Effective Management of Anaesthetic Crises

Presentation

* Difficult to ventilate
Decreased compliance in reservoir bag, poor chest expansion, low minute volume
* High airway pressure/ alarm
* Abnormal CO2 trace
Up sloping- bronchospasm
Low- reduced cardiac output
* Hypoxia
* Circulatory collapse
Occluded expiratory limb, tension pneumothorax, anaphylaxis

Initial response

* Check patient+ review environment
ABC
Oximeter, capnograph
Machine + circuit
Surgical activity
Hand ventilate 100% oxygen
* Exclude obvious causes
Fighting ventilator- not paralysed
Closed expiratory limb- ballooning of reservoir bag
Excessive tidal volumes/ ventilator settings

Consider context

* Position- prone, trendelenburg
* Pre-existing disease- asthma, obesity, ARDS
* Timing of event- post cvc
* Prior events
* Risk factors- allergy
* Surgery- laparoscopy + pneumoperitoneum

Systematic review

* Anaesthetic circuit
Check with alternate circuit i.e. ambu bag
* Endotracheal tube
Kinked?
Position at lips?
Obstructed? Rx. deflate cuff pass suction catheter
* Low threshold to change tube!

Causes

* Common problem
* Potentially life threatening
* Requires systematic approach after exclusion obvious and common causes



* Non patient
* Circuit/ gas supply Endotracheal Tube Patient
decreased chest wall compliance decreased lung compliance increased airway resistance

Non Patient Problems

* Gas supply
O2 flush stuck on
High pressure gas source
* Circuit
Blockage, compression, kinking or incorrect connection of:
Scavenging, reservoir bag, filter, humidifier
APL valve, PEEP valve
Ventilator, angle piece, tube connector
Breathing hoses + valves etc
Excessive tidal volumes
* Endotracheal Tube
Kinked
Misplaced
Oesophageal
Endobronchial
Obstructed
Sputum, blood …
Cuff herniation
Too small

Patient Problems

* decreased chest wall compliance
Chest wall rigidity
MH or opioids
Prone/ position
Obesity
Kyphoscoliosis
Abdominal pressure
distension
laparoscopy
gastroschisis repair
Inadequate paralysis/ fighting ventilator
* decreased lung compliance
Pneumothorax/ haemothorax
Atelectasis
Pulmonary oedema
>Fibrosis
ARDS
* increased airway resistance
Bronchospasm
Foreign body
Anaphylaxis/ anaphylactoid
Aspiration
Amniotic fluid embolism