Complications of of of of Anesthesia.pptx

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1. Complications of Anesthesia By Dr / Ahmed Almoatasem Ammar Lecturer of Anesthesia and surgical ICU, Alexandria University, Egypt.

2. OBJECTIVES Epidemiology and risk factors OF Anesthetic complications Classification of anesthetic complications Management of these complications. Universal management steps. Specific management for each complications. Take home messages.

3. EPIDEMIOLOGY Incidence of anesthetic complications is 3-16%. The most frequent complications are; hypotension, arrythmias and adverse drug effects

4. Risk factors of Anesthetic complications SURGERY RELATED { prolonged, emergency, cpb , … etc } PATIENT RELATED { elder, morbid obese, advanced ASA physical status,…. etc } ANESTHETIC RELATED { unexperienced staff, lack of monitoring, obestetric anesthesia,…. etc }

5. classifications

6. GA related complications

7. Regional anesthesia related complications

8. Universal management steps Do not panic. Call for help and notify surgeon. In life threatening complications, start A, B, C approach. Set differential diagnosis and search for the cause. Don not forget anesthetic triade { loss of consciousness, muscle relaxation, and analgesia}.

9. Cardiovascular complications 1- hypotension The most common complication MAP less than 60 mmHg May be due to: Anesthetic agents Hypovolemia Anaphylaxis Managed by: Treatment of cause Fluids Vasopressors and/or inotropes.

10. Cardiovascular complications 2- Arrythmias May be in form of brady {HR < 60} or tachy {HR˃ 90} arrythmias The cause is usually unbalanced vagal { brady } or sympathetic stimulation { tachy }. Managed by: Treatment of cause Atropine for bradyarrythmias . Manage tachyarrythmias according to ACLS

11. Respiratory complications 1- Hypoxia Defined as decreased oxygen tension at tissue levels Four identified types: Hypoxic hypoxia Anemic hypoxia Stagnant hypoxia Histotoxic hypoxia

12. Hypoxia Usually hypoxic hypoxia is the most common one that we face and may be due to: Inhaled hypoxic mixture V/Q mismatch Shunt Hypoventilation Clinically , it is associated with sympathetic overstimulation followed myocardial depression { bradycardia , hypotension, cardiac arrest}

13. Hypoxia Management should be prompt as any delay may cause long term undesirable consequences. Exclude delivary of hypoxic mixture{ O2 analyser } Confirm tube position{ ETCO2} Test integrity of system and compliance of lung by bag mask ventilation Exclude pneumothorax Use PEEP

14. Respiratory complications 2- Hypercapnia May be due to: Ventilatory failure Rebreathing{ exhausted soda lime, malfunctioning unidirectional valve Increased CO2 production{ malignant hyperthermia, thyrotoxic crises}

15. Hypercapnia ETCO2 is essential monitor for ventilation Characterized clinically by sympathetic overstimulation and oozing from surgical field Treatment: Cause identification and treatment Increase tidal volume and/or respiratory rate

16. CNS complications 1- awareness under anesthesia There are two types of memory Implicit{subconscious processing of information} Explicit{ consciously recalling of information} Awareness may occur with or without pain Causes: Light anaesthesia Machine or circuit dysfunction Unanticipated difficult airway

17. Awareness Risk factors: TIVA Emergency, CPB, obstetric surgeries Use of muscle relaxation Management is to prevent incidence of awareness by: Checklist of anesthesia machine Use monitors for level of consciousness Use amnesic agents Pay attention for difficult intubation

18. Temperature disturbances 1- hypothermia Defined as core body temperature < 36° C Causes: Decreased ambient temperature Anesthesia related{ cold fluids, no humidifier} Surgery related{ cold fluids, prolonged surgery} Patient related {critically ill, hypothyroid, old}

19. Hypothermia Side effects: Delayed recovery Arrythmias Increased bleeding tendency Impaired peripheral perfusion Shivering Prophylaxis : Increase ambient temperature Use gas humidifiers Warm fluids Warming blankets

20. Adverse drug effects Includes: Allergic reactions Idiosyncratic reactions Drug interactions Others; incorrect route, dose, choice

21. a) Allergic reactions 1- Anaphylaxis Type I hypersensitivity reaction { IgE mediated} Clinically: cardiac; hypotension, tachycardia pulmonary; bronchospasm, laryngeal edema Dermatological; urticaria , edema, pruritis management: 4A, 3B, 3C

22. ANAPHYLAXIS 4A; AGENT STOP AIRWAY CONTROL{ 100% O2+ intubation} Adrenaline {0.01-0.5 mg iv} then infusion Antihistamines 3B; Blood volume restoration Bicarbonate Bronchodilators 3C; Corticosteroids CPR CEREBRAL AND RENAL PROTECTION

23. ALLERGIC REACTIONS 2- LATEX ALLERGY Predisposing factors; Chronic exposure to latex + atopy Patients with spina bifida, and spinal cord injury Foods that cross react to latex{ kiwi, banana,..} Prophylaxis; Identify patients at risk Use latex free materials Treatment ….. As anaphylaxis

24. Idiosyncratic reactions Defined as : abnormal and harmful drug effect which is precipitated by usual drug doses. Examples: Succinyl choline apnea Malignant hyperthermia

25. Malignant Hyperthermia Acute hypermetabolic state affecting mainly the skeletal muscles following exposure to triggering agents in susceptible patient. Pathophysiology:

26. Malignant Hyperthermia Clinically ; The early sign …… uncontrollable increase in ETCO2 Fever Tachycardia, arrythmia , hypertension Acidosis, hyperkalemia, low mixed venous oxygen Muscle rigidity{ masseter spasm}

27. Malignant Hyperthermia Management ; … HOSPITAL H ELP O XYGEN S TOP INHALATIONAL AGENT AND SURGERY P ROPOFOL INFUSION I NTRAVENOUS DANTROLENE T EMPERATURE REGULATION A DDRESS METABOLIC DERANGEMENT L IAISE WITH ICU

28. Delayed recovery Inability to regain consciousness beyond the expected duration of used anesthetic technique causes:

29. Delayed recovery Never forget to avoid awareness

30. Postoperative nausea and vomiting(PONV) RISK FACTORS:

31. PONV ADVERSE EFFECTS: Patient distress Delayed mobilization Delayed oral intake Long hospital stay Wound disruption Dehydration and electrolyte disturbances

32. PONV Management : Identify patient at high risk Prevention rather than treatment Use propofol and TIVA multimodal analgesia to decrease opioid Use dexamethasone, 5HT3 blockers, prokinetics

33. Postoperative blindness Risk factors: External compression from wrong positioning Prlonged hypotension Air embolism Mechanisms: Ischemic optic neuritis Central or branched retinal artery occlusion Acute angle glaucoma

34. Complications due to improper positioning Hemodynamic instability Decrease FRC and postoperative atelectasis and hypoxia Peripheral nerve damage Postoperative blindness Venous air embolism

35. Neuraxial anesthesia complications 1- Hypotension Due to sympathetic block Prevented by good pre load, and control level of block. 2- Bradycardia Due to high sympathetic blockade(t1-t4) Treatment by atropine 3- nausea and vomiting Due to: Hypotension Anxiety Surgical traction Hypoxemia Treated by treatment of cause and use of antiemetics

36. Neuraxial anesthesia complications 4- high or total spinal Risk factors: Pregnant females Obese Old Characterized by: Hypotension, bradycardia , arrest Dyspnea, apnea Agitation then coma Treatment: A, B, C approach Atropine , vasopressors

37. Neuraxial anesthesia complications 5- Postdural puncture headache (PDPH) Mechanism: CSF LEAKAGE….. Decreased ICP……..traction on dura Clinical picture: Throbbing pain started within 12-72 h of procedure Fronto -occipital Increased by strain and sitting Relieved by lying down Risk factors: Large needle size and multiple trials Young, female, pregnant Treatment: Conservative( fluid, rest, caffeine intake) Epidural blood patch

38. Neuraxial anesthesia complications 6- Urine retention: LA blocks S2-S4 fibres that interfer with voiding The urine retention increased with addition of opioid to LA 7- Epidural hematoma Need rapid diagnosis and treatment Onset more sudden compared to abscess Imaging and neurological consultation 8- Epidural abscess Characterized by four classical stages Back pain Radicular pain Motor or sensory deficit Paraplegia Imaging and neurological consultation

39. LA toxicity Clinical features: Depends on plasma level concentrations; Light headness , tinnitus, circumoral numbness Visual disturbances, agitation Tonic- clonic convulsions and respiratory arrest Cardiovascular collapse and malignant arrythmias Preventive measures: Avoid exceeding toxic dose Frequent aspiration before injections Titrate the LA and keep in contact with the patient

40. LA toxicity Management: Stop LA injection and call for help ACLS approach Control convulsions by benzodiazepine Consider use of intralipid 20% Continue CPR (MAY TAKE LONG TIME)

41. Peripheral nerve injury following regional anesthesia Risk factors: Neural ischemia ( prolonged hypotension, improper positioning, intraneural injection). Patient with pre existing neurological deficits. Infectious complications. Onset: may be early onset or delayed onset Diagnosis: neurophysiological studies Prevention: Complete aseptic technique Short blunt insulated needles Choose new modalities of nerve visualization Avoid injection against high resistance Gentle needle advancement

42. TAKE HOME MESSAGES MOST OF ANESTHETIC COMPLICATIONS ARE AVOIDABLE DO NOT PANIC, CALL FOR HELP, AND STATE DIFFERENTIAL DIAGNOSIS . USE OF MONITORING IS IMPORTANT, BUT PRESENCE OF VIGILANT ANESTHESIOLOGIST IS MUCH MORE IMPORTANT.