Generic Events




Acute Hemorrhage


Definition


Acute hemorrhage is the acute loss of a large volume of blood and can be either overt or covert.




  • Overt




    • Can be visualized in the surgical field, on sponges, or in the suction containers




  • Covert




    • No outward sign of bleeding (e.g., retroperitoneal or intrapleural hemorrhage, blood loss hidden in drapes)




Etiology





  • Bleeding from large blood vessel (artery or vein) secondary to surgical manipulation, trauma, or disease



  • May be related to disorders of coagulation or therapeutic anticoagulation



Typical Situations





  • Vascular, cardiac, thoracic, or hepatic surgery



  • Coagulopathy



  • Major trauma



  • Covert hemorrhage more likely when the surgical field is obscured by drapes or distant from the anesthesia professional, or during laparoscopic surgery



  • Delayed complication of earlier injury, surgery, or invasive procedure (e.g., surgical clip slipping off a vessel)



  • Occult blood loss (e.g., femoral fracture, gastrointestinal [GI] bleed)



  • Retroperitoneal surgery or injury



  • Obstetric emergencies



Prevention





  • Identify and correct coagulopathy early




    • Monitor prothrombin time (PT)/partial thromboplastin time (PTT) during warfarin or heparin therapy



    • Monitor activated clotting time (ACT) during intraoperative anticoagulation or after administration of protamine




  • Identify and institute prophylaxis for potential bleeding sites (e.g., GI tract ulcers in ICU patients)



  • Perform a focused assessment with sonography in trauma (FAST) examination in trauma cases to assess the presence of intraabdominal or pericardial fluid



  • Insert the largest possible IV catheter if you anticipate having to administer blood during a case


    Insert arterial line if significant blood loss is anticipated



  • Establish an institutional massive transfusion protocol (MTP)



Manifestations





  • Overt




    • Blood in the surgical field



    • Blood on surgical sponges, drapes, and floor



    • Suction noise and accumulation of blood in suction containers



    • Fall in arterial pressure and filling pressures and increased HR



    • Increased pulse pressure variation during positive pressure ventilation



    • Hypovolemia assessed by transesophageal echocardiogram (TEE) or transthoracic echocardiogram (TTE)



    • Surgeon’s comments (e.g., “Have you given any blood yet?”)




  • Covert




    • Unexplained fall in arterial and filling pressures and/or increase in HR



    • Low filling pressures assessed by TEE or TTE



    • Fall in mixed venous O 2 (if monitored), especially in surgery where covert blood loss is possible



    • Increase in fluid requirements above what is expected



    • Little or transient BP response to administration of an IV fluid bolus or to vasopressor



    • Excessive response to vasodilator or anesthetic agents



    • Unexplained fall in urine output or hematocrit (a late sign)



    • Expanding abdomen or thigh, flank discoloration



    • Decreased oxygenation, increased peak inspiratory pressure (PIP) if hemothorax



    • Increased pulse pressure variation during positive-pressure ventilation




Similar Events





Management





  • Inform surgeons of the problem




    • Keep them informed of its severity



    • Options for surgeon to consider:




      • Convert from laparoscopic to open surgery



      • Clamp bleeding vessels, hold pressure on bleeding site, or pack to temporize bleeding



      • Clamp the aorta below the diaphragm (may be essential for resuscitation of the patient) (see Event 14, The Trauma Patient )



      • Apply hemostatic agents



      • Obtain expert surgical assistance




    • If the abdomen is open, cannulate a large intraabdominal vein for rapid transfusion and cannulate the aorta directly for an arterial line



    • Consider surgical exploration (if postoperative hemorrhage is suspected)




  • Increase FiO 2 to 100% with high fresh gas flow




    • Replace volatile anesthetic as tolerated with opioids, midazolam




  • Check and verify BP and other vital signs



  • Treat severe hypotension with IV bolus of vasopressor




    • Ephedrine IV, 5 to 50 mg



    • Epinephrine, 10 to 100 μg



    • Phenylephrine, 50 to 200 μg



    • Repeat as necessary to maintain an acceptable BP




  • Activate local MTP to get emergency release of blood products



  • Rapidly restore circulating blood volume




    • Use crystalloid, colloid, or blood to replace circulating blood volume




      • For massive hemorrhage




        • Transfuse a balanced ratio (1:1) of red blood cells (RBCs) to fresh frozen plasma (FFP)



        • Transfuse 1 apheresis unit of platelets per 6 units of RBCs, until labs are available





    • If blood loss is sudden but may be controlled soon, delay giving blood and continue to give crystalloid as needed until bleeding is stopped



    • Depending on patient comorbidities and extent of hemorrhage, consider tolerating low-normal BP to decrease blood loss and hemodilution until bleeding is controlled



    • A pressurized bag of saline or colloid will run much faster than a unit of RBCs through a small peripheral IV



    • Dilute RBCs with saline to increase the speed with which they can be infused



    • Use an additional small-pore filter to avoid occluding the IV giving-set filter with debris



    • Warm IV fluids and use other patient warming devices to maintain body temperature (see Event 44, Hypothermia )




  • Call for Help if major fluid resuscitation is necessary




    • If possible, the primary anesthesiologist should monitor the patient and surgical status and direct activities of OR personnel



    • Additional help should




      • Check and transfuse blood products, and obtain and reorder blood products when necessary



      • Set up rapid transfusor device, if available



      • Set up cell saver unit for autotransfusion of RBCs if blood is not contaminated





  • Ensure adequate IV access; consider intraosseus (IO) line




    • Have a minimum of one 16-gauge or larger IV line, preferably more. In the case of severe blood loss, place at least one very large-bore IV line (such as 8.5 French catheter introducer) in a suitable peripheral or central vein. Use large-bore rapid transfusion IV tubing if available.



    • If IV access is difficult, change a small IV cannula to a large IV cannula by using the Seldinger technique



    • Use ultrasound guidance for more access



    • Check IV site to make sure IV line is not infiltrated



    • Consider IO line placement early in the resuscitation if IV access is difficult




  • Obtain adequate supplies of IV fluid (colloid or crystalloid)



  • Continue to NOTIFY BLOOD BANK of blood product needs, per local protocol



  • If emergency release blood products are administered (O-neg RBCs), send a new blood sample to blood bank for type and screen procedure as soon as possible and prior to transfusion of type-specific blood



  • Monitor hemodynamic status for adequacy of volume resuscitation




    • BP and HR



    • Central venous pressure (CVP) and/or pulmonary artery (PA) pressure



    • TEE or TTE




  • Monitor labs at regular intervals: hematocrit, electrolytes, arterial blood gas (ABG), PT/PTT, fibrinogen every 30 to 60 minutes



  • Further transfusion of blood and blood products should be guided by lab results



  • Keep track of surgical events and inform surgeon periodically about resuscitation efforts



Complications





  • Coagulopathy/disseminated intravascular coagulation (DIC)



  • Volume overload from overshoot of fluid resuscitation



  • Hypothermia



  • Hyperkalemia



  • Hypocalcemia



  • Irreversible shock



  • Acute respiratory distress syndrome (ARDS)/transfusion-related acute lung injury (TRALI)



  • Allergic/anaphylactic reaction to blood



  • Transfusion-related viral infection



  • Myocardial ischemia, arrhythmias



  • Renal failure



  • Neurologic injury



  • Cardiac arrest



Suggested Reading


  • 1. Young P.P., Cotton B.A., Goodnough L.T.: Massive transfusion protocols for patients with substantial hemorrhage. Transfus Med Rev 2011; 25: pp. 293-303.
  • 2. Hajjar L.A., Vincent J.L., Galas F.R., et. al.: Transfusion requirements after cardiac surgery: the TRACS randomized controlled trial. JAMA 2010; 304: pp. 1559-1567.
  • 3. Carson J.L., Noveck H., Berlin J.A., Gould S.A.: Mortality and morbidity in patients with very low postoperative Hb levels who decline blood transfusion. Transfusion 2002; 42: pp. 812.
  • 4. Niles S.E., McLaughlin D.F., Perkins J.G., et. al.: Increased mortality associated with the early coagulopathy of trauma in combat casualties. J Trauma 2008; 64: pp. 1459-1463.
  • 5. Burtelow M., Riley E., Druzin M., et. al.: How we treat: management of life threatening primary postpartum hemorrhage using a standardized massive transfusion protocol. Transfusion 2007; 47: pp. 1564-1572.



  • Cardiac Arrest


    Definition


    Cardiac arrest is the absence of effective mechanical activity of the heart.


    Etiology


    Cardiovascular disease (e.g., myocardial infarction [MI], myocardial ischemia, cardiomyopathy, arrhythmia, valvular disease, aortic dissection)




    • Hypovolemia




      • Surgical maneuvers or positioning that causes decreased venous return



      • Hemorrhage




    • Hypoxemia




      • Failed airway management



      • Respiratory arrest




    • Shock (e.g., anaphylaxis, sepsis)



    • Bradycardia




      • After neuraxial blockade or any acute vagal reflex



      • After repeated doses of succinylcholine




    • Tension pneumothorax



    • Auto positive end-expiratory pressure (PEEP)



    • Pulmonary, venous air, or amniotic fluid embolism



    • Cardiac tamponade



    • Toxins (e.g., cocaine, methamphetamine)



    • Anesthetic drug-related complications (e.g., IV or anesthetic overdose, medication error, vasodilator bolus, local anesthetic systemic toxicity [LAST])



    • MH



    • Acidosis



    • Hypoglycemia



    • Electrolyte abnormalities (e.g., hyperkalemia, particularly in renal failure)



    • Hypothermia



    • Pulmonary hypertension



    • Transfusion reactions



    • Pacemaker failure



    Typical Situations





    • ACS



    • Arrhythmias



    • Major trauma



    • Acute hemorrhage



    • Shock (e.g., anaphylaxis, sepsis)



    • Following a respiratory arrest



    • Difficult intubation or ventilation



    • Hypoxemia (e.g., unrecognized esophageal intubation)



    • Hypercarbia



    • PE



    • Bradycardia during neuraxial blockade



    • Acute vagal reflex



    • Drug toxicity (e.g., contraindications to succinylcholine, local anesthetic overdose)



    • Tension pneumothorax



    • Cardiac tamponade



    • Direct myocardial contact with the electrocautery



    • Pacemaker failure



    • Electrolyte abnormalities (e.g., hyperkalemia, hypocalcemia)



    • Obstetric complications



    Prevention





    • Evaluate pacemaker function prior to surgery and manage appropriately



    • Place a transvenous or transcutaneous pacemaker prophylactically for patients with high-grade atrioventricular (AV) block or significant sinus bradycardia



    • Treat arrhythmias with appropriate antiarrhythmic therapy and continue through surgery



    • Aggressively treat bradycardia/hypotension following neuraxial blockade



    • Treat ACS to restore myocardial blood flow



    • Avoid surgery and anesthesia after recent MI



    • Administer vagolytic drug in patients or in procedures with a high risk of increased vagal tone (e.g., neuraxial blockade)



    • Drill and practice management of unstable patients (using simulation if available)



    • Administer vagolytic prior to, or mixed with, anticholinesterases that cause bradycardia



    Manifestations





    • Unresponsive to verbal commands



    • Absence of pulse oximeter waveform



    • Loss of consciousness or seizure-like activity



    • No palpable carotid pulse (palpation of peripheral pulses unreliable)




      • Noninvasive blood pressure (NIBP) unmeasurable



      • Invasive arterial pressure without pulsations




        • Mean arterial pressure (MAP) less than 20 mm Hg without CPR





    • Absence of heart tones on auscultation



    • Apnea




      • Loss of, or decreased, ET CO 2




    • Arrhythmias (ventricular tachycardia [VT], ventricular fibrillation [VF], asystole)



    • Pulseless electrical activity (PEA) (rhythm in PEA may appear normal)



    • Cyanosis



    • Regurgitation and possible aspiration of gastric contents



    • Lack of ventricular contraction on TEE or TTE



    Similar Events





    Management





    • Treat the patient, not the monitor



    • Verify that there is no pulse (and that an “awake” patient has become unresponsive)




      • Check pulse oximeter and ET CO 2 waveforms



      • Palpate the carotid, femoral, or other pulse




        • Surgeon may have better access to palpable pulses




      • Check NIBP and ECG monitors and leads



      • Check arterial line waveform




    • Immediately notify surgeons and other OR personnel of the cardiac arrest




      • Call for help



      • Call OR or hospital “code”



      • Call for crash cart and defibrillator



      • Start CPR immediately (C-A-B: compressions, airway, breathing)



      • Apply defibrillation pads to chest




    • Turn off ALL anesthetics



    • Administer 100% O 2 at high flows to flush circuit of inhaled anesthetics and verify change



    • Begin basic life support (BLS)




      • Assign someone to start chest compressions




        • Compressions should be at least 100 per minute and at least 2 inches deep



        • Rotate compressors every 2 minutes and monitor for fatigue of the person performing chest compressions



        • Allow for complete recoil of the chest with each compression



        • Minimize interruptions in compressions and keep interruptions brief (less than 10 seconds)



        • Adequate compressions should generate an ET CO 2 of at least 10 mm Hg and a diastolic pressure of greater than 20 mm Hg (if an arterial line is in place). You MUST improve CPR quality and vascular tone if above conditions are not met.




      • Airway/Ventilation




        • If patient is not intubated, establish bag mask ventilation with 100% O 2 at a compression to ventilation ratio of 30:2 and prepare for definitive airway




          • Place a supraglottic airway (SGA) or endotracheal tube ( ETT) without stopping compressions and then ventilate at a rate of 10/minute with continuous compressions






    • Assign tasks to skilled responders




      • Ensure adequate IV access




        • If difficult IV access, place IO infusion line




      • Place arterial line



      • Call for TEE/TTE machine




    • Begin ACLS



    • Employ cognitive aids (ACLS algorithms) to help determine diagnosis and treatment



    • Diagnose and treat arrhythmias




      • Determine if patient is in a shockable rhythm




        • Analyze rhythm during very short breaks in CPR (e.g., during ventilation phase of the 30:2 compression-to-ventilation ratio or while rotating compressors)




          • CPR artifact can appear as a shockable rhythm





      • VT/VF (shockable pathway)




        • Continue high-quality CPR



        • Defibrillate as soon as possible with 200 J or follow manufacturer’s recommendations



        • Immediately resume chest compressions after each defibrillation




          • Do not check pulse or rhythm




        • If a shockable rhythm persists after the initial defibrillation, continue CPR and administer epinephrine IV, 1 mg every 3 to 5 minutes



        • Consider replacing 1 dose of epinephrine with vasopressin IV, 40 units



        • DEFIBRILLATE EVERY 2 MINUTES



        • Consider antiarrhythmics




          • Amiodarone IV, 300 mg



          • Lidocaine IV, 100 mg




        • Search for treatable causes for VT/VF






      • If rhythm changes to non-shockable rhythm, switch to PEA/asystole pathway



      • PEA/asystole (non-shockable pathway)




        • Continue high-quality CPR



        • Administer epinephrine IV, 1 mg every 3 to 5 minutes



        • Consider replacing 1 dose of epinephrine with vasopressin IV, 40 units




      • Search for treatable causes of PEA/asystole




        • Hypovolemia (see Event 1, Acute Hemorrhage , and Event 9, Hypotension )




          • Administer fluid bolus, rule out occult bleeding, administer sufficient blood products for massive hemorrhage or severe anemia



          • Evaluate fluid status with TEE or TTE



          • Inadequate preload from caval compression




            • Release pneumoperitoneum



            • Left uterine displacement for gravid uterus



            • Return prone patient with large abdomen to supine position



            • Release surgical retraction



            • Disconnect breathing circuit if breath stacking (auto-PEEP) and adjust ventilation appropriately





        • Hypoxemia (see Event 10, Hypoxemia )




          • Ventilate and oxygenate with 100% O 2



          • Auscultate breath sounds



          • Suction ETT



          • Reconfirm presence of ET CO 2




        • Tension pneumothorax (see Event 35, Pneumothorax )




          • Auscultate for unilateral breath sounds



          • Absence of sliding pleura sign on TTE



          • Distended neck veins or deviated trachea




            • Perform emergent needle decompression at 2nd intercostal space, mid-clavicular line




              • Patient will require pleural drainage after needle decompression






        • Coronary thrombosis (see Event 15, Acute Coronary Syndrome )




          • Unexplained cardiac arrest may be secondary to MI; consider TEE or TTE to evaluate global myocardial function and regional wall motion abnormalities




        • Toxins (including infusions)




          • Confirm that IV and volatile anesthetics are off



          • Check all infusions




            • Confirm they are the correct drug and rate of administration



            • Discontinue if they are not indicated




          • If the potential for LAST exists (see Event 52, Local Anesthetic Systemic Toxicity )




            • Administer 20% lipid emulsion (Intralipid)



            • Consider Intralipid for any overdose of a lipid-soluble drug




          • Send toxicology screen




        • Cardiac tamponade




          • Use TEE or TTE to rule out pericardial effusion




            • If present, perform emergent pericardiocentesis





        • Electrolyte and acid/base abnormalities




          • Send stat labs (ABG and metabolic panel)




            • Evaluate for acidosis, hyperkalemia, hypokalemia, hypoglycemia, hypocalcemia





        • VGE (see Event 24, Venous Gas Embolism )




          • Acute hypotension with drop in ET CO 2



          • Flood surgical field with saline



          • Aspirate CVP catheter, if present




        • PE (see Event 21, Pulmonary Embolism )



        • Pulmonary hypertension




          • Use TTE or TEE to assess right ventricular (RV) function




        • Hyperthermia





        • Hypothermia (see Event 44, Hypothermia )





    • Continually reassess patient without interrupting chest compressions




      • Return of spontaneous circulation is indicated by




        • ECG and palpable pulse or BP



        • Pulse oximetry waveform



        • Increase in ET CO 2





    • Consider postresuscitation hypothermia for brain protection



    Complications





    • Aspiration of gastric contents



    • Laceration of liver



    • Pneumothorax or hemothorax



    • Rib fracture



    • Hypoxic brain injury



    • Death



    Suggested Reading


  • 1. Neumar R.W., Otto C.W., Link M.S., et. al.: 2010 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care science. Part 8: adult advanced cardiovascular life support. Circulation 2010; 122: pp. S729-S767.
  • 2. Moitra V.K., Gabrielli A., Maccioli G.A., O’Connor M.F.: Anesthesia advanced circulatory life support. Can J Anesth 2012; 59: pp. 586-603.



  • Difficult Tracheal Intubation


    Definition


    Difficult tracheal intubation occurs when successful intubation of the trachea is not accomplished within the first two attempts by an experienced anesthesia professional.


    Etiology





    • Anatomical causes of a difficult airway




      • Full dentition



      • Obesity/short neck




    • Physician factors




      • Inexperience with airway management



      • Failure to respond effectively to a rapidly deteriorating situation




    • Equipment factors




      • Inexperience with equipment



      • Inadequate backup or alternative airway adjuncts or intubating devices




    Typical Situations





    • Any patient with anatomy that makes direct laryngoscopy difficult




      • Short “bull” neck



      • Prominent maxillary incisors



      • Limited range of neck or jaw movement



      • Short thyromental distance



      • Late stages of pregnancy




    • Congenital syndromes associated with difficulty in endotracheal intubation



    • Infections of the airway



    • Acquired anatomic abnormalities




      • Intrinsic or extrinsic tumors of the airway



      • Following radiation therapy to the head and/or neck



      • Acromegaly



      • Morbid obesity



      • History of sleep apnea



      • Tracheal stenosis



      • Significant neck swelling or hematoma compressing the airway




    Prevention





    • Carefully assess airway anatomy




      • Samsoon and Young modification of Mallampati classification




        • Class I: Visualize soft palate, uvula, tonsillar pillars, fauces (same as Mallampati class I)



        • Class II: Visualize soft palate, uvula, fauces



        • Class III: Visualize soft palate, base of uvula only



        • Class IV: Visualize hard palate only (same as Mallampati class III)




      • Class III and IV airways are associated with increased difficulty with tracheal intubation




    • Assess other patient factors




      • Patient’s ability to cooperate with airway management plan



      • Degree of difficulty with mask ventilation (e.g., facial hair, edentulous patients)



      • Degree of difficulty with SGA placement (e.g., limited mouth opening)



      • Degree of difficulty with surgical airway access (e.g., limited neck extension, goiter)




    • Create difficult airway cart with necessary supplies and equipment



    • Drill and practice management of difficult airway/failed intubation algorithm (using simulation if available)



    Manifestations





    • Expected or known difficult tracheal intubation




      • Previous history of difficult airway or tracheal intubation



      • Airway examination classified as Samsoon and Young’s class III or IV



      • Presence of other anatomic features that make the patient difficult to intubate




    • Unexpected difficult tracheal intubation




      • Failure to intubate the trachea after two attempts by an experienced anesthesia professional




        • May be secondary to difficult laryngoscopy or difficulty passing the ETT into the trachea





    Similar Events





    • Normal airway but unsuccessful intubation owing to inexperience of the laryngoscopist



    Management





    • Expected Difficult Intubation



    • Err on the side of caution




      • Review previous anesthesia records, focusing on airway management



      • Perform a careful airway assessment; obtain a second opinion about the airway if you are still unsure of how to proceed



      • Consider alternatives to general anesthesia but remember that airway management will be difficult if a major complication or inadequate anesthesia occurs




    • If difficult airway is known or anticipated, consider performing an awake fiberoptic intubation




      • This will be the safest option in most cases



      • Awake intubation will be harder to perform if prior attempts at direct laryngoscopy have caused bleeding, secretions, or tissue edema




        • Administer glycopyrrolate IV, 0.4 mg as antisialagogue



        • Topicalize oropharynx




          • Lidocaine 4% nebulized and supplement if necessary




            • Be aware of total local anesthetic dose administered





        • Consider Williams airway in oropharynx and intubate over the fiberoptic bronchoscope with a 6.0 to 8.0 ETT



        • Do not oversedate the patient




      • Awake intubation can also be performed using video-assisted laryngoscopy with topical anesthesia




    • Prepare contingency plans and obtain appropriate equipment (difficult airway cart)




      • Multiple laryngoscope blades (different sizes of Miller and Macintosh blades)



      • Multiple ETT sizes (at least two sizes smaller than the expected size needed)



      • Bougie, airway introducers



      • SGA (e.g., LMA)



      • Intubating LMA



      • Video-assisted laryngoscope



      • Fiberoptic bronchoscope



      • A cricothyrotomy set (will require a trained person to perform)




        • If cricothyrotomy would be difficult or impossible, consider CPB standby





    • Unexpected Difficult Intubation



    • Call for help (e.g., anesthesia professional, anesthesia technician and surgeon capable of establishing surgical airway)




      • Call for difficult airway cart



      • Once help arrives, have them set up additional airway equipment




    • Mask ventilate with 100% O 2 ; consider using cricoid pressure but release if mask ventilation is difficult




      • Assess adequacy of ventilation and oxygenation




        • Place an oral or nasopharyngeal airway



        • Consider two-person mask ventilation technique




      • If mask ventilation is possible




        • Optimize patient’s position for intubation




      • Most experienced person should perform subsequent laryngoscopies




        • Limit intubation to three attempts



        • Consider intubation with video-assisted laryngoscopy



        • Use stylet or bougie



        • Use smaller ETT if difficulty in passing ETT through cords




      • Consider placing an SGA to be used as the primary airway device or to be used as a conduit for fiberoptic intubation with an Aintree exchange catheter



      • Consider an asleep fiberoptic intubation



      • Consider using an intubating LMA



      • Consider allowing spontaneous ventilation to return if possible and awaken the patient; convert to an awake intubation or cancel the case




    • If mask ventilation or intubation is impossible




      • Attempt to place an SGA




        • If successful, consider whether to wake the patient, continue the case with the SGA, or attempt to intubate the trachea through the device with an Aintree exchange catheter as outlined earlier




      • If SGA is unsuccessful, move early and aggressively to emergency cricothyrotomy or tracheostomy. DO NOT WAIT for the O 2 saturation to fall precipitously




    • Follow up



    After an unexpected difficult intubation, ensure that the patient is informed of the complications and recommend that he or she obtain a MedicAlert bracelet ( www.medicalert.org ) to inform future anesthesia professionals about history of difficult intubation


    Complications





    • Damage to airway structures



    • Bleeding in the airway



    • Airway obstruction from loss of airway reflexes or laryngospasm



    • Hypoxemia



    • Esophageal intubation



    • Gastric distention



    • Regurgitation and aspiration of gastric contents



    • Damage to the cervical spine during attempts at intubation



    Suggested Reading


  • 1. Launcelott G.O., Johnson L.B.: Surgical airway. Hung O. Murphy M.F. Management of the difficult and failed airway . 2012. McGraw-Hill New York: chapter 13
  • 2. Phero J.C., Patil Y.J., Hurford W.E.: Evaluation of the patient with a difficult airway. Longnecker D.E. Newman M.F. Brown D.L. Zapol W.M. Anesthesiology . 2012. McGraw-Hill New York: chapter 10
  • 3. Apfelbaum J.L., Silverstein J.H., Chung F.F., et. al.: Practice guidelines for management of the difficult airway: an updated report by the American Society of Anesthesiologists Task Force on management of the difficult airway. Updated by the Committee on Standards and Practice Parameters. Anesthesiology 2013; 118: pp. 251-270.



  • Emergent (Crash) Induction of Anesthesia


    Definition





    • Emergent induction of anesthesia to facilitate an immediate lifesaving intervention



    Etiology





    • Catastrophic event that results in the immediate need for life-saving surgical intervention



    Typical Situations





    • Trauma



    • Stat cesarean section



    • Vascular catastrophes (e.g., ruptured aortic aneurysm)



    • Emergent surgical reexploration




      • Cardiac tamponade



      • Disruption of surgical anastomosis




    • Cath lab crash



    • Necrotizing fasciitis



    Prevention





    • Resuscitate the patient prior to induction of anesthesia and surgical intervention



    • Have an OR and anesthesia workstation that is fully functional and ready for use



    • Have appropriate staff and equipment available



    • Drill and practice management of stat and urgent surgical cases (using simulation if available)



    Manifestations





    • Stat call to the OR, ICU, emergency department (ED), cath lab, obstetrics (OB) suite, etc., for emergent case



    • Patient may arrive at the OR with little notice



    • Stat call to patient’s bedside with a decision to go emergently to the OR



    Management


    Do not transport the patient from an area where monitoring and resuscitation are occurring to the OR until it is set up and the anesthesia team and nursing staff are ready to care for the patient.




    • Call for additional help




      • Anesthesia professionals



      • Nursing staff (scrub nurse[s] and circulating nurse)



      • Technical support (anesthesia and surgical support technicians)



      • Surgical assistants




    • Prepare anesthesia equipment




      • If patient is already in the OR, assign someone to monitor the patient as you set up



      • Turn on anesthesia machine and monitors



      • If time allows, perform full machine check




        • At minimum, confirm that you are able to provide positive pressure ventilation with machine and circuit



        • Confirm suction is functional




      • Confirm presence of self-inflating bag/mask



      • Confirm airway equipment, including oral airway, ETT, functional laryngoscope blades and handles



      • Confirm presence of SGA (e.g., LMA) and bougie for possible difficult airway



      • Confirm that video-assisted laryngoscope is present




    • Prepare medications




      • Induction agent as indicated (ketamine, etomidate, propofol)



      • Neuromuscular blocker (succinylcholine unless contraindicated)



      • Emergency medications (ephedrine, phenylephrine, and/or epinephrine)




    • Obtain brief history and physical




      • Information can come from patient, medical record, or caregivers




        • Check critical lab values



        • Check whether sample has been sent to blood bank for type and cross




      • Reassess and confirm it is a life-threatening emergency




        • Avoid crash induction if not medically necessary




      • Assess whether the patient has allergies to any medications



      • Assess for major cardiopulmonary disease (e.g., valvular heart disease, low ejection fraction, asthma, chronic obstructive pulmonary disease [COPD])



      • Perform airway examination




    • Monitoring




      • Determine what IV access and lines are functional




        • Place additional IV access as indicated



        • Consider IO line if unable to quickly achieve vascular access




      • Connect ECG, NIBP, pulse oximeter, and all invasive monitoring lines that are present



      • Consider placement of arterial line preinduction if not already present in situ




        • Assign this task to skilled help





    • Induction




      • Preoxygenate while setting up and placing monitors



      • Confirm left uterine displacement for OB patient



      • Assume full stomach




        • Consider administration of Bicitra (PO), 30 mL




      • Modify induction dose of anesthetic based on hemodynamic parameters and patient comorbidities




        • Consider using ketamine or etomidate as an induction agent if hemodynamically unstable



        • Consider IV fluid bolus while preoxygenating patient




      • Consider video-assisted laryngoscopy as first choice for intubation




        • Turn device on



        • ETT with appropriate stylet




      • Laryngoscope, ETT, suction on and ready at head of bed



      • Perform RSI with cricoid pressure




        • Release or manipulate cricoid pressure if unable to visualize the vocal cords or to intubate the trachea



        • Ensure correct placement of ETT via ET CO 2 and auscultation




      • If unable to intubate, move to video-assisted laryngoscope (see Event 3, Difficult Tracheal Intubation )




    • Postinduction




      • Monitor patient




        • Expect instability and search for treatable causes



        • Support as needed with vasopressors and fluid



        • Consider placement of TEE to monitor myocardial filling and function




      • Establish additional IV access as indicated



      • Provide anesthesia as tolerated




        • Balance risk of awareness with hemodynamic stability




      • Obtain RBCs and other blood products as indicated



      • Send labs for ABG, blood glucose, and lactate as indicated



      • Administer appropriate antibiotics




    Complications





    • Aspiration of gastric contents



    • Difficult intubation



    • Awareness under anesthesia



    • Cardiac arrest



    Suggested Reading


  • 1. Gray L.D., Morris C.G.: The principles and conduct of anaesthesia for emergency surgery. Anaesthesia 2013; 68: pp. 14-29.



  • Esophageal Intubation


    Definition


    Esophageal intubation is the placement of the ETT in the esophagus at the time of intubation or the subsequent displacement of the ETT from the trachea into the esophagus.


    Etiology





    • Difficulty in visualizing the larynx at the time of intubation



    • Difficulty in passing the ETT



    • Change in position of the ETT after correct placement



    • Dislodgement by objects placed into, or removed from, the oropharyngeal cavity



    Typical Situations





    • After a difficult or “blind” intubation



    • During intubation by an inexperienced laryngoscopist



    • After manipulation of the patient’s head or neck



    • After placing or removing devices from the esophagus (e.g., TEE probe or nasogastric tube [NGT])



    • Nasotracheal intubations



    Prevention





    • Use proper intubation technique for optimal visualization of the larynx



    • Observe the ETT passing between the vocal cords



    • Secure the ETT carefully before allowing movement or positioning of the patient’s head



    • Check the position of the ETT after each change of the patient’s position or manipulation of the ETT



    • Visualize the carina during fiberoptic intubation



    • Use video-assisted laryngoscopy for difficult intubations or as a confirmation of proper ETT placement



    Manifestations





    • Abnormally low or absent ET CO 2 waveform after the first few breaths



    • Equivocal or absent thoracic breath sounds



    • Breath sounds or gurgling heard over the epigastrium



    • Abnormal compliance during hand or mechanical ventilation



    • Leakage around the ETT with a normal ETT cuff volume



    • In the awake patient, continued vocalization after the cuff of the ETT is inflated



    • Visualization of the ETT in the esophagus on direct or video-assisted laryngoscopy



    • Inability to palpate the cuff of the ETT in the sternal notch



    • Regurgitation of gastric contents up the ETT



    • Late signs




      • Decreasing O 2 saturation and cyanosis



      • Hypotension



      • Bradycardia, premature ventricular contractions (PVCs), tachyarrhythmias, asystole



      • VT/VF




    Similar Events





    Management


    Development of hypoxemia within 10 minutes of intubation must be assumed to be due to esophageal intubation unless capnography demonstrates a sustained normal CO 2 waveform or video-assisted laryngoscopy clearly shows ETT passing through the vocal cords.




    • Preoxygenate the patient before induction; check ET O 2




      • Administer 100% O 2 until ETT placement is verified




    • Verify position of the ETT after intubation




      • Inflate ETT cuff and check for leak



      • Check for a normal ET CO 2 waveform on the capnograph



      • Listen for breath sounds in both axillae and over the stomach



      • Look for bilateral chest expansion



      • Manually ventilate the patient; assess the compliance of the reservoir bag



      • Perform direct or video-assisted laryngoscopy to visualize the position of the ETT relative to the vocal cords



      • Get help if there are problems determining the position of the ETT




        • Have assistant prepare fiberoptic bronchoscope to assist with ETT verification and placement





    • If the patient desaturates and you are unable to verify ETT placement




      • Remove ETT and ventilate with 100% O 2 by mask or SGA




    • If esophageal intubation is confirmed




      • Remove the misplaced ETT



      • Ventilate with 100% O 2 by mask or SGA if O 2 saturation is < 95%



      • Reintubate the trachea with a clean ETT using video-assisted laryngoscope




    • If intubation was difficult on the first attempt or reintubation fails (see Event 3, Difficult Tracheal Intubation )




      • Ventilate with 100% O 2 by mask if O 2 saturation is < 95%



      • Call for help and for difficult airway equipment



      • Prepare to place an SGA (e.g., LMA)



      • Consider waking the patient for possible awake intubation



      • Prepare for possible fiberoptic intubation



      • Prepare for surgical airway




    After tracheal intubation, place an orogastric tube to empty the stomach


    Complications





    • Hypoxemia



    • Hypercarbia



    • Cardiac arrest



    • Airway, pharyngeal, or dental trauma from repeated laryngoscopy



    • Aspiration of gastric contents



    • Hypertension, tachycardia



    • Myocardial ischemia/infarction



    Suggested Reading


  • 1. Salem M.R.: Verification of endotracheal tube position. Anesthesiol Clin North America 2001; 19: pp. 813-839.
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    Feb 22, 2019 | Posted by in ANESTHESIA | Comments Off on Generic Events
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