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CHAPTER 46 COMPLICATIONS OF ANAESTHESIA Outline: Anaesthetic complications are classified according to the system most affected. If the problem mainly involves the heart and circulation it is classified as cardiovascular. Problems involving the respiratory tract or the lungs are classified as respiratory and so on. • • • • • • • Cardiovascular complications Respiratory complications Gastrointestinal complications Urinary complications Neurological complications Complications in eye surgery Other complications − Shivering − Awareness during anaesthesia − Malignant hyperpyrexia

The following are dealt with in specific chapters: • Complications of endotracheal intubation: see Chapter 9 • Complications of anaesthetic drugs, including anaphylaxis: see Chapters 6 and 62 • Complications of blood transfusions: see Chapter 49 • Complications of regional techniques: see Chapters 18 and 19 1

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CARDIOVASCULAR COMPLICATIONS Hypotension Hypotension under anaesthesia may have several causes. The easiest way to consider these causes is to group them under three headings: Anaesthetic causes: • Drugs • Premedicant drugs, e.g. opioids • Induction agents, e.g. thiopentone • Inhalational agents e.g. halothane and ether • Muscle relaxants, e.g. pancuronium, atracurium An overdose or hypersensitivity reaction can produce hypotension. • Over inflation of the lungs (excessive positive pressure) • Pneumothorax (see under respiratory complications) • Hypoxia and hypercarbia in the later stages • Incompatible blood transfusions • Spinals or epidurals Surgical causes • Position, e.g. reverse Trendelenburg or lateral position • Blood loss with inadequate fluid replacement • Vagal stimulation- reflex bradycardia • Following the release of a tourniquet or clamp • Embolism, e.g. air or amniotic fluid • Packs or retractors obstructing the inferior vena cava. Patient causes (related to the general medical state of the patient) • Hypovolaemia i.e. blood loss or dehydration • Heart disease (ischaemic) and heart failure. Arrhythmias: tachycardia and bradycardia • Pre-operative medication e.g. hypotensive agents, recent steroid therapy 2

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• • •

Supine hypotensive syndrome – see Chapter 21 Spinal shock, quadriplegia, which often causes variations in blood pressure Septic shock.

Marked hypotension (a fall in blood pressure more than 25 mm below the resting blood pressure) and also a hypotensive trend (a gradual decline in the blood pressure) must be treated very seriously. Hypotension if untreated may be followed by cardiac arrest. Even if cardiac arrest does not result, marked hypotension carries the risk of cerebral, myocardial and renal damage following ischaemia or thrombus formation. There are other factors besides blood pressure involved in delivery of oxygen to the tissues e.g. blood flow in the organ and the oxygen content of the blood but every effort must be made to correct the hypotensive state. This is especially so for the elderly, severely ill and patients with a history of hypertension. Treatment of hypotension • Find and treat the cause. • Start a rapid infusion of intravenous fluids (Hartmann’s, saline or colloid) e.g. 10ml/kg stat. • Increase the concentration of oxygen and reduce the concentration of anaesthetic agent. If the blood pressure is below 80mmHg, then turn off the volatile and give the patient 100% oxygen. • Use vasopressors to raise the blood pressure when it is dangerously low (below 80mmHg in spite of measures mentioned above). Vasopressors are of most use if the hypotension is due to peripheral vasodilation, e.g. after a spinal or after certain anaesthetic agents. If the low blood pressure is due to haemorrhage or dehydration then they are of temporary use (while fluid is given to replace deficits) as the vessels are already constricted. Similarly, if the hypotension is due to cardiac failure they do not help 3

phaeochromocytoma. Surgical • Infiltration with adrenaline. The patient’s feet can be raised above the level of the trunk to help venous return. • Certain anaesthetic agents. e. The maximum dose of adrenaline that should be used is 200 micrograms in a concentration of 5 micrograms/ml solution (1 in 200. e. • Inadequate ventilation resulting in the retention of carbon dioxide.000). phaeochromocytoma.g. ergometrine • Posture: Trendelenburg position • Clamping of major blood vessels Patient causes (related to the past history of the patient) • Pre-existing known hypertension • Undiagnosed hypertension. • Patients on a group of tranquillisers termed the monoamine oxidase inhibitors. • Use of oxytocics.Awetahagn abreha • much.e.g. • Other less common causes − Over transfusion − Malignant hyperpyrexia − Rare endocrine causes i. Both hypoxia and hypercarbia may initially present with a rise in blood pressure. ketamine or pancuronium. Hypertension The causes can be classified as follows: Anaesthetic • Inadequate anaesthesia and/or intra-operative pain relief.g. • Traction on viscera (may cause bradycardia and also hypotension). e. (MAOI’s) • Pre-eclampsia • Full bladder • Quadriplegia 4 .

Awetahagn abreha • Head injury with raised intracranial pressure Dangers of persistent hypertension during anaesthesia are: • Cardiac failure – leading to pulmonary oedema • Cerebrovascular accident (stroke) • Cardiac arrest • Myocardial hypoxia • Cardiac arrhythmias. Treatment of hypertension during anaesthesia: • Correct and treat the cause e.g. Increase in concentration of volatile agents should be tried first. ARRHYTHMIAS Bradycardia Anaesthetic causes • Drugs: Suxamethonium Neostigmine Halothane Local anaesthetics • Reflex bradycardia. then a hypotensive agent such as hydralazine (5mg IV) or propranolol (1mg IV) may be used and repeated as necessary. • Hypoxia in the late stages (the initial response to hypoxia is tachycardia which may be rapidly followed by bradycardia if the hypoxia is not corrected).g. • High spinals 5 . e. during intubation under light anaesthesia. − Deepen anaesthesia − Relieve pain − Increase ventilation • Elevate the head of the table • Drug treatment If the above measures do not reduce the blood pressure and the diastolic blood pressure persists above 100 mmHg.

Tachycardia Anaesthetic causes • Drugs. digoxin. e. e. • Drugs (pre-operative medication) may give the patient a bradycardia.g. Treatment of bradycardia • Find and treat the cause.6mg IV in divided doses. • Idiopathic bradycardia . atropine. treatment is needed more urgently. pancuronium • Hypercarbia from any cause • Hypoxia from any cause • Hypotension • Inadequate depth of general anaesthetic Surgical causes • Infiltration with adrenaline • Traction on viscera • Neurosurgical and cardiac surgery 6 .especially in athletes.g. The indication to treat the bradycardia would be its effect on the cardiac output and therefore on the blood pressure. • Hypothermia • Patients with increased intracranial pressure (late sign). beta-blockers.Awetahagn abreha Surgical causes • Traction on the mesentery • Traction on the eyeball or carotid sinus • Neurosurgery • Anal stretch • Dilatation of cervix Patient causes • Pre-existing heart disease associated with a slow pulse. If the bradycardia is associated with a fall in blood pressure. • If the pulse rate is less than 60/min and the patient is hypotensive give atropine 0.

Treatment of tachycardia and other arrhythmias Find and treat the cause. Cardiac arrest See Chapter 58 under Cardiopulmonary Resuscitation. An ECG is necessary to diagnose the type of arrhythmia. especially if performed in the sitting or steep reverse Trendelenburg (head-up) position. pulmonary embolism) • Air • Fat • Tumour • Amniotic fluid Causes of air embolism: • Head and neck surgery.Awetahagn abreha Patient causes • Cardiac failure • Thyrotoxicosis • Fever • Hypovolaemia • Pre-existing arrhythmia • A patient who is very ill or moribund. Emboli may be: • Blood clots (e.g. Air embolism An embolus is any foreign matter in the blood stream. Atrial fibrillation and atrial flutter need to be excluded or diagnosed and treated. The above list refers predominantly to sinus tachycardia. Treatment of the specific arrhythmia must be left in the hands of the doctor. • Pelvic surgery • Laparoscopy • Open heart and chest surgery • Maxillary antrum wash out 7 .

8 . Treatment • Speedy recognition is essential. • CNS − Convulsions followed by coma. • Place the patient in the left lateral head-down position. • Treat hypotension and arrhythmias. • Give oxygen by mask. On examination the patient will be cyanosed and the blood dark. Signs and Symptoms • CVS − Marked hypotension − Arrhythmias − Myocardial ischaemia − O/E a “mill-wheel murmur” at the apex. This will help trap the air bubbles in the right atrium and prevent entry into the lungs. − Cardiac arrest • RS − Respirations may become irregular (if the patient is breathing spontaneously). • Prevent further entry of air into the blood stream by jugular compression and by flooding the wound with saline. Hip surgery The volume of air required for clinical signs to present themselves is 10 to 15ml. 100% oxygen if intubated. • Discontinue N2O.Awetahagn abreha • • • • • • Insufflation of the fallopian tubes Delivery in the presence of placenta praevia Criminal abortions Pneumo-encephalograms Infusions and CVP lines. This has been described as (on auscultation) "waves lapping against the shore".

Fat embolism This is usually associated with fractures of the lower limb long bones.Awetahagn abreha • Aspirate the air from the right heart by means of a catheter. cardiovascular and renal. Other signs are fever and tachycardia. High dose steroids have been advocated but their use is not supported by clinical data. The fracture should be stabilized. brain and skin. Cardiac failure This complication is dealt with in Chapter 49. Treatment This is mainly supportive – respiratory. The symptoms may appear soon after the injury or up to 2-3 days post injury. pulmonary oedema with bilateral shadowing on chest x-ray. RESPIRATORY COMPLICATIONS Respiratory obstruction • Spasm of jaw muscles • Tongue falling back • Laryngeal spasm 9 . reduced haematocrit and platelet count. Rapid transfusion and overloading the circulation with fluid can result in pulmonary oedema. Signs and symptoms • Dyspnoea • Petechiae – usually in neck.Prognosis Prognosis is variable and in severe cases mortality is high. Particles of fat are carried in the blood stream and deposited in the lungs. If a CVP line is in place this can be used to aspirate air. hypoxia. axillae and conjunctivae • Mental confusion These three signs in the presence of a long bone fracture are diagnostic of fat embolism.

Treatment: Remove the airway and suction the pharynx.g. halothane − Hypoxia − Hypercarbia − Shock 10 . Causes − Inadequate depth of anaesthesia − The stimulant effect of the anaesthetic agent used: ether. This delays the uptake of the vapour and therefore the process of induction. e.Awetahagn abreha • Bronchospasm The causes. − Laryngoscope. The tidal volume is small and therefore the exchange of gases is poor. symptoms and signs are dealt with in Chapter 8 Hypoventilation from any cause See Chapter 57 under Respiratory failure Apnoea See Chapter 57 under Respiratory failure Coughing This may occur under the following conditions: • Induction of anaesthesia with an inhalational agent. They tire the patient. • Irritation of the larynx by: − An oropharyngeal airway. Give oxygen if required. Guedel airway. − Secretions. • Induction with an intravenous agent.g. Deepen the anaesthesia. Tachypnoea (rapid respiration) Fast respirations are shallow. − Regurgitated gastric contents. attempting intubation when the patient is not deeply asleep. It is more likely to occur when the inspired concentration is increased too rapidly. e.

if the patient is light the anaesthetic must be deepened. i. Squeeze the bag or press down the bellows as the patient takes a breath and so increase the tidal volume. Carbon dioxide Retention Hypoventilation and apnoea generally result in hypoxia and carbon dioxide (CO2) retention. as when large masks or connectors are used for children. This may occur during the operation and post operatively in the recovery room. • A high oxygen concentration in patients with chronic obstructive airway disease can result in CO2 retention. excessive use of opioids causing respiratory depression. The patient is ventilated at a rate decided by the anaesthetist using a nondepolarising muscle relaxant if necessary. However. In the presence of a high inspired oxygen concentration hypoxia may not occur.e. • Assist ventilation. • The use of a T piece (paediatric anaesthesia) with inadequate gas flows. • Control ventilation. it is important to remember that if the inspired oxygen concentration is very high. This may be necessary depending on how rapid and shallow the respiration is. especially at low gas flows. • Exhaustion of the soda lime canister. Causes of CO2 excess • Hypoventilation from any cause. • Respiratory obstruction.Awetahagn abreha − Hyperpyrexia Treatment • The cause must be found and treated first. • The presence of a large dead space. then CO2 retention may occur unaccompanied by hypoxia. For instance. This 11 . • Misplacement of the endotracheal tube down one main bronchus (usually the right). • Defective exhalation valves on an anaesthetic machine.

• Pneumothorax may follow certain surgical procedures: − Thyroidectomy − Tracheostomy − Surgery on the neck.g. • Tension: a flap of pleura may act like a valve. The lung on that side then collapses and gaseous exchange does not occur. The mediastinum gets pushed to the opposite side and compresses the normal lung. neck dissection − Kidney surgery − Gall bladder surgery − Insertion of a subclavian or internal jugular catheter (CVP) − Certain regional techniques such as intercostal block or a supraclavicular brachial plexus block. e.P. Types of pneumothorax • Closed: where there is no communication with the atmosphere.Awetahagn abreha is rare and hypoxia from inadequate oxygen administration is a more common problem.V. The condition is made worse by I. This will enable air to enter the pleural cavity during inspiration but prevent it from leaving during expiration. Causes of pneumothorax in the surgical patient • Rupture of an emphysematous bulla.P. Air may be trapped in the pleural cavity when the chest wall is intact • Open: here there is free communication with the atmosphere through an opening in the chest wall or through a broncho-pleural fistula. 12 . Pneumothorax Pneumothorax is the term used to describe air in the pleural cavity. This is very dangerous. This may occur spontaneously or after IPPV. Careful monitoring is required.

POST-OPERATIVE CHEST COMPLICATIONS Such complications occur in 5% of all operations. However treatment is always on the basis of clinical findings.Awetahagn abreha Diagnosis: A pneumothorax must be suspected if it becomes increasingly difficult to ventilate the patient and the patient's condition rapidly deteriorates. At least 10% of all abdominal surgery is followed by some degree of complication. The air entry on the side of the pneumothorax will be decreased or absent. A chest tube connected to an underwater seal drain must also be inserted as quickly as possible. right main bronchus intubation. Treatment: (tension pneumothorax) As soon as the diagnosis is suspected a 14G or 16G needle must be inserted into the pleural cavity on the affected side in the 2nd intercostal space in the mid-clavicular line. Early signs are − A fall in oxygen saturation − Cyanosis / dyspnoea − Tachycardia − Hypotension Exclude other causes of difficulty in ventilation e g respiratory obstruction in the tube or upper airways. There may also be displacement of the trachea to the unaffected side and later. Causes of post-operative complications: 13 . In the case of a tension pneumothorax there is not time for a chest X-Ray. bronchospasm and inadequate relaxation of the muscles of the chest wall. The diagnosis is made by listening to the chest. The diagnosis is confirmed by CXR. • Once diagnosis is confirmed an underwater-seal drain should be inserted. crepitus. Aspiration of air will confirm the diagnosis. Treatment: (open and closed pneumothorax) • Discontinue nitrous oxide and give 100% oxygen.

Surgical causes • Chest complications are most common after upper abdominal surgery. Patients with acute chest infections should not be subjected to routine surgery. Those requiring emergency surgery will do better with a regional anaesthetic. • Inadequate pre-operative preparation. in an 14 . • Pre-existing lung disease. • Acute upper respiratory infection may result in chest infections. • Smoking. Complications are six times more frequent in smokers than in non-smokers. Prolonged anaesthesia inhibits ciliary activity and delays return of airway reflexes. If time permits those with chronic chest infections should be treated with physiotherapy and antibiotics if indicated. If appropriate. Chest complications are more frequent in older people. Pulmonary embolism is more common after pelvic surgery and lower limb orthopaedic surgery. Anaesthetic causes • Excessive premedication. • Sex. • Surgery which involves handling the bowel and retraction of organs. • The longer the duration of surgery. Such complications are three times more common in males.Awetahagn abreha Patient causes • Age. • Surgery which involves prolonged post-operative bed rest. regional anaesthesia may be a better choice for patients with acute chest infections requiring emergency surgery. Opiates can predispose to chest complications if given in excess. • Steep Trendelenburg and lithotomy positions increase the incidence of complications. the greater the chance of complications.

e.e. fever.g. • Hypoventilation from any cause. Bronchitis This vague term is used to describe cough. physiotherapy. etc. e. The pathological change is inflammation of the bronchioles. peritonitis or subphrenic abscess. • Disease in the abdomen. • Contaminated equipment. The infective organism may reach the lung from many sources. supportive therapy (i. It is more common in those with preexisting chest disease. • Contaminated equipment. oxygen therapy. • Aspiration of stomach contents or secretions whilst under anaesthesia. sputum. • Excessive post-operative sedation.g. examples being: • The upper respiratory tract. dyspnoea and wheezing.) and bronchodilators. which can be the source of bacteria responsible for post-operative infection. Treatment consists of antibiotics. • The aspiration of gastric contents.Awetahagn abreha attempt to optimise their condition. • Prolonged shock. as from dental sepsis. endotracheal tubes. Pneumonia and less commonly lung abscesses may occur in addition to bronchitis. • Previous infection. Collapse of the Lung Collapse of the lung may be classified depending on the extent of lung involvement: • Entire lung • Lobular collapse • Segmental collapse /atelectasis Lobular collapse or atelectasis This usually develops in the first 48 hours after the operation with: • Fever 15 .

− Encourage coughing. • Avoid excessive pre-operative sedation. − Perform percussion of the chest (to dislodge a plug of mucus) and postural drainage. All the signs and symptoms mentioned above require attention. 16 . • Give adequate pain relief. preferably longer. If the patient has inadequate pain relief. • Instruct the patient to stop smoking for at least 48 hours pre-op. • Treat oral sepsis. The most important aspect of treatment of atelectasis is prevention. The danger of atelectasis is that secondary infection may develop and this can lead to pneumonia. breathing will be shallow. − Start deep breathing exercises. • Organise preoperative physiotherapy (deep breathing exercises) for all patients scheduled for major surgery. Treatment of atelectasis once it has occurred • Chest physiotherapy: − Turn the patient regularly. bronchiectasis. Post-operative preventive measures • Start chest physiotherapy and encourage early mobilisation. Pre-operative preventive measures • Treat all pre-existing chest disease before anaesthesia. lung abscess and pleural effusions.Awetahagn abreha • Increased difficulty in breathing • Dry cough • Rapid heart rate • Dilatation of the alae nasae • Cyanosis • Restricted chest movements on the affected side • Diminished breath sounds on the affected side.

5. is a dangerous problem. Segmental or lobular atelectasis is the commonest complication after anaesthesia. as a result of vomiting or regurgitation.e. • Treat any bronchospasm with bronchodilators. This was originally described by Mendelson in obstetric patients where the risk of aspiration was high and the stomach contents had a lower than normal pH. provided there is no contraindication. • Use a non-particulate (i.g. Dose 30ml of 0. • Attempt to empty the stomach by using a wide-bore orogastric or nasogastric tube. e. Signs and symptoms • Dyspnoea • Tachycardia • Tachypnoea (rapid respirations) • Bronchospasm • Pulmonary oedema • Cardiovascular collapse i. • Use a regional technique if anaesthesia is needed. Prevention: The patients likely to vomit or regurgitate will be discussed under gastrointestinal complications on the next page. If the pH is less than 2.e.3M solution orally. sodium citrate) antacid within 30 minutes of induction. Ventolin or aminophylline. Aspiration pneumonitis (Mendelson’s Syndrome) Aspiration of stomach contents. 17 . (which means the contents are very acid) and if the stomach contents reach the lungs then a pneumonitis results.Awetahagn abreha − Mobilise as soon as possible. (Antacids make gastric contents less acid). hypotension • CXR mottled opacities. The gastric contents are acid. • Treat the infection with an appropriate antibiotic.

Metoclopramide 10mg reduces gastric volume if given at least one hour before surgery. Examples are cimetidine and ranitidine. PEEP is usually indicated to maintain oxygenation. focal pulmonary collapse suggesting large airway obstruction. Omeprazole is another useful drug. • Give antibiotics if the aspiration is likely to be infected fluid. in this case immediate broad-spectrum antibiotics are indicated. • IPPV may be required. if the aspiration is of gastric contents only (most likely sterile) it is best to withhold antibiotic treatment until signs of infection.Awetahagn abreha • • • An awake intubation may be attempted in the very ill and poor risk patient. with positive cultures. • Bronchoscopy.g. described in Chapter 16 must be used. Other drugs (Histamine H2-receptor antagonists) decrease the volume and acidity of gastric contents. A rapid sequence induction with cricoid pressure. have been established. • Cardiovascular support. or chest x-ray evidence of foreign bodies. aminophylline or salbutamol. e. Therapeutic bronchoscopy is indicated if there is particulate aspiration. • Bronchodilator drugs for treatment of bronchospasm. 18 . for example in bowel obstructions. In severe aspiration a shock-like syndrome develops which requires aggressive fluid management with possible inotrope support. • Further oxygen by mask. preceded by oxygen administration. Treatment • Repeated tracheal suction. Steroids have no proof of benefit in aspiration syndrome and may be harmful causing delayed healing and a tendency to infection. However.

• Use calf stimulators during surgery. Treatment: • Give oxygen • Give analgesia for pain • Treat any arrhythmias which may occur. It is important to remember that pulmonary embolism may occur without any warning sign of deep vein thrombosis. A chest x-ray and ECG may help. e. In rare cases surgical embolectomy is necessary. then the patient presents with fever. Symptoms: The symptoms will depend on the size of the clot. Prevention: The most important measure is to prevent deep vein thrombosis.Awetahagn abreha Pulmonary Embolism This occurs when a clot from a vein in the lower limb or the pelvis is detached and carried to the lung. • Give prophylactic anticoagulants: Heparin 5000 units SC. 12 hourly. It may be difficult to differentiate pulmonary infarction from a chest infection. Pulmonary infarction is said to have occurred. It usually happens 321 days after the operation and is more common in older patients who have had prolonged bed rest. If it is large. • Use regional techniques if possible – this can reduce the incidence of DVT by as much as 20%. cough. it may obstruct the pulmonary artery which conducts the blood from the right ventricle to the lungs and sudden death may result. feet and toes 19 . • Encourage patients to move the legs. haemoptysis. then in hospitals with specialised facilities a filter can be inserted into the inferior vena cava to prevent clots travelling to the heart. Heparin • Surgery. If the clot is small. If the patient continues to have pulmonary emboli in spite of anticoagulant therapy. dyspnoea and chest pain.g. • Start on anticoagulants.

It does not involve any 20 . Pulmonary oedema The most common causes of post-operative pulmonary oedema are fluid overload. GASTROINTESTINAL COMPLICATIONS Vomiting and aspiration Differences between vomiting and regurgitation.Awetahagn abreha • frequently. Commence anticoagulants if there is any evidence of deep vein thrombosis. the groin and feet. Teach deep breathing exercises. • Regurgitation which is passive. Examine the usual sites for DVT in the calf. especially of the hip or knee. prolonged airway obstruction and trauma These are discussed in Chapters 34 and 62. It is the expulsion of the material from the alimentary tract by muscular contraction. Stomach contents can reach the lungs by two mechanisms: • Vomiting which is an active process. Patients at high risk of DVT and pulmonary embolism • • • • • • • • • • Obese Diabetics Marked peripheral arterial disease Elderly Varicose veins Those who have been in shock Congestive cardiac failure Prolonged surgery Pelvic surgery Orthopaedic surgery. cardiac failure.

Large volumes of liquid can flood the lungs. In intestinal obstruction the absorption from the gut is 21 .Awetahagn abreha muscle action. • Those with obstructions in any part of the gastrointestinal tract.g. The aspirated material can cause laryngeal spasm. worms and foreign bodies. This is more likely if the gastric contents are very acid (pH< 2. gallstones. hernia or intussusception.5). hiatus hernia − Small or large intestine: adhesions. Cardiac arrhythmias secondary to hypoxia. • Those with material in the gastrointestinal tract. The dangers are: Hypoxia. tumours. volvulus. atelectasis. This material may be food or blood. bronchopneumonia. tumour. It occurs silently and is more dangerous than vomiting. if there has been bleeding into the gastrointestinal tract. − Oesophagus: stricture. Respiratory infections. Solid particles of food can obstruct the inlet.discussed earlier in this Chapter. e. Dangers of Vomiting and aspiration Vomiting and aspiration of gastric contents can occur during the induction and maintenance phases of the anaesthetic or during recovery. Aspiration pneumonitis (Mendelson's Syndrome) . Patients at risk of vomiting or regurgitating under anaesthesia The following patients should always be anaesthetised using the technique of rapid sequence induction with cricoid pressure to help reduce the risk of regurgitation. pouch − Stomach: pyloric stenosis.

g.Awetahagn abreha • • • impaired but the secretions continue to be poured into the intestine. the underlying cause must be sought. e. − Obesity − Pregnancy − A tumour (for instance. For example after a perforated typhoid or duodenal ulcer. • Hypotension is a major cause of nausea after a spinal. It is a good practice to check the patient's blood pressure immediately when a complaint of nausea is made. Those who have an incompetent lower oesophageal sphincter (the sphincter between the oesophagus and the stomach). This is particularly important in patients for caesarian section. • Narcotic analgesics given as premedication 22 . lithotomy. which may be caused by: − Peritonitis. Another risk factor is raised intra-abdominal pressure. Those who have fasted for the 6-hour period required by anaesthetists but who have a delay in the gastric emptying time: − Pregnant women − Seriously ill patients − Those with head injuries − Patients who have received opiate drugs. ovarian) − Ascites − Position. Intra operative nausea and vomiting after a spinal or epidural Before any medication is given for the symptoms. • Hypoxia from hypoventilation • Surgical traction on the intestines • Increased intestinal peristalsis as a result of the spinal block.

IV (250micrograms over one minute) or IM (500micrograms four hourly for adults).Awetahagn abreha • Anxiety on the part of the patient. Treatment • Treat the cause. wet or moist breath sounds. The patient may show evidence of dyspnoea. Treatment of aspiration during anaesthesia • Oxygen therapy • Bronchodilators: − Ventolin is the mainstay of treatment given via nebules. • Give oxygen.e. Correct hypotension and hypoxia and reduce surgical traction.12. Clear the airway of any vomitus. • Suction.50 mg IM or IV Ondansetron . Always watch for signs of aspiration. • Reassure the patient • The following drugs may be used: Prochlorperazine (Stemetil) . − Aminophylline 250 mg stat IV over 10 mins followed by an infusion if necessary. refractory hypoxia. A CXR must be done if this is suspected. • Bronchoscopy • Active chest physiotherapy It requires special expertise to anaesthetise patients with full 23 . • IPPV with oxygen . Cyclizine . wheezing.25mg IM.5mg IM Metoclopramide (Maxolon) -10-20 mg IM or IV Promethazine (Phenergan) .if severe i. lateral position.4 mg IV Management of vomiting during anaesthesia If vomiting does occur take the following measures: • Position: Head down. (This minimises the chance of the vomited material being aspirated). either at the time of vomiting or some hours after the incident.

Awetahagn abreha stomachs or those likely to vomit under anaesthesia. 24 . These techniques are discussed in Chapter 16.

Hiccups This is a state of intermittent spasm of the diaphragm. vagotomy etc and may also be associated with gastric distension. ether / N2O. Hiccups may occur during gastrectomy. • Use a muscle relaxant and IPPV. as a result of central stimulation of the medulla. Vomiting is more likely in young females. pethidine. morphine.g. Upper abdominal surgery. Gastric distension The stomach may become distended in the following 25 . as occurs with upper abdominal or thoracic surgery. • A combination of anti-emetic drugs. • Deepen anaesthesia. can cause vomiting.g. • The type and concentration of anaesthetic agent used e. especially surgery on the biliary tract and pelvic surgery are associated with vomiting. etc. • The surgical procedure performed. caused by stimulation of the sensory nerve endings in the diaphragm. Hiccups may sometimes be seen in uraemic patients. • Premedication. e. Treatment • Prevention is the most important. • Minimise irritation or stimulation of the diaphragm. Treatment (often no treatment is required) • Gastric decompression using a nasogastric tube. if available. is thought to improve treatment.Awetahagn abreha Post-operative nausea and vomiting Consider the following: • The sex and age of the patient. Gastric distension or the presence of gastric contents predispose to vomiting. • The condition of the stomach. • Drug treatment is outlined above. Opiates.

• Increased risk of aspiration • Post-operative vomiting • Hiccups • Interference with surgical procedure. Capnography is valuable. • When an air leak occurs around the endotracheal tube. Other causes are: Halothane hepatitis The incidence of post-operative liver damage after halothane anaesthesia is very rare. It is identical to infectious hepatitis. • Surgical manipulation of stomach. intestine and mesentery. both clinically and biochemically. • Accidental oesophageal placement of the endotracheal tube. It is vital to visualise the vocal cords during intubation and to auscultate the chest for breath sounds after intubation. This may occur if too small a tube has been inserted into the patient's larynx or if the cuff of the endo-tracheal tube has ruptured in situ.000 in adults. Treatment: Relieve gastric distension by passing a nasogastric tube. Liver damage The main cause of liver damage under anaesthesia is hypoxia especially in association with hypotension. 1 in 10. Halothane hepatitis is believed to be a hypersensitivity reaction. 26 . during and after surgery. due to splinting of the diaphragm. even more rare in children. This is more likely if the airway is partially obstructed or if high gas flows have been used.Awetahagn abreha situations: • During IPPV when a mask is used. Dangers • Respiratory embarrassment.

If all else fails catheterisation is necessary. nausea and vomiting appear 2-5 days after the halothane anaesthetic. Reduction in output (oliguria or anuria) The normal urine output is about 1 ml/kg/hr.e. The minimum acceptable urine output is 27 . i. especially in obese middle-aged women. It is more common in anxious patients. URINARY COMPLICATIONS Difficulty in passing urine This is more common after a spinal anaesthetic but may also occur after a general anaesthetic. unless the indications are clinically overriding. indicating hepatitis. Ether anaesthesia Like most general anaesthetic agents. Enflurane (Ethrane) Hepatitis has been reported following the use of enflurane. Every means of encouraging a patient to urinate should be tried. This is also associated with abnormal liver function tests. however. The fever. those who have had heavy sedation and in those patients with enlarged prostates.Awetahagn abreha Some Important Points • Allow at least 12 weeks between administrations of halothane. those who have had abdominal. it is extremely rare. pelvic or perineal surgery. It has no hepatotoxic action. • Do not use halothane if the previous administration was associated with a fever of unknown origin. about 60 ml/hr in the adult patient. • Pre-existing liver disease (if not due to halothane hepatitis) is not a contraindication to the use of halothane provided the patient is considered otherwise fit for surgery and anaesthesia. ether is associated with a reduction in blood flow to the liver. • A single administration of halothane is unlikely to be associated with severe liver damage.

The fall in urine output can be corrected by a fluid load. fall in blood pressure plus a low central venous pressure (CVP) would also suggest pre-renal oliguria. A fall in the urine output can be due to: Pre-renal causes: Usually associated with volume depletion (dehydration or blood loss). There will be evidence of an enlarged bladder if the obstruction is distal to it. tachycardia.g. Ether convulsions are discussed in Chapter 6. urethral stricture. Overdose of local anaesthetic drugs is one of the more common causes. e.5ml/kg/hr.g.Awetahagn abreha 0. 1 litre of Hartmann's/ saline solution administered over half an hour. NEUROLOGICAL COMPLICATIONS Complications involving the central nervous system: Coma and convulsions These may follow the use of regional techniques or general anaesthesia. Enflurane may 28 . prostatic enlargement. Post renal causes: In this situation oliguria or anuria is due to some obstruction in the urinary tract or catheter. Renal causes: The renal tubules are damaged by hypoxia. loss of skin turgor. mismatched blood transfusions and drugs (e. e. kinking or obstruction of the catheter. bacterial toxins. • Convulsions and coma as a result of local anaesthetic drugs or regional techniques have been discussed in the appropriate chapters. non-steroidal anti-inflammatory drugs). • Convulsions may occur in known or latent epileptics especially those who are poorly controlled. it is important to maintain adequate renal perfusion. gentamicin.g. The usual signs of dehydration such as dry tongue. Maintaining electrolyte balance is important and in more severe cases renal dialysis is necessary. However. If a diagnosis of renal oliguria or anuria is made then careful fluid management to avoid fluid overload is necessary. hypotension.

diabetic state. cerebrovascular accident or myocardial infarction with reduced cardiac output and as a consequence of hypotension. Recovery may be delayed: the patient may regain consciousness only to lapse into coma again. overdose of anaesthetic agents.). retention of carbon dioxide. treat any associated cerebral oedema.Awetahagn abreha • • cause convulsions in epileptics and propofol has been associated with convulsions (pseudo-seizures) often occurring some time after administration. Convulsions may follow neurosurgery. for example.g. diazepam. perhaps after a period of acute hypoxia (e. − Maintain normotension and oxygenation. • Abducting the arm no more than 90 degrees at the shoulder 29 . Peripheral nerve injuries may result from faulty positioning Injury to nerves can be avoided by: • Padding the shoulder braces if they are used. − Tilt the head up at 30°. Acute porphyria and preoperative treatment with monoamine oxidase inhibitors may also cause coma.g. − Mannitol 20% 0.5gm/kg Coma can also be due to many other causes.g. The cerebral oedema associated with hypoxia must be treated. e. shock. midazolam or thiopentone. Convulsions and coma may also occur during or after general anaesthesia. associated with a partially obstructed airway or hypoventilation. Treatment of convulsions − Treat the cause − Give oxygen − Give anticonvulsants. Generally the prognosis is poor. − Support the circulation. − Assist or control ventilation as required. etc. Again. associated with a cardiac arrest) or a period of chronic hypoxia (e. liver or renal disease.

Prevent this from happening by: − Using a sterile ointment in the eyes during anaesthesia. • Spinal anaesthesia .The neurological consequences of spinal anaesthesia have been discussed in Chapter 19 OPHTHALMIC COMPLICATIONS Corneal abrasions These can occur very easily under anaesthesia if the eyes are left open. − Closing the eyes carefully with a piece of adhesive tape. Careless positioning when the patient is prone can also cause serious eye damage. can result in serious damage or blindness by occluding the blood supply to the eyes. Prolonged surgery and cold IV fluids also contribute to hypothermia. A further loss of heat occurs from the respiratory tract when dry gases are breathed in through an endotracheal tube. thiopentone) in the region of the peripheral nerves. Other causes of peripheral nerve injuries • Extravasation of injected drugs (e. Blindness Excessive pressure of the mask on the eyeball.Awetahagn abreha • • joint. The cornea dries very quickly and is easily injured. It may be the body's response to heat loss following vasodilation that accompanies general anaesthesia. especially if the patient is hypotensive.g. Padding the arm board so that it is level with the mattress on the table. ether and even thiopentone. OTHER COMPLICATIONS Shivering: This is seen after general anaesthesia with halothane. A cold operating room may also cause shivering 30 . enflurane. Protecting the ulnar and lateral popliteal nerves by foam rubber to avoid excessive pressure.

enflurane. • A family history of anaesthetic problems. The problem of awareness can normally be avoided by using a “supplement” with nitrous oxide and oxygen (i. • Sedation if shivering is excessive e. isoflurane). or by suxamethonium. King/Denborough disease and Central Core disease). Treatment • Warm blankets • Oxygen by mask as long as the shivering continues. halothane.e. There may be an association with squint surgery. • Malignant hyperpyrexia is thought to be more common in patients with muscular dystrophies and related disorders.g. It runs in families being an inherited disorder of skeletal muscle triggered by some common anaesthetic drugs. volatiles) and by carefully monitoring the patient’s pulse and blood pressure. pethidine 15-25mg IV. • Raised CPK enzyme level.e.e. It may also occur in obstetrics where a narcotic premedication is avoided and a smaller dose of thiopentone is often used for fear of depressing the baby. • The reaction may be triggered by either a volatile agent (i. relaxant anaesthetics. These are the most potent triggers of 31 . (Note that patients with pre-eclampsia should have the normal induction dose of thiopentone to help reduce the hypertensive response to intubation). The patient may show some or all of the following features. This occurs when ether. See also Chapter 51 (Hypothermia) Awareness during anaesthesia Many reports of awareness have come from patients receiving nitrous oxide/oxygen. halothane or other volatile is not used. Malignant hyperpyrexia This condition is rare but very dangerous.Awetahagn abreha postoperatively. The only proven associations are with rare genetic muscle disorders (i.

• Unexplained tachycardia • Hypercapnia in ventilated patients • Tachypnoea in spontaneously breathing patients • Cyanosis • Arrhythmias • Rise in temperature • Hyperkalaemia Later signs include renal and cardiac failure. oesophageal. It is prepared with sterile water and as each ampoule contains 20mg of Dantrolene this can be quite labour intensive. • Correction of acidosis with bicarbonate (0. 32 . Dantrolene is difficult to prepare and therefore requires a dedicated person.5-1 mEq/L) is controversial.Awetahagn abreha • malignant hyperpyrexia.g. Then 1mg/kg (up to 10mg/kg) repeated every 10-15 minutes. Hyperventilate the patient. • Cool the patient: Insert core temperature probe e. (60ml of sterile water for each ampoule). • Give 100% oxygen via endotracheal tube. Clinical signs under anaesthesia • Spasm of the masseter muscle of the jaw and a general increase in muscle tone in spite of neuro-muscular blockade. nasal. • Dantrolene if available: initial dose 2. Unless there is adequate ventilation or the patient is aggressively hyperventilated this will cause an intracellular acidosis. • Treatment of any arrhythmias as they occur.5mg/kg. A previous uncomplicated general anaesthetic does not exclude the development of malignant hyperpyrexia. − Pack patient in ice or immerse in a cooling bath. Management of malignant hyperpyrexia: • Stop the anaesthetic and surgery.

• Maintain general anaesthesia with nitrous oxide/ oxygen and IV opiate or with ketamine or propofol infusion. Anaesthesia for a malignant hyperpyrexia susceptible patient • A regional technique. pulse and blood pressure. • Keep patient sedated throughout with IV midazolam or diazepam. if appropriate. propofol or ketamine then muscle relaxation with a non-depolarising agent. temperature. Stop cooling when central temperature falls to 38oC. − Cooling fans.Awetahagn abreha Give IV infusion of cold fluids (cooled saline solution. − 33 . The anaesthetic machine should be free of vapourisers and have been flushed with oxygen for 20. sedation and thrombophlebitis with tissue necrosis following extravasation. If a general anaesthetic is essential: • Monitor ECG and temperature meticulously and end-tidal carbon dioxide if available. 1000ml/10 minutes for 30 minutes). would be safest • Ketamine techniques are also useful. • Treat electrolyte imbalance • Support circulation • Maintain urine output with fluids. − Gastric. The muscle weakness may require postoperative ventilation until muscle strength returns to allow spontaneous breathing. The side effects of Dantrolene include muscle weakness. • IV induction with thiopentone.30 mins before use. wound and rectal lavage with cold saline solutions. frusemide and mannitol. Other measures: The rest of the family should be tested (if possible) and warned of possible anaesthetic problems. • Monitor ECG.

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