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Anesthetic Problems and Emergencies A&A Chapter 12 pg. 319- 349 Why Do Problems Arise? 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 Failure to obtain an adequate history or physical exam on the patient 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: Owner drops patient off in a hurry Patient brought in by neighbor or friend Receptionist takes the history HISTORY? Human Error Lack of familiarity with the anesthetic machine or drugs Thank goodness for LVTs! Human Error Fatigue Distracted or rushed Proper scheduling of surgeries can help with this Usually you have your surgical patient and… Inattentiveness Having a low level of anxiety is good! Human Error Incorrect administration of drugs Inaccurate weight Math errors – calculating OR drawing up Use of wrong medication Use of wrong ______________ Incorrect route of administration Enro, ketamine, dexamethasone, pred IV v. IM Confusion between syringes Equipment Failure CO2 ABSORBER EXHAUSTION How is CO2 removed from a rebreathing system? How is CO2 removed from a non-rebreathing system? Best ways to keep an eye on exhaled CO2? Exhausted granules can cause your patient to rebreathe what substance? ↑ CO2 = Tachypnea, tachycardia, arrhythmias Equipment Failure NO OXYGEN FLOW 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 Periodically check this! *Which breathing system can go without new O2 flow longer? Equipment Failure ANESTHETIC MACHINE MISASSEMBLED 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 ENDOTRACHEAL TUBE PROBLEMS Blocked tube 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? Solution: Check signs of tube properly in the trachea *If truly blocked Equipment Failure ENDOTRACHEAL TUBE PROBLEMS Tube advanced too far into a bronchus How do you solve this? Cuff or tube is damaged Solution? Equipment Failure VAPORIZER PROBLEMS Wrong anesthetic in the vaporizer Non-precise concentration will be delivered Solution: Tipped over or over-filled Solution: Vaporizer dial may be jammed Solution: Equipment Failure POP-OFF VALVE PROBLEMS 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?? 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 Anesthetic protocol should be chosen based on the patient’s needs Anesthetist must be familiar with drug side effects Such as? Understand why balanced anesthesia is safer! Patient Factors 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 Increased risk for hypervolemia Prolonged recovery Poor response to stress Higher 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 Over hydration common Increased risk of hypoglycemia, hypotension, bradycardia Inefficient excretion of drugs- non developed liver Difficult intubation and IV cath placement 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 Elongated soft palate w/ redundant tissue Small nasal openings Small diameter trachea Abnormally 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 (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 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 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 Physiologic anemia- high plasma but not RBC Increased risk of vomiting/regurgitation- not fasted 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 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 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 Delayed excretion of anesthetic agents Metabolites are excreted via kidneys Electrolyte imbalances common 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 SOLUTION: