NAPs and TIVA

Conclusions
-well documented changes in practice over the last decade
-marked increase in use
-a risk for AAGA , especially if used without care or attention to detail
-pEEG monitoring goes hand in hand and has increased dramatically
-TIVA (especially prop+remi)

In the registry phase of NAP7 a common theme was of isolated severe hypotension or leading to perioperative cardiac arrest.

This related to patients who were high risk from
-old age
-frailty
-high ASA
-acute disease processes

Within this cohort both propofol & TIVA with

In NAP7 (perioperative cardiac arrest) we collected data on TIVA & pEEG use but not on NMB use

-TIVA use rose dramatically to 26%
*a 4-fold rise in a decade
-pEEG rose to 19%
*a 7-fold rise
-pEEG use during TIVA rose to 62% (likely close to 100% during TIVA + NMB though

In NAP6 (anaphylaxis) we took stock of all drugs used during anaesthesia

-use of TIVA rose to 8%
-pEEG monitoring was used in 12%
*rising to 32% with TIVA
*38% with TIVA + NMB
-with variation by specialty, anaesthetist seniority & BMI

rcoa.ac.uk/sites/default/…

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NAPs and TIVA and pEEG monitoring

Quick summary 🧵 for amongst others
Julian Fuller

NAP5
Awareness
-TIVA was associated with a doubling in frequency of accidental awareness (during general anaesthesia (AAGA)
-what a lot of people missed was that when TIVA was used

Andrew Kane Royal College of Anaesthetists Claire Shannon VASGBI Thank you Andrew. Important snippets from Royal College of Anaesthetists National Audit Projects in vascular were included in the lecture
…-publications.onlinelibrary.wiley.com/doi/10.1111/an…

𝘈𝘯𝘢𝘦𝘴𝘵𝘩𝘦𝘴𝘪𝘢 Royal College of Anaesthetists Richard Armstrong Gudrun Kunst Andrew Kane Emira Kuršumović Nuala Lucas National Audit Projects Jasmeet Soar Vascular surgery - like cardiac surgery & cath lab cases involving anaesthesia each represent around 1% of anaesthesia (surgical) activity but close to 10% of perioperative cardiac arrests.

Of note the patients having a cardiac arrest in cardiac surgery (80% ROSC) do very well

Congratulations to ronelle mouton🏳️‍🌈 who delivered the Macintosh Professorship lecture at our Cardiac Symposium today.

'Strategies to optimise outcomes following abdominal aortic aneurysm surgery'

Award presented by Claire Shannon, citation by Dr Dan Taylor chair of VASGBI.

Let's have better informed pre-operative discussions about the risks & outcomes for patients undergoing vascular surgery.

Read the Royal College of Anaesthetists NAP7 recommendations for vascular anaesthesia from an institutional, individual and research perspective 👇

🔗…-publications.onlinelibrary.wiley.com/doi/10.1111/an…

🔓Cardiac arrest in vascular surgical patients receiving anaesthetic care: an analysis from the Royal College of Anaesthetists 7th National Audit Project (NAP7)

Richard Armstrong Tim Cook Gudrun Kunst Andrew Kane Emira Kuršumović Nuala Lucas National Audit Projects Jasmeet Soar @RonelleMouton506

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🩸Cardiac arrest and vascular surgery🩸

Royal College of Anaesthetists National Audit Projects

🔺Incidence of 15/10,000

🔺83% during non-elective surgery

🔺55% during aortic surgery

🔺57% caused by major haemorrhage

🔺88% caused by 'patient factors'

🔗 …-publications.onlinelibrary.wiley.com/doi/10.1111/an…

⚠️Attention obstetric anaesthetists!⚠️

Outcomes from the Royal College of Anaesthetists NAP7 study

➡️Haemorrhage was the single leading cause of peri-operative cardiac arrest in obstetric patients

➡️Underestimated severity & inadequate early resuscitation contributed

🔗…-publications.onlinelibrary.wiley.com/doi/10.1111/an…

What causes cardiac arrest in obstetric patients?

🩸Haemorrhage🩸

What else?

➡️High neuraxial block
➡️Bradyarrhythmia
➡️Amniotic fluid embolism
➡️Drug error

🚫Note - NO cardiac arrests related to failed airway management or remifentanil PCA

🔗…-publications.onlinelibrary.wiley.com/doi/10.1111/an…

Cardiac arrest in obstetric patients receiving anaesthetic care: results from the 7th National Audit Project of the Royal College of Anaesthetists

Nuala Lucas Emira Kuršumović Tim Cook Andrew Kane Richard Armstrong National Audit Projects Jasmeet Soar

…-publications.onlinelibrary.wiley.com/doi/10.1111/an…

What were the most common airway complications found in the
Royal College of Anaesthetists NAP7 study?

➡️laryngospasm (37%)
➡️airway failure (30%)
➡️aspiration (6%)

How common is FONA?

⭐️1 in 8370⭐️

Tim Cook Dr Fi Oglesby Andrew Kane Richard Armstrong Emira Kuršumović @jas_soar368

🔗…-publications.onlinelibrary.wiley.com/doi/10.1111/an…

𝘈𝘯𝘢𝘦𝘴𝘵𝘩𝘦𝘴𝘪𝘢 Royal College of Anaesthetists National Audit Projects Iain Moppett Andrew Kane Richard Armstrong Emira Kuršumović Jasmeet Soar One thing that surprised me in the NAP7 analysis was the failure to match levels of monitoring to degree of frailty

Intensity of monitoring seems to rise to clinical frailty scale score 4 (pre-frail)
- then peak or fall off as frailty increases

Why?
Do we need to rethink?

🔓Peri-operative cardiac arrest in the older frail patient as reported to the 7th National Audit Project of the Royal College of Anaesthetists

National Audit Projects Iain Moppett Andrew Kane Richard Armstrong Emira Kuršumović Jasmeet Soar Tim Cook

🔗…-publications.onlinelibrary.wiley.com/doi/10.1111/an…

𝘈𝘯𝘢𝘦𝘴𝘵𝘩𝘦𝘴𝘪𝘢 Royal College of Anaesthetists National Audit Projects Iain Moppett Andrew Kane Richard Armstrong Emira Kuršumović Jasmeet Soar FRAILTY OLDER AGE & SURGERY

Among the most notable findings in this group is that as frailty increases
- urgency of surgery increases
- severity of surgery increases
(both are factors strongly associated with complications & poor outcomes)

But intensity of anaesthetic

Frailty is a hot topic in peri-operative care!

Check out the Royal College of Anaesthetists NAP7 findings on the older frail patient and cardiac arrest! 👇

National Audit Projects Iain Moppett Andrew Kane Richard Armstrong Emira Kuršumović Jasmeet Soar Tim Cook

🔗…-publications.onlinelibrary.wiley.com/doi/10.1111/an…

Some examples of poor care of older and frail patients from Royal College of Anaesthetists NAP7 include:

➡️a lack of use of objective tools for pre-operative risk stratification
➡️inappropriately large doses of drugs during spinal and GA
➡️a lack of invasive BP monitoring

🔗…-publications.onlinelibrary.wiley.com/doi/10.1111/an…