OR HAZARD, OR RISKS, ANESTHESIA HAZARD, ANESTHESIA RISKS, OPERATION ROOM HAZARDS, OPERATION ROOM RISKS,

1. OPERATIONROOMHAZARDS
BY ABAYNEH BELIHUN
AKSUM UNIVERSITY
DEPARTMENT OF ANESTHESIOLOGY

2. Definition
• Hazard: a situation that poses a level of threat to life,
health, property, or environment.
• A hazard does not exist when it is not happening.
• Anesthesia and surgery are conducted in technologically
intense envt……potentially hazardous.

3. The most common hazards in OR
• Fires and Explosion
• Static Electricity
• Electrical Hazards
• Radiation Injury
• Air Pollution and
• Power Failure

4. Fires
explosions
• Both of these can cause death or injury to the patient.
• Only occur if we have 3 things:
– spark or a hot surface,
– flammable substance and
– source of oxygen

5. Sources of sparks or heat
– Static electricity
– Faulty electrical switches and apparatus, e.g. saws, plaster cutters and
drills
– Foreign matter, e.g. dirt or grease in the oxygen or nitrous oxide
cylinders
– Diathermy
– Open flames.
• Flammable substances: Includes ether, ethyl chloride and solution in
sprits. The addition of oxygen increased flammability.

6. Static electricity 1
• Electricity present in the atm.
• Occurs if two materials which conduct
electricity poorly are brought into contact and
then separated.
• If there is friction or movement between the
two, a spark is produced and a spark, of course,
can produce an explosion.

7. Static electricity 2
• EX. Woolen fabrics, non-conducting rubber,
and synthetic materials such as nylon.
• Should be avoided in the OR, using graphite
impregnated yellow coded rubber instead.

8. OTHER PRECAUTIONS TO REDUCE STATIC ELECTRICITY 1
• Conductor floor (Concrete or conductive rubber
or plastic, placed on floors)
• Avoid wool, plastic and nylon fabrics and wear
cotton or other anti-static outer clothes instead.
• Wear aprons of conductive rubber.
• Wear anti-static boots or conductive canvas
overshoes.
• Maintain humidity of 60%. Static sparks are more
frequent when the air is dry.

9. OTHER PRECAUTIONS TO REDUCE STATIC ELECTRICITY 2
• Ventilation- Anesthetic gases are heavier than
air and tend to collect at ground level.
• Regular inspection of electric switch &
apparatus
• Firefighting equipment should always be
available
• Smoking and open flames must be forbidden

10. Electrical hazards 1
• They may occur when patients are:
– In contact with faulty electrically-operated medical
equipment
– Accidentally connected to electric circuits by spillage of
blood or saline
– Dependent on electrical equipment to replace or support
vital organ functions
– Exposed to fire or explosions
– Undergoing treatment when safe levels of electrical energy
are exceeded.

11. Electrical hazards 2
Electric shock:
• When the body actually becomes part of an
electrical circuit with significant current
• Wiring defects, faulty equipment components
and deteriorated insulation
• Lack of maintenance and misuse are the usual
causes.

12. Electrical hazards 3
Macroshock
• Most common
• occurs when the body conducts an electric current
which does not pass directly through the heart.
• Mild sensory stimulation@5 to 10 mA
• @50 to 60mA- muscular contraction
• @100mA- breathing becomes extremely difficult.
• Somewhere above this level respiratory paralysis,
cardiac arrest and severe burning occur.

13. Electrical hazards 4
Microshock
• When very tiny currents, such as 100µA, are
intentionally passed directly thru heart muscle
– e.g. direct cardiac catheterization, CO measmt

14. Electrical hazards 5
• High frequency currents above 50 hertz are less likely to
produce electric shock but can cause burns and
interference with other devices such as pacemakers.
• DC is less likely to cause VF than high frequency AC
(above 50Hz) but can cause muscle contraction.
• Nerve damage often occurs with high currents.
• The SC may be involved by large currents passing from
head to foot or from arm to arm.

15. Electrical burns and electrically initiated burns
• Three types
– Carbonization of skin (from burns at very high
temperatures of 1,000°C)
– Flame burns
– Direct heating of tissues produce coagulation and
necrosis at entry and exit points and associated
injury in muscle and BV.

16. Electrosurgical units
• Diathermy are arranged so that current from
the active electrode flows through the patient
and back to the generator
• Don’t use electric blankets in conjunction with
electro-surgery.

17. Air pollution 1
• RISKS
– Spontaneous miscarriage,
– Congenital abnormalities and
– Liver disorders.
• Waste anesthetic gases escape from:
– Faulty valves
– The ventilator
– Poorly fitted components in the breathing circuit
– Spilt anesthetic drugs
– Expired gases from the spill valve of the anesthetic breathing system
– Gases exhaled by the patient

18. Remedies
• This pollution can be reduced by
– Regular thorough inspection of all anesthetic equipment
– Limit or avoid the use of inhalational gases and agents e.g., circle
system, TIVA and RA
– An efficient scavenging system.
– Closed circuits
– Anti spill devices

19. POWER FAILURE!!!

20. Power failure
• Critical areas employing electrically driven
equipment such as respirators (Ventilators) and
dialysis machines require standby equipment
(i.e. generators).

21. ANESTHESIA
RELATED
HAZARDS/ RISKS

22. RISK
• Risk is the potential that a chosen action will
lead to a loss or an undesirable outcome.
• Risk is a ubiquitous, natural part of life, because
everything we do, including doing nothing,
poses uncertain outcome.
• Occasionally the term refer to the outcome
itself (e.g., death as one risk of anesthesia).

23. Anesthesia risk and accidents
• Accident is an unplanned, unexpected, and undesired event
• Because there are no standard methods for assigning causality
yet, no accurate estimates of the rate of adverse out-come
• Errors related to AW mgt, monitoring, and sudden cardiac
arrest during SA, equipment failures, or nerve injuries.

24. Adverse respiratory events
• The most serious hazards in anesthesia.
• Causes of death and brain damage are inadequate ventilation,
esophageal intubation, and difficult ETI.
• Cases in the first 2 causes were judged to have been preventable if
better monitoring had been employed.
• Anticipated difficult ETI- refer to better institution or surgical AW
should be performed before anesthesia.

25. Failure to monitoring
• An important contributor to anesthesia adverse
events.
• There are numerous ways in which pulse oximetry,
capnometry, and automated blood pressure
monitors can give false information, leading to
missed or incorrect diagnoses.

26. Medication errors
• The most frequent error in anesthesia, and in
healthcare practice in general.
• Similarity of drug names, containers, and label colors

27. Medication errors
• Dosing errors related to the frequent need for individual
• Error in numerical calculations when drawing and
mixing drugs for bolus administration or IV infusion.
• Wrong drug (e.g., among various insulin formulations)
• Flushing a catheter with a solution containing another
potent drug,
• Confusion in the programming of infusion pumps

28. Recommendation
• Read the label carefully 3 times!

29. Errors in diagnosis
• Especially during the management of critical
events.

30. Equipment errors and failures
• Current anesthesia machines and associated
technology incorporate substantial safety features.
• Frequent and can occur in many ways, but rarely
causes injury directly.
• Equipment associated injury; it is more likely to be
from misuse than from overt failure of a device.

31. lack of standard practice and unusual situations
• Accidental dislodgement of ETT during transportation
• Undiluted phenytoin by rapid IV infusion - refractory HN,
arrhythmias, and death.
• Undiluted K+ by rapid IV infusion - VF and cardiac arrest.
• Neostigmine given without an antimuscarinic cause
asystole/severe bradycardia and AV block, and can be fatal.

32. lack of standard practice and unusual situations
• Inadvertent IV injection of LA- neurologic and
cardiac toxicity, which can be fatal (especially
with bupivacaine).
• Air embolism during the placement or removal
of central venous catheter
• Limb necrosis if the tourniquet is left on the
patient for a prolonged period

33. Summary of Risk Management
RISK IS UBIQUITOUS
RISK ASSESSMENT
Stratification,
prioritization and
intervention

34. WHAT IF YOU FAIL TO DO ALL THIS?

35. Enhancing patient safety
11/23/2015 OR Hazard and strategies to enhence PS 35
• Avoidance, prevention, and amelioration of
adverse outcomes or injuries
• Quality of care: Extent to which health services
for individuals and populations increase
likelihood of desired health outcomes and are
consistent with current professional
knowledge.

36. …………
• Patient safety is focused on prevention of injury.
• Quality assurance generally deals with the broader
spectrum of quality, including the success of
treatments.
• Risk management is focused on proactive patient
safety, based on the principle that prevention of
injuries via error reduction and system
improvements

37. Practical elements 1
• Avoidance of unnecessary risk taking
• Almost unending anticipation of what might go wrong,
• Projection of actions in anticipation of failure and, above all,
mindfulness
• Being patient centered……..PATIENT IS ABOVE OUR EGO!

38. Practical elements 2
Maintaining vigilance:
• The anesthesia provider must maintain alertness and be
aware of, compensate for, and counteract the forces
working against vigilance.
• Fatigue and sleep deprivation are probably the most
common causes of lapses in vigilance.

39. Practical elements 3
• Practice in a system of care
• Teamwork
• Preparation
• Monitoring
• Control for human factors: organized arrangement
of supplies and drugs, esp labeling, and
establishing and adhering to local standards.

40. Practical elements 4
• Care to keep IV cannula and monitoring cables orderly,
lighting, and reducing clutter, noise, and distractions
• Infection Control
• Antibiotic administration in the perioperative interval
reduces postoperative wound infection.
• Surgical wound infection rates are increased 3-fold by
hypothermia.

41. Anesthesia crisis management
11/23/2015 OR Hazard and strategies to enhence PS 41
• Seek assistance early and quickly inform others
• Establish clarity of roles for each person involved in mgt. of event
(event manager)
• Use effective communication processes
• Use resources effectively and identify what additional resource
(people, supplies, equipment, transportation) are available to
manage situation.

42. 11/23/2015 OR Hazard and strategies to enhence PS 42
CRISS MANAGEMENT DURING ANESTHESIA
C1 Circulation Adequacy of peripheral circulation (rate, rhythm, and character of
pulse). If pulse is absent (CPR)
C2 Color Note saturation. Examine for evidence of central cyanosis,Pulseoximetry
O1 Oxygen Check rotameter settings; ensure inspired mixture is not hypoxic.
O2 Oxygen
analyzer
Adjust inspired oxygen concentration to 100%
Check that oxygen analyzer shows a rising oxygen concentration distal
to common gas outlet.
V1 Ventilation Ventilate lungs by hand to assess breathing circuit integrity, airway
patency, chest compliance, and air entry by “feel,” careful observation,
and auscultation.
Also inspect capnograph’s trace if available
V2 Vaporizer Check all vaporizer filler ports, seating’s, and connections for liquid or
gas leaks during pressurization of the system.
Consider possibility of wrong agent being in vaporizer.

43. 43
CRISIS MANAGEMENT DURING ANESTHESIA (CONT…)
E1 ETT check ET tube (if in use) Ensure no leaks or kinks or obstructions.
Check capnograp, oximeter for possible
endobronchial position
E2 Elimination Eliminate anesthetic machine and ventilate with self-inflating
(e.g., Ambu) bag with 100%
R1 Review
monitor
Oxygen analyzer, capnograph, oximeter, blood pressure, ECG,
temperature and NMJ monitor)
R2 Review all
other
equipt
Review all other equipment in contact with or relevant to patient
(e.g., diathermy, humidifiers, heating blankets, endoscopes,
probes, prostheses, retractors…

44. 44
CRISIS MANAGEMENT DURING ANESTHESIA (CONT…)
A Air way Check patency of non-intubated airway. Consider laryngospasm,
FB, blood, gastric contents, or nasopharyngeal or bronchial
secretions
B Breathing Assess pattern, adequacy, and distribution of ventilation. Consider,
examine, and auscultate for bronchospasm, pulmonary edema,
lobar collapse, and pneumo- or hemothorax
C Circulatio
n
Repeat evaluation of peripheral perfusion, pulse, BP, ECG, and
filling pressures and any possible obstruction to venous return,
raised intra thoracic pressure (e.g., inadvertent PEEP)
D Drugs Review intended (unintended) drug or substance administered
Consider whether problem may be a consequence of an
unexpected effect, a failure of administration, or wrong dose,
route, or manner of administration of drug

45. HAZARDS FOR ANASTHETISTS
• Fire & explosions
• Electrical accidents
• Pollutions by anesthetic agents
• Radiations
• Infections
• Incompatibilities / allergies
• Stress
• Chemical dependence
OR

46. Infections
• Physical spread-HSV,CMV
• Blood borne-HIV,HBV,HCV
• Air borne-Mtb

47. Infections
• Blood borne diseases thro’ Needle stick injuries- HIV:0.3%,
HBV:3%, HCV30%
• 32% had at least 1 NSI in the preceding 12M.(only half of them
took treatment).
• More risk with hollow-core & large bore
• NSI more in non dominated hands
• NSI more during disposal of contaminated needles.
• Anesthesiologists have risk for occupational infection during
30years of exposure-0.045-4.5%

48. Infections-HIV
• Health care workers contribute 5% of total
cases
• 4% of emergency department pts are
unidentified cases.
• Pts considered infective if both screening
(ELISA) & confirmatory (western blot, indirect
fluorescent ab) tests are positive.

49. Infections-HIV
• 54 reported cases of occupationally acquired
HIV(1998).
• 88% of them had H/O NSI
• ? Quantity of inoculums- ( a case report :100-200µml of blood
thro” i.v. produced HIV).
• Risk for the pts- 6 cases reported.

50. Infections-HBV
• Non immunized HCW- higher risks
• 17.8% 0f seropositive among anesthesiologist
• 30% became positive after 11 years of exposure
• Disinfectants & gloves are not completely protective-
viruses viable for >14 days in needles, gloves, & surfaces.

51. Infections-HCV
• No immunization available
• No specific treatment available
• Advice: serologic monitoring for HCV & LFT 3-
6 monthly.

52. Infections
Management of occupational infections.
SAFE PRACTICE
1. Protective equipments
2. Washing methods
3. Disposal methods

53. Infections - CDC recommendations
Universal precautions-1980
-considering as all pts, blood & body fluids are
infective.
Isolation precautions-1996
-2 tier recommendations
1. Standard precautions -to be followed for handling all pts
as infective.
2. Transmission based precautions -for handling pts known
to be / suspected of being risks.

54. Infections -CDC recommendations
Transmission based precautions
• Based on properties of specific pathogens
• Airborne precautions [measles, varicella, Tb] -to prevent from
small particles<5µm by specific filters air handling devices.-
HEPA, Negative pressure environment
• Droplet precautions [HBV, mycoplasma, streptococcal
pharyngitis, rubella]-to prevent from large particles>5µm, keep
distance>1m
• Contact precautions [HAV, HSV, viral conjunctivitis]

55. Incompatibilities / Allergies
Latex allergy
• Type IV/ type I
• Risk groups :
1. Spina bifida,
2. Urogenital abnormalities ,
3. HCW,
4. Rubber factory workers.

56. Latex allergy
Managements
1. Identification of risk groups
2. Use latex free objects-latex free environment
3. Tests: RAST[radio-allergo-sorbent test]
SPT
Sr.histamine
Urinary histamine
Sr.IgE
Sr.compliments
Sr.tryptase
Tests for anaphylaxis
Screening
tests

57. Latex allergy
Managements-drug regimens
• Preoperative protocol:
1. Dipenhydramine -1mg/kg,po/iv,q 6hr at 13,7,1hr before
surgery
2. Prednisolone -1mg/kg,po/iv,q 6hr at 13,7,1hr before
surgery or hydro cortisone 4g/kg
3. Ranitidine - 2mg/kg po, 1mg/kg iv,q 12hr at 13,1hr
before surgery
• Postop protocol
-drugs to be repeated for 12hrs

58. Stress
• Inevitable, universal phenomenon to which no
one is immune
• Job related stress are unavoidable but may be
controlled
• 2 types-Unavoidable & Avoidable
• Unavoidable-professional stress
• Avoidable-sleep related

59. Stress
Unavoidable Stress
• Professional Stress
• Co-worker relationships
• Work load
• Litigations
• Peer review
• Professional dissatisfaction
• Administrative responsibilities

60. Stress
Avoidable Stress
• Sleep related-altered sleep pattern, sleep
deprivation
• Coincide with natural sleep peaks
• Identification of sleep disturbances
• Regulations of working hours

61. Chemical dependence
Self administration of drugs & suicide rates are high among
anesthesiologist.
• Addiction :compulsive, continued use of drugs inspite of
adverse, a chronic, relapsing condition resulting from long
term effects of drugs on brain, due to molecular, structural,
cellular, & functional changes.
• Dependence: physical / psychological inability to control drug
use
• Abuse :use of drugs in detrimental way but not to the point of
addiction. a pre addiction level, can easily quit. a voluntary act.

62. Chemical dependence
Causes
• Stress
• Availabilities
• Curiosity for experimentation
• Drug potency
• Others-genetic predisposition

63. Chemical dependence
Management
• Identification
• Intervention
• Referral
• Rehabilitation

64. References
11/23/2015 OR Hazard and strategies to enhence PS 64
• Safe anesthesia –third edition
• Ronald D Miller and Manuel C Pardo, Jr
• Airway management in emergencies, George Kovacs and J. Adam
Law, 2008
• Clinical Anesthesiology, 4th Edition, G. Edward Morgan, Jr., Maged S.
Mikhail, Michael J. Murray
• Clinical Anesthesia, 5th Edition by Barash, Paul G.; Cullen, Bruce F.;
Stoelting, Robert K. 2006
• Miller’s Anesthesia, 7th edition by Ronald D. Miller, 2010
• Decontamination of medical equipment, update in anesthesia
content number 7, 1997