The Operating Theatre Journal - Journal - Page 6
“PERUSE before you Infuse”
is a mnemonic designed to
reduce error when using total
intravenous anaesthesia (TIVA).
It is now used in multiple Trusts
across the UK, and elsewhere.
The poster is also currently
available to download from the
websites of the Association of
Anaesthetists, and the Society
for Intravenous Anaesthesia,
although it is not currently
formally endorsed by either
organisation.
The check was created to
highlight and prevent the more
common
errors,
omissions,
substitutions and other issues
which may occur when using
TIVA, as identified by the 5th
National Audit Project of the
Royal College of Anaesthetists
and
the
Association
of
Anaesthetists (NAP5), as well as
subsequent regional surveys.
It should be used as an addition
to usual good practice and other
safety checks. It was not designed
to be a guide of practice. It is
intended to be spoken aloud and
confirmed by a second person,
immediately before commencing
the infusions.
For more information and
background to the project,
please view the Association of
Anaesthetists “Education Shot”,
linked below:
“PERUSE before you Infuse”
PERUSE before you Infuse
– a safety initiative for total intravenous anaesthesia
In comparison, the engineering of TIVA equipment is in its infancy.
TIVA frequently involves two syringe pumps that may be almost
identical, and which will do whatever we programme them to
do. Most are able to deliver propofol using an infusion model
designed for remifentanil, or deliver the syringe contents onto
the floor or into subcutaneous tissues while still displaying a
calculated effect site concentration. Many potential errors are not
prevented by the equipment, as evidenced by the fact that we
are still making them. Manufacturers should be encouraged to
develop hard design safety solutions. However, in the meantime
we should consider other solutions lower down the hierarchy to
mitigate error.
A little over a year ago, I made an error when using TIVA. Fortunately, I recognised my error and
corrected it before any harm occurred. Discussions with colleagues revealed that several others
in my department had experienced similar near-misses within a relatively short period of time.
An email recommending increased vigilance was circulated, but it occurred to me that errors that
happen to multiple people represent a problem in need of a systems-based solution.
The 5th National Audit Project of the RCoA and Association of
Anaesthetists (NAP5) reviewed cases of accidental awareness
during general anaesthesia [1]. TIVA was associated with a
disproportionately high rate of awareness compared with use
of volatile agents, with over three quarters of events deemed
to have been preventable. Failure to deliver the intended
anaesthetic dose was highlighted as an important cause.
Expanding on the recommendations of NAP5, a joint guideline
for the safe practice of TIVA was published by the Association of
Anaesthetists and the Society for Intravenous Anaesthesia (SIVA)
last year [2]. Many of the recommendations in this guideline are
practical methods of reducing the likelihood of error, such as
standardising the concentrations of propofol and remifentanil,
and use of administration sets specifically designed for TIVA.
To determine if others were following this guidance and still
making errors, I carried out a regional email survey across eight
Trusts in the East Midlands. The questionnaire focussed on TIVA
practice, errors encountered, and related patient events and
harm [3].
There were 180 responses from trainees, SAS doctors and
consultants. Unsurprisingly, there was significant variation in
use between individuals and between departments. Fourteen
percent of respondents reported that they ‘never’ use TIVA
and 9.4% reported ‘almost always’ or ‘exclusively’ using TIVA.
Although this may not be a representative sample as the
respondents were self-selected, TIVA was reportedly used in
approximately 20% of general anaesthetics, considerably higher
than the 8% found by NAP5.
Most anaesthetists who use TIVA reported good adherence to
the national guidance, and in some ways exceeded it. Almost
two thirds of respondents reported always using processed
EEG with TIVA, rather than just in higher-risk scenarios such as
use of neuromuscular blockade. However, more than 80% of
respondents had experienced at least one of the more common
errors or issues when using TIVA (Table 1). The survey also
demonstrated that these errors have the potential to cause
patient harm. Cases of unintentionally deep or light anaesthesia
due to error were reported by 22% and 25% of respondents
respectively, with resulting haemodynamic instability in 8.9% and
even cases of accidental awareness. It appears that despite good
practice, errors when using TIVA remain common, with adverse
consequences.
Table 1
Figure 1.
When using TIVA, have you made or witnessed the
following errors / issues? Select all that apply (please
be honest).
Pump battery failure (as a result of not being charged
during use)
Cannula failure intraoperatively
Frequency
HIERARCHY OF
INTERVENTION EFFECTIVENESS
48.9%
33.9%
Protocol / drug mismatching: (e.g. propofol
33.3%
administered using remifentanil TCI model or vice versa)
Cannula failure at induction
Drugs not present in the infusion (e.g. remifentanil not
added to the remifentanil syringe)
Incorrect concentration of drug for programmed
protocol (e.g. 1%/ 2% propofol, remifentanil dilution
errors)
RULES
AND
TRAINING
POLICIES
REMINDERS,
CHECKLISTS
AND
DOUBLE CHECKS
30.0%
Pump misprogrammed: Incorrect patient demographics
26.7%
(e.g. height, weight, age or gender)
Pump misprogrammed: Correct drug, but incorrect
18.3%
protocol selected (e.g. effect site instead of plasma
targeting, Marsh instead of Schnider etc.)
Infusion set not connected to patient when infusion
10.6%
commenced
Infusion set not primed with drugs before connection
EDUCATION
AND
PEOPLE FOCUSED
.
8.3%
8.3%
7.8%
Other errors / issues (please specify)
7.8%
SYSTEM FOCUSED
To that end, I have developed a simple check before induction
of anaesthesia using TIVA. ‘PERUSE before you Infuse’ (Figure 2)
is a short mnemonic covering the most common errors / issues
reported in my survey, as well as those featured in NAP5. The
check is in addition to normal TIVA use, and is not intended to
replace any other aspect of routine practice. It takes less than 60 s,
and is performed by the anaesthetist and a second person, usually
the anaesthetic assistant. It is intended to be spoken out loud
immediately before commencing the infusions.
NS
Robert James Fleming
Specialty Doctor in Anaesthesia
Nottingham University Hospitals
References
1.
2.
3.
National Audit Projects. Accidental Awareness During General Anaesthesia in
the UK and Ireland, 2014. https://www.nationalauditprojects.org.uk/NAP5report
(accessed 27/5/20).
Nimmo AF, Absalom AR, Bagshaw O, et al. Guidelines for the safe practice of
total intravenous anaesthesia (TIVA). Anaesthesia 2018; 74: 211-24.
Learn with NUH. TIVA safety: local / regional survey, 2019. https://youtu.be/vCEIOeMOAg (accessed 27/5/20).
Twitter: @robjimfleming
Enquiries to: robert.fleming@nuh.nhs.uk
19 Anaesthesia News | July 2020 | Issue 396
https://vimeo.com/584833348/cd7b63ebbf
USING TIVA?
PERUSE BEFORE YOU INFUSE
PERUSE
INFUSE
TWO-PERSON POSITIVE CONFIRMATORY CHECK,
BEFORE STARTING THE INFUSIONS
6
THE OPERATING THEATRE JOURNAL
FORCING
FUNCTIONS
At the time of writing, ‘PERUSE before you Infuse’ has been rolled
out at Nottingham University Hospitals NHS Trust, and discussion
is underway with several other trusts for it to become part of
their usual TIVA practice. Until more of the equipment we use is
designed to prevent error, it is my hope that anaesthetists will
use this system to help ensure successful delivery of the intended
doses of their anaesthetic drugs.
Previous patient demographics not cleared and used for
3.9%
a subsequent patient
Drugs or giving set from previous patient connected to a
2.2%
subsequent patient
Drugs syphoning from syringes into patient under
0.6%
gravity
The reasons for this are multiple, but it could be argued
that much of the current equipment used for TIVA is underengineered. In high reliability industries, design improvements
are at the top of the hierarchy of intervention effectiveness to
prevent error (Figure 1). The safety of the anaesthetic machine
has undergone many such iterative design improvements
over many years. These include: oxygen failure alarms and the
O2/ N2O chain link; colour coding of pipes, valves, cylinders,
vaporisers, bottles and displays; non-interchangeable fittings
for Schrader sockets/ collars, pipeline screw thread connectors,
the key fill system for vaporisers and the pin index system for
cylinders. These features help to prevent the anaesthetist from
delivering anything other than the intended gas mixture.
AUTOMATION
AND
COMPUTERISATION
INCREASING EFFECTIVENESS
10.0%
Drugs refluxing into the giving set of connected fluids
SIMPLIFICATION
AND
STANDARDISATION
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