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APA > Complications > Flashcards

Complications Flashcards

1
Q

What are the differences between preventable and non-preventable complications?

A

Preventable -had someone done something differently or if equipment had been functioning, pt would not have been injured
Unpreventable - would have happened no matter what
- suddenly death syndrome
- fatal idiosyncratic drug reactions
- poor outcomes despite proper management

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2
Q

What are the top 3 closed claims from the ‘90s?

A
  • Death: 22% of claims
  • nerve injury 18%
  • brain damage 9%

(Emerging claims in regional anesthesia and pain management as more is being done for them )

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3
Q

What is accounted for in human error?

A

** unrecognized breathing circuit disconnect *
—> if vent alarming- don’t just silence it- make sure it’s connected
- medication labels- always ready labels
- airway management- not being prepared or having equipment ready or continuing the same thing instead of calling for help air moving down the algorithm
- anesthesia machine misuse
- fluid mismanagement
- IV line disconnection

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4
Q

How can anesthesia complications be prevented?

A
  • improved pt monitoring
  • improved anesthesia techniques
  • improved education of anesthesia providers
  • comprehensive protocols
  • standards of practice (standardized monitors)
  • active risk management programs
    • most important factor is the focus on pt safety—> WE are the gatekeepers!! **
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5
Q

What are the different types of complications?

A
  • airway injury
  • Peripheral nerve injury
  • awareness
  • eye injury
  • cardiopulmonary arrest during spinal anesthesia
  • hearing loss
  • allergic reactions
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6
Q

What can happen with injury to the airway?

A

The two most common post op issues are sore throat and nausea—> make sure to tell pt ahead of time to expect this

  • sore throat
  • dysphasia
  • dental injury: most common claim—> with poor dentition let them know possibility of tooth falling out
  • TMJ: when pulling on jaw it may lock in place
  • VOCAL CORD PARALYSIS: be very cautious with singers
  • VOCAL CORD GRANULOMA
  • ARYTENOID DISLOCATION—> painful
  • ESOPHAGEAL PERFORATION
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7
Q

What are some possible nerve injuries?

A
  • positioning —> hypotension
  • most common injures:
    • brachial plexus
    • common peroneal
    • radial
    • ulnar
    • retinal ischemia
    • skin necrosis
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8
Q

When does awareness usually happen?

A

~ 0.1-0.4%

  • trauma when pt too unstable to give a whole lot of anesthetic
  • crash OB cases—> c section where you/surgeon are really hurrying to get the baby out
  • CV surgery with CPB—> sternotomy is extremely stimulating and perfusionist runs anesthetic- may run them light
  • or forgot to turn gas on-awake paralysis
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9
Q

What are the differences between versed and scopolamine?

A
  • versed causes anterograde amnesia (this point forward)
  • scopolamine causes retrograde amnesia
    • if you had no gas running for an hour, give scopolamine to prevent recall—> still chart, but be careful with your wording
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10
Q

How can you prevent intra-operative recall?

A
  • routinely discuss recall with pt and steps taken to decrease it
  • Define MAC with sedation for pt- if sedation will be light, let them know ahead of time
  • use volatile anesthetic agents at level consistent with amnesia
    • MAC 0.6 when used with opioids and N2O
    • MAC 0.8-1.0 when used alone
      • add benzos. Or scoplalamine
  • use BIS
  • document end tidal concentrations of agent
  • document admin of amnesia drugs
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11
Q

What is the treatment for intra-op. Awareness?

A
  • assess during post op visit
  • obtain detailed account of patient’s experience
  • Be sympathetic
  • answer patients questions
  • refer to psych. Counseling if needed
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12
Q

What are common types of intra-op eye injury?

A
  1. ) corneal abrasion- by far the most common and transient eye injury
  2. ) blindness-
    - movement during ophthalmic surgery
    - during GA or MAC
  3. ) ION (Ischemic Optic Neuropathy)
    * most common cause of operative vision loss *
    - optic. Nerve infarct- from decreased O2 delivery from arterioles
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13
Q

What are patient risk factors that contribute to eye injury?

A
  • HTN
  • DM
  • CAD
  • smoking
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14
Q

What are surgical risk factors contributing to eye injury?

A
  • deliberate intra-op hypotension
  • anemia
  • prolong surgical time in position that compromises blood flow—> prone, T-berg, compressed abdomen
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15
Q

How long does it take to notice ION?

A

Immediate onset to POD 12

Ranges of decreased visual acuity to complete blindness

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16
Q

How can ION be prevented?

A
  • head up position to enhance venous outflow
  • minimize abdominal constriction
  • art line for close BP monitoring
  • limit duration and degree of hypotension
  • when high risk for ION—> avoid anemia and stage surgeries if they will be long
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17
Q

What groups most commonly arrest during spinal anesthesia?

A

~36 years of age
ASA I-II
Higher level of block (T4) with appropriate does of LA
- associated with sub-clinical respiratory depression with hypercarbia from sedation

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18
Q

What are s/s prior to arrest after spinal anesthesia?

A
  • gradual decrease in HR and BP

- cyanosis

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19
Q

How can spinal anesthesia arrest be treated?

A
  • vent support
  • atropine
  • ephedrine
  • epinephrine: its ok to use small doses (5-10ng) for bradycardia that is unresponsive to atropine and ephedrine, or larger doses if needed
  • CPR (11 min average)
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20
Q

What are some documentation pitfalls to avoid?

A
  • completing entries before they occur
  • incomplete description of procedures and management
  • conflicting times between different records
  • loss of critical patient data
  • incomplete/poorly though out notes following an adverse event
  • signing in accurate documents without reading them
  • failing to document meeting with family or patient
  • failure to obtain supporting documentation from others
21
Q

What are the 4 types of allergic-hypersensitivity reactions?

A
  1. ) TYPE 1: IMMEDIATE
    - hay fever (atopy), urticaria-angioedema, anaphylaxis
  2. ) TYPE 2: ANTIBODY MEDIATED, BLOOD TYPE INCOMPATIBILITIES
    - hemolytic transfusion reactions, autoimmune hemolytic, HIT

3.) TYPE 3: IMMUNE COMPLEX (RA, SERUM SICKNESS)

  1. ) TYPE 4: DELAYED, CELL MEDIATED, CYTOTOXIC
    - contact dermatitis, graft rejection
22
Q

What’s the difference between under and over reactions?

A
  • both involve T and B cells
  • under reaction = loss of immunity
    Cancer, infants, immunodeficiency
23
Q

What is anaphylaxis?

A
  • an exaggerated response, mediated by type 1 hypersensitivity reaction
  • appears within minutes of exposure to antigen in sensitized individuals
  • s/s present as acute respiratory distress and/or circulatory shock
    • death may occur
24
Q

What is the incidence of anaphylaxis during anesthesia?

A

~ 1:5,000-1:25,000

25
Q

What are mediators of anaphylaxis?

A
  • histamine: vasodilation, runny nose
  • leukotrienes: asthmatic resp. Reaction
  • BK-A
  • platelet activation factor
26
Q

What are clinical manifestations of anaphylaxis?

A
  • CV: hypotension, tachycardia, arrythmias
  • PULM: bronchospasm, cough, dyspnea, pulmonary edema, laryngeal edema, hypoxia
  • DERM: urticaria, facial edema, pruritis
27
Q

What is an anaphylactoid reaction?

A

No IgE interaction with antigen

- equal to anaphylaxis otherwise—> equally life-threatening

28
Q

What is the treatment for anaphylaxis/anaphylactoid reactions?

A
  • stop drug administration
  • give 100% O2
  • epi (0.01-0.5 mg IV or IM)
  • consider intubation or tracheostomy
  • IVF (1-2 L LR)
  • Diphenhydramine (50-75 mg IV)
  • Ranitidine (150 mg IV)
  • Hydrocortisone (up to 200 mg IV) or methylprednisolone (1-2 mg/kg)
29
Q

What are drugs that cause anaphylaxis

A
  • muscle relaxants: most common cause of anaphylaxis during anesthesia
  • hypnotics: mainly Pentothal and propofol
    (True allergic reactions to Etomidate, ketamine and benzos are extremely rare)

opioids: non-immune histamine release more common than true allergic reaction

local anesthetics: mostly vaso vagal and toxic reactions or s/s from epi

  • Ester type LAs:
  • IgE mediated reactions
  • share common antigenicity with PABA
  • expect cross sensitivity with other esters

Amide LAs:

  • true anaphylaxis extremely rare
  • preservative parabans are the cause

Volatile inhaled anesthetics: NO DOCUMENTED REPORTS OF ANAPHYLAXIS

  • ANTIBIOTICS * many true allergies are d/t ABG
  • B-lactate abx (PCN, cephalosporins)
  • sulfonamides
  • vancomycin “red man syndrome”- slow infusion rate down
30
Q

What happens with a latex allergy?

A
  • 2nd cause of anaphylaxis during surgery
  • rang from mild- life threatening
  • Direct IgE mediate immune response to polypeptides in natural latex
  • Type 4 sensitivity reaction to chemicals from manufacturing process
  • foods that cross react: mango, kiwi, chestnut, avocado, passion fruit, banana
31
Q

How do you prevent a latex reaction?

A
  • absolute avoidance
  • pharmacological prophylaxis
    • pre-op admin, of H1 and H2 histamine antagonists
    • steroids—> controversial
32
Q

What is the occurrence of malignant hyperthermia?

A

1:40,000 adults and 1:15,000 pediatrics

33
Q

What are the s/s MH?

A 
* occurs >1 hour from exposure to triggering agent
HYPERMETABOLISM
- elevated O2
- decreased O2 and mixed venous O2
- metabolic acidosis
- cyanosis
- mottling
INCREASED SYMPATHETIC ACTIVITY
- tachycardia
- initial HTN 
- arrhythmias/ V-fib
MUSCLE DAMAGE
- masseter spasm
- generalized rigidity
- elevated CK, K, Na, Phos
- myoglobinemia/urea
HYPERTHERMIA
- fever/sweating
- late sign
- temp can rise as much as 1 C Q 5 minutes
34
Q

What is the pathophysiology of MH?

A
  • sudden release fo Ca from sarcoplasmic reticulum, removes inhibition of troponin—> causes intense muscle contractions
  • Dramatically enhanced and sustained ATP activity results in uncontrolled increase in metabolism (aerobic and anaerobic)

** if untreated—> sudden death in as little as 15 minutes **

35
Q

What are some possible causes of MH?

A
  • abnormal Ryr 1 receptor (ryanadine)
  • abnormal 2nd messengers and modulators of Ca release
  • abnormal Na Chanel in skeletal muscle
36
Q

What is the dose of dantrolene and what does it do?

A

Give 2.5mg/kg- 10mg/kg until episode terminated

  • intracellular dissociation of excitation-contraction coupling
  • binds to Ryr receptor on Ca channel—> inhibits Ca release from sarcoplasmic reticulum
37
Q

Other than MH, what other conditions is dantrolene used for?

A
  • hyperthermia associated with thyroid storm
  • neuroleptic malignant syndrome
  • treatment of chronic spastic disorders
38
Q

What are side effects of dantrolene?

A
  • muscle weakness
  • respiratory insufficiency
  • risk of aspiration
  • phlebitis in small hang veins —> CVC if possible
39
Q

What is laryngospasm?

A

Complete spasmodic closure of larynx resulting from constriction fo laryngeal muscles from outside stimulus

40
Q

How can you tell the difference between complete and partial laryngospasm?

A

Complete: silent paradoxical movement of chest, tracheal tug, no ventilation
Partial: crowing noise, mismatch between respiratory effort and ventilatory effectiveness

Also will see desaturation, bradycardia, central cyanosis, inspiratory stridor

41
Q

What is the treatment for laryngospasm?

A
  • clear airway (suction)
  • deepen anesthesia
  • 100% O2
  • gentle chin lift/jaw thrust
  • call for help
  • positive pressure/incubate if needed
  • stop surgical stimulation
  • *** risk of awareness—> follow up with pt afterwards
42
Q

What is bronchospasm?

A

Spasmatic constriction of bronchial smooth muscle—> narrow airway and increases resistance

43
Q

What are s/s of bronchospasm?

A
  • prolonged expiration
  • increased inflation pressures
  • expiratory wheezes
  • low O2 sats
  • elevated ETCO2
  • decrease in tidal volumes
44
Q

How do you treat bronchospasm?

A
  • give 100% O2
  • stop surgical stimulation
  • call for help
  • deepen anesthesia
  • rule out bronchial or esophageal intubation
  • give epinephrine
  • consider anaphylaxis, pulmonary edema, pneumothorax, or kinked ETT
45
Q

Who is responsible for fire prevention in the OR?

A

Entire team:

  • surgeon controls ignition source
  • anesthetists controls oxidizing agents
  • surgical nurse controls fuel source
46
Q

What area occupational hazards for the nurse anesthetist?

A
  • chronic gas exposure
  • infectious disease exposure—> always use universal precautions
  • substance abuse
  • radiation exposure
47
Q

What are the maximum acceptable trace exposure amounts in the O.R. For inhaled gases?

A

N2O alone— < 25ppm
N2O + halogenated agent— <25ppm and 0.5 ppm HA
Halogenated agent only — ~2ppm

48
Q

How can you prevent radiation exposure?

A
  • use lead barriers
  • stay the maximum distance from the source—> inverse square law—-> amount of radiation changes inversely with the square of the distance
    • at 4 m exposure will be 1/16 that at 1 m
  • maximum whole body exposure is 5 rem/year

APA (8 decks)

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