Journal of perioperative practice
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It is increasingly common for patients to be scheduled for anaesthesia and surgery with a 'Do Not Attempt Cardiopulmonary Resuscitation' (DNACPR) decision in place. Updated guidelines for the implementation and management of DNACPR decisions were published jointly by the British Medical Association (BMA), the Resuscitation Council (UK) and the Royal College of Nursing (RCN) in 2014 (BMA, RC(UK), RCN 2014). The Association of Anaesthetists of Great Britain and Ireland (AAGBI) published specific guidelines in 2009 to guide the perioperative management of such patients (AAGBI 2009). In this article, we explain these guidelines with a focus on how DNACPR decisions are made and how they can be modified in order to permit appropriate surgery to take place.
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In many emergency situations rapid vascular access is a priority, particularly in cases involving haemodynamic compromise. Traditional vascular access through the use of an intravenous cannula, although the preferred first line method, can in certain circumstances have a high rate of failure. A study by Minville et al (2006) showed that the success rate of first attempt venous cannulation can be as low as 76%. Repeated attempts at venous cannulation in patients with difficult vascular access wastes valuable time which in some situations could prove fatal.
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Over many centuries, from the early writings of Galen, 'the father of Medicine', wounds of the heart were considered fatal and outside the remit of surgery. With the advent of anaesthesia, (ether was introduced by William Morton in 1846) and of antiseptic surgery, (Joseph Lister's first publication was in 1867), there was an explosion in the surgery of the abdominal cavity, the chest, the skull and the limbs, yet the heart was considered by the surgical fraternity to be the 'no-go' area of the body. ⋯ In London, Stephen Paget, in 1896, wrote: "No new method and no new discovery can overcome the natural difficulties that attend a wound of the heart. It is true that suture has been vaguely proposed as a possible procedure and has been done in animals but I cannot find that it has ever been attempted in practice". (In fact, the heart is an amazingly tough and efficient pump that goes on working, year after year, without ever stopping for a service!).
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This simple quality initiative won the best innovation in clinical practice at the recent CEO healthcare awards gala event in the North West of Ireland. It demonstrated how a simple collaborative idea led to improving the quality and safety of care in the operating room. As practitioners we have a huge contribution to make in providing quality and safe care to our patients. It is crucial that we share knowledge and have our input recognised.