Anaesthetic Deaths

Re: Anaesthetic Deaths

Anthony Todd — Sat, 13 Jun 2015 12:01:42 GMT

[quote user="Bob Russell"]Our capnograph keeps wonderfully silent unless a parameter slips outside the norm.[/quote]

That's the only alarm, from the posts, the surgeon needs. The sensitivity can be set.

Pilots, who are as competent as a veterinary nurse, when it comes to monitoring, all seem to agree that alarms are necessary and vital in an emergency.

Nobody has suggested multiple alarms in veterinary anaesthesia and they have added to the stress in emergency aviation situations.

Re: Anaesthetic Deaths

Hannah Wynne Richards — Sat, 13 Jun 2015 11:16:24 GMT

I couldn't agree more. I know where my pulse oximeter is - but only because it's part of the same monitor as the capnograph and the ECG.

Wynne

Re: Anaesthetic Deaths

Bob Russell — Sat, 13 Jun 2015 10:54:34 GMT

When things are going well there are no warning alerts in a cockpit. Peace reigns! This is what I want from my monitors. Our capnograph keeps wonderfully silent unless a parameter slips outside the norm.

I have a very competent member of staff watching the animal closely. I study the trace on the capnograph out of the corner of my eye. Amazing how quickly you can pick up changes.

Not sure where our pulse ox is. O2 and iso levels are shown on screen in addition to the CO2 trace.

Any anaesthetic monitoring with aircraft level complexity of warnings has to be dangerous IMO. Many years ago I had a multiparameter monitor demonstrated during a dog castration. Beeps and alarms every few seconds. Totally distracting and the salesman failed to close a deal. Patient slept blissfully unaware through the whole procedure in direct comparison with the surgeon. I was close to being a gibbering wreck by the end!!

Pilots have crashed planes, in part because of the confusion caused by alarms!

Re: Anaesthetic Deaths

Hannah Wynne Richards — Sat, 13 Jun 2015 10:37:58 GMT

Anthony

Re Train Failing Medic

and Tank Crisis Aviation(fuel) Shortage?

Wynne

Re: Anaesthetic Deaths

Anthony Todd — Sat, 13 Jun 2015 09:49:44 GMT

And another reply:

In aviation, we are fortunate that most of our audible alerts have been standardised; one sound means the same thing across all manufacturers. In the ward and theatre, this standardisation has not taken place, and clinicians have to cope with different machines which use the same sound for completely different, sometimes opposite, alert conditions. I'm not sure if that's true in the veterinary world.

Generally, I agree with vapilot; a well-trained, experienced, and alert, nurse, with the back-up of appropriate audible and visual alerts, would be my preference.

Me too.

Re: Anaesthetic Deaths

Anthony Todd — Fri, 12 Jun 2015 23:36:30 GMT

I asked "roughly how many audible alarms there are in a modern cockpit on Pprune?" and got this reply among others:

Attention getters (master warning / caution) for malfunctions
Similar tones for invalid configuration (taking off without flaps, trying to land with gear up)
Fire warnings
Autopilot / Autothrottle disengagement
Weather alerts (Windshear)
Traffic alerts
Terrain alerts (the famous "Pull Up" warning)
Not an alarm, but audible terrain closure announcements (a countdown of altitude)
Similar, runway awareness (approaching a runway)
Alerts for normal situations (incoming message, cabin calling cockpit, etc)

and

Discrete warning alarms with distinct sounds (and I'm sure I'll miss some): master warning, autopilot disconnect, stall warning (horn, beeps, verbal "Stall!, Stall!"), stick-shaker "rattle", "Wind Shear!," overspeed, take-off configuration, "sink rate/Don't sink!," engine fire bells, ground proximity ("Terrain! Pull UP!"), excessive rate of descent ("Pull UP!"), traffic (TCAS) alerts, TCAS resolution advisories ("Climb! Climb!/Descend! Descend!"), bank angle, landing gear not down, (what I can think of off the top of my head).

which pilots seem to accept

and

Vet fees aren't exorbitant enough already, need more gadgets to charge for?

which we mightn't......

Re: Anaesthetic Deaths

Anthony Todd — Fri, 12 Jun 2015 18:43:26 GMT

Sorry it should have been RTFM

Although a friend says "only poofters read instructions...."

Re: Anaesthetic Deaths

Hannah Wynne Richards — Fri, 12 Jun 2015 18:29:06 GMT

Anthony, you really disappoint me! I would never have put you down as a demented scrabble player.

Wynne

Re: Anaesthetic Deaths

Anthony Todd — Fri, 12 Jun 2015 18:12:01 GMT

[quote user="Anthony Todd"]Audible alarm? [/quote]

Sorry, if all else fails, RTFM

Re: Anaesthetic Deaths

Anthony Todd — Fri, 12 Jun 2015 17:46:09 GMT

[quote user="Michael Woodhouse"]http://www.vetronic.co.uk/index.php/S=0/products/article/capnovet-10[/quote]

Sounds like a no- brainer to me,

What happens if the animal stops breathing? Audible alarm?

Any disadvantages or caveats?

Does anyone [these days] do a GA without one?

Re: Anaesthetic Deaths

Martin Atkinson — Fri, 12 Jun 2015 16:12:54 GMT

[quote user="Neil Wheadon"]Spot of lidocaine, long tube, down the tube, condensing on the inside of the tube, chances of still getting a mist to the end??[/quote]OK, 'a spot' is colloquial for 'enough to get to the business end of the tube if you blow down it to encourage its journey', probably about 0.1ml, Trust me it works, albeit I get a numb lip every now and again!

[quote user="Neil Wheadon"]Do you use a cut tube?[/quote]No just a standard Portex Blueline 3, 2.5 or 2mm uncuffed tube depending on the size of the bunny.

I have been using this method for years as I'm useless at using a laryngoscope and I'm much happier knowing the tube is securely tied in place rather than using one of those weird soft latex jobbies that have become fashionable.

Re: Anaesthetic Deaths

Michael Woodhouse — Fri, 12 Jun 2015 16:03:20 GMT

[quote user="Anthony Todd"]

[quote user="Sarah McGurk"]I think it would be useful to have separate equipment for the carbon dioxide readings.[/quote]

Is there such an instrument?

Can you adjust the sensitivity?

[/quote]

http://www.vetronic.co.uk/index.php/S=0/products/article/capnovet-10

http://www.surgivet.com/catalog/monitoring-equipment/v9004-series-capnograph-monitor.html

http://www.nonin.com/RespSenseVET

Re: Anaesthetic Deaths

Lucy Fleming — Fri, 12 Jun 2015 15:55:33 GMT

[quote user="Anthony Todd"]

[quote user="Martin Atkinson"]however we find stethoscopes, especially an oesophageal one, quite useful![/quote]

Why? I know they're good at telling you when the heart has stopped, which is usually some time after the animal has stopped breathing, and the "shit" has happened some minutes ago....

And I refer to GOM's post and the 45 second delay....

[/quote]

I think the delay mentioned was the 45 second delay between the nurse noticing the heart and respiration stopping (admittedly with the advantage of having seen it be euthanased!) and the monitors registering anything.

Re: Anaesthetic Deaths

Neil Wheadon — Fri, 12 Jun 2015 15:32:29 GMT

[quote user="Martin Atkinson"]Squirt a dot of lidocaine down[/quote]

OK crazy question, maybe?

Spot of lidocaine, long tube, down the tube, condensing on the inside of the tube, chances of still getting a mist to the end??

Do you use a cut tube?

Willing to try this

Neil

Re: Anaesthetic Deaths

Evelyn Barbour-Hill — Fri, 12 Jun 2015 15:21:20 GMT

[quote user="Anthony Todd"]Why? I know they're good at telling you when the heart has stopped, which is usually some time after the animal has stopped breathing[/quote]

Oesophageal stethoscope monitors respiration as well as heart! Have it on an amplifier and loudspeaker.

It's the only monitoring aid that I consider indispensible.

Pulse oximeters are almost useless.

Re: Anaesthetic Deaths

Martin Atkinson — Fri, 12 Jun 2015 15:08:37 GMT

[quote user="grumpyoldman"]I still find tubing rabbits tricky and variable[/quote]Place the bunny in sternal recumbancy and kneel down so your head is at table level, pass the ET tube blind into the mouth with your ear against the connector and advance it until you can just hear breathing sounds. Squirt a dot of lidocaine down and withdraw, wait a minute with it on an oxygen mask with a sniff of gas if necessary. Repeat the procedure, press the tip down slightly as you hear breathing again to depress the epiglottis and 95% of the time the tube goes straight into the trachea, advance it and confirm its still in with a little squeeze of the chest. If you go too far and into the oesophagus, withdraw and try again. I rarely need more than 2-3 attempts and can intubate a 1kg bunny with a 2 mm uncuffed tube. I can occasionally tube Gn.pigs this way but not as predictably.

Re: Anaesthetic Deaths

Anthony Todd — Fri, 12 Jun 2015 15:04:46 GMT

[quote user="Sarah McGurk"]I think it would be useful to have separate equipment for the carbon dioxide readings.[/quote]

Is there such an instrument?

Can you adjust the sensitivity?

Sooner or later, without an audible alarm, with the best of staff etc. etc., you are likely to have the SHF [new achronym, as they're so modern....]

Re: Anaesthetic Deaths

Anthony Todd — Fri, 12 Jun 2015 14:59:18 GMT

[quote user="Martin Atkinson"]however we find stethoscopes, especially an oesophageal one, quite useful![/quote]

Why? I know they're good at telling you when the heart has stopped, which is usually some time after the animal has stopped breathing, and the "shit" has happened some minutes ago....

And I refer to GOM's post and the 45 second delay....

Re: Anaesthetic Deaths

Hannah Wynne Richards — Fri, 12 Jun 2015 14:03:26 GMT

Bullying can work 2 ways. Some nurses really love to bully new graduates, who can end up totally terrorised.

Wynne

Re: Anaesthetic Deaths

Neil Wheadon — Fri, 12 Jun 2015 13:59:38 GMT

[quote user="robloxley"]Shouldn't be bullying, but need to remember that during a GA the buck stops with the vet, particularly when the proverbial hits the fan, hence the vet's concern[/quote]

Depends how you do it

[quote user="robloxley"]Another top tip - if placing a dental throat pack always tie it to the ET tube so it doesn't get forgotten when the animal is extubated[/quote]

Fantastic idea, dogs swallow them too leading to blockages, not just choking, so if you can't see it in the throat, don't assume someone pulled it out

Neil

Re: Anaesthetic Deaths

Rob Loxley — Fri, 12 Jun 2015 13:48:57 GMT

[quote user="Neil Wheadon"]trust the nurse and concentrate on what you are doing[/quote]

Shouldn't be bullying, but need to remember that during a GA the buck stops with the vet, particularly when the proverbial hits the fan, hence the vet's concern

Another top tip - if placing a dental throat pack always tie it to the ET tube so it doesn't get forgotten when the animal is extubated

Re: Anaesthetic Deaths

grumpyoldman — Fri, 12 Jun 2015 12:56:18 GMT

next time you euthanise an Ex lap on the table just see how long it take the monitors to notice its snuffed it after the nurse with the oesophageal stethoscope notices , its at least 45 seconds.

Re: Anaesthetic Deaths

grumpyoldman — Fri, 12 Jun 2015 12:52:54 GMT

I still find tubing rabbits tricky and variable , bought the fecknell kit with the guide wire that helped a bit but still need the auroscope , if its not teeth tend to use the v-gels but you need 3 sizes , wish we could find a better way with guinea pigs too.

Re: Anaesthetic Deaths

Neil Wheadon — Fri, 12 Jun 2015 12:41:59 GMT

I had an interesting conversation with a nurse just the other day. It was in regards to bullying at work by vets and I was curious how she felt intimidated. Her reply was anaesthetics, where even though the vet was deep in an abdomen they felt that they could dictate the anaesthetic as well, constantly telling the nurses to turn up, turn down. My view is that a nurse is simply better at it than I am and the best are those that monitor vital signs using the toys as a guide. I do an occasional locum where 2 vets do the anaesthetic and if it's my turn, I find it amazingly stressful, and must be a lot worse if you are being placed under pressure from someone delving about at the other end of the animal. So my advise is, trust the nurse and concentrate on what you are doing.

Neil

Re: Anaesthetic Deaths

Martin Atkinson — Fri, 12 Jun 2015 12:13:18 GMT

[quote user="Kate Richardson"]

Most nurses monitor respiratory rate and pattern, mucous membrane colour, capillary refill time, peripheral pulses, jaw tone, eye position, rectal temperature, as well as having their head 'buried in a stethoscope'. I think you are doing them a disservice. They may have monitoring equipment as well, and I can only speak for our nurses, but they certainly don't rely on it alone.

[/quote]Hear, hear. Mine have to fill in a chart recording recording all this every minute, apart from temperature. I am more likely to be shouting at them to turn the bloody anaesthetic up than worrying it's too deep but they still ignore me because even though I trained them they are better than I am. They certainly don't rely on monitors and forever curse their lack of reliability especially the pulse oximeter, however we find stethoscopes, especially an oesophageal one, quite useful!