3⃣ COMO FAZER UM CHECKLIST PARA ANESTESIA | Anestesia é o Básico #3

Our video lesson starts on October 30, 1935, when the Boeing B-17 aircraft from the U. S. Air Force took off from one of the bases in the state of Ohio.

A few seconds after takeoff, the plane suddenly lost altitude and crashed to the ground, resulting on the death of the pilot and a crew member, besides three other seriously injured people. Now, what has this tragic accident to do with our video lesson? We will find out after the clip.

Bring it on! Checklist: Anaesthesia Unravelled What's up, NAVE crew? !

In this video from Anesthesia Unravelled we will be talking a little about the anesthesia checklist. This plane crash that took place in 1935 changed the routine of the entire world. At that time, people didn't make checklists for anything at all, so just imagine, the pilot would take off and followed the rules of his preference.

There wasn't a pre-established stardard set. Why was this accident so important for the whole world? Because during the investigations they were unable to find any signs of a mechanical failure and concluded that the pilot must have failed to unlock the rudder of the plane.

Because of that, he was unable to control the aircraft and, on the way up, it was hit by a side gust that resulted in the plane crash. Me? I had no idea.

From then on, it was decided that every flight should go through a checklist. Just to get an idea, in aviation today, five checklists are made before take-off. But the checklist isn't done exclusively in situations that involve life.

Today, any organization that intends on minimizing harm to people and also minimize financial losses, are sure to make checklists. Therefore, checklists are associated with quality. Specifically regarding anesthesia, we have to keep in mind that, sometimes, there won't be enough time to go looking for something or solving a problem, so we have to predict everything that can go wrong and avoid it, before it happens.

This is so important in anesthesia that several magazines frequently publish articles related to the theme, even in this editorial of the Veterinary Record. Here in Pirassununga, the first thing an intern learns to do is the checklist. Most of them don't like it at first, because it's kind of boring, right?

The person wants to go there, get the venous access and everything and ends up on a situation of having to check things out before the anesthesia. I don’t want it! What they don't understand is that this will avoid some problems.

Something very important in the process of anesthesia is that the anesthesiologist be extremely organized. Will my wife watch this? I may be sloppy in my house, but inside the surgery room, I'm extremely demanding and methodical, even a bit OCD.

Sometimes, new people won't understand and think it's excessively methodical and extremely boring to do that, but in fact, I have witnessed several problems that, today, I try to avoid by making a checklist. In this video lesson we will be following the steps of the anesthesia checklists that we use here in Pirassununga. But it should be adapted according to the routine of each one of you, not necessarily ours is complex or simple, it has only been adapted to our own needs.

So, each one of you can adapt your own. If you don’t do the checklist, then have a problem, don't go on crying, please. Checklist: Patient The first part of our checklist is completed outside the surgery room.

Our team checks if the animal is identified and what procedure is to be performed, if the complementary exams were seen, if anamnesis and physical evaluation were performed, and also if the owner has signed all the consent forms. In this regard, there are to two things that we need to highlight Firstly, identifying the animal, because we keep complaining that we see on TV that the guy comes and operates the person's wrong knee, amputates the wrong arm, but it can happen to us. A little while ago, I was teaching a graduation class and we nearly neutered an animal that came to take a blood test.

Just think of that. Who's next? !

I don't know what happened, I think there must have shone a holly light down on me that urged me to recheck that animal. I went there, talked to the owner and the guy said: 'doctor, we came here just to take a blood test' The students drive me insane in practical classes. Checking the patient and the procedure to be performed are extremely important, especially in the hospital environment where there is a lot of movement and a lot of people.

Another important thing is that the owner signs the form of consent, because if something happens during the anesthetic procedure this is going to count as a legal document proving that the owner has been warned of the risks of anesthesia. Checklist: Medical gases The next step is to check if we have oxygen and compressed air, this is when the first problem starts, because you ask people to go check if there's enough oxygen and compressed air and the person doesn't have the slightest clue of what's going on in that valve. Actually, it isn't as complicated as it looks.

What we have here is a pressure reducing valve and the bottom pressure gauge indicates the pressure inside the cylinder while the upper gauge indicates the pressure in the system. When we receive a cylinder, we have to know what's the volume inside this cylinder and what is the pressure in the cylinder. In general, a full cylinder has an internal pressure between 150 and 200 kgf/cm².

In essence, 1 kgf/cm² is the same as 'bar'. But well, the thing is, if you look how much oxygen you have in the cylinder it will show, for example, that it has 50 litres, and 50 litres is not enough for an anesthesia longer than one hour, for example. But we have to remember that this volume is under high pressure.

To find out the actual volume we have to consider during anesthesia we have to remember Boyle's law. Boyle's law is simple: So just for a little practice here, we will imagine that we have a 10 cubic meter oxygen cylinder, which is equivalent to 50 litres of oxygen at a pressure of 200 kgf/cm². When we bring this gas outside, it goes into an atmosphere of 1 kgf/cm².

So, by using this equation, we get a volume of 10,000 litres. Which makes a lot more sense, so if I ask the intern to go and check the volume, he will give me the pressure in the cylinder and we can do the calculation very fast. We always have to know the ammount of oxygen available.

Here we have four cylinders, so it's very easy to exchange them, in a matter of one or two seconds we flip the switch. Now, imagine you are working as a freelancer and go do an anesthesia in a clinic and there is no oxygen available. Then, we hear: 'No, this will never happen to me' Well, it might not happen to you, but it has happened to me.

Once, I was on an overnight colic anesthesia and oxygen went out midway through the procedure. There was no one to call, there was no one to cry to, a illuminated being suddenly remembered of the existence of an oxygen cylinder in one of the offices from the dentistry course. We went there, took it and managed to finish the anesthesia.

So remember, no one wants go through these problems, because they turn into a huge trouble. After that, we need to check if oxygen is arriving at the surgery room. For that, there are some alarms, as we can see in this picture, which display the internal pressure.

Usually, the gas network has a pressure between three and seven kgf/cm², it varies between each place. We need to connect the whip line of the exact color to the gas being administered and then we check on the equipment if oxygen it's being adequately delivered. Checklist: The anaesthetic machine Good anaesthetic machines usually show us what is the pressure in the network.

We can see here, in this machine, that the pressure of compressed air is good, but the oxygen pressure is not adequate. Check again all the way from the cylinder to the machine. Here we see that we needed to properly tighten the connecton of the fill whip to the oxygen outlet.

Now we have oxygen to supply to the patient. Next, check the flowmeters of oxygen and compressed air, make sure you have enough inhalation anesthetic for the procedure, if the soda lime is in good shape for the procedure, and make a quick test to see if there are any leaks in the circuit. Checklist: drugs and accesses Continuing our checklist, we will see if there are enough drugs for the anesthetic procedure.

This has to be very well organized, whether it's a cart or a briefcase, remember that organization is paramount. We can see in this image of our cart, the way I caught it once, there was ephedrine where there should be dobutamine, sodium chloride where there should be potassium chloride, open syringes, it all leads a person to make mistakes, because sometimes they get the drugs quickly thinking they're administering one thing and they're actually giving something else, the patient can end up dead. Afterwards, we choose the anesthetic protocol and it must be checked and approved by the most experienced anesthetist present.

We can't forget that the emergency doses must already be calculated and written on the anesthetic record, because at a given moment, we won't have time to waste. To make it easier, we have a table fixed to the wall that contains the doses and volumes calculated for each weight. It will be available below, in this video's description.

After that, we check if there's everything we need for the venous access and the material for intubation. One important tip: have on hand three tubes of very close sizes and with cuffs tested to see if there is no leak, because in a moment of rush, there'll be no time to get another tube. Checklist: Equipments Then, we move on to infusion pumps.

This depends a lot on the type of anesthesia we will choose, so you can have an infusion pump for saline, por example, or if it's going to be a continuous-infusion anesthesia, you should have more pumps. They should be checked, evaluated for accuracy and also check if you have enough battery for the procedure. Remember that we should already have pre-calculated the fluids and fixed them to the pump.

Next part is the monitoring. Hence, at this moment, we’ll check if the monitor is working properly. We'll check the oximeter, electrocardiograph, capnograph, non-invasive blood pressure device, invasive blood pressure device, thermometer and other parameters that can be available, as for example a blood gas analyzer.

Not necessarily we'll need to have all these parameters available, this depends a lot on each situation. So, depending on the procedure, I can even, for example, not have invasive blood pressure, but I will have to be aware that I won't have IBP during the procedure and this will have to be informed in the checklist, So, regarding the monitoring, we have to have an adequate monitoring for each surgical procedure. Once the entire checklist is done, we have this setup: The anesthetic machine assembled, with oxygen and inhalation anesthetic supply, infusion pump set to the desired rate, multiparametric monitor with all modules checked, drugs available for any complications and all monitoring sensors already in place to be connected immediately.

Another tip: I don't know if you paid attention to the image, but all sensors are already in place to be placed on the animal immediately, so we can see here that the capnographer is already attached to the Y-connector, the oxymeter and temperature sensors are hung up, the ECG clamps are already in the correct positions for the animal and, in this case that the blood pressure is going to be non-invasively monitored, the cuff is already in the correct place for being positioned around the tail or on the dorsal pedal artery. After that, we are done! Or not.

We’re going to make a checklist to the recovery from anesthesia too, that here we end up using the term 'checkout'. In this instance, we need to remember to turn off the flow of anesthetic gases, extubate the patient only after positive tracheal reflex, to monitor this animal until its temperature reaches 36. 5°C, disconnect and organize all the equipment wires, check whether there's need to replace the soda lime, check the patient's analgesic protocol, review the prescriptions and then discharge the patient after explaining all the instructions to the owner.

We can not forget that the checkout is important because, soon after, another anesthesiologist will come to use the same equipments. If it's you, even better, because you’re doing it for yourself. This will prevent damage, losses and will save time.

As a conclusion to this video lesson, we should remember that the checklist is intimately related to the quality of the procedure. It doesn't matter how much you have and what you will do, but yes, to make sure everything is organized. The checklist starts from the identification of the animal until the delivery to its owner, passing through the checking of oxygen, anaesthetic machine, infusion pumps, drugs and monitoring.

Remember: the checklist should be daily routine and can never be forgotten. Well folks, I hope you enjoyed this video lesson. Don't forget there's a lot of relevant information in the video's description, alright?

Don't forget to subscribe, like, share and follow us on social media and I hope to see you in the next video lesson! See you soon! and when it was going up, it got 'gusted' 'gusted'?

and when it was going up, it got. . .

how was that?