Perioperative Complications Flashcards
Perioperative complications include (11):
SSHHHH!!!
MOPP B
- sinus tach
- sinus brady
- hypotension
- hypertension
- hypoxia
- hypercarbia
- myocardial ischemia
- oliguria
- bronchospasm
- pulmonary aspiration
- pulmonary edema
_______ is the most common dysrhythmia. It is defined as HR _____ w/ normal P wave.
Sinus tach
>100 bpm w/ normal P wave
Causes of sinus tachycardia include:
1) increased _____ ______ ______
2) reflex response to ______ or _______
3) ______ or _____
4) ______ ______
5) ________
6) Medications
7) ________
1 - endogenous catecholamine release 2 - hypotension or hypovolemia 3 - fever or MH 4 - pulmonary embolus 5 - pheochromocytoma 7 - thyrotoxicosis
The following cause increased endogenous catecholamine release:
- preoperative ______
- surgical _____ from incision
- __ and _____ intubation
- ____/____ stimuli
- _______ anesthetic depth
- h_____
- h________
- excessive _____ inflation time
- e________
anxiety stimulation DL and trachea noxious/painful inadequate hypoxia hypercarbia tourniquet emergence
Medications that can cause sinus tachycardia include:
1) Vagolytics such as _______ used for NMB reversal and antisialagogue effects.
2) _______
3) Muscle relaxants - specifically ______
4) ______ anesthetics (______ initial rapid uptake)
1 - antimuscarinics
2 - sympathomimetics
3 - pancuronium
4 - volatile - desflurance
Treatment for Sinus Tach:
1) Verify tachycardia isn’t artifact or ESU interference (check ___________)
2) Determine and treat underlying cause! (Don’t just give esomolol….)
3) Ensure adequate ______ and ______
4) Adequate ____ _____
5) Correct ______ or ______
6) Pharmacological Management:
- _____
- ______ to buy time
- Preop ______
- ______ (rarely)
**a lot of times if the patient is deep + tachycardia, it is d/t ____ _____& typically corrects w/ ____
1- pulse ox waveform 3 - oxygenation, ventilation 4 - anesthetic depth 5 - hypovolemia, hypotension 6 - opioids, beta adrenergic blockers, anxiolysis, CCBs
**a lot of times if the patient is deep + tachycardia, it is d/t fluid deficit & typically corrects w/ bolus
Sinus bradycardia is defined as HR < ____ BPM w/ normal P wave. It is ______ in young health patients and usually does NOT require treatment if ______ _______.
Rarely, it can deteriorate to sinus arrest.
<60 BPM
common
hemodynamically asymptomatic
**if BP is good and HR is 40 - do NOT mess w/ it
Sinus bradycardia can be caused by:
1) ______ response to surgical manipulation
2) High level _____ _____ (_____ anesthesia)
3) ______ nerve stimulation
4) _____ anesthetics
5) ______ in neonates and children
6) Medications
1 - vagal
2 - sympathetic block - neuraxial anesthesia
3 - trigeminal
4 - volatiles (halothane, sevoflurane)
5 - hypoxia (in children causes bradycardia, adults is tachycardia)
High level sympathetic blocks (neuraxial) blocks effect ________ fibers (T1-T5) and results in increased predominance of ______ response mediated by the _____ and results in sinus bradycardia.
cardio-accelerator
PSNS
vagus
Trigeminal nerve stimulation used in ______ ______ can cause bradycardia. Pretreat w/ ______ to prevent the huge PNS outflow.
electroconvulsive therapy
Robinul
Drugs commonly used during anesthesia can cause bradycardia:
- Narcotics such as _____ and _____
- Alpha 1 agonists (______)
- ________ muscle relaxants
- Reversal agents such as _______
fentanyl, alfentanil
phenylephrine (squeezes and lowers HR)
depolarizing (Succinylcholine - usually on 2nd dose - mimics ACh)
neostigmine
Treatment of sinus bradycardia includes:
1) May NOT require Rx if ______ ____
2) Maintain ______ and ______
3) May require _______ depth of anesthesia
4) Remove/extinguish ____ ______
5) _________ (Atropine or Robinul)
6) ________ agents (Isoproterenol)
7) ____ ______ (rarely utilized)
1 - hemodynamically stable 2 - oxygenation, ventilation 3 - decreasing 4 - vagal stimulus 5 - antimuscarinics 6 - chronotropic agents 7 - cardiac pacing
vagal response to surgical manipulation can cause bradycardia.
Examples include:
- ____ manipulation
- Abdominal _____
- _____ stimulation (cervix)
- ____ _____ traction
- ____ surgery or retractor use or stimulation
- Tracheal ______ or ______ (CAN cause vagal response)
- ______ laryngoscopy
- Ophthalmic surgery, optic pressure, or traction of extraocular muscles
Bowel insufflation Peritoneum Lumbar spine Neck intubation or extubation Direct
Ophthalmic surgery optic pressure or traction of extraocular muscles can cause a vagal response. It involves the ______ reflex arc - _______ trigeminal and _____ vagus.
The oculocardiac reflex produces ______ in 90% of patients.
______ increases the OC reflex.
Antimuscarinics such as atropine do NOT ______ the reflex.
trigeminovagal
afferent trigeminal
effect vagus
bradycardia
hypercarbia
prevent
**best thing to do is to tell the surgeon to stop pulling on the eye muscles
The second most common intraoperative complication is _______.
hypotension
Causes of hypotension can include:
1) BP measurement _____
2) Lack of or decreased magnitude of _____ _____
3) Decreased _______
4) Decreased _____
5) Decreased ____ _____
6) ______ response to surgical stimulation
7) _______
1 - error 2 - surgical stimulation (decreased SNS activity/catecholamines - may need gtt until surgery starts) 3 - contractility 4 - SVR 5 - venous return 6 - vasovagal response 7 - dysrhythmias
BP measurement error resulting in a hypotensive reading can be caused by:
- transducer height or calibration error
- ______ invasive system
- limb cuff _____, _____, or improperly fitting
overdamped
oversize, loose
Decreased contractility can result in hypotension and can be caused by:
1) _____ agents
2) _____
3) cardiac meds such as ____ _____
4) cardiac dysfunction such as _____, _____ imbalance, acidosis or alkalosis, or ____thermia.
1 - volatile
2 - opioids
3 - beta blockers
4 - ischemia, electrolyte, hypothermia
Decreased SVR can result in hypotension and can be caused by:
- _____ anesthetics
- ______
- ________
- various other drugs administered during anesthesia
- ______ outflow blockade such as w/ ____ ______
- increased ______ tone
- ______
- vasoactive metabolites (____ _____ and _____ _____)
- allergic reactions d/t increased ______ release
- _______
- volatiles
- opioids
- benzos (all 3 work synergistically)
- sympathetic blockade (neuraxial)
- parasympathetic tone
- sepsis
- tourniquet release (metabolite release works as massive vasodilators) & anaerobic respiration
- histamine
- hypoxemia
Decreased venous return can result in hypotension and can be caused by:
1) _______ d/t fasting, bowel prep, vomiting/diarrhea, acute hemorrhage, diuretic therapy or HTN-induced diuresis
2) Vena cava ______ or _____ use
3) Increased _____ _____/______
4) Increased ______ _____ d/t PEEP, excessive Vt
5) _______ and ____ ______
6) Dramatic ____ _____
*Decreased venous return leads to decreased stroke volume and ultimately decreased CO.
1 - hypovolemia 2 - compression, retractor 3 - venous capacitance, pooling of blood 4 - intrathoracic pressure 5 - pneumothorax and cardiac tamponade 6 - position changes
The vasovagal response to surgical stimulation results in decreased ____, ____, and hypotension.
SVR, HR
Dysrhythmias can cause ______ and include tachyarrhythmias, AF, AFlutter (reduced ventricular filling & no atrial kick w/ 30% less SV), and bradyarrhythmias.
hypotension
Treatment for Perioperative Hypotension:
1) FIRST _____ _____ - treat the patient not the monitor.
2) Ensure measurement is not erroneous.
- Check transducer calibration and assess damping
- Confirm appropriate cuff size and fitting
- Palpate and assess peripheral pulses
- Assess any acute pulse oximetry waveform changes
- Assess any acute capnography waveform changes such as _____ ETCO2.
- Confirm adequate oxygenation and ventilation
3) Determine and treat underlying cause.
4) ______ expansion, restore _____ status w/ _____.
5) ______ anesthetic depth or _____ opioid use if able.
6) ______ or place in _______
7) Consider ______ in patients prone to hypotension.
8) Vasopressors including ______ and/or ______
9) Treat dysrhythmias w/ _____ or antidysrhythmics
10) Reduce _____ or ______ (may require increased rate)
11) Chest tube placement or pericardiocentesis
1 - retake BP! 2 - decreased ETCO2 - if reading is low and ETCO2 also drops, the BP reading is probably accurate 4 - volume, fluid w/ bolus 5 - lighten, reduce opioids 6 - reposition, trendelenburg 7 - Ketamine 8 - sympathomimetics, inotropes 9 - vagolytics 10 - Vt or PEEP
If you have to lighten the anesthetic depth or reduce opioids to treat hypotension, it may be necessary to apply an _______ monitor. You will also need to increase ______ to ensure motionless.
awareness
paralysis
** Granny in for a trauma, can’t support BP, turn down anesthetic to 0.5 MAC - risk pt. being aware.
Hypotensive and worried about anesthetic depth - give ketamine.
Nitrous can also cause brief SNS output.
Ketamine can be used in patients prone to hypotension b/c it increases ____ outflow. It causes increased ___ and _____ (SBP increases 20-40 mmHg in <5 minutes).
This can be beneficial in trauma patients but have the potential to unmask the mild ______ ______ effects in patients with depleted ________ stores. Also not good for elderly debilitated patients with poor compensatory CV ability.
SNS
HR and vasoconstriction
myocardial depressant
catecholamine
Postoperative HTN incidence is 6-20% and commonly d/t _____.
- 30-80% reported following CABG
- Risk factors for developing post-op HTN include:
1) increased ____, _____, & _____ disease
2) inadequate _____
3) Preop h/o _____
4) Preop h/o _____
pain
increased age, smoking, renal disease
ventilation
hypertension
angina
Perioperative HTN can complicate surgical outcomes:
1) ______
2) _____ suture lines
3) ______
4) myocardial _____
5) _______
1 - hemorrhage 2 - ruptured 3 - CVA 4 - ischemia 5 - dysrhythmias
RICH D
Causes of perioperative HTN include:
1) Increased ______ release
2) H/o ______
3) Increased _____ _____
4) Systemic vasoconstrictor absorption of _____ or ______
5) Rebound HTN resulting from d/c of ___ ______
6) Distended _____
7) Aortic ____ _____
8) _____ _____ dye
9) Exaggerated drug effects d/t ______ use.
1 - catecholamine release 2 - HTN (pts. w/ h/o HTN also have increased risk for intraop hypotension - take ALL BP meds before except for lisinopril) 3 - intracranial pressure 4 - epi, phenylephrine 5 - BP meds 6 - bladder 7 - cross clamping 8 - indigo carmine 9 - MAOI use
Perioperative HTN Treatment:
1) Increase _____ – most common
2) IV ________
3) Preoperative _____
4) Evacuate urine from distended bladder
5) Beta blockers (3)
6) Vasodilators (3)
7) CCBs
8) ACEIs, angiotensin receptor blocker, alpha 1 blocker, alpha 2 agonist such as _______
1 - anesthetic depth 2 - opioid narcotics (fentanyl – but do not give right at end of case) 3 - anxiolysis 5 - labetalol, esomolol, metoprolol 6 - nipride, NTG (FAST), hydralazine 8 - alpha 2 agonist = Precedex
Hypoxia is reduced O2 tension (PaO2) at the _____ level.
There are 5 categories:
1) hypoxemia
2) anemic
3) circulatory
4) affinity
5) histiocystic
tissue
An oxyhemoglobin shift to the right means _____ unloading of O2 by Hgb to tissues. A shift left means ______ unloading of O2 to tissues for any given PO2.
right = easier left = more difficult
**easy to be right, hard to take a left
________ hypoxia: decreased blood oxygen tension & decreased PaO2 - can be caused by low FiO2, hypoventilation, V/Q mismatch (shunt), or diffusion limitations.
hypoxemia
______ hypoxia results from not enough Hgb.
- low hemoglobin concentration
- Hgb w/ decreased _____ for oxygen (abnormal Hgb)
Treatment: _______
ASA task force recommendations:
Rarely if Hgb > _____
Nearly always if Hgb < ____
anemic
affinity
transfusion of PRBCs
rarely if >10 gm/dL
always if <6 gm/dL
Read Clinical Predictors of Increased Perioperative CV Risk on slide 34.
Will always perform preop EKG for those in the MAJOR category, possibly for those in the intermediate category, and rarely for those in the minor category.
Review Factors That Contribute to Myocardial Ischemia on Slide 35.
Read Intraoperative Events That Influence the Balance Between Myocardial Oxygen Delivery & Oxygen Requirements on slide 36.
Review Intraoperative Monitors for Ischemia on slide 40.
Review Management of Myocardial Ischemia on slide 54.
Review Causes of Acute Bronchospasm in Anesthetized Patients on slide 58.
Review Causes of Non-bronchospastic Wheezing in Anesthetized Patients on slide 63.
