1、Wanawimol Saengchote M.D.Department of Anesthesiology,Ramathibodi Hospital,Mahidol U SAFETYAnesthesia Incident Monitoring StudyJanuary to June 2007.200,000 cases,2537 incidents A standardized incident report form was developed in order to fill in what,where,when,how,and why it happenedDO2=CO x 10 x
2、CaO2Tissue O2 delivery =cardiac output x arterial O2 contentCO=SV x HRSV preload,contractility,afterloadCO=EF x LVEDV x SVR x HRPatients comorbid:controllability?Anesthetic management:drugs,techniques,process,anesthesia personnelSurgical procedurePreoperativeIntraoperative&PO.HypovolemiaPreop NPOTra
3、uma-fracturesPeritonitisN/v,diarrheaBowel prepDiureticsBlood lossMajor fluid shiftTissue edemaEffusionDiuresis(concealed blood loss)TachycardiaPeripheral vasoconstrictionLow systolic blood pressureNarrow pulse pressureCold,clammy skin and extremitiesLow urine output(anemia not apparent in acute loss
4、 without adequate volume replacement)With beta blocker effect,no tachycardia detectedClass IClass IIClass IIIClass IVPulse rate100/min120/min140/minBPnormalnormaldroppeddroppedPulse pr.normaldecreaseddecreaseddecreasedRR14-20/min20-30/min30/min35/minUrine30ml/hr20-30ml/hr5-15ml/hrminimalCapill.refil
5、normaldelayeddelayeddelayedMental st.Sl.anxiousanxiousconfusedlethargicBl.loss(ml.,%)7502,00040%Fluidcrystalloid+colloid+colloid,bl.+colloid,bl.Alert to environment,notice surgeons(and team)expressionGood communicationAdequate volume loading is all the time necessary (crystalloid colloid)Blood and b
6、lood component as requiredCritical perfusion pressure should be maintained (MAP 65 mmHg)Concern about distribution of regional blood flow 1.Drug effect:nearly all anesthetic agents depress myocardial contractility-Potent inhalation agents-Nitrous oxide in compromised heart-Intravenous:thiopental,pro
7、pofol,ketamine-Opioid:pethidine(arrhythmogenic effect to be discussed later)Coronary artery disease Myocardial ischemia/infarctCardiogenic shockValvular heart diseaseCongestive heart failure most common rheumatic heart disease:mitral,aortic,tricuspid valveAcute ischemic episode large or significant
8、myocardial loss serious ventricular arrhythmia,pulmonary congestion,hypotension.Hemodynamic support :inotropes,antiarrhythmic,mechanical deviceCardiac markers:troponin I,AST,LDH,CK-MBcTnT 0.1 ng/L,cTnI 2 x normal)Obstruction to heart,cardiac chambers or great vessels reduced stroke volumeCauses:1.Ca
9、rdiac tamponade from injury,post cardiac surgery,cardiac catheterization*2.Tension pneumothorax*3.Pulmonary embolism*4.Surgical manipulation in chest,esophageal,cardiac surgery5.Supine hypotensive syndrome1.drug interactions:concurrent drug use+anesthetic effectACEI,CCB,opioids,IV anesthetic,inhalat
10、ion agent2.regional anesthesia :spinal,epidural an.with sympathetic blockade effect3.various drug effect:antibiotics,protamine,4.bone cement5.sepsis,adrenal insufficiency,blood transfusion20%of population with hypertensive diseasesCauses of intraoperative HTNResponse to laryngoscopy and intubationLi
11、ght anesthesia HypercarbiaHypoxemiaDrug effectHypervolemia1.Specific surgical procedure Causes of HTN postop and at emergence1.Stimuli from endotracheal&extubation2.Pain3.Hypoventilation,airway obstruction4.Hypothermia,shivering5.Acidosis6.Full bladder7.Antihypertensive withdrawalRisk FactorsHyperte
12、nsionDiabetes mellitusUnderlying heart disease:CAD,VHDLiver disease,renal diseaseHead injurySepsisCarbon monoxide poisoning(elderly,malnutrition,hypoalbuminemia)A 62 yr-old female suspected CBD stone,scheduled for ERCP,plan for post procedural admission.Anesthetic time 1 hr 15 mins.,uneventful an.an
13、d surgical procedureAfter extubation,?Abn.breathing pattern,occ.fine crepitations BLL.Later SPO2 dropIV fluid 800 mL,minimal blood lossDiuretic given,PACU 2 hrs.At ward SBP drop,intubate ventilate,on dopa1.Physiological disturbances during anesthesiaAnesthetics modify body mechanism+vagal dominant,a
14、cidosis,hypoxia/hypercarbia,electrolyte disorder,hypovolemia2.Pathological disturbancesCAD:heart block,PVC,Thyrotoxicosis,MH,pheochromocytoma3.Pharmacological causes:ketamine,NMB4.Anesthesia procedures:IT,CVP,SASerious cardiac arrhythmia:6H,5THypovolemia,hypoxemia,acidosis,K-Ca hypothermia,PE,tamponadetension pneumothoraxKnow how,Know why,Care why
