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APA I > Complications > Flashcards

Complications Flashcards

1
Q

What is considered perioperative mortality?

A

Death that occurs within 48 hrs of surgery

Current rate of anesthesia related death is 1 per 100,000 anesthetics

*prior to 80s death rate significantly higher

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2
Q

Goals of the ASA closed claims project

A
  • identify major areas of loss in anesthesia
  • identity patterns of injury
  • identity strategies for prevention
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3
Q

Difference between preventable vs unpreventable anesthetic mishaps

A

Unpreventable

  • sudden death syndrome
  • fatal idiosyncratic drug reactions
  • poor outcomes despite proper mgmt

Preventable

  • human error
  • equipment malfunction
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4
Q

Top 3 ASA closed claims in the 1990s

A

Death: 22%
Nerve injury: 18%
Brain damage: 9%

*% of law suits

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5
Q

What are emerging claims areas?

A

Regional anesthesia: 16%
Chronic pain mgmt: 18%
Acute pain: 9%

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6
Q

What are some human errors that lead to preventable anesthetic accidents?

A
  • unrecognized breathing circuit disconnect
  • medication errors
  • airway mgmt (not preparing)
  • anesthesia machine misuse (too big volumes, too little anesthetic)
  • fluid mgmt
  • IV line disconnection
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7
Q

What are some example of equipment malfunctions that lead to preventable anesthetic accidents?

A
  • breathing circuit
  • monitoring device
  • ventilator
  • anesthesia machine
  • laryngoscope
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8
Q

Some factors associated with human error and equipment misuse

A
  • inadequate preparation
  • inadequate experience or training
  • environmental limitations (ie inability to visualize surgical field, poor communication with surgeon)
  • physical and emotional factors (fatigue)
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9
Q

Improvements that have helped prevent anesthetic complications

A
  • improved pt monitoring
  • improved anesthetic techniques
  • improved education of anesthesia providers
  • comprehensive protocols
  • active risk mgmt programs

*focus on pt safety is the most important factor that has improved safety

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10
Q

Examples of complications of anesthesia

A
  • airway injury (sore throat)
  • peripheral nerve injury
  • awareness
  • eye injury
  • cardiopulmonary arrest during spinal anesthesia
  • hearing loss
  • allergic reactions
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11
Q

Examples of types of airway injury

A 
Sore throat
Dysphasia
Dental injury
TMJ (risk of locked jaw)
Vocal cord paralysis
Vocal cord granuloma (typically with long intubation)
Arytenoid dislocation
Esophageal perforation
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12
Q

Complications related to positioning

A

Peripheral nerve injury

Hypotension

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13
Q

Incidence of anesthesia awareness

A

0.2-0.4% in most studies

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14
Q

When awareness does occur, pt may exhibit what symptoms

A 
Mild anxiety
Sleep disturbance
Nightmares
Post-traumatic stress disorder
Social difficulties
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15
Q

Types of surgeries most associated with awareness

A

Major traumas: 43%
Obstetrics: 1.5%
Cardiac surgery: 0.4%

*in many instances awareness is related to the depth of anesthesia that can be tolerated

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16
Q

Ways to prevent intraoperative recall

A
  • use inhaled agents at a level consistent with amnesia
    • MAC 0.6 when used with opioids and N2O
    • MAC 0.8-1.0 when used alone
      • add benzo or IV scopolamine
  • BIS monitor if available

*IV scopolamine has retrograde amnesia affects

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17
Q

How to treat pt that has had intraoperative awareness

A
  • obtain detailed account of the pts experience
  • by sympathetic
  • answer pt questions
  • refer pt for psychological counseling if appropriate
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18
Q

Types of eye injury

A
  • corneal abrasion: most common and transient eye injury
  • Blindess
    • pt movement during ophthalmic surgery
    • during general or MAC anesthesia
  • ischemic optic neuropathy (ION)
    • most common cause of posts-op loss of vision
    • optical nerve infarction due to decrease O2 delivery via one or more arteriole supplying the optic nerve
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19
Q

Ischemic Optic Neuropathy is commonly reported after these surgeries

A

Cardiopulmonary bypass
Radical neck dissection
Abdominal and hip procedures
Prone spinal surgeries

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20
Q

Pt factors that contribute to ION

A

HTN
DM
CAD
Smoking

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21
Q

Surgical and anesthetic factors that contribute to ION

A
  • Intra-op deliberate hypotension
  • anemia
  • prolonged surgical time in position that compromises venous outflow
    • prone
    • head down
    • compressed ABD
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22
Q

Symptoms of ION

A
  • range from decreased visual acuity to complete blindness

- onset immediately and through 12th post-op day

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23
Q

How to prevent ION

A
  • enhance venous outflow by positioning the pt head up
  • minimize ABD constriction
  • monitor BP carefully with a-line
  • lipid degree and duration of deliberate hypotension
  • avoid anemia in pts at risk for ION
  • consider staging long surgical procedures in pts at risk for ION
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24
Q

Some fun facts about cardiopulmonary arrest during spinal anesthesia based on closed claims case analysis of 14 pts

A

-average age: 36
-ASA: 1-2
-high level of block prior to arrest (T4 level)
-

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25
Q

Signs and symptoms prior to arrest during spinal anesthesia

A
  • gradual decline in HR and BP (20% below baseline values)
  • bradycardia
  • hypotension
  • cyanosis
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26
Q

Treatment for arrest after spinal anesthesia

A
  • ventilatory support
  • ephedrine
  • atropine
  • epinephrine
    • do no hesitate to use epi in small doses (5-10mg) for bradycardia that is unresponsive to atropine and ephedrine. Use larger doses if necessary
  • CPR (average duration 11 min)
  • once arrest occurs begin ACLS protocols and doses
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27
Q

Cause of hearing loss after spinal anesthesia and treatment

A
  • due to CSF leak

- Rx with blood patch

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28
Q

Causes of hearing loss after GA

A
  • less predictable
  • surgical manipulation
  • middle ear barotrauama
  • vascular injury
  • ototoxicity of drugs
  • s/p cardiopulmonary bypass
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29
Q

Common documentation errors to avoid

A
  • completing entries for events before they occur
  • incomplete descriptions of procedures or mgnt
  • inaccurate of conflicting times between records
  • loss of critical pt data
  • signing documents without reading them
  • failure to document meetings with the pt or family
  • failure to obtain supporting documentation from others
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30
Q

These are exaggerated immunologic responses to antigenic stimulation in a previously sensitized individual

A

Allergic reactions

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31
Q

The allergen or antigen is typically what type of molecule that is covalently bound to a carrier protein

A

Protein, polypeptide, or smaller molecule

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32
Q

Ways in which a pt is exposed to allergens

A

Nose, lungs, eyes, skin, GI tract, IV injection

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33
Q

T/F: anaphylactic reaction can happen after the first exposure to a substance

A

False

First response triggers production of IgE antibodies. After subsequent exposure to same antigen, mast cells release histamine and others mediators

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34
Q

What are the 4 types of hypersensitivity reactions?

A

Type I: immediate
Type II: Cytotoxic
Type III: immune complex
Type IV: delayed, cell-mediated

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35
Q

What is Type I allergic reaction?

A

Immediate

  • major type of reaction
  • atropy
  • urticaria - angioedema
  • anaphylaxis
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36
Q

What is type II allergic reaction?

A

Cytotoxic

  • hemolytic transfusion reactions
  • autoimmune hemolytic anemia
  • heparin-induced thrombocytopenia
37
Q

What is type III allergic reaction

A

Immune complex

Allergies????

38
Q

What is Type IV allergic reaction

A

Delayed, cell-mediated

-contact dermatitis

39
Q

Anaphylaxis characteristically presents as:

A

Acute respiratory distress,

Circulatory shock, or both

40
Q

Incidence of anaphylactic reactions during anesthesia

A

1:5000 - 1: 25:000 anesthetics

41
Q

Mediators of anaphylaxis

A

Histamine
Leukotrienes
BK-A
Platelet activating factor

42
Q

Cardiovascular manifestations of anaphylaxis

A

Hypotension, tachycardia, arrhythmias

43
Q

Pulmonary manifestations of anaphylaxis

A

Bronchospasm, cough, dyspnea, pulmonary edema, laryngeal edema, hypoxia

44
Q

Dermatologic manifestations of anaphylaxis

A

Urticaria, facial edema, pruritus

45
Q

Anaphylactoid reactions

A

Resembles anaphylaxis but does not depend on IgE antibody interaction with antigen.

46
Q

How do you tell the difference between anaphylaxis and anaphylactoid reactions?

A

You can’t. They are clinically indistinguishable and equally life threatening

47
Q

Risk factors associated with hypersensitivity to anesthetics

A

Female gender
Atopic history
Preexisting allergies
Previous anesthetic exposure

48
Q

Treatment of anaphylactic and anaphylactoid reactions

A

-discontinue drug administration
-100% O2
-epi 0;01-0.5mg IV or IM
-consider intubation or trach
-IVF 1-2L LR
-Benadryl 50-75mg IV
-ranitidine 150mg IV
Hydrocortisone up to 200mg IV or methylprednisolone 1-2mg/kg

49
Q

Anaphylactoid reaction

A

Resembles anaphylaxis but does not depend on IgE antibody interaction with antigen

50
Q

This anesthetic drug is the most common cause of anaphylaxis during anesthesia

A

Muscle relaxants

Rocuronium, succinylcholine, atracurium

Account for 70% of reactions perioperativiely

51
Q

Mechanism of anaphylactic reactions to muscle relaxants

A

IgE antibodies directed against tertiary or quarter army ion epitomes

52
Q

How can a pt have an anaphylactic reaction to muscle relaxant during anesthesia if no previous exposure to muscle relaxants?

A

Bc OTC things (drugs, cosmetics, food products may contain some items) in muscle relaxants

53
Q

Hypnotic agents that cause allergic reactions

A

Pentothal: 1 in 30.000
Propofol: 1 in 60,000

True allergies to etomidate, ketamine, and bentos extremely rare

54
Q

Are allergic reactions to opioids common

A

Rare

Non-immune histamine release more common (morphine)

55
Q

Reactions to local anesthetics

A
  • rare allergic reactions
  • vasovagal reactions
  • toxic reactions
  • side effects of epi
56
Q

Reactions to Ester type local anesthetics

A
  • IgE mediated reaction
  • share common antigenicity with PABA
  • cross reactivity should be expected
57
Q

Allergic reactions to Amide local anesthetics

A
  • true anaphylaxis extremely rare

- preservative paraben or methylparaben is causative

58
Q

Is there cross sensitivity between Ester and Amide local anesthetics?

A

No

59
Q

Allergic reactions to volatile inhalation agents?

A

No reports of anaphylaxis

60
Q

Allergic reactions to antibiotics

A

*many true allergies are due to antibiotics

61
Q

Running what antibiotic too fast can cause “red Man’s syndrome”?

A

Vancomycin

62
Q

Name B-lactam antibiotics

A

PCN

Cephalosporin

63
Q

This is the second most common cause of anaphylaxis during anesthesia

A

Latex

64
Q

What type of sensitivity reaction is a latex allergy?.

A

Type IV sensitivity reaction to chemicals from manufacturing process

65
Q

What foods can cross react with a latex allergy?

A 
Mango
Kiwi
Chestnut
Avocado
Passion fruit
Banana
66
Q

What are some ways to avoid potential latex exposure during surgery?

A
  • remove rubber stoppers from drug vials prior to use
  • injections made through plastic stop cocks
  • remove all latex from the room
  • use latex free breathing bag
67
Q

What pharmacologic prophylaxis can be used for latex allergy?

A

Pre-op administration of H1 and H2 histamine antagonists

Steroid coverage is controversial

68
Q

This is a rare myopathy characterized by an acute hypermetobolic state in muscle tissue after induction of general anesthesia

A

Malignant hyperthermia

69
Q

T/F: MH can occur without exposure to known triggers

A

True

70
Q

Signs of MH

A 
Hypermetabolism
-increases CO2
-increased O2 consumption
-metabolic acidosis
-cyanosis
-mottling
Increased sympathetic activity
-tachycardia
-initial hypertension
-arrhythmias
Muscle damage
-massester spasm
-generalized rigidity
-elevated serum creating kinase
-hyperkalemia
-hyperphophatemia
-myoglobinemia
-myoglobinuria
Hyperthermia
-fever
-sweating
71
Q

During MH, core temp care rise at as fast as what rate?

A

1 degree Celsius every 5 minutes

72
Q

During MH, there is an uncontrolled increase of what in the intracellular skeletal muscle

A

Calcium

73
Q

Dramatically enhanced and sustained _____ activity results in uncontrolled _______ in aerobic and anaerobic metabolism

A

ATP

Increase

74
Q

During MH there is an efflux of what electrolyte?

A

Potassium

75
Q

What receptor is abnormal in MH?

A

Abnormal Ryanodine Ryr1 receptors

  • abnormal secondary messengers and modulators of calcium release
  • abnormal sodium channel in skeletal muscle
76
Q

Drugs known to trigger MH

A
  • Halogenated general anesthetics

- non-depolarizing muscle relaxants (succinylcholine)

77
Q

Treatment protocol of MH

A
  • D/C anesthetic gas and succinylcholine
  • call for help
  • hyperventilate with 100% O2 at high flows
  • give sodium bicarbonate 1-2mEq/Kg IV
  • mix Dantrolene with sterile water and give 2.5mg/kn IV ASAP
  • institute cooling measures
  • give inotropes and antiarrhythmic agents PRN
  • give additional doses of Dantrolene as needed up to 10mg/kg
  • change anesthetic tubing and soda lime
  • monitor urine output, labs, BP, ETCO2, and clotting studies
  • treat severe hyperkalemia with dextrose, 25-50g IV and regular insulin 10-20u IV
  • consider invasive monitoring (a-line, CVP)
  • call hotline
78
Q

How does Dantrolene work?

A
  • hydantoin derivative
  • directly interferes with muscle contraction by binding Ryr1 receptor, calcium channel and inhibiting calcium ion release from sarcoplasmic reticulum
  • intracellular dissociation of excitation-contraction coupling
79
Q

Dantrolene can also be used for treatment of what?

A
  • Hyperthermia associated with thyroid storm
  • neurolept malignant syndrome
  • chronic spastic disorders
80
Q

What is the greatest complication of acute administration of Dantrolene?

A

Muscle weakness, respiratory insufficient energy and risk of aspiration

81
Q

How can you tell the difference between complete and partial laryngospasm?

A

Complete
-silent, paradoxical movement of the chest, tracheal tug, and not ventilation

Partial
-crowing noise, with mismatch between respiratory effort and ventilatory effectiveness

82
Q

What is the most common way to break laryngospasm?

A

CPAP

83
Q

What are some signs of bronchospasm?

A

Prolonged expiration
High inflation pressures
Expiratory wheezes
Decreased O2 saturation

84
Q

This is caused by spasmodic constriction of bronchial smooth muscle creates narrowing of airway passages and increases airway resistance

A

Bronchospasm

85
Q

What pts are at a higher risk of bronchospasm?

A

Asthmatics

86
Q

What 3 things need to be present for a fire?

A

Ignition source
Oxidizing agent
Fuel source

87
Q

What is the maximum acceptable trace concentration of anesthetic gases?

A
  • N2O: <25ppm
  • N2O and halogenated agent: < 25ppm adn 0.5 HA
  • Halogenated agent only: 2ppm
88
Q

How do you minimize radiation exposure in the OR?

A
  • use proper barriers

- maximize distance from source

89
Q

What is the maximum occupational whole body exposure annually for radiation?

A

5 rem/year

APA I (9 decks)

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