Clinical Related Complications Flashcards
1
Q
Laryngospasm causes (4)
A
- Foreign (secretions) substances
- visceral pain reflex
- Extubation during light anesthesia (Stage II)
- insertion of oral airway
2
Q
Signs and Symptoms of Laryngospasms
A
- partial = crowing sound, stridorous breath sounds
* total= no sound d/t no air movement.
3
Q
Tx of Laryngospasm
A
Goal: Support ventilation
- head tilt/jaw thrust (call for an assistant) with 100% Fi02 + gentle airway pressure
- Give 1.5 mgs/kg Lidocaine IV
- Give 0.15-0.30 mg/kg Anectine IV ; SL/IM 5mg/kg
- Reintubate (+ ETCO2 and improving sats)
- Sedate patient and SIMV or AV
4
Q
Complications of Laryngospasm
CXR, breaths
A
Cx:** pink frothy sputum = Negative Pressure Pulmonary Edema
** Coarse breath sounds
5
Q
TX of complications of Laryngospasm :
A
Increase Fi02 CPAP/PEEP NO fluid restrictions NO diuretics = will self correct within 24 hrs
6
Q
Laryngeal Edema Tx
A
***laryngeal edema
TX: nebulized racemic epinephrine
IV corticosteroids
7
Q
Bronchospasm=
A
is bronchoconstriction
8
Q
Causes of Bronchospasm
A
mechanical obstruction
foreign bodies
ET is irritating carina
Light anesthesia
9
Q
S/SX of Bronchospasm
A
intraoperative wheezing (r/o mechanical or physical obstruction, pulmonary edema or pneumothorax)
ETC02 waveform = upstroke rises slowly
10
Q
Tx of Bronchospasm R/O 2. Administer 100% 3. anesthesia 4. Give
A
- R/O obstruction d/t migration of ETT, secretions, and kinking *most definitive is through fiberoptic
- Administer 100% Fi02 and manually
ventilate with sufficient expiratory time. - Deepen anesthesia
- Give Beta adrenergic agonist (Albuterol)
11
Q
Most definitive Dx of Bronchospasm is through
A
Fiberoptic
12
Q
Tx of Bronchospasm (5-7)
Give IV
6. IV or IM
7.
A
- Give IV Aminophylline, SQ Terbutaline, or IV/nebulized lidocaine
- Ketamine IV or IM
- Extubation = very controversial; ETT contributory factor.
13
Q
Intraoperative Aspiration
Mortality is ____
A
Aspiration = is the active (vomiting) or passive (regurgitation) passage of material from the stomach, esophagus, pharynx, mouth, or nose to the trachea.
Mortality is 5%
14
Q
Recurization
A
Paralyzed again after extubation
15
Q
Reintubation in the PACU
A
Affect reimbursement
16
Q
Intraoperative aspiration AVERAGE HOSPITAL STAY IS
A
21 DAYS WITH ICU
17
Q
Complications of Intraoperative aspirations:BPA
A
Bronchospasm Pneumonia ARDS lung abscess empyema.
18
Q
Signs you can reverse
A
Sustained head lift
Tetany for 5 seconds w/o fade
19
Q
Intraoperative aspiration causes
A
Food or any foreign body
Fluids (blood, saliva, GI contents = pH <2.5 and content >25 mls)
20
Q
S/sx: Acidic Aspirates
A
-> alveolar-capillary breakdown -> interstitial edema , intraalveolar hemorrhage, increased airway resistance ->
hypoxia.
21
Q
S/sx: Non-Acidic Aspirates PATHO
A
- > destroys surfactant, alveolar collapse and atelectasis
- -> hypoxia
22
Q
Particulate/food matter
A
–> physical obstruction and later inflammatory response ->
alternating areas of atelectasis and hyperexpansion ->hypoxia, hypercapnia
23
Q
S/sx of Intraoperative Aspiration
A
Fever (90%)
Tachypnea
Rales in 70% of cases
Cough, cyanosis & wheezing (30-40%)
24
Q
Tx of intraoperative Aspiration
ABCC
A
A. Prevention. Recognize risks in preop. (Coexisting, fasting times, preop meds).
B. Induction. RSI. However, ETT does not guarantee that no aspiration will occur.
C. After the fact: Supportive care remains mainstay. a. Suction asap.
C. Fi02 x 100% PEEP < CPAP (severe insult, atelectasis, or respiratory failure)
25
Negative pressure Pulmonary Edema
PInk frothy sputum
| Need POSITIVE PRESSURE
26
```
Tx of Intraoperative Aspiration
Monitor
Pulmonary
_____
Controversial?
not shown to be helpful
```
d. Monitor fluid and cardiovascular status
e. Pulmonary lavage with obstruction (not
with aspiration).
f. Rigid Bronchoscopy = only when removing
solid particles
g. Antibiotics and corticosteroids still
controversial
h. Lavage trachea with sodium bicarbonate =
not shown to be helpful.
27
Pneumothorax Causes
Causes:
1. Positive pressure ventilation
2. Central venous access placement
3. Bronchoscopy procedure
4. Surgical and invasive procedures near the proximity of the lungs.
28
Laryngospasm FULL
MASK VENTILATE DIFFICULT
More propofol
Muscle relaxants
BAG
29
5 hallmarks of tension Pneumothorax:
```
1. hypotension
2. hypoxemia
3. tachycardia
4. increased CVP
5. increase PIP
```
30
```
Pneumothorax
breath sounds
ventilatory pressures (PIP, MA)
chest
progressive
lungs
changes
Displacement of
percussion
02 saturation
Extreme
```
```
unilateral decreased in breath sounds
increased ventilatory pressures (PIP, MA)
Asymmetric chest
progressive tracheal deviation
wheezing
cardiovascular changes
Displacement of cardiac impulse
Hyperresonance topercussion
02 desaturation d/t V/Q mismatch
Extreme anxiety
```
31
IF tube too deep by carina
You may have spasm
32
Patient is bucking
Take off vent
Manual vent
Give more propofol
33
Pneumothorax Tx: definitive
***** Chest decompression
34
Chest decompression for pneumothorax done by
_______where ?
What do you leave?
large bore needle through chest wall
2nd intercostal space mid clavicular line
= leave needle in place until chest tube is placed or thoracotomy is performed
35
PE Causes:
1. DVT from non mobility (hospital or activity related).
2. FAT EMBOLISM from Total Joint Replacement
(long bones, pelvis, ribs)
3. Bone Cement Embolism
36
Fat Embolism when does it occur
may occur 12-40 hours after trauma or surgery.
37
```
FAT embolism Early S/Sx:
Neuro
Urine
Skin
CNS
Lungs
```
```
Hypoxia
Altered mental state,
Fat globules in urine/sputum,
Petechiae (chest, axilla, upper extremities, conjunctiva), CNS depression
Pulmonary edema
```
38
FAT EMBOLISM Minor s/sx:
| HR, temp, ESR, urine, Platelet /hematocrit
↑HR, ↑temp, ↑ESR, fat emboli(retinal), urinary and/or sputum fat, ↓platelet or hematocrit.
39
FAT embolism TRIAD
Hypoxemia, Confusion, Petechiae
40
Type I DM
Always Full Stomach
41
```
PE Signs and Symptoms
acute/sudden onset of
lungs
skin symptoms
BP
HR
Psychological
O2 sats
HTN
bronchioles, PIP
ETC02
NEURO
```
```
acute/sudden onset of dyspnea (80-85%).
wheezing
diaphoresis
increasing hypotension
tachycardia
sense of impending doom
Hypoxemia unresponsive to 02 treatment)
Pulmonary hypertension
Bronchospasm ↑PIP
Decreased ETC02
Altered mental State
```
42
PE Treatment
```
Tx:
Give supplemental 02
reintubate PRN
Support CV function = be aggressive with
hypotension.
give Heparin IV
```
43
Cause of Airway Fire
* most common is laser surgery of the airway
* another cause is cautery with pooled skin prep;
* Remember your
44
Airway Fire triad
Triad: 02, heat, fuel
| s/sx: duh
45
Airway Fire: Ventilation Techniques
Ventilation Techniques with Laser Surgery
| Jet Ventilation
46
Jet Ventilation and Risks
through operating laryngoscope attached wall 02 (entrains air/02 mixture thru Venturi effect)
aim at trachea.
Risks: barotraumas, pneumothorax mediastinal or SQ air.
47
Spontaneous Ventilation and RISKS=
inhalation agents
thru laryngoscope attachment.
Risks: hypoventilation, hypercarbia and aspiration.
48
Airway and ventilation techniques ETT =
PVC (least flammable), red rubber,
| silicone ET, ETs wrapped with metallic tape.
49
Airway Fire Interventions
An ounce of prevention:
Reduce flammability of airway by decreasing 02
concentration (Fi02 23%) and use of wet lap sponges.
50
AIRWAY FIRE PROTOCOL
1. stop
2. disconnect
3. remove
4. surgical field
5. Fi02
6. perform ___And _____ to ______
7. full monitors
8. use
9. continue____and _______ as needed.
1. stop ventilation
2. disconnect 02 source
3. remove ETT
4. flood surgical field with saline
5. mask ventilate with 100% Fi02 then reintubate
6. perform rigid laryngoscopy and bronchoscopy to assess damage and remove
debris
7. full monitors x 24 hours
8. use short term steroids
9. continue ventilatory support and antibiotics as needed.
51
FACTS of ATYPICAL PSEUDOCHOLINESTERASES
| Typical = normal
Anectine, mivacurium, local anesthetics and trimethaphan = affect Dibucaine Test
52
Primary route of elimination for Anectine?
PseudoChE.
53
Secondary route of elimination for Anectine?
Kidneys = longer!
54
The longer the case
The more risk for PE
55
Dibucaine is an
amide local anesthetic
56
Dibucaine number =
reflects the effectiveness and quality of the enzyme; not
| the quantity or concentration of the enzyme in plasma
57
DIBUCAINE TST: Hence, even in homozygote type,
the concentration of the enzyme is normal. The
| quality of both enzyme is abnormal.
58
Dibucaine Test Procedure is a_______ procedure
blood test
59
Airway fire LASER CASES
Armored tube
Foil wrap tubes
wrap ETT tube with wet gauze
60
Dibucaine test Result Classification:
| 1. Normal test result =
test will decrease pseudoChE by 80.
61
DIBUCAINE 1 normal and 1 abnormal (Heterozygotes) =
| test will decrease pseudoChE by
30-70 , Anectine will be slightly prolonged.
62
Abnormal (Homozygotes) = test will
| decrease peudoChE by
16-25 Anectine will be prolonged (6-8 hrs).
63
```
Treatment Goal of Atypical
Ensure
a pure phase II block is reversible with _____
if a block is mixed (phase I and 2),giving an anti
cholinesterase will _______the block
most practitioners:
Giving blood is
Allergy:
Testing for
```
Ensure an adequate airway and gas exchange
a pure phaseII block is reversible with anticholinesterase
if a block is mixed (phase I and 2),giving an anti
cholinesterase will prolong the block
most practitioners: ventilatory support until muscle strength returns
Giving blood is more risky than beneficial.
Allergy: Sux!
Testing for Dibucaine Number
64
MH first sign
MASSETER SPASM
65
Recurarizaton
= immediately apparent in the PACU d/t declining 02 sats and respiratory effort.
66
Recurarizaiton S/Sx
```
s/sx:
02 sats
unresponsive patient
appears “floppy” or uncoordinated
ineffective abdominal and intercostal
activity
S/sx:
• sometimes can verbalize: suffocating feeling
• unable to sustain head lift or hand grasp
```
67
Dandrolene intiial dose
2.5mg/kg up to 10 mg
68
Recurarization worst case Signs and symptoms
pharyngeal collapse and respiratory obstruction
69
Ryanodex
Each vial of RYANODEX® contains 250 mg of dantrolene sodium and requires reconstitution with only 5 mL
70
Recurarization Treatment goal
Treatment Goal: Treat urgently and aggressively
Re-sedate the patient
Give additional reversalagents in divided doses
(Neostigmine 0.05 mg/kg IV = longer duration of
action. Careful with bradycardia).
71
MMA embolism first sign
HYPOTENSION
72
ACUTE DISSEMINATED INTRAVASCULAR COAGULATION
| (DIC) Causes:
shock
ischemia
infection
OB (abruption, amniotic fluid embolism)
73
S/sx of DIC
```
bleeding with oozing
platelet (thrombocytopenia)
prolonged PT/thrombin time
Factors: I,IIa, V, VIII, XIII.
increased fibrin degradation products.
```
74
DIC Classification:
| Type 1 (Secondary Fibrinolysis) =
90% --> generation of thrombin and activation of
| plasmin.
75
DIC Classificaiton :Type 2
(consumptive) --> plasminogen is exhausted and uncontrolled clotting occurs.
76
Type 3
(Primary) exclusive activation of
| plasmin alone.
77
DIC Treatment:
removal of underlying cause
| give platelets, FFP, and cryoprecipitate
78
What is MH?
What is increased?
Not able to
defect is in the Sarcoplasmic Reticulum of skeletal muscle; SR fails to sequester Ca++ leading to hypercalcemia
→sustained contraction and ↑BMR
Hypothalamus is not able to regulate heat
during this event.
79
Trigger agents of MH
Trigger Agents: Anectine, Vapors, dTubocurarine
80
```
Signs and Symptoms of MH
What happens to metabolism? HR, RR? O2? BP?
ECG, K, CA, H+
Early sign
Temp
CPK
```
```
Increase metabolism --> SNS activation
Increase HR and RR
Cyanosis
Unstable BP
dysrhythmias
Increase K+, Ca++, H+; Decrease 02
Masseter muscle spasm (early sign)
Temperature Increase 1-2C every 5mins.
CPK >20,000
```
81
Most sensitive and earliest sign.
ETC02 (>100 mmHg with pH<7.0)
| most sensitive and earliest sign.
82
Decrease SPO2 means
?hypotension
83
Interventions for a KNOWN MH
1. Epidural without dantrolene pre treatment.
2. Room Preparation
preop meds are ok
disposable circuit
change soda lime
drain/empty/disconnect vaporizers
flush machine for several hours at 3-5 L/min02
84
3. GETA with dantrolene pre treatment
non depolarizers can be used except dTubocurarine
| preop meds are ok
85
Intraoperative Considerations of MH
use non triggering agents
vigilance with 2 parameters: ETC02 and temperature
Continued Postoperative VIGILANCE
86
Drugs of choice of MH
Dandrolene
87
Dandrolene act on
the Ryanodine receptor on the skeletal muscle cell
88
Main action is to
↓ CA release from SR
89
Dose of dandrolene
2.5mg/kg max 20mg/kg
90
Therapeutic levels
2.5mg/ml
91
Acute interventions for acute MH
Cool patient
gastric lavage stop at 38C not ESOPHAGEAL
]temperature
92
MH: Lidocaine treatment for PVC
15m/kg IV
93
Diagnosis made on CPK>
20000
94
Another diagnostic test
Halothane Caffeine Contracture test
95
MH: Sodium Bicarbonate
1-2 moles/kg
96
Treatment for Hyperkalemia: MH
Immediate direct reversal of cardiotoxicity with administration of CaCl
Quickly assist with K shift from ECF to cells
Hyperventilation
Beta adrenergic stimulation
sodium bicarbonate
Insulin and glucose
97
Removal of K+ from the body (definitive
| treatment)
diuretics
Kayexalate
Dialysis
98
Treatment for dysrhythmias = starts with
PVCs→ Vtach →V fib (d/t hyperkalemia: same treatment as above withhyperkalemia)
99
(MMA)
METHYLMETHACRYLATE EMBOLISM
100
Methylmethacrylate =
is the usual bone cement used to stabilize implant with the bone in orthopedic surgeries (usually knees and hips)
101
MMA heat from cement
expands intramedullary gas, raises intramedullary pressure and forces fat and air into venous circulation
102
IN MMA intense heat causes
reflex bradycardia or cardiac arrest
103
In MMA intrapulmonary MMA
intrapulmonary MMA activation of the clotting
cascade pro inflammatory substance
production.
104
Prophylaxis pre-cementing:
```
Increase Fi02
D/C N20
maintain euvolemia
create vent holes in the distal femur
high pressure lavage of femoral shaft to remove
debris
using uncemented femoral component
```
105
MMA Embolism s/sx:
Sudden hypotension (30-60 secs. Post
cementing).
Hypotension (10 mins post cementing).
106
MMA Embolism s/sx:
Sudden hypotension (30-60 secs. Post
cementing).
Hypotension (10 mins post cementing).
107
BONE CEMENT IMPLANTATION
| SYNDROME (BCIS)
closely resembles Fat Embolism syndrome
| survivors develop subacute form of FES over 24-48 hours.
108
BONE CEMENT IMPLANTATION SYNDROME (BCIS)
closely resembles Fat Embolism syndrome
109
BCIS survivors develop
subacute form of FES over 24-48 hours.
110
Risk factors of BCIS
elderly and debilitated pts
preexisting cardiopulmonary disease
CAD
Pulmonary hypertension
111
BCIS signs and symptoms
| O2 sats, BP, ECG, pulm, CO
1. Acute pulmonary hypertension
2. Hypoxemia
3. Hypotension with (hypoxia, dysrhythmia, pulmonary HTN), decreased cardiac output
4. Right ventricular failure
5. Circulatory collapse
112
1. Provide
2. Support
3. Augment
4. Consider
Provide 100% 02 and controlled ventilation
Support aortic pressure and Right ventricular
contractility with vasopressors
Augment right ventricular preload with CVP with or
without PAC guidance
Consider future treatment of pulmonary hypertensive crisis with inhaled Nitric Oxide or prostacyclin
113
VAE Cause:
operative field is elevated 5 cm
| or more above the heart’s right atrium
114
VAE Incidence:
40-45% operated on sitting position
115
VAE: Most Sensitive → least sensitive
| monitors
TEE > Precordial Doppler > PAC> Capnography (ETC02) > Mass spectrometry (ETN2)
116
VAE Interventions
1. Notify surgeon immediately
2. Surgical field flooded with saline and packed
3. Bone edges are waxed
4. Turn off N20 (if being used); give Fi02 100%
5. Neck veins are compressed as means of ↑Jugular venous pressure
117
VAE aspiration
Aspiration of air from the ______atrial catheter (tip should be ____Cm. where? . Doppler over ____should be placed over ____or_____ intercostals space at _____
Aspiration of air from the right atrial catheter (tip should be 3 cms. Below the junction of SVC and RA). Doppler over RA should be placed over 3rd to 6th intercostals space at right of sternum.
118
TEE and VAE aspiration
TEE is still 5-10x more sensitive.
119
If significant VAE,
lower the head to heart level
120
VAE Support pressure if Hypotensive with
pressors and rapid volume infusion
121
VAE AVOID:
PEEP or valsalva maneuver to further avoid paradoxical VAE thru a patent PFO.
122
VAE : Position horizontal
→ failed → left lateral with slight Trendelenburg (head down) →failed→ supine and begin CPR
