NAP5
The 5th National Audit Project
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Phases of Anaesthesia
Jeremy Radcliffe
National Hospital for Neurology & Neurosurgery,
UCLH, London
NAP5
The 5th National Audit Project
NAP5
The 5th National Audit Project
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Commendation
• Local coordinators and reporting clinicians
• Patients’ descriptions, which allowed NAP5 interpretation
• RCoA Bulletin 87, September 2014 p.28 ; ‘Introductory
remarks’
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The 5th National Audit Project
NAP5
The 5th National Audit Project
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Definitions
• Phases
(‘dynamic’ vs. ‘stable’)
– Induction and Transfer; before procedure
– Maintenance; during procedure
– Extubation and Emergence;
• Allocation and assessment by review panel
–
–
–
–
Experience
Causation
Avoidability
Quality of care
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The 5th National Audit Project
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The 5th National Audit Project
Expectations
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• ‘Classic’ ?
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Expectations
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• ‘Classic’ ?
• Or brief recollection …
‘The patient reported having seen lights, people overhead
and experienced pain (like “animals biting”). The patient
tried to speak, but couldn’t. This lasted about a minute. The
patient developed a new sleep disturbance, anxiety state and
PTSD type symptoms’ ….
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The 5th National Audit Project
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The 5th National Audit Project
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Expectations
• Studies and Publications focus on ‘Maintenance’ phase
Induction
Maintenance
Emergence
50%
36%
18%
( n = 141
72 (58i:12t)
51
26 )
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%
Gender (F)
ASA 1, 2
Emerg/Urgent
Overweight
NMB recorded
65
79
50~
49
93
64
76
36
38
65
35
59
96
(survey)
(42)
(45)
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The 5th National Audit Project
Causation
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• Induction (not 10% classed ‘syringe’ error)
• Maintenance
Unintended awareness during neuromuscular blockade
• Emergence
Unintended neuromuscular blockade during awareness
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Causation / mechanism
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• Induction
– The ‘Gap’: Airway, Vaporiser, Transfer
– Underdosing: Planned and Unplanned
– Management of Induction: Opioid omitted, RSI, Thiopentone, dose titration
• Maintenance
– The Gap?
– Underdosing: Planned and Unplanned
– Uncertain (25%)
• Emergence
– NMB too long or too late = perceived residual paralysis
No nerve stimulator use recorded in 88%
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Causation
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• Induction
– The ‘Gap’: Airway,
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Causation
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• Induction
– The ‘Gap’: Airway,
‘ ……. It was unclear whether the plan was to wake the
patient up or to continue with attempts to secure the airway.’
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Experience
%
Induction
Maintenance
Emergence
Distress
43
54
73
------------------------------------------------------------------------------------Experience
paralysis
51
57
84
pain
49 (both 37)
tactile
34
------------------------------------------------------------------------------------Preventable
58
74
88
Poor care quality 33
74
88
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The 5th National Audit Project
Recommendations
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• Distilled: 23
• Research implications noted: 15
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Caution
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• Other clinical issues before adopting changes to practice.
• Until NAP5, all current pressures on the anaesthetist are to
reduce/minimise anaesthetic agent exposure.
NAP5
The 5th National Audit Project
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The 5th National Audit Project
Practice Recommendations
•
•
•
•
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Plan and review drug requirements.
Develop Check-list and communication in ‘theatre’.
Promote use of a nerve stimulator.
Verbal reassurance should be a part of immediate
actions if AAGA is suspected.
NAP5
The 5th National Audit Project