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UTMB DEPARTMENT OF ANESTHESIOLOGY EMERGENCY PROTOCOLSBY: Samip Sheth, Michelle ScanlonFACULTY MENTORS: Dr. Woodson, Dr. PrzkoraJune 2014Table of Contents1Unable to Deliver Set Tidal Volume2Delayed Emergence/Hypoxemia and No Train of Four3Local Anesthetic Toxicity4Amniotic Fluid Embolism5Anaphylaxis6Bronchospasm (Intubated Patient)7 Delayed Emergence8Difficult Airway (Unanticipated)9Hemorrhage (Massive Transfusion)10 Severe Hypotension11Hypoxemia12 Malignant Hyperthermia13Myocardial Ischemia14Oxygen Failure/O2 Crossover/Pipeline Failure15Pneumothorax16Power Failure17Tachycardia – Stable SVT18Total Spinal Anesthesia19Transfusion Reaction20 Venous Air Embolism21Post-Extubation Airway Compromise22Lost ETCO2 Tracing(1) UNABLE TO DELIVER SET TIDAL VOLUMESigns include:Hypoxia and Hypercarbia DesaturationDecreased minute ventilationSmell of volatile anestheticRule Out:Cardiac Arrest (No ETCO2 tracing + hemodynamically unstable) CALL FOR HELP ACLS algorithmNo ETCO2 and hemodynamically stable Check both ends of CO2 tubing If connected Loss of ETCO2 algorithmManagement: Ventilate with Ambubag and prepare to switch to TIVA techniqueCheck External Circuit Connections: Elbow, CO2 detector on patient and machine side, Inspiratory/Expiratory limbs at the machine, Inspiratory/Expiratory valvesCheck ETT CuffAdd air if necessaryIf ruptured, notify surgeons and change ETT with Cook catheter + DLListen for bilateral equal breath soundsNo Breath Sounds: Rule out extubation DL to ensure ETT cuff past vocal cords If not past cords, deflate cuff, advance ETT, inflate, recheck for bilateral breath sounds, secure ETTUnilateral breath sounds: Withdraw ETT: Deflate cuff, Withdraw, Reinflate, Check BBS, secure ETTETT well-positioned + No breath sounds +/- High PIP: Suction ETT (mucus plug) Consider changing ETTIncreased PIP + Bilateral expiratory wheezing Go to Bronchospasm and/or Anaphylaxis algorithmsCheck machine factors other than the circuit, Call BiomedVaporizer caps tightCO2 absorber tightValvesScavenger systemIf Major/InternalMachine Fault Ventilate patient with Ambubag Look for bilateral chest rise, ETCO2 while on 100% O2 Switch to a TIVA technique while Biomed works on fixing the issue vs. replacing the machine(2) Delayed Emergence/ Hypoxemia AND NO TRAIN OF FOUR (Continued from Delayed Emergence or Hypoxemia algorithms)Signs include:Respiratory insufficiency/distress (Minimal chest rise, No/minimal fogging of mask)Inability to move extremities or flailing aroundSomnolence (from CO2 narcosis)High suspicion if:Deep block (Intermediate/long-acting muscle relaxant + short procedure, 0 or 1 twitch prior to reversal, No reversal given, Older patient)Drug interactionsPatient/Family history of delayed emergence, No prior anestheticsManagement:If Patient Intubated:Keep intubated with low-dose inhaled or IV anesthetic PACU with full monitors, Ambubag, Ventilator in PACURecheck TOF or post-tetanic twitch at 2 locationsIf No Twitches Wait until return of at least 1 twitch Give remaining/full reversal doseWait to meet extubation criteria and wean anesthetic. (If extubating in PACU, ensure all monitors, airway equipment, and suction present prior to extubationIf Patient Extubated:Support ventilation with bag/mask, Notify patient of situation if awakeCheck TOF If < 4 strong twitches Give remaining/full reversalConsider reintubation/LMA placement if 0 or 1 twitch and start low dose anesthetic, Monitor either in OR or PACUIf Patient Extubated in PACU:Support breathing with bag/mask, Full monitors, Tell patient what is happening if awakeCheck TOF If inadequate Call RT to bring ventilator, Consider reintubation vs. bag/mask, IV sedationIf not fully reversed, reversal agentConsider ABG to determine CO2 level, ventilation status(3) LOCAL ANESTHETIC TOXICITYSymptoms:Tinnitus, Metallic Taste, or Circumoral numbnessAltered mental statusSeizuresHypotensionBradycardiaVentricular arrhythmiasCardiovascular collapseCALL FOR HELPCODE CART, INTRALIPID KITINFORM TEAM Treatment:Stop LA injection/infusionGet intralipid kit100% O2 high flow Consider ETTTreat seizure activity with BZD’sIf signs persist or patient unstable: Rapidly give 1.5 mL/kg of 20% intralipid IV (70kg adult = 105 mL)Start infusion at 0.25 ml/kg/min (18 mL/min.)If CV collapse: repeat loading dose up to 3 total dosesIf patient remains hypotensive: Increase infusion rate to 0.5 mL/kg/min.Monitor for hemodynamic instability, treat hypotensionPulseless CPR and ACLS algorithmArrythmias ACLS algorithmsIf refractory to treatment Alert CT team for possible cardiopulmonary bypassIf attain circulatory stability:Continue intralipid infusion for at least 10 mins. Afterwards (Upper limit 10 ml/kg over 1st 30 mins.)Monitor in ICU for 12-24 hours after eventNotes:Consider reducing epinephrine doses to < 1mcg/kg IVAvoid Vasopressin, Beta blockers, Calcium channel blockersMay require prolonged resuscitation(4) AMNIOTIC FLUID EMBOLISMSigns (Pregnant or Postpartum patient)Respiratory distress, Decreased O2 saturationCV collapse: Hypotension, Tachycardia, Arrythmias, Cardiac ArrestCoagulopathy +/- DICSeizuresAltered mental statusUnexplained fetal compromiseCALL FOR HELPCODE CARTINFORM TEAMTreatment:Place patient in LUD (left uterine displacement)100% O2 High FlowLarge-bore IV accessSupport hemodynamics with IV fluid, Vasopressors (Epi/Norepi/Phenylephrine) and Inotropes (Dobutamine)Prepare for emergent intubation (Propofol, Succ, Cricoid pressure)If possible, place arterial line and consider CVCAnticipiate massive hemorrhage and DIC Activate massive transfusion protocol Go to Hemorrhage alogrithmConsider circulatory support with CPB/ECMO/IABPRule Out:EclampsiaHemorrhageAir EmbolismAspirationAnaphylaxisPulmonary embolismAnesthetic overdoseSepsisCardiomyopathy/Cardiac valvular abnormality/MI(5) ANAPHYLAXISSigns:Hypoxemia, Difficulty breathing, TachypneaRash/HivesHypotension (Maybe severe)TachycardiaBronchospasm/WheezingIncrease in PIPAngioedemaCALL FOR HELPCODE CARTINFORM TEAMPrepare Epinephrine 10 ug/mL or 100 ug/mLConsider pausing surgeryIf patient becomes pulseless CPR, Epinephrine 1 mg IV bolusses, large volume IV fluid Go to PEA algorithmTreatment:Discontinue potential allergens: Colloids, Blood products, Latex products, AntibioticsDiscontinue volatile anesthetic if hypotensive and give Ketamine/Versed100% O2 high flowIV fluid bolus (May require many liters)Epinephrine: Start 10-100 ug and increase dose q2 mins. until clinical improvement, May require large dosesVasopressin 2-4 unitsTreat bronchospasm with Albuterol or EpinephrineGive H1 antagonist (Diphenhydramine 25-50 mg IV)Consider steroids (Methylprednisolone 125 mg IV) to decrease biphasic responseConsider early intubation to secure airway prior to angioedemaConsider additional PIV, Arterial line(6) BRONCHOSPASM (Intubated patient)Signs:Increased peak airway pressuresBilateral wheezingIncreased expiratory timeIncreased ETCO2 with upsloping ETCO2 tracingDecreased tidal volumes if pressure controlledCALL FOR HELPCODE CART?Treatment:If patient hypotensive, disconnect patient circuit (to relieve air trapping)100% O2 High FlowIncrease expiratory timeDeepen volatile anestheticSuction ETTMedications:Give inhaled Albuterol +/- IpratropiumIf severe Epinephrine IV start 10 ug and escalateKetamine 0.2 – 1 mg/kg IVHydrocortisone 100 mg IVNebulized racemic epinephrineConsider ABGRule Out:Mainstem intubationAnaphylaxis Go to anaphylaxis algorithm(7) DELAYED EMERGENCEManagement:All anesthetics OffNo residual muscle paralysis Go to Residual Paralysis algorithm Hypoxemia/Hypercarbia Bag/Mask vs. IntubationHypothermia: Warm Blankets and fluids, Bare hugger, Warm the roomABG with electrolytes: If CO2 narcosis Intubate, Correct electrolytesRule out medication swap or dosing error See belowIf all of the above negative/normal: consider STAT Head CT and consult neurology/neurosurgery (If intubated, look for pupils, asymmetric movement, gagging)If residual mental status abnormalities, monitor in ICU with serial neurologic exams and repeat imaging as neededIf suspect medication overdose:Opioid reversal: Naloxone 40 ug IV: Repeat q2 minutes up to 5 doses (200 ug total)BZD reversal: Flumazenil 0.2 mg IV: Repeat q1 minutes up to 5 doses (1 mg total)Scopolamine patch reversal: Physostigmine 1 mg IV (Have Atropine ready for potential cholinergic crisis)(8) DIFFICULT AIRWAY UNANTICIPATEDAfter 1st failed DL Attempt: Go to A or BIf Difficult Mask:Call for Help and Difficult AW CartOral or Nasal airway2-handed maskLMA vs. Intubating LMA vs. CombitubeIf above masking measures fail:Call ENT STATGet percutaneous cricothyrotomy kit ready vs. Transtracheal jet ventilationIf Easy mask:If could not get a viewReposition patientBURP external laryngeal manipulation (Back, Up, Rt.)Call for CMAC and/or FOBTry again with different blade (ensure adequate anesthetic on board), suction as neededIf no view again CMAC, FOB, LMA, Fastrach LMA +/- FOBIf could not pass ETT:Make sure patient adequately anesthetizedUse a BougieUse a smaller ETTIf still unable to pass FOB(9) HEMORRHAGE – MASSIVE TRANSFUSIONCALL FOR HELPCODE CART IN ROOMManagement:Call blood bank to activate MTPGet T&C if not already done100% O2 High flowTurn down/off agentIV fluid bolus Trendelenburg position vs. Leg elevationVasopressors temporarilyPhenylephrineEphedrineEpinephrine (double dilute)Call for Belmont or Level 1, Cell Saver Additional IV Access: IO or EJ if needed + Hot lineCommunicate with surgeon and monitor blood lossCan transfuse O- blood if T&C not done yetUse Hotline and Bare hugger to keep pt. warmPlace arterial line if needed, Ask nurse for foley if neededMonitor ABG’sCall for cell saverIf continued blood loss: Replace before labsIf > 1 blood volume lost: For every 1 unit PRBC, 1 unit FFP and for every 6 units PRBC, 1 apheresis unit of plateletsComponents:PRBC: If Hgb < 7-10 based on comorbidities and rate of blood loss (1 unit raises Hgb 1 g/dL)FFP: For PT/INR or PTT > 1.5X normal, 10-15 ml/kg, 1:1 ratio with PRBC’sPlatelets: For platelets < 50-100K with ongoing bleeding. 6 units PRBC: 1 apheresis unit of platelets (1 unit raises 50K/uL)Cryoprecipitate: For fibrinogen < 80-100 mg/dl (10 units raises fibrinogen 50mg/dL)EBL = EBV X Hct starting –Hct measured Hct starting(Blood Volume estimate = 4500 mL for 70kg person)(10) SEVERE HYPOTENSIONCALL FOR HELPCODE CARTManagement Ensure pulse, and regular rate and rhythm If not, go to ACLSInspect field for blood loss or If non-bleeding cause: Pause surgeryIf bleeding cause Hemorrhage algorithmIV Fluid bolusPressorsPhenylephrine and EphedrineIf severe: Epinephrine 10-100 mcg, Vasopressin 1-4 units100% O2 High flowTurn down/off anesthetic agentTalk to surgeonGo to Other managementOther management:Algorithms for ACLS, Anaphylaxis, Hemorrhage, Hypoxemia, Local anesthetic toxicity, Myocardial ischemia, Pneumothorax, Total spinal anesthesia, Transfusion rxn, VAETEEMore IV access and Arterial lineSteroid for adrenal insufficiency (Hydrocortisone 100mg IV)Send labs: ABG, Hgb, Electrolytes, T&CFoley catheter to monitor UOPDifferential Diagnosis:MAP = CO X SVR and CO = SV X HRSV depends on preload, contractility, and afterload↓ Preload: Hemorrhage Hemorrhage algorithmHypovolemiaAuto-PEEP: D/C circuitIVC Compression: Decrease tidal volume, Reposition patientEmbolism (Air/Fat/Blood/AFE): Go to algorithmPneumothorax Pneumothorax algorithmPneumoperitoneum or Surgical manipulation↓ Contractility:MI/Ischemia myocardial ischemia algorithmLow EF: InotropeValvular disease, HOCMHypoxemiaMedicationsLocal anesthetic toxicityArrythmias↑ Afterload:Pneumoperitoneum or surgical manipulationMedications↓ HR:Vagal stimulus: Pause surgery if needed↓ SVR:High volatile anesthetic Neuraxial blockadeAnaphylaxis Go to algorithmMedicationsShock: Sepsis, Spinal NeurogenicEndocrine abnormalities Steroids(11) HYPOXEMIACALL FOR HELPCODE CARTManagement:100% O2Check FiO2, ETCO2, PIP, BP, PulseHand-ventilate to check complianceListen for bilateral breath soundsSuction ETTOther Management:Large recruitment breaths (unless hypotensive)Bronchodilators (Albuterol)Additional muscle relaxantHead up (to increase FRC)FOB to r/o mainstem intubation or obstructionABG and/or CXRTerminate surgery if refractoryDDx:Hypoventilation:Signs: High or Low ETCO2, Poor chest rise, Decreased breath sounds, Patient buckingLow TV or RR Change settingsCircuit leakObstructed/Kinked ETTHigh PIPResidual NMBPatient breathing asynchronously with ventilatorBronchospasmPulmonary edemaHigh spinalPainLow FiO2:If Low FiO2 while on 100% O2 Go to O2 failure algorithmV/Q mismatch or shunt:Mainstem inubationAtelectasisAspirationBronchospasm (Anaphylaxis)Mucus plugPleural effusionRare causes: Pneumothorax, Hypotension, Embolism (Air, blood, fat, amniotic fluid)Diffusion abnormality: Usually chronic lung diseaseIncreased metabolic O2 demand: MH, Thyrotoxicosis, Sepsis, HyperthermiaArtifacts: Confirm with ABGPoor waveform (probe malposition, cold extremity, light interference, cautery)Dyes (methylene blue, indigocarmine, blue nail polish)(12) MALIGNANT HYPERTHERMIAEarly Signs:1. Increased ETCO2 2. Tachycardia 3. Tachypnea 4. Mixed Metabolic and Respiratory Acidosis (ABG) 5. Masseter spasm/ trismus 6. Sudden cardiac arrest in young person due to hyperkalemia (peaked T waves)Late Signs: 1. Hyperthermia 2. Muscle rigidity 3. Myoglobinuria 4. Cardiac Arrest CALL FOR HELPCALL FOR MH CART, START PREPARING DANTROLENEINFORM TEAMDifferential Diagnosis:1. Light anesthesia 2. Hypoventilation 3. Over-heating (external) 4. Thyroid storm 5. Pheochromocytoma 6. Hypoxemia 7. Insufflation of CO2 Treatment: 1. Discontinue anesthetic triggers (volatiles and succinylcholine) and increase fresh gas flow to 10 L/min. Do NOT change machine or circuit 2. Halt procedure. If emergent, continue with non-triggering anesthetic 3. Hyperventilate, FiO2 100%, high flow O2 4. Assign several people to prepare 2.5 mg/kg IV Dantrolene bolus. Dilute each 20 mg Dantrolene vial in 60 mL preservative-free sterile water (for 70kg person give 175 mg so prepare 9 vials of 20 mg Dantrolene each as above) 5. Rapidly administer Dantrolene. Continue giving until patient stable (may give up to 10 mg/kg) 6. Administer sodium bicarbonate 1-2 mEq/kg for metabolic acidosis/hyperkalemia 7. Actively cool patient with ice packs, lavage if open abdomen. Stop cooling at 38°C 8. Arrhythmias are usually secondary to Hyperkalemia. Go to ACLS algorithms as needed. 9. Treat hyperkalemia with: Calcium Chloride 1 g IV D50 1 Amp IV (25 g Dextrose) + Regular Insulin 10 units IV (monitor glucose) Sodium Bicarbonate 1 Ampule. Avoid calcium channel blockers 10. Send labs for ABG, CPK, myoglobin, PT/PTT, and lactic acid 11. Place foley catheter. Monitor urine output. Goal 2 cc/ kg per hour urine output. Can give IV fluid and diuretics 12. Arrange ICU bed. Mechanical ventilation usually required. 13. Continue Dantrolene 1mg/kg every 4-6 hours for 24-36 hours, observe closely 24 hours. Call MH hotline with questions. Additional Information:Contact the Malignant Hyperthermia Association of the United States (MHAUS hotline) at any time for consultation if MH is suspected: 1-800-MH-HYPER (1-800-644-9737) or online at (13) MYOCARDIAL ISCHEMIASigns:1. Depression or elevation of ST segment. 2. Arrhythmias: conduction abnormalities, unexplained tachycardia, bradycardia, or hypotension. 3. Regional wall motion abnormalities or new/worse mitral regurgitation on TEE. 4. In an awake patient: Chest pain, SOB, diaphoresis, etc.CALL FOR HELPCALL FOR CODE CARTINFORM TEAMTreatment:1. Increase to 100% O2, high flow 2. Verify ischemia (expanded monitor view vs 12-lead EKG) 3. Treat hypotension or hypertension 4. Beta-blocker to slow heart rate. Hold for bradycardia or hypotension 5. Consider aspirin rectal or PO or NG/OG 6. Consult Cardiology - stat 7. Treat pain with narcotics (fentanyl or morphine) 8. Consider nitroglycerin infusion (hold until hypotension treated) 9. Place arterial line and send Labs: ABG, CBC, Troponin 10. If Anemic, treat with packed red blood cells 11. Consider TEE for monitoring volume status and regional wall motion abnormalities 12. Consider central venous access 13. If hemodynamically unstable, consider Intra-Aortic Balloon Pump 14. Be Prepared for Arrhythmias and have Code Cart at Bedside (14) OXYGEN FAILURE/O2 CROSSOVER/PIPELINE FAILURESigns:Audible O2 failure alarm soundsLow FiO2 on gas analyzer while on 100% oxygenImmediate Actions:1. Disconnect the patient from the machine and ventilate with an AmbuTM bag on Room Air Do not connect the patient to auxiliary flowmeter on machine – comes from SAME central source! 2. Open O2 tank on back of anesthesia machine (check not empty) and disconnect pipeline oxygen to force flow from tank into circuit Alternative: Obtain full E cylinder of O2 with a regulator. Ventilate with AmbuTM bag or Jackson Rees circuit attached to new O2 tank 3. Connect elbow adaptor to allow monitoring of respiratory gases: Is the patient receiving 100% oxygen? 4. Maintain anesthesia (if necessary) with IV drugs CALL FOR HELPCONSIDER HAVING CODE CART AVAILABLEINFORM TEAMSecondary Actions:1. Reduce O2 flow rates to minimum needed to conserve oxygen 2. Obtain extra backup sources of O2 3. When patient more stable, contact Bioengineers to alert them to problem and enlist help with machine diagnosis while you focus on patient 4. Inform OR leadership, ICU, hospital of potential large-scale O2 problem 5. Discuss with surgeon implications of O2 failure for this patient's management and OR schedule (15) PNEUMOTHORAXSigns:1. Increased peak inspiratory pressures 2. Tachycardia 3. Hypotension 4. Hypoxemia 5. Decreased or asymmetric breath sounds (breath sounds decreased or absent on ipsilateral side)6. Hyper resonance of chest to percussion 7. Tracheal deviation (late sign) 8. Increased JVD/CVP 9. Have high index of suspicion for pneumothorax in trauma patients, COPD patients, or when a CVC has been recently placed in the jugular or subclavian veins. CALL FOR HELPCONSIDER HAVING CODE CART AVAILABLEINFORM TEAMTreatment:1. DO NOT WAIT FOR X-RAY TO TREAT IF HEMODYNAMICALLY UNSTABLE 2. Increase to 100% O2, high flow 3. Rule out mainstem intubation 4. Consider stat CXR or TTE to assess 5. Place 14 or 16 gauge needle mid clavicular line 2nd intercostal space on affected side, should hear a whoosh of air if under tension 6. Immediately follow up needle decompression with thoracostomy (chest tube) (16) POWER FAILUREImmediate Actions:1. Get additional light sources: - Laryngoscopes, cell phones, flashlights, etc 2. Open doors and shades to let in ambient light 3. Confirm ventilator is working and if not, ventilate patient with Ambu bag and switch to TIVA 4. If monitors fail, check pulse and manual blood pressure 5. Request Transport Monitor or defibrillator monitor 6. Confirm adequate backup O2 supply - Power failure may affect oxygen supply or alarms. 7. Check extent of power failure - Call bio-med or engineering - Is the problem in one OR, all ORs, or hospital-wide? - If only in your OR, check if circuit breaker has been tripped (17) TACHYCARDIA – STABLE SVTSigns:CHECK FOR PULSE If no pulse, Go to PEA algorithmIf Unstable, Go to SVT – UNSTABLE and Prepare for Synchronized Cardioversion UNSTABLE = SBP<80, BP low for patient, rapid BP decrease, or acute ischemia Sinus Tachycardia is NOT SVT. May be compensatory. Search for and treat underlying cause(s) More likely SVT if any of: Rate > 150 Sudden onset Irregular rhythmCALL FOR HELPCONSIDER HAVING CODE CART AVAILABLEINFORM TEAMTreatment:1. Increase to 100% O2, high flow 2. Confirm adequate ventilation, oxygenation 3. Consider 12-lead EKG or Print Rhythm Strip, then treat per rhythm 4. If UNSTABLE at any point: Go to Unstable SVT algorithm 5. If still STABLE Supraventricular Tachycardia: a. Consider cardiology consult b. Consider ABG with electrolytes Narrow Complex and Regular 1. To convert: Adenosine 6 mg IV push with flush. May give 2nd dose: 12 mg IV 2. If NOT converted, may Rate Control Choose beta blocker or calcium channel blocker: a. Esmolol: Start 0.5 mg/kg IV over 1 min. May repeat after 1 min and may start infusion 50 ?g/kg/min b. Metoprolol: Start 1-2.5 mg IV. May repeat or double after 2.5 min c. Diltiazem: 5-10 mg IV over 2 min. May repeat after 5 min 3. Amiodarone: 150 mg IV SLOWLY over 10 min. May repeat once. Start infusion 1mg/min for first 6 hours Narrow Complex and Irregular Choose beta blocker or calcium channel blocker: Esmolol: Start 0.5 mg/kg IV over 1 min. May repeat after 1 min and may start infusion 50 ?g/kg/min Metoprolol: Start 1-2.5 mg IV. May repeat or double after 2.5 min Diltiazem: 5-10 mg IV over 2 min. May repeat after 5 min Amiodarone: 150 mg IV SLOWLY over 10 min. May repeat once. Start infusion 1 mg/min for first 6 hours Wide Complex and Regular Amiodarone: 150 mg IV SLOWLY over 10 min. May repeat once. Start infusion 1 mg/min for first 6 hours May also consider Procainamide or Sotalol Wide Complex and Irregular (Likely Polymorphic VT) Prepare to defibrillate Go to Ventricular Tachycardia & Ventricular Fibrillation (VT/VF) algorithm (18) TOTAL SPINAL ANESTHESIASigns:AFTER NEURAXIAL ANESTHESIA BLOCK 1. Unexpected rapid rise in sensory blockade 2. Numbness or weakness in upper extremities 3. Dyspnea 4. Bradycardia 5. Hypotension 6. Loss of consciousness 7. Apnea 8. Cardiac arrest If Cardiac Arrest: Start CPR, Immediate Epinephrine, Go to PEA algorithmCALL FOR HELPCALL FOR CODE CARTINFORM TEAMTreatment:1. Support ventilation and intubate if necessary 2. Treat significant bradycardia with immediate epinephrine (start 10-100 ?g, increase as needed, go to appropriate ACLS algorithm). If mild, consider atropine (0.5 mg - 1 mg), but progress quickly to epinephrine if needed 3. Administer IV fluid bolus 4. If parturient, prepare for possible emergent C-section, Left Uterine Displacement, monitor fetal heart rate (19) TRANSFUSION REACTIONSigns:Hemolytic Transfusion Reaction1. Tachycardia 2. Tachypnea 3. Hypotension 4. Disseminated Intravascular Coagulation 5. Dark Urine Febrile Reaction1.FeverAnaphylactic Reaction1. Tachycardia 2. Wheezing 3. Urticaria/ Hives 4. Hypotension CALL FOR HELPCONSIDER HAVING CODE CART AVAILABLEINFORM TEAMTreatment:1. Stop transfusion 2. Support blood pressure with IV fluids and vasoactive medications if needed 3. If anaphylactic reaction, Go to anaphylaxis algorithm 4. Consider antihistamine and antipyretic (Diphenhydramine, Acetaminophen) 5. For hemolytic reaction, maintain urinary output with IV fluids, diuretics, renal dose dopamine 6. Monitor for and treat disseminated intravascular coagulation if hemolytic reaction 7. Monitor for TRALI (lung injury) and treat accordingly, may require post operative ventilation 8. Notify blood bank of reaction. They will need further blood samples. May need to contact transfusion medicine MD(20 VENOUS AIR EMBOLISMSigns:Sudden Decrease in blood pressure and ETCO2 Sudden Decrease in SpO2 Sudden Rise in CVP Sudden Onset of dyspnea and respiratory distress in awake patient Air on TEE (if monitoring) CALL FOR HELPCONSIDER HAVING CODE CART AVAILABLEINFORM TEAMTreatment:1. Increase to 100% O2, high flow 2. Flood surgical field with saline 3. Place surgical site below heart (if able) 4. Aspirate air from the central line if present 5. Give rapid fluid bolus to increase CVP 6.Turn down or off volatile anesthetic 7. Give Epinephrine (start 10-100 ?g) to maintain Cardiac Output 8. Start CPR if BP catastrophically low 9. Consider TEE to assess air & RV function 10. Consider left lateral decubitus positioning11. If severe, terminate procedure if able (21) POST-EXTUBATION AIRWAY COMPROMISEDifferential Diagnosis:Inadequate reversal of neuromuscular blockadeDecreased Train-of Four and TOF ratioLaryngospasmInspiratory stridorInspiratory wheezingDiminished stridor may represent total airway obstructionDecreased air movementAirway obstructionHigh index of suspicion for laryngeal edema after prolonged intubation or in neonates/infants/children whose laryngeal diameter is already smallLaryngeal edema may be caused by large ETT, traumatic intubation, excessive manipulation of the head and neck during surgery, excessive coughing or bucking on ETT, current or recurrent URIsConsider recurrent laryngeal nerve damage following thyroid resection and other neck surgeriesConsider obstructive hematoma following neck and ENT surgeriesConsider hypocalcemia 24-96 hours following parathyroidectomy (purposeful or accidental)Post-obstructive Pulmonary EdemaInitial post-extubation airway obstructionImmediately followed by respiratory distressHemoptysisPink frothy sputumCXR changes consistent with pulmonary edemaAcute AspirationCoughingWheezingFeverChest discomfortVisible gastric contents in the orpharynxTreatment:Inadequate reversal of neuromuscular blockadeIf zero twitches on TOF, immediately reintubate and mechanically ventilateIf patient with at least 1 twitch on TOF but significantly weak, immediately reintubateIf patient ventilating but weak, may need increased dose of reversal agents with close monitoring and emergency airway equipment preparedMaintain mechanical ventilation and close monitoring until patient is exhibiting full strength and meeting all criteria for extubationMay need workup for pseudocholinesterase deficiency if prolonged Succinylcholine paralysisLaryngospasmMask ventilate with positive pressureIncrease positive pressure if original pressures not effectiveConsider Propofol in order to deepen anestheticConsider Succinylcholine (IM or IV) to relax vocal cordsAirway obstructionIf significant laryngeal edema or tracheomalacia suspected, consider FOB in order to make definitive diagnosis. Reintubate if significantly narrowed laryngeal diameter. Administer steroidsIf recurrent laryngeal nerve damage is suspected, may consider FOB or rigid bronchoscopy to make definitive diagnosis. If bilateral vocal cord paralysis, immediately reintubate and notify surgeonIf expanding neck or peritracheal hematoma is visualized or suspected, immediately reintubate for airway protection and notify surgeonIf hypocalcemia suspected, reiuntubate for airway protection. Draw labs and replete CalciumPost-obstructive Pulmonary EdemaImmediately provide supplemental oxygenDiuresis to relieve pulmonary edema, unless patient significantly hypovolemicIf obstruction is severe enough, may require reintubation and PPVProlonged PACU monitoring or ICU monitoring in severe casesAcute AspirationPlace patient in head down position to prevent further migration of gastric contents into lung parenchymaOropharyngeal suctioningConsider reintubation if patient cannot protect the airwayMonitor in inpatient setting for at least 48 hoursConsider FOB to remove non-particulate matterCurrently, steroids, antibiotics, or bronchopulmonary lavage are not recommended initiallyAntibiotics may eventually be required if not improvement in > 48 hours(22) LOST ETCO2 TRACINGDifferential Diagnosis:Problems with the Anesthesia EquipmentKinked ETTDefective or disconnected CO2 analyzerDisconnected circuit, significant leakDefective ventilatorProblems with the PatientEsophageal intubation or unplanned extubationLost cardiac output (decreased or no delivery of CO2 to lungs)Severe Bronchospasm (minimal or no air movement)Embolic eventSevere hypotension (severe blood loss, anaphylaxis, cardiac depression or cardiac dysfunction)1609725-428625Loss of ETCO2 Waveform:Differential Diagnosis00Loss of ETCO2 Waveform:Differential Diagnosis16192513246101. Circuit disconnect-> check circuit starting from patient and tracing back to ventilator2. CO2 tubing or analyzer disconnected or malfunctioned -> check capnograph with own expiratory air 3. Significant circuit leak -> do high pressure leak test, manually ventilate -> airway pressures will likely be low4. Kinked or obstructed ETT-> visually inspect ETT, consider FOB for inspection of internal lumen -> airway pressures will likely be elevated5. Ventilator malfunction-> do manual high pressure leak test, disconnect from ventilator to complete test -> manual ventilation will be possible and effective4000001. Circuit disconnect-> check circuit starting from patient and tracing back to ventilator2. CO2 tubing or analyzer disconnected or malfunctioned -> check capnograph with own expiratory air 3. Significant circuit leak -> do high pressure leak test, manually ventilate -> airway pressures will likely be low4. Kinked or obstructed ETT-> visually inspect ETT, consider FOB for inspection of internal lumen -> airway pressures will likely be elevated5. Ventilator malfunction-> do manual high pressure leak test, disconnect from ventilator to complete test -> manual ventilation will be possible and effective357187513246101. Esophageal intubation or accidental extubation-> direct laryngoscopy to confirm ETT placement, lung auscultation, chest rise-> hypoxemia may eventually cause PVCs, desaturation, hypotension, bradycardia, eventual PEA2. Cardiac Arrest-> usually accompanied by severe hypotension, decrease in amplitude or complete loss of SpO2 waveform, arrhythmias -> check pulses, monitor VS3. Severe Bronchospasm-> lung auscultation will indicate little or no air movement4. Pulmonary Embolism-> usually accompanied by desaturation, hypotension, normal initial ECG, with eventual PVCs from hypoxemia-> lung auscultation usually non-contributory as problem is dead space ventilation5. Severe Hypotension-> significant EBL, volume depletion, anaphylaxis, SIRS/shock 4000001. Esophageal intubation or accidental extubation-> direct laryngoscopy to confirm ETT placement, lung auscultation, chest rise-> hypoxemia may eventually cause PVCs, desaturation, hypotension, bradycardia, eventual PEA2. Cardiac Arrest-> usually accompanied by severe hypotension, decrease in amplitude or complete loss of SpO2 waveform, arrhythmias -> check pulses, monitor VS3. Severe Bronchospasm-> lung auscultation will indicate little or no air movement4. Pulmonary Embolism-> usually accompanied by desaturation, hypotension, normal initial ECG, with eventual PVCs from hypoxemia-> lung auscultation usually non-contributory as problem is dead space ventilation5. Severe Hypotension-> significant EBL, volume depletion, anaphylaxis, SIRS/shock 3571875543560Patient SourceOther vital signs likely abnormalPatient possibly in significant danger00Patient SourceOther vital signs likely abnormalPatient possibly in significant danger35725108572500161925543560Anesthesia Equipment SourceOther vital signs usually unaffectedPatient unlikely in immediate danger400000Anesthesia Equipment SourceOther vital signs usually unaffectedPatient unlikely in immediate danger25628608572500357187513430251. Esophageal intubation or accidental extubation -> reintubate patient via direct laryngoscopy -> follow difficult airway algorithm if unable to reintubate2. Cardiac Arrest -> call for help -> initiate ACLS3. Severe Bronchospasm -> deepen anesthetic plane with IV anesthetics -> give Epinephrine 10-100mcg -> give bronchodilators 4. Pulmonary Embolism -> call for help -> give Epinephrine 10-100 mcg -> may need to initiate ACLS5. Severe Hypotension-> treat hypovolemia with blood products, colloid, or crystalloid -> trend PPV (may trend CVP) -> give appropriate pressors 4000001. Esophageal intubation or accidental extubation -> reintubate patient via direct laryngoscopy -> follow difficult airway algorithm if unable to reintubate2. Cardiac Arrest -> call for help -> initiate ACLS3. Severe Bronchospasm -> deepen anesthetic plane with IV anesthetics -> give Epinephrine 10-100mcg -> give bronchodilators 4. Pulmonary Embolism -> call for help -> give Epinephrine 10-100 mcg -> may need to initiate ACLS5. Severe Hypotension-> treat hypovolemia with blood products, colloid, or crystalloid -> trend PPV (may trend CVP) -> give appropriate pressors 16192513335001. Circuit disconnect -> reconnect circuit2. CO2 tubing or analyzer disconnected or malfunctioned -> replace CO2 tubing or analyzer 3. Significant circuit leak -> inflate ETT if possible -> change ETT if torn cuff -> consider manual ventilation with ambu bag 4. Kinked or obstructed ETT-> consider inserting bite block or repositioning patient-> consider replacing ETT if significant internal obstruction -> consider exchanging to wire reinforced ETT5. Ventilator malfunction-> manually ventilate with ambu bag while troubleshooting machine -> call for replacement ventilator4000001. Circuit disconnect -> reconnect circuit2. CO2 tubing or analyzer disconnected or malfunctioned -> replace CO2 tubing or analyzer 3. Significant circuit leak -> inflate ETT if possible -> change ETT if torn cuff -> consider manual ventilation with ambu bag 4. Kinked or obstructed ETT-> consider inserting bite block or repositioning patient-> consider replacing ETT if significant internal obstruction -> consider exchanging to wire reinforced ETT5. Ventilator malfunction-> manually ventilate with ambu bag while troubleshooting machine -> call for replacement ventilator3571875552450Patient SourceOther vital signs likely abnormalPatient possibly in significant danger00Patient SourceOther vital signs likely abnormalPatient possibly in significant danger161925523875Anesthesia Equipment SourceOther vital signs usually unaffected Patient unlikely in immediate danger400000Anesthesia Equipment SourceOther vital signs usually unaffected Patient unlikely in immediate danger35718759525000236283595250001609725-752475Loss of ETCO2 Waveform:Treatment00Loss of ETCO2 Waveform:TreatmentREFERENCES:Barash, Cullen, Stoelting, Cahalan, & Stock (Eds.). (2009). Clinical Anesthesia. Philadelphia, PA: Lippincott Williams & Wilkins.Goldhaber-Fiebert, Sara and Steven Howard. “Implementing Emergency Manuals: Can Cognitive Aids Help Translate Best Practices for Patient Care During Acute Events?” Anesthesia-Analgesia 117.5 (2013): 1149-1161. Print.Horlocker, et al. “Regional Anesthesia in the Patient Receiving Antithrombotic or Thrombolytic Therapy: American Society of Regional Anesthesia and Pain Medicine Evidence-Based Guidelines (Third Edition)” Regional Anesthesia and Pain Medicine. 35.1 (2010): 64-101. Print. Miller, Ronald (Ed.). (2010). Miller’s Anesthesia. Philadelphia, PA: Churchill Livingstone.Runciman, Kluger, Morris, Paix, Watterson, &Webb. “Crisis Management during anesthesia: the developmentof an anesthetic crisis management manual.” Qual Saf Health Care 14.1 (2005). Print.Stanford Anesthesia Cognitive Aid Group. Emergency Manual: Cognitive Aids for Perioperative Critical Events. See manual.stanford.edu for latest version. Creative Commons BY-NC-ND. 2014 (Version 2) ................
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