Anesthesia

Complications - I
NAMS
NOVEMBER 7, 2014
Objectives of the presentation

 Enlist common complications encountered in routine anesthesia practice

(general, regional and local anesthesia)
 Be aware of the etiopathogeneis and sequelae of some of the major
complications
 Be able to take precautions to prevent known complications and manage
accordingly, if they occur
 Be aware that malpractice litigations are an increasingly important part of
medical practice
 Presentation divided into two parts, with focus on basic concepts rather
than detailed information
Overview

 Complications
 Preventable
 Unpreventable
 Various causes
 Patient’s underlying disease
 Surgical procedure
 Anesthesia (mis)management
 Wide range of manifestations
 Minor
 Catastrophic
Anesthesia Complications

Cardio-
Respiratory vascular

Neurologic Miscellany
Respiratory Complications
Airway, ETT
related
Hypoxia,
Hypercapnia
Respiratory

Atelectasis

Barotrauma

Aspiration

Bronchospam,
Laryngospasm

Pneumothorax
Cardiovascular Complications

Cardiovascular Hypotension

Hypertension

Arrythmia

Mycardial
Ischemia

Thrombo-
embolism

Stroke
Neurologic Complications
Seizure

Delayed
recovery
Neurologic

Nerve injury
(position, blocks)

Raised ICP

Stroke

Awareness
Miscellaneous Complications
PONV

Hypothermia
Miscellaneous

Fire/Electric
related

Anaphylaxis

Ocular Injury

Infection

Equipment
related
Anesthesia Complications:
classification
 Complications related to
 Local anesthesia
 Regional anesthesia
 General anesthesia
Complications: Local Anesthesia

 Pain
 Bleeding and hematoma formation
 Nerve injury due to direct injury
 Infection
 Ischemic necrosis (use of adjuvants/vasopressors)
 Anesthesia toxicity (overdose)
Complications: Regional Anesthesia

 Post-dural puncture headache

 Hypotension, bradycardia
 Epidural or intrathecal bleed
 High block
 Direct nerve damage
 Damage to the spinal cord - may be transient or permanent
 Infection
 Urinary retention
 Local anesthetic toxicity
Complications: General Anesthesia

 Complications are of different types and varying severity

 Different organ systems may be involved
Complications cont…

 Mortality and Brain Injury

 Primary mechanism: CVS or pulmonary
 Preventable causes:
 Esophageal intubation
 Premature extubation
 Inadequate ventilation
Complications cont…

 Airway Injury
 Causes: Insertion of ETT, LMA, NG, suction catheters, bougies, TEE
probes, laryngoscope, oral/nasal airway
 Minor : sore throat, dysphagia, dental/gum injury
 Major
 TMJ injuries
 Larynx: bleeding, laryngospasm, vocal cord paralysis, arytenoid
dislocation
 Trachea: Direct injury, pressure necrosis (excessive cuff pressure)
 Esophagus: perforation
 Prevention/minimize: thorough PAC, anticipation and preparedness
Complications cont…

 Peripheral nerve injury

 Usually due to poor positioning
 Upper extremeties
 Ulnar nerve
 Brachial plexus
 Median nerve
 Lower extremeties
 Peroneal
 Sciatic
 Femoral
Ref: Nerve Injury Closed Claims: 1990-2010
Specific Complications cont…

 Peripheral nerve injury:

ulnar nerve
 Causes: External compression
in the cubital tunnel (elbow) and
prolonged elbow flextion
 Symptom: Inability to adduct
the fifth finger and numbness
and tingling of the fourth and
fifth fingers
 Prevention: Avoid prolonged
pronation of the forearm and
pad the condylar groove area
Complications cont…

 Peripheral nerve injury:

brachial plexus
 Causes: Stretch injury to the
roots of the brachial plexus
 Symptom: Limp/paralyzed
arm, lack of muscle control in
the arm/wrist/hand and/or lack
of sensation in the arm or
hand.
 Prevention: Avoid arm
abduction >90˚ and avoid
extreme head rotation
Brachial Plexus Anatomy
Complications cont…

 Peripheral nerve injury:

peroneal nerve
 Causes: Compression at the
neck of fibula
 Symptom: foot drop
 Prevention: Padding of the
area over the head of the
fibula and the lateral aspect of
the knee
Complications cont…

 Peripheral nerve injury: features

 Most cases, injuries resolve within 6-12 weeks.
 >50% of patients typically regain full sensory and motor function
within 12 months.
 Permanent injury may be minor (such as small area of sensory
or major and disabling (such as significant motor loss and
chronic pain)
Complications cont…

 Awareness
 Incidence difficult to measure
 Symptoms range from mild anxiety to post-traumatic stress
disorder
 Possible causes: inadequate inhalational anesthetic delivery,
medication errors, interpersonal variation in requirement of
anesthetics
 Increased focus on monitoring depth of anesthesia to minimize
awareness and memory formation (eg: Bispectral index)
Complications cont…

 Awareness: Increased role of monitoring

depth of anesthesia
 Example of such monitors: BIS, Entropy,
Patient Safety Index, Narcotrend,
monitoring of end tidal anesthetic gases
etc
Complications cont…

 Eye injury
 Can range from simple corneal abrasion to blindness
 Prevention: proper size face mask, secure eye tape/patch, avoid direct
pressure during prone/lateral positions
 Types of vision loss
 Ischemic retinal artery occlusion
Most common after spine,
 Cortical blindness cardiac and orthopedic surgeries.
 Acute glaucoma
 Post-TURP: transient
Complications cont…

 Eye injury (visual loss) causes:

 Improper positioning: direct ocular pressure
 Embolization
 Patients undergoing prolonged surgeries in prone position
with voluminous blood loss at increased risk
Complications cont…

 Hearing Loss
 Usually transient, often goes unnoticed
 Can occur both after regional and general anesthesia
 Causes
 Middle ear barotrauma, vascular injury, ototoxic drugs
(NSAIDs, aminoglycosides), emobolic injury in cardiac
surgeries
 Can also occur in regional anesthesia because of dural
puncture with subsequent CSF leak
End of Part I

Thank You