Preoperative Risk Assessment and Intraoperative Monitoring

  • Catherine Gibb
  • W. John Russell
  • Brendon J. Coventry
Chapter
Part of the Surgery: Complications, Risks and Consequences book series (SCRC)

Abstract

In emergency surgical settings, opportunities for optimization of the patient are usually limited due to the lack of time and often the hours during which surgery is required. However, in elective surgical settings, especially with higher-risk patients who have multiple comorbidities, preoperative evaluation and optimization are important considerations to reduce the risk of adverse events and to improve clinical outcomes. This chapter aims to provide information on perioperative assessment and intraoperative monitoring in an effort to reduce the rates of complications, risks, and consequences associated with surgery. For other associated procedures, refer to the relevant chapter or volume.

Keywords

Obesity Ischemia Nicotine Angiotensin Fentanyl 

Further Reading, References, and Resources

  1. Alkire MT. Quantitative EEG, correlations with brain glucose metabolic rate during anesthesia in volunteers. Anesthesiology. 1998;89(2):323–33.PubMedCrossRefGoogle Scholar
  2. American Society of Anesthesiologists. Standards of the American Society of Anesthesiologists: standards for basic anesthetic monitoring. Available at: http://www.asahq.org/Standards/02.html. Accessed 23 May 2009.
  3. Centers for Disease Control and Prevention. Measuring physical activity intensity: Metabolic Equivalent (MET) level. Atlanta: Centers for Disease Control and Prevention.Google Scholar
  4. Cockings JG, Webb RK, Klepper ID, Currie M, Morgan C. The Australian Incident Monitoring Study. Blood pressure monitoring-applications and limitations: an analysis of 2000 incident reports. Anaesth Intensive Care. 1993;21:565–9.PubMedGoogle Scholar
  5. Deaths during general anesthesia: technology-related, due to human error, or unavoidable? An ECRI technology assessment. J Health Care Technol. 1985;1:155–75.Google Scholar
  6. Eichhorn JH. Prevention of intraoperative anesthesia accidents and related severe injury through safety monitoring. Anesthesiology. 1989;70:572–7.PubMedCrossRefGoogle Scholar
  7. Eichhorn JH. Effect of monitoring standards on anesthesia outcome. Int Anesthesiol Clin. 1993;31:181–96.PubMedCrossRefGoogle Scholar
  8. Findlay GP, Spittal MJ, Radcliffe JJ. The recognition of critical incidents: quantification of monitor effectiveness. Anaesthesia. 1998;53:595–8.PubMedCrossRefGoogle Scholar
  9. Flaishon R, Windsor A, Sigl J, Sebel PS. Recovery of consciousness after thiopental or propofol. Bispectral index and isolated forearm technique. Anesthesiology. 1997;86(3):613–9.PubMedCrossRefGoogle Scholar
  10. Fleisher LA, Beckman JA, Brown KA, Calkins H, Chaikof E, Fleischmann KE, et al., American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to revise the 2002 guidelines on perioperative cardiovascular evaluation for noncardiac surgery); American Society of Echocardiography; American Society of Nuclear Cardiology; Heart Rhythm Society; Society of Cardiovascular Anesthesiologists; Society for Cardiovascular Angiography and Interventions; Society for Vascular Medicine and Biology; Society for Vascular Surgery. Circulation. 200723;116(17):e418–99. Erratum in: Circulation. 2008;118(9):e143–4. Circulation. 2008;117(5):e154.Google Scholar
  11. Fleisher LA, Beckman JA, Brown KA, Calkins H, Chaikof E, Fleischmann KE, et al. ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 guidelines on perioperative cardiovascular evaluation for noncardiac surgery). Anesth Analg. 2008;106(3):685–712.PubMedCrossRefGoogle Scholar
  12. Freeman WK, Gibbons RJ. Perioperative cardiovascular assessment of patients undergoing noncardiac surgery. Mayo Clin Proc. 2009;84(1):79–90.PubMedCrossRefGoogle Scholar
  13. Gupta PK, Gupta H, Sundaram A, Kaushik M, Fang X, Miller WJ, et al. Development and validation of a risk calculator for prediction of cardiac risk after surgery. Circulation. 2011;124(4):381–7.PubMedCrossRefGoogle Scholar
  14. Hewer I, Drew B, Karp K, Stotts N. The utilization of automated ST segment analysis in the determination of myocardial ischemia. AANA J. 1997;65:351–6.PubMedGoogle Scholar
  15. Hoeks SE, Scholte OP, Reimer WJ, Lenzen MJ, van Urk H, Jörning PJ, Boersma E, et al. Guidelines for cardiac management in noncardiac surgery are poorly implemented in clinical practice: results from a peripheral vascular survey in the Netherlands. Anesthesiology. 2007;107(4):537–44.PubMedCrossRefGoogle Scholar
  16. Karnofsky DA, Burchenal JH. The clinical evaluation of chemotherapeutic agents in cancer. In: MacLeod CM, editor. Evaluation of chemotherapeutic agents. New York: Columbia University Press; 1949. p. 196.Google Scholar
  17. Kearse Jr LA, Rosow C, Zaslavsky A, Connors P, Dershwitz M, Denman W. Bispectral analysis of the electroencephalogram predicts conscious processing of information during propofol sedation and hypnosis. Anesthesiology. 1998;88(1):25–34.PubMedCrossRefGoogle Scholar
  18. Klepper ID, Webb RK, Van der Walt JH, Ludbrook GL, Cockings J. The Australian Incident Monitoring Study. The stethoscope: applications and limitations-an analysis of 2000 incident reports. Anaesth Intensive Care. 1993;21:575–8.PubMedGoogle Scholar
  19. Lansky SB, List MA, Lansky LL, Ritter-Sterr C, Miller DR. The measurement of performance in childhood cancer patients. Cancer. 1987;60:1651–6.PubMedCrossRefGoogle Scholar
  20. Lee T, Marcantonio E, Mangione C, Thomas E, Polanczyk C, Cook E, et al. Derivation and prospective evaluation of a simple index for prediction of cardiac risk of major noncardiac surgery. Circulation. 1999;100(10):1043–9.PubMedCrossRefGoogle Scholar
  21. Lennmaarken C, Sandin R. Neuromonitoring for awareness during surgery. Lancet. 2004;363:1747–8.CrossRefGoogle Scholar
  22. Lienhart A, Auroy Y, Péquignot F, Benhamou D, Warszawski J, Bovet M, Jougla E. Survey of anesthesia-related mortality in France. Anesthesiology. 2006;105(6):1087–97.PubMedCrossRefGoogle Scholar
  23. Mayson SE, Greenspon AJ, Adams S, Decaro MV, Sheth M, Weitz HH, et al. The changing face of postoperative atrial fibrillation prevention: a review of current medical therapy. Cardiol Rev. 2007;15(5):231–41. Review.PubMedCrossRefGoogle Scholar
  24. Mi WD, Sakai T, Takahashi S, Matsuki A. Haemodynamic and electroencephalograph responses to intubation during induction with propofol or propofol/fentanyl. Can J Anaesth. 1998;45(1):19–22.PubMedCrossRefGoogle Scholar
  25. Moller JT, Johannessen NW, Espersen K, Ravlo O, Pedersen BD, Jensen PF, et al. Randomized evaluation of pulse oximetry in 20,802 patients: II. Perioperative events and postoperative complications. Anesthesiology. 1993;78:445–53.PubMedCrossRefGoogle Scholar
  26. Myles PS, Leslie K, McNeil J, Forbes A, Chan MT. Bispectral index monitoring to prevent awareness during anesthesia: the B-Aware randomized controlled trial. Lancet. 2004;363:1757–63.PubMedCrossRefGoogle Scholar
  27. National Transportation Safety Board. Aviation accident statistics. Available at: http://www.ntsb.gov/aviation/Stats.htm. Accessed 28 May 2001.
  28. Oken MM, Creech RH, Tormey DC, Horton J, Davis TE, McFadden ET, et al. Toxicity and response criteria of the Eastern Cooperative Oncology Group. Am J Clin Oncol. 1982;5:649–55.PubMedCrossRefGoogle Scholar
  29. Rodseth RN, Lurati Buse GA, Bolliger D, Burkhart CS, Cuthbertson BH, Gibson SC, et al. The predictive ability of pre-operative B-type natriuretic peptide in vascular patients for major adverse cardiac events: an individual patient data meta-analysis. J Am Coll Cardiol. 2011;58(5):522–9.PubMedCrossRefGoogle Scholar
  30. Rosow C, Manberg PJ. Bispectral index monitoring. Anesthesiol Clin North America. 2001;19(4):947–66, xi.PubMedCrossRefGoogle Scholar
  31. Salim DI, Auerbach AD. Chapter 24. The impact of intraoperative monitoring on patient safety. http://www.ahrq.gov/clinic/ptsafety/chap24.htm.
  32. Schwarz G, Mausser G, Litscher G, Ohner U, Schoepfer A, Friedrich G. BIS readings of aspect A 2000 monitor are not contaminated by transmitted oscillations induced by jet ventilation. Internet J Neuromonit. 2005;4(1). http://www.cdc.gov/nccdphp/dnpa/physical/measuring/met.htm.
  33. Sebel PS. Central nervous system monitoring during open heart surgery: an update. J Cardiothorac Vasc Anesth. 1998;12(2 Suppl 1):3–8. Review.PubMedGoogle Scholar
  34. Spittal MJ, Findlay GP, Spencer I. A prospective analysis of critical incidents attributable to anaesthesia. Int J Qual Health Care. 1995;7:363–71.PubMedGoogle Scholar
  35. Webb RK, van der Walt JH, Runciman WB, Williamson JA, Cockings J, Russell WJ, et al. The Australian Incident Monitoring Study. Which monitor? An analysis of 2000 incident reports. Anaesth Intensive Care. 1993;21:529–42.PubMedGoogle Scholar
  36. Williamson JA, Webb RK, Cockings J, Morgan C. The Australian Incident Monitoring Study. The capnograph: applications and limitations-an analysis of 2000 incident reports. Anaesth Intensive Care. 1993;21:551–7.PubMedGoogle Scholar

Beta-Blockers

  1. Effects of extended-release metoprolol succinate in patients undergoing non-cardiac surgery (POISE trial): a randomised controlled trial. Lancet. 2008;371(9627):1839–47.Google Scholar
  2. Juul AB, Wetterslev J, Gluud C, Kofoed-Enevoldsen A, Jensen G, Callesen T, Nørgaard P, et al. Effect of perioperative β blockade in patients with diabetes undergoing major non-cardiac surgery: randomised placebo controlled, blinded multicentre trial. BMJ. 2006;332:1482.PubMedCrossRefGoogle Scholar
  3. Lindenauer PK, Pekow P, Wang K, Mamidi DK, Gutierrez B, Benjamin EM, et al. Perioperative beta-blocker therapy and mortality after major noncardiac surgery. N Engl J Med. 2005;353:349–61.PubMedCrossRefGoogle Scholar
  4. Mangano DT, Layug EL, Wallace A, Tateo I. Effect of atenolol on mortality and cardiovascular morbidity after noncardiac surgery. N Engl J Med. 1996;335:1713–20.PubMedCrossRefGoogle Scholar
  5. POBBLE Trial Investigators. Perioperative β blockade (POBBLE) for patients undergoing infrarenal vascular surgery: results of a randomised double-blind controlled trial. J Vasc Surg. 2005;41:602–9.CrossRefGoogle Scholar
  6. Poldermans D, Boersman E, Bax JJ, Thomson IR, van de Ven LL, Blankensteijn JD, et al. The effect of bisoprolol on perioperative mortality and myocardial infarction in high-risk patients undergoing vascular surgery. N Engl J Med. 1999;341:1789–94.PubMedCrossRefGoogle Scholar
  7. Wiesbauer F, Schalager O, Domanovits H, Wildner B, Maurer G, Muellner M, et al. Perioperative [beta]-blockers for preventing surgery-related mortality and morbidity: a systematic review and meta-analysis. Anesth Analg. 2007;104:27–41.PubMedCrossRefGoogle Scholar
  8. Yang H, Raymer K, Butler R, Parlow J, Roberts R. The effects of perioperative [beta]-blockade: results of the metoprolol after vascular surgery (MaVS) study, a randomised controlled trial. AHJ. 2006;152:983–90.PubMedCrossRefGoogle Scholar

Statins

  1. Durazzo AE, Machado FS, Ikeoka DT, DeBernoche C, Monachini MC, Puech-Leao P, et al. Reduction in cardiovascular events after vascular surgery with atorvastatin: a randomized trial. J Vasc Surg. 2004;39:967–76.PubMedCrossRefGoogle Scholar
  2. Laws PE, Spark JI, Cowled PA, Fitridge RA. The role of statins in vascular disease. Eur J Vasc Endovasc Surg Rev. 2004;27(1):6–16.CrossRefGoogle Scholar
  3. Lindenauer PK, Pekow P, Wang K, Gutierrez B, Benjamin E. Lipid-lowering therapy and in-hospital mortality following major noncardiac surgery. JAMA. 2004;291:2092–9.PubMedCrossRefGoogle Scholar
  4. O’Neil-Callahan K, Katsimaglis G, Tepper MR, Ryan J, Mosby C, Ioannidis JP, et al. Statins decrease perioperative cardiac complications in patients undergoing noncardiac vascular surgery: the Statins for Risk Reduction in Surgery (StaRRS) study. J Am Coll Card. 2005;45:336–42.CrossRefGoogle Scholar
  5. Poldermans D, Bax J, Kertai M, Krenning B, Westerhout C, Schinkel A, et al. Statins are associated with a reduced incidence of perioperative mortality in patients undergoing major noncardiac surgery. Circulation. 2003;107:1848.PubMedCrossRefGoogle Scholar
  6. Schouten O, Bax J, Dunkelgrun M, Feringa H, van Urk H, Poldermans D. Statins for the prevention of perioperative cardiovascular complications in surgery. J Vasc Surg. 2006;44(2):419–24.PubMedCrossRefGoogle Scholar

Obstructive Sleep Apnea

  1. Kaw R, Michota F, Jaffer AM, Ghamande S, Auckley D, Golish J. Unrecognised sleep apnea in the surgical patient. Chest. 2006;129:198–205.PubMedCrossRefGoogle Scholar

Drug-Eluting Stents

  1. Laskey W, Yancy C, Maisel W. Thrombosis in coronary drug-eluting stents: report from the meeting of the Circulatory System Medical Devices Advisory Panel of the Food and Drug Administration Centre for Devices and Radiologic Health, December 7–8, 2006. Circulation. 2007;115(17):2352–7.Google Scholar
  2. Serruys PW, Kutryk MJ, Ong AT. Drug therapy: coronary-artery stents. N Engl J Med. 2006;354:483–95.PubMedCrossRefGoogle Scholar

Preoperative Revascularization

  1. McFalls E, Ward H, Moritz T, Goldman S, Krupski W, Littooy F, et al. Coronary-artery revascularization before elective major vascular surgery. N Engl J Med. 2004;351:2795–804.PubMedCrossRefGoogle Scholar
  2. Poldermans D, Schouten O, Vidakovic R, Bax JJ, Thomson IR, Hoeks SE, et al. A clinical randomised trial to evaluate the safety of a non-invasive approach in high-risk patients undergoing major vascular surgery: the DECREASE-V pilot study. J Am Coll Cardiol. 2007;49:1763–9.PubMedCrossRefGoogle Scholar

Pulmonary Assessment

  1. Smetana G, Lawrence V, Cornell J. Preoperative pulmonary risk stratification for noncardiac surgery. Ann Int Med. 2006;144(8):581–95.PubMedCrossRefGoogle Scholar

Review Articles

  1. Dawson J, Vig S, Choke E, Blundell J, Horne G, Downham C, et al. Medical optimisation can reduce morbidity and mortality associated with elective aortic aneurysm repair. Eur J Vasc Endovasc Surg. 2007;33:100–4.PubMedCrossRefGoogle Scholar
  2. Mercado D, Ling D, Smetana G. Perioperative cardiac evaluation: novel interventions and clinical challenges. South Med J. 2007;100(5):486–92.PubMedCrossRefGoogle Scholar
  3. Otto CM, Lind BK, Kitzman DW, Gersh BJ, Siscovick DS, The Cardiovascular Health Study. Association of aortic-valve sclerosis with cardiovascular mortality and morbidity in the elderly. N Engl J Med. 1999;341:142.PubMedCrossRefGoogle Scholar

Preoperative Assessment

  1. Ainsworth BE, Haskell WL, Leon AS, Jacobs Jr DR, Montoye HJ, Sallis JF, Paffenbarger Jr RS. Compendium of physical activities: classification of energy costs of human physical activities. Med Sci Sports Exerc. 1993;25(1):71–80.PubMedCrossRefGoogle Scholar
  2. Ainsworth BE, Haskell WL, Herrmann SD, Meckes N, Bassett Jr DR, Tudor-Locke C, Greer JL, Vezina J, Whitt-Glover MC, Leon AS. Compendium of Physical Activities: a second update of codes and MET values. Med Sci Sports Exerc. 2011;43(8):1575–81.Google Scholar
  3. Arora R, Rai F. Atherothrombosis and the management of the vulnerable vascular patient. Am J Ther. 2009a;16(1):24–34.PubMedCrossRefGoogle Scholar
  4. Arora RR, Rai F. Antiplatelet intervention in acute coronary syndrome. Am J Ther. 2009b;16(5):e29–40.PubMedCrossRefGoogle Scholar
  5. Colice GL, Shafazand S, Griffin JP, Keenan R, Bolliger CT, American College of Chest Physicians. Physiologic evaluation of the patient with lung cancer being considered for resectional surgery: ACCP evidenced-based clinical practice guidelines. 2nd edition. Chest. 2007;132(3 Suppl):161S–77S.Google Scholar
  6. Detsky A, Abrams H, McLaughlin J, Drucker D, Sasson Z, Johnston N, et al. Predicting cardiac complications in patients undergoing noncardiac surgery. J Gen Intern Med. 1986;1:211–9.PubMedCrossRefGoogle Scholar
  7. Fleisher L, Beckman J, Brown K, Calkins H, Chaikof E, Fleischmann K, et al. ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and care for non-cardiac surgery. Circulation. 2007;116(17):e418–e500.Google Scholar
  8. Fleisher LA, Beckman JA, Brown KA, Calkins H, Chaikof EL, Fleischmann KE, et al. ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 guidelines on perioperative cardiovascular evaluation for noncardiac surgery) developed in collaboration with the American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, and Society for Vascular Surgery. J Am Colloid Cardiol. 2007;50(17):1707–32. Erratum in: J Am Colloid Cardiol. 2008;52(9):794–7.Google Scholar

Perioperative Antiplatelet Therapy

  1. Chassot P, Delabays A, Spahn D. Perioperative antiplatelet therapy: the case for continuing therapy in patients at risk of myocardial infarction. Br J Anaesth. 2007;99(3):316–28.PubMedCrossRefGoogle Scholar

Assessment of Exercise Tolerance

  1. Reilly D, McNeely M, Doerner D, Greenberg D, Staiger T, Geist M, et al. Self reported exercise tolerance and the risk of serious perioperative complications. Arch Int Med. 1999;159(18):2185–92.CrossRefGoogle Scholar

Ageing and Surgery

  1. Jingming B, Jun H, Tadaki N, Takayuki S, Atsushi K. Influence of ageing on perioperative cardiac risk in non-cardiac surgery. Age Ageing. 2007;36(2):68–72.Google Scholar

Perioperative Venous Thromboprophylaxis

  1. Gage BF, Waterman AD, Shannon W, Boechler M, Rich MW, Radford MJ. Validation of clinical classification schemes for predicting stroke: results from the National Registry of Atrial Fibrillation. JAMA. 2001;285(22):2864–70.PubMedCrossRefGoogle Scholar
  2. Geerts W, Pineo G, Heit J, Bergqvist D, Lassen M, Colwell C, Ray J. Prevention of venous thromboembolism: the 7th ACCP conference on antithrombotic and thrombolytic therapy. Chest. 2004;126:338S–400S.Google Scholar
  3. Hirsh J, Guyatt G, Albers GW, Schünemann HJ. The seventh ACCP conference on antithrombotic and thrombolytic therapy: evidence-based guidelines. Chest. 2004;126(3_Suppl):172S–3.CrossRefGoogle Scholar
  4. National Health and Medical Research Council. Clinical practice guideline for the prevention of venous thromboembolism (deep vein thrombosis and pulmonary embolism) in patients admitted to Australian hospitals. Melbourne: National Health and Medical Research Council; 2009. ISBN Online: 1864964480. www.nhmrc.gov.au.

Online Resources (Accessed June 2008)

  1. American College of Cardiology Guidelines for cardiac diseases. 2007. www.acc.org.
  2. Australian and New Zealand College of Anaesthetists Report. Safety of anaesthesia in Australia: a review of anaesthesia-related mortality 2000–2002. http://www.anzca.edu.au/resources/books-and-publications.
  3. Bacon AK, Morris RW, Runciman WB, Currie M. Crisis management during anaesthesia: recovering from a crisis. Qual Saf Health Care. 2005;14(3):e25.PubMedCrossRefGoogle Scholar
  4. Chapman MJ, Myburgh JA, Kluger MT, Runciman WB. Crisis management during anaesthesia: pulmonary oedema. Qual Saf Health Care. 2005;14(3):e8.PubMedCrossRefGoogle Scholar
  5. Fox MA, Morris RW, Runciman WB, Paix AD. Crisis management during regional anaesthesia. Qual Saf Health Care. 2005;14(3):e24.PubMedCrossRefGoogle Scholar
  6. Katz RI, Lagasse RS. Factors influencing the reporting of adverse perioperative outcomes to a quality management program. Anesth Analg. 2000;90(2):344–50.PubMedGoogle Scholar
  7. Kidney Health Australia Resource and useful quick online eGFR calculator. www.kidney.org.au.
  8. Lagasse RS. Anesthesia safety: model or myth? A review of the published literature and analysis of current original data. Review. Anesthesiology. 2002;97(6):1609–17.PubMedCrossRefGoogle Scholar
  9. Osborne GA, Bacon AK, Runciman WB, Helps SC. Crisis management during anaesthesia: awareness and anaesthesia. Qual Saf Health Care. 2005;14(3):e16.PubMedCrossRefGoogle Scholar
  10. Paix AD, Williamson JA, Runciman WB. Crisis management during anaesthesia: difficult intubation. Qual Saf Health Care. 2005a;14(3):e5.PubMedCrossRefGoogle Scholar
  11. Paix AD, Bullock MF, Runciman WB, Williamson JA. Crisis management during anaesthesia: problems associated with drug administration during anaesthesia. Qual Saf Health Care. 2005b;14(3):e15.PubMedCrossRefGoogle Scholar
  12. Paix AD, Runciman WB, Horan BF, Chapman MJ, Currie M. Crisis management during anaesthesia: hypertension. Qual Saf Health Care. 2005c;14(3):e12.PubMedCrossRefGoogle Scholar
  13. Runciman WB. Iatrogenic harm and anaesthesia in Australia. Anaesth Intensive Care. 2005;33(3):297–300.PubMedGoogle Scholar
  14. Runciman WB, Merry AF. Crises in clinical care: an approach to management. Qual Saf Health Care. 2005;14(3):156–63.PubMedCrossRefGoogle Scholar
  15. Runciman WB, Webb RK, Lee R, Holland R. The Australian Incident Monitoring Study. System failure: an analysis of 2000 incident reports. Anaesth Intensive Care. 1993;21(5):684–95.PubMedGoogle Scholar
  16. Runciman WB, Morris RW, Watterson LM, Williamson JA, Paix AD. Crisis management during anaesthesia: cardiac arrest. Qual Saf Health Care. 2005;14(3):e14.PubMedCrossRefGoogle Scholar
  17. Society for Preoperative Assessment and Quality Improvement. www.spaqi.org.
  18. Szekely SM, Runciman WB, Webb RK, Ludbrook GL. Crisis management during anaesthesia: desaturation. Qual Saf Health Care. 2005;14(3):e6.PubMedCrossRefGoogle Scholar
  19. The National Institute for Clinical Excellence Guidelines for best practice. www.nice.org.uk.
  20. Williamson JA, Helps SC, Westhorpe RN, Mackay P. Crisis management during anaesthesia: embolism. Qual Saf Health Care. 2005;14(3):e17.PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag London 2014

Authors and Affiliations

  • Catherine Gibb
    • 1
    • 2
  • W. John Russell
    • 3
  • Brendon J. Coventry
    • 4
  1. 1.Department of AnaesthesiaUniversity of AdelaideAdelaideAustralia
  2. 2.Queen Elizabeth Hospital and Royal Adelaide HospitalAdelaideAustralia
  3. 3.Royal Adelaide HospitalUniversity of AdelaideAdelaideAustralia
  4. 4.Discipline of Surgery, Royal Adelaide HospitalUniversity of AdelaideAdelaideAustralia

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