Arise,awake doctors

ANAESTHESIA AND FATIGUE: THE GLOBAL

SCENARIO

DR UNNIKRISHNAN PNEUROANAESTHESIA

ARISE, AWAKE…DOCTORS!

Unmet needs; who will answer?.

CHANGE

TECHNOLOGY

SCIENCE

RULES

Sounds familiar ?

“How many clinicians have got Nobel prize?

“A dream is what keeps you awake. - Abdul Kalam”

Sleep has become our dream..

CREATIVITY DEVELOPS WHEN WE START ENJOYING OUR WORK

DEBACLES OCCUR AFTER HECTIC SCHEDULES

Fatigue and Doctors- Can science help us? .

Precious things

The fact that sleep is essential to human biology and neurocognitive function is well appreciated. Factors that disrupt or otherwise deny sleep are known to degrade both psychomotor and mental-task performance.

Hello..hello… I’m not hearing

Fatigue caused by lack of adequate sleep results in diminished cognitive function, impaired vigilance, decay in problem-solving ability, degradation in memory, and eroded motivation.4

SLEEP[LESSNESS] is injurious to health

Medical culture has traditionally fostered unsatisfactory ways of behaving.Long hours of either high intensity or boring work have been seen as the norm.Protest against them has been viewed as lazy or unprofessional. National Confidential Enquiry into Perioperative Deaths (NCEPOD) studies that it is inappropriate for the most interesting and complex cases to take place at night, where the risks will be still further increased.

After 36 hrs of service… I ve become very efficient in sleeping….

ECG interpretation accuracy is reduced amongst sleep-deprived house staff

intubation skill diminished in emergency room physicians working the night shift compared with similar staff during the day

I’ve given something to somebody……..?anaesthesia Gaba DM Howard SK and Jump B, Production pressure in

the work environment: Californian anesthesiologists’ attitudes and experiences, Anesthesiology 1994; 81: 488-500

Gravenstein JS, Cooper JB, and Orkin FK, Work and rest cycles in anesthesia practice, Anesthesiology 1990

report that more than 50% of “anaesthesia providers” admit that they had made errors in medical judgement which were attributed to fatigue

Mile stones….small and big!

15.7% of respondents reported falling asleep during the anesthetic care of a patient, and 48.8% of respondents reported observing a colleague engaged in sleep-related behavior during care [Chuck Biddle, CRNA,John Aker et al AANA]

A fatal case report of an anesthesiologist who fell asleep whilst anaesthetising an eight-year-old made front page in the Denver Post 23,

Come on…join hands with us

Surgeons who had limited opportunity for sleep had significantly higher rates of complications than those who had a longer sleep opportunity (odds ratio 1.72; 95% CI 1.02-2.89).

3 idiots…..among them 1 is doing Sx;2 are sleeping

spontaneous “microsleeps”, which may last secs, or even mins, and the individual may be unaware and can be unresponsive to external stimuli.

Extreme pressure for sleep can result in “shut down”

I’m getting enough kick without spending a penny

17 hours of wakefulness results in a decrease in performance equal to that produced by a blood alcohol level of 50 mg% and, after 24 hour without sleep, this decrement was equal to that produced by 100 mg% of blood alcohol.

The greatest risk occurs where significant sleep loss is combined with circadian rhythm disturbance.

Need to address fatigue scientifically…

A significant factor identified as avoiding serious outcome was providing relief for fatigued anaesthetists

Based on ….The Australian Incident Monitoring Scheme (AIMS) reported 152 incidents (2.7% of all reports) up to 1997

Hmmmmm………

Studies have shown that adaptation does not occur despite prolonged exposure to night work1. Many individuals cannot reset their body clock to allow for effective daytime sleep after night duties. Daytime sleep is typically shorter and of inferior quality compared with sleep at night40

Relieved…somebody is listening!!

William Clayton Petty, MD, observed that, “Fatigue can induce a state in anesthesia providers that will cause more medical errors. It is time we stop giving lip service to this problem and take positive steps towards solving it.”

How Research can help?

.

Can give inputs in formulating tools

The AMA 2006 Safe Hours Audit revealed that many doctors worked a similar number of hours, but often had very different risk ratings.To produce more biocompatible schedulesAMA has developed an on-line fatigue assessment tool. Doctors who use the assessment tool will receive an on-line assessment of the fatigue risks of their roster. Doctors who are assessed as being at risk are encouraged to raise this with hospital management.

Who will answer? h

? h

Who will answer? h

We need light…..(work)

bright light exposure has been successful in shifting rhythms in controlled laboratory situations but workplace studies have yet to be conducted.

Pharmacological studies of night workers are gaining support from drug manufacturers. All of these studies have been in acute laboratory situations. Long-term studies have not been reported and are clearly needed because of the side effects and abuse potential of drugs.

Research into DRUGS

alertness-enhancing drugs [not

recommended at present]

amphetamine analogues such as modafinil

Melatonin has been shown to promote

natural sleep and may cause a ‘circadian

shift’ to a new schedule. It can have adverse

effects on mood and the cardiovascular

system.

alertness-promoting properties

fewer side effects

little effect on recovery sleep

Further research into sleep & circadian rhythm inrelation to fatigue…and

the effect of circadian (and other body) rhythms on the responses of organisms to outside influences such as drugsBoth the pharmacokinetics and pharmacodynamics of drugs can be influenced by their time of administrationit has now been clearly demonstrated that the response to noxious stimuli is not constant over the 24 hour period. Although the temporal relationship is complex means there is a diurnal variation in pain perception

I think slapping has a better effect on you….

napping has been shown to be of positive benefit to improve subsequent alertness and performance

References Association of Anaesthetists of Great Britain and Ireland Fatigue and Anaesthetists – Expanded Web Version 1995-2012 Australian Medical Association Limited.Privacy Statement

• Howard SK, Rosekind MR et al, Fatigue in Anesthesia, Anesthesiology 2002,: 97;1281 – 1294

• ANZCA Professional Document (PS43) – Statement on Fatigue and the Anaesthetist (2001) Australian and New Zealand College of Anaesthetists

• Robinson JS, Howells TH, and Smith WDA, Fatigue in the practice of anaesthesia(letter), Anaesthesia 1978:33;62-3

Our weak defence against hazards posed by inhalational anaesthetics

Despite the huge improvement in the infrastructure for providing anaesthesia to patients, why are we not taking measures in preventing us from getting a share from it

Why we are not implementing effective scavenging methods in O.T.?

Whether N2O is having a significant influence on male fertility pattern..?

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Who will answer? h

THANK

YOU