OF ANESTHESIA



AIRWAY/DENTAL COMPLICATIONS


Airway Complications


Incidence


•  Unknown owing to varying significance/detection of injuries


•  Minor trauma to larynx & pharynx may be as common as 6%


•  Damage typically ↑ in relation to duration of intubation (many injuries result from placement of endotracheal tube)


•  Many injuries occur during routine, “easy” intubations


•  Delayed, chronic complications often present weeks to even months after extubation, particularly with prolonged intubations (>5 d)


Risk Factors for Intubation Trauma


•  Difficult, traumatic, multiple attempts at intubation


•  Laryngeal abnormalities (past trauma, inflammatory conditions, infection)


•  Movement of endotracheal tube (tube manipulation/surgical repositioning, coughing/bucking)


•  Impaired clearance of secretions


•  Gastroesophageal reflux




Prevention


•  Use small ETTs with lowest possible cuff pressures (leak <30 cm in pediatric pts)


•  Limit use of adjuncts (such as intubating stylets)


•  Wean ventilator to minimize duration of intubation


•  Treat airway infections aggressively & early


•  Minimize aspiration risk (when risk factors present)


•  Perform detailed assessment to prevent unanticipated airway difficulty (to ↓ chance of otherwise preventable airway injury)


•  Prepare alternative plans if intubation fails


•  Discuss risk of airway injury with pts preop (shown to ↓ litigation)


Management


•  Acute airway edema/stridor: Nebulized racemic epinephrine; dexamethasone controversial


•  Prolonged intubation (>5 d): Consider laryngeal evaluation to evaluate for injury


•  Chronic injury from repeated/prolonged intubation: Surgical correction may be required


•  Tracheobronchial rupture: Emergent surgical correction


Obtain follow-up if concerned about airway trauma


•  Inform pts if airway management was difficult/nonstandard


Dental Injuries


•  Dental trauma: Most common permanent airway injury & leading source of malpractice claims (30–40%)


•  Injuries: Fractured teeth, displaced restorations, subluxation, & avulsion (upper incisors most commonly affected secondary to use as fulcrum for laryngoscope)


Deciduous tooth loss → can result in problems with permanent teeth


•  Adverse outcomes → related to aspiration of teeth/restorations


Incidence


•  Overall incidence: Reports range from 0.02–12% (75% of injuries occur during intubation)


•  Injuries can occur during maintenance (poorly positioned airway, bite block, masseter spasm during wakeup)


Risk Factors


•  Tracheal intubation; poor dentition/periodontal disease; difficult airway characteristics; past dental restoration/endodontic treatment; elderly pts; brittle enamel; loose deciduous teeth; inexperienced laryngoscopist


Prevention


•  Detailed preop history & examination:


→ Caries/loose teeth, prostheses, past dental work


→ Assess mouth opening


→ Evaluate dentition, evidence of periodontal disease, tooth hypermobility


→ Document preexisting conditions (reduces litigation if damage occurs)


•  Consider tooth protection


→ Protectors (prefabricated rubber/custom-made by dentist)


Management


•  Loosened tooth


Return to original position promptly; splint with tape/suture


•  Displaced fragment of tooth/restoration:


Locate & recover all pieces; consider radiographs (chest, lateral head & neck) to exclude passage through glottis


•  Avulsed tooth


Immediately replace tooth to original position


Avoid wiping or drying root surface


Splint temporarily with tape/suture


If aspiration concern prevents immediate reimplantation


→ carefully place tooth in suitable medium (saline/milk)


Immediate dental referral, injury documentation & discussion with pt important


•  Most hospitals require filing an incident report


•  Reimbursement responsibility depends on hospital policy


Burns


Intraoperative burns are rare; can be devastating/fatal


Surgical Fire


•  200 surgical fires per year in the United States


•  Fire requires O2, flammable materials, & ignition source


→ O2 commonly administered in OR (endotracheal, nasal cannula)


→ Flammable materials = surgical drapes, alcohol prep solutions, plastic ETTs


→ Ignition sources = laser, electrosurgical units (ESUs), cautery


•  Head & neck surgeries represent most cases involving fire in OR


→ Higher risk since nasal cannulas + laser/electrocautery → combustion


→ ETT carrying enriched O2 can also ignite, leading to a “blowtorch” effect during positive-pressure ventilation


Airway Fire


• Prevention: Decrease FiO2 during lasering; Use heliox; Use fire resistant ETTs; Wrap ETT in metal tape; Fill ETT cuff with saline, not air


• Management: Remove ETT/stop ventilation, discontinue O2, douse fire with saline/water, mask-ventilate pt; Perform bronchoscopy to assess airway damage


Electrocautery/Electrosurgical Unit


•  Current path: Electrosurgical pencil → through pt → out grounding pad


•  Current density dissipated over large surface area → limits risk of burn (because of low impedance return electrode)


•  ESU-associated burns:


→ Improper placement of return electrode (↓ contact surface area)


→ Fluids (blood, irrigation, skin prep) cause improper electrode contact


→ Avoid placement of return electrode over bony prominences


→ ESUs can serve as ignition source (esp if ↑ O2 conc in use)


Magnetic Resonance Imaging


•  Complications usually involve metallic objects flying into magnetic field & burns


•  MRI radio frequency can cause heating of current conducting materials:


→ ECG cables & electrodes


Remove excess cables & avoid cable contact with skin


Do not loop cables, ensure that ECG electrodes are firmly attached


→ Medicated patches


Some contain aluminized backing (can heat in MRI)


Avoid testosterone, nitro, nicotine, scopolamine, clonidine patches


Perioperative Blindness



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Aug 28, 2016 | Posted by in ANESTHESIA | Comments Off on OF ANESTHESIA

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