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Qual Saf Health Care 2005;14:e17 doi:10.1136/qshc.2002.004366
  • Crisis management

Crisis management during anaesthesia: embolism

  1. J A Williamson1,
  2. S C Helps2,
  3. R N Westhorpe3,
  4. P Mackay4
  1. 1Consultant Specialist, Australian Patient Safety Foundation; Visiting Research Fellow, University of Adelaide and Royal Adelaide Hospital, Adelaide, South Australia, Australia
  2. 2Department of Medical Biochemistry, School of Medicine, Flinders University, Bedford Park, South Australia, Australia
  3. 3Deputy Director, Department of Paediatric Anaesthesia and Pain Management, Royal Children’s Hospital, Parkville, Victoria, Australia
  4. 4Consultant Anaesthetist, Royal Melbourne Hospital, Parkville, Victoria, Australia; Chairman, Victorian Consultative Council on Anaesthetic Mortality and Morbidity
  1. Correspondence to:
 Professor W B Runciman
 President, Australian Patient Safety Foundation, GPO Box 400, Adelaide, South Australia, 5001, Australia; researchapsf.net.au
  • Accepted 12 January 2005

Abstract

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.

Footnotes

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

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