Fatigue among Anesthesia Personnel

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Fatigue among Anesthesia Personnel

• Dr. Abdullah M. Kaki, MD, FRCPC,
• Department of Anesthesia Critical Care, Faculty
  of Medicine,
• King Abdulaziz University

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Definition

• Is the inability or unwillingness to continue
  effective performance and is caused by excessive
  workload, stress, sleep loss, and circadian
  disruption.

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Fatigue

• Achilles' heel of the medical profession.1

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Once Upon A Time (On-call Duties)

• Attend anesth all emergency cases in OR
• Member of code blue team
• Member of trauma team
• Epidural provider to all pregnant ladies (LR)
• Attend all meconium stained deliveries
• Provide outside services (consultations,
  cardioversion,)
• Preop visit for some consultants
• Other wise you can sleep

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• Health care is 24 / 7 service
• Anesthesiologists deliver critical
  around-the-clock care to a variety of patients.
• Fatigue is Physiological challenge
• Circadian pattern
• alertness and performance ? sleep.
• Patient safety has taken center stage in health
  care

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• In March 1984, Libby Zion, 18 yr old ? New York
  Hosp by parents with a high fever, dehydration,
  and chills ? admitted to medical ward.
• She was never examined by an attending physician
  (intern and a junior resident), both up for 18
  hrs. She became increasingly delirious, placed in
  physical restraints. AM, she was dead.
• Death has been attributed to the inexperience and
  fatigue of resident physicians who lacked the
  direct supervision of an attending physician.

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Fatigue risks safety

• Circadian factors were identified as contributing
  to the errors that resulted in the nuclear
  accident at Three Miles Island and Chernobyl.
• Fatigue resulting from the workrest patterns of
  managers was an important component of the flawed
  decision-making that contributed to the space
  shuttle Challenger accident.

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Fatigue risks safety

• N. S.F. 12 drivers driven while drowsy /yr, 15
  nodded off while driving.
• Fatigue ? 100,000 crashes/ yr ? 76,000 injuries
  1,550 fatalities.
• Recently, fatigue is the cause in 1520 of all
  transportation accidents, gt ETOH drugs in RTA.

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Intraop patient care requires

• Cognitive demands data collection, evaluation of
  its relevance to pt status, development and
  implementation of plans to maintain desired pt
  status, monitoring the outcome of interventions,
  and prompt response to acute changes
• Sleep providers can not have adequate sleep

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Does fatigue impair performance?

• Loss of sleep circadian disruption
• ?reduced attentionvigilance, impaired memory and
  decision-making, prolonged reaction time, and
  disrupted communications.
• ?increased risk for the occurrence of errors,
  critical incidents, and accidents.
• Speed-accuracy trade-off effect.
• Microsleeps

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• Denisco et al. on a simulated monitoring task
  subjects were asked to monitor and record time of
  significant deviation of clinical variables (HR,
  BP) ? lower vigilance scores in the group that
  had been on call.
• Interpret ECG changes and to do simple
  mathematical calculations is compromised among
  sleep-deprived house officers.
• Speed and quality of ETT was ? among ER doctors
  working night shift opp to their performance
  while working during day.

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Fatigue effects on health

• Several studies long-term exposure to shift ?
  independent risk factor for GI CVS diseases.
• A recent study ? working night shift 60 gt risk
  for breast ca compared with ? never worked the
  late shift.
• A meta-analysis (29 studies, 160,000 ? )
  evaluated physically demanding work, prolonged
  standing, long work hrs, and cumulative fatigue
  score. Positive assoc between that and preterm
  births, PIH, SGA.

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• Sleep restriction ? immunity, endocrine
  functions, cerebral metabolism.
• A prospective study (1000,000 persons with
  cancer) reported ? daily sleep times lt 4 h were
  2.8 times more likely to have died within a
  6-year than ? had 7.07.9 h of sleep.

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Sleep Factor

• Microsleep
• Brief, uncontrolled, and spontaneous episodes of
  physiologic sleep
• last sec min, intermittent in onset, difficult
  to predict, individual underestimates level of
  sleepiness.
• occur during low workload or when maximally
  sleepy.
• Frequent and longer microsleeps increase the
  number of errors of omission.

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Sleep Inertia

• Period of reduced ability to function optimally
  immediately on awakening.
• Impaired performance for 15- 30 min after
  awakening.
• Common during early morning circadian trough (2
  to 5 am).
• Awakened out of deep sleep to provide emergency
  care to pts (e.g., emergency C/S or emergency
  ETT).

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• The risk of LDP was greater at night (0000-800)
  among inexperienced practitioners.

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Evaluation of physiologic sleepiness in
anesthesia residents

• Using MSLT, evaluated physio daytime sleepiness
  of anesth residents under 3 different
  conditions
• baseline (daytime shift, no on-call in the
  previous 48 hrs),
• post-call (immediately after a 24-hr work ),
• sleep extended residents allowed to arrive for
  work at 10 am for 4 consecutive days .
• MSLT score of 6.7 5.3 min in baseline
• 4.9 4.7 min in post-call, both scores
  revealing the nearly pathologic levels of daytime
  sleepiness (narcolepsy or sleep apnea).
• baseline group slept an average of 7.1 1.5
  hrs / night, post-call 6.3 1.9 hrs
  sleep-extended, the subjects extended their
  sleep to an average of more than 9 hrs / night,
  and MSLT scores were in the normal range (12.0
  6.4 minutes).
• Data indicate that under normal working
  conditions, residents studied were
  physiologically sleepy to nearly pathologic
  levels.

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Risks to Patients and Healthcare Providers

• In 2 studies of anesth ? 50 reported having
  committed an error in medical judgment due to
  fatigue. Cooper et al., using critical incident
  method of evaluating anesth errors, estimated
  that human error played a role in ? 80 of anesth
  mishaps fatigue in 6 of reported critical
  incidents.
• In a survey of New Zealand anesthesiologists 86
  reported having committed a fatigue-related
  error.
• Data from 5,600 reports of critical incidents to
  the Australian Incident Monitoring Study
  (1987-1997) fatigue was listed as a contributing
  factor in (3).

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• Needle stick injuries, Among residents and
  medical students, a 50 greater risk of
  sustaining a blood borne pathogen exposure during
  night work than during days.
• Residents (Ped ER) suffer twice expected number
  of accidents, while driving home after being on
  call.
• Retrospective study among anesthesia trainees, 8
  accidents were reported. protective circadian
  alerting effect during the drive home (810 am).

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Effect on Mood

• Pilcher and Huffcutt, a meta-analysis effects of
  sleep deprivation on performance (medical and
  nonmedical) (19/56 published studies, 1,932 total
  sample size).
• Sleep-deprived subjects performed at a level 1.37
  lt rested subjects, ? impact was on mood and
  cognitive measures, with little change in motor
  performance.

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Correction Strategies

• Education During 7 yr of medical school and
  residency, little or no information regarding
  sleep, sleep disorders, and related topics.
• Lacking this knowledge, physicians are unlikely
  to appreciate the need for change.
• Alertness Strategies
• planned naps NASA study (naps in the cockpit).
  40-min nap ? performance by 34 and physiologic
  alertness by 54 compared with a no-nap
  condition.

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• Caffeine use
• widely used stimulant.
• Pharmacologic onset of caffeine occurs 1530
  min after ingestion and lasts about 34 h.
• Tolerance reduces its alerting effects. A
  significant performance and alertness boost (200
  mg of caffeine, 100-600 mg).
• Good sleep habits
• Light therapy
• Noise
• Temp

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Better Scheduling

• On call no more often than every 3rd night.
• Prohibited from administering anesthesia on the
  day after in-house overnight call (free of duty
  for 24 hr).
• Working ? 80 total hrs /week (Ideal 45-50 hr)
• Avoid any surgery between 2 am and 5 am.

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• Modafinil or pimoline is non-amphetamine
  wakefulness agents.
• Treat narcolepsy or OS apnea
• Used by military, Not in medical field

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Melatonin

• Hormone by pineal gland with sleep-promoting
  effects
• Used for jet lag and for shift work.
• Doses of 0.380 mg.
• It has circadian phase-shifting effects
• Studies evaluating the efficacy of melatonin in
  shift workers have yielded mixed results.

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Anesthesiologist Pilot
Responsibility 1-2 pt 10-800 passengers
Minimum Rest pre/ post-duty period 0 10 hr
Max flying time 24 hr 14 hr
Max duty / wk 40 - 80 hr 30 hr
On-call 3-4 days daily
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Long term plan

1. Implement education program regarding fatigue
   risks, physiologic factors, and effective
   countermeasures required for individuals
   throughout the healthcare system.
2. Implementation of effective alertness strategies
   through education and appropriate institutional
   policies.
3. Recommendations for workrest schedules in health
   care similar to those that have been promulgated
   in aviation.

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