Anes. Surgical Complicaitons Flashcards
In regards to the difficult airway algorithm, what is the first thing to consider with an unsuccessful intubation of a patient that has been inducted?
call for help
In regards to the difficult airway algorithm, what should you do if face mask ventilation is not adequate?
consider/attempt LMA
In regards to the difficult airway algorithm, what should be done if an LMA is not feasible?
Emergency non-invasive airway ventilation
What are examples of emergency non-invasive airway ventilation techniques?
rigid bronchoscope
esophageal-tracheal combitube
transtracheal jet ventilation
IIn regards to the difficult airway algorithm, if non-invasive airway is unsuccessful what is the next step?
invasive airway access — (i.e. surgical/percutaneous tracheostomy or cricothyrotomy.
what are some clinical presentations that may prove for a difficult intubation?
MAL 3 or 4
thyromental distance < 6 cm
loud snoring
small mouth (opening < 3 cm)
limited ROM
obesity
neck pathology (mass, scar, radiation therapy)
What are some examples of conditions that would necessitate a contiued intubation?
epiglottitis
localized edema (angioedema)
Recurrent larangeal nerve damage
Bleeding
Hemodynamic instability
Obtundation due to Anes. drugs
What is the the most frequently encountered serious complication in PACU?
respiratory problems (i.e. airway obstruction, hypoventilation, hypoxemia)
hypoventilation (most common)
What are some common causes of airway obstruction?
posterior displacement of tongue
secrections/fluids (blood, vomit)
laryngospasm
pressure on trachea (ie. bleeing in the neck)
what is the quickest and easiest way to correct an airway obstruction?
jaw thrust, head tilt
You have an obese patient that reports a history of snoring and use of CPAP, what measure might you take prevent airway obstruction after extubation?
Nasal airway
what sign/symptom would indicate an airway obstruction?
paradoical chest movements (i.e. guppy breathing)
You’ve just extubated you’re patient, you place the anesthesia mask on to confirm the 3 Cs. They are not present, even after a jaw thrust/head tilt. What could be the problem?
laryngospasm
What dose of succinylcholine should be used to break the laryngospasm?
0.1 mg/kg or 10-20 mg (0.5-1 ml)
How is hypoventilation generally defined in regards to PaCO2?
PaCO2 > 45 mmHg
what is considered significant hypoventilation?
PaCO2 > 60 mmHg pH < 7.25
What are common signs and symptoms of hypoventilation?
Somnolence
Airway obstruction
Slow RR
Tachypnea w/shallow breathing
Labored breathing
In regards to acid base balance what does hypoventilation cause?
respiratory acidosis
what are symptoms of respiratory acidosis?
HTN
tachypnea
cardiac irritability (cardiac depression)
what are possible causes of hypoventilation in regards to the Anes. drugs?
- too much narcotic
- residual paralysis
What can be done to correct too much opioid?
Narcan
What are the cons of using Narcan
Pain HTN crisis pulmonary edema myocardial ischemia
What is considered hypoxia?
PaO2 < 60 mmHg
what are the ealry signs of hypoxia?
restlessness tachycardia cardiac irritability
what are late signs of hypoxia?
obtunded bradycardia hypotension cardiac arrest
what can be used to confirm hypoxia?
SpO2 Arterial blood gas (ABG)
what are some causes of hypoxia?
hypoventilation R-L shunting intrapulmonary shunting
What are examples of intrapulmonay shunting?
pulmonary atelectasis parenchymal infiltrates pneumothorax
what most often causes intrapulmonary shunting
decreased FRC
what are other causes of intrapulmonary shunting?
Prolonged intraoperative hypoventilation Endobronchial intubation Lobar collapse from obstruction Pulmonary aspiration Pulmonary edema
On chest x-ray where should the tip of the ETT be?
T2-T4
What is depth of tube position, in reference to teeth?
male - 23 cm female - 21 cm
what level is the carina at?
generally T6 but can be T5-T7
what are treatments for hypoxia?
oxygen therapy
bronchodilators (if bronchospasm)
diuretics (if fluid overload - pulm edema)
PEEP/CPAP (if atelectasis)
cardiac optimization
What type of patient would you be cautious with when providing O2 therapy for hypoxia?
pts with obstructive airway disease (COPD)
what is the most common GI complication in the PACU?
PONV
what are some common etiologies of PONV?
Autonomic afferents from GI/mediastinum
Vestibular component CN 8
Visual/cortical stimuli
Chemoreceptor trigger zone
what are the most common circulatory complications in PACU?
Hypotension
Hypertension
Arrhythmias
In regards to resolving cirulatory complications, what should you always consider when thinking about causes?
respiratory disturbances (i.e. hypoxia causes hypotension)
What is considered hypotension?
30 % difference in baseline
What are common etiologies of hypotension?
decreased venous return
LV dysfunction
excessive arterial vasodilatation
what are examples of decreased Venous Return
Hypothermic venoconstriction (shivering)
hypovolemia,
third spacing,
postop blood loss,
what are examples of LV dysfunction?
Pneumothorax, (pushing on heart)
cardiac tamponade,
fluid overload,
CAD,
valvular disease,
dysrhythmias
What are examples of excessive arterial vasodilatation
Neuraxial procedures,
adrenergic blockade venodilators,
sepsis,
allergic rxn
What are primary causes of HTN
Noxious stimulus (surgical incision)
Endotracheal intubation
Bladder distension
What are 2nd causes of HTN
Hypoxemia
Hypercapnea
Metabolic acidosis
Elevated ICP
Vascular volume overload
Which arhythmia is extremely common in PACU
sinus tachycardia
Common causes of Arrhythmias
HIS DEBS
hypoxia
ischemia
sympathetic stimuli
drugs
elecrolyte disturbances
bradycardia
stretch
which lead is commonly used for detection of cardiac dysrhythmias ?
why?
a. lead II
b. paralles P wave vector
what is arrhythmia is Ominous sign of severe hypoxemia ( more common in OR)
sinus brady ( < 60 bpm)
trx required when hemodynamicly unstable (i.e. b/p change > 30%)
what is the worst arrhythmia for a patient with CAD?
Sinus Tach. (> 100 bpm)
What are common medications used to trx ST in the OR?
b - blockers (esmolol - metoprolol)
what happens to QRS in regards to a PVC?
wide QRS ( > 0.12 s)
strange shape
what are some common causes of PVCs
hypokalemia
hypomagnesemia
Myocardial ischemia
what is considered V. Tach?
> 3 consecutive PVCs
rate 100 - 200 bpm
wide QRS (not proceded by P wave)
when does V. tach often become V. fib?
> 30 beats of sustained VT
what happens to cariac output with V. Tach?
decreases (low B/P)
What is the defibrillation trx for V. tach?
200 J
300 J
360 J
What anti-dysrhythmics are used for V-tach
amiodarone
lidocaine?
what’s most common dysrhythmia associated with sudden cardiac arrest?
v. fib
what arrhythmia has quivering, pulseless ventricular movements but has a rate of > 300 bpm
V. Fib (can be course or fine)
what is the iatagenic cause of asystole?
hyperkalemia
what is lab value for hyperkalemia?
> 5.0 mEq/L
You’re in the middle of a surgery that requires labs to be done, a CMP reveals hyperkalemia. What should you do first?
- STAT recheck of K
What are causes of psuedohyperkalemia?
hemolysis
leukocytosis
thrombocytosis
What are examples of excess K intake
K supplements
K penicillin
stored blood
salt substitutes
clay
What are causes of translocation of K from ICF to ECF
succinylcholine
catecholamine deficiency states
hyperosmolality
b-blockers
acidosis
aldosterone antagonists (diuretic - spironlactone)
what decreased excretory capacity contribute to hyperkalemia?
renal failure & renal tubular disease
oliguria
K-sparing diuretics
ACE inhibitors
NSAIDS
hypoaldosteroneism
What are ecg findings that indicate hyperkalemia
peaked T waves
decreased P waves,
prolonged PR interval wide QRS,
sine wave
what are cardiovascular clinical features of hyperkalemia? (other than ecg wave form changes)
Arrhythmias
Heart block
Delayed conduction
Ventricular standstill
what are neuromuscular clinical features of hyperkalemia?
Paresthesias
Weakness, respiratory insufficiency
Flaccid paralysis
Mental confusion
what complication is a rare inherited myopathy characterized by
Ineffective uptake of calcium by SR or
Inappropriate release of intracellular Ca+2
Malignant Hyperthermia
what are triggers for malignant hyperthermia
Inhaled anesthetics (EXCEPT N2O)
succinylcholine
What are the signs of malignant hyperthermia
Hyperthermia (40-43 C)
Hypercarbia (Increased EtCO2)*
Tachycardia
Increased CO
What type of metabolism is associated with the hypermetabolic state of the muscles in Mailgnant hyperthermia?
Metabolic acidosis
Cellular hypoxia
Rhabdomyolysis ( Hyperkalemia, Myoglobinemia )
Cardiac/Renal failure
what is the first thing you do to treat malignant hyperthermia? Then what?
a. halt administration of trigger
100 % O2,
ice packs irrigate stomach (if open),
art line (ABG &enzyme monitoring),
what medication can be used to treat Malignant hyperthermia?
Dantrolene 2mg/kg q 5 min (max 10 mg/kg)
what are some safe anesthetic agents for Malignant hyperthermia?
Barbiturates
Etomidate
Droperiodol
NDMB - (roc, vec)
Anticholinesterases (neostigmine)
Local Anesthetics
N2O
Antihistamines
Catecholamines and sympathomimetics
What is the most common peripheral nerve injury
ulnar n.
what is a human error or equipment failure that could have led (if not discovered or corrected in time) or did lead to an undesirable outcome, ranging from increased length of hospital stay to death.
critical incident
what is the most common type of critical incident
human error
