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INTRODUCTION

FOCUS POINTS

  1. Complications can occur even when we provide excellent care to patients.

  2. Successful anesthesia complication and crisis management requires a structured team-based approach.

  3. Simulation helps teams practice crisis scenarios in a protected, safe environment. Simulation helps improve performance when actual crisis situations occur. Simulation is especially helpful for situations not commonly encountered in routine practice.

  4. Cognitive aids can help prevent complications before they occur and also help manage active crises. Such aids include checklists, protocols, guidelines, and smartphone applications.

  5. Complications and bad outcomes must always be discussed fully and honestly with patients and their families.

  6. Malpractice lawsuits can arise from complications; therefore, risk managers and attorneys may provide guidance to involved parties.

  7. Delivery of bad news must be joint effort between involved surgeons and anesthesiologists. The SPIKES protocol discussed within provides a family-centered framework for bad news discussions.

  8. Complications encountered in pediatric anesthesia practice include medication errors, cardiac events, aspiration, laryngospasm, dental injury, and malignant hyperthermia.

Complications and crises occur during anesthetic care even with meticulous attention to clinical detail. The best complication and crisis management strategies rely on forward thinking and planning rather than unorganized or reactionary behavior. Thus, training, simulation, and resource mobilization are hallmarks of effective crisis management. This preemptive approach embodies the ideal anesthesiologist mindset. With preparation and planning an anesthesiologist can successfully manage a full spectrum of complications from routine to rare.

Precise complication rates in pediatric anesthesiology are difficult to quantify; most are minor and quickly resolved with appropriate management, and therefore are not uniformly documented or transferred to complication registries. Laryngospasm, for example, is common in pediatric anesthesia practice. Many practitioners do not document or database laryngospasm when resolved quickly by positive pressure ventilation. However, major complications like cardiac arrest are nearly universally documented, and often are databased in registries. Therefore, we have anecdotal data on statistics of minor complications and more concrete data regarding frequency of major complications.

This chapter examines crisis management topics including simulation, cognitive aids, discussion of bad news, and legal issues. It will then explore common complications and select uncommon complications, along with their respective management.

CRISIS MANAGEMENT PRINCIPLES

Conceptual framework for anesthesiology crisis management has been adapted from strategies found in commercial aviation. This is not surprising, as aviation shares many attributes with anesthesiology including periods of “smooth sailing” punctuated by potential crisis events that the lay public (and even other medical practitioners) never know of, appreciate, or understand.

Structured crisis management training in medicine had at one point been nearly nonexistent. Anesthesiologists made major efforts in the 1990s to incorporate formalized crisis training into residency education, with efforts focused on simulation.1 In fact, anesthesiology as a field has pioneered crisis management within medicine. Our efforts have spread into nearly every other field of medicine and even into governmental health policy efforts.

Crisis resource management ...

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