Anesthetic Problems and Emergencies PDF

ANESTHETIC PROBLEMS, & EMERGENCIES VETC2015 LAURA COUCH RVT, MSc, One Health (GradCert), AMEE ESME (Cert), BSc TITLE LOREM Sit Dolor Amet 6th Edition p.396-401  Active Technician Roles in common anesthetic problems We play a very active role in problem prevention & identificat...

ANESTHETIC PROBLEMS, & EMERGENCIES VETC2015 LAURA COUCH RVT, MSc, One Health (GradCert), AMEE ESME (Cert), BSc TITLE LOREM Sit Dolor Amet 6th Edition p.396-401  Active Technician Roles in common anesthetic problems We play a very active role in problem prevention & identification Must know your skill set, supplies, equipment, drugs, & patient status Ask for help/2nd opinion when unsure! Don’t be a hero Must practice scenarios with staff – role play an emergency VT are very active in resuscitation & all things surrounding it Maintain adequate supplies for when things break or for high consumable items List some anesthetic problems or emergencies… List some things you have learned that will prevent medical errors: Must Watch https://youtu.be/MfWpMrEOlJ8?si=xLcDAkN0A 6  Triage what YOU need Think before to do TO DO. Know your room & supplies acting before being faced with an ER Crash cart supplied and ready – daily & after each use Drug list and supplies up to Responding date to an Closed Loop Communication! Emergency Do no harm – don’t Get others involves panic, deep breaths & – more brains the maintain clarity better Post-emergency follow up discussion 7  Causes of Anesthetic Problems Human Error Equipment Failure Adverse Effects Increased Patient Risk Anesthetic Problems and Emergencies: Human Error Inadequate training lack of familiarity with equipment or agents Failure to obtain adequate history Failure to perform adequate physical examination Drug calculation & administration errors Errors caused by fatigue, haste, or inattention Inadequate care & maintenance of supplies & equipment Inappropriate operation of equipment Equipment-related errors 9 Anesthetic Problems and Emergencies: Adverse Effects of Drugs Reduce adverse effects at all costs Choose a protocol suitable for the condition or needs of the patient Be familiar with disadvantages/adverse effects & contraindications Balanced Anesthesia: Multidrug protocols are safer than single drug protocols, & are MAC sparing! Give minimal required amount Titrate to effect! Adjust inhalant frequently % adjustments and depth assessments 10 Anesthetic Problems and Emergencies: Equipment: ADS Issues Equipment failure or inaccuracy Carbon dioxide absorbent exhaustion (rebreathing system) Failure of oxygen supply Endotracheal tube (ET) blockage Connections disconnected or kinked Blocked parts: flutter valves stuck, scavenge not patent... 11  …Equipment: ADS Issues APL / Pop-Off Valve Problems Leaving the pop-off valve in a closed position – No tread feature during IPPV – Being distracted and leaving it closed – Breaks in a closed position Pop-off in a semi closed positions Components within APL are faulty During leak test when you open the APL it should decompress, if not then there is likely an issue and it should NOT be used Sticky spring feature 12  …Equipment: ADS Issues APL / Pop-Off Valve Problems Notice excessive pressure? – RIP BAG OFF MACHINE! This is a fast solution to saving life – Yes WAG! 13  …Equipment: ADS Issues Vaporizer problems Usually result in delivering TOO much = overdose Using the wrong anesthetic agent: avoidable with key fillers Tipping the vaporizer, or moving a lot and the agent splashes around Vaporizer dial becomes stuck or jammed Vaporizer is overfilled Two vaporizers used at the same time Oxygen flow rate less than 0.5L/min for most vaporizers Not serviced or within delivery specifications (0.2% +/-) 14  1. Animals that will not stay anesthetized ere 2. Animals that are too deeply anesthetized red h 3. Pale mucous membranes Cov e Common 4. Prolonged capillary refill time Emergencies 5. Hypotension during 6. Dyspnea and/or cyanosis 7. Tachypnea Anesthesia 8. Apnea 9. Abnormal heart rate & rhythm r ate 10. Respiratory arrest ,L 11. Cardiac arrest II rt 12. Vomiting/Regurgitation Pa 13. Higher Risk Patients 14. Recovery  1. Will Not become anesthetized (or stay anesthetized) An inadequate vaporizer setting – monitor your %! Leak around the ETTube cuff - inadequately cuffed or defective – remember once patient at plane II check for leaks again as they are more relax you may find a new leak Respiratory: Apnea or low/inadequate tidal volume Tachypnea - rapid, shallow breathing – inadequate inhalation of iso commonly seen in toy dogs and obese animals or those who are in a light plane or have a lung pathology 16  …1. Animals that will not stay anesthetized A blocked, misplaced, or disconnected endotracheal tube A blocked ETT will increase breathing system pressure but a semi blocked may just feel like there is resistance when giving an IPPV or show a negative breathing system pressure Confirm that the endotracheal tube is not blocked (try to give IPPV), is it in the trachea (ETCO2 y/n), and that the breathing circuit is attached (visually inspect, low compliance in IPPV?) An endotracheal tube too small 17 1. …won’t stay anesthetized Responding to Inadequate Anesthetic Depth Be prepared to give injectable anesthetic drugs to keep patient asleep – e.g. propofol or MAC sparing agent Loose or misassembled, leaks in ADS Check that air is not leaking around the endotracheal tube cuff Inadequate oxygen flow? Provide IPPV: normal? Okay lung compliance? leaks? 18 1. …won’t stay anesthetized..responding to inadequate anesthetic depth Check that the vaporizer setting is appropriate and adjust it accordingly. A vaporizer inadequately filled with liquid anesthetic Re-check the patient’s monitoring parameters Consult team for troubleshooting If none of the previously listed causes are identified, switch the patient to another machine 19  2. Too Deeply Anesthetized Signs: 15-18 ETCO2 goal  May need to add more air to cuff as increased pressure in the chest from compression can cause a leak. 22 2. …too deep Responding to Excessive Anesthetic Depth The use of intravenous fluids, external heat, and reversal drugs such (such as atipamezole, or naloxone) may be advised If the veterinarian is not immediately available to assess the patient’s condition, it is safest to assume that the animal’s anesthetic depth is too deep (no reflexes or tone, hypotensive & hypoventilating) decrease the vaporizer setting while observing the animal carefully for signs of arousal and monitor vitals. 23 3. Pale Mucous Membranes Preexisting conditions Blood loss during surgery Anesthetic agent that causes vasodilation and hypotension (e.g., acepromazine), or vasoconstriction (e.g., dexmedetomidine) Hypothermia Pain – causes vasoconstriction from sympathetic response Stress 24 …3. Pale Mucous Membranes Treating Pale Mucous Membranes Check depth – ensure they are receiving the least amount of inhalant to achieve desired depth (plane i or plane ii) Check other vital signs including heart rate, respiration, pulse strength, and capillary refill time Provide IPPV to rule out problems with oxygen delivery (low FiO2) & confirm 100% O2 supply okay Does IPPV feel okay/normal? Good or poor compliance? 25 …3. Pale Mucous Membranes Treating Pale Mucous Membranes Respiratory System Depression – Hypoventilation – If hypoventing on ROOM air = hypoxia – COMMON at RECOVERY if not careful Prevent – extube only when ready Provide flowby for 5 minutes as they convert back to room air Monitor SpO2 througout recovery! Rule out possible causes including hypothermia, hypotension, drug reactions, and blood loss, and pain Veterinarian should be consulted 26 4. Prolonged capillary refill time (>2 seconds) Blood pressure cannot adequately perfuse superficial tissues (hypoperfusion) May result from conditions present prior to induction May be secondary to blood loss during surgery May be seen in animals in deep anesthesia 27 4. …Prolonged capillary refill time (>2 seconds) Treating Prolonged Capillary Refill Time immediately check the animal’s pulse and blood pressure observe the animal for other signs of shock, including hypothermia and tachycardia (or bradycardia in later stages of shock). Discuss with DVM 28 5. Hypotension – blood pressure less than normal If @ or under the below values your patient is hypotensive & hypoperfused (organ damage, hypoxia, cellular damage) ≤80 mmHg SAP ≤ 50 mmHg DAP ≤ 60 mmHG MAP ANY of these must be immediately addressed PREVENT from getting this low! Recognize trends! 29 5. Hypotension – prevention/awareness Pre-anesthesia prevention- minimal use of vasodilation drugs Recall inhalants cause DOSE dependent vasodilation = hypotension & hypothermia Optimize pain control with injectable analgesics to reduce inhalants (MAC) Several drug options available to stabilize blood pressure Keep the patient warm through by supplemental heat If blood pressure cannot be maintained, colloids may be given in concert with crystalloids, or blood product if required 30 5. Hypotension & Treatment 1st Reduce Inhalant: if patient is not light, reduce vasodilation to improve BP continuously until showing signs of being light 2nd Fluids. Determine if patient requires cardiovascular volume with DVM, & administer a 10 mL/kg bolus STAT 3rd Drugs. Determine if patient requires CV drugs with DVM & administer accordingly – e.g. vasoconstrictors or drugs that improve cardiac contractility 31