Intraoperative crisis manegement

2. Crisis:
A time of great danger or trouble whose
outcome decides whether possible bad
consequences will follow.
Anesthesiology, by its nature,
involves crises; The combination of
complexity and dynamism makes crises
much more likely to occur and more
difficult to deal with.

3.  Crisis perceived as sudden in onset and rapid in
development
It happened all of a sudden
 Triggering events may
initiate a problem.
 A problem is an
abnormal situation that
requires attention ,
which if not detected or
corrected can lead to
→→adverse outcomes

4. Expertise” in Anesthesia (or who
would I choose to do MY anesthesia)
 Intelligence +
Motivation + anesthesia
training = Expertise in
anesthesia (?)
 CME’s, Refresher
Courses, M & M
conferences – maintains
“expertise” (?)
 Is every “expert” then a
good crisis manager?

5. Elements of Core Mental Process
Observation
 Verification
 Problem Recognition
 Prediction of future states
 Decision-making
 Action implementation
 Reevaluation
 Start again with observation
 Several studies have shown
that not all crises are managed
well, including by
experienced
anaesthesiologists

6. Crisis management during
anaesthesia: laryngospasm
Inspiratory stridor/airway obstruction
Increased inspiratory efforts/tracheal tug
Paradoxical chest/abdominal movements
Desaturation, bradycardia, central cyanosis
PRECIPITATING FACTORS
Airway irritation and/or obstruction
Blood/secretions in the airway
Regurgitation and aspiration
Excessive stimulation/"light" anaesthesia
Failure of anaesthesia delivery system

7. EMERGENCY MANAGEMENT
 Cease stimulation/surgery .
 100% Oxygen .
 Try gentle chin lift/jaw thrust .
 Request immediate assistance.

Deepen anaesthesia with an IV agent .
 Visualise and clear the pharynx/airway
If you suspect aspiration then go to Regurgitation (6)
If you suspect airway obstruction go to Airway Obstruction .
 Try mask CPAP/IPPV, if this is unsuccessful
Give suxamethonium unless contraindicated
Give atropine unless contraindicated .
 Again, try mask CPAP/IPPV .
 Intubate and ventilate .

8. Crisis management during
anaesthesia:desaturation
EMERGENCY MANAGEMENT
Complete COVER ABCD-A SWIFT CHECK .
Hand ventilate with 100% oxygen
Confirm the FIO2 is appropriate
Confirm the ETCO2 is appropriate, if it is low consider:
Anaphylaxis
Pneumothorax
Air (or other) embolism.
Auscultate again, specifically exclude endobronchial intubation .

9. REVIEW AND TREAT OTHER POSSIBLE CAUSES
 Underlying cardiopulmonary problems.
 If bronchial secretions or plugs are suspected .
Posture and suction ETT/bronchi
Give a "long slow blow" especially in children
If cardiovascularly stable consider PEEP/CPAP
 If acute shunt is suspected .
Ensure the patient is supine and level.
 If a pneumoperitoneum is present, deflate the abdomen
Consider gas embolism .
 Pulse oximeter malfunction .
 Consider: polycythaemia, methaemoglobinaemia, acute tricuspid
incompetence, probe sited distal to an AV fistula.

10. Crisis management during
anaesthesia: bronchospasm
In cases ofsevere bronchospasm, the chest may be
silent on auscultation and the diagnosis may rest on
correct assessment ofincreased inflation pressures.
May appear as an entity in its own right or
be a component of another problem such as
anaphylaxis.
usually triggered by some manoeuvre, often in
patients
with a pre-existing airway disease such as asthma.

11.  misplacement of the endotracheal
 tube (in the oesophagus or a bronchus, for
example) and
 with pulmonary oedema or adult respiratory
distress syndrome
 (ARDS).

12. LOOK FOR
Increasing circuit pressure
Desaturation
Wheeze (auscultate)
Rising ETCO2 and prolonged expiration
Reduction in tidal volumes
THINK OF
Anaphylaxis/allergy to drugs/IV fluids/latex
Airway manipulation/irritation/secretions/regurgitation
Oesophageal/endobronchial intubation
Pneumothorax
Inadequate anaesthetic depth or failure of anaesthetic delivery system

13. EMERGENCY MANAGEMENT
 100% Oxygen
Cease stimulation/surgery
Request immediate assistance
Deepen anaesthesia .
If intubated exclude endobronchial or oesophageal position .
If mask/LMA in use consider:
Laryngospasm / Airway Obstruction
Regurgitation / Vomit/Aspiration
Give adrenaline or salbutamol .
If you cannot ventilate via an ETT consider: Misplaced/kinked/blocked ETT, catheter
mount, filter or circuit
Pneumothorax
Aspiration
Consider possible obstruction distal to ETT
Try pushing a small tube past it, or push the obstruction down one bronchus and
ventilate the other lung.
 Consider Anaphylaxis
Consider Pulmonary oedema

14. Crisis management during
anaesthesia:hypertension
LOOK FOR
Drug errors .
Awareness or light anaesthesia .
Pre-existing hypertension .
Airway problems .
Surgical factors .
Hypercarbia .
Uncommon/unusual conditions
Fluid overload
Raised intracranial pressure
Hyperthyroidism
Phaeochromocytoma/carcinoid
Malignant hyperthermia

15. EMERGENCY MANAGEMENT
 Complete COVER ABCD - A SWIFT CHECK .
Confirm the blood pressure change is real .
Deepen anaesthesia/assess depth
Cease any vasopressor therapy .
Inform the surgeon; cease stimulation
Recheck for drug errors and delivery of anaesthesia
Consider an appropriate dose of opioid .
Consider antihypertensive therapy:
BE CAUTIOUS USING HYPOTENSIVE AGENTS IF THE
POSSIBILITY OF LIGHT ANAESTHESIA EXISTS
Consider glyceryl trinitrate 50 mg in 500 ml 5% Dextrose and start at
5ml/hr for adults (0.1 ml/kg/hour for children).
If tachycardia is troublesome:
Give atenolol 0.015 mg/kg IV bolus injections .
Titrate drugs against effect

16. Crisis management during anaesthesia:
Tachycardia
DIAGNOSE RHYTHM
If primary sinus tachycardia, with or without hypotension, treat tachycardia first .
If non-sinus tachycardia, choose treatment based on severity of hypotension .
If severe, use cardioversion
For adults, start at 100 Joules, if unsuccessful, 200 Joules (synchronised mode)
For children
for pulseless VT:
start at 2 Joules/kg, try twice then increase to 4 J/kg (unsynchronised mode)
for SVT:
0.5 – 1 Joules/kg (synchronised mode)
Consider antiarrhythmic drugs.
If mild, use appropriate antiarrhythmic drugs - adult doses only:
VT: Lignocaine 70mg IV (or amiodarone 200mg IV over 10 min) .
AF: Digoxin 0.5 mg IV (or amiodarone 200mg IV over 10 min) .
SVT: Adenosine 6-12 mg IV (or titrated beta blocker: atenolol 1 mg boluses)
 For less urgent SVT in children: Adenosine 0.05 mg/kg, increasing to 0.25 mg/kg, by
rapid IV or intraoral bolus.

17. REVIEW AND TREAT PROBABLE CAUSES
 Hypovolaemia
Consider: Blood loss, dehydration, diuresis, sepsis Þ page xxx
Ensure: Adequate IV access, fluid replacement cross match and check haematocrit.
Drugs
Consider: Induction and inhalation agents, atropine, local anaesthetic toxicity, adrenaline, cocaine,
vasopressors.
Airway:
Hypoventilation
Hypoxia (see Desaturation)
Anaphylaxis
Reflex Stimulation
Consider: Laryngoscopy, CVC insertion, surgical manipulation.
Consider Awareness
Cardiopulmonary Problems
Consider: Tension pneumothorax, haemothorax, tamponade,
embolism (gas, amniotic or thrombus),
sepsis ,
myocardial irritability (from drugs, ischaemia, electrolytes,
trauma),
pulmonary oedema.
Ensure: Review of appropriate pages in manual, including both cardiac arrest pages:
(advanced life support, and basic life support during anaesthesia)

18. Crisis management during anaesthesia:
Bradycardia
–EMERGENCY MANAGEMENT
–Complete COVER ABCD A SWIFT_CHECK
Do not hesitate to treat as Cardiac Arrest
–Ensure adequacy of oxygenation and ventilation
If hypotensive
Inform the surgeon, stop retraction/stimulation
Turn off vaporiser
Crystalloid 500ml bolus and repeat if necessary
Atropine 0.6mg IV for an adult; 0.012mg/kg IV for child
Consider adrenaline slow IV bolus: 0.05 mg (adult); 0.001mg/kg (child)
followed if necessary by an infusion of adrenaline:
For adults, 1mg in 100ml burette starting at 60mls/hr (10 mcg/min)
For children, 1 mg in 1000 ml, start at 0.1 mcg/kg/minute
Increase monitoring - ECG, arterial line, CVP
Consider external pacemaker (transvenous or transcutaneous)

19. REVIEW AND TREAT PROBABLE CAUSES:
 Drugs
Inhalational agent overdose. Consider also suxamethonium, induction agents, neostigmine, and
opioids. Check drugs
given by surgeon.
Airway
Hypoventilation
Hypoxia
Vagal Reflexes
Cease stimulation
Regional Anaesthetic
Consider: Vasodilation, respiratory failure.
Ensure: Volume loading, vasopressors (early adrenaline), airway support, left lateral displacement
during pregnancy.
Surgical Factors
Consider: IVC compression, pneumoperitoneum, retractors position.
Ensure: Surgeon aware.
Undetected Blood Loss
Improve IV access, fluid replacement, cross match.
Cardiac Event
Consider: Tension pneumothorax, haemothorax, tamponade, embolism (gas, amniotic or thrombus
-
sepsis, myocardial depression (from drugs, ischaemia, electrolytes, trauma.
Ensure: Review of appropriate pages in manual.

20. Crisis management during
anaesthesia:Hypotension
–EMERGENCY MANAGEMENT
–Complete COVER ABCD - A SWIFT CHECK
Confirm the blood pressure change is real
Don't hesitate to treat as cardiac arrest
Inform and discuss with surgeon
Recheck vaporisers are off
Improve posture: lie flat, elevate legs if possible
IV fluids: crystalloid bolus - 10 ml/kg, and repeat as necessary
Give vasopressor: metaraminol bolus 0.005-0.01 mg/kg IV
If severe give adrenaline: For an adult, 0.1 mg IV bolus very slowly.
For a child 0.001 mg/kg IV very slowly;
titrate to clinical response,
followed if necessary by an infusion of adrenaline
For adults, 1 mg in 100 ml burette starting at 60ml/hr.
For children, 1 mg in 1000 ml (1 mcg/ml), starting at 0.1 mcg/kg/minute
If erythema, rash or wheeze is evident go to anaphylaxis
If bradycardic go to bradycardia
If desaturated or cyanosed go to desaturation
If pulseless go to cardiac arrest
Increase monitoring - ECG, arterial line, CVP, filling pressures.

21. Crisis management during anaesthesia:
Myocardial ischemia
–LOOK FOR ST changes - elevation
or depression,
T wave flattening or inversion
Ventricular dysrhythmias
–PRECIPITATING FACTORS
Pre-existing cardiovascular disease
Haemodynamic instability
Tachy- or bradycardia
Hyper- or hypotension
Desaturation
Pulmonary oedema
Awareness / light anaesthesia /
intubation

22. EMERGENCY MANAGEMENT
 Inform the surgeon
Defer, or rapidly complete surgery
Ensure adequate oxygenation
Correct any haemodynamic derangement
If hypotensive
If hypertensive
If tachycardic
If bradycardic
If ischaemia does not resolve rapidly .
commence glyceryl trinitrate (50mg in 500ml 5% dextrose) Start at 0.1
ml/kg/hr
titrate against clinical response
Consider multilead ECG monitoring
Monitor ECG continuously
Aim for haematocrit - 30%
For significant myocardial ischaemia, consider a short-acting β-blocker to
cover emergence from anaesthesia.

23. Crisis management during anaesthesia:
awareness and anaesthesia
HIGH RISK SITUATIONS
Patient factors:
History of drug/alcohol abuse
Highly anxious patient
Previous awareness
Equipment problems:
Vaporiser leaking/empty/mal-positioned
Incorrectly calibrated vaporiser
Nitrous oxide run out
Failure of drug delivery with TIVA
Drug errors:
Syringe swap causing paralysis before induction
Syringe swap causing non delivery of opioid/sedative
Anaesthetic technique:
Deliberate light anaesthesia during crisis management or caesarean section
Opioid based anaesthesia
Regional/local anaesthetic techniques
Anaesthesia with paralysis
Other problems:
Laryngospasm/airway obstruction
Difficult/prolonged intubation
Delayed extubation

24.  Stop painful surgical or other stimuli
Verbally reassure the patient
Rapidly deepen anaesthesia
Consider amnestic drugs: eg. midazolam 3mg IV bolus.
 Interview the patient post operatively as soon as possible, and again several
days later
 Reassure the patient
Explain what has happened
Be honest and sympathetic
Arrange for follow up
 The most frequently cause of awareness was a low concentration of volatile
agent ,secondary to a failure to check equipment, specifically the vaporiser.
 In total intravenous anaesthesia, caused by failure to deliver the drug to the
patient. Failure to deliver nitrous oxide was also reported.

25. Crisis management during
anaesthesia:AIR (AND OTHER) EMBOLISM
LOOK FOR
A sudden fall in ETCO2
Desaturation and/or central cyanosis
Air in surgical field or vascular line
Hypotension
A sudden change in spontaneous breathing pattern
A change in the heart rate
A change in the ECG configuration
Raised CVP or distended neck veins
A cardiac murmur or mottled skin

26. EMERGENCY MANAGEMENT
 Inform the surgeon
Prevent further entrainment/infusion of gas
 Flood the field with fluid
Aspirate central venous line if already in situ
100% oxygen and hand ventilate
Consider valsalva or PEEP
Level the patient
Do not hesitate to treat as a cardiac arrest
Turn the vaporiser off
If hypotensive:
-Volume expansion with crystalloid 10 ml/kg
-Consider adrenaline initial bolus 0.1 mg IV (adults); in children 2.0 mcg/kg IV
Repeat if necessary or follow with an infusion 1mg in 100ml burette, start at
60mls/hr (adults)
For a generally useful adult catecholamine infusion preparation see the bottom
lines
of the adrenaline dosage calculations page in this manual
. For children adrenalin infusion dosages,

27. Crisis management during anaesthesia:
difficult intubation
REMEMBER, PATIENTS DO NOT DIE FROM FAILED
INTUBATION - ONLY FAILED VENTILATION .
Always have skilled assistance, preferably another anaesthetist, when
difficulty is expected or the patient's cardio-respiratory reserve is low.
Avoid multiple attempts at laryngoscopy/intubation, as this may cause
bleeding and laryngeal oedema, worsening the
situation.
The LMA is easy to insert and works well in 95% cases. It does not
provide airway protection.
Document the problem in the case notes and give the patient a letter to
warn future anaesthetists. If a particular
precipitating event was significant, or a particular action was useful in
resolving the crisis, this should be clearly
explained and documented.

There is a risk of awareness:
Go and see the patient in the ward
Explain the full circumstances and reassure them

28. CRISIS MANAGEMENT MANUAL
It must always be remembered that no manual will
work in every circumstance and a good outcome
cannot be guaranteed. Always use your common
sense, and revert, if necessary, to working from first
principles.
The Manual is based on the mnemonic "COVER
ABCD - A SWIFT CHECK", and is designed for use
when any patient is undergoing general or regional
anaesthesia. It applies whether the patient is
ventilated or spontaneously breathing.

29. EMERGENCY MANAGEMENT
 Call for help
Complete COVER ABCD - A SWIFT CHECK
Inform the surgeon
Stop surgery/blood loss
Place patient supine and expose the chest
Praecordial thump (in witnessed or monitored adult arrest
only)/external cardiac compression
Australian Resuscitation Council Life support algorithms
Intubate and ventilate with 100% oxygen
ECG, for rhythm clues .
Delegate tasks

30. Crisis management during anaesthesia:
cardiac arrest
PRECIPITATING FACTOR
Pre-existing disease states .
Cardiac
Respiratory
Renal
Consequent upon surgical manoeuvres .
Error or fault in anaesthetic technique
Inadequate ventilation
Essential monitoring not in use
Drug problems
Overdose (e.g. opioids)
Induction/reversal drugs
Anaphylaxis
Wrong route

31. Crisis management during anaesthesia:
regurgitation, vomiting, and aspiration
EMERGENCY MANAGEMENT
Inform the surgeon
Head down, lateral posture, if feasible
Apply cricoid pressure (release cricoid pressure if active vomiting occurs)
Try to clear and suction the airway
Give 100% oxygen
Consider deepening anaesthesia to visualise and clear the pharynx/airway
Try gentle mask CPAP/IPPV with cricoid pressure
Ventilate the lungs with cricoid pressure
IF YOU CANNOT VENTILATE see laryngospasm
Give suxamethonium 2 mg/kg (100mg adult dosage) IV & atropine 0.6
mg IV
Intubate using cricoid pressure, expedite surgery.