Video 1 shows the implantable port placement
Table 2. Types and sizes of implanted ports from different manufacturers (in alphabetical order)
Company Body Catheter Tip Catheter sizea Lumen

AngioDynamics Titanium, plastic Silicone, polyurethane Open-ended 5 Fr, 6.9 Fr, 7.5 Fr, 8.4 Fr, 9.6 Fr Single, dual
Bard Titanium, plastic Silicone, polyurethane Open-ended, 6 Fr, 6.6 Fr, 7 Fr, 8 Fr, 9.5 Fr Single, dual
(attachable/pre-attached) valved
B Braun Titanium, epoxy, Silicone, polyurethane Open-ended, 4.5 Fr, 5 Fr, 6.5 Fr, 8.5 Fr, 10 Fr Single, dual
polysulfone valved
Cook Medical Titanium, plastic Silicone (attachable/ Open-ended 6.5 Fr, 7.5 Fr, 9.5 Fr Single, dual
pre-attached)
Districlass Médical Titanium, polysulfone Silicone, polyurethane Open-ended 5 Fr, 6 Fr, 6.6 Fr, 8 Fr, 9.3 Fr Single, dual
Isomed Titanium, polyoxymethylene Silicone Open-ended 6 Fr, 7 Fr, 7.8 Fr, 9.6 Fr Single
Lexel Titanium Silicone Open-ended 5.5 Fr, 7 Fr, 9 Fr Single
Medcomp Titanium, plastic Silicone, polyurethane Open-ended 5 Fr, 6.6 Fr, 8 Fr, 9 Fr, 9.6 Fr Single, dual
(attachable/pre-attached)
Navilyst Titanium, polysulfone Polyurethane, silicone Open-ended, 6 Fr, 6.6 Fr, 7 Fr, 8 Fr, 9 Fr, 9.6 Fr, Single, dual
(attachable/pre-attached) valved 10 Fr
PakuMed Titanium Silicone, polyurethane Open-ended 1.9 Fr (fetal), 3 Fr, 5.1 Fr, 7.5 Fr, Single
9 Fr
Smiths Medical Titanium, polysulfone Silicone, polyurethane Open-ended 6 Fr, 7 Fr, 8.5 Fr, 9 Fr, 11 Fr Single, dual
(attachable/pre-attached)
Teleflex/Arrow Polysite Titanium, plastic Polyurethane Open-ended 6 Fr, 7 Fr, 8 Fr Single
Vygon Titanium Silicone (attachable/ Open-ended 4 Fr, 5.1 Fr, 6 Fr, 6.6 Fr, 8.4 Fr, Single
pre-attached) 9.6 Fr
Table 3. Components and characteristics of implantable ports
Component Characteristic
Port body
Titanium MRI compatiblea but can cause artefacts if the desired scanning area is within 40 cm2 range of the port
More longevity, less prone to fracture, preferred in treatments lasting for years
Plastic MRI safe; preferred in patients with breast, chest wall and thoracic malignancies who may need repeated MRI
scans
Less durable, prone to fracture, posterior wall puncture with Huber needle5
Catheter
Silicone Biocompatible, least thrombogenic, lower material strength
Smaller inner diameter with the same external diameter as polyurethane catheter
Polyurethane Slightly higher incidence of thrombosis and infection than with silicone catheter
Larger inner diameter allows better flow rate at the same external diameter; useful for apheresis and blood
product transfusions
Catheter tip
Open-ended Easy backflow and forward-flow
Needs heparin for flushing
Flushing interval 28 days
Close-ended with valve Slight resistance in back flow and forward flow causing difficulty transfusing blood
Only requires saline flushing; useful in heparin allergy and heparin-induced thrombocytopenia
Flushing interval 90 days; helpful in patients with poor visit compliance
MRI, magnetic resonance imaging.
MRI compatible up to 3 tesla but could cause MRI-related heating of the port up to 1.9°C.
a
are described in Box 1.4 Infection is a common complication that

can be intra-luminal or in the port pocket. The incidence of infection
is higher in patients with haematological disease than in those with
non-haematological disease.9 Catheter occlusion can be treated with
thrombolytic agents. Catheter-related vein thrombosis requires
anticoagulation and may necessitate port removal. Catheter pinch-off
syndrome is the pinching or fracture of the part of the catheter
between the clavicle and the first rib (Figure 4). Catheter embolisation
can be completely asymptomatic or a patient may complain of chest
pain, palpitations, dyspnoea and cough.10 The incidence of catheter
pinch-off syndrome is believed to be 1% of subclavian vein port
Video 1. Video showing the technique for implantable port placements.11,12 The incidence can be reduced or completely avoided
placement.8 https://www.dropbox.com/s/2i3cknssigjzhmk/ by selecting a more lateral puncture site.
Video%201.mp4?dl=0
Box 1. Complications of implantable ports4

• Early complications (procedure related)
–– haemorrhage
–– haemothorax
–– pneumothorax
• Delayed complications (procedure related)
–– delayed wound healing
–– port pocket haematoma
–– wound infections
• Late complications
–– catheter malposition
–– catheter occlusion
–– catheter pinch-off syndrome
Figure 3. A postoperative chest radiograph obtained after
implantable port placement to confirm the final location and rule –– catheter-related bloodstream infection (CLABSI)
out pneumothorax. –– extravasation
–– port fracture
–– vein thrombosis
technique.8 Postoperative chest radiography is performed to confirm
the final placement and rule out pneumothorax (Figure 3). The
ideal position of the tip is the lower one-third of the superior vena
cava. This correlates with the lower margin of the third costo-sternal
junction or the sixth thoracic vertebral level (Figure 3). The port can
be accessed immediately after the procedure if the Huber needle is
placed during the procedure. It is advisable to start chemotherapy
after a week, to allow for healing of the wound.
Precautions during placement

• A Trendelenburg position of 10–15° and thumb over the open
sheath should be practised to avoid air embolism.
• Care should be taken to place a wider loop while tunnelling
from the insertion site to the port pocket to minimise kinking
of the catheter.
• Good haemostasis is essential to avoid occurrence of port pocket
haematoma.
Complications
Complications during placement include arrhythmias, air embolism Figure 4. Fluoroscopic image showing, on dye injection, a catheter
and inadvertent arterial injury. Early, delayed and late complications break due to catheter pinch-off syndrome.
Maintenance care of infection. Any pain while injecting suggests extravasation or

• It is recommended that there be a policy with respect to accessing port fracture and should be evaluated immediately. The needle
and caring for long-term venous access ports developed by each should be replaced if in doubt. Injection of dye into the port
local hospital and that these protocols be adhered to as well as under fluoroscopy can be used to rule out extravasation.
the manufacturer’s instructions.
• The port must be accessed using sterile technique. After cleaning
the area over the port body, it is held and the Huber needle is Device removal
inserted until loss of resistance is encountered. Backflow of blood The port is removed after completion of treatment. Premature
confirms the correct position of the needle. removal may be needed when the port is infected, occluded or
• Flushing is carried out with 10–20 ml of normal saline using a malpositioned. Port removal is commonly performed in the
pulsatile technique. operating theatre under anaesthesia. A fibrous sheath forms around
• A syringe size of > 10 ml should not be used for flushing as it a long-standing implanted port. The sheath should be dissected and
may generate higher pressures, predisposing to rupture of the removed to prevent the formation of a potential space for serous fluid
catheter.13 However, power ports tolerate higher pressures. or haematoma collection. Once the port is removed it is visually
• The accessed port is covered with a sterile transparent dressing. inspected for completeness and integrity.
The transparent dressing and the Huber needle should be replaced
every 7 days.
• Aseptic non-touch technique is essential while using an accessed TUNNELLED CUFFED CATHETERS
port. Port hubs should be scrubbed with alcohol or chlorhexidine
for at least 15–30 seconds before connecting the medication. Tunnelled cuffed catheters were first introduced for prolonged
• A port should be flushed with 10–20 ml of saline and locked parenteral nutrition in 1973. They were called Broviac catheters.
with 5 ml of heparinised saline when not in use and before They were made of silicone rubber and had an internal diameter
de-accessing the port (Table 4). Application of positive pressure of around 1.00 mm.15 The Hickman catheter is another tunnelled
during de-accessing the needle reduces the reflux of blood in the catheter that was first used in marrow transplant recipients.16 These
catheter tip and may prevent occlusion.14 catheters were characterised by the presence of a Dacron cuff.17 The
• The port should be monitored for erythema, induration and signs cuff provided a point on the catheter that can be used for anchorage
Table 4. Flushing protocols for long-term venous access
Procedure Open-ended ports Groshong tip ports Tunnelled catheter

After each medication use 10 ml of saline followed by 5 ml of 10 ml of saline 3–10 ml of saline before and after
heparinised (10 U/ml) saline medication use
After blood draw or 20 ml of saline followed by 5 ml of 20 ml of saline 10 ml of saline followed by 3 ml of
transfusion of blood and heparinised (10 U/ml) saline heparinised (10 U/ml) saline
viscous products
When not in use 5 ml of heparinised (100 U/ml) saline 5 ml of saline once every 3 months 3 ml of heparinised (10 U/ml)
once a month saline once or twice weekly
Note: a minimum of twice the volume of the reservoir of long-term venous access should be used for flushing.
Table 5. Characteristics of tunnelled catheters
Total catheter
French size, number of lumens length (cm) Lumen size OD/ID (mm), colour
BROVIAC® 4.2 Fr, single-lumen catheter with peel-apart introducer (paediatric) 71 1.4/0.7
BROVIAC® 6.6 Fr, single-lumen catheter with peel-apart introducer (paediatric) 90 2.2/1.0
HICKMAN® 9.6 Fr, single-lumen catheter with peel-apart introducer 90 3.2/1.6
HICKMAN® 7.0 Fr, dual-lumen catheter with peel-apart introducer 65 2.3/1.0 red; 2.3/0.8 white
HICKMAN® 10.0 Fr, triple-lumen catheter with peel-apart introducer 97 3.3/1.5 red; 3.3/0.8 white; 3.3/0.8 blue
HICKMAN® 12.5 Fr, triple-lumen catheter with peel-apart introducer 90 4.2/1.5 red; 4.2/1.0 white; 4.2/1.0 blue
ID, internal diameter; OD, outer diameter.
Video 2. Video showing the technique for Hickman catheter

placement.21 https://www.dropbox.com/s/uwcw4lrnwkq1cws/
Video%202.mp4?dl=0
Figure 5. An explanted Broviac catheter showing the different parts:
Dacron cuff, silicone catheter, protective clamping sleeve, clamp and cava. This cut end of the catheter is pushed into the vein while gently
catheter hub. peeling off the sheath. Sterile dressings are applied to the percutaneous
venous access and catheter exit sites. Video 2 shows placement of
in the subcutaneous plane. It also forms a seal of fibrous tissue around the Hickman catheter.21
the catheter. The cuff may also act as a microbial barrier, though
the evidence for this is unclear.18,19 The parts of a Broviac catheter
are shown in Figure 5. Tunnelled catheters are available in various Precautions during placement
lengths and sizes (Table 5). • Arrhythmias should be monitored for while passing the
guidewire.
• The angled tip of the tunnelling rod has to be kept upwards at
Indications all times to prevent damage to the underlying structures and to
Tunnelled catheters are indicated when longer duration intermittent ensure the correct direction while tunnelling.
or continuous therapy is anticipated. Typical indications include • Wetting the Dacron cuff with normal saline prior to insertion
haematological malignancies, long-term antibiotic therapy, parenteral aids fibrosis.
nutrition, apheresis treatments and repeated blood and blood product • In women with pendulous breasts, the catheter exit site is made
transfusions. near the sternal edge to avoid catheter displacement in the erect
posture.
• A chest radiograph should be obtained after placement to check
Contraindications the catheter position and identify potential complications such
Contraindications of tunnelled catheters are similar to those for as pneumothorax (Figure 6).
implanted ports described earlier.
Placement technique
Maximal barrier precautions and aseptic technique must be followed
for placement of tunnelled catheters. The catheters are tunnelled in
the subcutaneous plane and are secured at the exit site with sutures,
usually on the anterior chest wall. Percutaneous insertion is preferred
for the Hickman catheter as it is technically easier than the surgical
cut-down technique.20 Sites for cannulation include the internal
jugular, subclavian or rarely the femoral vein. Ultrasound guidance
and fluoroscopy is recommended for vein cannulation and catheter
placement.
The vein is cannulated using the Seldinger technique. A skin incision

of 0.5–1 cm is made at the chosen catheter exit site on the chest.
Tunnelling is carried out in the subcutaneous tissue and the catheter Figure 6. A postoperative chest radiograph taken after placement of
is brought out just at the vein cannulation site, taking care not to a double-lumen Hickman catheter via the right subclavian vein. The
dislodge the guidewire. It is recommended to keep the Dacron cuff tunnelled part of the catheter on the left (two arrows), the catheter
around 5 cm from the exit site. The catheter is then cut to the desired loop outside the body at the bottom right (one arrow) and the
length so that the tip lies in the lower one-third of the superior vena catheter tip are seen.
Complications SUMMARY
Procedure-related complications include arrhythmias, arterial
puncture, kinking of the guidewire, bleeding, sheath or introducer Knowledge of long-term venous access devices is essential as their
kink/damage and pneumothorax.20,22,23 Late complications are similar indications and use are increasing. Familiarity with these devices and
to those for ports and include infection, occlusion, thrombosis and their handling protocols will enable anaesthesiologists to safely use
extravasation. Catheter pinch-off can occur, although this is less long-term venous access. Insertion of these devices should be learnt
common than in implanted ports.10 under supervision. Anaesthesiologists should take the opportunity
to lead the ‘vascular access team’, set protocols and train nurses, to
provide safe care of patients with these devices.
Maintenance care
• Catheter access must be carried out using aseptic non-touch
technique. REFERENCES
• The hub is scrubbed for at least 15–30 seconds using a 2%
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• Clamping is performed only over the protective clamping sleeve et al. Polyurethane versus silicone catheters for central venous port
to avoid damage to the catheter. devices implanted at the forearm. Eur J Cancer 2016; 59: 113–24.
• The site is monitored for erythema, tenderness, warmth and
3. Gyves J, Ensminger W, Niederhuber J, Liepman M, Cozzi E, Doan
purulent discharge. K et al. Totally implanted system for intravenous chemotherapy in
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changed every 7 days or sooner if soiled or wet.
• If found to be damaged, the catheter can be repaired using a 4. Blanco-Guzman MO. Implanted vascular access device options:
repair kit provided by the manufacturer. a focused review on safety and outcomes. Transfusion 2018; 58:
558–68.
5. Dillon PA, Foglia RP. Complications associated with an implantable
Device removal vascular access device. J Pediatr Surg 2006; 41: 1582–7.
Indications for removal of tunnelled catheters are similar to those 6. Bamba R, Lorenz JM, Lale AJ, Funaki BS, Zangan SM. Clinical
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et al. Central venous access in oncology: ESMO Clinical Practice
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puncture site to stop the bleeding. Skin closure with sutures and a 8. Zaghal A, Khalife M, Mukherji D, El Majzoub N, Shamseddine A,
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is likely that more patients with such devices will be encountered Spielmann RP et al. Intravascular embolization of venous catheter
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12. Mirza B, Vanek VW, Kupensky DT. Pinch-off syndrome: case report
flow rates. Ports could be used during cardiopulmonary resuscitation
and collective review of the literature. Am Surg 2004; 70: 635–44.
but may be inadequate for fluid resuscitation.
13. Gorski L. Infusion therapy standards of practice. J Infus Nurs 2016; 39
(Suppl. 1): S58.
14. Lapalu J, Losser MR, Albert O, Levert A, Villiers S, Faure P et al. Totally 19. Keohane PP, Jones BJ, Attrill H, Cribb A, Northover J, Frost P et al.
implantable port management: impact of positive pressure during Effect of catheter tunnelling and a nutrition nurse on catheter
needle withdrawal on catheter tip occlusion (an experimental sepsis during parenteral nutrition. A controlled trial. Lancet 1983; 2:
study). J Vasc Access 2010; 11: 46–51. 1388–90.
15. Broviac JW, Cole JJ, Scribner BH. A silicone rubber atrial catheter for 20. Ahmed Z, Mohyuddin Z. Complications associated with different
prolonged parenteral alimentation. Surg Gynecol Obstet 1973; 136: insertion techniques for Hickman catheters. Postgrad Med J 1998;
602–6. 74: 104–7.
16. Hickman RO, Buckner CD, Clift RA, Sanders JE, Stewart P, Thomas ED. 21. Arul GS, Lewis N, Bromley P, Bennett J. Ultrasound-guided
A modified right atrial catheter for access to the venous system in percutaneous insertion of Hickman lines in children. Prospective
marrow transplant recipients. Surg Gynecol Obstet 1979; 148: 871–5. study of 500 consecutive procedures. J Pediatr Surg 2009; 44:
1371–6.
17. Galloway S, Bodenham A. Long-term central venous access. Br J
Anaesth 2004; 92: 722–34. 22. Ray S, Stacey R, Imrie M, Filshie J. A review of 560 Hickman catheter
insertions. Anaesthesia 1996; 51: 981–5.
18. de Cicco M, Panarello G, Chiaradia V, Fracasso A, Veronesi A, Testa
V et al. Source and route of microbial colonisation of parenteral 23. Ng F, Mastoroudes H, Paul E, Davies N, Tibballs J, Hochhauser D
nutrition catheters. Lancet 1989; 2: 1258–61. et al. A comparison of Hickman line- and Port-a-Cath-associated
complications in patients with solid tumours undergoing
chemotherapy. Clin Oncol 2007; 19: 551–6.
Update in
Anaesthesia
Successful management of malignant

hyperthermia without dantrolene in paediatric
anaesthesia
Sami Menasri, Rabie Slimani, Nadia Grainat, Nejma Brinis, Haithem
Bourenane and Yacine Zerizer
Correspondence: s.menasri@hotmail.fr
KEY WORDS 1 in 15,000.4 It occurs more frequently in males than

females.4,5 The incidence of MH in Algeria may not
Malignant hyperthermia, paediatric anaesthesia, be as low as expected, especially before the systematic
dantrolene sodium use of capnography. Genetically, MH is an autosomal
dominant condition.1,4 The pathophysiology of MH
involves altered sarcoplasmic reticulum calcium
ABSTRACT channel-gating kinetics.1 The high level of calcium in
sarcoplasmic reticulum results in aerobic metabolism,
Malignant hyperthermia is a rare inherited disorder glycolysis and neutralisation of hydrogen ions and
that develops following exposure to volatile anaesthetic hydrolysis of high-energy phosphate compounds
agents and depolarising muscle relaxants. The overall leading to acidosis, rigidity, altered permeability,
incidence of malignant hyperthermia during general hyperkalaemia and a rise in temperature. The first
anaesthesia is estimated to range from 1 in 5000 to 1 sign of MH under anaesthesia is the increase in
Sami Menasri
Batna University Hospital in 50,000–100,000 and the mortality rate is estimated end-tidal CO2 exponentially. Early management of
Batna to be < 5% in the presence of standard care.1,2 In MH, strongly suspected on a clinical basis, could alter
Algeria Algeria, this incidence is even lower because of the a patient’s outcomes.6,7
absence of the succinylcholine second triggering agent,
but there is no centre where an in vitro caffeine–
Rabie Slimani
halothane contracture test is performed to confirm CASE DESCRIPTION
Batna University Hospital
Batna
the diagnosis in suspected cases. The drug of choice
Algeria for this condition, dantrolene, is not freely available An active, healthy, 7-year-old boy weighing 22 kg
in Algeria. We hereby report the case of a 7-year-old was scheduled to undergo laparoscopic surgery for
boy who had previously undergone uneventful general undescended left testicle under general anaesthesia. In
Nadia Grainat anaesthesia. He developed malignant hyperthermia the pre-anaesthetic examination, neither the patient
Batna University Hospital and survived the condition despite the non-availability nor his family had any history of a neuromuscular
Batna
of dantrolene, emphasising the role of early detection disease or a family history of anesthetic complications.
Algeria
and aggressive management in these cases. Survival The patient received surgery for right ectopic testes
without dantrolene remains exceptional, especially at the age of 5 years under general anaesthesia using
Nejma Brinis in paediatric cases (there are few cases in the recent halothane, propofol and fentanyl and no significant
Batna University Hospital literature).3,4 This is probably the first case report of complications occurred. Clinical examination detected
Batna this disease from Algeria. a thoracic deformity (globular thorax) and the airway
Algeria was Mallampati grade II. All routine hematological
and biochemical investigations were found to be
Haithem Bourenane INTRODUCTION normal. In the operating room, an intravenous line
Batna University Hospital was secured under inhalation anaesthesia (sevoflurane)
Batna Malignant hyperthermia (MH) is a hypermetabolic and minimum basic monitoring of the patient was
Algeria response to volatile anaesthetic gases such as carried out [peripheral capillary oxygen saturation,
sevoflurane and the depolarising muscle relaxant non-invasive blood pressure, electrocardiography and
Yacine Zerizer succinylcholine, as a result of a pharmacogenetic end-tidal carbon dioxide (CO2)]. Temperature is not
Batna University Hospital disorder of skeletal muscle. 3 The incidence and routinely monitored for such surgery; the temperature
Batna prevalence of MH vary with age and gender. The probe was inserted only during crisis management.
Algeria incidence in adults is 1 in 50,000 and in children is Anaesthesia was induced using propofol, fentanyl
Table 1. Creatinine phosphokinase (CPK) levels in the patient

and rocuronium and the patient was ventilated with oxygen and
sevoflurane; the patient was intubated with a cuffed endotracheal Time period CPK (IU/l)
tube and connected to the ventilator. Anaesthesia was maintained
with 50% oxygen–50% nitrous oxide and sevoflurane with boluses Operative day 3904
of rocuronium. After 75 minutes, a rising trend in end-tidal CO2 First postoperative day 16,000
was noticed at 54 mmHg, with lack of relaxation signalled by the Second postoperative day 13,214
surgeon; bilateral breath sounds without wheezing were maintained Fourth postoperative day 10,100
and measured. Temperature was 36.2°C. Initially, adjustment in Sixth postoperative day 1150
minute ventilation, circuit check and reinjection of rocuronium Seventh postoperative day 160
was carried out, but the end-tidal CO2 continued to rise, with
the maximum rise of end-tidal CO2 to 80 mmHg. There was an
associated rise in temperature, with a maximum reading of 38.3°C patients report previous uneventful anaesthesia and 75% report a
recorded by a nasopharyngeal probe. The surgeons reported that negative family history.9 The clinical presentations of MH are diverse,
muscle tension was still very high and the lower extremities remained ranging from mild to moderate symptoms to life-threatening crises
rigid and warm to touch. The patient also had an elevated heart rate caused by severe rhabdomyolysis.8 This was a typical case of MH
and blood pressure, with maximum readings of 130 beats/minute and because of the high level of end-tidal CO2, increase in temperature
135 mmHg, respectively. Suspecting MH, sevoflurane was stopped, and muscle rigidity. In children, sinus tachycardia and hypercapnia
propofol infusion was started and the patient was ventilated with have been shown to be the two most reliable early clinical signs.10
100% oxygen through a new anaesthetic circuit using higher gas Fever, hyperkalaemia and elevated creatine kinase are late signs and
flows and higher minute ventilation. The surgeon was informed and their absence does not exclude the diagnosis.11 The moderate clinical
asked to expedite surgery. Active cooling was started with ice-cold presentation was the result of the early recognition of non-specific
saline intravenously. A urinary catheter was inserted to check for clinical signs of MH and the initiation of rapid appropriate treatment.
diuresis. The results of tests carried out intraoperatively were as
follows: creatinine kinase 3905 IU/l, sodium 140 mEq/l, potassium The severity of MH also depends on the dose of triggering agents
4.4 mEq/l, blood urea 0.3 g/l, creatinine 8 mg/l. A blood gas sample given to the patient.12 Sevoflurane is thought to be a less potent
was unavailable at this time. The drug of choice for MH, dantrolene, trigger, with there often being a more gradual onset of MH or the
could not be used as it was not available in our hospital. With active occurrence of an incomplete form of MH.11 A clinical grading scale
cooling, the temperature decreased significantly and normalised. is considered a useful tool for the detection of MH.13 This numerical
With high minute ventilation end-tidal CO2 was also controlled. assessment tool, developed by Larach et al.,14 can be used to indicate
Surgery was completed without severe haemodynamic changes and the likelihood that an adverse anaesthetic event represents MH.
pulmonary complications; the patient recovered and was extubated Scores of 35–49 suggest that MH is very likely and scores of ≥ 50
successfully in the operating room once the end-tidal CO2 and indicate an almost certain probability of MH. Our patient had a
temperature returned to normal and the patient achieved criteria for calculated raw score of 63 (Table 2), placing him in the ‘almost
extubation. The patient was carefully monitored and investigated in certain’ range for an MH event.13
the postoperative period and a severe rise in creatine phosphokinase
was recorded at 24 hours. The rest of the laboratory work-up was Other causes of the hypermetabolic crisis were ruled out as the patient
normal. There were no active complaints from the patient except had a normal thyroid function test, was not on any antipsychotic
for muscle rigidity and body aches. His creatinine phosphokinase drugs and had no history suggestive of phaeochromocytoma.
levels are shown in Table 1. To avoid rhabdomyolysis-associated renal Overall, the anesthetist needs to apply good clinical judgement and
injury he received volume loading. The patient was discharged on have a strong suspicion for MH if end-tidal CO2 continues to rise
the eighth day. The patient and his attendants were made aware of
the suspected diagnosis of MH and the risks of recurrence in the
Table 2. MH clinical presentation score: likelihood that an adverse
patient and other family members.
anaesthetic event represents MH
Score
DISCUSSION Parameter (points)
Rigidity (generalised muscular rigidity) 15
We made the diagnosis of MH on the basis of clinical features. As
Muscle breakdown (elevated creatine kinase 15
demonstrated in this case, any patient may develop MH during
concentration > 10,000 IU/l)
or shortly after an anaesthetic procedure when trigger agents are
Respiratory acidosis (PaCO2 > 60 mmHg with 15
used, and this may occur even in patients who have had uneventful
appropriately controlled ventilation)
anaesthesia previously.8 It has been estimated that on average three
Temperature increase (inappropriately rapid increase in 15
anaesthetics are required before an adverse event is triggered in an temperature, in the anesthetist’s judgement)
MH-susceptible patient.1 Although a detailed anaesthetic history
Cardiac involvement (inappropriate sinus tachycardia) 3
is an important part of the perioperative assessment, 21% of MH
2. Rosero EB, Adesanya AO, Timaran CH, Joshi GP. Trends and
despite adjusted minute ventilation. This case illustrates the value of
outcomes of malignant hyperthermia in the United States, 2000 to
capnography monitoring for the timely recognition of the condition, 2005. Anesthesiology 2009; 110: 89–94.
which is key to patient survival. Some cases of MH have probably
not been diagnosed because of a lack of this essential monitoring, 3. Hopkins PM. Malignant hyperthermia: advances in clinical
particularly in some peripheral centres and in private practice in management and diagnosis. Br J Anaesth 2000; 85: 118–28
Algeria. The early suspicion of MH and rapid appropriate treatment 4. Brady JE, Sun LS, Rosenberg H, Li G. Prevalence of malignant
led to a favourable prognosis of this MH crisis.8 In addition to being hyperthermia due to anesthesia in New York State, 2001–2005.
a specific treatment for MH, dantrolene can decrease the mortality Anesth Analg 2009; 109: 1162–6.
rate;1 other immediate interventions include stopping the trigger 5. Sumitani M, Uchida K, Yasunaga H, Horiguchi H, Kusakabe Y,
agents, changing to total intravenous anaesthesia and removing Matsuda S et al. Prevalence of malignant hyperthermia and
the volatile anaesthesia from the anaesthesia machine, Changing relationship with anesthetics in Japan: data from the diagnosis
the breathing circuits and hyperventilating with 100% oxygen at procedure combination database. Anesthesiology 2011; 114: 84–90.
a maximum fresh gas flow will help remove the triggering agent
6. Monnier N, Kozak-Ribbens G, Krivosic-Horber R, Nivoche Y, Qi D,
and accumulated CO2 as well as compensate for the increased
Kraev N et al. Correlations between genotype and pharmacological,
metabolic oxygen requirement. Cooling techniques such as gastric histological, functional, and clinical phenotypes in malignant
lavage or placing ice internally and externally can help lower the hyperthermia susceptibility. Hum Mutat 2005; 26: 413–25.
core temperature. Using ice-cold intravenous fluids will also rapidly
decrease the core temperature, as in our case. 7. Torpy JM, Lynm C, Glass RM. Malignant hyperthermia. JAMA 2005;
293: 2958.
The successful outcome in this case without administration of 8. Schneiderbanger D, Johannsen S, Roewer N, Schuster F.
dantrolene was the result of the early diagnosis and intervention by Management of malignant hyperthermia: diagnosis and treatment.
multiple trained personnel. Cases of survival without dantrolene Ther Clin Risk Manag 2014; 10: 355–62.
have been reported in paediatric practice. Continued monitoring 9. Strazis KP, Fox AW. Malignant hyperthermia: a review of published
is of particular importance as the recurrence of symptoms has been cases. Anesth Analg 1993; 77: 297–304.
reported in 14.4% of paediatric patients after the initial treatment.10
Thus, fluid infusion was employed to prevent acute renal failure in our 10. Nelson P, Litman RS. Malignant hyperthermia in children: an analysis
of the North American malignant hyperthermia registry. Anesth
case.11 For a definitive diagnosis of MH an in vitro caffeine–halothane
Analg 2014; 118: 369–74.
contracture test is used.15 This test is not available in Algeria and
so we relied on the clinical grading scale.13 High MH scores are 11. Glahn KP, Ellis FR, Halsall PJ. Recognizing and managing a malignant
significantly correlated with the caffeine–halothane contracture test.16 hyperthermia crisis: guidelines from the European Malignant
DNA testing is now used routinely for diagnosis before muscle biopsy Hyperthermia Group. Br J Anaesth 2010; 105: 417–20.
when a familial RYR1 mutation is known.17 Genetic testing for MH 12. Hopkins PM. Malignant hyperthermia: pharmacology of triggering.
is not available in Algeria. Br J Anaesth 2011; 107: 48–56.
13. Larach MG, Localio AR, Allen GC, Denborough MA, Ellis FR, Gronert
GA et al. A clinical grading scale to predict malignant hyperthermia
CONCLUSION susceptibility. Anesthesiology 1994; 80: 771–9.
This case highlights the importance of clinical vigilance for this 14. Larach MG, Gronert GA, Allen GC, Brandom BW, Lehman EB.
rare condition, It may be encountered only once in an anesthetist’s Clinical presentation, treatment, and complications of malignant
hyperthermia in North America from 1987 to 2006. Anesth Analg
career, We strongly support the monitoring of capnography and
2010; 110: 498–507.
temperature during anaesthesia as they are the most common clinical
signs of acute MH. Anaesthesia providers should have a high level of 15. Gupta PK, Hopkins PM. Editorial. Malignant hyperthermia in India.
suspicion for an MH event; early awareness and proper management Anaesthesia 2010; 65: 1059–68.
including initial and symptomatic treatment is crucially important, 16. Studo RT, Cunha LB, Carmo PL, Matos AR, Trachez MM, Cardoso
and dantrolene, which remains the gold standard for treatment, LA et al. Use of the caffeine halothane contracture test for the
should be made available. diagnosis of malignant hyperthermia in Brazil. Braz J Med Biol Res
2010; 43: 549–56.
17. Urwyler A, Deufel T, McCarthy T, West S, European Malignant
REFERENCES Hyperthermia Group. Guidelines for molecular genetic detection
of susceptibility to malignant hyperthermia. Br J Anaesth 2001; 86:
1. Rosenberg H, Davis M, James D, Pollock N, Stowell K. Malignant 283–7.
hyperthermia. Orphanet J Rare Dis 2007; 2: 21.
Update in
Anaesthesia
In Memory
Paul Clyburn let us know the sad news of the • Member, Committee on Quality of Practice,
passing of Michael Rosen (https://www.rcoa.ac.uk/ RSM, London, 1999.
news-and-bulletin/rcoa-news-and-statements/passing- • Past appointments: President, Association of
of-professor-michael-rosen). Many of you will have Anaesthetists of Great Britain and Ireland,
known Professor Michael Rosen. 1986–88; President, Royal College of Anaesthe-
tists, 1988–91; Treasurer and Founder Member
Michael was charming, wise, possessed infectious European Academy of Anaesthesiology, 1986–91.
enthusiasm, dedicated to the WFSA and anesthesia • Member, Confidential Enquiry into Maternal
In Memory
world-wide, and had boundless energy. I will miss him. Deaths, 1988–93; Enquiry into Stillbirths and
Deaths in Infancy, 1993–93; Member, General
John Moyers Medical Council, 1989–92.
• Honours: Commander of British Empire (CBE)
The following information about Professor Rosen 1989; Doctor of Law (LLD), Dundee; Honor-
comes from the WFSA archives: ary Member: Australian, French and Japanese
Societies.
• Treasurer, WFSA, 1992–2000.
• Chairman, WFSA Obstetric Anaesthesia Com- Julian Gore-Booth, CEO WFSA
mittee, 1980–88.
Guide for contributors
MISSION OF UIA Manuscripts are screened by the editorial staff and are sent to
independent reviewers who are not informed of the identity of the
Update in Anaesthesia (UIA) is an official journal of the World author(s). The reviewers’ comments and suggested revisions will be
Federation of Societies of Anaesthesiologists (WFSA). UIA’s primary forwarded to the corresponding author. Manuscripts will be reviewed
goal is to provide high-calibre, peer-reviewed, clinically relevant with plagiarism detection software.
educational articles aimed at improving the quality and safety of
anaesthesia care around the world. Some readers of UIA may not use English as their first language.
Enlist the guidance of a consultant to assist in the proper use of
UIA welcomes manuscripts focused on, and not limited to, English grammar and syntax. Please keep text straightforward and
anaesthesia that is relevant to resource-limited settings. avoid long sentences and complex terminology. Explain words and
abbreviations that may not be universally standardised.
Manuscripts should be submitted to
Aim to include the full range of therapies available worldwide. Provide
https://www.editorialmanager.com/wfsa/default.aspx detailed descriptions of therapies available in resource-limited set-
tings. When appropriate, discuss older medications such as halothane
UIA also serves to share knowledge from affiliated associations such and thiopentone that may still be used around the world.
as the World Health Organization (WHO) and surgical societies
and educators that recognise safe anaesthesia as an essential part of Authors must acknowledge any financial support received or conflict
safe surgery. of interest related to the contents of a submitted manuscript.
Over 16,000 anaesthetists around the world access UIA on the Contributions to the (1) clinical care or research described in a
internet at: manuscript or (2) preparation of a manuscript made by persons
other than the authors may be acknowledged.
http://www.wfsahq.org/resources/update-in-anaesthesia
On acceptance for publication, copyright becomes vested with the
The printed version of UIA is sent free of charge to over 1500 journal.
English-speaking anaesthetists and is also translated into Spanish,
Russian, French and Mandarin. UIA is read by many others including Manuscripts based on clinical investigation of human subjects must
anaesthesia trainees, nurses, surgeons and medical students. adhere to the ethical principles of the Declaration of Helsinki
developed by the World Medical Association:
GENERAL CONSIDERATIONS FOR PREPARATION AND https://www.wma.net/policies-post/wma-declaration-of-helsinki-

SUBMISSION OF A MANUSCRIPT ethical-principles-for-medical-research-involving-human-subjects/
Manuscripts should adhere to Uniform Requirements for Manuscripts based on clinical investigation of human subjects must
Manuscripts Submitted to Biomedical Journals prepared by the include the consent of the patients or study participants and a
International Committee of Medical Journal Editors: statement of approval from an appropriate Institutional Review
Board (IRB)/Ethics Committee. The IRB/Ethics Committee must
http://www.icmje.org/recommendations/browse/manuscript- review and provide oversight or grant exemption from requiring
preparation/preparing-for-submission.html patients’ or study participants’ consent for the performance of audits
and this should be referred to in the text.
A major focus of UIA is to provide educational materials for those
working with limited resources. The types of manuscripts that are Manuscripts must protect patients and study participants from being
published in the journal reflect this. If you have an idea for an article identified. UIA adheres to the USA HIPAA Privacy Rule, which
and would like to discuss this further, please email the Editor-in-chief defines 18 identifiers that must be removed to assure the protection
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Manuscripts may not have been published in whole or any part in Booklet.pdf (specifically refer to page 10).
another journal.
MANUSCRIPT TYPES Text accompanying tables, figures, graphs and illustrations should
be supplied on a page separate from the image.
As an official journal of the WFSA, UIA is the appropriate forum
for publication of articles describing anaesthesia patient care, Tables, figures, graphs and illustrations copied from other publica-
original research and audit conducted in, and specifically relevant tions must be accompanied by a statement that permission for
to, low-resource settings. reproduction has been obtained from the publisher. A footnote
acknowledging permission to reproduce must accompany the copied
Manuscripts describing clinical care, research, procedures, techniques table, figure, graph or illustration and the full reference of the original
or equipment adapted by anaesthetists to the limited-resource setting source must be included in the reference list.
in which they care for patients are welcome in any of the following
formats: If patients appear in an identifiable photo, a copy of their consent
to the use of their image must be submitted.
• Case Report/Clinical Overview (1500 words maximum);
• Review – Basic Science or Clinical (3000 words maximum);
• Original Research (3000 words maximum); REFERENCES
• UIA Short Reports (750 words maximum);
• Editorials (1200 words maximum); A minority of UIA readers have extensive access to journals.
• Editorials are by invitation of the Editor-in-chief; References, therefore, should in general be limited to those that are
• Proposals for Editorials may be sent to the Editor-in-chief for considered ‘desirable supplemental reading’. Number the references
consideration and potential invitation; in the order they appear in the text, using the reference number as
• Review of Books or other Educational Materials (e.g. web app) a superscript at the relevant point in the text.
(750 words maximum);
• Letters to the Editor (1000 words maximum); Reference style should adhere to the format set out in the Uniform
• Correspondence is welcome on any topic, article or editorial that Requirements for Manuscripts Submitted to Biomedical Journals
has appeared in UIA or is of interest to individuals providing prepared by the International Committee of Medical Journal Editors:
anaesthesia patient care. http://www.icmje.org
Abbreviations for journal titles should follow Index Medicus format:

COMPONENTS OF THE MANUSCRIPT http://www2.bg.am.poznan.pl/czasopisma/medicus.php?lang=eng
Title page that includes: Examples of the recommended format for references are noted below
and can be found at https://www.nlm.nih.gov/bsd/uniform_require-
• title of the article; ments.html
• name and affiliation of each author;
• email, postal address and telephone contact details of the cor- 1. Reynolds F, O’Sullivan G. Lumbar puncture and headache.
responding author; ‘Atraumatic needle’ is a better term than ‘blunt needle’. Br Med J
• key words using terms from the Medical Subject Headings 1998; 316: 1018.
(MeSH) of Index Medicus (https://www.nlm.nih.gov/mesh).
2. Costigan SN, Sprigge JS. Dural puncture: the patients’ perspective.
Abstract that includes: A patient survey of cases at a DGH maternity unit 1983–1993. Acta
Anaesthesiol Scand 1996; 40: 710–14.
• no more than 200 words.
3. Spriggs DA, Burn DJ, French J, Cartlidge NE, Bates D. Is bedrest
For research manuscripts include Background, Methods, Results, useful after diagnostic lumbar puncture? Postgrad Med J 1992; 68:
and Conclusions. 581–3.
References to textbooks should give book title, place of publication,

ILLUSTRATIONS / FIGURES publisher and year; those with multiple authorship should also
include chapter title, first and last page numbers, and names and
Tables, figures, graphs and illustrations should be submitted as initials of editors. For example:
electronic versions of drawings (black on white) or as black and white
or color picture files in JPEG format. If computer or internet access is 1. Roberts F. Chapter 22: Ear, nose and throat surgery. In Allman
unavailable, print versions may be submitted. If facilities to produce KG, Wilson IH (editors). Oxford Handbook of Anaesthesia, 1st edn.
drawings are unavailable, contact the Editor-in-chief for assistance. Oxford University Press, Oxford; 2001. pp. 506–39.
Unpublished manuscripts in preparation or submitted yet not Manuscripts should be submitted to

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MEDICATIONS
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Use international units, e.g. mg.kg−1 rather than mg/kg. Use SI nota- Department of Anesthesiology and Critical Care Medicine
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Update in
Anaesthesia Education for anaesthesia providers worldwide
Volume 33 January 2019
EDITORIAL ORIGINAL SCHOLARLY PUBLICATIONS

1 Update on Update! 26 World Health Organization Surgical Safety Checklist
Natasha Woodman and Dr Isabeau Walker
SAFE-T SUMMIT 2018 REPORTS
2 The global challenge for patient safety: scope and 34 Patient Safety Update: Infusion safety, preoperative
definition assessment, bone cement implantation syndrome
Tore Laerdal Toby Reynolds, Queenie Lo and Isabeau Walker
6 A global surgery, obstetrics and anaesthesia 39 Patient Safety Update: Central Neuraxial Blockade,
metamorphosis Drug Errors and ‘Never Events’
Isabelle Citron and John G Meara Dr T Reynolds and Dr Isabeau Walker
9 Surgical capacity indicators in 2018 and beyond 45 The Vital Anaesthesia Simulation Training (VAST)
Thomas G Weiser course: immersive simulation designed for low-
resource settings
11 The SAFE-T Summit 2018: implications for the WFSA Adam Mossenson, Christian Mukwesi and Patricia
Safety and Quality of Practice Committee Livingston
Fauzia Anis Khan
62 Long-term venous access devices and
13 Progress and challenges in global surgical and anaesthesiologists
anaesthesia care and safety: proceedings of the Vibhavari Milind Naik, Keerthi S Rao, Basanth Kumar
SAFE-T Summit 2018 Rayani, Maddirala Subrahmanyam and Rajeev
Kerry A Vaughan and Walter D Johnson Subramanyam
16 Transforming surgical and anaesthesia capacity and 70 Successful management of malignant hyperthermia
safety – the path to success: the European Society without dantrolene in paediatric anaesthesia
of Anaesthesiologists’ perspective Sami Menasri, Rabie Slimani, Nadia Grainat, Nejma
Stefan De Hert Brinis, Haithem Bourenane and Yacine Zerizer
19 The NGO perspective: SAFE operating theatre 73 In Memory

Mona Guckian Fisher
74 Guide for contributors
21 Safe anaesthesia for everybody – today’s initiative:
the anaesthesia patient safety perspective
Mark A Warner
22 The WFSA SAFE-T Summit: overview and

commentary
Berend Mets and Alan Merry

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Anaesthesia Education for anaesthesia providers worldwide

Volume 33 January 2019

Editor-in-chief: Alan Jay Schwartz ISSN 1353-4882

Associate editors: Christina Lundgren and Victoria Howell

• SAFE-T Summit 2018

The Journal of the World Federation of Societies of Anaesthesiologists

Editorial Board of Update in Anaesthesia

Typeset by Prepress Projects Ltd, Perth, UK

Printed by COS Printers Pte Ltd, Singapore

Alan Jay Schwartz, MD MSEd

Department of Anesthesiology and Critical Care Medicine

Professor of Clinical Anesthesiology and Critical Care

The WFSA would like to thank Baxter

The global challenge for patient safety: scope

Out-of-hospital survival from SCA is estimated to average around

The course uses scenario-based training in pairs. A low-cost, culturally

US Institute of Medicine:12 train in teams those who work in teams CONCLUSION

A global surgery, obstetrics and anaesthesia

Just 3 years ago it was inconceivable to imagine the

2 Procedure density Procedures performed in an operating room per 100,000 population

development – the Zambian experience. Bull Am Coll Surg 2017;

SAFE-T Summit 2018 Reports

3. Debas HT, Donkor P, Gawande A, Jamison DT, Kruk ME, Mock CN

SAFE-T Summit 2018 Reports

SAFE-T Summit 2018 Reports

12. United Nations General Assembly. Resolution 70/1. Transforming our

Transforming surgical and anaesthesia capacity

SAFE-T Summit 2018 Reports

SAFE-T Summit 2018 Reports

The WFSA SAFE-T Summit: overview and

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incidents in 2013–2014. Over 3000 of these incidents were related

In a pilot study of the WHO checklist implementation, Professor

BRIEFING AND DEBRIEFING Resources Underlying processes of care

Subscribe to ATOTW tutorials by visiting www.wfsahq.org/resources/anaesthesia-tutorial-of-the-week

Figure 4. Diagram highlighting important steps in WHO checklist implementation.

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Patient Safety Updates contain learning from incidents

INFUSION SAFETY Vasoactive and analgesic drug infusions

The ultimate responsibility for ensuring that a patient has been

Missing medical records and difficulty accessing relevant test results

CENTRAL NEURAXIAL BLOCKADE

Risk factors for development of meningitis after CNB

• Human factors ‘It is difficult enough to overcome the inertia natural to

Original Scholarly Publications

KEY WORDS 5 billion of the world’s 7 billion people do not have

COLLABORATION To achieve a balance between breadth of content and feasibility of

training programme, in a low-resource setting. Some revision of

• Parallel simulation groups can be run in order to accommodate

Table 2. VAST course equipment list

Table 2. VAST course equipment list continued

APPENDIX 2: EXAMPLE SCENARIOS

- C-section under spinal anaesthesia

Recognise and treat post-spinal hypotension

Location Operating theatre

Layout Patient on stretcher, surgical instruments on a small table

2.3 – BRIEFING INSTRUCTIONS

Prepare the scenario

Volume 33 January 2019

Editor-in-chief: Alan Jay Schwartz ISSN 1353-4882