Transcript anesthetic problems and emergencies

Anesthetic Problems and
Emergencies
A&A Chapter 12 pg. 319- 349
Why Do Problems Arise?
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Human error
Equipment error
Drug adverse effects
Patient factors
Anesthetic problems will inevitably occur at
some point in your career.
No anesthetic experience is the same, so
beware of the false sense of security!
Human Error
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Failure to obtain an adequate history or
physical exam on the patient
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Ideally, every patient scheduled for anesthesia
should have a complete PE, and a thorough history
obtained with the owner present.
*Less than ideal circumstances are common:
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Owner drops patient off in a hurry
Patient brought in by neighbor or friend
Receptionist takes the history
HISTORY?
Human Error
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Lack of familiarity with the anesthetic
machine or drugs
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Thank goodness for LVTs!
Human Error
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Fatigue
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Distracted or rushed
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Proper scheduling of surgeries can help with this
Usually you have your surgical patient and…
Inattentiveness
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Having a low level of anxiety is good!
Human Error
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Incorrect administration of drugs
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Inaccurate weight
Math errors – calculating OR drawing up
Use of wrong medication
Use of wrong ______________
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Incorrect route of administration
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Enro, ketamine, dexamethasone, pred
IV v. IM
Confusion between
syringes
Equipment Failure
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CO2 ABSORBER EXHAUSTION
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How is CO2 removed from a rebreathing system?
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How is CO2 removed from a non-rebreathing system?
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Best ways to keep an eye on exhaled CO2?
Exhausted granules can cause your patient to rebreathe
what substance?
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↑ CO2 = Tachypnea, tachycardia, arrhythmias
Equipment Failure
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NO OXYGEN FLOW
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Which two parts of the machine may be malfunctioning?
Oxygen tank: check for empty tank, disconnected hose,
leaks
Flow meter: will gradually fall as the O2 tank empties
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Periodically check this!
*Which breathing system can go without new O2 flow longer?
Equipment Failure
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ANESTHETIC MACHINE MISASSEMBLED
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The better you know this machine and the flow of
gas, the quicker you will be able to solve problems.
*Where do some of the most common misassembled
parts happen on the machine?
Equipment Failure
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ENDOTRACHEAL TUBE PROBLEMS
 Blocked tube
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Twisting or kinking of the tube (inappropriate
positioning)
Accumulation of material such as blood, mucus,
excess lubricant
*What tubes do you need to pay special attention to?
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Solution: Check signs of tube properly in the trachea
*If truly blocked 
Equipment Failure
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ENDOTRACHEAL TUBE PROBLEMS
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Tube advanced too far into a bronchus
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How do you solve this?
Cuff or tube is damaged
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Solution?
Equipment Failure
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VAPORIZER PROBLEMS
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Wrong anesthetic in the vaporizer
Non-precise concentration will be delivered
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Tipped over or over-filled
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Solution:
Vaporizer dial may be jammed
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Solution:
Equipment Failure
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POP-OFF VALVE PROBLEMS
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The pop-off valve is inadvertently left closed 
pressure builds  patient cannot exhale 
=rupture of lungs and decreased
venous return to
Reasons why pop off would be closed??
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Solution:
*Can adjust the amount of gas in the reservoir bag by
Anesthetic Agents
“Every injectable or inhalation agent has the potential to
harm a patient and, in some cases, cause death”.
(Page 323)
Review the description of the physiological effects of pre-anesthetic
and general anesthetic agents in chapter 3.
Anesthetic Agents
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Anesthetic protocol should be chosen based on the
patient’s needs
Anesthetist must be familiar with drug side effects
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Such as?
Understand why balanced anesthesia is safer!
Patient Factors
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Pages 323-334
Age
Reproductive status
Weight
Breed
Trauma
Organ disease
ASA Physical Status Classification
Patient description and examples
Potential problems
Solutions
Geriatric Patients
ASA P2
(75% of life expectancy)
POTENTIAL PROBLEMS
 Reduced organ function
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Increased risk for hypervolemia
Prolonged recovery
 Poor
response to stress
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risk for degenerative disorders
Cancer, cardiac disease, diabetes
 Increased
risk for hypothermia- reduced
ability to thermoregulate
Geriatric Patients
ASA P2
(75% of life expectancy)
POTENTIAL SOLUTIONS
Pediatric Patients
ASA P2
(<3 months of age)
POTENTIAL PROBLEMS
 Increased risk for hypothermia- can’t shiver, lack of
body fat; high body surface area
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Over hydration common
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Increased risk of hypoglycemia, hypotension,
bradycardia
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Inefficient excretion of drugs- non developed liver
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Difficult intubation and IV cath placement
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Unpredictable response to atropine <14 days
Pediatric Patients
ASA P2
(<3 months)
POTENTIAL SOLUTIONS
Brachycephalic Patients
ASA P1
Pug, Pekingese, Boston Terrier, etc.
POTENTIAL PROBLEMS
 Conformational tendency toward airway
obstruction
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Elongated soft palate w/ redundant tissue
Small nasal openings
Small diameter trachea
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high vagal tone (parasympathetic)
Bradycardia common
Ocular surgery consideration?
Brachycephalic Patients
ASA P1
Pug, Pekingese, Boston Terrier, etc
POTENTIAL SOLUTIONS
Sighthounds
ASA P1
Greyhound, afghan hound, whippet, borzoi, saluki, Russian
wolfhound
POTENTIAL PROBLEMS
 Increased sensitivity to barbiturates
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(ex. thiopental)
Highly lipid soluble drugs that leave brain for fat
Hounds- lack of body fat for redistribution/elimination
of the drug  drug stays on the brain longer
POTENTIAL SOLUTION
Obese Patients
ASA P2
Body condition score 5/5
POTENTIAL PROBLEMS
 Accurate dosing is difficult based on weight
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Poor distribution of drugs- no blood supply to fat
 Respiratory
difficulty; rapid shallow resps
Obese Patients
ASA P2
Body condition score 5/5
POTENTIAL SOLUTIONS
Cesarean Patients
ASA P1
POTENTIAL PROBLEMS
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Increased workload to heart
Respiration compromised due to decreased lung
capacity- fetuses pressing on diaphragm
Increased risk of hemorrhage from uterus- already
anemic from plasma going to fetuses
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Physiologic anemia- high plasma but not RBC
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Increased risk of vomiting/regurgitation- not fasted
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Decreased Ax requirement- increased progesterone
already stimulates GABA receptors (inhibitory)
Fetuses will receive drugs
Cesarean Patients
ASA P1
POTENTIAL SOLUTIONS
Delivered Neonates
POTENTIAL PROBLEMS
 Susceptibility to the effects of the anesthetic
agents (reduced CV and resp. function)
 Not breathing
POTENTIAL SOLUTIONS
Trauma Patients
ASA P3, P4 or P5
POTENTIAL PROBLEMS
1. Respiratory distress
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Pneumothorax: air in pleural space
 No negative pressure = lung collapse
Pleural effusion: fluid in pleural space
 Fluid compressing lung expansion = lung collapse
Pulmonary contusions/edema: fluid in lung parenchyma
 Fluid in alveoli = no gas exchange
Trauma Patients
ASA P3, P4 or P5
Respiratory distress
POTENTIAL SOLUTIONS
Trauma Patients
POTENTIAL PROBLEMS
2. Cardiac arrhythmias
Solution:
3. Shock/hemorrhage
Solution:
4. Fractures/organ rupture  blood loss
Solution:
5. Unknown internal injuries
Solution:
Patients w/ Cardiovascular Disease
ASA P3, P4, P5
POTENTIAL PROBLEMS
 Circulation
compromised
 Pulmonary
edema common
 Increased
tendency to develop arrhythmias
Patients w/ Cardiovascular Disease
ASA P3, P4, P5
POTENTIAL SOLUTIONS
Patients w/ Respiratory Disease
ASA P3, P4, P5
POTENTIAL PROBLEMS
 Poor
oxygenation of tissues
 Patient
may be anxious and difficult
to restrain
 Increased
risk of respiratory arrest
Patients w/ Respiratory Disease
ASA P3, P4, P5
POTENTIAL SOLUTIONS
Patients w/ Hepatic Disease
ASA P3, P4, P5
POTENTIAL PROBLEMS
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Delayed metabolism of drugs filtered through
liver
Decreased synthesis of clotting factors and
proteins = coagulation issues and
hypoproteinemia
 Increased potency of barbituates (unbound
drug molecules go to brain)
Icteric- no MM vitals
Prolonged recovery
Improper glycogen/gluconeogenesis 
hypoglycemia
Patients w/ Hepatic Disease
ASA P3, P4, P5
POTENTIAL SOLUTIONS
Patients w/ Renal Disease
ASA P3, P4, P5
POTENTIAL PROBLEMS
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Delayed excretion of anesthetic agents
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Metabolites are excreted via kidneys
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Electrolyte imbalances common
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Dehydration may be present
Patients w/ Renal Disease
ASA P3, P4, P5
POTENTIAL SOLUTIONS
Patients w/ Renal Disease
POTENTIAL PROBLEM
 Blocked Toms
Hyperkalemic  cardiac arrhythmias  arrest
 Dehydrated, painful
 Uremic
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SOLUTION: