Event Response

Question 1

Breathing Circuit Leak

Answer 1

1. Maintain adequate oxygenation and ventilation (and anesthetic)
   - if necessary, switch to separate BVM connected to 100% oxygen and start TIVA
2. Test integrity of machine
   - switch to spontaneous ventilation and test ability of reservoir bag to deliver PPV
   * if able to do so, leak is in ventilator
3. Test integrity of circuit
   - disconnect y-piece from patient and occlude while holding O2 flush
   * if pressure maintained, problem with patient or ETT
4. Check for ETT leak

Question 2

Bronchospasm

Answer 2

1. Maintain oxygenation and ventilation
   - 100% O2 and hand ventilate (assess compliance)
2. Auscultate chest for bilateral breath sounds and wheezing
3. Pass suction catheter down ETT to rule out kinking
4. Deepen anesthesia (propofol, sevoflurane)
5. B2 agonist (albuterol)
6. Epi
7. Steroids (methylprednisolone 40 mg IV q6h)
8. Adjust ventilator (adjust I:E ratio AND respiratory rate to maximize expiratory time; pressure control ventilation allows greater inspiratory flow which permits longer expiratory time and decreases dynamic hyperinflation)

Question 3

Delayed Awakening

Answer 3

1. Scan vitals and ensure adequate oxygenation/ventilation
2. Verify all anesthetics are off (IV and inhaled)
3. Stimulate patient
4. Review medications/doses and consider reversal (naloxone, flumazenil, check TOF)
5. R/o metabolic causes (glucose, temp, lytes, ABG)
6. Neuro exam (pupillary reaction, gag reflex)
7. ICU and neurology consult

Question 4

High Airway Pressures

Answer 4

1. Increase FiO2 to 100%
2. Hand ventilate
3. Check circuit and ETT
4. Auscultate chest
5. Check vitals
6. Exclude ETT obstruction (suction catheter)
7. Check other causes of decreased compliance (MH, aspiration, inadequate muscle relaxation, surgical retraction)

Question 5

Hypercarbia

Answer 5

1. Establish/maintain a patent airway
2. Ensure adequate oxygenation (titrate FiO2/PEEP as needed)
3. Increase minute ventilation (if ventilated) or assist with PPV/CPAP (if spontaneous)
4. Confirm diagnosis w/ABG
5. Confirm and treat cause of hypercarbia
   - evaluate residual anesthetics, opioids, NMBDs
   - check inspired CO2 (stuck valve, exhausted soda lime)
   - MH: check temp, muscle rigidity, reddish-brown urine
   - check for possibility of fever/infection/sepsis, thyrotoxicosis, TPN regimen

Question 6

Hyperkalemia

Answer 6

1. Check EKG for signs (peaked T waves, increased PR interval, widened QRS complex)
   - if no EKG signs, send stat lab to confirm diagnosis
2. K>6.0 or EKG changes, start treatment
   - stabilize myocardium with calcium gluconate (raises threshold potential)
   - shift K intracellularly (insulin/glucose, albuterol, bicarb, hyperventilation)
   - forced diuresis (fluids and 10 mg furosemide)
3. Consider hemodialysis if life threatening or accompanied by volume overload
4. If mild, cation exchange resins (eg kayexalate) to exchange K for Na in the gut

Question 7

Hypertension

Answer 7

1. Verify that HTN is real
2. Assess depth of anesthesia
3. Ensure adequate oxygenation and ventilation
4. Check fluids and drug administration
5. Rule out other causes of anesthesia (renal, endocrine)
6. If no correctable cause, administer antihypertensive

Question 8

Hypotension

Answer 8

1. Ensure adequate oxygenation and ventilation
2. Verify hypotension
3. Check vitals (HR, EKG, temperature)
4. Turn off vaporizers and other vasodilating drugs
5. Inform surgeon and assess surgical field for blood loss or IVC compression
6. Expand circulating volume (Trendelenburg position, IV fluid bolus)
7. Administer vasopressor (phenylephrine 100 mcg)
8. Review and treat probable causes (fluids, vasopressors, inotropes, arterial line?, TEE?)

Question 9

Hyperthermia

Answer 9

1. Verify temperature is real (esophageal, rectal, or PA)
2. Assess vital signs (HR, BP, EKG)
3. Ensure adequate oxygenation and ventilation
4. Identify and treat causes
5. Supportive measures

Question 10

Hyponatremia

Answer 10

1. Assess duration and severity
2. Measure osmolality
3. Assess volume status
4. Correct (not too quick–>central pontine myelinolysis) max 12 mEq/L/day
5. Depending on dx, treat with hypertonic saline, isotonic saline, or fluid restriction

Question 11

Hypoxia

Answer 11

1. Hand ventilate with 100% FiO2 and high flows
2. Auscultate chest
3. Check vitals (HR, BP, EKG) and monitor (PIP, EtCO2)
4. Quickly assess circuit and ETT
5. Pass suction catheter down ETT to rule out secretions or mucus plug
6. Consider adding PEEP
7. Restore circulating volume with crystalloid and/or pRBCs if warranted

Question 12

Oliguria

Answer 12

• Determine pre, intra, or post
• Increase renal perfusion: maintain euvolemia, enhance CO, ensure adequate MAP
• Avoid nephrotoxins: contrast dye, ahminoglycosides (gent), and NSAIDs
• Treat cause (eg. outlet obstruction)