3 - Complications and PACU Flashcards
Estimated mortality related to anesthesia
1:10,000
Incidence of Awareness during general anesthesia
20:10,000
Incidence of Damage to Teeth
2-5:10,000
Percentage of Elderly Patients with Post-Op cognitive dysfunction
16%
Key Factors in prevention of patient injury
Vigilance Adequate Monitoring Up-To-Date Knowledge
What are critical incidents?
Near misses
What are sentinel events?
single, isolated events that may indicate a systemic problem
To be successful in a malpractice suit, the plaintiff must prove: (4)
Duty: That the anesthesiologist owed the patient a duty
Breach of duty: That the anesthesiologist failed to fulfill his or her duty
Causation: That a reasonably close causal relation exists between the anesthesiologist’s acts and the resultant injury
Damages: That actual damage resulted because of a breach of the standard of care.
doctrine of res ipsa loquitor
“The thing speaks for itself”
Burden of proof is on the physician instead of the patient if:
typically would not occur in the absence of negligence.
caused by something under the exclusive control of the anesthesiologist.
not attributable to any contribution on the part of the patient.
evidence for the explanation of events is more accessible to the anesthesiologist than to the patient.
What are the three types of damages?
General: damages for pain and suffering
Special: actual damages from bills, lost income etc
Punitive: intended as punishment
Proof in a malpractice case only means:
more likely than not
What is a Type I hypersensitivity reaction?
immediate hypersensitivity
occurs with 15-30 min
What is the most important moderator of type 1 hypersensitivity reactions?
Histamine
What are the two triggers of Type 1 hypersensitivity reactions?
IgE (requires prior exposure to substance)
Non-IgE (anaphylactoid, can occur on first exposure to substance)
What is the treatment for Type 1 hypersensitivity reactions?
Anithistamines
Most anesthesia related hypersensitivity reactions are _________
Type I IgE mediated Type 1 reactions
Which anesthetic drugs account for 50-70% of hypersensitivity reactions?
NMBAs
Believed to be caused by the ammonium structure
What is a Type II hypersensitivity reaction?
Cytotoxic hypersensitivity
Mediated by IgM or IgG
What are some examples of Type II hypersensitivity?
Type I DM
Myasthenia Gravis
Thrombocytopenia
Transfusion Reactions
Goodpasture’s nephritis
What is the treatment for a Type II hypersensitivity reaction?
Anti-inflammatory and immunosuppressive agents
What is a Type III hypersensitivity reaction?
Immune complex hypersensitivity
Failure of the immune system to get rid of antibody-antigen complexes
These complexes lodge in joints and tissues where they activate complement and stimulate mediators
What are some examples of Type III hypersensitivity reactions?
SLE
RA
What is a Type IV hypersensitivity reaction?
cell mediated or delayed type hypersensitivity
takes 24 hours to 14 days
NO ANTIBODIES INVOLVED
What are some examples of Type IV hypersensitivity reactions?
Contact hypersensitivity (like poison ivy)
granulomatous sensitivity (TB or leprosy)
What is a Type V Hypersensitivity Reaction?
results from auto-antibodies that bind and stimulate specific cell targets
What is an example of a Type V Hypersensitivity Reaction?
Graves Disease
antibodies stimulate the TSH receptor on the thyroid gland, leading to excessive secretion of thyroid hormone
What is alloimmunity?
response of the immune system towards the tissues of other members of the same species
blood transfusions, GVHD, organ transplants
What is transient neonatal disease?
Alloimmunity
Rhogam
What is autoimmunity?
Abnormal response to self antigens resulting in production of self-antibodies and damage to self tissues
The highest incidence of MH is in ________
children under 15
How is MH susceptibility inherited?
autosomal dominant
What drug should never be administered with dantrolene?
Ca Channel Blockers
Leads to life threatening myocardial depression and hyperkalemia
What does dantrolene do?
Binds to the ryanodine calcium channel and reduces calcium efflux from SR
Which patients should have core temperature monitoring?
Any patient under GA for more than 30 minutes
Why is mild respiratory acidemia expected in PACU patients?
atelectasis and decreased MV
A laryngospasm can be overcome by:
- Continuous positive pressure of 10-20mmHg
- Small dose of succ (not an induction dose) or propofol
A severe laryngospasm can be caused by excision of the _______
parathyroid d/t acute hypocalcemia
What effect does histamine have on bronchial smooth muscle tone?
Vasoconstricts
Patients who have increased airway pressure preop are at risk for _________ post op
bronchospasm
Increased airway resistance is manifested by:
wheezing
Which has more cardiovascular effects: albuterol or racemic epi?
Racemic Epi
Besides Levalbuterol and Epi nebs, what other meds can reduce elevated airway resistance?
isoproterenol neb
IM or sublingual terbutaline
Anticholinergics (atropine)
Epinephrine drip (if severe)
What metrics indicate readiness to come off mechanical ventilation?
Raise head for 10 seconds
Forced vital capacity of 10-12 ml/kg
Insp > -25
Tactile TOF
During anesthesia, how is CO2 production impacted?
Decreased by 60%
What is the difference between compliance and elasticity?
Compliance is the ease with which you can stretch something
Elasticity is the strength of recoil from stretch
What are the three factors that influence lung compliance?
Elasticity of the lungs
Elasticity of the chest wall
Surface Tension
What happens to compliance and elasticity in pulmonary fibrosis?
The compliance decreases, because the lungs don’t want to stretch.
BUT the elasticity increases, because as the pressure goes up and volume goes down, elasticity increases
What happens to compliance and elasticity in emphysema?
The elastic tissue over alveoli and lung tissues is broken down, so elasticity is increased
BUT
compliance is increased (because the lung can easily inflate, but it can’t snap back)
What happens to compliance and elasticity of the chest wall in patients with Ankylosing Spondylitis/Kyphosis/Scoliosis?
Chest wall compliance is decreased (difficult to expand)
There isn’t a huge change in elasticity, most of the disease process is due to decreased compliance
When alveolar surface tension is increased, what happens to compliance?
Compliance is decreased and elasticity is increased
Very high work of breathing to get those alveoli to expand
What osmolality, pH, and sodium concentration in urine is reassuring that tubules are intact and functional?
They should be disparate from serum values
if values closely resemble serum values, it is non-reassuring
What is the most common occular complication in general anesthesia?
Corneal abrasion
Which tooth is number one?
Back tooth on right side of upper mandible
The front teeth are numbered
8 & 9
The middle bottom two teeth are numbered
24 & 25
How long do sensory neuropathies usually last?
5 days
PACU stay is increased by ________ minutes by hypothermia
40-90 min
Postop hypothermia causes:
Increased SNS
Decreased venous compliance
Increased PVR
What diagnostics and labs would you perform on patient who has not emerged from anesthesia after 70 minutes?
End-tidal anesthetic concentration
Nerve stimulator
ABG
CT Scan
What are some metabolic causes for delayed emergence?
Pseudocholinesterase Deficiency
Hypercarbia/hypoxia
Resp and metabolic acidosis
Hyper/hyponatremia
Hypo/hyperthermia
What drug crosses the blood brain barrier and is used to reverse the anticholinergic effects of scopolamine and atropine
Physostigmine
Emergence delirium is prevalent in which age bracket?
Children and young adults
What should you bear in mind when caring for a postop myringotomy?
They are hearing normally for the first time, and may be very sensitive to sound
When scopolamine is used in pre-treatment intraop, what can happen post op?
disorientation, combativeness, paranoia
can be reversed with physostigmine
How long do most emergence reactions last?
10-15 minutes
Avoiding which drugs reduces the risk of post op delirium?
Benzos
Anticholinergics
meperidine
Which has a lower instance of PONV: TIVA or Inhalation?
TIVA, esp propofol
Laryngospasm may be caused by a closure of the glottis by _________
Or a closure of the larynx by __________
Glottis = intrinsic muscles
larynx = extrinsic muscles
Glottic closure manifests as _______
Larnyx closure manifests as ________
intermittent obstruction
complete obstruction
If succinylcholine is effective in resolving a laryngospasm, you must still:
support breathing for 5-10 min with bag ventilation
Negative-pressure pulmonary edema is caused by _________
a decrease in interstitial pressure
What is the most common cause of postop hypoxemia?
atelectasis
Virchow’s Triad
Venous Stasis
Hypercoaguability
Vessel Damage
What is another name for chemical pneumonitis
Mendelson Syndrome
In an intubated patients, Bronchospasm is caused by increased ______ which manifests as ______
airway resistance
increased peak inspiratory pressure
Increased _____ (electrolyte) and decreased ____ may prolong anesthesia blockade
magnesium
potassium
Hypothermia contributes to which two dysrhythmias?
Why?
sinus brady, a fib
prolongs the refractory period
Name three herbal supplements that can cause delayed awakening
Kava kava
St. John’s Wort
Valerian
Serotonin Syndrome can look like _________
MH or delayed awakening
How does zofran work?
Blocks serotonin receptors in the vomiting center
How does Haldol or Droperidol assist with nausea?
blocks dopamine receptor sites in the vomiting center
How do compazine and reglan work?
Block dopamine receptors
How do phenergan and benadryl help with nausea?
Block histamine receptors
How does a scop patch help with nausea?
Blocks muscarinic receptors
