Critical Incidents during perioperative period

Dhawala Perera
Consultant Anaesthetist Military Hospital Colombo

Definition

An event which had the potential to lead to an undesirable outcome

if left to progress

Crisis Management Algorithm COVER ABCD A SWIFT CHECK C Circulation Capnograph Colour (Saturation)

A
B

Airway
Breathing

O Oxygen Supply Oxygen Analyser V Ventilation (Ventilated Pts) Vaporisers

C
D

Circulation
Drugs

E Endotracheal Tube Eliminate Machine

R Review Monitors Review Equipment

AA SS W W II FF TT CC HH EE CC KK

Awareness, Air embolism, Air in pleura, Anaphylaxis Surgical complications, Stimulation and Sepsis Wound and Water Intoxication Infarct, Insufflation Fat syndrome and Full bladder Trauma, Tourniquet Catheter, Chest drain Hyper / Hypoglycaemia, Hyperthermia Embolism Cement K+
4

Airway Problems Laryngeal spasm Bronchospasm Respiratory Problems Inadequate ventilation Pulmonary Aspiration Pulmonary oedema Pneumothorax Cardiovascular Problems Hypotension Hypertension Cardiac dysrrhythmias Venous air embolism
5

Drug related complications Anaphylaxis Intra-arterial injection of TPS Malignant hyperpyrexia Suxamethonium apnoea local anaesthetic toxicity

ANAPHYLAXIS

Anaphylaxis
Due to explosive release histamine & other mediators from mast cells Causing : bronchoconstriction Vasodilatation Increased capillary permeability : i.v. induction agents muscle relaxants antibiotics
9

Common with

Signs
Unexplained severe hypotension Tachycardia and cyanosis Rashes, flushing or pallor, facial oedema Bronchospasm and increased AWP Pharyngeal, Laryngeal, Pulmonary or generalized oedema Oozing in the operating site

10

Management
Stop of the drug immediately & change the infusion set Call for help Ventilate with 100 % O2 Intubate if unintubated as laryngeal oedema may occur Position the patient flat and elevate the lower limbs Give Adrenaline 10 g/kg ( 1000 g = 1mg = 1ml of 1:1000) if circulation is adequate 0.5-1.0 mg i.m. or in the tongue every 10 min. if circulation is not adequate 0.5-1.0 mg i.v. (1mg in 10ml) over 1min. titrated Intravenous volume expansion with crystalloids or colloids Hydrocortisone 100-500mg i.v.
11

Management contd.
H1 antagonists
Promethezine 50mg Chlopheniramine 10mg

H2 antagonists
Ranitidine 50mg slow i.v.

Management of bronchospasm Admit to HDU / ICU Identify the causative agent and inform the patient After 1 hr take 10ml of blood for serum tryptase
12

LARYNGOSPASM

LARYNGOSPASM
LOOK FOR
Inspiratory stridor High pitched sound during inspiration higher the pitch greater the obstruction silent with complete obstruction Paradoxical chest/abdominal movements (rocking boat effect) with supra-sternal and sub-costal recession during inspiration Increased inspiratory efforts/tracheal tug
Desaturation, bradycardia, central cyanosis
14

LARYNGOSPASM
PRECIPITATING FACTORS
Airway irritation and / or obstruction Blood/secretions in the airway Intolerance of oro-pharyngeal airway Regurgitation and aspiration Excessive stimulation / "light" anaesthesia surgical stimulation under light anaesthesia removal of ETT under light anaesthesia

15

Management
1. Cease stimulation / surgery 2. Optimize air entry Try gentle chin lift/jaw thrust with 100% Oxygen via pressurised system by closing expiratory valve 3. Request immediate assistance 4. If Partial SV If complete IPPV 5. Deepen anaesthesia with an IV agent if necessary 6. Find & Treat the cause Visualise and clear the pharynx/airway ? aspiration ? airway obstruction ? Light GA 7. Try mask CPAP/IPPV, if this is unsuccessful & Desaturate Propofol & Sux (0.25-0.3mg/kg) mask CPAP/IPPV with 100% O2 8. ? Intubate & Ventilate
16

FURTHER CARE
Careful postoperative review of the patient to:
confirm a clear airway exclude pulmonary aspiration

exclude post obstructive pulmonary oedema

exclude distension of stomach explain what happened to the patient.

17

18

BRONCHOSPASM

19

BRONCHOSPASM
Signs
Difficulty in ventilation
SV : wheezing with inadequate, laboured breathing little thoracic movement

IPPV :

high AWP with poor chest expansion

Rhonchi ( absent breath sounds if very severe) Desaturation & Cyanosis ETCO2 - rising sloping expiratory phase
20

BRONCHOSPASM
Use COVER ABC to exclude other causes
endobronchial and oesophageal intubation upper airway or tracheal obstruction bilateral pneumothorax

If Bronchospasm + Hypotension ? Pulmonary oedema

? Aspiration
? Anaphylaxis
21

Causes
Bronchial asthma or preoperative wheezing Release of Histamine triggered by drugs Morphine , Atracurium Intubation or surgical stimulation under inadequate anaesthesia Aspiration

22

Management
Cease stimulation / surgery Request immediate assistance Manual ventilation using slow gentle compressions with a long expiratory period to force 100% O2 into chest Remove triggering factors : Light anaesthesia Treat other causes : Anaphylaxis , Aspiration Deepen anaesthesia with Ketamine and Halothane or Isoflurane

23

Management contd.
Salbutamol 0.2mg slow i.v. or 3-20 g/min infusion or 5mg in 5ml nebulisation 250mg (5mg/kg) in 20ml slow i.v. followed by an infusion of 0.6mg/kg/min

aminophylline

Hydrocortisone
Other drugs Ipratropium Ketamine MgSO4 Adrenaline

200mg i.v.

0.25mg nebulization 2mg/kg 2g slow i.v. 1:10000

24

Monitor
ECG

for arrhythmias due to

hypercarbia, hypokalaemia, aminophylline Pulse BP SpO2 Clinical Auscultation ABG
25

26

High airway pressures

27

 Common problem Potentially life threatening

Requires systematic approach after exclusion of obvious and common causes

28

Presentation
Difficult to ventilate
Decreased compliance in reservoir bag, poor chest expansion, low minute volume

High airway pressure/ alarm Abnormal CO2 trace Hypoxia Circulatory collapse

29

Initial response
Check patient + review environment ABC Oximeter, capnograph Machine + circuit Surgical activity

Hand ventilate 100% oxygen

Exclude obvious causes Fighting ventilator - not paralysed Closed expiratory limb - ballooning of reservoir bag Excessive tidal volumes / ventilator settings Kinked tubing
30

Find the Cause & Treat Causes

Non patient Circuit/ gas supply Endotracheal Tube

Patient Decreased chest wall compliance Decreased lung compliance Increased airway resistance
31

Non Patient Problems

Gas supply O2 flush stuck on High pressure gas source

Excessive tidal volumes

32

Non Patient Problems Circuit Blockage, compression, kinking or incorrect connection of: Scavenging, reservoir bag, filter, Humidifier APL valve, PEEP valve Ventilator, angle piece, tube connector Breathing hoses + valves etc
33

Non Patient Problems Endotracheal Tube

Kinked Misplaced Oesophageal Endobronchial Obstructed Sputum, blood Cuff herniation Too small
34

Patient Problems Decreased chest wall compliance Chest wall rigidity MH or opioids Prone / position Obesity Kyphoscoliosis Abdominal pressure Distension Laparoscopy Gastroschisis repair Inadequate paralysis/ fighting ventilator
35

Patient Problems
Decreased lung compliance

Pneumothorax/ haemothorax
Atelectasis

Pulmonary oedema
Fibrosis

ARDS

36

Patient Problems Increased airway resistance

Bronchospasm
Foreign body Anaphylaxis/ anaphylactoid Aspiration Amniotic fluid embolism
37

38

PNEUMOTHORAX

Pneumothorax
Classification
Simple : the gas is not under tension
Open : continuing communication between source of the gas and pleural cavity

closed :

no communication

Tension Pneumothorax

the gas is under tension as gas flow in to the pleural cavity is unidirectional. Valve mechanism
40

High risk patients

Patient : After chest trauma or with lung disease. eg:emphysematous bullae

Surgery : Kidney, thorax, diaphragm, neck or laparoscopic cholecystectomy

Anaes : Brachial plexus block, CVP, Barotrauma due to high pressure

41

Signs
Difficulty in ventilation with high airway pressures Desaturation Unilateral breath sounds despite withdrawing ETT Deviation of trachea to opposite side (tension pneumothorax) Hypotension, Tachycardia, arrhythmias Distended neck veins, raised CVP

42

Management
Omit N2O 100% O2

Simple Pneumothorax due to damage to pleura

Ventilate with large Vt and expand the lung during the last sutures IC tube may be necessary

Simple Pneumothorax due to damage to lung

Insert IC tube

43

Mgt. : Tension Pneumothorax

If BP falls acutely Em. treatment is life saving Insert 14G cannula in 2nd IC Space in mid clavicular line to release the air to improve ventilation and BP until chest drain is inserted

Confirm and position of ICT with CXR Observe the bottle for bubbling and / or swinging
44

?? further deterioration
It may be due to:
Increased or continuing air leak Kinked/blocked/capped/clamped underwater seal drain Contra-lateral pneumothorax Misplaced pleural drain tip Trauma caused by drain insertion Misconnection of drain apparatus

45

Further Care
If the problem persists, Consider cardiac tamponade Consider peri-cardiocentesis and/or opening the chest. Arrange a chest X-ray and look for: -state of re-expansion of the lung -mediastinal shift -position of the tip of the drain

46

47

HYPERTENSION

48

Hypertension
Diagnosis
Increase of BP by >20% of the base line

Aetiology of Perioperative Hypertension

Sympathetic response Pre-existing hypertension Hypercarbia Drug effects Cerebral ischaemia Preload (Volume overload) Afterload
49

Sympathetic response

Light anaesthesia Painful stimulus Emergence Bladder distention Tourniquet

50

Pre-existing hypertension
Essential hypertension Renovascular Pre-eclampsia Autonomic dysreflexia Other endocrine-e.g. phaeo, hyperthyroid

51

Drug Effects
Vasopressors Withdrawal E.g. Clonidine Beta blockers. Methyldopa. Interactions-e.g.MAOIs with Pethidine Metaraminol Ephedrine Cocaine
52

Cerebral Ischaemia
Raised ICP Carotid/Vertebral occlusion, e.g. from neck positioning

53

High Afterload

Aortic cross clamp Pneumoperitoneum Hypothermia

54

Management
Deepen anaesthesia volatile agent, anxiolytics and analgesics Identify the cause & treat Identify and treat complications

55

Treatment for Hypertension

Vasodilators Alpha-blockers Beta blockers Especially if associated with tachycardia Beware contraindications

56

Dilators
Hydralazine: 5-10 mg I.V. repeat every 20 min GTN: 50mg in 50 mls Start @ 3ml/hr & titrate Na Nitroprusside Start @ 20 g/min & titrate Or 0.5-8.0 g/kg/min

57

Alpha-blockers

Clonidine: 150 g I.V. in divided doses

Phentolamine: 0.5-1mg increments

58

Beta Blockers
Atenolol 1-2mg i.v. up to 10 mg

Esmolol 5g in 500ml 5% dextrose & titrated to heart rate

Indicated with associated tachycardia, evidence of cardiac ischaemia, or known C.A.D Consider contraindications: Significant broncospasm Suspected phaeochromocytoma

59

Raised I.C.P.
Mannitol 0.5-2 g/kg I.V. Moderate hyperventilation Down to arterial pCO2 30mmHg Frusemide 5-10 mg I.V. The aim is to preserve cerebral perfusion pressure Followed by urgent neurosurgical intervention

60

61

HYPOTENSION

Hypotension
Critical BP requiring intervention depends on many factors 1. Capacity for Compensation Old Age, Diabetes, Arteriosclerosis Oxygen Availability Hb % , SpO2 Organ Dysfunction Heart, Kidney

2.
3.

Hypotension associated with Desaturation is an EMERGENCY

63

High Risk Patients Patient :

Inefficient compensatory mechanisms Hypertensive, Elderly, Cardiac compromised, Autonomic neuropathy, on antihypertensive therapy

Surgical :
Haemorrhage Fluid loss from GIT

Anaesthesia :
Drugs and interactions Techniques Positioning
64

Diagnosis
30% decrease of BP from baseline BP
< 80mmHg

65

Causes Preload reduced

Haemorrhage concealed Reduced VR compression of IVC Uterus / Retractors Head high position Afterload reduced Vasodilatation by drugs SAB / EDB Anaphylaxis Sepsis

Contractility reduced
Myocardial ischaemia Myocardial depression
66

Management
Identify & treat The cause Minimize effect of anaesthesia Reduce or omit Volatile agent Increase FIO2 50% If on IPPV reduce Vt & convert I:E ratio to 1:4 Correct hypovolaemia give rapid fluid challenges and elevate legs Vasopressors Ephedrine Metaraminol (0.005- 0.01 mg/kg i.v. ) Phenylephrine (10mg/500ml) titrated to effect
67

68

69

HYPOXEMIA

70

HYPOXEMIA

Definition SaO2 PaO2 < 90 %, < 60mmHg

71

Mechanisms

Low FiO2 Inadequate VA V/Q mismatch Anatomic shunt Excess metabolic O2 demand Low cardiac output

72

Clinical Causes
Inadequate ventilation Airway obstruction Hypoventilation Endobronchial intubation Patients with increased A-a gradient Pre-existing lung disease Pneumothorax Pulmonary oedema Aspiration Atelectasis Pulmonary embolism Low cardiac output
73

Prevention

Check anaesthetic machine O2 analyser & alarms Adequate Ventilation (esp. tidal volume) Monitor & adjust FiO2 High normal range tidal volume Caution with spontaneous ventilation in lung disease

74

Manifestations
Pulse Oximetry Malfunction can occur: check waveform & probe position

Hypothermia Poor peripheral circulation Artefacts: diathermy, motion, ambient lighting Cyanosis
Dark blood in surgical field

Late signs bradycardia , myocardial ischaemia & dysrrhythmias, hypotension and cardiac arrest

75

Management
Assume low SpO2 = hypoxaemia Increase FiO2 Verify FiO2 increases Check pulse, BP Check EtCO2 & pulse oximeter Hand ventilate - assess lung compliance, give large TV Check chest movements & auscultate chest Exclude endobronchial intubation ABGs Posture sitting up

76

Verify Pulse Oximeter

Assess signal amplitude Check waveform Check position Correlate reading with diathermy Shield probe Change site

77

Persistent hypoxemia causes

Pulmonary Pneumothorax - consider CXR Aspiration Massive atelectasis Pulmonary embolism Aspiration of foreign body Acute pulmonary oedema

Extra-Pulmonary Low cardiac output Intracardiac shunting in CHD

78

Persistent hypoxemia management

Use aggressive pulmonary toilet Suction ETT Consider bronchoscopy Consider addition of PEEP Restore circulating blood volume Maintain CO and Hb levels (Hb >100g/L) Consider inotropes

79

Persistent hypoxemia Mgt. Contd.

Inform surgeons (earlier if appropriate) Check retractors Transfer to supine position Terminate surgery ASAP Investigations in PACU Incl. CXR, ABGs Arrange transfer to ICU
80

Awake patient
Look for cause Inadequate Ventilation airway, depressed VA Pulmonary and extra-pulmonary

Also

diffusion hypoxaemia, laryngospasm, inadequate reversal, Shivering

Management High flow O2 - CPAP - re-intubation Drug reversal relaxants, opioids

81

82

83

Hypercapnia

84

In most cases, the increase CO2 per se is not a problem (exception e.g. neurosurgery) In most cases, the cause is simply hypoventilation (i.e. V < ~100mls/min/kg)

In most other cases (where the minute volume would otherwise be adequate), the treatment, if any is required, is still simply to increase the minute volume

85

Situations requiring specific Rx (other than simply increasing ventilation)

Malignant hyperpyrexia thyroid storm circuit problems ( = increased FiCO2) exhausted soda lime expiratory valve failure inadequate fresh gas flow in partial rebreathing circuits excessive circuit dead space (i.e. on patient side of Y-piece)

86

MH Is it?Isnt it? Unfortunately, signs with higher +ve predictive values are not available immediately (e.g. increased CK, myoglobinuria, worsening metabolic acidosis) Immediately available clinical signs are non-specific (e.g. increased HR) Beware masseter spasm, rigidity of other muscle groups, mottled skin, increased TC (late sign) Keep MH in mind if CO2 continues to rise despite adequate minute ventilation
87

Causes of hypercapnia

Increased CO2 production

Decreased CO2 excretion Increased CO2 delivery to lungs

88

Increased CO2 production

Increased temperature (including MH, Sepsis) Hyperthyroidism (including thyroid storm) Exogenous (e.g. CO2 pneumoperitoneum) NaHCO3 administration Tourniquet release Shivering Convulsions Compensation for metabolic alkalosis

89

Decreased CO2 excretion

IPPV : inadequate ventilator settings Spontaneous ventilation : respiratory depressant drugs Partial airway obstruction Altered respiratory mechanics e.g. decreased compliance due to pneumoperitoneum, obesity, Trendelenburg

90

Increased CO2 delivery to the lungs

Increased cardiac output
R to L shunt

91

Management

Ensure adequate oxygenation Ensure adequate ventilation Check FiO2 Blood gases to confirm capnography Consider secondary causes, especially those requiring specific Rx (MH, thyroid storm etc.) Treat complications of hypercapnia

92

Ensure adequate ventilation

Check airway (e.g. is LMA seated well ? ) Check circuit (e.g. ventilate manually any obstruction ? )

Check minute ventilation (e.g. ventilator settings or spirometry)

93

If FiCO2 raised:
Check valves (e.g. expiratory valve stuck open) Check if soda lime exhausted Check if fresh gas flow inadequate

94

Complications of hypercapnia

Hypertension, tachycardia Pulmonary hypertension Arrhythmias

95

96

Hypocapnia

Hypocapnia
No ETCO2 Timing ? Never or suddenly absent Concurrent events ? Surgical, anaesthetic or change in position Low ETCO2 Timing ? Always low, suddenly low or falling Concurrent events ?

98

No ETCO2
Oesophageal intubation Accidental extubation Disconnection Equipment failure has the machine and monitor been checked prior to induction? Cardiac arrest

99

Low ETCO2
Airway Circuit Ventilation Gas exchange Decreased production

100

Airway
Oesophageal intubation Accidental extubation

101

Circuit

Air entrainment (leak)

Dilution with circuit gases (sampling problem)

102

Ventilation
Ventilation settings Overenthusiastic hand ventilation

Metabolic acidosis spontaneously ventilating patient

103

Gas Exchange
Pulmonary embolism Air Clot Fat Decreased cardiac output/arrest Severe hypotension

104

Decreased Production

Hypothermia
Hypothyroidism

105

Thank you !

106