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.
