prevention and treatment of

1
Chapter 14 prevention and treatment of serious
complications during general anesthesia
2
Introduction Complications of anesthesia involve
three aspects 1. Patient's condition 2.
Diathesis of anesthetist 3. Influence and fault
of anesthetics? anesthetic apparatus and
correlated instrument
3
Serious Complications during General Anesthesia
Respiratory tract obstruction
Respiratory depression Hypotension and
Hypertension Myocardial ischemia
Hyperthermia and Hypothermia
Awarenss and Delay of Awake
Cough?Singultus?Postoperative vomiting?
Postoperative pulmonary infection
Malignant hyperthermia
4
Respiratory Obstruction ??Glossocoma
1.Aetiology 2.Liability factor (1)Justo
major of corpus linguae (2)Short and
stout (3)Short neck (4)Lymphadenosis of throat
posterior wall (5)Hypertrophy of tonsils
5
Respiratory Obstruction 3.Clinical features
4.Management (1)Side lying? (2)Head
hypsokinesis? (3)Lift submaxilla? (4)Oropharyngeal
parichnos Nasopharyngeal parichnos
6
(No Transcript)
7
Respiratory Obstruction ??Airway obstruction
by secretion? purulent sputum?blood
and foreign object
1.Aetiology (1)Inhalation of stimulant
anesthetic, (2)Bronchiectasis?pulmonary abscess?
pulmonary tuberculous cavity
8
Respiratory Obstruction (3)Operation of cavum
nasopharyngeum? oral
cavity?Harelip (4)Desquamation of tooth or
artifcal teeth 2.Management (1)Sufficient
belladonna premedication (2)Intubation (3)Suck
respiratory tract (4)Pull out dentium vacillatia
or artifcal teet
9
Respiratory Obstruction ??Regurgitation and
Aspiration 1.AetiologyAnticholinergic agent
Morphine
General anaesthetics
Muscle relaxant
2.Clinical features (1)Bronchospasm (2)Tachypnea
and dyspnea (3)Moist rales (4)Sever hypoxia
10
Respiratory Obstruction 3.Management (1)Fast
ing Adult8h before anesthesia
Children milk and solid diet liquid
lt 6 m 4h
2h 636 m 6h
3h gt 36 m
8h 3h
11
Respiratory Obstruction (2)Preoperative
administration of an H2-receptor
antagonist(cimetidine or ranitidine)to
decrease further secretion of additional
acid. (3)Application of gastric decompression by
a wide- bore nasogastric tube
Preparing for suction (4)Full stomach/high level
ileusawake intubation (5)Rapid - sequence
induction and intubation without
positive - pressure ventilation before
intubation.
12
Respiratory Obstruction (6)Application of
cricoid compression to control
regurgitation of gastric contents (7)Extubation
when the patient is fully awake (8)Aspiration
Head down position,suck vomitus
Bronchial antispasmodic and antibiotics
Respiration support Lavage
of trachea using 0.9NaCl
13
Respiratory Obstruction ??Malposition of
catheter?Obstruction of
lumina?Anaeshetic machine failure 1.
AetiologyCatheter twist
Block by sputum
Corrugated tube twist
Malfunction of respiration valve 2.
ManagementExamine position of catheter
Respiratory sound
Breathing circuit
Respiration valve
14
Respiratory Obstruction ??Trachea Compression 1.
Aetiologytumor of neck or mediastinum
hematoma ?edema calidum 2.
Management ??Inflam affection of pharyngo-oral
cavity? Larynx tumer?Allergia laryngeal
oedema 1. Aetiologyperitonsillar abscess? Larynx
tumor pharynx
posterior wall abscess 2. Management
15
Respiratory Obstruction ??Laryngospasm and
Bronchospasm (?)Laryngospasm 1.
Aetiologypharyngeal vagus nerve excitability? 2.
Evoked reasons (1)hyoxemia?hypercapnia?secretion?
intubation oropharynx
parichnos?laryngoscope (2)light anesthesia 3.
Clinical features 4. Management
16
Respiratory Obstruction 5. Preventionavoid
light anesthesia?hypoxia
carbon dioxide accumulation
(?)Bronchospasm 1. Aetiology (1)Tracheal
intubation?aspiration?suck sputum (2)Operation
stimulate (3)Thiopental Sodium?Morphine 2.
Clinical features 3. Management
17
Respiratory depression ??Central Respiratory
depression 1.Aetiologyanesthetics?hyperventila
tion narcotic
analgesics ? inflate
lung unduly 2.Management (1)Anesthetics ?
reduce depth of anesthesia (2)Narcotic analgesics
? Naloxone (3)Hyperventilation?inflate lung
unduly??VT
18
Respiratory depression ??Peripheral
Respiratory depression 1. Aetiologymuscle
relaxant
hypopotassemia
general anaesthesia epidural block 2.
Management (1)Muscle relaxant ? Neostigmine
Bromide (2)Hypopotassemia ? supply potassium in
time (3)Spinal nerve block ? wait
19
Respiratory depression ??Respiration
Management 1. Effective ventilation 2.
Select of ventilation mode (1)Assistor
respiration (2)Controlled respiration
20
Hypotention and Hypertension ??Hypotension
1.Hypotensiongt 20 or ?80mmHg
2.Aetiology (1)anesthesia aspects (2)operation
aspects (3)patient aspects
21
Hypotention and Hypertension
3.Prevention (1)Insufficient body fluid ?
sufficiently supply (2)Severe
anaemia (3)Severe mitral valve stenosis (4)Myocard
ial ischemia ? maintain
blood pressure
22
Hypotention and Hypertension (5) Myocardial
infarction (6) Congestive heart failure
(7) ?BBB?sick sinus syndrome
? pacemaker (8) Hypopotassemia
(9) Atrial fibrilation ? 80120 bpm
(10)Using long-term corticosteroid
23
Hypotention and Hypertension
4.Management (1)Reduce depth of anesthesia
(2)Transfusion,Ephedrine (3)Severe coronary
heart disease ? support cardiac pump
function (4)Drag internal organs
?stop operative procedure (5)Adrenal
insufficiency ?large dose of
dexamethasone (6)Cardiac arrest?cardiac
resuscitation
24
Hypotention and Hypertension
??Hypertension 1.Hypertension
2.Aetiology (1)Anesthesia aspects
(2)Operation aspects (3)Patient aspects
25
Hypotention and Hypertension 3.
Prevention (1)Sufficient premedication (2)Phaeoch
romocytoma?hyperthyroidism (3)Intubation ?
enhance anesthesia
surface anaesthesia
a or ß-receptor blocker (4)Avoid hypoxia
and carbon dioxide accumulation
26
Hypotention and Hypertension (5)Craniocerebral
operations?droperidol (6)Operation stress ?
compound with
epidural block 4.Management (1)Incr
ease depth of anesthesia (2)a or ß-Receptor
blocker vascular smooth muscle
relaxant (3)?Ventilatory capacity??FiO2
27
Myocardiac Ischemia ??Correlative
physiological knowledge 1. Oxygen consumption
of myocardium (1)HR (2)myocardial
contractility (3)intraventricular pressure 2.
Coronary Perfusion Pressure AOP IMP
AOP- aortic pressure IMP-
intramyocardial pressure
28
Myocardiac Ischemia ??Diagnostic methodECG 1.
Cardiac conduction abnormality 2. Arhythmia 3.
Q wave,R wave progressive step down 4. S-T?gt l
mm or ?gt 2 mm 5. T wave is low?bidirection or
inversion
29
Myocardiac Ischemia ??Aetiology 1.
Tension?fear?pain 2. Hypotension or
hypertension 3. Myocardial contractility
suppression and vessel distension by
anesthetic 4. Hypoxia 5. Tachyrhythmia or
Arhythmia
30
Myocardiac Ischemia ??Management 1. Maintain
the balance of Oxygen supply- demand 2. Delay
selective operation 3. MonitorECG?MAP?CVP?CO?
SVR?Urine volume 4.
ß-receptor blocker or calcium channel blocker
5. Analgesia using morphine 6. General
anaesthesia epidural block
31
HYPERTHERMIA AND HYPOTHERMIA ??Heat
Production and Elimination 1.Heat
Production 2.Heat Elimination
(1)Radiationgt 60 (2)Conduction3
(3)Cconvection12 (4)Evaporation25
32
HYPERTHERMIA AND HYPOTHERMIA ??Normal
Thermoregulation 1. Thermoregulatory
control system (1)Cold-response
thresholds36.5?,vasoconstriction (2)Warm-response
thresholds37?,sweat 2. Thermoregulation
during General Anesthesia (1)warm-response
thresholds?1? to 38? (2)cold-response
thresholds?2? to 34.5? 3. Responses in
infants and the elderly
33
HYPOTHERMIA ??Hypothermiacore temperature lt
36? 1.Evoked reasons (1)Cold operating
rooms (2)Indoor vent (3)Administration of cold
intravenous fluids (4)Evaporation from surgical
incisions (5)General anesthetic
34
HYPOTHERMIA 2.Influence of
hypothermia (1)Drug metabolism is markedly ? ?
duration of action of anesthetics
? (2)Coagulation is impaired (3)Blood
vicidity? (4)Oxygen dissociation curve shift to
left (5)Shivering ? oxygen capacity??
3.Prevention
35
HYPERTHERMIA ??Hyperthermia 1.Evoked
reasons (1)Room temperature gt 28? (2)????????? (3
)???????????? (4)large dosage of
atropine (5)Response to transfusions
(6)Ventilation?????
36
HYPERTHERMIA 2.Influence of
Hyperthermia (1)Basal metabolic
rate? (2)Metabolic acidosis?hyperkaliemia
hyperglycosemia (3)gt 40??convulsion
3.Prevention
37
Awarenss and Delay of Awake ??Awarenss 1.
Neurophysiology of Awarenss 2. Anaesthetic
technique (1)N2O-O2- Muscle relaxant (2)Fentanyl
- Diazepam (3)Thiopental or Thiopental
- Ketamine
38
Awarenss (4)N2O- Fentanyl (5)Etomidate -
Fentanyl (6)Procaine combined anesthesia 3.
Management (1)Avoid light anaesthesia (2)Monitor
brain stem auditory evoked
potential(BSAEP)
39
PRST???? ??
?? ?? ???(mmHg) lt
??? 15 0
lt ??? 30 1
gt
??? 30 2 ??(?/min)
lt ??? 15 0
lt ??? 30
1
gt ??? 30 2 ??
?
0
???? 1
????
2 ??
???????? 0
???????? 1
???????
2
40
Delay of Awake ??Delay of Awakegt 30min 1.
Aetiology (1)Influence of Anaesthetic
Premedication Inhalation
Anaesthetic Narcotic Analgesic
Muscle Relaxant
41
Delay of Awake (2)Respiratory depression
Narcotic Analgesic and Muscle Relaxant
Hypocapnia Hypercarbia
Kaliopenia Overdose of Transfusion
Complications of operation Severe
metabolic acidosis
42
Delay of Awake (3)Severe Complications
massive bleeding
serious cardiac arrhythmias
acute myocardial infarction
rupture of intracranial aneurysm
cerebral hemorrhage
cerebral embolism (4)Long time
of hypotension and hypothermia (5)Cerebral
vessels affection before operation
43
Delay of Awake 2. Management (1)Aspect of
Anaesthetic technique (2)corresponding
management (3) dehydrationencephaledema
intracranial
hypertension (4)hypothermia - warm (5)long-term
hypotension (6)primary cerebral disease
44
Cough?Singultus?Postoperative vomiting and
postoperative pulmonary infection ??Cough
1. Degree of cough (1)???????????? (2)??????????
??,???? ??????? (3)????????
????????? ???????,??????
??????????
45
Cough 2. Harmful effects of
cough (1)??????????????????
??????? (2)?????,??????????
?????? (3)????????????????
? ??????
46
Cough 3.Evoked reasons of cough (1)Barbitura
tes (2)Cold volatility anaesthetics and
secretion of trachea (3)Intubate and suck
sputum under light
anaesthesia (4)Aspiration
47
Cough 4.Management (1)Sufficient muscle
relaxant (2)Diazepam and Droperidol (3)Aspiration
? balloon tracheal catheter?
gastrointestinal decompression
48
Singultus ??Singultus 1. Evoked
reasons (1)????????????????? (2)??????????????
2. Harmful effects of cough 3.
Management (1)Sufficient muscle
relaxant (2)Postoperation ?Diazepam and
Droperidol acupuncture
of endoclosure cave
49
Postoperative vomiting ??Postoperative
vomiting 1. Aetiology (1)role of
anaesthetics inhalation anestheticether gt
methoxyflurane gt enflurane gt
isoflurane gt N2O gt sevoflurane intravenous
anesthetic (2)category of operation (3)conditions
of patients
50
Postoperative vomiting 2. Harmful effects of
cough (1)pain?wound dehiscence (2)vomit
aspiration or asphyxiation (3)Water-Electrolyte
unbalance and Acid-Base unbalance
3. Management
51
Postoperative pulmonary infection
??Postoperative pulmonary infection (?)Pathogenic
bacteria (?)Aetiology 1. Aerosolizer
pollution 2. Intubation?incision of
trachea? endotracheal anesthesia
3. Aspiration 4. Surgery 5. Abuse
medication
52
Postoperative pulmonary infection (?)Clinical
manifestation 1. Sings and symptoms 2.
Examination of bacteriology (1)Smear of sputum
and bacterial culture (2)Hemoculture 3. Chest
X-ray
53
Postoperative pulmonary infection (?)Diagnostic
criteria 1. Fever?rales,X-ray 2.
Pathogenic bacteria 3. Hemoculturepositive
4. Secretion of lower respiratory tract
5. Secretion of respiratory tract?serum ?
and other body fluid
54
Postoperative pulmonary infection (?)Treatment
1. antibiotics 2. immunotherapy 3.
upportive treatment
55
Malignant Hyperthermia Malignant
hyperthermia(MH) an eerie and erratic
metabolic mayhem, is a clinical syndrome that in
its classic form occurs during anesthesia with a
potent volatile agent such as halothane and the
depolarizing muscle relaxant succinylcholine,
producing rapidly increasing temperature(by as
much as 1 ?/5 min)and extreme acidosis.
incidence was 11.610104,mortality rate was 73
56
Malignant Hyperthermia ??Evoked
reasonshalothane?ethoxyflurane
enflurane?scoline?

chloropromazine
lidocaine?bupivacaine ??Clinical
Syndromes 1. Temperature increases  exceed
43? 2. Whole-body rigidity occurs
57
Malignant Hyperthermia 3. Myocardial function is
severely altered 4. Increased serum levels of CK
myoglobinuria 5. Contractile response 6.
PaCO2 may exceed 100 mm Hg, and pHa may
be less than 7.00
58
Malignant Hyperthermia ??Treatment 1.
Discontinue all anesthetic agents and
hyperventilate with 100 oxygen. 2. Control
fever by iced fluids, surface cooling,
cooling of body cavities with sterile iced
fluids, and a heat exchanger with a pump
oxygenator 3. Administer bicarbonate(2 to 4
mEq/kg)
59
Malignant Hyperthermia 4. Repeat administration
of dantrolene 2mg/kg,5l0 min repeat 5.
Treatment of hyperkalemia 10u insulin 6. Monitor
urinary output mannitol 0.5g/kg
frusemide l
mg/kg 7. Corticosteroids 8. ICU monitor and
treat for 48h
60
???? ??????,15?,2004?4?23???
???????,?????? ?????????? ?????????????????
???,???? ??????? ???
??? ??ECG?MAP?SpO2?PETCO2
61
???? ??3??? PETCO2 ??60 mmHg,????
?? ??150160 bpm ????41.3?
??pH lt 7.0 ?PaCO2 gt 110 mmHg
K 5.6 mmol/L ?Ca2 1.27 mmol/L
???? 1775 u/L ????70/40mmHg??
???????????????
62
?????? ???????????,??????? ???????
?????????????? 2h?????37?
??pH 6.85?PaCO2 80 mmHg
BE -19mmol/L ?? 80
ml/h ????????ICU
63
ICU?? ??3mm??????????????
??37.0???,????,?????? ??130bpm???91/56mmHg?CV
P 20 mmHg ??PaCO2 41 mmHg
???????????,???? ?????97 umol/L?333
umol/L ?????19.2mmol/L
64
??GOT 5022 u/L?GPT 20025 u/L? LDH
7733u/L????3.9 ?????????? 31s
????????107s
????40000µ/L?? ???????? 22500 u/L
???? 20000 u/L ??????? 610 u/L
65
ICU?? (1)??????,????37??? (2)???????,????????
(3)???? (4)?????????????? (5)??6????????? (6)????
???????????? (7)TPN??????????
66
?? 48????????????
???????? ??4??????????? ??7??????????? ??14???
GOT 92.6 u/L?GPT 51.7 u/L
?????? ??16?????,??1050 ml/h ??17????????????
67
? ? (?)?? 1.?????????,???????,???? 2.???
??????????????? 3.??????? (1)????????????(???????
?) (2)???????? (3)??????????(???)
???????????? 4.???????????????????????
68
(?)????? 1.???????????????? 2.?????????,?????????
3.??????,?????? 4.?????????????????? 5.?????????
??????
???????????? 6.??????,????????????? 7.????????????
,??????????
69
????? ????????????????????????????
???????????,??????????
??????????????????????? (?)???? 1.????(1)??????
????????? (2)??????????
(3)?????
(4)?? (5)??
(6)????,?????????????
(7)???/?????-???????
70
2.??????????????,???????
?????????
????? ????????
?????????????
(?)???? 1.?? (1)???????????FRC?
(2)?????????/?????????????
?FRC?????????????????? 2.???????????????????????
? (??????) 3.
PS?????????????????
71
(?)???? 1.??????,??????????,???? 2.??????????????
???,
????,????????
???????? (?)?? 1.????23w 2.???????????,??????
?23w 3.???????????????,57?????? 4.?????? (1)???
???(?????????) ? ??????????? (2)????????
??????
72
5.??????,??????????,?????? 6.????-O2??,?????O2 7.?
?????,????????,??????? 8.ICU?????????,???????????
9.?????????????????
EA???
????????
73
(?)????????,????,????? 1.??????????,??????? 2.
?????,?????????,?????? 3.???????????(FiO20.6)
??PEEP(1015cmH2O)
????? 4.?????????????
???????? 5.???????????????,????????
74
????? (?)?? 1.???? (1)???????????????
?????????(???
??????)???? (2)?????
???????? (3)??N???N???N??????????? (4)?????????(??
????????) 2.???? (1)??????????????????? (2)??????
?????????????? (3)????????????,????????
75
(?)???? 1.?????? 2. gt 1/5????????????????????????
3.?????????V/Q???????????,?????
??????????????????? 4.??????
??????????????????????
?CO????? ? ???????? 5.?????????????????????,??????
???????????????????????? 6.??PaO
2 ???PaCO2 ? 7.??????????,???????????????
76
(?)?? 1.??????? 2. ??????????2??3???????? 3.?????
???????????????
???????? 4.???????
77
? ? ? ? ? ???????????-80,????????????
???-20,?????????????
????????,??????,?????????????,????????????????????
???????????? (?)????? 1.?? (1)????????????????
???????????
???????????????? (2)?????????(??)???????????????
???????????????????
????????????,?1??????1
/3 (3)???????????????????????????
?????????????
78
(4)??????????????????
BBC????Hct gt50????????????


??????? (5)??????(?????)???????????????
?????????????????????? (6)???????
?????????????? 2.?? (1)????????,???????????????
?? ?A??????????????
??????????????? (2)
??????????(CT?MRl)??????? 3.?? (1)??????????????
?,???????????
160/95mmHg?????????4???????? (2)?????????????????,
?????????
79
(?)????????? 1.?? ?????????????????????????
?,???????? 2.??CT?MRI,?CT????????????
? 3.??????????????????
??????????????? 4.?? (1)??????????? (2)?????????,
??????? (3)???????????? ??????(????) (4)????????
(????)?????? (5)?????????????
80
????? ???????????????????????????
??????????????????????
???????????
??????????,???????????? (?)???????????????? 1.???
? ???????????????????????
??????????????????????
????? 2.???? (1)??????????????????? (2)??????????
??????????? (3)??????????????????
81
3.???? (1) ?? ????????????????????????????
????????????? ??????,?????? ??
?????????????
???????RBC???????????? (2) ??????????????????????
??? ????????????? ?????????????????????????????
????????????????
(3)???????????CVP????????CO2?N2??
V????A????????????gt40ml??? (4)????????
????????????????V/??
??????????????????,?DIC
82
(?)??????????????????????? 1.????????????????????
???????? ???????????CO????????
??? ??????75?????1h??? 2.?????
??????????????????????
?V/Q??????? (?)???? 1.????????????,??(X?)?????? 2
.?A?????,????A?????????????? 3.ECG
?????ST???????
ECG?S1Q3T3--I??S???,?????Q??T??? 4.???????????? 5.
???????????????????????
83
(?)??????,????1030,?????? 1.?????????????????
?????????? ?????,?????????????????
, ????????????????????? 2.
CT?????????????? 3.?????????????????????
?????,?????????????? 4.??????
???????? 5.??????,??????? (?)?? 1.???????? 2.???
???????????????? 3.??????,??????
84
4.???????????? 5.??????????????? 6.??????,????????
7.??????????????? 8.????????????????
(?)?? 1.???????? (1)????????????????????? (2)?
??????,?????????,???????? (3)????????????,??????
?? ?????????? (4)????????????????
????????? (5)??????????????
85
2.????? (1)???????????
????????????N2????????? (2)???????????????????????
? (3)????????????????????? (4)???????????????? 3.?
???????V???A??????????? (1)???? ?V?????A????????
???????????? ?PEEP?????????????????????????? ?????
?(??????)???????????????? (2)?? ????????????,????
?? ???????? ????(????????????)