Investigation into Significant Anesthesia Adverse Events during the Post-Op Period - PowerPoint Presentation

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Investigation into Significant Anesthesia Adverse Events during the Post-Op Period

Research by:

Ryan Dietz RNAI

Stephen Both RNAI

Gonzaga University

Providence Sacred Heart Medical Center

March 20, 2014

Slide2

Methodology

Retrospective Chart ReviewAt PHSMCPopulationsStrokes, cardiopulmonary arrests (CPAs), and deaths (within 30 days of an anesthetic)PACU physiologic instability Hemodynamic problemsBleeding Oxygenation issues

Slide3

Study numbers:Charts from 2013PACU physiologic instability 29 Strokes 13 CPAs 16 Mortality 41 99

Number of Patients Investigated

(1 mo.)

(6mo.)

(6mo.)

(6mo.)

Slide4

~

Inpatient Research Study

~

Slide5

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Hypotension Dynamics

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44% of this group

received

Spinal Anesthesia

Slide8

Slide9

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Determinants of Cerebral Blood Flow

Two Determinants of cerebral blood flow:Cerebral Vascular ResistancePaCO2PaO2MetabolismCerebral Perfusion Pressure (CPP)Blood PressureICP

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EMBOLIC STROKES

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PaCO2

39.4-42.6

44.2-49.628.8-33.2

J. of Cerebral Blood Flow, (2003) : 23 (6). 665-670

[15]

Slide13

Detrimental Effect of Hypocapnia

Hypocapnia[1,2,3,8,9]Directly neurotoxic↑ neuronal excitability while ↓ cerebral O2 supply↓ V/Q matchingCauses lung injury via inflammation activationIncrease risk of infectionUndermines respiratory drive postop↓myocardial O2 supply ST depression syndrome↓ SvO2Prolongs wakeups↑Pain in postop

Slide14

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Summary of Findings

Hypertension was the #1 cause of physiologic instability in the PACU

44% of ASA II patients that experienced hypotension also received spinals

54% of patients that experienced strokes during the post op period had etCO2 levels maintained between 25-30 mmHg

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Hypertension Recommendations

Clinical SituationDrug of ChoicePainAnalgesicHypertension without cardiac complicationsHydralazinePhentolamineNifedipineNicardipineSevere acute hypertensionSodium NitroprussideHypertension plus ischemiaNitroglycerine infusionHypertension plus tachycardia and ischemiaEsmolol, bolus or infusionHypertension plus heart failureAce Inhibitor, dobutamineHypertension caused by pheochromocytomaPhentolamine, LabetalolDoxazosin, prazosin, terazocin

Continuing Education in Anaesthesia, Critical Care & Pain. (2004) 4 (5): 139-143

[10]

Miller’s Anesthesia

(2010)

p.1094-1095

[21]

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Journal of PeriAnesthesia Nursing. (2002). 17 (3) 159-163

.

[7]

Hypotension

Algorithm

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Spinal Hypotension

A) Blockade of sympathetic efferents (arterial and venodilation) B) Potential for cardiac accelerator suppression (T1-T4) Treatment[5]Crystalloid: (500-1500ml ) pretreatment better than co-treatment Colloid: superior to crystalloid (↑SVR) (30 min half-life) Hespan= $12.04/500ml bag *Ephedrine superior to Phenylephrine (caution tachyphylaxis)Dopamine short term upon ephedrine tachyphylaxis onsetCautious use of phenylephrine in the elderly: with reports of ↓ C.O. and LV dysfunction

* Cost at PSHMC /Tony Hill (Materials Management Manager PSHMC)

Mechanism

[5]

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Hypercapnia

Benign (paCO2≤70)

[

1

]

Enhances respiratory drive

[9]

Protects lung tissues

[14]

Advance warning of inadequate analgesia and relaxation

[

1

]

↑in PaCO2 by 10mmHG

↑the C.I. by about

10-15%

[17]

↓ SVR, ↑SvO2

[17]

3-5% alteration in CBF for every 1 mmHg change in PaCO2

[2]

Decrease in infection postop

[2,3,34]

Avoid hypercapnia and hypocapnia in known cerebral ischemic patients

[21]

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Mild Respiratory Acidosis (A good Thing?)

Hypercapnia can, and many times will lead to mild respiratory acidosis

[14,28]

Respiratory Acidosis is different than metabolic acidosis

(

slight sympathetic activation)

[17]

↑ Inotropy

↓ SVR

↑ Blood pressure

↑ HR

PH of 7.15 is tolerated before buffering agents/ ↑RR are necessary

[14,28]

“

I’m pretty comfortable with a low pH threshold of 7.17 in the healthy or appropriate respiratory acidosis patient

”

Dr. Chris Vernon DO (Intensivist

PSHMC )

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Elevated ICP Recommendations

Hypocapnia: Should only be utilized in two instances[13] Impending brain herniation To increase surgical field of view Normal goal in head injury or elevated ICP is a PaCO2=35-40 [13] Hypocapnia is only viable for 20 minutes due to cerebral ischemia [13] Treating impending herniation with hyperventilation [6,21,30]Goal of PaCO2=30-32Strictly avoid PaCO2 levels below 25 mm HGNot to be used for >20 minutes

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Recommendations: Stroke Group

Delay elective surgery at least 6 weeks after stroke [21]Continue anticoagulation for minor surgeries (esp. afib + prior stroke) [25]Continue low dose aspirin in patients under procedures of high risk for bleeding and stroke (Bridge with heparin for pt with afib and Hx of Tia/Stroke) [25]Continue beta blockers and statins preop and restart postop [25]Metoprolol controversial during the case (3-4 fold ↑ in strokes). Esmolol & Labetalol, Bisoprolol better choices [4,19,27]

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Recommendations: Stroke Group

Regional is only beneficial

in orthopedic cases

[20,25]

Avoid hyperventilation during surgery: theories such as “Inverse steal” and “Robin Hood” actually increase the region at risk for stroke

[22,29,33]

Recommended goal of PCO2 should be normocapnia (35-45). Avoid hypo and hypercapnia in potential cerebral ischemia cases

[24]

Hypo-albuminemia is a predictor of stroke risk

[12]

Maintain glucose 60-150mg/dl

[11,16]

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Conclusion

The purpose of this research project was to identify potential themes in

patient comorbidities

,

surgery type

,

and anesthetic management

that may potentially contribute to significant postop complications.

Although we did not uncover any “smoking gun” anesthesia related issues, we highlighted and made recommendations regarding 3 interesting findings. Anesthesia is a journey and we will need to continually re-evaluate the method in which we deliver anesthesia.

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QUESTIONS?

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Slide28

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