06/12/2021

Asynchronous Complications and Hazards of Anesthesia

Anesthesiology
Victoria Uy-Hofileña, M.D., DPBA

AnatB1
OUTLINE

I. Introduction
II. Upper Airway Obstruction
III. Hypoxemia at the Post-Anesthesia Care Unit (PACU)
IV. Hemodynamic Instability
V. Body Temperature and Shivering
VI. Post-Operative Nausea and Vomiting (PONV)
VII. Spinal Headache
VIII. Others
IX. Hazards in Anesthesia
X. References

INTRODUCTION
Adopted from Lagasse RS: Anesthesia safety: Model or Myth? A review of the
 Emergence is associated with physiologic disturbances published literature and analysis of current original data. Anesthesiology
 Most common: 97:1609, 2002
o Postoperative nausea and vomiting (PONV)
 Studies on anesthesia related mortality shows a 1:185,000
o Hypoxemia
incidence in the united states and is usually related to ASA
o Hypothermia and shivering Physical status.
o Cardiovascular instability
 There are so many risks to your anesthesia. There are some we Complications vs. Anesthetic Technique
can control, and there are some we cannot. Complications Anesthetic Technique p-
 Up to 7% of anesthesia related malpractice in the US were
GA RA NB Combined value
related to recovery room incidents and the most common is your
Headaches 38 16 - - <0.001*
post op nausea and vomiting. But the most serious outcomes are
Sore throat 211 7 2 2 <0.001*
related to your respiratory and vascular compromise
Myalgia 56 10 1 - 0.825
Nausea 128 22 1 - 0.490
Vomiting 98 23 1 - 0.573
Oral trauma 93 4 - - <0.001*
Teeth trauma 4 - - - -
Thrombophlebiti 85 12 2 - 0.065
s
Memory loss 6 1 - - 0.405
Micturition 36 10 - - 0.952
problems
Nightmares 9 - - - -
Back pain 68 17 - - 0.925
Motor deficit 12 2 1 - 0.163
Paresthesia 31 12 1 1 0.029*
GA: General Anesthesia; RA: Regional Anesthesia; NB: Nerve Block

 Upto 7% of anesthesia related malpractice claims in the US were

attributed to recovery room incidents. most common is PONV.
But more serious outcomes are related to airway or respiratory
and cardiovascular compromise
Death Totally Attributable to Each Component of Risk in the
Confidential Enquiry into Perioperative Deaths UPPER AIRWAY OBSTRUCTION
Component Mortality Rate Contribution
 Most frequent cause: Loss of pharyngeal muscle tone
Patient 1:870
o Attributed to inhaled and IV anesthetics, NMBD, and opioid
Operation 1:2860
used during anesthesia
Anesthetic 1:185,056
Adopted from Buck N, Devlin HB, Lunn JL,: Report of a Confidential Enquiry into
o Presents with “Paradoxical breathing pattern”
Perioperative Deaths, Nuffield Provincial Hospitals Trust. London, The King’s  Normally the abdomen moves outward during
Fund Publishing House, 1987 inspiration, so when you breath against an obstructed
airway, what happens is that what you call your “see-
saw” breathing type of pattern.
o Released by:
 Jaw thrust maneuver
 CPAP by mask ventilation

CPU College of Medicine | Revised By: Victores Valetudinis | 2022

 Resident Neuromuscular Blockade

 Considered in patients recovering from anesthesia

 Recovery from NMBD
o Diaphragm recovers before pharyngeal muscles
 Supportive measures
o Thermoregulation
o Airway support
o Correct electrolyte imbalance

Laryngospasm

In awake patients, opening of the airway is facilitated by the

contraction of your pharyngeal muscles that goes hand in hand
with the negative inspiratory pressure during breathing. This
tone is however depressed in patients who are sleeping or
sedated and the airway will collapse causing a paradoxical
breathing pattern.
 Most often occurs at time of extubation
 Jaw thrust + Continuous Positive Airway Pressure (CPAP) is
often sufficient to break the spasm.
 Immediate muscle relaxation can be achieved with
succinylcholine.

Obstructive Sleep Apnea (OSA)

 Particularly prone to airway obstruction

 Plans should be made post-operatively.
o “Like for example, allowing the patient to bring CPAP at
home so he can use it post-op.”
 Should not be extubated until fully awake

Management of Upper Airway Obstruction

 Immediate attention to open airways

o Non-invasive
 Jaw thrust
 CPAP
 Oral/nasal airways
 Laryngeal mask airway
o Reintubation of the trachea
 If non-invasive measures fail.
Normally, abdomen moves outward during inspiration. When
you breath against an obstructed airway what happens is what HYPOXEMIA AT THE POST-ANESTHESIA CARE UNIT (PACU)
we call a see-saw type of breathing.
 Most common causes
o Atelectasis
o Alveolar hypoventilation

Alveolar hypoventilation

 Normal ventilator drive:

Obstruction is relieved by simply doing the Jaw thrust and
CPAP via facemask ventilation. During the perioperative
period, support of the airways is needed until the patient is
adequately recovered from the effects of drugs used during
anesthesia.
o Increase PaCo2= Hyperventilation
 Post op= depressed ventilatory drive
o Hypercarbia= Increase PaCo2
o Most common cause of hypercarbia is hypoventilation.
o “In healthy person’s breathing room air, what happens if your
PaCO2 increases? Increase in RR. So, there should be
increase in respiratory rate or hyperventilation, however, in
the post-op period, because of the effects of your
anesthetics, residual neuromuscular blockers, etc., this
response to hypercarbia is depressed, increasing the risk
of your patient to develop hypoxemia. There may also be
pulmonary edema, gastric aspiration, and pneumonia which
causes your V/Q mismatch.”
 Arterial hypoxemia can be reversed by:
o Supplemental oxygen
o Reversal of sedatives
o External stimulation to awaken the patient

CPU College of Medicine | Revised by: Victores Valetudinis | 2022 Page 2 of 6

 o Dysrhythmias

V/Q Mismatch

 Atelectasis: most common cause of post-op pulmonary shunting BODY TEMPERATURE AND SHIVERING
o Management:
 Mobilization and sitting position  Incidence of post-op shivering
 Incentive spirometry o Up to 65% after General Anesthesia (GA)
 Positive pressure ventilation by face mask o Up to 33% after epidural
 Risk factors:
HEMODYNAMIC INSTABILITY o Male gender
o Induction agents ~ propofol
 Manifestations:
o Hypertension Shivering Mechanism
o Hypotension
o Tachycardia  Associated (but not always) with hypothermia
o Bradycardia  Thermoregulatory in hypothermic patients
o “Hypertension and tachycardia: higher mortality rate”  Brain and spinal cord do not recover simultaneously from general
anesthesia
Hypertension o Spinal cord recovers faster
o Uninhibited spinal reflexes ~ clonic activity
 Risk Factors:
o Essential hypertension Clinical Effects
o Pain
o Post-operative Nausea and Vomiting (PONV)  Patient discomfort
o Hypoventilation with hypercarbia  Increase Oxygen consumption
o Urinary retention  Increase CO2 production
o Advanced age  Increased cardiac output, heart rate and blood pressure
 “Hypertension must be controlled at the PACU.”  Long term effects:
o MI, delayed wound healing, increased mortality
Hypotension
Treatment
 Classified as:
o Hypovolemic  Identification and treatment of hypothermia
o Distributive  Accurate temperature monitoring
o Cardiogenic  Pharmacologic
1. Hypovolemic (Decreased Preload) o Prophylaxis: pre-op Ketamine
 Decreased intravascular volume o Opioids: Meperidine
o Blood loss or inadequate replacement
o Third space losses POST-OP NAUSEA AND VOMITING
o “Will respond to IV fluids, and sometimes transfusion
may be necessary.”  Incidence: 10-80% develop PONV after general anesthesia
2. Distributive (Decreased Afterload) o “Patients consider it as the most undesirable complication
 Causes: of anesthesia.”
o Iatrogenic sympathectomy  Consequences:
 Sympathectomy: the loss of sympathetic tone o Delayed discharge from PACU
 It is an important cause of hypotension peri- o Unanticipated hospital admission
operatively. o Pulmonary aspiration
 “Peri-operatively, what can cause this loss in
sympathetic tone? An example is a patient who will
undergo surgery under neuroaxial anesthesia or
spinal or epidural anesthesia and he/she would
be at risk for hypotension.”
 “How does hypotension happen during sympathetic
blocking? Because of vasodilatation that will
cause venous pooling which will lead to
decrease in venous return, thus the decrease in
preload, afterload and decrease in cardiac output.”
o Critical illness
o Allergic reaction
o Sepsis
3. Cardiogenic (Pump Failure)
 Causes:
o Myocardial ischemia and infarction
o Cardiomyopathy
o Cardiac tamponade

CPU College of Medicine | Revised by: Victores Valetudinis | 2022 Page 3 of 6

 o Vestibular apparatus
o Cerebral cortex
 The Vomit center itself has intrinsic chemoreceptors that can
stimulate or repress vomiting and each of these 4 areas also
respond to different stimuli to affect the vomiting center and how
all these areas interact to modulate nausea and vomiting may
lead us to its specific treatment.

Consequences of PONV

Hospital Physical Psychological

 Delayed  Dehydration  Aversion surgery
discharge from  Electrolyte  Increased patient
PACU by an imbalance discomfort
additional 15 to  Anorexia  Dissatisfaction
35 minutes  Wound
(average 25 dehiscence
minutes)  Bleeding
 Additional staff  Aspiration
time of 35  Loss of vision
minutes per  Esophageal tears
patient on the
average impose
an incremental
cost per patient
over the initial 3
hours

 PONV has a lot of consequences. For the hospital, For the

medical practitioner, and most importantly for the patient.
 It is a major cause of delayed discharge from the PACU and can
can cost an additional of upto P3000 worth for overtime stay.
 Physically for the patient. It can cause dehydration, electrolyte
imbalance, wound dehiscence and other complications. And
PONV maybe the only experience that the patient remembers
and this is a very important cause of patient dissatisfaction.

PONV Process Risk Factors for PONV

 The risk for PONV is best predicted by a simplified risk score.

Risk factors include female gender, nonsmoking status, history of
PONV and/or motion sickness, and use of opioids, in addition, the
type of anesthesia and the surgery also impacts PONV
What triggers nausea and vomiting?
 The vomiting center located in the medulla oblongata receives Simplified Risk Score to Predict PONV in Adults
input from 4 major areas:
o GIT  Risk of PONV increases with number of risk factors present
o Chemoreceptor trigger zone

CPU College of Medicine | Revised by: Victores Valetudinis | 2022 Page 4 of 6

 Prevention of PONV should be induced if ≥ 2 risk factors are
present.

Risk Factors Points

 Female 1
 Non-smoker 1
 History of PONV/Motion Sickness 1
 Post-operative opioids 1
Sum = 0, 1, 2, 3, 4

 The risk score is calculated by giving 1 point for the presence of

each risk factor. It follows that the risk of PONV increases with
the number of risk factors present.
 Gender is the strongest patient-specific predictor
 3-4x more likely to have PONV
 Etiology is unknown but it is associated with higher levels of
progesterone, estrogen
 Higher incidence in reproductive period and declines at age 70.

Risk Factors for PONV

 After assessing patient risk and reducing baseline risk factors, ANTIEMETIC DRUGS
guidelines recommend prophylaxis for moderate risk patients
using 1 to 2 interventions with the following drugs. And for high-
First-line Antiemetics
risk patients – a multimodal approach is suggested.
 ASA 2002
o Prophylaxis with:  Three classes with similar efficacy and a relative reduction risk of
~25%
 5 HT3 RA, Droperidol, Dexamethasone,
o 5HT3 RAs
Metoclopramide, 5 HT3 RA + Dexa
o If required, rescue with 5 HT3 RA o Corticosteroids
o Dopamine antagonists
 ASPAN 2006
o Prophylaxis with 1 or more:  Act independently
 Have additive effects when used in combination
 5 HT3 RA, Droperidol, Dexamethasone, H1 receptor
blocker, Transdermal scopolamine
Second-line Antiemetics
o If required, rescue with Promethazine, Prochlorperazine or
Metoclopramide
 SAMBA 2007  Drugs with less favorable side effect profiles or limited efficacy
o Assess patient risk o Metoclopramide
o Reduce baseline risk factors o Haloperidol
o Moderate risk: Prophylaxis with 1-2 interventions: o Dimenhydrinate
 5 HT3 RA, Droperidol, Haloperidol, Dexamethasone, H1 o Transdermal Scopolamine
receptor blocker, Transdermal scopolamine,
Promethazine, Ephedrine SPINAL HEADACHE
o High risk- multimodal approach
o If required administer another category of agent  Occurs after a neuroaxial anesthesia, more commonly spinal than
 Samba 2014 - What’s New? dural. Worsens when standing up, relieved by lying down and
o Risk scoring system for PDNV intake of NSAIDs.
o New antiemetics (palonosetron, neurokinin-1 RA)  Leakage of CSF from the dura can cause reduced intracranial
pressure aggravated by sitting up
Algorithm for PONV Prophylaxis  Headache after spinal anesthesia which is worsened when sitting
up
 NSAIDs can be given for pain relief
 Increased fluid intake and lying flat

OTHERS

 Delirium: in 10% of patients, common in elderly

 Emergency excitement: transient confusional state common in
children
 Delayed awakening
o Response to stimulation after anesthesia should occur within
60-90 minutes
o Residual sedative: most common cause
 Sore throat
 Damage to teeth, lips and tongue
 Damage to eyes during GA

CPU College of Medicine | Revised by: Victores Valetudinis | 2022 Page 5 of 6

 Nerve damage Figure 16. Relationship between Stress Levels and
o Complications may be avoided by performing with due care Performance Happiness and Health
during intubation

HAZARDS IN ANESTHESIA  There must be balance between happiness and stress. As future
doctors, you must remember that time management is important
 Biological to maintain a balance in your life.
 Mechanical
 Chemical REFERENCES
 Physical
 Personal  Dr. Hofileña’s PowerPoint Presentattion
 MAM Trans
Biological Hazards

 Infectious diseases
 Precautions should be exercised:
o Prevent infection between patients-anesthesiologist
o Hand hygiene
o Sterilization of all equipment
o Dispose onetime use equipment

Mechanical Hazards

 Injury and harm to the anesthesiologist in the workplace

o Slips and falls
o Burns

Chemical Hazards

 Noxious pollutants
 Anesthetic gases
 Fire and explosion

Physical Hazards

 Noise pollution
 Physical injury: orthopedic, soft tissue injury, eye injury
 Electrical hazards
 Radiation and nuclear hazards

Personal Hazards

 Drug use and addiction: 1-15 doctors with drug or alcohol abuse
 Stress and burnout
 Exhaustion and fatigue: mental, physical and emotional
 Suicide
o More common in anesthesiologists compared to other
specialties because of high levels of stress

CPU College of Medicine | Revised by: Victores Valetudinis | 2022 Page 6 of 6