Principles of Anesthesia Crisis Resource Management

  • Seek assistance early and quickly inform others on the surgical team and call for extra assistance as soon as unusual circumstances are recognized.
  • Establish clarity of roles for each per-son involved in management of the event; especially identify who will manage the event (event manager).
  • Use effective communication processes, including reading back of instructions, being clear to whom directions are being given.
  • Use resources effectively and identify what additional resources (people, supplies, equipment, transportation, etc.) are available to manage the situation.
  • Maintain situational awareness and avoid fixations, which is perhaps the most challenging task as situational awareness is difficult to retrieve once it is lost. Having one person act as event manager, observing the big picture rather than becoming immersed in the details is thought to be effective.


Table 6.1 Crisis Management During Anesthesia

C1 Circulation Establish adequacy of peripheral circulation (rate, rhythm, and character of pulse). If pulse is absent, institute cardiopulmonary resuscitation (CPR). The core algorithm must still be completed as soon as possible.
C2 Color Note saturation. Examine for evidence of central cyanosis.. Test probe on own finger, if necessary, while proceeding with O1 and O2.
O1 Oxygen Check rotameter settings; ensure inspired mixture is not hypoxic.
O2 Oxygen analyzer Adjust inspired oxygen concentration to 100% and note that only the oxygen flowmeter is operating. Check that the oxygen analyzer shows a rising oxygen concentration distal to the common gas outlet.
V1 Ventilation Ventilate the lungs by hand to assess breathing circuit integrity, airway patency, chest compliance, and air entry by "feel" careful observation, and auscultation. Also inspect capnographs trace if available.
V2 Vaporizer Note settings and levels of agents. Check all vaporizer filler ports, seating's, and connections for liquid or gas leaks during pressurization of the system. Consider the possibility of the wrong agent being in the vaporizer.
E1 Endotracheal tube Systematically check the endotracheal tube (if in use). Ensure that it is patent with no leaks or kinks or obstructions. Check capnograph for tracheal placement. If necessary, adjust, deflate cuff, pass a catheter, or remove and replace.
E2 Elimination Eliminate the anesthetic machine and ventilate with self-inflating (e.g., Ambu) bag with 100% oxygen (from alternative source if necessary). Retain gas monitor sampling port, but be aware of possible problems.
R1 Review monitors Review all monitors in use (preferably oxygen analyzer, capnograph, oximeter, blood pressure, electrocardiograph, temperature and neuromuscular junction monitor). For proper use, the algorithm requires all monitors to have been correctly sited, checked, and calibrated
R2 Review all other equipment Review all other equipment in contact with or relevant to the patient (e.g., diathermy, humidifiers, heating blankets, endoscopes, probes, prostheses, retractors, and other appliances).
A Air way Check patency of the non-intubated airway. Consider laryngospasm or presence of foreign body, 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 Circulation Repeat evaluation of peripheral perfusion, pulse, blood pressure, electrocardiograph, and filling pressures (where possible) and any possible obstruction to venous return, raised intrathoracic pressure (e.g., inadvertent peak end-expiratory pressure) or direct interference to (e.g., tamponade of the heart. Note any trends on records.
D Drugs Review intended (and consider possible unintended) drug or substance administered. Consider whether the problem may be a consequence of an unexpected effect, a failure of administration, or wrong dose, route, or manner of administration of an intended or wrong drug. Review all possible routes of drug administration
Last modified: Wednesday, 16 November 2016, 9:40 AM