complication of general anesthesia


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1 : COMPLICATIONS OF GENERAL ANESTHESIA. MODERATOR:-DR BIPIN CHETIA. Associate professor.dept of anesthesiology AMCH Dibrugarh. Presentor:-Dr phanidhar gogoi. PGT Anesthesiology. AMCH Dibrugarh.
2 : INTRUDUCTION Complications related to the delivery of anesthesia care are inevitable. Even the most experienced, diligent and careful practitioner will have to manage complication despite acting well within the standard of care. These complication will range from minor (e.g.- infiltrated intravenous line ) to catastrophic (hypoxic brain injury or death). These complications will trigger institutional review, peer review and potential legal action. Litigation may occur despite the best effort to communicate with the patient family about the intraoperative events, management decisions and avoidance of catastrophic complications. It is essential to document the preoperative airway examination ,to record maneuvers such as preoxygenetion and cricoid pressure and details of laryngoscopy and write a complete post anesthesia note so that the action of anesthesiologist can be defended should litigation occur.
3 : ADVERSE ANESTHETIC OUTCOMES. INCIDENCE. Perioperative mortality is usually define as death within 48hr of surgery. It is clear that most perioperative fatalities are due to patient’s - Preoperative disease . - or the surgical procedure. Recent perioperative mortality rate is 1:20,000.
4 : CAUSES. Anesthetics mishaps can be categorized as:- 1.Unpreventable:-sudden death syndrome, fatal idiosyncratic drug reactions. 2.Preventable incidents:-human error, equipment malfunctions and misuse. Common human error:- Unrecognized breathing circuit disconnection. Mistaken drug administration. Airway mismanagement. Anesthesia machine misuse. Fluid mismanagement. Intravenous line disconnection.
5 : Breathing circuit. Monitoring device. Ventilator. Anesthesia machine. Laryngoscope. COMMON EQUIPMENT MALFUNCTIONS
6 : Factor associated with human error and equipment misuse. Factor Example Inadequate experience and Unfamilarity with anesthetic technique Training. Or equipment. Environmental limitations Inability to visualize surgical field, poor Communication with surgeon. Physical and emotional factor. Fatigue, personal problem. Inadequate preparation No machine checkup or preoperative evaluation; hast and carelessness.
7 : COMPLICATIONS. Cardiovascular - Myocardial ischemia and infarction. - Hypotension. - Hypertension. - Cardiac arrhythmias. - Stroke. - Air or gas embolism. - Thromboembolism. Neurological - Abnormal muscle movt ,convulsion. - Delayed recovery. - Acute dystonic reactions. - Awareness . Complication due to posture. Increase ICT Others PNV, Regurgitate. Aspiration, - Malignant hyp,thermia, - Masseter M spasm, - Stress response, - Hypothrmia - Hypoxia, Hypercarbia, Anaphylactic reaction, Electrical H, Fire explo, Ophthalmic, Pollution, Radiation, Infection. Respiratory - Due to ET. - Upper airway obst. - Lower airway obst. - Atelctasis and infection. - Sleep apnea. - Pulmonary barotraumas. Pneumothorax. inadequate ventilation. Decrease compliance. Increased co2 production.
8 : COMPLICTION DURING PREMEDICATION. 1.Over dose. 2.Low dose. 3.Forget to give . 4.Cross injections. 5.Reaction to drugs.
9 : DURING MASK VENTILATION. Difficult mask ventilation:- - Edentulous patient. - Beard - Senile patient - Obese patient. - Elderly. Obstruction of airway:- by the tongue and lip . Distension of stomach.
10 : DURING INTUBATION &LARYNGOSCOPY. . Malposition:- Esophageal intubation. Bronchial intubation. L cuff position. Airway trauma:- Dental damage. Lip and tongue. Mucosal injury. Sore throat. Retropharyngeal Laceration. Mandibular dislocation. Injury to laryngeal cartilage. L nerve injury. Vocal cord injury.
11 : CONTINUE…….. Can’t ventilate can’t intubate. Cricothyrotomy. Tracheostomy. PHYSIOLGICAL REFLEX:- Hypertension Tachycardia Hypoxia Hypercarbia. Increase ICP Increase IOP. Laryngospasm. Bronchospasm.
12 : Diagnosed by:- Spontaneous;- Excessive abdominal movement and paradoxical movement of chest wall. Noisy breathing especially inspiration (stridor) . Progressive hypercapnia and hypoxemia. During anesthesia:- During anesthesia reduced or absent movement of the reservoir bag. High pressure during IPPV. Absent or diminished capnograph trace. CAUSES AND MANAGEMENT:- Equipment fault. UPPER AIRWAY OBSTRUCTION
13 : OBSTRUCTION ABOVE THE GLOTTIS. Due to loss of muscular tone:- Tongue can fall back against posterior pharyngeal wall (swallowing tongue). Management:-By extending the head at atlanto –occipital joint (chin lift) and lifting the jaw up and forward (jaw thrust) - Or by placing the patient in the lateral position. OBSTRUCTION AT THE GLOTTIS. Laryngeal spasm_:-May result from stimulation of larynx by the E Tube , pharyngeal secretions, gastric aspiration and cold irritant gases. SURGICAL STIMULOUS:- Sometimes dilatation of cervix or anus may precipretate laryngospasm.
14 : Lower airway obstruction:-(brochospasm) Caused by:- Asthma. - Surgical stimulation, intubation under light anesthesia. - Drug reactions. - Aspiration. - Respiratory infection. - Pulmonary edema. -Tension pneumothorax.
15 : Defined as collapse or closer of alveoli resulting in reduce or absence gas exchange. -The impairment of mucocilliary transport in the lung after inhalation of cold dry gases. - Common in upper abdominal surgery. - Infection. - Obese pt and smoker with pre existing lung disease. Diagnosed by:- Rapid breathing. 30 - 60/min. -Tachycardia. - Hypoxaemia. - Restricted chest movement. - Radiographic shadows similar to those in bronchopneumonia. ATELECTASIS AND INFECTION.
16 : ATELECTASIS
17 : SLEEP APNOEA It is due to either airway obstruction or central respiratory depression. It is common in obese patient. Airway abnormalities. With large adenoid and tonsil in children. Management:- - Using regional technique , - Avoid opiates and long acting relaxants. - Extubate with the pt. wide awake and sitting position. - Oxygen and consider CPAP.
18 : Pulmonary barotraumas & Pneumothorax It is also known as Volutrauma, biotrauma,airtrauma. Alveolar capillary membrane disrupted and air enter to the interstitial space leading to subcute surgical emphysema, Closed pneumothorax, pneumomediastinum . Common in ARDS, emphysema , Asthma, COPD.
19 : OTHER RESPIRATORY OMPLICATION. Inadequate ventilation. Decrease compliance . Increase dead space. Increase carbon dioxide production. Carbon monoxide poisoning. Neuromuscular and skeletal problem.
20 : CARDIOVUSCULAR COMPLICATIONS Myocardial ischemia and infarction:- MI can be thought of as an Imbalance between myocardial oxygen demand and supply. Factor affecting oxygen supply are :- - Coronary perfusion pressure, - Oxygen content of arterial blood. - Coronary vascular resistance, -Tachycardia*. Factor affecting oxygen demand:- - Heart rate. - Ventricular pressure during systole. (after load ) - Contractility*. - Muscle mass. MI is higher in those with history of:-CCF, IHD, valvular disease, low ejection fraction, smoking, anemia and hypertension.
21 : HYPOTENSION. Causes:-Decrease peripheral resistance ,myocardial depression by the following anesthetic drug. Inducing agents:-Thiopental, thiamylal, methohexitol, propofol, Etomidate, droperidol. Opoids:-Remifentanyl, alfentanyl,sufentanyl fentanyl. Inhalation anesthetics:-Halothane, isoflurance, desflurance, sevoflurance. Neuromuscular blocking agent;- Atacurium, mivacurium, vacuronium, Antihypertensive drug:-Clonidin, beta-blocker, NTG, Dehydration , haemorrhage .
22 : HYPERTENSION During anesthesia: - Hypercarbia,I V fluid. - Light anesthesia. Post anesthesia:- Pain or full bladder. - Hypercapnia. - Confusion after anesthesia - Vasoconstriction after cardiopulmonary bypass. -Thyroid crisis. - Unsuspected phaeochromocytoma. - Antihypotensive - dopamine, ephedrine, - Anesthetics- ketamine ,
23 : CARDIAC ARRHYTHMIAS. Factors that increases SNS activity:- - Noxious stimuli:-pain, full bladder, tracheal intubation. - Adverse physiological conditions:-Hypercarbia, hypoxia, hypotension, hypoglycemia, electrolyte imbalance. - Medications:-Ephedrine epinephrine, isopreterenol,dopamine bhonchodilators,antihypertensives. Anesthetics- ketamine, isoflurane. Factors that decreases PNS activity:- parasympatholytics - atropine, glycopyrolate, Relaxant- pancuronium, Atracurium. CARDIC CAUSES -Ventricular fibrillation. - Supraventicular tachycardia. - Atrial fibrillation. Tachycardia:-
24 : BRADYCARDIA CAUSES: - Condition that increased PNS activity, - Condition that decrease SNS activity, - SSS, - Sinoatrial nodal ischemia, - Severe hypoxia. RISK:- - Hypotension, - Complete Heart block in bifascicular block, - Cardiac arrest,
25 : STROKE. - Incidence is 0.2%, - Usually after 2-10 days postoperatively. - Causes are sometimes uncertain. - Emboli when in atrial fibrillation. -Thrombosis due to hypotension. - Hypercoagulable state that occur after surgery. - Obstruction to a vertebral artery when the neck is rotated.
26 : AIR OR GAS EMBOLISM. 0.5-1 ml /kg air or gas is required. Cause:- Accidentally entering air into the circulation during intravenous techniques. Diagnosis:- An abrupt fall of the ET carbon dioxide. - A hissing sound in the wound. - A loud mill- wheel murmur. Treatment:- Prevent more air entry. - place the pt. on his left side so that bubble are kept away from the pulmonary artery. - Stop nitrous oxide immediately. - give 100% oxygen. - if a cvp catheter in place aspirate directly from right heart.
27 : THROMBOEMBOLISM. Risk factors:- Age over 40yrs. - A previous history of DVT. - Immobilization. - Oral contraceptives. - Cancer. - Certain op:- pelvic surgery, hip surgery and varicose veins. - Factor V Leiden mutation and similar condition. - Polycytheamia, Post partum.
28 : HYPOXIA Hypoventilation alone is sufficient to cause arterial hypoxia. Factors:- obstruction of airway. mismatch ventilation perfusion , CCF, Pulmonary edema, diffusion hypoxia, aspiration, pulmonary embolism, pneumothorax, shivering, Sepsis, transfusion related lung injury,ARDS, advanced age obesity and pregnancy.
29 : Presentation:-PE:-sudden onset of chest pain, fever, faintness dyspnoea, pleural pain, haemoptysis and collapse. DVT:-sign those of inflammation. Treatment:- Heparin 5000 unit iv loading dose. Prevention:- Early ambulation. - Prevent hypovolaemia. - Intermittent calf compression. - Elastic support stockings - Stop OC tab 4wk before major surgery to leg. - Low dose heparin and elastic support stockings. CONTINUE………….
30 : NEUROLOGICAL COMPLICATIONS. Abnormal muscle movement and convulsion:- Clonus:-occurs on light anesthesia disappearing on deep anesthesia. Myoclonus:- after volatile agent . Involuntary muscle movt. With etomidate. Convulsions with propofol.
31 : Caused by:- - Sedative drugs taken preop. - Drug overdose- phenothiazines, thiopental, volatile agent. - Disturbances resulting from condition like- hypercarbia, hypoxia, Electrolyte imbalance, hypotension, hypothermia. - Disturbances resulting from surgery-septicemia, embolism, - Operative trauma in neurosurgery. - Diseases like stroke, MI, myxoedema, hypoglycemia, adrenal deficiency ,uremia, liver failure . DELAYED RCOVERY FROM ANESTHESIA.
32 : AWARENESS DURING GENERAL ANESTHESIA Postoperative recall of events occurring during general anesthesia. Responsiveness during GA without post operative recall. Auditory awareness is the common one . Sometimes it results in disabling psychological sequelae for the pt. may leads to litigation. Causes:- Normal requirement- low delivery. Incidence 1%. - Low requirement- very low delivery. - High requirement – normal delivery. Detection: - Clinically. - EEG.with bispectral index. - Evoked potentials. - Other technique.
33 : LOW DELIVERY OF ANESTHETIC GAS DUE TO. Improperly set I-flow/time leading to incomplete below compression. Large circuit compliance >5ml/cm of H2O. Circuit loss ( leaks , sampling). Switching from manual to machine ventilator require two steps-mechanical/electrical.
34 : BISPECTRAL INDEX
35 : COPLICATIONS RESULTING FROM POSTURE. SUPINE POSITION:- Ulnar nerve injury at elbow. - Injury to calf muscle and may lead to DVT. - Backach in pt with lumber lordosis. CHANGE OF POSITION OF HEAD AND NECK. - Crebral hypoxia. TRENDELENBURG POSITION:-Obese pt reduce lung volume. Cyanosis may develop in some plethoric patient.increase CVP, fall in cerebral perfusion, cerebral edema, and retinal detachment
36 : LITHOTOMY POSITION. INTROPERATIVE COMPLICATIONS:- 1.Impeded respiratory muscle excursion 2.Lower limb compartment syndrome. 3.Reflex of stomach contents. POSTOPERATIVE COMPLICATIONS:-Peripheral nerve injury . 1. Sciatic nerve by exaggerated knee extension. Thigh flexion and external rotation. 2.Femoral nerve by adduction and rotation of thigh. 3.Common peroneal nerve by compression between the fibula and stirrup. 4.Posterior tibial nerve by stirrup compression. 5.Saphenous nerve by compression between the stirrup and medial maleolus. 6.Deep vein thrombosis. 7.Backache.
37 : LATERAL POSITION:- - Ventilation perfusion mismatch. - Nerve compression with arm. PRONE POSITION:- - Corneal abrasion. - Skeletal injury. OTHER NERVE PALSY :- - Facial nerve. - Radial nerve. - Ulnar nerve. - Brachial plexus. - Supraobital nerve. - Median nerve. - Pudendal nerve. - Femoral nerve. .
38 : ULNER NERVE COURSE AND RELATIVE INJURY SITE.
39 : COMMON PERONEAL NERVE INJURY IN LITHOTOMY POSITION
40 : SAPHENOUS NERVE INJURY SITE.
41 : OTHER COMPLICATIONS VOMITING-It is a active physiological reflex is the removal of subst. From upper GIT, as follows. - Mechanoreceptor in the gut, chemoreceptor (CTZ), central co ordination-through vomiting center. - Vomiting can occurs in very light anesthesia, especially when the Base of tongue or pharynx is stimulated by airway - There are some risk of aspiration of stomach content into bronchial tree and may lead to catastrophic complications. Post operative nausea and vomiting is very common 25-30% PONV influenced by following factor. Patient factor:-pt of motion sickness, women ,young age, smoker suffer less. Anesthetic factor:-barbiturates, opoids, inhalation agents, poor airway management and TIVA. Surgical factor:-prolong operation. Laparoscopic ,gynecological, abdominal, eye, throat, and neurosurgery.
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43 : OTHER COMPLICATIONS REGURGITATION:-Passive movement of gastric content into the pharynx under the force of gravity. Usually occurs in – - Anesthesia which itself reduced the barrier pressure. - Atropine, glycopyrolate. - Head down position. - Increased gastric pressure; pregnancy, full stomach , or bowel,gas from face mask ventilation ,laparoscopy. - Incompetence of cardiac sphincter ( hiatus hernia, presence of nasogastric tube)
44 : ASPIRATION Acid with a volume of greater then 25ml and a pH of 2.5 is sufficient To cause lung damage. Risk factor of aspiration:- Gastric oro- esophageal disease state. Incompetent lower esophageal sphincter . Emergency surgery. Drugs decreasing esophageal sphincter tone. (opoid , anticholinrgic benzodiazepines, thiapentone , volatile agents. Obesity. Diabetes, peptic ulcer disease, stress, pain , trauma.
45 : CONTINUE….. Prevention:- Use regional technique, awake intubation. Ensure empty stomach. Inhibit secretion of gastric acid . Rapid sequence induction. (sellick maneuver ) Extubate when pt fully awake.
46 : MALIGNANT HYPERTHERMIA. It is a genetically determined condition (autosomal Dominant.) in which trigger agents typically suxamm. Volatile agent cause an abnormal rise in intracellular Calcium. Incidence is 1 in 5000-50000 pt. Mortality rate is 5% with use of dantrolene. Presentation:- - Masseter muscle spasm following suxamn. - Tachycardia and arrhythmias. - Rise of ET CO2. - Tachypnoea. - Unexpected changes in blood pressure. - Fall in oxygen saturation and cyanosis. -Rise in temperature (late). Treatment:-dentrolene 1mg/kg iv repeated as necessary every 5 minute until pco2 come down, stop the operation, discontinue volatile agent.
47 : MOLECULAR DEFECT IN MALIGNANT HYPERTHERMIA
48 : HYPOTHERMIA. Hypothermia is defined as core temp of less than 36 degree centigrade. During General anesthesia :- - Heat production reduced. - Shivering mechanism is lost. - Aggravated conditions like hypothyroidism, hypopituitarism,adrenal failure,drug overdose, near drowning, immobility , coma and IV fluid. Heat may lost during anesthesia by:- - Radiation. - Convection. - Conduction. - Evaporation.
49 : CONTINUE……… Factor plays important rule in hypothermia:- Air conditioner in operation theatre. Cold iv fluid infusion. Cold irrigation fluid used by the surgeon. Halothane anesthesia.
50 : CONTINUE………… PHYSIOLGICAL EFFECTS:- - Metabolism. - Cardiovascular system - Respiratory system. - Central nervous system. - Acid base balance. - Electrolytes. - Neuromuscular block.
51 : SHIVERING its incidence after GA is about 65%. Male gender are suffer more. Propofol and thiopental are the causative agent. Mechanism:- Thermoregulatory. - spinal cord recover more quickly than brain from anesthesia. - kappa alkaloid, NMDA, 5 HT receptor
52 : EMERGENCE EXCITEMENT& REACTIONS It is a transient confusional state that is Associated with emergence from GA. Common in children of 2-4 years. Incidence is 30%. Usually occurs within first 10 minute. Agitation and delirium are main symptoms. Occurs after Isoflurane and halothane anesthesia. Preoperative midazolam is the treatment. E. AGITATION OR REACTION:- - Occurs due to ketamine.
53 : Adverse drug reactions during anesthesia. Non-allergic reactions:- - Relative overdose. - Intolerance of known side effects. - Rare but recognized side effects. - Wrong drug or diluents - Drug interactions. Anaphylactic and anaphylactoid reactions:- - Incidence is 1 in 10000 anesthetics. - Drug responsible commonly is neuromuscular blocking - agent. - Latex and antibiotics , - colloids, induction agents and opoids. Presentation:- Commonly cardiovascular collapse, sometimes combination with bronchospasm and skin change. - Hypotension that resistance to treatment should therefore arouse the suspicion of anaphylaxis.
54 : MANAGEMENT Immediate management:-withdraw all possible drugs and stop anesthesia if possible. - Administer oxygen and ensure airway patency. - Give iv adrenaline 50-100 micro gm as bolus dose. 1micro gm/kg. - Elevate the leg if possible. - IV fluid . - IPPV and bronchodilator, antihistamines , corticosteroids. Further treatment:-Collect 10 ml of blood sample in glass tube immediate after reaction. Then repeat after 1 hr and 24hr. write full clinical notes, And send a yellow card adverse drug reaction to the committee on safety of medicine. - Explain the situation to the party.
55 : METABOLIC COMPLICATIONS. Respiratory acidemia / alkalemia. Hyperglycemia. Hyperkalemia. Calcium and magnesium.
56 : ELECTRICAL HAZARD. ELECTROCUTION:- SURGICAL DIATHERMY:- UNIPOLAR. - BIPOLAR. FIRES AND EXPLOSIONS:-
57 : ELECTRICAL GROUNDING
58 : OPHTHALMIC COMPLICATION. CORNEAL ABRASIONS. ISCHAEMIC OPTIC NEUROPATHY. CENTRAL RETINAL ARTERY OCCLUSION. TURP SYNDROME.
59 : PERIOPERATIVE EYE COMPLICATION.
60 : HEARING LOSS. Causes:- Surgical manipulation. - Middle ear barotraumas. - Vascular injury. - Drugs :-Amino glycosides. - Loop diuretics. - anti-inflammatory agent. - Embolism.
61 : RENAL DYSFUNCTION. Factors:- - Hypotension. - sepsis. - older age. - Increase intra-abdominal pressure.
62 : CENTRAL ANTICHOLINERGIC SYNDROME. Symptom and signs:- Central:-agitation, amnesia, confusion, excitement, coma, Hallucination, delirium. emotional instability. Peripheral :-Dry mouth , dry skin, thirst, blurred vision, Photophobia, tachycardia, difficulty in micturition. CAUSES:- - Belladonna alkaloid. - Antihistamines. - Anesthetic agents. - Opoids. - Benzodiazepines. - Ketamine. Incidence is 9.4% following GA. Treatment:-Physostigmine o.o4mg/kg IV.
63 : HALOTHANE HEPATITIS. Incidence of mild form is high as 20% Incidence of fatal hepatitis is about 1:35000. Risk factors:- age, obesity, female sex, repeat exposure particularly within 28 days. Prevention- - Careful history. - should not use within 3 month of previous halothane anesthetic. - Unexplained jaundice or fever after a previous halothane anesthetic is absolute contraindication.
64 : CLINICAL FEATURE OF HALOTHANE HEPATITIS.
65 : HAZARDS TO HOSPITAL STUFF. Pollution:- It causes drowsiness. - Abortion. - Teratogenic. - Effect on performance. Maximum safety level:- 2 – 50ppm for volatile agent. 25 – 100ppm for nitrous oxide. Measure to reduce pollution:- Adequate ventilation of OT. Disposal of waste gases to outside air . Use low flow breathing circuit. Use TIVA or regional technique. Careful filling of vaporizers with anti-spilt devices.
66 : RADIATION. Gamma radiation:- During radio isotope imaging tech. X-ray:- particularly from image intensifiers in theatres. Prevention:- - Staying well back . - wear lead coat .
67 : INFECTIONS:- Hepatitis virus:- A and E. - B and C. Human immunodeficiency virus:- SARS. Tuberculosis. Prevention:- - Wear gloves during induction of anesthesia. - Wear plastic apron ,mask and eye protection. - Dispose all needles directly into a sharp box. - Cover of all cuts and abrasion . - Hospital or theatre suite should have infection control policy. - All medical stuff should be immunized against hepatitis.
68 : POST OPERATIVE COGNITIVE DYSFUNCTION. TYPE:-Delirium. characterized by change in level of consciousness and primarily disturbance in attention. - Short term cognitive disturbance. - Long term POCD. Characterized by impair ment of memory , learning difficulties, and reduced ability to concentrate. Risk factor:-Cardiac surgery .50%-70% after one week. (CPB). Non cardiac surgery :- 7% Age 60-70yrs, un educated , prolong duration of surgery, second operation.
69 : DOCUMENTATION ISSUE. Common documentation pitfalls to avoid:- Completing entries for events prior to when they occur. Incomplete descriptions of procedure or management. Inaccurate or conflicting times between deferent records. Lost critical patient data. Incomplete or poor thought-out notes following an adverse event. Signing inaccurate document or documents without reading them. Failure to document meeting with the patient / family. leaving open the possibility of conflicting recollection. Failure to obtain supporting document from others.
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72 : COMPARISON OF PAEDIATRIC AND ADULT DAMAGING EVENT
73 : ACCIDENT MAY OCCUR AT ANY TIME, AT ANY MOMENT, SO WE SHOULD ALLWAYS BE ALERT , KEEN OBSERVER AND GOOD KNOWLEDEABLE , WHILE GIVING ANESTHESIA OTHERWISE WE MAY BE A CAUSE OF COMPLICATIONS BECAUSE , WE ARE DEALING WITH POISONOUS MEDICINES……….
74 : THANK YOU

 

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