1
Q
What are the differences between preventable and non-preventable complications?
A
Preventable -had someone done something differently or if equipment had been functioning, pt would not have been injured
Unpreventable - would have happened no matter what
- suddenly death syndrome
- fatal idiosyncratic drug reactions
- poor outcomes despite proper management
2
Q
What are the top 3 closed claims from the â90s?
A
- Death: 22% of claims
- nerve injury 18%
- brain damage 9%
(Emerging claims in regional anesthesia and pain management as more is being done for them )
3
Q
What is accounted for in human error?
A
** unrecognized breathing circuit disconnect *
â> if vent alarming- donât just silence it- make sure itâs connected
- medication labels- always ready labels
- airway management- not being prepared or having equipment ready or continuing the same thing instead of calling for help air moving down the algorithm
- anesthesia machine misuse
- fluid mismanagement
- IV line disconnection
4
Q
How can anesthesia complications be prevented?
A
- improved pt monitoring
- improved anesthesia techniques
- improved education of anesthesia providers
- comprehensive protocols
- standards of practice (standardized monitors)
- active risk management programs
- most important factor is the focus on pt safetyâ> WE are the gatekeepers!! **
5
Q
What are the different types of complications?
A
- airway injury
- Peripheral nerve injury
- awareness
- eye injury
- cardiopulmonary arrest during spinal anesthesia
- hearing loss
- allergic reactions
6
Q
What can happen with injury to the airway?
A
The two most common post op issues are sore throat and nauseaâ> make sure to tell pt ahead of time to expect this
- sore throat
- dysphasia
- dental injury: most common claimâ> with poor dentition let them know possibility of tooth falling out
- TMJ: when pulling on jaw it may lock in place
- VOCAL CORD PARALYSIS: be very cautious with singers
- VOCAL CORD GRANULOMA
- ARYTENOID DISLOCATIONâ> painful
- ESOPHAGEAL PERFORATION
7
Q
What are some possible nerve injuries?
A
- positioning â> hypotension
- most common injures:
- brachial plexus
- common peroneal
- radial
- ulnar
- retinal ischemia
- skin necrosis
8
Q
When does awareness usually happen?
A
~ 0.1-0.4%
- trauma when pt too unstable to give a whole lot of anesthetic
- crash OB casesâ> c section where you/surgeon are really hurrying to get the baby out
- CV surgery with CPBâ> sternotomy is extremely stimulating and perfusionist runs anesthetic- may run them light
- or forgot to turn gas on-awake paralysis
9
Q
What are the differences between versed and scopolamine?
A
- versed causes anterograde amnesia (this point forward)
- scopolamine causes retrograde amnesia
- if you had no gas running for an hour, give scopolamine to prevent recallâ> still chart, but be careful with your wording
10
Q
How can you prevent intra-operative recall?
A
- routinely discuss recall with pt and steps taken to decrease it
- Define MAC with sedation for pt- if sedation will be light, let them know ahead of time
- use volatile anesthetic agents at level consistent with amnesia
- MAC 0.6 when used with opioids and N2O
- MAC 0.8-1.0 when used alone
- add benzos. Or scoplalamine
- use BIS
- document end tidal concentrations of agent
- document admin of amnesia drugs
11
Q
What is the treatment for intra-op. Awareness?
A
- assess during post op visit
- obtain detailed account of patientâs experience
- Be sympathetic
- answer patients questions
- refer to psych. Counseling if needed
12
Q
What are common types of intra-op eye injury?
A
- ) corneal abrasion- by far the most common and transient eye injury
- ) blindness-
- movement during ophthalmic surgery
- during GA or MAC - ) ION (Ischemic Optic Neuropathy)
* most common cause of operative vision loss *
- optic. Nerve infarct- from decreased O2 delivery from arterioles
13
Q
What are patient risk factors that contribute to eye injury?
A
- HTN
- DM
- CAD
- smoking
14
Q
What are surgical risk factors contributing to eye injury?
A
- deliberate intra-op hypotension
- anemia
- prolong surgical time in position that compromises blood flowâ> prone, T-berg, compressed abdomen
15
Q
How long does it take to notice ION?
A
Immediate onset to POD 12
Ranges of decreased visual acuity to complete blindness
16
Q
How can ION be prevented?
A
- head up position to enhance venous outflow
- minimize abdominal constriction
- art line for close BP monitoring
- limit duration and degree of hypotension
- when high risk for IONâ> avoid anemia and stage surgeries if they will be long
17
Q
What groups most commonly arrest during spinal anesthesia?
A
~36 years of age
ASA I-II
Higher level of block (T4) with appropriate does of LA
- associated with sub-clinical respiratory depression with hypercarbia from sedation
18
Q
What are s/s prior to arrest after spinal anesthesia?
A
- gradual decrease in HR and BP
- cyanosis
19
Q
How can spinal anesthesia arrest be treated?
A
- vent support
- atropine
- ephedrine
- epinephrine: its ok to use small doses (5-10ng) for bradycardia that is unresponsive to atropine and ephedrine, or larger doses if needed
- CPR (11 min average)
20
Q
What are some documentation pitfalls to avoid?
A
- completing entries before they occur
- incomplete description of procedures and management
- conflicting times between different records
- loss of critical patient data
- incomplete/poorly though out notes following an adverse event
- signing in accurate documents without reading them
- failing to document meeting with family or patient
- failure to obtain supporting documentation from others
21
Q
What are the 4 types of allergic-hypersensitivity reactions?
A
- ) TYPE 1: IMMEDIATE
- hay fever (atopy), urticaria-angioedema, anaphylaxis - ) TYPE 2: ANTIBODY MEDIATED, BLOOD TYPE INCOMPATIBILITIES
- hemolytic transfusion reactions, autoimmune hemolytic, HIT
3.) TYPE 3: IMMUNE COMPLEX (RA, SERUM SICKNESS)
- ) TYPE 4: DELAYED, CELL MEDIATED, CYTOTOXIC
- contact dermatitis, graft rejection
22
Q
Whatâs the difference between under and over reactions?
A
- both involve T and B cells
- under reaction = loss of immunity
Cancer, infants, immunodeficiency
23
Q
What is anaphylaxis?
A
- an exaggerated response, mediated by type 1 hypersensitivity reaction
- appears within minutes of exposure to antigen in sensitized individuals
- s/s present as acute respiratory distress and/or circulatory shock
- death may occur
24
Q
What is the incidence of anaphylaxis during anesthesia?
A
~ 1:5,000-1:25,000
25
What are mediators of anaphylaxis?
- histamine: vasodilation, runny nose
- leukotrienes: asthmatic resp. Reaction
- BK-A
- platelet activation factor
26
What are clinical manifestations of anaphylaxis?
- CV: hypotension, tachycardia, arrythmias
- PULM: bronchospasm, cough, dyspnea, pulmonary edema, laryngeal edema, hypoxia
- DERM: urticaria, facial edema, pruritis
27
What is an anaphylactoid reaction?
No IgE interaction with antigen
| - equal to anaphylaxis otherwiseâ> equally life-threatening
28
What is the treatment for anaphylaxis/anaphylactoid reactions?
- stop drug administration
- give 100% O2
- epi (0.01-0.5 mg IV or IM)
- consider intubation or tracheostomy
- IVF (1-2 L LR)
- Diphenhydramine (50-75 mg IV)
- Ranitidine (150 mg IV)
- Hydrocortisone (up to 200 mg IV) or methylprednisolone (1-2 mg/kg)
29
What are drugs that cause anaphylaxis
- muscle relaxants: most common cause of anaphylaxis during anesthesia
- hypnotics: mainly Pentothal and propofol
(True allergic reactions to Etomidate, ketamine and benzos are extremely rare)
opioids: non-immune histamine release more common than true allergic reaction
local anesthetics: mostly vaso vagal and toxic reactions or s/s from epi
* Ester type LAs:
- IgE mediated reactions
- share common antigenicity with PABA
- expect cross sensitivity with other esters
Amide LAs:
- true anaphylaxis extremely rare
- preservative parabans are the cause
Volatile inhaled anesthetics: NO DOCUMENTED REPORTS OF ANAPHYLAXIS
* ANTIBIOTICS * many true allergies are d/t ABG
- B-lactate abx (PCN, cephalosporins)
- sulfonamides
- vancomycin âred man syndromeâ- slow infusion rate down
30
What happens with a latex allergy?
* 2nd cause of anaphylaxis during surgery
- rang from mild- life threatening
* Direct IgE mediate immune response to polypeptides in natural latex
* Type 4 sensitivity reaction to chemicals from manufacturing process
- foods that cross react: mango, kiwi, chestnut, avocado, passion fruit, banana
31
How do you prevent a latex reaction?
- absolute avoidance
- pharmacological prophylaxis
- pre-op admin, of H1 and H2 histamine antagonists
- steroidsâ> controversial
32
What is the occurrence of malignant hyperthermia?
1:40,000 adults and 1:15,000 pediatrics
33
What are the s/s MH?
```
* occurs >1 hour from exposure to triggering agent
HYPERMETABOLISM
- elevated O2
- decreased O2 and mixed venous O2
- metabolic acidosis
- cyanosis
- mottling
INCREASED SYMPATHETIC ACTIVITY
- tachycardia
- initial HTN
- arrhythmias/ V-fib
MUSCLE DAMAGE
- masseter spasm
- generalized rigidity
- elevated CK, K, Na, Phos
- myoglobinemia/urea
HYPERTHERMIA
- fever/sweating
- late sign
- temp can rise as much as 1 C Q 5 minutes
```
34
What is the pathophysiology of MH?
- sudden release fo Ca from sarcoplasmic reticulum, removes inhibition of troponinâ> causes intense muscle contractions
- Dramatically enhanced and sustained ATP activity results in uncontrolled increase in metabolism (aerobic and anaerobic)
** if untreatedâ> sudden death in as little as 15 minutes **
35
What are some possible causes of MH?
- abnormal Ryr 1 receptor (ryanadine)
- abnormal 2nd messengers and modulators of Ca release
- abnormal Na Chanel in skeletal muscle
36
What is the dose of dantrolene and what does it do?
Give 2.5mg/kg- 10mg/kg until episode terminated
- intracellular dissociation of excitation-contraction coupling
- binds to Ryr receptor on Ca channelâ> inhibits Ca release from sarcoplasmic reticulum
37
Other than MH, what other conditions is dantrolene used for?
- hyperthermia associated with thyroid storm
- neuroleptic malignant syndrome
- treatment of chronic spastic disorders
38
What are side effects of dantrolene?
- muscle weakness
- respiratory insufficiency
- risk of aspiration
- phlebitis in small hang veins â> CVC if possible
39
What is laryngospasm?
Complete spasmodic closure of larynx resulting from constriction fo laryngeal muscles from outside stimulus
40
How can you tell the difference between complete and partial laryngospasm?
Complete: silent paradoxical movement of chest, tracheal tug, no ventilation
Partial: crowing noise, mismatch between respiratory effort and ventilatory effectiveness
Also will see desaturation, bradycardia, central cyanosis, inspiratory stridor
41
What is the treatment for laryngospasm?
- clear airway (suction)
- deepen anesthesia
- 100% O2
- gentle chin lift/jaw thrust
- call for help
- positive pressure/incubate if needed
- stop surgical stimulation
* *** risk of awarenessâ> follow up with pt afterwards
42
What is bronchospasm?
Spasmatic constriction of bronchial smooth muscleâ> narrow airway and increases resistance
43
What are s/s of bronchospasm?
- prolonged expiration
- increased inflation pressures
- expiratory wheezes
- low O2 sats
- elevated ETCO2
- decrease in tidal volumes
44
How do you treat bronchospasm?
- give 100% O2
- stop surgical stimulation
- call for help
- deepen anesthesia
- rule out bronchial or esophageal intubation
- give epinephrine
- consider anaphylaxis, pulmonary edema, pneumothorax, or kinked ETT
45
Who is responsible for fire prevention in the OR?
Entire team:
- surgeon controls ignition source
- anesthetists controls oxidizing agents
- surgical nurse controls fuel source
46
What area occupational hazards for the nurse anesthetist?
- chronic gas exposure
- infectious disease exposureâ> always use universal precautions
- substance abuse
- radiation exposure
47
What are the maximum acceptable trace exposure amounts in the O.R. For inhaled gases?
N2O aloneâ < 25ppm
N2O + halogenated agentâ <25ppm and 0.5 ppm HA
Halogenated agent only â ~2ppm
48
How can you prevent radiation exposure?
- use lead barriers
- stay the maximum distance from the sourceâ> inverse square lawâ-> amount of radiation changes inversely with the square of the distance
- at 4 m exposure will be 1/16 that at 1 m
* maximum whole body exposure is 5 rem/year
