Anaesthetic Problems Research Articles

Detection of endobronchial intubation by monitoring the CO2 level above the endotracheal cuff.

Early detection of accidental endobronchial intubation (EBI) is still an unsolved problem in anesthesia and critical care daily practice. The aim of this study was to evaluate the ability of monitoring above cuff CO2 to detect EBI (the working hypothesis was that the origin of CO2 is from the unventilated, but still perfused, lung). Six goats were intubated under general anesthesia and the ETT positioning was verified by a flexible bronchoscope. The AnapnoGuard system, already successfully used to detect air leak around the ETT cuff, was used for continuous monitoring of above-the-cuff CO2 level. When the ETT distal tip was located in the trachea, with an average cuff pressure of 15mmHg, absence of CO2 above the cuff was observed. The ETT was then deliberately advanced into one of the main bronchi under flexible bronchoscopic vision. In all six cases the immediate presence of CO2 above the cuff was identified. Further automatic inflation of the cuff, up to a level of 27mmHg, did not affect the above-the-cuff measured CO2 level. Withdrawal of the ETT and repositioning of its distal tip in mid-trachea caused the disappearance of CO2 above the cuff in a maximum of 3min, confirming the absence of air leak and the correct positioning of the ETT. Our results suggest that measurement of the above-the-cuff CO2 level could offer a reliable, on-line solution for early identification of accidental EBI. Further studies are planned to validate the efficacy of the method in a clinical setup.

Intraoperative adverse events during laparoscopic colorectal resection—better laparoscopic treatment but unchanged incidence. Lessons learnt from a Swiss multi-institutional analysis of 3,928 patients

Intraoperative adverse events significantly influence morbidity and mortality of laparoscopic colorectal resections. Over an 11-year period, the changes of occurrence of such intraoperative adverse events were assessed in this study. Analysis of 3,928 patients undergoing elective laparoscopic colorectal resection based on the prospective database of the Swiss Association of Laparoscopic and Thoracoscopic Surgery was performed. Overall, 377 intraoperative adverse events occurred in 329 patients (overall incidence of 8.4%). Of 377 events, 163 (43%) were surgical complications and 214 (57%) were nonsurgical adverse events. Surgical complications were iatrogenic injury to solid organs (n = 63; incidence of 1.6%), bleeding (n = 62; 1.6%), lesion by puncture (n = 25; 0.6%), and intraoperative anastomotic leakage (n = 13; 0.3%). Of note, 11% of intraoperative organ/puncture lesions requiring re-intervention were missed intraoperatively. Nonsurgical adverse events were problems with equipment (n = 127; 3.2%), anesthetic problems (n = 30; 0.8%), and various (n = 57; 1.5%). Over time, the rate of intraoperative adverse events decreased, but not significantly. Bleeding complications significantly decreased (p = 0.015), and equipment problems increased (p = 0.036). However, the rate of adverse events requiring conversion significantly decreased with time (p < 0.001). Patients with an intraoperative adverse event had a significantly higher rate of postoperative local and general morbidity (41.2 and 32.9% vs. 18.0 and 17.2%, p < 0.001 and p < 0.001, respectively). Intraoperative surgical complications and adverse events in laparoscopic colorectal resections did not change significantly over time and are associated with an increased postoperative morbidity.

Factors affecting anesthetic complications in children undergoing congenital cardiac catheterization

Background Anesthetic complications are among the most common adverse effects in congenital cardiac catheterization. Although the presence of an expert pediatric anesthetist will markedly reduce these complications, other factors may contribute toward their development. Objectives To determine the factors associated with the development of anesthetic complications in children undergoing congenital cardiac catheterization. Materials and Methods We carried out a prospective study of 71 patients who underwent cardiac catheterization over a period of 6 months and analyzed the intracatheterization and postcatheterization anesthetic complications. Results The most common anesthetic complication was delayed recovery (11.3%). Other less common adverse events included postoperative vomiting (2.8%), sinus tachycardia (2.8%), postoperative agitation (1.4%), intraoperative arousal (1.4%), and intraoperative apnea (1.4%). Patients who had no anesthetic adverse events were significantly older and had higher body weight compared with those who had one or more anesthetic problems. In addition, patients who had anesthetic adverse events had significantly longer procedure time compared with those who had no anesthetic complications. Conclusion Factors that can contribute toward anesthetic adverse events in children undergoing cardiac catheterization include a longer procedure time, longer duration of anesthesia, and younger age.

Ultrasound-Guided Axillary Block in an Anticoagulated Patient after Heartmate II Implantation

Objective: This case exemplifies the understanding of the physiological changes associate with 1) Left Ventricular Assist Devices, 2) monitoring challenges associated with Left Ventricular Assist Devices and 3) the usefulness of peripheral nerve blocks in this subset of patients. Case report: A 73-year-old man was scheduled for left wrist arthroscopy and debridement to treat a very painful septic joint. He had undergone Heartmate II Left Ventricular Assist Device implantation uneventfully for Destination Therapy 4 months prior. The patient required maintenance of therapeutic anticoagulation. We elected for an ultrasound-guided axillary block, which limits the risks of vascular injury in presence of high INR. The axillary nerve block enabled us to overcome potential anesthetic problems in a patient with a continuous flow LVAD. Conclusion: The physiologic principles of Left Ventricular Assist Device function should be understood before the initiation of anesthesia. Regional Anesthesiologists can offer a very significant contribution to the safe care of patients with heart failure requiring a continuous flow Left Ventricular Assist Device.

Delayed traumatic diaphragmatic hernia mimicking hydropneumothorax.

Traumatic diaphragmatic hernia (TDH) is generally a consequence of thoraco-abdominal trauma. Anaesthetic problems arise due to herniation of abdominal contents into the thoracic cavity causing diaphragmatic dysfunction, lung collapse, mediastinal shift and haemodynamic instability. Diagnosis depends on history, clinical signs and radiological investigations. Sometimes, it may be misdiagnosed as hydropneumothorax due to the presence of air and fluid in the viscera lying in the pleural cavity. We report a case of TDH mimicking hydropneumothorax on radiological investigations and subsequent surgical management, which led to serious complications.

Anaesthesia for emergency ventriculo-peritoneal shunt in an adolescent with Noonan's syndrome.

A 15-year-old boy with Noonan's syndrome was admitted for emergency ventriculo-peritoneal shunt. Intraoperative course was complicated by hypertensive urgency, which was effectively managed with high doses of esmolol (500 μg/kg/min). Difficult airway was anticipated due to presence of webbed neck and facial dysmorphism. Tracheal intubation was however successfully accomplished with the aid of a bougie. This report thus highlights the unique anaesthetic problems encountered during anaesthetic management of such a case, which is worth sharing.

An audit of the efficacy of a structured handover tool in obstetric anaesthesia

IntroductionThe SAFE handover tool was developed to reduce critical omissions during handovers in obstetric anaesthesia. It comprises a simple proforma onto which the outgoing team documents patients who fall into one of four anaesthetically relevant categories: Sick patients; At-risk patients (of emergency caesarean section, major haemorrhage or anaesthetic problems); Follow-ups; and Epidurals. We hypothesised that its use would reduce the number of critical omissions at handover. MethodsThe efficacy of the SAFE handover tool was assessed through several audit cycles in a single maternity unit. The four SAFE categories were considered the gold standard, since they encompassed the consensus opinion of senior obstetric anaesthetists with respect to parturients they most wanted to know about at handover. Against these criteria it was possible to compare the number of cases that should have been handed-over against the number that were actually handed-over. ResultsAfter implementation of the handover tool, patients were four times more likely to be handed-over than without the use of the tool: an increase from 49% to 79% of relevant cases (P<0.0001, OR 4.1, 95% CI 2.19–7.6). The handover tool was particularly effective at increasing the handover rates of Sick and At-risk parturients, which increased from 21% to 67% (P<0.0001, OR 7.7, 95% CI 2.7–21.7) and 25% to 78% (P<0.01, OR 9.9, 95% CI 1.6–61.6), respectively. ConclusionThe SAFE handover tool significantly increased handover rates of anaesthetically relevant parturients. It is easy to remember and consistent with UK National Health Service Litigation Authority’s guidance on risk management in maternity units.

Quality of Information in the Process of Informed Consent for Anaesthesia

ObjectivesTo assess the quality of the information that patients receive in the informed consent document signed prior to surgery. Materials and methodsCross-sectional study of a sample of cancer patients admitted for surgery at the University Hospital San Cecilio of Granada in 2011. After checking the inclusion criteria and obtaining their consent, demographic data were collected and procedure data, and a questionnaire “ad hoc” to assess the quality and comprehensiveness of the information provided in the informed consent. Results150 patients were studied. The majority (109 over 150) said they had received sufficient information, in appropriate language, and had the opportunity to ask questions, but only 44.7% correctly answered three or more issues related to anaesthesia. University education level, knowledge of the intervention, information about the anaesthesia problems and appropriate language were associated. ConclusionsAlthough systematic informed consent is regularly obtained, half of the patients did not comprehend the anaesthesia risks. Variables primarily related to the information received were associated with the quality of the response, but not with patient characteristics.

Calidad de la información en el proceso del consentimiento informado para anestesia

ObjectivesTo assess the quality of the information that patients receive in the informed consent document signed prior to surgery. Material and methodsCross-sectional study of a sample of cancer patients admitted for surgery at the University Hospital San Cecilio of Granada in 2011. After checking the inclusion criteria and obtaining their consent, demographic data were collected and procedure data, and a questionnaire «ad hoc» to assess the quality and comprehensiveness of the information provided in the informed consent. Results150 patients were studied. The majority (109 over 150) said they had received sufficient information, in appropriate language, and had the opportunity to ask questions, but only 44.7% correctly answered three or more issues related to anesthesia. University education level, knowledge of the intervention, information about the anesthesia problems and appropriate language were associated. ConclusionsAlthough systematic informed consent was performed, half of the patients did not comprehend the anesthesia risks. Variables primarily related to the information received were associated with the quality of the response, but not with patient characteristics.

Was bedeutet Sicherheit im Krankenhaus?

Patient safety in hospitals is difficult to define and is not measurable by operational safety parameters as in other fields. So-called adverse events (AE) are a collective of complications, failures, mistakes, errors and violations. Estimations of at least 9.2 % AEs in surgery with 0.1 % fatalities are given worldwide but there are no correlations between objective quantification of AEs and subjective or public perception of safety during the perioperative period. Patient safety during this period is mostly endangered by wound infections (safety 98 %) and nosocomial infections (safety 97 %). In spite of these facts, safety parameters for problems in anesthesia, blood transfusion, in retaining surgical instruments and so-called index events, such as patient and side identification errors are much higher. Patient safety is maintained in hospitals by objective means (surgical). Checklists have been proven to improve safety and critical incidence reporting, training and changing of attitudes could have further advantages but they are difficult to measure.

Evaluation of suspected malignant hyperthermia events during anesthesia

BackgroundMalignant hyperthermia (MH), a metabolic myopathy triggered by volatile anesthetics and depolarizing muscle relaxants, is a potentially lethal complication of general anesthesia in susceptible patients. The implementation of modern inhalation anesthetics that research indicates as less potent trigger substances and the recommended limitations of succinylcholine use, suggests there may be considerable decline of fulminant MH cases. In the presented study, the authors analyzed suspected MH episodes during general anesthesia of patients that were referred to the Wuerzburg MH unit between 2007 and 2011, assuming that MH is still a relevant anesthetic problem in our days.MethodsWith approval of the local ethics committee data of patients that underwent muscle biopsy and in vitro contracture test (IVCT) between 2007 and 2011 were analyzed. Only patients with a history of suspected MH crisis were included in the study. The incidents were evaluated retrospectively using anesthetic documentation and medical records.ResultsBetween 2007 and 2011 a total of 124 patients were tested. 19 of them were referred because of suspected MH events; 7 patients were diagnosed MH-susceptible, 4 MH-equivocal and 8 MH-non-susceptible by IVCT. In a majority of cases masseter spasm after succinylcholine had been the primary symptom. Cardiac arrhythmias and hypercapnia frequently occurred early in the course of events. Interestingly, dantrolene treatment was initiated in a few cases only.ConclusionsMH is still an important anesthetic complication. Every anesthetist must be aware of this life-threatening syndrome at any time. The rapid onset of adequate therapy is crucial to avoid major harm and possibly lethal outcome. Dantrolene must be readily available wherever MH triggering agents are used for anesthesia.

Analgesia, Anaesthesia and Pregnancy. A Practical GuideS.Yentis &amp; S.MalhotraCambridge University Press, ISBN 9781107601598, 456 pp., Price £45.00

This is the third edition of a well-established practical guide to obstetric anaesthesia. As with the preceding two editions, the authors have succeeded in covering the essentials of the subject, as well as providing an easy to follow guide to the majority of procedures undertaken in obstetric anaesthesia. Analgesia, Anaesthesia and Pregnancy is primarily targeted at anaesthetic trainees starting in the maternity ward or preparing for exams. Few areas are covered in much depth but the breadth of topics addressed does make it a useful practical guide for senior anaesthetists faced with less common, complex cases. The original format of the first two editions has been followed. The book is divided into four sections covering preconception and conception, pregnancy, the postpartum period and the organisational aspects of working in obstetrics. The largest section, being the pregnancy section, is further subdivided into seven main headings containing short chapters covering normal procedures and processes, anaesthetic and obstetric problems as well as other general medical conditions which may have implications in obstetric cases. Coverage of each topic follows a consistent approach, providing a concise introduction, an outline of the problem or special considerations and a management strategy. The suggested clinical management is generally evidence-based and widely reflects standard British practice. The key points section at the end of every chapter provides a useful summary for those looking for a quick reference to help solve a particular problem. This is not a text that seeks to address current controversies in obstetric anaesthesia but the references list does point the interested reader to some of the relevant literature. The authors have responded to events such as the flu pandemics and findings of recent Confidential Enquiries into Maternal Deaths by the addition of new chapters on topics such as pneumonia, malaria and migrants/disadvantaged women. The notable omission of shoulder dystocia from the obstetric problems section in the previous editions has been rectified, though this is one chapter where illustrations or diagrams would prove particularly helpful. One of the most appealing aspects of this book is the structured approach used in covering different aspects of obstetric anaesthesia. It is well indexed and the contents section lists the sections, subsections and chapters with page numbers, making it easy to identify topics at a glance. In summary, this book is a user-friendly practical guide. It is easy to carry and would serve well as a study aid as well as a useful addition to every labour ward and departmental library.

Preventing complications of OOKP surgery

AbstractOsteo‐odonto‐keratoprosthesis (OOKP) is the procedure of choice for end stage ocular surface disease with severe dryness and keratinisation, and in those eyes with structural and functional lid abnormalities. The device retention rates and visual outcomes of the OOKP are far superior than any other keratoprosthesis. However, this device can have complications at every step during surgery and unto many years afterwards. Complications after the Stage 1 include: mucosal thinning and ulceration, mouth related, resorption of the implanted lamina and infections. Complications after the Stage 2 include: mucosal thinning and ulceration, mucosal overgrowth onto the optic, lid malpositions, lamina problems like resorption, tilting, infection, posterior segment complications like retinal detachment and vitreous haemorrhage. Glaucoma is a major cause of visual loss in a successful OOKP eye. Social and psychological complications can arise after visual restoration or the preexisting problems can continue. In addition, operative complications, systemic morbidity and anesthetic related problems do occur. A majority of the complications can be sight threatening if not rectified appropriately in a good time. They may be preventable or reducible with correct patient selection, improvements in preoperative and postoperative patient care and education. A sound surgical technique, reflective learning, harnessing the medical technology and multidisciplinary team approach can effectively reduce and treat the complications of OOKP surgery. Multidisciplinary team approach, having an experienced anesthetist and psychologist on board, and a continuous social support will prevent patient morbidity and optimise good outcomes.

Residual neuromuscular block in elderly patients after surgical procedures under general anaesthesia with rocuronium

Incomplete recovery of neuromuscular function following the administration of medium-acting, non- -depolarising agents is one of the most feared complications in anaesthesia. We assessed the incidence of postoperative residual curarisation (PORC) after general anaesthesia with rocuronium in elderly and young patients, and we evaluated possible complications of postoperative residual curarisation. This observational study included 415 patients (ASA physical status I-III) who were undergoing different surgical procedures: 184 patients were aged ≥ 65 (range: 65-89) years, and 231 patients were aged 19-57 years. No patients had renal or hepatic disorders. Patients received rocuronium for relaxation. Neuromuscular monitoring was not used intraoperatively. Neuromuscular function recovery was spontaneous. Patients were transferred to the post-anaesthesia care unit (PACU) after anaesthesia. During the first ten minutes in the post-anaesthesia care unit, the presence of postoperative residual curarisation was assessed by acceleromyography and train-of-four (TOF) stimulation. Patient well-being was monitored continuously. During hospitalisation, patient medical documentation was assessed for postoperative residual curarisation-related complications. TOF ratios were < 0.7 in 31% of all patients, whereas the block was clinically completely recovered in all patients. Postoperative residual curarisation was more frequent in elderly (44%) than younger patients (20%) (P < 0.05). Only 73 patients (21 elderly, 52 younger patients) had TOF ratios ≥ 0.9. Hypoxia was more frequent in elderly patients in the PACU: 17.9% vs. 8.2% (P < 0.05). Postoperative residual curarisation-related pneumonia was observed in one elderly patient. Residual paralysis remains a major problem in geriatric clinical anaesthesia. Neuromuscular function monitoring is obligatory, and pharmacological reversal of relaxation should be advised in geriatric patients after using relaxants for general anaesthesia.

Obesity deleteriously affects anesthetic and surgical outcome in body mass index-dependent fashion

ObjectivesTo evaluate obesity effect on anesthetic and surgical outcome of patients of varying BMI assigned for open abdominal surgery.Patients and methodsSixty patients were categorized according to WHO classification of obesity into three classes: class I (n = 30), class II (n = 18) and class III (n = 12). All patients underwent open laparotomy under combined anesthesia using continuous remifentanil infusion and balanced sevoflurane anesthesia. Hemodynamic variables, duration of surgery, intraoperative bleeding, frequency of blood transfusion, recovery times and intraoperative anesthetic or surgical problems were recorded. The occurrence of postoperative complications, admission to ICU, duration till 1st ambulation, 1st oral intake, hospital stay period and rates of morbidity and mortality were recorded.ResultsInduction of anesthesia significantly decreased arterial pressures and heart rate compared both to preoperative and pre-induction measures. After extubation all parameters returned to preoperative levels. Mean operative time was significantly longer and mean intraoperative blood loss was significantly more in patients of class III compared to those of class I and II. All recovery times showed BMI dependence as all were significantly prolonged in class II and III patients compared to class I patients with significantly shorter awakening and extubation times in class II patients than class III patients. Mean time till 1st walk was significantly longer in class III patients than class I and II patients, but time till 1st oral intake was non-significantly different. Sixteen patients developed PO complications. Mean PO hospital stay was significantly longer in class III patients compared to class I and II patients with significantly shorter duration in class II patients than those of class III.ConclusionObesity caused deleterious anesthetic and surgical effects with prolonged operative and recovery times and more need for blood transfusion, ICU admission and prolonged hospital stay duration. The used anesthetic regimen allowed controlled hypotension without compromising patients’ general condition.

Drug error – problem in anaesthesia

Describes an error of using adrenaline instead of atropine. DOI: http://dx.doi.org/10.4038/slja.v21i2.5420

Anesthetic management in an appendix tumor patient undergoing hyperthermic chemotherapy

Cytoreductive surgery combined with hyperthermic intra­peritoneal chemotherapy (HIPEC) is a complex and mul­tidiscipliner procedure that is being used increasingly for peritoneal and appendix malignency. First of all the mac­roscopic tumor tissues are extracted after that peritoneal perfusion is started with giving heated 42°C chemother­apeutic solution via abdominal drains. It is important to maintain normovolemia, to regulate coagulation and renal parameters during perioperative period, to compansate hypothermia during cytoreductive surgery and hyperther­mia during HIPEC and to regulate hemodynamic changes due to increased abdominal pressure during HIPEC. In this case report, we aimed to share anaesthetic experi­ence and to evaluate anaesthetic problems in 45 years old ASA I patient undergoing cytoreductive surgery and hypertermic intraperitoneal chemotherapy in which newly established in our hospital for appendix tumor.

Recogida y análisis sistemático de problemas anestésicos intraoperatorios

ObjectiveThe purpose of the study was to systematically collect and analyse the frequency, type and severity of all untoward intraoperative anaesthetic-related problems in a hospital over a 6-month period. MethodsAn observational, systematic, prospective, and cross sectional study was conducted on the events and their risk factors. The study is based on a system in which anaesthesia-related data are recorded from all anaesthetic cases on a routine basis, including sedation and obstetric analgesia. The variables were demographic, procedural data, and a checklist with problem type and severity. Data were analysed using chi-square, Fisher's test, or Student's test. A P<.05 was considered statistically significant. ResultsThe frequency of intraoperative anaesthetic-related problems was 17.2%, with 1.3 anaesthetic problems per case, being 9 times more frequent the adverse effects with low severity grade. During anaesthesia, respiratory problems occurred in 13, circulatory problems in 8, and technical problems in 2 out of every 100 procedures. The factors associated with the patient in whom the anaesthetic problem occurred were: the use of general anaesthesia, supraumbilical surgery, and a higher preoperative anaesthetic risk. ConclusionsUse of a systematic intraoperative anaesthetic-related database with a checklist of problems and severity plays an important part in quality assurance strategies. An analysis of non-fatal problems provides a basis for establishing corrective strategies before significant morbidity occurs, and by separating the surgical and anaesthesia problems.

Laparoscopic cholecystectomy in patients with anesthetic problems

Laparoscopic cholecystectomy is a standard operation for benign gallbladder disease. As experience with laparoscopic cholecystectomy has increased, the procedure has become possible in patients with anesthetic problems. Patients with ankylosing spondylitis or severe kyphosis represent a challenging group to anesthesiologists and laparoscopic surgeons since these diseases are associated with difficult intubation, restrictive ventilatory defects, and cardiac problems. The relatively new approach of awake fiberoptic intubation is considered to be the safest option for patients with anticipated airway difficulties. Laparoscopic cholecystectomy is usually performed under general anesthesia but considerable difficulties in anesthetic management are encountered during laparoscopic surgery; for example, hemodynamic instability may develop in patients with cardiopulmonary dysfunction due to pneumoperitoneum and position changes during the operation. Nonetheless, regional anesthesia can be considered as a valid option for patients with gallbladder disease who are poor candidates for general anesthesia due to cardiopulmonary problems. We report three cases of laparoscopic cholecystectomy successfully performed in patients with anesthetic problems that included cardiopulmonary disease, severe kyphosis, and ankylosing spondylitis.

Anesthesia for Emergency Cesarean Section in a Parturient with Noonan Syndrome

Patients with Noonan syndrome are characterized by many anesthetic problems, primarily related to potential difficult airway and technical issues with regional anesthesia. We describe the anesthetic management of a difficult case of a parturient with Noonan syndrome requiring emergency Cesarean section under spinal anesthesia. We had to evaluate the patient within a limited amount of time because of fetal distress. Although spinal injection was easily accomplished, it resulted in inadequate sensory block requiring supplemental analgesics and sedatives.