complication of anesthesia

1. COMPLICATIONSCOMPLICATIONS
OF GENERALOF GENERAL
ANESTHESIAANESTHESIA
Done byDone by
Shaymaa AfifShaymaa Afif

2. What it is Genaral anasthesia??
• is a state of unconsciousness and loss of
protective reflexes resulting from the
administration of one or more general
anaesthetic agents. A variety
of medications may be administered, with
the overall aim of ensuring
hypnosis, amnesia, analgesia, relaxation
of skeletal muscles, and loss of control
of reflexes of the autonomic nervous
system

3. Complications of anesthesia
• Complications of anesthesia are inevitable even with
most experienced Doctors.
• These complications range from minor to
catastrophic.
• When anesthetic complications occur, appropriate
evaluation, management, and documentation to
minimize the negative outcomes.
• Incidence
• Perioperative mortality rate due to anesthetic cause
account is less than 1:20,000.

4. Classification..
1. Respiratory complications
2. Cardiovascular complications
3. Neurological complications
4. PONV
5. Temperature changes
6. Adverse drug effect and
hypersensitivity
7. Complications of positioning
8. Miscellaneous

5. A) Respiratory complications
I. Complications of laryngoscopy and
intubation
II. Respiratory obstruction
III.Hypoxemia
IV. Hypercapnia and hypocapnia
V. Hypoventilation
VI. Aspiration pneumonia

6. I- Complications of laryngoscopy and intubationI- Complications of laryngoscopy and intubation
1. Errors of ETT positioning:1. Errors of ETT positioning:
a. Esophageal intubation
b. Endobronchial intubation
c. Position of the cuff in the larynx
2. Airway trauma:2. Airway trauma:
a. Tooth damage.
b. Dislocated mandible.
c. Sore throat.
d. Pressure injury on trachea.
e. Edema of glottis or trachea.
f. Post intubation granuloma of vocal cords.
3. Physiologic responses to airway instrumentation:3. Physiologic responses to airway instrumentation:
a. Sympathetic stimulation
b. Laryngospasm
c. Bronchospasm
4. ETT malfunction:4. ETT malfunction:
a. Risk of ignition
b. ETT obstruction
c. Cuff perforation

7. II- Respiratory obstructionII- Respiratory obstruction::
SignsSigns::
11..Inadequate tidal volumeInadequate tidal volume..
22..Retraction of the chest wall and of theRetraction of the chest wall and of the
supraclavicular,infraclavicular and suprasternalsupraclavicular,infraclavicular and suprasternal
spacesspaces..
33..Excessive abdominal movementExcessive abdominal movement..
44..Use of accessory muscles of respirationUse of accessory muscles of respiration..
55..Noisy breathing (unless obstruction is absolute andNoisy breathing (unless obstruction is absolute and
completecomplete(.(.
66..CyanosisCyanosis..
Sites of obstructionSites of obstruction::
 At the lips.
 By the tongue
 Above the glottis
 At the glottis: laryngeal spasm, Bronchospasm
 Faults of apparatus: Kink or obstruction of ETT

8. III- HypoxemiaIII- Hypoxemia::
PaO2 less 60 mmHg or SaO2 less 90%PaO2 less 60 mmHg or SaO2 less 90%
CausesCauses::
11..Decreased FiO2Decreased FiO2
22..HypoventilationHypoventilation
33..V/Q mismatchV/Q mismatch
44..Increased O2 utilization by tissuesIncreased O2 utilization by tissues
55..Tissue hypoxiaTissue hypoxia
Clinical signs of hypoxiaClinical signs of hypoxia
))sweating, tachycardia, cardiac arrhythmias, hypertension, andsweating, tachycardia, cardiac arrhythmias, hypertension, and
hypotension) are nonspecific; bradycardia, hypotension, and cardiachypotension) are nonspecific; bradycardia, hypotension, and cardiac
arrest are late signsarrest are late signs..
Increased intrapulmonary shunting relative to closing capacity is theIncreased intrapulmonary shunting relative to closing capacity is the
most common cause of hypoxemia following general anesthesiamost common cause of hypoxemia following general anesthesia..
TreatmentTreatment::
oxygen therapy with or without positive airway pressure.oxygen therapy with or without positive airway pressure.
Additionally, treatment of the causeAdditionally, treatment of the cause..

9. IV) HypercapniaIV) Hypercapnia
PaCO2 or ETCO2 > 40 mmHgPaCO2 or ETCO2 > 40 mmHg..
CausesCauses::
Increased FiCO2
Hypoventilation
Increased dead space
Increased CO2 production by tissues
Treatment:Treatment: of the causeof the cause

10. V) HypoventilationV) Hypoventilation
A. CausesA. Causes::
11--Respiratory obstructionRespiratory obstruction
22--Factors affecting the ventilatory driveFactors affecting the ventilatory drive
a. Respiratory depressant drugsa. Respiratory depressant drugs
b. Hypothermiab. Hypothermia
c. CV strokec. CV stroke
33--Peripheral factorsPeripheral factors
a. Muscle weaknessa. Muscle weakness
b. Painb. Pain
c. Decreased diaphragmatic movementc. Decreased diaphragmatic movement..
d. Pneumo or hemothoraxd. Pneumo or hemothorax..
e. Decreased chest wall compliance e.g. kyphoscoliosise. Decreased chest wall compliance e.g. kyphoscoliosis..
C.C. TreatmentTreatment::
should be directed at the underlying cause. Marked hypoventilationshould be directed at the underlying cause. Marked hypoventilation
may require controlled ventilation until contributory factors aremay require controlled ventilation until contributory factors are
identified and correctedidentified and corrected..

11. VI- Pulmonary aspirationVI- Pulmonary aspiration
Incidence and severity increase in emergency cases, especially patientsIncidence and severity increase in emergency cases, especially patients
with delayed gastric emptying such aswith delayed gastric emptying such as CSCS,, intestinal obstructionintestinal obstruction..
- Aspiration of material with a pH less than 2.5 causes extensive lungAspiration of material with a pH less than 2.5 causes extensive lung
damage.damage.
ManifestationsManifestations::
They vary depending on the degree of aspiration. The patient mayThey vary depending on the degree of aspiration. The patient may
become hypoxic, tachycardic and tachypnoeic. Bronchospasm oftenbecome hypoxic, tachycardic and tachypnoeic. Bronchospasm often
occurs and auscultation of the chest may reveal wheeze and crepitations.occurs and auscultation of the chest may reveal wheeze and crepitations.

12. B) Hemodynamic ComplicationsB) Hemodynamic Complications
I. HypotensionI. Hypotension
A.CausesA.Causes ::
hypoxemia, hypovolemia, decreased myocardial contractilityhypoxemia, hypovolemia, decreased myocardial contractility
(myocardial ischemia, pulmonary edema), decreased systemic(myocardial ischemia, pulmonary edema), decreased systemic
vascular resistance, cardiac dysrhythmias, pulmonary embolus,vascular resistance, cardiac dysrhythmias, pulmonary embolus,
pneumothorax, cardiac tamponade.pneumothorax, cardiac tamponade.
B.TreatmentB.Treatment::
fluid challenge; pharmacologic treatment includes inotropicfluid challenge; pharmacologic treatment includes inotropic
agents (dopamine, dobutamine, epinephrine) and alpha receptoragents (dopamine, dobutamine, epinephrine) and alpha receptor
agonists (phenylephrine). CVP and PA catheter monitoring may beagonists (phenylephrine). CVP and PA catheter monitoring may be
needed to guide therapyneeded to guide therapy

13. II. HypertensionII. Hypertension
A.A. CausesCauses::
enhanced SNS activity (pain, bladder distension),enhanced SNS activity (pain, bladder distension),
preoperative hypertension, hypervolemia, hypoxemia,preoperative hypertension, hypervolemia, hypoxemia,
increased intracranial pressure, and vasopressors.increased intracranial pressure, and vasopressors.
B.TreatmentB.Treatment::
correction of the initiating cause; various medicationscorrection of the initiating cause; various medications
can be used to treat hypertension including betacan be used to treat hypertension including beta
blockers, calcium channel blockers, nitroprusside orblockers, calcium channel blockers, nitroprusside or
nitroglycerin.nitroglycerin.
III. Cardiac dysrhythmiasIII. Cardiac dysrhythmias
A. CausesA. Causes: hypoxemia, hypercarbia, hypovolemia, pain,: hypoxemia, hypercarbia, hypovolemia, pain,
electrolyte and acid-base imbalance, myocardialelectrolyte and acid-base imbalance, myocardial
ischemia, increased ICP, digitalis toxicity, hypothermia,ischemia, increased ICP, digitalis toxicity, hypothermia,
anticholinesterases and malignant hyperthermia.anticholinesterases and malignant hyperthermia.
B.TreatmentB.Treatment: of the cause.: of the cause.

14. C) Neurological complicationsC) Neurological complications
I- Awareness:I- Awareness:
Incidence: 0.2% Increased in obstetric,Incidence: 0.2% Increased in obstetric,
cardiac anesthesia and hypovolemiccardiac anesthesia and hypovolemic
patients.patients.
II- Delayed recovery:II- Delayed recovery:
A.A. Metabolic and electrolyte causesMetabolic and electrolyte causes
B.B. Cerebral hypoperfusionCerebral hypoperfusion
C.C. Cerebral depression by drugsCerebral depression by drugs
III- Perioperative Neuropathy:III- Perioperative Neuropathy:

15. D) Complications of positioning
Complication Position Prevention
Air embolism Sitting, prone, reverse
Trendelenburg
Maintain venous pressure above
0 at the wound.
Backache Any Lumbar support, padding, and
slight hip flexion.
Compartment syndrome Especially lithotomy Maintain perfusion pressure and
avoid external compression.
Corneal abrasion Especially prone Taping and/or lubricating eye.
Nerve palsies
Brachial plexus Any Avoid stretching or direct
compression at neck or axilla.
Common peroneal Lithotomy, lateral decubitus Pad lateral aspect of upper
fibula.
Radial Any Avoid compression of lateral
humerus.
Ulnar Any Padding at elbow, forearm
supination.
Retinal ischemia Prone, sitting Avoid pressure on globe.
Skin necrosis Any Padding over bony prominences.

16. E) Postoperative Nausea and VomitingE) Postoperative Nausea and Vomiting
Risk factorsRisk factors
A.A. Patient risk factors: short fasting status, anxiety, young age,Patient risk factors: short fasting status, anxiety, young age,
female,female,
obesity, gastroparesis, pain, history of postoperativeobesity, gastroparesis, pain, history of postoperative
nausea/vomiting or motion sickness.nausea/vomiting or motion sickness.
B. Surgery-related factors: gynecological, abdominal, ENT, ophthalmic,B. Surgery-related factors: gynecological, abdominal, ENT, ophthalmic,
and plastic surgery; endocrine effects of surgery; duration ofand plastic surgery; endocrine effects of surgery; duration of
surgery.surgery.
C. Anesthesia-related factors: premedicants (morphine and otherC. Anesthesia-related factors: premedicants (morphine and other
opioids), anesthetics agents (nitrous oxide, inhalational agents,opioids), anesthetics agents (nitrous oxide, inhalational agents,
etomidate, methohexital, ketamine), anticholinesterase reversaletomidate, methohexital, ketamine), anticholinesterase reversal
agents, gastric distention, longer duration of anesthesia, maskagents, gastric distention, longer duration of anesthesia, mask
ventilation, intraoperative pain medications, regional anesthesia.ventilation, intraoperative pain medications, regional anesthesia.
D. Postoperative factors: pain, dizziness, movement after surgery,D. Postoperative factors: pain, dizziness, movement after surgery,
premature oral intake, opioid administration.premature oral intake, opioid administration.
Treatment of Postoperative Nausea and Vomiting (PONV)Treatment of Postoperative Nausea and Vomiting (PONV)
Droperidol, Metoclopramide, Ondansetron, Dolasetron, GranisetronDroperidol, Metoclopramide, Ondansetron, Dolasetron, Granisetron
Propofol 10-20 mg IV, Dexamethasone, Promethazine. CombinationPropofol 10-20 mg IV, Dexamethasone, Promethazine. Combination
therapy is the most effective.therapy is the most effective.

17. F) Allergic Drug Reactions
• 1. Anaphylaxis
• 2. Anaphylactoid reactions
A. Initial therapy
1. Discontinue drug administration and all anesthetic agents.
2. Administer 100% oxygen.
3. Intravenous fluids (1-5 liters of LR).
4. Epinephrine (10-100 mcg IV bolus for hypotension; 0.1-0.5 mg IV
for cardiovascular collapse).
B. Secondary treatment
 Antihistaminic medications IV.
 Epinephrine 2-4 mcg/min, norepinephrine 2-4 mcg/min.
 Aminophylline 5-6 mg/kg IV over 20 minutes.
 1-2 grams methylprednisolone or 0.25-1 gm hydrocortisone.
 Sodium bicarbonate 0.5-1 mEq/kg.
 Airway evaluation (prior to extubation).

18. G)G) Temperature changesTemperature changes
I) Hypothermia:I) Hypothermia:
It is unintentional decrease of core body temperature to < 35 C during anesthesiaIt is unintentional decrease of core body temperature to < 35 C during anesthesia
Causes:Causes:
I.I. Drop in core temperature.Drop in core temperature.
II.II. Central inhibition of thermoregulation.Central inhibition of thermoregulation.
Contributing factorsContributing factors::
Extremes of age, prolonged surgery, cold infusion or irrigation fluids, muscleExtremes of age, prolonged surgery, cold infusion or irrigation fluids, muscle
relaxantsrelaxants..
PreventionPrevention::
A.A. increase ambient temp and humidityincrease ambient temp and humidity
B.B. warm solutionswarm solutions
C.C. enclose exposed visceraenclose exposed viscera
D.D. humidify the inspired gaseshumidify the inspired gases
E.E. warm mattress and blanketwarm mattress and blanket
F.F. use low flow anesthesia.use low flow anesthesia.

19. II) Malignant Hyperthermia
• It is a fulminant skeletal muscle hypermetabolic
syndrome occurring in genetically susceptible
patients after exposure to an anesthetic
triggering agent. Triggering anesthetics include
halothane, enflurane, isoflurane, desflurane,
sevoflurane, and succinylcholine.
• Early signs: tachycardia, tachypnea, unstable
blood pressure, arrhythmias, cyanosis, mottling,
sweating, rapid temperature increase, and cola-
colored urine.
• Late (6-24 hours) signs: pyrexia, skeletal muscle
swelling, left heart failure, renal failure, DIC,
hepatic failure.

20. Cont……..
• Incidence and mortality
• A. Children: approx 1:15,000 general anesthetics.
• B. Adults: approx 1:40,000 general anesthetics
when succinylcholine is used; approx 1:220,000
general anesthetics when agents other than
succinylcholine are used.
• C. Familial autosomal dominant transmission.
• D. Mortality: 10% overall; up to 70% without
dantrolene therapy. Early therapy reduces
mortality for less than 5%.

21. H) MISCELLANEOUS
• Renal dysfunction: Oliguria (urine
output less then 0.5 mL/kg/hour)
most likely reflects decreased renal
blood flow due to hypovolemia or
decreased cardiac output.