34th Annual Scientific Meeting proceedings

“Only a fool learns from his own mistakes. The wise man learns from the mistakes of others.”― Otto von Bismarck

"To make no mistakes is not in the power of man; but from their errors and mistakes the wise and good learn wisdom for the future"- Plutarch

Introduction
What is a mistake – there are many definitions; The Cambridge Dictionary gives a meaning that works well in a surgical context; being described as ‘an action, decision, or judgment that produces an unwanted or unintentional result’  (https://dictionary.cambridge.org/dictionary/english/mistake). We all make mistakes, since to err is human, the key is to learn from them, and importantly that we try to eliminate mistakes before they occur and be as well prepared as we can be, so that the risk of error is minimised. 

It is essential that we understand the anatomy, the procedure and the potential complications that can occur in carrying out a TECA/LBO in both the dog and cat ^1–8.  In addition, we not only need to learn how to deal with adverse events when they do occur but also teach our mentees how to manage adverse situations when they arise ^9–15 .

The focus of this presentation will be on understanding the complications that can occur, to minimise the risk of them occurring and how to deal with them as a surgeon and as team in the operating theatre.  The potential complications fall into 3 periods intraoperative, immediately postoperative and late postoperative^5–7 .

Dealing with a complication
Severe haemorrhage though rare is a potentially life threatening event and it is essential to know where the possible sources are and what can be done to stop it. It’s not just knowing the anatomy but having the tools to deal with the situation if it arises.  To this end there is a need to be prepared as an individual and as a team on the operating theatre.

This in my view is where pre surgery checklists come into their own.  That’s all well and good but going through a checklist takes time and we’re all busy surgeons and nurses. However, if it saves a life, it is time well spent.  Studies from hectic human critical care facilities have shown that using a checklist in a crisis is associated with a six-fold reduction in failure to adhere to critical steps in the management of the emergency.  Essentially it helps avoid missing crucial steps in highly pressurized situations and have shown a greater than one-third reduction in complications ^16,17 . Some of the key questions on our checklist are based around critical events (Fig1).  During the ‘time out’ when these questions are being asked is the ideal time for the theatre team to discuss the potential risk of haemorrhage and what can be done to mitigate it. This period is also key to reduce any perceived hierarchical gradients in the team.  It is essential that all those involved in that case are able to speak up without any fear of any come back¹² .  Two highly effective questions that should be asked during the time out are:

1. what if..?
2. what am I expected to do if something goes wrong?

This prepares the team for possible complications,

• “what if?” situations will have been discussed and will therefore be fresh in our minds.

Every member of the team should know in advance their role in the unlikely event of a major problem or complication.

The surgeon should be prepared, knowing their anatomy, that the likely vessels they could traumatise, namely the emissary vein of the retroarticular or retroglenoid foramen, the internal maxillary vein and less likely the superficial temporal and maxillary arteries.  It is essential to have requested electrocautery or vessel sealing device together with either a topical haemostatic agent or bone wax.  During the time out the team will become aware that there is a risk of severe haemorrhage and can ensure that there are blood products or colloids readily available should they be needed.  The decision may also be made to blood type if the surgeon is concerned or relatively inexperienced.

How should we deal with a severe haemorrhage? This is where building situational awareness (SA) in the individual and the team is so important^12,18 . The use of simple mnemonics such ‘SLAM’ (Fig 2) or STOPS (Fig 3) can help build SA in an individual and in the team¹² . 

Figure 2 (from Brennan et al 2020)¹² 

Clearly stopping completely should only be done if it is safe to do so in the circumstances¹⁹ .  With severe haemorrhage the first step would be to pack the wound with surgical swabs and apply pressure. Then you can stop and think – where is it most likely to be bleeding from.  The surgeon should take this time to inform the team of the issue and request topical haemostatic agents and/or bone wax to be opened, if they had not been previously.  By communicating in this way, the team can be prepared to send for blood products or colloids or contact other clinicians such as anaesthetists or ECC in case they are needed. The surgeon should not be dealing with the haemorrhage in isolation.

After a period of reflection the swabs should be removed and the source of the haemorrhaging identified.  There may of necessity be a need to repack or use suction if the haemorrhage obscures the structures deep in the wound.  Ideally there should be an assistant surgeon who can help retract tissues and use the suction tip whilst the primary surgeon deals with the haemorrhage.  Bone wax after it has been softened can be packed into the retroarticular/retroglenoid foramen, and the bulla (it must be removed from the bulla before wound closure).  Diathermy rarely works on the emissary vein as it retracts into the foramen.  Alternately a topical haemostatic agent can be applied.  Traumatised arteries and veins should be sealed with diathermy or a vessel sealing device.

Post Surgery
Regardless of whether the error was dealt with well or not there should be a debrief session, it is essential that no individual should try to cope with difficult situations and outcomes in the ‘silo of silent surgical culture’^20,21 .

The presentation will expand on these themes.

 References

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