Authors : Assistant Professor Ngamjit Pattaravit, MD. Professor Polpun Boonmark, MD. Graphic design : Textbook Production Unit, Faculty of Medicine Prince of Songkhla University, Hat Yai, Songkhla 90110, Thaiand Book design by : Patcharin Potong Cover design by : Wisawat Tang-on First pubished : Sahamit Pattana Printing (1992) Co., Ltd. (Head Office) 1st edition : May, 2023 (ebook) ________________________________________________________________________________________________________________________________________________________________________________________________________________ Pubished by The Royal College of Anesthesiologists of Thailand Chalermprabaramee Golden Jubilee Building, 5th Floor, No. 2 Soi Soonvijai New Petchburi Road, Bangkapi, Huaykwang, Bangkok 10310 Telephone 02-716-7220, Fax 02-716-7771, Mobile 085-261-0066, 081-906-3066 http://www.anesthai.org ________________________________________________________________________________________________________________________________________________________________________________________________________________ (All rights reserved under the Copyright Act of 1994) National Library of Thailand Cataloging in Publication Data Ngamjit Pattaravit. Quick action handbook for anesthesia crisis.-- Bangkok : The Royal College of Anesthesiologists of Thailand, 2023. 52 p. 1. Anesthesia. I. Polpun Boonmark, jt.auth. II. Title. 615.781 ISBN (ebook) 978-616-8277-09-6 Quick Action Handbook for ANESTHESIA CRISIS
1 Quick Action Handbook for ANESTHESIA CRISIS Advisors 1. Dr. Prapa Rattanachai : Former president of the Royal College of Anesthesiologists of Thailand 2. Professor Somrat Charuluxananan : Former president of the Royal College of Anesthesiologists of Thailand 3. Professor Suwanee Suraseraneewong : Former president of the Royal College of Anesthesiologists of Thailand 4. Professor Ruenreong Leelanukrom : President of the Royal College of Anesthesiologists of Thailand 5. Dr. Pannawit Benjawaleemas 6. Capt. Dr. Kornprom Saengaram List of Authors 1. Assistant Professor Ngamjit Pattaravit. MD., FRCAT., FRCPT. : Department of Anesthesiology, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand. Editor 2. Professor Polpun Boonmak. MD., FRCAT. : Anesthesiology Department, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand. Co-Editor 3. Associate Professor Wariya Sukhupragarn, MD., FRCAT. : Department of Anesthesiology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand. 4. Associate Professor Pichaya Waitayawinyu, MD., FRCAT. : Department of Anesthesiology, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand.
5. Dr. Sunisa Sangtongjaraskul, MD., FRCAT. : Department of Anesthesiology, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand. 6. Assistant Professor Jittiya Watcharotayangul, MD., FRCAT. : Department of Anesthesiology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand. 7. Dr. Kittikhun Narkasawet, MD., FRCAT. : Department of Anesthesiology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand. 8. Dr. Dujduen Srilamatr, MD., FRCAT. : Department of Anesthesiology, Faculty of Medicine, Srinakharinwirot University. Nakhon Nayok, Thailand. 9. Dr. Walaiporn Aroonrat, MD., FRCAT. : Department of Anesthesiology, Vachira Phuket Hospital, Phuket, Thailand. 10. Dr. Jaroonpong Choorat, MD., FRCAT. : Department of Anesthesiology, Sanpasitthiprasong Hospital, Ubon Ratchatani, Thailand. 11. Dr. Chattong Somcharoenwattana, MD., FRCAT. : Department of Anesthesiology, Phattalung Hospital, Phattalung, Thailand. 12. Dr. Onkanya Chimpalee, MD., FRCAT. : Department of Anesthesiology, Paholpolpayuhasena Hospital, Kanchanaburi, Thailand. 13. Dr. Phongsak Nitikaroon. MD., FRCAT., FRCPT. : Department of Anesthesiology, Prapokklao Hospital, Chanthaburi, Thailand.
PREFACE Currently, medical safety focuses on patients and personnel in the event of an emergency in patients. In addition to the potential harm to a patient, psychological effects can also occur. Ongoing operational impacts may have legal effects on medical personnel as well. A crisis requires accurate, complete, and prompt management. Since a crisis occasionally happens quite unexpectedly, even rehearsals may miss some important points. Therefore, the authors from many institute in Thailand including medical schools and the Ministry of Public Health jointly proposed developing a handbook entitled Quick Action Handbook for Anesthesia Crisis to enhance safety in the practice of anesthesia. This handbook is the result of brainstorming, complete validation, and employing the research process. Finally, the user-friendly version was launched. As the former president of the Royal College of Anesthesiologists of Thailand, I would like to recommend and congratulate the valuable contributions of all authors who undertook the task of putting together this handbook. This handbook will support the safety of our patients and all anesthetists. Professor Suwanee Suraseranivongse Former president of the Royal College of Anesthesiologists of Thailand 2020-2021
ACKNOWLEDGEMENTS The World Health Organization (WHO) has emphasized the safety of patients around the world for decades. The mnemonic "S I M P L E" is used as a reminder in the context of safety. The letter "E" of "S I M P L E" stands for Emergency Response which is crucial in anesthesia. Proper clinical management will enhance the patient safety. Abnormal clinical signs and important details frequently encountered may present dangerous situation if there is no adequate knowledge or timely correction. This handbook, Quick Action Handbook for Anesthesia Crisis, provides concise and comprehensive advice for anesthesia personnel as a cognitive aid to provide treatment in a timely and proper manner. As the former president of the Royal College of Anesthesiologists of Thailand, I congratulate and thank all anesthesiology team members who worked hard to create this useful handbook. I sincerely thank the following people who have created valuable work for the Thai anesthesiology profession and health care system, Firstly, Capt. Dr. Kornprom Saengaram and his volunteer team the Thai Airways Corporation who inspired the safety. concerns, secondly, Dr. Ngamjit Pattaravit, Dr. Polpun Boonmak, and their contributing team from all over the country who dedicated to accomplish this book. Dr. Prapa Ratanachai Former president of the Royal College of Anesthesiologists of Thailand 2018-2019
Quick Action Handbook for Anesthesia Crisis Facing unexpected anesthesia events may arise at any given moment. Once such as event occurs, there should be a proper process to resolve the problem and free the patient from harm. However, anesthesia personnel may not be prepared for the unexpected event or they may need more time to resolve the crisis. Knowledge, skills, and human factors, which include physical or mental conditions such as stress and fatigue, can cause delays in the management of a crisis that consequently affect the safety of the patient. The use of cognitive aids and checklists is one method that has proven valuable and is accepted throughout the aviation and medical industry and can help reduce the incidence of errors caused by human factors. Therefore, the authors created the Quick Action Handbook for Anesthesia Crisis as a valuable tool for anesthesia personnel when faced with a crisis. In the preparation process, the working group gathered knowledge from a medical literature review and brainstormed the collection of problems that are commonly found in 12 anesthesia conditions during general anesthesia. The handbook provides a step-bystep problem-solving process, which, when the user proceeds accordingly, will help solve problems that arise. For experienced personnel, the checklist format can be used to complete the troubleshooting process. which has been partially implemented.. In the 2nd edition of the manual, some content has been revised to complete and maximize the benefits of use. The checklist follows the static sequential with verification format. The Quick Action Handbook for Anesthesia Crisis needs to be studied and practiced before implementation in anesthesia service. The Anesthesia crisis working group
User Guidance of the Quick Action Handbook (QAH) for Anesthesia Crisis The QAH for an anesthesia crisis is a handbook designed to help anesthesiologists manage anes- thesia crises correctly and promptly. The handbook includes a Quick Action Reference (QAR) list of 12 common anesthesia crises that includes one sheet per condition with a critical cut-off point for each condition. The QAR list of crises in this manual are in alphabetical order: Bradyarrhythmia, Car- diac arrest, Desaturation, Increased airway pressure, Hypercapnia, Hypertension, Hyperthermia, Hypo- capnia, Hypotension, Hypothermia, Suspected intraoperative Myocardial ischemia, and Tachyarrhyth- mia. For each QAR sheet, the front part has steps to follow in caring for the patient. The back part provides a list of possible causes and initial treatment for each particular condition. To completely use all manual functions, the users should follow these steps. 1. Remove all QAR sheets required for the patient keeping in mind that one patient may have more than one problem. 2. Start with the most important or severe problem. 3. The static sequential with verification checklist requires two users. The first person reads the QAR step by step and checks that the second person provides management step by step appropriately until the end of the QAR (sign ===) The second person provides the management according to the checklist read aloud by the first person and provides two-way communication (confirmation) at each step even if the crisis has been resolved. In the case of one user (static parallel) Read the QAR and follow the advice step by step to the end of the QAR (sign ===) 4. If the clinical condition fits the criteria in the green box, which indicates a severe crisis, the user must provide complete management along with the instruction in the green box. The user then proceeds to the white box when the condition in the green box is resolved or is waiting for investigation results. 5. If the patient's condition does not fit the criteria in the green box, the user can start management in the white box from item 1 in the QAR from beginning to end (sign ===) 6. In the case of a crisis relapse, start the QAR again in the same process as before from the beginning to the end of the QAR. 7. If multiple crisis events arise simultaneously, select the most severe event (red [emergency], yellow [urgent], black [less urgent but requires management]). Once the most severe crisis is resolved, go to another QAR and manage according to the instructions until each crisis has been resolved. 8. Reassess the patient's condition periodically. If the problem arises again, it must be managed following the relevant QAR. Note 1. Suppose the patient's condition does not improve. In that case, even though complete management was performed according to the QAR instructions, the user must redo the management by starting again going from top to bottom and flipping the QAR to the back side to determine the possible causes. 2. Color codes: Red = Emergency Yellow = Urgent Black = Less urgent but requires management Vocabulary and Signs Check = Verify Continuous monitoring = maintain regular surveillance Notify = Inform someone, for example a surgeon or nurse Perform = Do as instructed Recheck = Check or verify something again. Repeat = Redo the process Review = Inspect * = go to a specific treatment session after providing initial management following the QAR / = or ===============: end of the QAR
Abbreviation ABG Arterial blood gas A-line Arterial line AF Atrial fibrillation amp ampule APL Adjustable pressure limiting AV Atrioventricular BP Blood pressure bpm Beat per minute BS Blood sugar BT Body temperature BUN Blood urea nitrogen CBC Complete blood count cm centimeter CK-MB Creatine kinase-myocardial band COPD Chronic obstructive pulmonary disease CPK Creatine phosphokinase CPR Cardiopulmonary resuscitation Cr Creatinine CT Computed tomography CVP Central venous pressure CVT Cardio-Vascular-Thoracic DIC Disseminated intravascular coagulopathy EDTA Ethylene diamine tetraacetic acid EKG Elektrokardiographie (electrocardiogram) EtCO2 End-tidal carbon dioxide ETT Endotracheal tube FDP Fibrin degradation product FGF Fresh gas flow FiO2 Fraction of inspired oxygen GA General anesthesia G/M blood grouping and cross matching Hb Hemoglobin HR Heart rate H2 O Water ICD Intercostal drainage ICU Intensive care unit IM Intramuscular IO Intraosseous IV Intravenous IVC Inferior vena cava K Potassium kg kilogram L Litre LDH Lactate dehydrogenase LMA Laryngeal mask airway LRS Lactate Ringer’s Solution MAP Mean arterial pressure mcg microgram mg milligram MgSO4 Magnesium sulfate MH Malignant hyperthermia MI Myocardial ischemia ml millilitre mmHg millimeters of mercury MV Minute ventilation NaHCO3 sodium bicarbonate NG nasogastric N2O Nitrous oxide O2 Oxygen PaCO2 Partial pressure of carbon dioxide PE Pulmonary embolism PEEP Positive end expiratory pressure PT Prothrombin time PTT Partial thromboplastin time q every RI Regular insulin SBP Systolic blood pressure SpO2 Oxygen saturation SVT Supraventricular tachycardia Trop-T Troponin T Trop-I Troponin I VT Ventricular tachycardia
Table of contents Treatment Guidances according to abnormal signs Brady-arrhythmia 1 Cardiac arrest 3 Desaturation 5 Increased airway pressure 7 Hypercapnia 9 Hypertension 11 Hyperthermia 13 Hypocapnia 15 Hypotension 17 Hypothermia 19 Suspected intraoperative myocardial ischemia 21 Tachy-arrhythmia 23 Recommended initial treatment for specific conditions Anaphylaxis 25 Local anesthetic systemic toxicity 26 Malignant hyperthermia 27 Pulmonary embolism 28 Sepsis 29 Transfusion reaction 30
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1 1 Bradyarrhythmia BRADY-ARRHYTHMIA HR < 50 bpm / If the patient has one of these conditions If Patient has one of these conditions MAP <65 mmHg / <20% from baseline / signs of shock / 2nd degree AV block Mobitz II / 3rd degree AV block A. Medication treatment …………………………………....………..………………..… ADMINISTRATION 1) Atropine 1.0 mg IV (bolus q 3-5 minutes, Maximum 3 mg) IF NOT IMPROVE 2) Dopamine 5-20 mcg/kg/minute IV infusion 3) Epinephrine 2-10 mcg/minute IV infusion B. Transcutaneous pacing ……..........…………………………………………………………..…. CONSIDER C. ECG …………………………………………………….……. Continuous MONITORING & RECHECK D. Consult cardiologist ………………………………..…………………..…….…...…………………. CONSIDER E. Blood pressure ……………………..…..………..........…… REPEAT q 1 minute until BP stable F. ECG 12 leads ...................................................................................................…..… PERFORM 1. Pulse and EtCO 2 waveform …………………………...……….…….…….........................… CHECK Normal ……………………......…………..........................…....……......….….… GO to step 2 No pulse / No EtCO2 waveform ……………....................…... CALL FOR HELP & START CPR IMMEDIATELY CARDIAC ARREST QAR (P.3) 2. Team member (anesth, surgeon, scrub) ….………......................... NOTIFY & STOP stimuli 3. Blood pressure Normal (+20% from baseline) ………………………..…….............................… GO to step 4 MAP <65 mmHg / <20% from baseline …................…. GO TO The GREEN BOX 4. SpO2 Normal …………………………………………...............................…….…….....………... GO to step 5 <90% ........................................................................................ Desaturation QAR (P.5) (if desaturation is the cause of bradycardia) 5. Depth of anesthesia Adequate ………………….……………………….…………….….............................…... GO to step 6 Too deep ………………………………………………………….......................….….…. REDUCE / OFF 6. Medications review (wrong drug / dose) …….….………….....................….………………… CHECK 7. Body temperature ……………………..…………….....................……………...………… KEEP 36.0-37.5o C 8. Causes of bradycardia (on the back side) ……….…………….................…………………. REVIEW 9. ECG ………..……………..............…………........……..……. Continuous MONITORING & RECHECK ==========================================================================
2 CAUSES OF BRADYCARDIA Cause Initial management Hypervagal response stop stimuli, reduce auto-PEEP Desaturation increase FiO 2 , fresh gas flow, and correct cause Deep anesthesia GA reduce or stop anesthetic drugs High spinal block closed monitoring and consider IV atropine / epinephrine Drugs stop medication and consider IV atropine / epinephrine Vasopressor reflex closed monitoring Hypovolemia volume resuscitation Obstructive shock Cardiac tamponade volume resuscitation, consult CVT Pulmonary embolism see page 28 Tension pneumothorax needle thoracotomy / ICD / stop N2 O Reference No. 1-7
3 Cardiac arrest CARDIAC ARREST Can not detect pulse (or not sure to affirm) within 10 seconds / can not measure or very low blood pressure / can not measure SpO2 / very low or can not measure EtCO2 A. CALL FOR HELP, EMERGENCY CART, DEFIBRILLATOR …...…...... IMMEDIATELY B. Team member (anesth, surgeon, scrub) ………….........……. NOTIFY & STOP stimuli C. START CPR ……………………………………………….…...........…………………..….. IMMEDIATELY CHEST COMPRESSION (depth > 5 cm, rate 100-120/minute, stop <10 seconds) D. Anesthetic medication ………………………………………………………..…….…........................………. OFF E. Advanced Cardiovascular Life Support (ACLS) ……………....….…..…...…..........…. PERFORM F. Causes of perioperative cardiac arrest (on the back side) ……..………..............… REVIEW ECG ……………………………………………………………………………….........................……………. PERFORM Ventricular fibrillation / Pulseless ventricular tachycardia o Defibrillation 120-200 joules IMMEDIATELY, repeat q 2 minutes o Amiodarone 300 mg (5 mg/kg) / lidocaine 100 mg IV/IO (1.5 mg/kg) o High-quality CPR o If Torsades de Pointes: MgSO4 1-2 g IV/IO Asystole / Pulseless Electrical Activity (PEA) o High-quality CPR VENTILATE WITH 100% O 2 ……………………………………………………............……… PERFORM o Bag-mask ventilation 2 times every 30 compressions / ETT ventilate q 6 seconds EPINEPHRINE 1 mg IV/IO (repeat q 3-5 minutes) …………………….......……… PERFORM IDENTIFY CAUSES & TREATMENT ...…………….…………………......….......……… PERFORM o Physical exam, EtCO2 , ABG, blood sugar, electrolytes, echocardiogram PREGNANCY (left uterine displacement / delivery in4 minutes) ............ PERFORM Extracorporeal membrane oxygenation (ECMO) ………..………............………. CONSIDER Post cardiac arrest care after return of spontaneous circulation (ROSC) …......… PERFORM ==========================================================================
4 CAUSES OF PERIOPERATIVE CARDIAC ARREST Airway and Breathing auto-PEEP hypoxemia tension pneumothorax Circulation cardiac tamponade coronary thrombosis hypovolemia pulmonary embolism sepsis vagal stimulus Drug and substance acidosis anaphylaxis anesthetic overdose high spinal block hypo / hyperglycemia hypo / hyperkalemia local anesthetic systemic toxicity medication error malignant hyperthermia H’s hydrogen ion (acidosis) hypo / hyperkalemia hypoxia hypovolemia hypothermia T’s cardiac tamponade coronary thrombosis pulmonary embolism tension pneumothorax toxins Reference No. 1-5, 7-14
5 Desaturation DESATURATION SpO2 < 90% If the patient has one of these conditions SpO2 < 85% / cyanosis / not improve within 3 minutes CALL FOR HELP ………………………………..……………………………….........………...…… IMMEDIATELY SpO2 < 90% 1. Pulse and EtCO 2 waveform ……………………………...……………….……................…… CHECK No pulse / No EtCO2 waveform ……….........................…….. CALL FOR HELP & START CPR IMMEDIATELY CARDIAC ARREST QAR (P.3) 2. Team member (anesth, surgeon, scrub) ………..................………. NOTIFY & STOP stimuli 3. SpO2 ……..……....................…........… Continuous MONITORING & RECHECK q 30 seconds 4. Fresh gas flow …………………………………………………………….......................…. increase, 100% O2 5. Tidal volume 6-10 ml/kg ……………………..…….….…….…...............................................……… GO to step 6 Inappropriate …………………………………........….........................…….… adjust tidal volume 6. Airway pressure <30 cmH 2 O ……………….………….....…….....................……………........…….….… GO to step 7 Sudden increase / >30 cmH 2 O o endobronchial / pneumothorax / bronchospasm / obstruction / tube kink ……………….……………………………...…...…..……......................…….......... CHECK Sudden decrease o leak / extubation / circuit disconnect ….…………..…............................……….... CHECK 7. Manual ventilation ……………………………..............................…………………………………… PERFORM Secretion / machine failure ……............................................................................…… CHECK 8. Breath sound Normal …………………………………….......………...........………................….....…….. GO to step 9 Wheezing ……………….....................….. Bronchodilator, increase depth of anesthesia Other abnormal breath sounds (on the back side) ……………......................…… REVIEW 9. SpO2 probe …………………….…………………………………………….......….........................……….. CHECK 10. Blood pressure ………………………………………………………......….........................………………. CHECK 11. Body temperature ……….……………..……............................................................................. CHECK 12. Causes of desaturation (on the back side) ……………………………........................…... REVIEW 13. SpO2 ……………………..……...................................…… Continuous MONITORING & RECHECK ==========================================================================
6 CAUSE OF DESATURATION Airway & Breathing endobronchial intubation, esophageal intubation hypoventilation, apnea laryngospasm, bronchospasm atelectasis, pulmonary edema pleural effusion, pneumothorax poor peripheral circulation Circulation hypotension, hyper-metabolic state, pulmonary embolism Drug & substance nail polish, methylene blue, methemoglobin Equipment anesthetic machine, probe displacement DESATURATION DIFFERENTIAL DIAGNOSIS BY BREATH SOUND Normal hypoventilation (low MV, high pressure) respiratory system compliance: lung & chest wall (low MV, high pressure) cardiac arrest (no EtCO2 , no pulse) pulmonary embolism (low EtCO2 , high PaCO2 ) sepsis / thyrotoxicosis / malignant hyperthermia / neuroleptic malignant syndrome (normal MV, high EtCO2 ) No sound esophageal intubation equipment problems (ETT, circuit, machine (inspired/expired valves, scavenging system, APL valve) Unequally endobronchial intubation (improper depth) atelectasis / hemothorax / pleural effusion (dullness percussion) pneumothorax (tympanic percussion) Crepitation pulmonary edema / pneumonia / aspiration Stridor laryngospasm (no / decrease EtCO2 ) Wheezing bronchospasm (high pressure) Reference No. 1-5, 15-20
7 Increased airway pressure INCREASED AIRWAY PRESSURE Airway pressure > 30 cmH 2 O / sudden increase SpO2 ……………………………………………………………………………………………............…………. CHECK <90% …………………………………….……....................………....…….. Desaturation QAR (P.5) <85% / cyanosis ………………..…........………………… CALL FOR HELP IMMEDIATELY Desaturation QAR (P.5) 1. Team member (anesth, surgeon, scrub) …..............................…..….....................…….. NOTIFY STOP stimuli / Desufflate CO 2 if applicable 2. ETT / LMA (kink / obstruction / endobronchial) …..……………...............………..……. CHECK 3. EtCO 2 waveform (obstructive pattern picture) …………………………...................………. CHECK 4. Manual ventilation ……………………......………………………......................……………………. PERFORM Secretion / machine failure …….........................................................................…… CHECK 5. Breath sound Normal ……………………………….......………............................……….....……………. GO to step 6 Wheezing …………......................……….. bronchodilator, increase depth of anesthesia Other abnormal breath sounds (on the back side) ………...................……..… REVIEW 6. Patient’s chest wall compression ………………………………….………....................………... RELIEVE 7. Depth of anesthesia ………………….......................…….…………………..……………… KEEP adequate 8. Anesthetic machine (kink / valve malfunction) ………………..........................….…..... CHECK 9. Causes of increased airway pressure (on the back side) ……………...............….….... REVIEW 10.Airway pressure ….….............…... Continuous MONITORING & RECHECK q 15 minutes ==========================================================================
8 CAUSE OF INCREASED AIRWAY PRESSURE Airway laryngospasm one-lung ventilation small tube size, kinked tube, obstructed tube (secretion / blood clot) Breathing bronchospasm chest wall rigidity, obesity pneumo / hemothorax, pneumoperitoneum pulmonary edema, aspiration, lung contusion, lung fibrosis, acute respiratory distress syndrome increase abdominal pressure Circulation ----- Drug & substance inadequate depth of anesthesia / relaxation Equipment kinked circuit, secretion block in breathing circuit (including HME filter), inspired / expired valve / APL valve problem improper ventilator setting INCREASED AIRWAY PRESSURE DIFFERENTIAL DIAGNOSIS BY BREATH SOUND Normal respiratory system compliance: lung & chest wall (low MV, high pressure) pulmonary embolism (low EtCO2 , high PaCO2 ) No sound esophageal intubation equipment problems (tube, circuit, machine (inspired/expired valves, scavenging system, APL valve) Unequally endobronchial intubation (improper depth) atelectasis / hemothorax / pleural effusion (dullness percussion) pneumothorax (tympanic percussion) Crepitation pulmonary edema / pneumonia / aspiration Stridor laryngospasm (no / decrease EtCO2 ) Wheezing bronchospasm (high pressure) Reference No. 1-5, 20-21
9 capnia HyperHYPERCAPNIA EtCO 2 > 40 mmHg 1. Team member (anesth, surgeon, scrub) ....................................................................... NOTIFY 2. ETT/LMA (kink / obstruction / malposition) ………………….....…....................…….….. CHECK 3. SpO2 >90% ....................…………………....................................................................... GO to step 4 <90% ………................................................................................. Desaturation QAR (P.5) 4. Minute ventilation ………..……………………….…………………………........................……………. CHECK 5-8 L/minute ……………………………..….…………….......................….....…....…… GO to step 5 Inappropriate ………………………..........................……..….. INCREASE minute ventilation 5. Sodalime and inspired EtCO2 ……………………………………………….......................………….. CHECK Inspired EtCO2 >0 mmHg / sodalime color change (exhausted) .…… increase FGF 6. Airway pressure ………………………………………….………………..….........................……………. CHECK Normal …………………………….……………………………….................................….… GO to step 7 Increase ………………………....................….…... Increased airway pressure QAR (P.7) 7. Manual ventilation …………………………………………………….....……….......................……. PERFORM Machine failure …….…….……………………………………………….........................……….. CHECK 8. Breath sound Normal …………..……………………………………………………..............................…... GO to step 9 Wheezing ………….......................…..….. bronchodilator, increase depth of anesthesia Abnormal breath sound (cause on the back side) ………....................…... PERFORM 9. Valve function ………………….………………….….……………………………..........................……….. CHECK Abnormal ………………………..................….... VENTILATE by self-inflating (AMBU) bag 10.Surgeon notify ……………………………..…..……..…..…..........................……… LOOK for Reperfusion 11.Body temperature >37.5๐ C ……………………………..…..……..…..….........................……… DECREASE temperature >39๐ C / increase >0.5๐ C in 10 minutes ………….................….…… CALL FOR HELP Observe malignant hyperthermia ==========================================================================
10 CAUSE OF HYPERCAPNIA Airway small tube size, kinked tube, obstructed tube one-lung ventilation Breathing hypoventilation bronchospasm airway disease (COPD, asthma, bronchiectasis, interstitial lung disease, cystic fibrosis) CO 2 insufflation Circulation hyper-metabolic state / sepsis / thyrotoxicosis / malignant hyperthermia / neuroleptic malignant syndrome reperfusion from tourniquet Drug & substance bicarbonate administration Equipment exhausted sodalime inadequate FGF valve malfunction HYPERCAPNIA DIFFERENTIAL DIAGNOSIS BY BREATH SOUND Normal hypoventilation (low MV, high pressure) respiratory system compliance: lung & chest wall (low MV, high pressure) sepsis / thyrotoxicosis / malignant hyperthermia / neuroleptic malignant syndrome (normal MV, high EtCO2 ) Unequally endobronchial intubation (improper depth) pneumothorax (tympanic percussion) atelectasis / hemothorax / pleural effusion (dullness percussion lung) Crepitation pulmonary edema / pneumonia / aspiration: increase PEEP, adjust FiO2 Wheezing bronchospasm (high pressure): bronchodilator, increase depth of anesthesia Reference No. 1-5, 22-24
11 tension HyperHYPERTENSION MAP > 20% from baseline If the patient has one of these conditions SBP >180 mmHg / DBP > 110 mmHg persist > 10 minutes Arrhythmia / ST-T change A. CALL FOR HELP ……………………………………...................…..………….….… IMMEDIATELY B. Nicardipine IV / Labetalol IV / NTG infusion …..………..…………...…………. PERFORM Aim to decrease MAP between 10-15% from initial crisis BP 1. Team member (anesth, surgeon, scrub) ………..…………….….......................……..…..… NOTIFY 2. Blood pressure ……………………………..........................………. REPEAT q 2 minutes until stable 3. Cuff size ………………………………………………………………………….........................………………. CHECK Appropriate …………………………….………………...............................…............... GO to step 4 Too small ………………………………………………………………….........................……….. CHANGE 4. ECG ………………………………………………….………………………………...........................……………. CHECK Normal ……………………………….…………………………………..............................…. GO to step 5 ST-T change ……………………………..…....................…………… ST-T changes QAR (P.21) Arrhythmia ……………....................…... Brady (P.1) / Tachyarrhythmia (P.23) QAR 5. EtCO 2 ………………………………………………….......................………………………… KEEP 35-40 mmHg 6. SpO2 ……………………………………………………………………….........................….……………. KEEP > 95% 7. Drug errors (IV line check, name, dose) …………………………………......................……… CHECK 8. Anesthetic gas delivery Normal …………………………………………….........................……...…………………… GO to step 9 Malfunction ....…....................…......… CHANGE machine, SWITCH to IV anesthesia 9. Anesthetic records Anesthetic medications ………................……...........…… ADJUST depth of anesthesia Inotropic / vasopressor ……….………............…….........……….………….….. REDUCE / OFF 10. A-line ……………...…………….…………………..........................................…….. CONSIDER PERFORM 11. Surgeon notify……………………………...........................………....……………..….………… STOP stimuli 12. Causes of hypertension (on the back side) …………….................………………………….. REVIEW 13. Consult cardiologist ………………………………….........................……………...…….…….... CONSIDER ==========================================================================
12 CAUSE OF HYPERTENSION Common cause pre-existing hypertension inadequate anesthesia and analgesia hypoxemia hypercapnia drug errors Surgery laparoscopic surgery adrenalectomy aortic Cross-clamp Patient volume overload increase intracranial pressure pheochromocytoma pre-eclampsia hyperthyroidism malignant hyperthermia Equipment inappropriate cuff size transducer height (A-line) MEDICATION FOR HYPERTENSION Drug Dose labetalol 5-10 mg (0.25-1 mg/kg) IV q 10 minutes (up to 300 mg), then 0.25-1 mg/minute IV infusion esmolol 500 mcg/kg, then 50-200 mcg/kg/minute IV infusion nicardipine 0.5-2 mg, then 5-15 mg/hour (0.5-3.5 mcg/kg/minute) IV infusion nitroprusside 0.5 to 10 mcg/kg/minute IV infusion nitroglycerin 0.5-5 mcg/minute IV infusion diltiazem 5-10 mg IV over 2 minutes Reference No. 1-5, 25-31
13 Hyperthermia HYPERTHERMIA Core temperature (nasopharynx / esophagus / bladder) > 37.5o C If the patient has one of these conditions core temperature > 39o C / increase > 0.5o C in 10 minutes arrhythmia / ST-T change / hypotension A. CALL FOR HELP ………………….………………….……………………..…..….......... IMMEDIATELY B. Malignant hyperthermia triggering agents (on the back side) ……......…..… OFF & GO to MH management P.27 1. Team member (anesth, surgeon, scrub) .…………....................................……………..… NOTIFY 2. Probe position ………………………..………………..………………….........................……….………… CHECK 3. SpO2 ………………………………...…..…………...........................………..….…..…………………… KEEP >95% 4. EtCO 2 ……………………….…..……..…………..………….......................………………. KEEP 35-40 mmHg 5. ECG Normal ……………………………………………………..............................……………….. GO to step 6 Tachy-arrhythmia …………...................……….….. TACHY-ARRHYTHMIA QAR (P.23) 6. Warming devices ……….…………………………………………….…….................................................. OFF 7. Patient ...….............................………………………................................................................ COOLING Tepid sponge / surface cooling / irrigation / antipyretic / drug 8. Cause of hyperthermia (on the back side) ……….……………..…….......................…….. REVIEW 9. Temperature ………………………….…………………......................…..……… RECHECK q 15 minutes Temp >37.5o C …..................................................... REPEAT HYPERTHERMIA QAR ==========================================================================
14 **MH triggering agents: succinylcholine, desflurane, isoflurane, sevoflurane CAUSE OF HYPERTHERMIA Normal EtCO 2 dehydration hypothalamus injury: head injury, stroke, encephalitis, meningitis drug & substance (misoprostol, atropine, alcohol, opioids, benzodiazepines, cocaine, amphetamine, aspirin, antidepressants, transfusion reaction) over warming High EtCO2 sepsis thyrotoxicosis status epilepticus pheochromocytoma (severe hypertension, flushing) malignant hyperthermia (muscle rigidity, acidosis, inhalation agents, succinylcholine) neuroleptic malignant syndrome (isocarboxazid, phenelzine, selegiline, tranylcypromine) Reference No. 1-5, 32-35
15 capnia HypoHYPOCAPNIA EtCO 2 < 20 mmHg NO EtCO 2 waveform ................................................ CHECK Pulse and SpO2 waveform No pulse / No SpO2 waveform ………………………............................ CALL FOR HELP & START CPR IMMEDIATELY CARDIAC ARREST QAR (P.3) 1. Team member (anesth, surgeon, scrub) ………..……………................................……..… NOTIFY 2. ETT/LMA (leak / kink / obstruction / malposition) .…….……………................…….... CHECK 3. Fresh gas flow ……………………………………………………….....................……... increase, 100% O 2 4. SpO2 >90% ....................……..……….............................…............................................ GO to step 5 <90% ………................................................................................... Desaturation QAR (P.5) 5. Blood pressure Normal / High ……………………..…….…………..…….…....................................… GO to step 6 MAP <65 / <20% from baseline ....……..….....................…. Hypotension QAR (P.17) 6. Minute ventilation Normal (5-8 L/minute) …………...…........……….....................................……… GO to step 7 High …………………………………………….…........................... DECREASE minute ventilation 7. Airway pressure Normal (<30 cmH 2 O) ……………………………...………............................….….… GO to step 8 High ……........................................................... Increased airway pressure QAR (P.7) 8. Manual ventilation (machine failure) …….…….………………...........................…....….. PERFORM 9. Breath sound Normal …………..……………………………….........................………………....………... GO to step 10 Wheezing ………………..................….. bronchodilator, INCREASE depth of anesthesia Abnormal breath sound (cause on the back side) ……....................……... PERFORM 10.Water trap / tubing Abnormal ……………………....................................................................................... CHANGE 11.CO 2 sidestream tube / mainstream Obstruction …………………………..........................……………………………..…………….. CHANGE Re-calibrate ……...........................................................................................……... PERFORM 12.Body temperature BT <36๐ C ……………………………..……......................……………… Hypothermia QAR (P.19) ==========================================================================
16 CAUSE OF HYPOCAPNIA Airway LMA/ETT: disconnect / displacement / obstruction esophageal intubation laryngospasm Breathing hyperventilation apnea cardiac arrest severe bronchospasm Circulation hypo-metabolic state: hypothermia, hypothyroid severe hypotension pulmonary embolism Drug & substance ----- Equipment gas sampler obstruction or misplace HYPOCARBIA DIFFERENTIAL DIAGNOSIS BY BREATH SOUND Normal hyperventilation (high MV) cardiac arrest (no EtCO2 , no pulse) pulmonary embolism (low EtCO2 , high PaCO2 ) hypometabolic state; hypothermia, hypothyroid No sound esophageal intubation / equipment problem (ETT, circuit, inspired valve, expired valve, scavenging system, APL valve) Unequally pneumothorax (tympanic percussion) atelectasis / hemothorax / pleural effusion (dullness percussion) Crepitation pulmonary edema / pneumonia / aspiration Wheezing severe bronchospasm (high pressure) Stridor laryngospasm (no/decrease EtCO2 ) Reference No. 1-5, 22, 36
17 Hypotension HYPOTENSION MAP < 65 mmHg / < 20% from baseline If the patient has one of these conditions MAP <65 mmHg / <20% from baseline after treatment >5 minutes Arrhythmia / ST-T change A. CALL FOR HELP …………………...…………………………………...…......…………. IMMEDIATELY B. Ephedrine / Norepinephrine / Epinephrine IV ……………...........…..………… PERFORM C. Inotropic / vasopressor infusion ……..………………………….…..……….......………..……. CONSIDER (drug and dose recommend on the back side) D. Arterial blood pressure (ABP) …………………......……………………………………………… CONSIDER E. Electrolytes and Blood sugar …………………………..…………………………....…………….……. CHECK 1. Team member (anesth, surgeon, scrub) ……….…………….…….................…………..….. NOTIFY 2. Blood pressure ………………………………….............…...…….. REPEAT q 1-2 minutes until stable 3. IV Fluid 10 ml/kg loading within 10 minutes (if no history of heart disease) ……… PERFORM IV line (disconnect) …………………....………………………………….........................…….. CHECK 4. Anesthetic medications …………..……………..……………………….……...................…………. REDUCE 5. Ephedrine / Norepinephrine IV stat …………………………………....……................……. PERFORM 6. Surgeon notify ……………………………………….................….……. Stop stimuli / CO 2 desufflation 7. ECG Normal ……………..………………………………..…………….................................….... GO to step 8 ST-T change ………..……………....................……….…..……….…. ST-T changes QAR (P.21) Arrhythmia ………................….… Brady QAR (P.1) / Tachyarrhythmia QAR (P.23) 8. Patient Bleeding ……………...................…….…………...… IV fluid / blood replacement and G/M PEEP / auto-PEEP ………………………..………………..................…………………….… MINIMIZE IVC compression (prone / pregnancy) …………………..................…………. REPOSITION Rash (anaphylaxis) …………….………………………..…………………....................………… CHECK Breath sound o Normal …………………………………………..…................................................... GO to step 9 o Unequal breath sound tension pneumothorax / massive hemothorax …........…........................ TREAT 9. Causes of hypotension (on the back side) …….……….…………….................…………….. REVIEW 10. Blood pressure ……....…………………..................….…….. REPEAT q 1-2 minutes until stable ==========================================================================
18 CAUSE OF HYPOTENSION Common cause anesthetics overdose hypovolemia (blood loss, dehydration, diuresis) vagal reflex (retraction) decrease venous return (IVC / retractor / pneumo- peritoneum) monitor malfunction: (A-line) transducer height REDUCTION OF Preload Contractility Afterload blood loss anesthetic drug anesthetic drug hypovolemia ischemic heart disease combine neuraxial decrease venous return cardiomyopathy blockade (IVC / retractor / arrhythmia antihypertensive pneumoperitoneum) valvular heart disease medication obstruction myocarditis sepsis o increase intrathoracic anaphylaxis pressure tourniquet release o cardiac tamponade reperfusion o pulmonary embolism DRUG FOR HYPOTENSION Drug Cause of shock Dose Dopamine cardiogenic shock, heart failure 2.0-20 mcg/kg/minute vasodilatory shock symptomatic bradycardia Dobutamine cardiogenic shock, heart failure 2.0-20 mcg/kg/minute sepsis-induced myocardial dysfunction Epinephrine cardiogenic shock, heart failure 0.01-0.1 mcg/kg/minute vasodilatory shock symptomatic bradycardia cardiac arrest 1 mg IV q 3-5 minute anaphylaxis shock 0.1-0.5 mg IM (up to 1 mg) Norepinephrine vasodilatory shock 0.01-3 mcg/kg/minute Phenylephrine vagal stimulation / drug 0.1-0.5 mg IV q 10-15 minutes aortic stenosis 0.4-9.1 mcg/kg/minute infusion hypertrophic cardiomyopathy with left ventricular outflow tract obstruction Reference No. 1-5, 28, 37-40
19 Hypothermia HYPOTHERMIA Core temperature (nasopharynx, esophagus) < 36๐ C If the patient has one of these conditions Core temperature <35๐ C Bradycardia Abnormal bleeding CALL FOR HELP ………………………………………….………...................……..……… IMMEDIATELY 1. Team member (anesth, surgeon, scrub) ……….…………..………….……........................… NOTIFY 2. Probe position ………………………..……………….……………….……..........................…….………… CHECK 3. ECG Normal ……………………………………………………………….….............................….. GO to step 4 Arrhythmia ……….…................ Brady QAR (P.1) / Tachyarrhythmia QAR (P.23) 4. Blanket / force air warmer / heat humidifier / warm IV fluid …………….........………. APPLY 5. Room temperature ……….…………………………….……………........................………….... KEEP >21๐ C 6. EtCO 2 ……………………………………….…………..…….......................…….…………. KEEP 35-40 mmHg 7. Causes of hypothermia on the back side ………….……..……...................………..…….. REVIEW 8. Temperature …………………………..……………….....................……..……… RECHECK q 15 minutes Temp <36.0o C ………...……………............................... REPEAT HYPOTHERMIA QAR ==========================================================================
20 CAUSE OF HYPOTHERMIA Heat loss low environment temperature blood loss and fluid resuscitation large non-cover area long duration of surgery intra-abdominal surgery wet surgical drape cold irrigation Disease hypothyroidism malnutrition adrenal insufficiency thiamine deficiency sepsis hypoglycemia neuromuscular disease burn Medication ethanol general anesthesia EFFECT OF HYPOTHERMIA < 28๐ C tachyarrhythmias, atrial fibrillation 28-30๐ C decrease rate of metabolism 30-32๐ C lethargy, coma 32-33๐ C mild arrhythmias 33-34๐ C prolong PR interval, prolong QT interval, widening QRS complex 34-35๐ C bradycardia, impair coagulation, impaired platelet function, low platelet count, altered clearance of drugs 35-36๐ C tachycardia Reference No. 1-5, 41-44
21 intraopera Suspected - tive MI SUSPECTED INTRAOPERATIVE MYOCARDIAL ISCHEMIA ST depression (> 1-2 mm in 2 leads), ST elevation (> 1-2 mm in 2 leads V1, V2, V3), Symmetric T waves inversion (> 1 mm in 2 leads), new Q-wave (30 ms in 2 leads), new LBBB If the patient has MAP <65 mmHg A. CALL FOR HELP & CALL FOR DEFIBRILLATOR ……........…………… IMMEDIATELY B. MAP <65 mmHg / <20% from baseline ………….…..…………..…. Hypotension QAR (P.17) C. KEEP Heart rate 60-80 bpm ………………………………………………………......……………. PERFORM D. KEEP Blood pressure (SBP 100-120 mmHg, MAP >75 mmHg ……….......….. PERFORM E. Optimize preload …………………………………………………………………………........…………..PERFORM o Avoid hypovolemia ……………………………………………………………......….………… CONSIDER F. Blood sample for Trop-T, Trop-I, Electrolytes, Hct ……….......................…...…… PERFORM G. A-line and CVP …………………………………………………………………….....…………..……..…. CONSIDER H. Consult cardiologist ……….....………………………………………….…………………...……….....PERFORM I. ICU reservation ………………………………………………………………………………........……….. PERFORM * Hemodynamic goal and medications for perioperative MI (on the back side) 1. Team member (anesth, surgeon, scrub) ………..…...................…. NOTIFY & STOP stimuli 2. Blood pressure Within 20% from baseline ……………………….....................….......…….…....... GO to step 3 BP >20% from baseline ………………..................…......... Hypertension QAR (P.11) 3. ECG 12 leads (if possible) ……………………………………….………….......................……… PERFORM No significant change ……………............................. REPEAT q 15 minutes * 2 times And GO to step 4 Suspicious perioperative MI ……………………….............…… GO TO GREEN BOX 4. EtCO 2 ……………………………………………………………………........................……… KEEP 35-40 mmHg 5. SpO2 ……………………………………………………………...........................………………….………. KEEP >94% 6. Depth of Anesthesia…………………………………………….............................….……… KEEP adequate 7. Volume status and bleeding …………………….......................……………..… IV fluid replacement 8. Hemoglobin …………………………..…........................…… KEEP Hb 10 mg/dL, blood transfusion 9. Continuous ECG monitoring …………………..................…………....….. PERFORM & RECHECK ==========================================================================
22 HEMODYNAMIC GOAL FOR PERIOPERATIVE MI Target Problem Management HR 60-80 bpm normotension with esmolol 0.25-0.5 mg/kg IV sinus tachycardia normotension with amiodarone 150 mg IV infusion tachydysrhythmias in 15 minutes hypotension with synchronized cardioversion 50-100 J tachydysrhythmias hypertension with esmolol 500 mcg/kg, then tachydysrhythmias 50-200 mcg/kg/minute IV SBP 100-120 mmHg hypotension dobutamine 2-20 mcg/kg/minute MAP > 75 mmHg norepinephrine 0.05-1 mcg/kg/minute phenylephrine 25-50 mcg IV hypertension increase depth of anesthesia nitroglycerin (NTG); 0.5-1 mcg/kg/minute IV infusion nitroprusside; 0.5 to 10 mcg/kg/minute IV infusion nicardipine; 0.5-2 mg then 5-15 mg/hour (0.5-3.5 mcg/kg/minute) IV infusion labetatol; 5-10 mg (0.25-1 mg/kg) IV q 10 minutes (up to 300 mg), then 0.25-1 mg/minute IV infusion Reference No. 1-6, 45-46
23 TACHY-ARRHYTHMIA HR > 120 bpm / Rapidly increased heart rate (SVT, AF, VT) If patient unstable: MAP <65 mmHg / sign of shock A. CALL FOR HELP, EMERGENCY CART & DEFIBRILLATOR …......… IMMEDIATELY B. HR >150 bpm ECG pattern: QRS complex ……………….....……… Continuous MONITORING & RECHECK (QRS >3 small box: wide complex, QRS <3 small boxes: narrow complex) narrow and regular ………….……......………...….. Synchronized cardioversion 50-100 J wide and regular ………………................................... Synchronized cardioversion 100 J narrow and irregular ……..……......................... Synchronized cardioversion 100-200 J wide and irregular ……...................….. Defibrillation 200 J and CPR IMMEDIATELY C. Blood pressure ……………………….…..………..……........….…… REPEAT q 2 minutes until stable D. Consult cardiologist ………………………………………………………….……..........………………. PERFORM E. Electrolytes, blood sugar and Hct …………….…………..………….…….………......…………… CHECK F. ECG ………………………………………………....……….……. Continuous MONITORING & RECHECK G. ECG 12 leads (if possible) .................................................................................…..… PERFORM 1. Pulse and EtCO 2 waveform No pulse / No EtCO2 waveform ……..................….….......... CALL FOR HELP & START CPR IMMEDIATELY (CARDIAC ARREST QAR) 2. Team member (anesth, surgeon, scrub) ……………..................…. NOTIFY & STOP stimuli 3. Blood pressure +20% from baseline ………………..……………………….…............................…… GO to step 4 MAP <65 mmHg / <20% from baseline ………................ GO TO GREEN BOX 4. ECG pattern (QRS complex, rate) …..……………………………………….…....................…..… CHECK 5. Depth of anesthesia …………………...................………………………………….…… KEEP ADEQUATE 6. SpO2 ............................................................................................................................... KEEP >94% 7. Treatment guide for stable tachy-arrhythmia (on the back side) …….............… REVIEW 8. Medications review (wrong med, wrong dose) …….….…...................…………………… CHECK 9. IV line (leakage) …………………………….………………………..………......................……………….. CHECK 10. Volume status and bleeding Hypovolemia …….……………….…………….................…………………..… IV fluid replacement Anemia ……………….……………….…………………………..................….……… Blood Transfusion 11. Body temperature ……………………..…………………………........................………… KEEP 36.0-37.5o C 12. ECG ………..……………………………........................……. Continuous MONITORING & RECHECK ========================================================================== Tachyarrhythmia
24 CAUSE OF TACHY-ARRHYTHMIA Anesthesia light anesthesia, pain Airway & Breathing hypoxia hypercarbia auto-PEEP Circulation hypovolemia heart disease Others electrolyte abnormalities (suggest ABG) sepsis thyrotoxicosis malignant hyperthermia fever TREATMENT FOR STABLE TACHY-ARRHYTHMIA <3 small boxes and regular QRS complex vagal maneuvers, adenosine, esmolol, diltiazem <3 small boxes and irregular QRS complex amiodarone, esmolol, diltiazem >3 small boxes and regular QRS complex amiodarone, lidocaine DRUG ADMINISTRATION adenosine 6 mg IV push (double syringe technique) repeat 2 times esmolol 0.5 mg/kg IV over 1 minute, then 50 mcg/kg/minute IV infusion diltiazem 5-10 mg IV over 2 minutes amiodarone 150 mg IV over 10 minute, then 1 mg/minute IV infusion for first 6 hours lidocaine 1-1.5 mg/kg IV Reference No. 1-7
Specific Treatment Recommendations
25 Recommended Initial Treatment for Specific Conditions Intraoperative Anaphylaxi1-5, 47-49 Stop the drug or drugs and remove any suspected causes, i.e. antibiotics, muscle relaxants, latex. Call for help and inform the team of anesthesiologists, surgeons, and scrub nurses. Give 100% oxygen. If the airway is compromised, consider intubation. In cardiac arrest, follow the CARDIAC ARREST QAR (P.3). Patients with hypotension or severe bronchospasm or both o Adults : epinephrine 0.5 mg IM in the thigh/outer arm or 50-200 mcg IV o Children : epinephrine 0.3 mg IM in the thigh/outer arm or 1 mcg/kg IV If symptoms do not improve or if low blood pressure persists, consider giving epinephrine 0.05-0.1 mcg/kg/min IV infusion or norepinephrine 0.05-0.1 mcg/kg/min IV infusion or both. Administer crystalloids/colloids (1-2 L in adults and 20 ml/kg in children). Consider administering as required o salbutamol o chlorpheniramine o hydrocortisone Consult a surgeon to plan continuation of patient care. Observe symptoms closely for at least 6 hours until vital signs are stable. In case of unstable vital signs, admit the patient to ICU and continuously monitor. Take 5-10 ml of blood and send for serum tryptase evaluation as soon as possible, i.e. within the first 1-2 hours and repeat the examination at 24 hours. Consult immunologists. 25
26 Local Anesthetic Systemic Toxicity (LAST)1-5, 50, 51 Immediately stop injecting anesthesia. Call for help and inform the team of anesthesiologists, surgeons, and scrub nurses. Check pulse — if absent, perform CPR according to guidelines but reduce epinephrine to <1 mcg/kg. Avoid giving calcium channel blockers and lidocaine. Ventilate with 100% oxygen without hyperventilation and consider intubation. Stop seizures with thiopental 50–100 mg IV or benzodiazepine IV propofol. Give 20% lipid emulsion (Intralipid®) when seizure or hypotension occurs based on the following weight parameters. o >70 kg: give 100 ml IV over 2-3 minutes followed by 200-250 ml continuous infusion over 15-20 minutes. <70 kg: give 1.5 ml/kg over 2-3 minutes followed by 0.25 ml/kg/minute (ideal body weight). o If hypotension or seizure occurs, lipid emulsion (Intralipid®) administration can be repeated 1-2 times at the same dose not to exceed 12 ml/kg in total. o The maximum amount of lipid emulsion (Intralipid®) is 1 L if resuscitation is longer than 30 minutes. Consider continuous monitoring of vital signs in the ICU. Intensive monitoring should be continued for at least 4–6 hours if hypotension occurs. In case of seizures, intensive monitoring should continue for at least 2 hours. 26
27 Malignant Hyperthermia (MH)1-5, 52 Discontinue the possible causes of MH such as volatile anesthetic agents and succinylcholine. Provide 100% oxygen via a self-inflating bag (AMBU bag) and hyperventilation. Call for help, i.e. the supportive team and MH cart* (if available) and notify the surgeon to suspend surgery or perform surgery as soon as possible. Closely monitor the changes in core body temperature, BP, and ECG, i.e. pulse, arrhythmias. Administer dantrolene 2.5 mg/kg IV and repeat 1–2 mg/kg every 10 minutes. Reduce body temperature by turning off the warmer, open the blanket to uncover the patient and provide surface cooling with cold air, towel, cold pack, or ice as appropriate. Provide internal cooling by irrigation via NG tube or Foley catheter or both. Correct acidosis and hyperkalemia with 7.5% NaHCO3 50 ml IV, 50% glucose 50 ml + RI 5-10 units IV, furosemide 20 mg IV. Intensively monitor for the recurrence of MH within 24 hours in the ICU. If applicable, request lab investigations for ABG, K, CPK, BUN, Cr, coagulogram, and RYR-1 (ryanodine receptor) gene changes. Avoid giving calcium channel blockers. *MH cart: - Dantrolene 5 vials (100 mg) Recommend — Sterile water 500 ml x 4 bottles - 7.5% NaHCO 3 50 ml x 6 amp - 50% glucose 50 ml x 2 amp - Furosemide 20 mg x 4 amp - 20% mannitol 100 ml x 5 bottles - Regular insulin x 1 vial - 2% xylocaine without adrenaline x 2 vials Note: Mix dantrolene in sterile water and shake for 20 minutes or until completely dissolved. 27
28 Pulmonary Embolism (PE)6, 53-55 Call for help and inform the team of anesthesiologists, surgeons, and scrub nurses. Stop or finish the surgery as soon as possible. Ventilate with 100% oxygen. Unstable PE, i.e. hypotension or signs of poor tissue perfusion exist. Administer fluid loading with crystalloids at least 30 ml/kg IV free flow. Consider increasing blood pressure using the appropriate medications, i.e. norepinephrine, dopamine, epinephrine. Consider performing an echocardiogram to confirm the diagnosis. Consider transferring the patient for a CT angiogram when the patient is stable. Notify a cardiothoracic surgeon to consider an embolectomy as required. Stable PE Consider transferring the patient for a CT angiogram. Discuss developing a treatment plan with the surgeon. Low-risk bleeding o High suspicion of PE: administer unfractionated heparin. o Moderate suspicion of PE: investigation should be done within 4 hours before starting heparin administration. o Low suspicion of PE: investigation should be done within 4 hours before starting heparin administration. High-risk bleeding o Suggest to the surgeon that emergency embolectomy treatment be performed. 28
29 Septic Shock56-62 Call for help and inform the team of anesthesiologists, surgeons, and scrub nurses. Ventilate with 100% oxygen. Keep mean arterial pressure (MAP) >65 mmHg o Balance volume status by administering crystalloid fluids starting at 20 ml/kg (typically at least 30 ml/kg, 2-5 L in total) IV bolus and reevaluate before the next loading dose. 5% albumin can be considered when a large volume of crystalloids is given. o Administer norepinephrine IV infusion to maintain blood pressure. o Consider adding dobutamine or switching to epinephrine IV infusion if the patient has signs of hypoperfusion and cardiac dysfunction. o Consider hydrocortisone 200 mg IV if the above treatments are ineffective. Consider administering or adjusting appropriate antibiotics within 1 hour of diagnosis of sepsis. Targets Lactate <4 mmol/L Pulse pressure variation <12% Central venous saturation (ScvO2 ) >70% Central venous pressure (CVP) >8 mmHg Consider A-line insertion when available Eliminate the source of infection Hemoglobin level >7 g/dl Blood sugar < 180 mg/dl 29
30 Reaction From Blood or Blood Components Transfusion63, 64 Immediately stop giving blood or blood components. Notify the team of anesthesiologists, surgeons, and scrub nurses. Check the matching of blood group names between the donor and the recipient. In case ABO incompatible is suspected o notify the blood bank, o collect 5-10 ml of the patient's blood into an EDTA tube and send it to the blood bank with the suspected blood bag set, i.e. blood bag unit and blood set. Consider IV fluid resuscitation if hypotension occurs. Maintain close observation for acute hemolytic reactions, i.e. hypotension, DIC, bleeding, dark urine, or lower output. o Consider IV fluid resuscitation. o Consider administering furosemide 1-2 mg/kg or mannitol 1 g/kg or hydrocortisone 300 mg IV, or all three medications. o Request laboratory investigations for D-dimer, FDP, renal function, liver function, CBC, PT, PTT, BUN/Cr, bilirubin, and LDH. Consider administering chlorpheniramine 10 mg IV if rash or redness develops. In case anaphylaxis is suspected, refer to anaphylaxis treatment guidelines (P.25). Consider ICU admission if hemodynamic instability exists. 30
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