Anesthesia, it’s just like riding a bike flying a plane! 

Author: Katie K. Zatroch, DVM, DACVAA (Head of Anesthesiology)
Philadelphia Animal Specialty and Emergency
 

I board my flight, pop in my earbuds, and begin scrolling through the options for in-flight entertainment. While I debate the merits of watching one early 2000s rom-com versus another, I have totally forgotten about the fact that I've loaded myself into a large metal contraption that will not only pitch me across the country at over 500 miles per hour but will also somehow land me safely at my destination. Am I worried? Not really.  

So, how has the aviation industry made such a heroic feat of physics feel like a normal, everyday experience for us? It wasn't always like this. Early on, aviation faced a host of challenges, and accidents were somewhat common. However, through the implementation of standardized flight procedures, advancements in in-flight monitoring and a shift in safety culture, fatal accidents per million flights have reduced 12-fold since 1970. This evolution has parallels in another high-risk field requiring advanced cognitive and technical skills:  anesthesia. Planning, procedure and checklists have directly contributed to error reduction in medicine and anesthesia, just as they have in aviation.  

Translating advances made in both flight and medicine, how can we continue to improve anesthesia safety in our veterinary practices? 
 

Pre-Flight Preparation 

Ahead of any anesthetic case, clear communication among the team is vital. Doctors should inform anesthesia technicians of a patient’s clinical status and comorbidities to avoid anyone “flying blind”. The entire care team is co-piloting the patient’s anesthetic event, and procedures, roles and responsibilities should be clear.  

Preparation is also key.  Aviation teams test equipment and confirm flight details prior to takeoff, not mid-flight. Similarly, intubation equipment should be laid out and tested prior to induction. Medications should be calculated, double-checked, drawn up and labeled ahead of time. Anesthetic machines should be set-up and leak tested.  Personally, I have found a memory device such as the MS-MAIDS acronym provides a quick, systematic way for anesthetists to prepare their anesthetic set-ups the same way every time, reducing the risk for error. I still use this acronym every time I set up for a case and anytime I am double checking someone else’s set-up.  

Many adverse anesthetic safety events are attributed to “rushing” or distraction, which feels unavoidable for many veterinary teams challenged with busy days and limited staff. However, time pressure can often be mitigated with a consistent process and a few brief pause points. Patient safety checklists, akin to aviation pre-flight safety checklists, provide a pause point to ensure no major avoidable risks are present and statistically improve patient outcomes. While this article provides an example of the checklist used at PASE, it is important to meet with one’s team to develop a checklist. When all interested parties have provided collective input on the structure of the checklist, successful compliance is much more likely.  

Once the team is comfortable with setting up in a similar way every time and takes the time to perform a preanesthetic checklist, it is likely that the pervasive “rushed” feeling will begin to wash away.  
 

In-Flight Monitoring 

Reaching cruising altitude during the maintenance phase of anesthesia provides a certain level of comfort, yet still requires constant vigilance. Just as pilots rely on instruments to monitor flight conditions, veterinary anesthetists employ both hands-on methods and multiparameter monitors to track the patient's vital signs during a procedure. What vital signs should be monitored under anesthesia? At minimum, the anesthetist should monitor signs of anesthetic depth, respiratory rate, oxygenation (typically via pulse oximetry) ventilation (via capnography), heart rate and rhythm (via ECG), capillary refill time, mucous membrane color and blood pressure (typically non-invasive, via oscillometric or Doppler). Technicians should develop a thorough and consistent routine of checking the patient, the monitor, and the equipment constantly throughout the procedure. Any deviations from normal values should prompt a discussion between the technician and doctor about intervention, akin to co-pilots addressing any fluctuations in flight parameters. Anesthesia records should also be meticulously maintained, documenting every aspect of the procedure and any complications or interventions. This comprehensive documentation not only aids in real-time decision-making but also serves as a valuable reference for future procedures or legal questions. The American Animal Hospital Association (AAHA) has updated resources for anesthetic monitoring and documentation.  
 

How We Handle Turbulence 

Despite meticulous planning and monitoring, there is still the potential to encounter turbulence or even rarely, a crash. Just as pilots undergo extensive training to handle emergency situations, veterinary professionals must be well-prepared to manage anesthetic complications. Regular training drills and simulations can enhance readiness, enabling swift and effective responses to unforeseen events. Fostering a culture of transparency and continuous improvement is also essential. Once appropriate measures are implemented for case preparation, team members should hold each other to these standards.  

That said, veterinary professionals are humans. Errors can be reduced, but never eliminated. Any unforeseen events should be approached from a place of care and discussions should be geared toward identifying solutions for the proximate and root causes of each issue. For example, if an APL valve was inadvertently left closed and a patient safety event occurred, what were the circumstances around it being left closed? Was the equipment checklist that could have caught this closure not performed? If so, why was it not performed? Was a leak test performed improperly ahead of the case and supplemental training needs to be implemented? Was a technician interrupted while giving a breath, and installing button-occlusion valves could have helped prevent this from happening? Having sensitive and open conversations about these issues not only allows for improvement in processes, but also in the safety culture of your hospital.  

Ensuring anesthesia patient safety in veterinary medicine requires a comprehensive approach. By drawing parallels with the aviation industry and adopting best practices, we can not only safeguard the care of our patients but also reduce anxiety in our clients and team members. Now, back to my rom-com….