CRITICAL INCIDENTS

Any unintended event that occurs when a patient receives treatment in the hospital,
a) that results in death, or serious disability, injury or harm to the patient, and
b) does not result primarily from the patients’ underlying medical condition or from a known risk
inherent in providing the treatment

Degree of harm is the severity and duration of harm, and any treatment implications, that result
from an incident. The degree of harm may be:
- None: patient outcome is not symptomatic and no treatment is required.
- Mild: patient outcome is symptomatic (mild), loss of function/harm is minimal/intermediate but
short term, and no/minimal intervention is required.
- Moderate: patient outcome is symptomatic, requiring intervention, an increased LOS, or causing
permanent or long-term harm or loss of function.
- Severe: patient outcome is symptomatic, requiring life‐saving or major surgical/medical
intervention, shortened life expectancy or major permanent or long-term harm or loss of function is
caused.
- Death: on balance of probabilities, death was caused or brought forward in the short term by the
incident.

Core clinical Learning Outcomes:

 To gain knowledge of the principle causes, detection and management of critical incidents that
can occur in theatre
 To be able to recognise critical incidents early and manage them with appropriate supervision
 To learn how to follow through a critical incident with reporting, presentation at audit meetings,
and discussions with patients
 To recognise the importance of personal non-technical skills and the use of simulation in
reducing the potential harm caused by critical incidents
 CARDIAC AND/OR RESPIRATORY ARREST
 UNEXPECTED FALL IN SPO2 WITH OR WITHOUT CYANOSIS
OXYGEN
Administer high flow oxygen if SpO2 is ≤94%

A – Is the airway clear?

 Is the patient breathing quietly without signs of obstruction?
 Are there signs of laryngospasm? (mild laryngospasm – high pitched inspiratory noise; severe
laryngospasm – silent, no gas passes between the vocal cords)
 Is there any vomit or blood in the airway?
 Is the tracheal tube in the right place?
Action
 Ensure that there is no obstruction. If breathing via a facemask
- chin lift, jaw thrust,
 Consider an oropharyngeal or nasopharyngeal airway,
 Check for laryngospasm and treat if necessary.
 Check the tracheal tube/LMA - if any doubt about the position, remove and use a facemask.
 Suction the airway to clear secretions.
 Consider waking the patient up if you have difficulty maintaining the airway immediately after induction
of anaesthesia.
 Consider intubation.
 If you ‘can’t intubate, can’t ventilate’ an emergency surgical airway may be required
Check the endotracheal tube and - ‘If in doubt, take it out’.
B - Is the patient breathing adequately?
Look, listen and feel:
 Are the chest movements and tidal volume adequate?
 Listen to both lungs – is there normal bilateral air entry? Are the breath sounds normal? Any wheeze or
added sounds?
 Is the chest movement symmetrical?
 Is anaesthesia causing respiratory depression?
 Is there a high spinal causing respiratory distress?
 Check ETCO2 levels
Action
 Assist ventilation with good tidal volumes to expand both lungs until the problem is diagnosed and
treated appropriately.
 If there is sufficient time, consider a chest X-ray to aid diagnosis.
 ventilate via a facemask, LMA or tracheal tube if the respiration is inadequate. This will rapidly reverse
hypoventilation due to drugs or a high spinal and a collapsed lung will re-expand.
 Suction lower airway with suction catheters to remove any secretions.
 A nasogastric tube should be passed to relieve stomach distension.

C - Is the circulation normal?

 Feel for a pulse and look for signs of life, including active bleeding from the surgical wound.
 Check the blood pressure.
 Check the peripheral perfusion and capillary refill time.
 Observe for signs of excessive blood loss in the suction bottles or wound swabs.
 Is anaesthesia too deep? Is there a high spinal block?
 Is venous return impaired by compression of the vena cava (gravid uterus, surgical compression).
 Is the patient in septic or cardiac shock?
Normally an inadequate circulation is revealed by the pulse oximeter as a loss or reduction of pulsatile
waveform or difficulty getting a pulse signal.
Action
 If the blood pressure is low, correct it.
 Check for hypovolaemia.
 Give IV fluids as appropriate (normal saline or blood as indicated).
 Consider head down or leg up position, or in the pregnant mother, left lateral displacement.
 Consider a vasoconstrictor such as ephedrine or phenylephrine.
 If the patient has suffered a cardiac arrest, commence cardiopulmonary resuscitation (CPR) and
consider reversible causes (4 H’s, 4T’s: Hypotension, Hypovolaemia, Hypoxia, Hypothermia; Tension
pneumothorax, Tamponade (cardiac), Toxic effects (deep anaesthesia, sepsis, drugs), Thromboemboli
(pulmonary embolism).

D – Drug effects
Check that all anaesthesia drugs are being given correctly.
 Excessive halothane (or other volatile agent) causes cardiac depression.
 Muscle relaxants will depress the ability to breathe if not reversed adequately at the end of surgery.
 Opioids and other sedatives may depress breathing.
 Anaphylaxis causes cardiovascular collapse, often with bronchospasm and skin flushing (rash). This
may occur if the patient is given a drug, blood or artificial colloid solution that they are allergic to. Some
patients are allergic to latex rubber.
Action
 Look for an adverse drug effect.
 In anaphylaxis, stop administering the causative agent, administer 100% oxygen, give intravenous
saline starting with a bolus of 10ml/kg, administer adrenaline and consider giving steroids,
bronchodilators and an antihistamine

E - Is the equipment working properly?

 Is there a problem with the oxygen delivery system to the patient?
 Does the oximeter show an adequate pulse signal?
Action
 Check for obstruction or disconnection of the breathing circuit or tracheal tube.
 Check that the oxygen cylinder is not empty.
 Check that the oxygen concentrator is working properly.
 Check that the central hospital oxygen supply is working properly.
 Change the probe to another site; check that it is working properly by trying it on your own finger.
If it is felt that the anaesthesia equipment is faulty, use a self-inflating bag to ventilate the patient with
air while new equipment or oxygen supplies are obtained. If equipment is missing, mouth to tracheal tube,
or mouth-to-mouth ventilation, may be lifesaving.
 UNEXPECTED INCREASE IN PEAK AIRWAY PRESSURE
CAUSES
 Circuit or machine problem:
o Ventilator/bag switch in wrong position
o Stuck valve (inspiratory/expiratory/APL)
o Oxygen flush valve stuck in "on" position
o Kinked/misconnected hose in circuit/scavenge limb
o Failure of check valves/regulators in machine, allowing high-pressure gas into low-pressure circuit
o PEEP valve accidentally placed in inspiratory limb

 ETT/supraglottic airway problem:

o Kinked tube
o Malpositioned supraglottic airway
o Endobronchial, esophageal, submucosal intubation
o Herniated cuff obstructing end of tube
o Dissection of interior surface of tube leading to airway narrowing

 ↓ Pulmonary compliance:
o ↑ intra-abdominal pressure
o Pulmonary aspiration
o Bronchospasm 
o ↓ chest wall compliance
o Pulmonary edema
o Pneumothorax

 Drug-induced problem
o Opioid-induced chest wall rigidity
o Inadequate muscle relaxation
o Malignant hyperthermia

 Laryngospasm (if using supraglottic airway)

MANAGEMENT
 ↑ FiO2 to 100%
 Verify the peak inspiratory pressure
 Switch to manually using reservoir bag; assess pulmonary & circuit compliance
 Disconnect circuit from ETT & squeeze bag:
o If PIP still high, obstruction in circuit; ventilate using BVM connected to 100% FiO2
o Get help to replace/repair circuit
 Auscultate chest & neck:
o Listen for symmetry (endobronchial, tension, or simple pneumothorax) & for adventitious sounds
(pulmonary edema, bronchospasm)
o Listen for stridorous sound of laryngospasm
 Examine trachea for deviation, check HR & BP
 Exclude ETT obstruction:
o Pass suction catheter down ETT & apply suction to clear secretions
o If ETT obstructed, deflate cuff & repeat
o Consider fiberoptic bronchoscopy to elucidate problem
o Remove & reintubate if necessary
 Check for other causes of ↓ chest compliance:
o Malignant hyperthermia
o Aspiration
o Inadequate muscle relaxation
o Opiates
o Excessive surgical retraction
o Abnormal anatomy (ie: scoliosis)
FALL IN END TIDAL CO2 / RISE IN END TIDAL CO2 / RISE IN INSPIRED CO2
PERIOPERATIVE HYPOTENSION

CAUSES MANAGEMENT
Preoperative
Hypovolemia Replace volume depletion with fluids according to the current guidelines or
local protocol, minimize starvation if possible
ACE-Is/ARBs Suspend medications in the perioperative period
Intraoperative
Excessive depth of Minimize excessive anesthesia intensity by monitoring the depth of the
anesthesia anesthetic plane
Neuraxial blockade Administer intravenous fluids, ephedrine, phenylephrine, ondansetron, leg
compression
Blood loss Replace volume depletion with fluids and blood products according to the
current guidelines or local protocol
Myocardial ischemia Hemodynamic and biohumoral markers assessment, intraoperative TEE to
detect and confirm alteration in myocardial contractility.
Postoperative
Myocardial ischemia Appropriate hemodynamic and biohumoral markers assessment
Hypovolemia Replace volume depletion with fluids and blood products according to the
current guidelines or local protocol
Arrhythmias Monitor ECG and correct arrythmia using ACLS, ALS or analogue protocols
Dynamic LVOT Administer fluids, give medications to lower heart rate (e.g beta blockers),
Obstruction stop beta agonists
Pneumothorax Treatment as needed (ranges from tight follow-up to chest tube insertion to
thoracic surgery)
Tamponade Drainage of the pericardial space
Pulmonary embolism Thrombolytic therapy
Sepsis Treatment according to the Surviving Sepsis Guidelines
Bleeding Replace volume depletion, monitor coagulation and correct shortage of
coagulation determinants if possible, according to the current protocols
Rescue Drugs
Epinephrine 10 mics boluses
Ephedrine 3-6 mg boluses
Phenylephrine 25-50 mics boluses
UNEXPECTED HYPERTENSION
Generally, elevations in SVR are more common in older adult patients and those with chronic hypertension,
while tachycardia leading to increased CO is more commonly associated with hypertension in younger
patients.

CAUSES MANAGEMENT
Inadequate depth of - Sympathetic Response to pain:
Anaesthesia  Ensure Adequate Analgesia
- Laryngoscopy Response: (One of the following)
 Propofol: 0.5 mg / ml
 Opioids: Fentanyl 1 mic / kg
 Dexmedetomidine: 0.5-1.0 mic / kg bolus over 10-20 mins prior to
laryngoscopy
 Beta-Blocker:
o Esmolol: 1 mg / kg 3 mins prior to intubation
o Labetalol: 0.25 mg / kg given over 1 min 5 mins prior to
laryngoscopy
 Lignocaine: 1-1.5 mg / kg 60-90 secs prior to laryngoscopy
- Responses to incision and surgical manipulations 
 Same as Laryngoscopy Response
Hypoxemia and/or - Ensure proper oxygenation / Increase fiO2
Hypercarbia - Increase minute ventilation to prevent increase in PCO2
Hypervolemia  - IV Furosemide: 10-20 mg
Emergence and tracheal - Ensure Adequate Analgesia
extubation
Antihypertensive - Labetalol: 5-25 mg
medication withdrawal  - Esmolol: 10-50 mg
- Metoprolol: 1-5 mg
- Hydralazine: 2.5-5 mg repeated every 5 mins to max 20 mg
- Nitro-glycerine: 50-100 mics boluses
- Dexmedetomidine: 0.1-0.7 mics / kg / hr
Bladder Distension - Ensure working urinary catheter if in place
Rule out rare causes - Alcohol or Benzodiazepines withdrawal / Thyroid storm / Malignant
Hyperthermia
SINUS TACHYCARDIA

 Tachycardia with Hypertension: Sympathetic stimulation

- Follow unexpected hypertension protocol

 Tachycardia with Hypotension

- Follow perioperative hypotension protocol

ARRHYTHMIAS:
· ST SEGMENT CHANGES
CONVULSIONS Simultaneously:

- Stabilise and support Airway and Breathing: Give 100% O2 -Identify and treat underlying cause
- Attach Monitors (Minimum Standards)  Hypoglycaemia
- Give 1st dose of Benzodiazepine:  Metabolic Abnormalities
 Fever / Infection
 Severe Traumatic Brain Injury
 Raised ICP
  Lorazepam: 2 mg / min / Repeat another 2 mg if needed
 Diazepam: 2.5 mg / min to a maximum of 10 mg
 Midazolam: 2.5 mg / min to max of 5 mg
- Give 1st dose of Anticonvulsants
 Levetiracetam: 60 mg / kg iv with max of 4500 mg in 5-15 mins
 Phenytoin: 20 mg / kg @ 100-150 mg / min
 Na Valproate: 40 mg / kg with max of 3000mg @ 10 mg / kg / min
- Reassess.
STEP 2
STEP 1
Seizure Stops Seizures Continue after 5 mins despite above
- Continue close Cardiovascular
monitoring - Give Second Dose of Benzodiazepine
- Neurological opinion - If stop follow Step 1
- If continue after 2nd dose and 5-10 mins follow Step 3

STEP 3

- Additional dose of phenytoin 5-10 mg / kg (Max

cumulative dose of 30 mg / kg)
- Urgent Neurological opinion
- Prepare to transfer to ICU
- Prepare for Intubation and Mechanical
Ventilation

- For Seizures Continuing beyond 30 mins

 RSI / Mechanical Ventilation
 Medications for Refractory Seizures
o Midazolam inf:
 0.1 mg / kg / hr to a max of 3 mg / hr:
 When seizures stop continue for 24 hrs before tapering the infusion
 If seizures persist after 45-60 mins of the above infusion change to propofol or phenobarbital
OR
o Propofol infusion:
 1-2 mg / kg loading dose with repeat dose of 0.5-1 mg / kg if seizures continue to a max of 10 mg / kg
 Start inf @ 20 mics / kg / min: titrate over next 45-60 min to achieve seizure freedom
 Boluses of 0.5-1.0 mg / kg for breakthrough seizures and increase 5-10 mics / kg every 5 mins until
seizures controlled
 Max rate: 200 mic / kg / min & 5 mg / kg / hr for 48 hrs
 When seizures stop continue for 24 hrs before tapering the infusion
OR
o Phenobarbital Infusion
 5 mg / kg IV bolus over 10 mins, max rate 50 mg / min
 Give additional 5 mg / kg doses if seizure continues
 Start inf @ 1 mg / kg / hr titrate up to a max dose of 5 mg / kg / hr.
 When seizures stop continue for 24 hrs before tapering the infusion

DIFFICULT/FAILED MASK VENTILATION

FAILED INTUBATION
CAN’T INTUBATE, CAN’T VENTILATE
REGURGITATION/ASPIRATION OF STOMACH CONTENTS
Management: key points
 Head down tilt
 Oropharyngeal suction
 100% oxygen
 Apply cricoid pressure and ventilate
 Deepen anaesthesia/perform RSI
 Intubate trachea
 Release cricoid once airway secured
 Tracheal suction
 Consider bronchoscopy
 Bronchodilators if necessary

LARYNGOSPASM
 - Remove Stimulus: Airway Manipulation / Surgical Stimulation / Suction
Secretions
- Administer 100% FiO2
- CPAP with Mask with
 Jaw thrust
 Neck Extension
 Mouth Open
 Laryngospasm notch pressure
 Oral Airway if needed

- Confirm if there is air entry

No YES
Complete Laryngospasm Incomplete Laryngospasm
-Call for help -Deepen Anaesthesia
-Propofol: 50-100 mg iv stat -Propofol 50 mg
-Give IPPV

- Reassess

If Laryngospasm does not improve

- Sux 25-50 mg iv
- IPPV: FM / LMA / ETT till muscle relaxant wears off
- If Bradycardia: 0.6 mg atropine

BRONCHOSPASM
 ANAPHYLAXIS
Further management of anaphylaxis

o Observe for at least six hours

o Beware biphasic reactions
o Advise patient to return immediately if symptoms reoccur
o Provide three-day prescription of oral steroid and antihistamine
o Consider an adrenaline auto-injecter (EpiPen)
o Referral to allergy specialist
TRANSFUSION REACTIONS, TRANSFUSION OF MIS-MATCHED BLOOD OR BLOOD
PRODUCTS
HIGH SPINAL BLOCK IN OBSTETRICS
LOCAL ANAESTHETIC TOXICITY
EMERGENCY TRACHEOSTOMY MANAGEMENT: PATENT UPPER AIRWAY
CONING DUE TO INCREASED INTRACRANIAL PRESSURE
MALIGNANT HYPERPYREXIA
HYPERKALEMIA IN CARDIAC ARREST