The Use of Emergency Manuals Leading to Successful Treatment of Severe Bronchospasm

On January 15, 2009, after a bird strike caused dual engine failure on U.S. Airways Flight 1549, Captain “Sully” Sullenberger ordered the first officer to read from the “dual engine failure” section of the emergency manual (EM) to ensure that they completed the necessary steps to be taken in the event of such a failure. The event resolved quickly and successfully. Cognitive aids (e.g., EMs) have been used in many high-stakes industries, including medicine. A simulation-based trial reported that during a set of intraoperative emergency crises, teams missed 6% of critical steps when checklists were accessible versus 23% of critical actions when they were not.1 Now EMs are increasingly being adopted and implemented in operating rooms.

Use of the Emergency Manual in Bronchospasm

Bronchospasm can be a serious, life-threatening anesthetic disaster. Rapid diagnosis and appropriate treatment are important for an uneventful patient outcome. EMs are an important tool to guide healthcare providers during operating room emergencies. Performing the right steps at the right time can be the difference between life and death in an OR emergency. One published report explains how a 4-month-old patient was saved from malignant hyperthermia with the guidance of an EM.(2)

We report a real-life example of the benefits resulting from the use of the EM. A 44-year-old man was scheduled for laparoscopic left hepatic lobectomy and cholecystectomy. The patient had been admitted to the hospital one year earlier with bronchitis, at which time he was treated with oxygen, antibiotics, and bronchodilators. He denied other significant medical histories. He had no known drug allergies and did not use any medications. He denied regular consumption of alcohol and had never smoked.

The preoperative CT scan showed a left extrahepatic bile duct stone, a common bile duct stone, and cholangitis. Preoperative examinations including echocardiogram and pulmonary functions tests were normal. Chest auscultation was normal before anesthesia. Anesthesia was induced with 5 mg intravenous midazolam, 15 mcg sufentanil, 20 mg etomidate, and 50 mg rocuronium. Video laryngoscopy was used to visualize the vocal cord, a 6.5-mm reinforced endotracheal tube (ETT) was inserted, end-tidal carbon dioxide was detected, and the ETT was secured. Anesthesia was maintained with sevoflurane in oxygen, and an intravenous infusion of propofol (150 mg/hr), remifentanil (1 mg/hr), and cisatracurium (5 mg/hr). The anesthesia machine airway pressure alarm sounded, and peak airway pressures increased from 22 cmH2O to 37 cmH2O. The anesthesiologist checked the ETT position and anesthesia circuit. Chest auscultation revealed wheezing bilaterally, then a complete absence of bilateral breath sounds. Oxygen saturation decreased from 99% to 52%, and blood pressure decreased from 125/75 to 75/56 mm Hg, with tachycardia (110 beats/min). Decreased lung compliance was detected by hand ventilation. ETCO2 demonstrated a marked prolonged expiratory upstroke on capnography. Bronchospasm was considered. The anesthesiologist called for help.

Immediately, three additional anesthesiologists joined the team, and a leader was assigned. The EM, which was readily available, was referenced and used as a cognitive aid in rapidly managing the patient. A reader was assigned, and she read the bronchospasm chapter aloud to the team. High-flow 100% O2 was given, and anesthesia was deepened by increasing the sevoflurane concentration. Albuterol was administered via a metered dose inhaler (10 puffs) through the endotracheal tube. IV infusions of doxofylline and hydrocortisone were administered. The patient’s airway pressure decreased from 37 to 21 cmH2O, and his SaO2 increased to 95%. His chest began to move more easily with hand ventilation, and his vital signs remained stable: BP 102/65 mmHg, HR 85 beats/min, SaO2 95%. An uncomplicated surgery then was performed with minimal blood loss in five hours. The patient was allowed to wake up and was extubated. He was transferred to the recovery room with no lasting adverse effects and was discharged home on postoperative day 3.

Discussion

The incidence of bronchospasm during anesthesia has been reported to be from 1.7% to 16% of patients.(3) Multiple risk factors may be associated with perioperative bronchospasm, such as smoking, chronic bronchitis, asthma, and intubation.(3-5) Bronchospasm by airway irritation occurred more often in patients who had one or more predisposing factors.(6) Serious consequences of perioperative bronchospasm included brain damage or death, both of which may be caused partly by substandard care or inadequate practice and system failures.(7,8) Therefore, it is crucial for anesthesia providers to be able to promptly recognize bronchospasm and provide optimal treatment.

Anesthesiologists can use operating room EMs to respond to crises more efficiently because EMs allow rapid application of treatment consistent with established guidelines.(8) Goldhaber-Fiebert et al.(9) reported that 45% of anesthesia residents self-report successful use of EMs during clinical critical events.

Use of Emergency Manuals in Our Clinic

The Stanford Operating Room Emergency Manual has been translated into Chinese. The two top Chinese anesthesiology societies encouraged anesthesiologists to incorporate the use of EMs in the management of critical events after appropriate training.(10) A recent survey in our department showed that 65% of anesthesia providers self-report use of EMs during a crisis.(11)

The section of the EM on bronchospasm helped us implement the necessary steps to immediately manage the patient in the critical event discussed earlier. In this case, bronchospasm was diagnosed at 14:37. The anesthesiologists began use of the EM at 14:38 and recorded its use in the anesthesia record. Treatment procedures were followed. After adequate and immediate treatment, bronchospasm was relieved. Airway pressure was reduced, and SaO2 was improved.

Crisis Simulation

In an operating room crisis simulation study, the leader assigned team members into three groups: procedure providers; recorders/readers; and runners.(12) The participants believed that the assignment helped them feel better organized throughout the simulated emergency.(12)

The role of a dedicated EM “reader” during a critical event has been studied.(13) During a simulated crisis, an EM reader read the steps aloud and then acknowledged completion of each step. The results showed that the rate of completion of necessary actions was increased significantly.(13) The reader role was described in a case report of successful use of the clinical EM to manage malignant hyperthermia.(2)

Studies have shown that immersive simulation trainings positively influenced later emergency manual use.

We have used EMs in our hospital since May 2016, when we placed EMs in each anesthesia workstation. Studies have shown that EM immersive simulation trainings positively influenced later EM use.(9,11) Therefore, we formed a simulation education team and organized several EM simulation trainings in our department. During the simulation training, trainees had the opportunity to play different roles (e.g., leader, procedure provider, reader, and runner). Education and simulation training helped us integrate use of the EM into clinical practice.

References

1. Arriaga AF, Bader AM, Wong JM, et al. Simulation-based trial of surgical-crisis checklists. N Engl J Med. 2013;368:246-253.

2. Ranganathan P, Phillips JH, Attaallah AF, et al. The use of cognitive aid checklist leading to successful treatment of malignant hyperthermia in an infant undergoing cranioplasty. Anesth Analg. 2014;118:1387.

3. Schwilk B, Bothner U, Schraag S, et al. Perioperative respiratory events in smokers and nonsmokers undergoing general anaesthesia. Acta Anaesthesiol Scand. 1997;41:348-355.

4. Dewachter P, Mouton-Faivre C, Emala CW. Anaphylaxis and anesthesia: controversies and new insights. Anesthesiology. 2009;111:1141-1150.

5. Fisher MM, Ramakrishnan N, Doig G, et al. The investigation of bronchospasm during induction of anaesthesia. Acta Anaesthesiol Scand. 2009;53:1006-1011.

6. Dewachter P, Mouton-Faivre C, Emala CW, et al. Case scenario: bronchospasm during anesthetic induction. Anesthesiology. 2011;114:1200-1210.

7. Cheney FW, Posner KL, Lee LA, et al. Trends in anesthesia-related death and brain damage: a closed claims analysis. Anesthesiology. 2006;105:1081-1086.

8. Auroy Y, Benhamou D, Péquignot F, et al. Mortality related to anaesthesia in France: analysis of deaths related to airway complications. Anaesthesia. 2009;64:366-370.

9. Goldhaber-Fiebert SN, Pollock J, Howard SK, et al. Emergency manual uses during actual critical events and changes in safety culture from the perspective of anesthesia residents: a pilot study. Anesth Analg. 2016;123:641-649.

10. Huang J. Implementation of emergency manuals in China. APSF Newsletter. 2016 Oct.

11. Ye F, Li M , Zhang J, Huang J. Organizing multidisciplinary Emergency Manuals simulation training to enhance crisis management skills and patient safety. PSQA (Perioperative Safety and Quality Assurance). 2017;1: 204-207.

12. Huang J. The initial steps of operating room emergency checklist. J Clin Anesth. 2015;27:692-693.

13. Burden AR, Carr ZJ, Staman GW, et al. Does every code need a “reader?” Improvement of rare event management with a cognitive aid “reader” during a simulated emergency: a pilot study. Simul Healthc. 2012;7:1-9.