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Crisis management during anaesthesia: embolism

¹ Consultant Specialist, Australian Patient Safety Foundation; Visiting Research Fellow, University of Adelaide and Royal Adelaide Hospital, Adelaide, South Australia, Australia
² Department of Medical Biochemistry, School of Medicine, Flinders University, Bedford Park, South Australia, Australia
³ Deputy Director, Department of Paediatric Anaesthesia and Pain Management, Royal Children’s Hospital, Parkville, Victoria, Australia
⁴ Consultant Anaesthetist, Royal Melbourne Hospital, Parkville, Victoria, Australia; Chairman, Victorian Consultative Council on Anaesthetic Mortality and Morbidity

Correspondence to:
Professor W B Runciman
President, Australian Patient Safety Foundation, GPO Box 400, Adelaide, South Australia, 5001, Australia; research{at}apsf.net.au Background: Embolism with gas, thrombus, fat, amniotic fluid, or particulate matter may occur suddenly and unexpectedly during anaesthesia, posing a diagnostic and management problem for the anaesthetist.

Objectives: To examine the role of a previously described core algorithm "COVER ABCD–A SWIFT CHECK" supplemented by a specific sub-algorithm for embolism, in the management of embolism occurring in association with anaesthesia.

Methods: The potential performance of this structured approach for each of the relevant incidents among the first 4000 reported to the Australian Incident Monitoring Study (AIMS) was compared with the actual management as reported by the anaesthetists involved.

Results: Among the first 4000 incidents reported to AIMS, 38 reports of embolism were found. A sudden fall in end-tidal carbon dioxide and oxygen saturation were the cardinal signs of embolism, each occurring in about two thirds of cases, with hypotension and electrocardiographic changes each occurring in about one third of cases.

Conclusion: The potential value of an explicit structured approach to the diagnosis and management of embolism was assessed in the light of AIMS reports. It was considered that, correctly applied, it potentially would have led to earlier recognition of the problem and/or better management in over 40% of cases.

Keywords: embolism; anaesthesia complications; crisis management; gas embolism; air embolism; thrombus; amniotic fluid; monitoring; oximetry; capnography

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				W B Runciman, M T Kluger, R W Morris, A D Paix, L M Watterson, and R K Webb Crisis management during anaesthesia: the development of an anaesthetic crisis management manual Qual. Saf. Health Care, June 1, 2005; 14(3): e1 - e1. [Abstract] [Full Text] [PDF]