Plications of General Anesthesia

COMPLICATIONS OF
GENERAL ANESTHESIA
RESPIRATORY COMPLICATIONS
PULMONARY ASPIRATION OF GASTRIC
CONTENTS
• It can occur at any time of induction or in the postoperative period.
• Pulmonary aspiration is a major cause of death associated with anesthesia. Mortality after
aspiration is 5 to 70% depending on the volume and pH of aspirated material and time
interval between detection and management.
PULMONARY ASPIRATION OF GASTRIC CONTENTS
• Hydrodynamics of regurgitation:
 Normal intragastric pressure is 5 to 7 cm H2O and regurgitation is prevented by the tone of
lower esophageal sphincter (LES).
 A pressure of >28 cm H2O is required to overcome the competency of LES which can lead
to regurgitation but in conditions like pregnancy, hiatus hernia which distorts the anatomy of
LES, a pressure > 15 cm H2O can cause regurgitation of gastric contents. During anesthesia
tone of cricopharyngeal sphincter is also decreased which can lead to aspiration.
• Predisposing factors:
 Full stomach: It is single most important factor. Therefore adequate fasting should be there.
 Depressed level of consciousness.
 Conditions decreasing the tone of LES:
 Pregnancy (acid aspiration in late pregnancy was described by Mendelson called it as Mendelson syndrome).
 Abdominal tumors.
 Obesity.
 Hiatus hernia.
 Presence of nasogastric tube.
 Drugs: Atropine/Glycopyrrolate, Opioids, Thiopental, Sodium nitroprusside, Dopamine, Halothane, ganglion
blockers.
 Conditions delaying gastric emptying: diabetes, hypothyroidism, narcotics, pain, anxiety.
• Risk factors:
 Volume > 25ml
 pH < 2.5
 Solid particles
 So acidic solid particles in large quantity (>25 ml) will produce the most fulminant reaction.
• Signs and symptoms:
 Tachypnea
 Tachycardia
 Cough due to laryngospasm/bronchospasm
 Wheezing and crepitation
 Cyanosis
 Continuous fall of oxygen saturation
 X-ray chest shows shadows.
• Pathology: Chemical trauma to bronchial and alveolar mucosa and injury to vascular
endothelium can cause exudative pneumonitis or pulmonary edema (ARDS).
• Prevention:
 Empty stomach as per recommendations.
 Inhibition of gastric acid secretion by H2 antagonists or PPI inhibitors night before surgery
in patients who are at high risk of aspiration.
 Metoclpramide: It fastens gastric emptying and increases the tone of LES.
 Neutralization of gastric content (to increase the pH) by antiacids like sodium citrate
• Full stomach patient should be managed in the following way to prevent aspiration:
 Regional anesthesia is preferred over general anesthesia.
 Awake intubation with topical analgesia in upper airways.
 If general anesthesia is to be given, it should be rapid sequence (crash) intubation while
assistant maintains the cricoid pressure (Sellik’s manoeuvre). Cricoid pressure compresses
esophagus against vertebral column preventing aspiration.
 In rapid sequence intubation after proxygenation for 4-5 min induction agent is given
followed immediately by succinylcholine. Ventilation with bag and mask is not done
because with bag and mask ventilation the air leak into stomach can achieve intragastric
pressure > 28 cm H2O (critical pressure for aspiration) easily. An assistant applies pressure
over cricoid to prevent regurgitation till the cuff of endotracheal tube is inflated.
• Treatment:
 Immediately turn the patient to one side with head low position.
 Do suction to prevent further aspiration. Tracheal suction may be sufficient in mild cases.
 Oxygen and CPAP (continuous positive airway pressure) in conscious patient till the patient
is maintaining the oxygen saturation. If saturation is still falling on CPAP paralyse the
patient and put on IPPV (intermittent positive pressure ventilation) with PEEP (positive end
expiratory pressure).
 Antibiotics, bronchodilators, steroids.
HYPOXIA
• Causes are:
 Inadequate oxygen supply which may be because of exhausted stores, leaks in machine and circuit,
disconnections and malpositioned tubes.
 Hypoventilation.
 Ventilation perfusion abnormalities which may occur in atelectasis, pulmonary edema, pneumothorax,
pulmonary embolism.
 Respiratory obstructions.
 Cardiac causes like shunts, shock.
 Others like cyanide toxicity, alkalosis, hypothermia.
• Treatment:
 Ventilation with 100% oxygen
 Treatment of cause.
HYPERCARIBIA
• Causes are:
 Hypoventilation.
 Increased airway resistance (bronchospasm).
 Exhausted sodalime.
 Increased production like in malignant hyperthermia, thyrotoxicosis.
• Treatment: Rectify the cause.
HYPOCAPNIA
• It is almost always due to hyperventilation.

RESPIRATORY OBSTRUCTION
• This may occur at induction or in postoperative period.

• Causes:
 Tongue fall: this is due to abolition of tone of genioglosuss muscle during anesthesia
 Treatment:
 Jaw is lifted upwards and forwards and head is extended.
 Oropharyngeal/nasopharyngeal airways.
 Intubation.
 Secretions: blood, mucous can irritate laryngx producing laryngospasm (glottinc closure) and cyanosis.
 Treatment:
 Remove the secretions by suction.
 IPPV with bag and mask relieves the laryngospasm in most of the cases.
 If not relieved with bag and mask ventilation, a small doses of succinylcholine (25 to 50 mg i.v.) should be given.
 I.v. lidocaine should be given to prevent further laryngospasm.
RESPIRATORY OBSTRUCTION
• Causes:
 Bronchospasm: Light anesthesia in asthmatics can induce bronchospasm. Secretions and noxious
stimuli can also induce bronchospasm.
 Treatment:
 Good depth of anesthesia.
 Bronchodilators.
 Light anesthesia during Lord’s (anal) stretching and cervical dilatation can initiate parasympathetic
overactivity causing laryngospasm, bronchospasm, bradycardia and even cardiac arrest. This reflex
is called as Breur Lockhgard reflex.
 Kinking or blockage of endotracheal tube by secretions.
 Treatment: Remove secretions through suction or change the tube.
HYPOVENTILATION
• Causes are:
 Overdosage of narcotics, barbiturates, benzodiazepines.
 CNS disorders.
 Overdosage of inhalational agents.
 Inadequate reversal.
 Pain and splints in thoracic and upper abdominal surgeries.
 Inappropriate ventilator setting.
 Leaks in machine and circuits.
 High spinal/epidural
• Treatment: Treat the cause.
COUGH/HICCUPS
• These are usually seen after light anesthesia with thiopental.

• Causes for hiccups:
 Light anesthesia
 Gastric and bowel distension
 Diaphragm irritation by touching diaphragm in upper abdominal surgeries
 Uremia
 Treatment:
 Increase the depth of anesthesia
 Muscle relaxants
 Pharyngeal stimulation by nasal catheter, Valsalva manoeuvre, CO2 inhalation.
 For intractable hiccups, phrenic nerve block may be required.
PNEUMOTHORAX
• This is a dangerous complication requiring immediate treatment. It is usually due to surgical

causes like rib resection, renal surgery and can occur after supraclavicular block. If general
anesthesia with IPPV is given for failed supraclavicular block it can convert a small
pneumothorax into tension pneumothorax.
• Treatment: chest tube drainage.
PULMONARY ATELECTASIS
• Most common pulmonary complication of general anesthesia in postoperative period.

PULMONARY EMBOLISM
• Usually present in second week but can present with sudden onset from 2 nd to 4th postoperative day.
• Signs and symptoms:
 Dyspnea
 Substernal discomfort/chest pain
 Pleural pain
 Haemoptysis
 Increased CVP
 Hypotension
 Gallop rhythm
 X-ray chest may show linear shadow, effusion or oligemia in embolus is large.
 ECG shows findings of right ventricular strain.
 Massive embolus may present as cardiac arrest.
PULMONARY EMBOLISM
• Treatment:
 Prevention of deep vein thrombosis (DVT) by:
 Early ambulation
 Pneumatic compression of calf muscles
 Leg movements in bed
 Low dose heparin/Low molecular weight heparin
 For small embolus, anticoagulant may be sufficient.
 For large embolus, streptokinase therapy should be instituted.
 For massive embolus, resuscitation followed by surgical embolectomy may be considered.
CARDIOVASCULAR COMPLICATIONS
HYPERTENSION
• May be seen intraoperatively and postoperatively.

• In intraoperative period causes are:
 Light anesthesia
 Response to laryngoscopy and intubation
 Hypercapnia
 Drugs like ketamine
 Undiagnosed pheochromocytoma
• In postoperative period causes are:
 Pain
 Hypercapnia
 Full bladder
 Emergence delirium
HYPOTENSION
• This may occur in intraoperative and postoperative period due to effect of anesthetic drugs,
inadequate fluid infusion, excessive loss, cardiac arrhythmias.
• Treatment:
 Adequate fluid infusion
 Vasopressors and inotropes
CARDIAC ARRHYTHMIAS
• May range from bradycardia to sinus arrest and from tachycardia to ventricular fibrillation
• Bradycardia – Atropine i.v.
• Ventricular tachycardia – Lidocaine i.v. or cardioversion
MYOCARDIAL ISCHEMIA
• Surgery and anesthesia are stress conditions and can precipitate MI in susceptible
individuals.
• Treatment includes:
 Oxygen
 Morphine
 Nitroglycerine
 Inotropes
 Thrombolytic therapy
 Intraaortic balloon counterpulsations
NEUROLOGICAL COMPLICATIONS
CONVULSIONS
• May be due to:
 Hypoxia
 Drugs like local analgesics, methohexital, enflurane, atracurium
 Cerebrovascular accidents
• Treatment: anticonvulsants
DELAYED RECOVERY
• Causes are:
 Inadequate reversal
 Overdosage of opioid/inhalational agents
 Electrolyte inbalance
 Acid base abnormalities
 Metabolic abnormalities like hypoglycemia
 Endocrinal disorders like hypothyroidism
 Liver and renal dysfunction
 Shock
Cerebrovascular accidents
CRANIAL NERVE PALSIES
• If trielene is used with closed circuit
AWARENESS
• Incidence is <1% but important from medicolegal point of view.
• Most common type is auditory.
• Usually seen when oxygen, nitrous oxide and opioids are used for maintenance of
anesthesia.
• Methods to prevent awareness and recall of events:
 Premedication with benzodiazepines (produce antegrade amnesia)
 Inhalational agents
EXTRAPYRAMIDAL SIDE EFFECTS
• Seen with neurolptanalgesia (droperidol + fentanyl)
AGITATION AND DELIRIUM
• Due to pain, full bladder, drugs
• Treatment:
 Treat the cause
 Diazepam
PERIPHERAL NEUROPATHIES
• Most common nerve injured during anesthesia is ulnar (34%) followed by brachial plexus
(24%). Lateral popliteal nerve is most frequently damaged nerve in lower limbs.
• Causes are:
 Faulty position
 Direct injection of drug in nerves during blocks
 Tourniquet palsies: Pressure in tourniquet should not be exceed more than 50% above
systolic pressure and duration in upper limb should be less than 1 hour and in lower limb
less than one and half hour
 Prolonged hypotension causing nerve ischemia
PERMANENT BRAIN DAMAGE
• Due to prolonged hypoxia following cardiac arrest, prolonged hypotension, cerebrovascular
accidents, raised ICT.
GIT COMPLICATIONS
NAUSEA AND VOMITING
• This is the most common complication (40%) in recovery room.
• Causes:
 Hypotension
 Hypoxia
 Drugs
 Idiopathic
 Treatment:
 Phenothiazines (Stemetil)
 Metoclopramide
Hyoscine
 Ondansetron (5-HT3 antagonist)
 Clonidine (has role in opioid induced nausea and vomiting)
THERMAL PERTUBATIONS
HYPOTHERMIA
• Hypothermia is the most common thermal perturbation seen in anesthesia.
• The reasons are:
 Most anesthetics are vasodilators, causing heat loss and hypothermia
 Cool room temperature
 Cold i.v. fluids
 Evaporation
 The heat loss during general anesthesia may be as high as 30kcal/hr
 Hypothermia may be defined as core temperature less than 36˚C. It is divided into mild
(28˚C to 35˚C), moderate (21˚C to 27˚C) and profound or severe (<20˚C).
HYPOTHERMIA
• Uses of induced hypothermia:
 For brain protection in cardiac arrest. Brain can be protected for 10 min at 30˚C and 60 min
at 15˚C.
 For tissue protection against ischemia in cardiac surgery.
 Hypothermia decreases basic metabolic rate and oxygen consumption.
 Each degree (˚C) fall in temperature reduces the metabolic rate by 6 to 7%.
 Basic metabolic rate and oxygen consumption of body is decreased by 25% in mild
hypothermia, by 50% in moderate and 80% in profound hypothermia.
 For clinical purposes only mild hypothermia is produced (temperature is kept around 32˚C).
HYPOTHERMIA
• Systemic effects of hypothermia:
 CVS:
 Bradycardia
 Hypotension
 Ventricular arrhythmia’s if temperature is less than 28˚C
 Cerebral: cerebral cortex can be protected for 10 min at 30˚C and for 1 hour at 15˚C.
 Respiratory system: Decreased minute volume and respiratory arrest below 23˚C.
 Oxygen dissociation curve is shifted to left.
Blood: Increased blood viscosity and platelet count
HYPOTHERMIA
• Systemic effects of hypothermia:
 Acid base balance: Increased solubility of blood gases. So less values on blood gas
analysis. Acidosis is the feature of hypothermia and is due t increased lactic acid production
because of blood stasis.
 Kidney: Decreased GFR, no urine output at 20˚C.
 Endocrine system: Decreased adrenaline and noradrenaline. Hyperglycemia because of
decreased insulin synthesis.
HYPOTHERMIA
• Treatment:
 Warm i.v. fluids.
 Increase room temperature: The ideal operation theatre temperature for adults is 21˚C and
for children - 28˚C.
 Cover the patient with blankets.
 Forced warm air by a special instrument (Bair Hugger airflow device).
SHIVERING
• Shivering occurs as s protective mechanism as inhalational agents, spinal/epidural block
causes vasodilatation leading to heat loss.
• Shivering can be abolished by inhibition of hypothalamus. Most commonly shivering is seen
after halothane.
• Treatment of shivering:
 Pethidine/Pentazocine/Tramadol
 O2 consumption may be increase to 4 times (400%) during shivering. So oxygen inhalation
during shivering is mandatory.
MALIGNANT HYPERTHERMIA
• It is a clinical syndrome observed during general anesthesia associated with rapidly increasing
temperature as great as 1˚C/5 min
• Etiology:
 It is due to abnormality of Ryanodine receptor which is calcium releasing channel of sarcoplasmic
reticulum. The abnormality leads to excessive accumulation of calcium which causes sustained
contraction of muscle.
 It is associated with conditions like Duchenne muscle dystrophy, arthrogryposis multiplex
congenital, osteogenesis imperfect, congenital strabismus, central core diseases.
 Patient with history of neuroleptic malignant syndrome are a high risk of developing malignant
hyperthermia.
 Patients who develop masseter spasm after succinylcholine are very prone to develop malignant
hyperthermia.
• Causative agents:
 Muscle relaxant: Succinylcholine is most commonly implicated drug.
 Inhalational agents: Halothane is most common inhalational agent. Others are isoflurane,
enflurane, desflurane, sevoflurane, methoxyflurane.
 Local anesthetics: Lidocaine.
 Other drugs: tricyclic antidepressants, monoamine oxidase inhibitors, phenothiazines.
• Clinical features:
 Hyperthermia
 Increased end tidal CO2. This may rise to more than 100 mmHg (normal 32 to 42 mm Hg).
 Hypoxia and cyanosis.
 Tachycardia, hypertension, cardiac arrhythmias.
 Severe metabolic acidosis (pH < 7.0).
 Hyperkalemia, muscle rigidity, increased creatine phosphokinase, increased myoglobin.
 Renal failure, DIC, pulmonary and cerebral edema.
Death
• Treatment:
 Stop all anesthetics immediately
 Hyperventilation with 100% oxygen
 Control temperature by ice cooling, ice cold saline.
 Correct acidosis
 Correct electrolyte imbalance (hyperkalemia)
 Maintain urine output
 Specific: Dantrolene 2 mg/kg to be repeated every 5 minutes to a maximum of 10 mg/kg
• Screening: creatine phosphokinase level is the basic screening tool. Individuals having high
creatine phosphokinase levels should not be subjected to causative agents.
• Anesthesia for patients susceptible for malignant hyperthermia:
 Local or regional anesthesia is preferred technique (but lidocaine should not be used).
 Safe drugs for general anesthesia are barbiturates, propofol, narcotics, benzodiazepines,
nitrous oxide, nondepolarizing muscle relaxants.
• Other causes of hyperthermia I anesthesia are:
 Hypermetabolic states like thyrotoxicosis and pheochromocytoma
 Neuroleptic malignant syndrome due to phenothiazines
 Anticholinergics (Atropine)
 Injury to hypothalamic temperature regulatory centres.
COMPLICATIONS OF DIFFERENT
POSITIONS
• Lithotomy: reduction in vital capacity is as high as 18% which increases the V/Q mismatch.
 Nerve injuries (peroneal nerve, saphenous nerve, femoral nerve, obturator nerve).
 Muscle injury – compartment syndrome
 Increased cardiac load due to increased venous return
• Trendelenburg: Increased cardiac load due to increased venous return, decreased vital
capacity (15%), increased central venous pressure, increased intraocular and intracranial
pressure, venous congestion of face, cerebral haemorrhage, lingual and buccal neuropathy.
COMPLICATIONS OF DIFFERENT
POSITIONS
• Sitting: spinal cord ischemia and quadriplegia can occur due to extreme flexion of neck.
Brachial plexus injury: weight of arm during general anesthesia can stretch the brachial
plexus. Femoral and obturator nerve injury due to extreme angulation at thigh. Venous air
embolism.
• Lateral: Transient Horner syndrome, brachial plexus injury, compartment syndrome of hand,
spinal cord ischemia (due to extreme flexion of neck), breast injury, genitalia injury, radial
and ulnar nerve injuries.
EYE COMPLICATIONS
• Eye keratitis (corneal abrasion) is very common complication of general anesthesia if eyes
remains open (because blinking reflex has been lost).
• To prevent keratitis artificial tears, eye ointment should be instilled and eyes are to be
covered with eye pads.
RENAL COMPLICATIONS
• Renal function may be impaired due to hypotension or nephrotoxic anesthetics like
methoxyflurane.
HEPATIC COMPLICATIONS
• Hepatic functions may be impaired due to hypotension or hepatotoxic anesthetics like
halothane.
ANAPHYLACTIC REACTION
• Anaphylactic reaction can occur with any of the drug used for general anesthesia.
• Treatment:
 Maintenance of airway (if laryngeal edema or bronchospasm develops).
 Adrenaline 1:10 000
 Steroids (hydrocortisone)
 Histamine antagonist like diphenhydramine

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Plications of General Anesthesia

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COMPLICATIONS OF

• It is almost always due to hyperventilation.

• This may occur at induction or in postoperative period.

• These are usually seen after light anesthesia with thiopental.

• This is a dangerous complication requiring immediate treatment. It is usually due to surgical

• Most common pulmonary complication of general anesthesia in postoperative period.

• May be seen intraoperatively and postoperatively.

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