Complications of General Anesthesia

General anesthesia (GA)

State produced when a patient receives medications for amnesia, analgesia, muscle paralysis, and sedation. An anesthetized patient - in a controlled, reversible state of unconsciousness. Enables a patient to tolerate surgical procedures that would otherwise inflict unbearable pain, potentiate extreme physiologic exacerbations, and result in unpleasant memories. The combination of anesthetic agents used for general anesthesia often leaves a patient
Unarousable even secondary to painful stimuli Unable to remember what happened (amnesia) Unable to maintain adequate airway protection and/or spontaneous ventilation as a result of muscle paralysis Cardiovascular changes secondary to stimulant/depressant effects of anesthetic agents

 General anesthesia uses intravenous and inhaled agents to allow adequate surgical access to the operative site Anesthesia providers are responsible for assessing all factors that influence a patient's medical condition and selecting the optimal anesthetic technique accordingly.

 Disadvantages
Requires increased complexity of care and associated costs Requires some degree of preoperative patient preparation Can induce physiologic fluctuations that require active intervention Associated with less serious complications such as nausea or vomiting, sore throat, headache, shivering, and delayed return to normal mental functioning Associated with malignant hyperthermia, a rare, inherited muscular condition in which exposure to some (but not all) general anesthetic agents results in acute and potentially lethal temperature rise, hypercarbia, metabolic acidosis, and hyperkalemia

 Complications of anesthesia are inevitable even with most experienced Doctors. These complications range from minor to catastrophic. Incidence of perioperative mortality due to anesthetic cause accounts to less than 1:20,000.

Classification..
Respiratory complications Cardiovascular complications Neurological complications PONV Temperature changes Adverse drug effect and hypersensitivity Miscellaneous

Respiratory complications
Complications of laryngoscopy and intubation Hypoxemia Hypercapnia Aspiration pneumonia Atelectasis Pneumothorax

Complications of laryngoscopy and intubation

Endotracheal tube (ETT) positioning:
Esophageal intubation Endobronchial intubation Airway trauma:
Tooth damage, soft tissue injury Dislocated mandible. Sore throat Pressure injury on trachea Edema of glottis or trachea Post intubation granuloma of vocal cords

Physiologic responses to airway instrumentation:

Sympathetic stimulation , increase in Intracranial pressure Laryngospasm Bronchospasm

ETT malfunction:
Risk of fires Kinking causing obstruction Cuff perforation

Hypoxemia
PaO2 < 60 mmHg or SaO2 < 90% Causes:
Low delivery of O2 , unintended extubation Obstruction ETT block/ kink, bronchospasm V/Q mismatch Increased O2 utilization by tissues Usually in disease states Tissue hypoxia Or related to surgical procedure Embolism (air, fat, thrombi) Pneumothorax

Hypercapnia
PaCO2 >45 or ETCO2 > 40 mmHg. Causes:
Hypoventilation Increased dead space Increased CO2 production by tissues V/Q mismatch Pneumothorax/ Capnothorax Laparoscopic surgeries

Pulmonary aspiration
Incidence and severity increase in emergency cases, especially patients with delayed gastric emptying such as CS, intestinal obstruction. Aspiration of material with a pH less than 2.5 causes extensive lung damage. Manifestations: The patient may become hypoxic, tachycardic and tachypnoeic. Bronchospasm often occurs and auscultation of the chest may reveal wheeze and crepitations.

Hemodynamic Complications
1. Hypotension
Causes :
Anesthetic drugs, inhalational agents hypovolemia decreased myocardial contractility, cardiac tamponade. decreased systemic vascular resistance, cardiac dysrhythmias pulmonary embolus pneumothorax

2. Hypertension
Causes: enhanced SNS activity ,preoperative hypertension, hypervolemia, hypoxemia, increased intracranial pressure, and vasopressors

3. Cardiac dysrhythmias
Causes: hypoxemia, hypercarbia, hypovolemia, pain, electrolyte and acid-base imbalance, myocardial ischemia, increased ICP, digitalis toxicity, hypothermia, anticholinesterases and malignant hyperthermia.

Neurological complications
Awareness: Incidence: 0.2% Increased in obstetric, cardiac anesthesia and septic patients. Delayed recovery: Metabolic and electrolyte causes, cerebral hypoperfusion, cerebral depression by drugs, prolonged neuromuscular block leading to respiratory paralysis. Perioperative Neuropathy: related to positioning Cervical spine injury : related to laryngoscopy and intubation

Postoperative Nausea and Vomiting

Patient risk factors: short fasting status, anxiety, young age, female, obesity, gastroparesis, pain, history of postoperative nausea/vomiting or motion sickness. Surgery-related factors: gynecological, abdominal, ENT, ophthalmic, and plastic surgery; endocrine effects of surgery; duration of surgery. Anesthesia-related factors: premedicants (morphine and other opioids), anesthetics agents (nitrous oxide, inhalational agents, etomidate, methohexital, ketamine), anticholinesterase reversal agents, gastric distention, longer duration of anesthesia, mask ventilation, intraoperative pain medications, regional anesthesia. Postoperative factors: pain, dizziness, movement after surgery, premature oral intake, opioid administration.

Miscellaneous
Hypothermia: It is unintentional decrease of core body temperature to < 35 C during anesthesia
Causes: Drop in core temperature. Central inhibition of thermoregulation. Contributing factors: Extremes of age, prolonged surgery, cold infusion or irrigation fluids, muscle relaxants.

Allergic Drug Reactions :anaphylaxis, anaphylactoid reactions Renal dysfunction: Oliguria (urine output less then 0.5 mL/kg/hour) reflects decreased renal blood flow due to hypovolemia or decreased cardiac output

Malignant Hyperthermia
It is a fulminant skeletal muscle hypermetabolic syndrome occurring in genetically susceptible patients after exposure to an anesthetic triggering agent. Incidence and mortality :Children 1:15,000, Adults: approx 1:40,000 with succinylcholine & approx 1:220,000 when agents other than succinylcholine are used. Familial autosomal dominant transmission. Mortality: 10% overall; up to 70% without dantrolene therapy. Early therapy reduces mortality for less than 5%. Triggering anesthetics: halothane, enflurane, isoflurane, desflurane, sevoflurane, and succinylcholine. Early signs: tachycardia, tachypnea, unstable blood pressure, arrhythmias, cyanosis, mottling, sweating, rapid temperature increase, and cola-colored urine. Late (6-24 hours) signs: pyrexia, skeletal muscle swelling, left heart failure, renal failure, DIC, hepatic failure.

 Before whom, In all time, Surgery was Agony By whom, pain in surgery was averted Since whom, science has control over pain
Inscribed on the tombstone of W T G Morton - the father of Anesthesia