All stressed doctors...Go through these facts!

1. ANAESTHESIA AND
FATIGUE: THE GLOBAL
SCENARIO
DR UNNIKRISHNAN P
NEUROANAESTHESIA

2. Unmet needs; who will
answer?
.
RULES
SCIENCE
TECHNOLOGY
CHANGE

3. Sounds familiar ?
“How many clinicians have got Nobel
prize?
“A dream is what keeps you awake. -
Abdul Kalam”

4. Sleep has become our dream..
CREATIVITY DEBACLES OCCUR
DEVELOPS WHEN AFTER HECTIC
WE START SCHEDULES
ENJOYING OUR
WORK

5. Fatigue and
Doctors- Can
science help us?
.

6. Precious things
The fact that sleep is essential to human
biology and neurocognitive function is
well appreciated.
Factors that disrupt or otherwise deny
sleep are known to degrade both
psychomotor and mental-task
performance.

7. Hello..hello… I‟m not hearing
Fatigue caused by lack of adequate
sleep results in diminished cognitive
function, impaired vigilance, decay in
problem-solving ability, degradation in
memory, and eroded motivation.4

8. SLEEP[LESSNESS] is injurious to
health
Medical culture has traditionally fostered
unsatisfactory ways of behaving.
Long hours of either high intensity or boring work
have been seen as the norm.
Protest against them has been viewed as lazy or
unprofessional.
National Confidential Enquiry into Perioperative
Deaths (NCEPOD) studies that it is inappropriate
for the most interesting and complex cases to take
place at night, where the risks will be still further
increased.

9. After 36 hrs of service… I ve
become very efficient in
sleeping….
ECG interpretation accuracy is reduced
amongst sleep-deprived house staff
intubation skill diminished in emergency
room physicians working the night shift
compared with similar staff during the day

10. I‟ve given something to
somebody…
…..?anaesthesia
Gaba DM Howard SK and Jump B, Production pressure in the
work environment: Californian anesthesiologists‟ attitudes and
experiences, Anesthesiology 1994; 81: 488-500
Gravenstein JS, Cooper JB, and Orkin FK, Work and rest cycles
in anesthesia practice, Anesthesiology 1990
report that more than 50% of
“anaesthesia providers” admit that they
had made errors in medical judgement
which were attributed to fatigue

11. Mile stones….small and big!
15.7% of respondents reported falling
asleep during the anesthetic care of a
patient, and 48.8% of respondents
reported observing a colleague
engaged in sleep-related behavior
during care [Chuck Biddle, CRNA,John Aker et al
AANA]
A fatal case report of an
anesthesiologist who fell asleep whilst

12. Come on…join hands with us
Surgeons who had limited opportunity
for sleep had significantly higher rates
of complications than those who had a
longer sleep opportunity (odds ratio
1.72; 95% CI 1.02-2.89).

13. 3 idiots…..
among them 1 is doing Sx;
2 are sleeping
spontaneous “microsleeps”, which may
last secs, or even mins, and the
individual may be unaware and can be
unresponsive to external stimuli.
Extreme pressure for sleep can result in
“shut down”

14. I‟m getting enough kick without
spending a penny
17 hours of wakefulness results in a decrease in
performance equal to that produced by a blood
alcohol level of 50 mg% and, after 24 hour without
sleep, this decrement was equal to that produced
by 100 mg% of blood alcohol.
The greatest risk occurs where significant sleep
loss is combined with circadian rhythm disturbance.

15. Need to address fatigue
scientifically…
A significant factor identified as avoiding
serious outcome was providing relief for
fatigued anaesthetists
Based on ….The Australian Incident Monitoring Scheme (AIMS)
reported 152 incidents (2.7% of all reports) up to 1997

16. Hmmmmm………
Studies have shown that adaptation
does not occur despite prolonged
exposure to night work1.
Many individuals cannot reset their body
clock to allow for effective daytime sleep
after night duties.
Daytime sleep is typically shorter and of
inferior quality compared with sleep at
night40

17. Relieved…somebody is listening!!
William Clayton Petty, MD, observed
that, “Fatigue can induce a state in
anesthesia providers that will cause
more medical errors. It is time we stop
giving lip service to this problem and
take positive steps towards solving it.”

18. .
How Research can help?

19. Can give inputs in formulating tools
The AMA 2006 Safe Hours Audit revealed
that many doctors worked a similar number
of hours, but often had very different risk
ratings.
To produce more biocompatible schedules
AMA has developed an on-line fatigue
assessment tool. Doctors who use the
assessment tool will receive an on-line
assessment of the fatigue risks of their
roster. Doctors who are assessed as being at
risk are encouraged to raise this with hospital

20. Who will answer?
h

21. ?
h

22. Who will answer?
h

23. We need light…..(work)
bright light exposure has been successful in
shifting rhythms in controlled laboratory situations
but workplace studies have yet to be conducted.
Pharmacological studies of night workers are
gaining support from drug manufacturers. All of
these studies have been in acute laboratory
situations. Long-term studies have not been
reported and are clearly needed because of the
side effects and abuse potential of drugs.

24. Research into DRUGS
alertness-enhancing drugs [not recommended at
present]
amphetamine analogues such as modafinil
alertness-promoting properties
fewer side effects
little effect on recovery sleep
Melatonin has been shown to promote natural
sleep and may cause a „circadian shift‟ to a new

25. Further research into sleep &
circadian rhythm inrelation to
fatigue…and
the effect of circadian (and other body)
rhythms on the responses of organisms to
outside influences such as drugs
Both the pharmacokinetics and
pharmacodynamics of drugs can be
influenced by their time of administration
it has now been clearly demonstrated that
the response to noxious stimuli is not
constant over the 24 hour period. Although
the temporal relationship is complex means
there is a diurnal variation in pain perception

26. napping has been shown to be of
positive benefit to improve subsequent
alertness and performance
I think slapping has a better effect on
you….

27. References
Association of Anaesthetists of Great Britain
and Ireland Fatigue and Anaesthetists –
Expanded Web Version
1995-2012 Australian Medical Association
Limited.Privacy Statement
• Howard SK, Rosekind MR et al, Fatigue in
Anesthesia, Anesthesiology 2002,: 97;1281
– 1294
• ANZCA Professional Document (PS43) –
Statement on Fatigue and the Anaesthetist
(2001) Australian and New Zealand College
of Anaesthetists
• Robinson JS, Howells TH, and Smith WDA,
Fatigue in the practice of
anaesthesia(letter), Anaesthesia
1978:33;62-3

28. Our weak defence against
hazards posed by inhalational
anaesthetics
Despite the huge improvement in the
infrastructure for providing anaesthesia to
patients, why are we not taking measures in
preventing us from getting a share from it
Why we are not implementing effective
scavenging methods in O.T.?
Whether N2O is having a significant influence
on male fertility pattern..?

29. Visit me@
www.thelaymedicalman.blogspot.com

30. Who will answer?
h