some common complications - South African Family Practice

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By Dr David McCoy BM, DA(UK)
On behaff of the Rural Health Task Group of the Academy of Fami\y Practice/Primaty
Care.
This series i,s also bei,ngproduced as a booklet,for the use of doctors i,n raral hospitak
and wi,Il be obtai,nablefrom SA Family Practice in 1997.
SOMECOMMONCOMPLICATIONS
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DI.JRNGAIAF'STHESIA
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The series will have the
following sections:
1. Introduction to anaestheticsand
anaestheticsafety checHist
2. Anaesthesia,intubation and
extubation
3. The preoperative assessment
4. Aruesthetic drugs I
5. Anaestheticdrugs tr
6. Spinal anaesthesia
7. CaesareanSections
8. Paediatricanaesthesia
9. Complicationsduring anaestlesia
10. local and regional anaesthesia
11. Ventilation and breathing systems
12.Blood transfusion
INTRODUCTION
Despite careful preparation, complications during anaesthesia
occur fairly commonly.It is therefore important that you are capable of respondingto a problem
quickly and effectively.Below is a
list of some of the complications
that occur in anaesthesia,and how
they can be preventedor managed.
This is not an exhaustivelist, and
guidelineson the managementof
cardiac arrhythmias, air emboli,
hypothermia and malignant hyperpyrexia should be obtainedfrom a
standardtextbook. A future chapter will deal specifically with the
complications of blood transfusion
and cardiac arrest.
Respiratory obstruction
Respiratoryobstruction can lead to
hypoxia, hypercapnia,coughing,
w
F
Blockage with secretions and
blood can usuallybe remediedby
inserting a suction catheter down
the tube, and if obstruction is
causedby blockage at the end of
the tube by the wall of the trachea,
gently pull the tube back by about
a centimetre to relieve this.
awakening of the patient, and
regurgitation. The signs of obstruction are snoring, a paradoxical
chest movement (a see-sawmotion
between the chest and abdomen),
stridor and little movement of the Bronchial intubation
reservoir/inflation bag.
If the endotrachealtube is pushed
too
far down the trachea, it will
Often the obstruction is causedby
enter
the right bronchus (especially
the tongue falling back and blockin
The left lung will then
children).
ing the larynx (especially in overbe
unventilated,
and will eventually
weight and short-neckedpatients).
collapse.
This
will
causehypoxia
The remedy for this is to lift the
post-operaangle of the mandible forward and and increasethe risk of
tive infection. Therefore,when you
up, or to insert a Guedel'sairway.
intubate, insert the tube up to the
point where the top of the cufflbalEven with an endotrachealtube,
loon lies just beyondthe vocal
obstruction may occur if the tube
cords.
b e c o m e sk i n k e d , i f i t b e c o m e s
blocked by blood and secretions,
Laryngeal spasm
or if the end is blocked off by the
wall of the trachea or bronchus. This complication has been disBlockage of the tube will also be cussedpreviously under the seca c c o m p a n i e d b y e x c e s s i v e i n - tion on extubation. However, be
flation pressuresbeing required to aware that Iaryngealspasm can
inflate the patient's lung.
also occur at induction or intraoperatively.The following are situTo prevent the tube from being ations that predisposeto laryngeal
kinked it is advisableto cut it to spasm:
the correct length so that there is
less chanceof it bending over
the premature insertion of the
itself. Many endotrachealtubes are
Iar5mgoscop
e without paralysis;
d e s i g n e dt o b e l o n g e n o u g hf o r
the presenceof secretionsand
both nasal and oral intubation, so
vomit in the larynx;
for oral intubation, you need to cut
surgical and laryngeal stimuseveral centimetres off the tube
lation in a lightly anaesthetised
(look for the mark on the tube).
patient;and
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cervical dilatation and anal
stretching,especiallyin a lightly
anaesthetisedpatient.
Gastric aspiration
Severegastric aspiration can be
fatal, and all precautions should be
routinely taken to prevent it from
Usually, laryngeal spasm is selfhappening(see earlier chapters).If
limiting, and requires time and
it does occur, the two main factors
100%oxygen before it resolves.
that determine its severity are the
However, on rare occasions you
PH of the gastric contents, and the
will need to abolish the spasmby
volume of the material aspirated.If
paralysing the patient with suxama patient vomits during an anaesethonium, and then intubating
thetic without the airway being
him/her.
protected, you must react quickly
and do the following:
Bronchospasm
are tachycardia,hypotension,bronchospasm,cyanosis,hypoxaemia
and surgical emphysema.If the
patient is being ventilated, the risk
of a tension pneumothoraxis high
and you will have to act quickly.
First of all, if you think there is a
t e n s i o n p n e u m o t h o r a x ,s t i c k a
needle(16G)into the secondintercostal space along the mid-clavicular line, turn off the N2O (which
will worsen the pneumothorax)
and give 100%oxygen. You may
want to turn off the ventilator and
bag the patient manually to give
yourself more control while the
patient settles down, and preparations are made to insert an intercostal drain.
First of all turn the patient over to
his/her side (you may have to disrupt whatever surgery is going on),
place the patient head down and
suck out as much of the vomit as
you can. Turn the oxygen to 100%,
ventilate gently, and treat any
Hypotension
bronchospasmas above.
Hypotensionis a frequentcomplicaNert, intubate the patient, and
tion of anaesthesia,and is usually
Bronchospasmmay also be trigonce this has been done, place a
gered in both asthmatic and nondue to multiple causes.The preurinary catheter to the end of the
vention
asthmatic patients by irritation of
of hypotensionis through
suction apparatus and gently pass
carefiil patient preparation, and safe
the larynx and airways with sethis down the tube to try and suck
anaestheticpractice.
cretiors, by laryngoscopy,and by the
out remaining gastric contents.
endohachealtube itself (especiallyif
Immediately start the patient on
The managementof hypotensionis
the carina is irritated). Other triggers Flagyl
and ampicillin, and continue
related to the cause(s) of it. Hypoof bronchospasminclude surgical
with standard asthma therapy for
volaemia
may suddenly manifest
stimulation in a lightly anaesthetised
bronchospasm.In severecases,the
patient, drug-inducedanaphylactic
itself with crashing hypotension
patient may need to remain ventiafter the administration of anaesreactions,and gastric aspAation.If a
lated in an intensive care unit until
patient suddenlydevelopsthe signs
the following day.
What to do when oxygen
of bronchospasm during anaessaturation drops
thesi4 rememberthat a pneumothoPneumothorax
. Exclude airway obstruction (see
rax can cause this, and must be
This may occur during any anaesexcluded.
above).
. Look at the patient's chest and
thesia, but especially if there is
The severity of bronchospasm can mechanical ventilation, and if the
make sure it is moving air in and
vary from a mild wheezeto severe patient has suffered a chest injury
out.
obstruction with stiff lungs, hypox- or is undergoingthoracic or cervi- . Check that everything is connectaemia and death. In moderate to cal surgery.Patients with chest
ed up from machine to patient, and
that there are no leaks in the
severecases,the patient should be injuries may already have a small
breathing system.
intubated, paralysed and venti- undetectedpneumothoraxpresent
.
Check that there is oxygen availlated. Use high concentrations of which would become severe durable
and being delivered to the
halothane (a potent broncho- ing anaesthesia.These patients
patient.
dilator) combined with 100%oxy- require the insertion of an intero Listen to the chest on both sides,
gen. Ketamine is also a good costal drain before anaesthesiaand
and exclude bronchial intubation,
bronchodilator which can be used. surgery. Therefore, some patients
bronchospasm,blockage of the
You can then continue to treat the may need a pre-operative X-ray to
tube, aspiration or pneumothorax.
patient using standard asthmatic exclude the presenceof a pneuNeuer ignore a falling orAgerl satudrugs,such as intravenoussalbuta- mothorax.
ration - it should alu;ays be aboae
mol or aminophylline,steroids and
95o/0.
adrenaline,accordingto the need.
The typical signs of a pneumothorax
The developmentof bronchospasm
during anaesthesiamay be the consequenceof a patient's poorly controlled asthma.Asthmatic patients
should never be anaesthetised
unless they have had their respiratory function optimised to the
maximum pre-operatively.
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thesia. It is often due to poor preoperative fluid management and an
underestimation of fluid loss, such
as with haemorrhage in fit patients,
abdominal obstruction and concealed intra-abdominal haemorrhage.
Remember that the elderly, the
hypertensive and the sick are especially prone to the hypotensive
effects of many anaesthetic agents.
Techniques for increasing the filling pressure on the right side of
the heart are to infuse fluids intravenously, tilting the patient's head
down, and Iifting up the legs of the
patient. Other less obvious causes
of hypotension include pneumothorax, bradycardia, aorto-caval
compression, pulmonary embolism
and cardiac arrhythmias, all of
which require specific intervention.
Hypertension
Hypertension is best prevented by
avoiding light anaesthesia,and by
ensuring that normally hypertensive
patients are well controlled before
surgery. Both Ketamine and laryngoscopy are also potent causesof
hypertension.
An important complication that
can manifest itself as hypertension is the 'paralysedbut awake'
patient. This is a patient who is
fully paralysedbut who is not
fully anaesthetisedand asleep. It
may occur when a patient is
paralysed and ventilated, and you
The SouthernTransvaalRegionof the South
African Academy of Family Practice/Primary
Carewill be holding a workshop on
Women and AIDS
The Familv Practitioner'sRole
Date:
Saturday5 October1996
Time:
2.00pm
Venue:
Indaba Hotel, Fourways
EDITOR - SA FAIIILY PRACTICE
Applications
areinvited
for thepostof part-time
editor
SA Family Practice.
As partof the Publications
DivisionTeam,the editorwill
be responsible
for:
.
.
Maternal and child issues in HIV
Psycho-social aspectsof HIV
Syndromic approach to STD management
Common clinical problems associated with HIV and
AIDS.
Speakers to include:
Helen Rees, Helen Schneider, Glenda Gray,
|ames Mclntyre, David Spencer, David Johnsory
David Coetzee.
Enquiries:
Dr Tembi Maleka (011) 982-5804
Convenor
Marie ]onker (011) 647-2090
Eventually, the patient will be
able to respond through a massive
surge of adrenaline which manifests as hypertension, tachycardia, dilated pupils and sweating.
Although quickly administering a
barbiturate like midazolam may
help to cause some retrospective
amnesia, the mainstay of management is to quickly turn up the
halothane to 50/ountil the patient
is anaesthetised, and to provide
honest post-operative counselling
afterwards.
SA ACADEMY OF FAMILY
PRACTICE/PRIMARY CARE
to touch on:
1.
2.
3.
4.
do not realise that the vaporiser is
empty of halothane. The patient
will eventually become awake
during the operation despite
being paralysed - a terrifying experience!
.
.
Liaison with the Editorial Board in respect of the overall directionand publicationphilosophyof the journal.
S o l i c i t i n g ,s e l e c t i n ga n d e d i t i n gs u i t a b l ee d i t o r i a lf o r
publication.
Activelyparticipatingin advancejournal planning.
Maintainingan effectiveworking relationshipwith productioncontrol,advertisingand layoutpersonnel.
T h e e d i t o r w i l l b e a c c o u n t a b l et o t h e M a n a g e m e n t
Committeeof the PublicationsDivisionand will report to
the EditorialBoard.
Commencementdate and remuneration:by negotiation.
Applicationdetails may be sent to: The Chairmanof the
J o u r n a l M a n a g e m e n tC o m m i t t e e ,c / o P O B o x 2 7 3 1,
Rivonia 2128, from whom further details may be
obtained.
Closingdate for applications:30 September1996.
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