1. Anesthetic Problems and Emergencies
A&A Chapter 12 pg

2. Why Do Problems Arise? Human error Equipment error
Drug adverse effects
Patient factors
Anesthetic problems will inevitably occur at some point in your career.
No anesthetic experience is the same, so beware of the false sense of security!

3. Human Error
Failure to obtain an adequate history or physical exam on the patient
Ideally, every patient scheduled for anesthesia should have a complete PE, and a thorough history obtained with the owner present.
*Less than ideal circumstances are common:
Owner drops patient off in a hurry
Patient brought in by neighbor or friend
Receptionist takes the history
HISTORY?

4. Human Error
Lack of familiarity with the anesthetic machine or drugs

5. Human Error Fatigue Distracted or rushed Inattentiveness
Proper scheduling of surgeries can help with this
Distracted or rushed
Usually you have your surgical patient and…
Inattentiveness
Having a low level of anxiety is good!

6. Human Error Incorrect administration of drugs Inaccurate weight
Math errors – calculating OR drawing up
Use of wrong medication
Use of wrong ______________
Ex: enrofloxcain, ketamine, dexamethasone, bupivicaine
Incorrect route of administration
IV v. IM
Confusion between
syringes

7. Equipment Failure CO2 ABSORBER EXHAUSTION
Exhausted granules can cause your patient to rebreathe what exhaled gas?
How is CO2 removed from a rebreathing system?
How is CO2 removed from a non-rebreathing system?
Best ways to keep an eye on exhaled CO2?
If using insofluane-
↑ CO2 (hypercapnia)= Tachypnea, tachycardia, cardiac arrhythmias

8. Equipment Failure NO OXYGEN FLOW
Which two parts of the machine may be malfunctioning?
Oxygen tank: check for empty tank, disconnected hose,
leaks
Flow meter: will gradually fall as the O2 tank empties
Periodically check this!
*Which breathing system can go without new O2 flow longer?

9. Equipment Failure ANESTHETIC MACHINE MISASSEMBLED
The better you know this machine and the flow of gas, the quicker you will be able to solve problems.
*Where do some of the most common misassembled
parts happen on the machine?

10. Equipment Failure ENDOTRACHEAL TUBE PROBLEMS Blocked tube
Twisting or kinking of the tube (inappropriate positioning)
Accumulation of material such as blood, mucus, excess lubricant
Solution: Check signs of tube properly in the trachea
*If truly blocked 
Magill, non-murphy eye

11. Equipment Failure ENDOTRACHEAL TUBE PROBLEMS
Tube advanced too far into a bronchus
Solution:
Air is heard escaping during PPV/can smell inhalant
Deflate first!

12. Equipment Failure Wrong anesthetic in the vaporizer
VAPORIZER PROBLEMS
Wrong anesthetic in the vaporizer
Non-precise concentration will be delivered
Solution:
Tipped over or over-filled
Vaporizer dial may be jammed

13. =rupture of lungs and decreased venous return to
Equipment Failure
POP-OFF VALVE PROBLEMS
The pop-off valve is inadvertently left closed  pressure builds  patient cannot exhale 
=rupture of lungs and decreased venous return to
Reasons why pop off would be closed??
Solution:

14. Anesthetic Agents
“Every injectable or inhalation agent has the potential to harm a patient and, in some cases, cause death”. (Page 323)
Review the description of the physiological effects of pre-anesthetic and general anesthetic agents in chapter 3.

15. Anesthetic Agents
Anesthetic protocol should be chosen based on the patient’s needs
Anesthetist must be familiar with drug side effects
Such as?
Understand why balanced anesthesia is safer!

16. Patient Factors Pages 323-334
Reproductive status
Weight
Breed
Trauma
Organ disease
ASA Physical Status Classification
Patient description and examples
Potential problems
Solutions

17. Geriatric Patients POTENTIAL PROBLEMS 1. Reduced organ function
ASA P2
(75% of life expectancy)
POTENTIAL PROBLEMS
1. Reduced organ function
Increased risk for hypervolemia
Prolonged recovery
2. Higher risk for degenerative disorders
Ex: cancer, cardiac disease, diabetes
3. Poor response to stress
4. Increased risk for hypothermia- reduced ability to thermoregulate

18. Geriatric Patients
ASA P2
(75% of life expectancy)
POTENTIAL SOLUTIONS

19. Pediatric Patients ASA P2 (<3 months of age) POTENTIAL PROBLEMS
1. Increased risk for hypothermia- can’t shiver, lack of body fat; high body surface area
2. Over hydration common
3. Increased risk of hypoglycemia, hypotension, bradycardia
4. Inefficient excretion of drugs- non developed liver
5. Difficult intubation and IV cath placement
6. Unpredictable response to atropine <14 days

20. Pediatric Patients
ASA P2
(<3 months)
POTENTIAL SOLUTIONS

21. Brachycephalic Patients
ASA P1
Pug, Pekingese, Boston Terrier, etc.
POTENTIAL PROBLEMS
1. Conformational tendency toward airway obstruction
Elongated soft palate w/ redundant tissue
Small nasal openings
Small diameter trachea
2. Abnormally high vagal tone (parasympathetic)
Bradycardia common
Ocular surgery consideration?

22. Brachycephalic Patients
ASA P1
Pug, Pekingese, Boston Terrier, etc
POTENTIAL SOLUTIONS

23. Sighthounds POTENTIAL PROBLEMS
ASA P1
Greyhound, afghan hound, whippet, borzoi, saluki, Russian wolfhound
POTENTIAL PROBLEMS
Increased sensitivity to barbiturates (ex. thiopental)
Highly lipid soluble drugs that leave brain for fat
Hounds- lack of body fat for redistribution/elimination of the drug  drug stays on the brain longer
SOLUTION

24. Obese Patients POTENTIAL PROBLEMS
ASA P2
Body condition score 5/5
POTENTIAL PROBLEMS
1. Accurate dosing is difficult based on weight
Poor distribution of drugs- no blood supply to fat
2. Respiratory difficulty; rapid shallow resps

25. Obese Patients
ASA P2
Body condition score 5/5
POTENTIAL SOLUTIONS

26. Cesarean Patients POTENTIAL PROBLEMS ASA P1
1. Increased workload to heart
2. Respiration compromised due to decreased lung capacity- fetuses pressing on diaphragm
3. Increased risk of hemorrhage from uterus- already anemic from RBCs going to fetuses
4. Physiologic anemia- high plasma but not RBC
5. Increased risk of vomiting/regurgitation- not fasted
6. Decreased Ax requirement- increased progesterone already stimulates GABA receptors (inhibitory)
7. Fetuses will receive drugs

27. Cesarean Patients
ASA P1
POTENTIAL SOLUTIONS

28. Trauma Patients POTENTIAL PROBLEMS Respiratory distress Examples:
ASA P3, P4 or P5
POTENTIAL PROBLEMS
Respiratory distress
Examples:
Pneumothorax: air in pleural space
No negative pressure = lung collapse
Pleural effusion: fluid in pleural space
Fluid compressing lung expansion = lung collapse
Pulmonary contusions/edema: fluid in lung parenchyma
Fluid in alveoli = no gas exchange

29. Trauma Patients POTENTIAL SOLUTIONS Respiratory distress
ASA P3, P4 or P5
Respiratory distress
POTENTIAL SOLUTIONS

31. Trauma Patients POTENTIAL PROBLEMS Solution: 3. Shock/hemorrhage
2. Cardiac arrhythmias
Solution:
3. Shock/hemorrhage
4. Fractures/organ rupture  blood loss
5. Unknown internal injuries

32. Patients w/ Cardiovascular Disease
ASA P3, P4, P5
POTENTIAL PROBLEMS
1. Circulation compromised
2. Pulmonary edema common
3. Increased tendency to develop arrhythmias

33. Patients w/ Cardiovascular Disease
ASA P3, P4, P5
POTENTIAL SOLUTIONS

34. Patients w/ Respiratory Disease
ASA P3, P4, P5
POTENTIAL PROBLEMS
1. Poor oxygenation of tissues
2. Patient may be anxious and difficult to restrain
3. Increased risk of respiratory arrest

35. Patients w/ Respiratory Disease
ASA P3, P4, P5
POTENTIAL SOLUTIONS

36. Patients w/ Hepatic Disease
ASA P3, P4, P5
POTENTIAL PROBLEMS
1. Delayed metabolism of drugs filtered through liver
2. Increased potency of barbituates (unbound drug molecules go to brain)
3. Decreased synthesis of clotting factors and proteins = coagulation issues and hypoproteinemia
4. Icteric
5. Improper glycogen/gluconeogenesis  hypoglycemia

37. Patients w/ Hepatic Disease
ASA P3, P4, P5
POTENTIAL SOLUTIONS

38. Patients w/ Renal Disease
ASA P3, P4, P5
POTENTIAL PROBLEMS
1. Delayed excretion of anesthetic agents
2. Electrolyte imbalances common
3. Dehydration may be present

39. Patients w/ Renal Disease
ASA P3, P4, P5
POTENTIAL SOLUTIONS