Critical incidents during anaesthesia: hypertension,

hypotension.
Massive hemorrhage.
Causes and treatment.

Ladan Zaghi
5th Year Medical School
Group 4b
 Table of content

Hypertension in intraoperative setting

● Causes
● Treatment
Hypotension in intraoperative setting
● Causes
● Treatment
Massive hemorrhage in intraoperative setting
● Causes
● Treatment
Hypertension
Causes
● Inadequate anaesthesia /analgesia
● Inadequate neuromuscular blockade
● Consider whether due to drug error
● Omission of usual antihypertensive
● Distended bladder
● Vasopressor administered by surgeon
● Surgical tourniquet - aortic cross clamping
● Excess fluid (over-administration/overload/TURP syndrome)
● Medical causes: drug interaction, renal failure, raised intracranial
pressure, seizure, thyrotoxicosis, pheochromocytoma
Hypertension → exclude a problem in adequate oxygen
delivery, airway & breathing first
1. Immediate actions
a. Recheck BP AND increase anaesthesia AND reduce stimulus
2. Adequate oxygen delivery
a. Check fresh gas flow for circuit in use AND check measured FiO2
b. Visual inspection of entire breathing system including valves & connections
c. Rapidly confirm reservoir bag moving OR ventilator bellows moving
3. Airway
a. Check position of airway device & listen for noise (including larynx & stomach)
b. Check capnogram shape compatible with patent airway
c. Check airway device is patent (consider passing suction catheter)
4. Breathing → exclude hypoxia & hypercarbia as causes
a. Check chest symmetry, breath sounds, SpO2, measured VTexp, ETCO2
b. Feel the airway pressure using reservoir bag & APL valve <3 breaths
Hypertension → exclude circulation, depth, underlying
causes
1. Circulation
a. Check rate, rhythm, perfusion, increase frequency of BP check
b. Check cuff size & location, consider intra-arterial monitoring
2. Depth
a. Ensure adequate depth of anaesthesia & analgesia
3. Consider underlying causes
4. Call for help & consider temporising drug if problem not resolving
a. Alfentanil 10 ug/kg (adult 0.5-1 mg)
b. Propofol 1 mg/kg (adult 50-100 mg)
c. Labetalol 0.5 mg/kg (adult 25-50 mg) Repeat when necessary
d. Esmolol 0.5 mg/kg (adult 25-50 mg) follow with infusion
e. Hydralazine 0.1 mg/kg (adult 5-10 mg)
f. Glyceryl titrate 0.5-5 ug/kg/min infusion (adult 2-20 ml/h of 1 mg/ml solution)
Hypotension
Definition
● Commonly due to
○ Unnecessarily deep anaesthesia
○ Autonomic effects of neuraxial block
○ Hypovolemia or combined causes
● Surgical causes
○ Decreased venous return e.g vena cava compression/pneumoperitoneum
○ Blood loss (unrecognised/undeclared/occult)
○ Vagal reaction to surgical stimulation
○ Embolism (gas/fat/blood/cement reaction)
Hypotension → exclude a problem in adequate oxygen
delivery, airway & breathing first
1. Adequate oxygen delivery
a. Pause surgery if possible
b. Increase fresh gas flow AND give 100% oxygen AND check measured FiO2
c. Visual inspection of entire breathing system including valves & connections
d. Rapidly confirm reservoir bag moving OR ventilator bellows moving
2. Airway
a. Check position of airway device & listen for noise (including larynx & stomach)
b. Check capnogram shape compatible with patent airway
c. Check airway AND airway device are patent (consider passing suction catheter)
3. Breathing
a. Check chest symmetry, rate, breath sounds, SpO2, measured VTexp, ETCO2
b. Feel the airway pressure using reservoir bag & APL valve <3 breaths
c. Exclude high intrathoracic pressure as a cause
Hypotension → exclude a problem in circulation, depth,
surgical causes, other causes
1. Circulation
a. Check heart rate, rhythm, perfusion, recheck blood pressure
b. If heart rate <60 bpm consider giving anticholinergic drug
i. Glycopyrrolate 5 ug/kg (adult 200-400 ug)
ii. Atropine 5 ug/kg (adult 300-600 ug)
c. Consider giving vasopressor & positioning e.g. move head down
i. Ephedrine 100 ug/kg (adult 3-12 mg)
ii. Phenylephrine 5 ug/kg (adult 100 ug)
iii. Metaraminol 5 ug/kg (adult 500 ug)
iv. Adrenaline 1 ug/kg (adult 10-100 ug) only in emergency
d. Consider fluid boluses (250 ml adult, & 10 ml/kg children
e. If heart rate > 100 bpm sinus rhythm → treat as hypovolemia give IV fluid bolus
f. If heart rate > 100 bpm & non-sinus → consider tachycardia
2. Depth
a. Ensure correct depth of anaesthesia AND analgesia
3. Exclude potential surgical causes
4. Consider other causes & call for help if problem not resolving quickly
a. Consider whether you have made a drug error
b. Pneumothorax & or high intrathoracic pressure can cause hypotension
c. Other causes →
i. Cardiac ischemia
ii. Anaphylaxis
iii. Cardiac tamponade
iv. Local anaesthetic toxicity
v. Sepsis
vi. Cardiac valvular problem
vii. Endocrine causes → steroid dependency
Massive hemorrhage
Causes

● Non-surgical uncontrolled bleeding despite PRBCs/FFP/Platelets

● Warfarin overdose
● Newer oral anticoagulants e.g. dabigatran, rivaroxaban
● Inherited bleeding disorder e.g. hemophilia, von Willebrand disease
MASSIVE HEMORRHAGE → TREATMENT
1. Call for help, inform theatre team of problem & note the time
2. Increase FiO2 & consider cautiously reducing inhalational/intravenous anaesthetics
3. Check & expose intravenous excess
4. Call blood bank (& assign one person in theatre to cooperate with them)
a. Activate major hemorrhage protocol
b. Communicate how quickly blood is required
c. Communicate how much blood & blood product is required
5. Begin active patient warming
6. Use rapid infusion & fluid warming equipment
7. Discuss management plan between surgical, anesthetic & nursing teams
a. Consult hematologist if necessary
b. Consider interventional radiology
c. Consider use of cell salvage equipment
8. Monitor progress
a. Use point of care testing: Hb, lactate, coagulation
b. Use lab testing: including calcium & fibrinogen
9. Replace calcium & consider giving tranexamic acid
10. If bleeding continues consider giving recombinant factor VIIa: cooperate with hematologist
11. Plan ongoing care in an appropriate clinical area
Transfusion goals
● Maintain Hb > 80 g/L
● Maintain platelet counts > 75x10^9 /L
● Maintain PT & APTT < 1.5 x mean control (FFP)
● Maintain fibrinogen > 1.0 g/L (cryoprecipitate)
● Avoid DIC (maintain BP, treat/prevent acidosis, avoid hypothermia, treat
hypocalcemia & hyperkalemia
Drug doses
CALCIUM: (use either the chloride or gluconate)
● Adult: 10 ml of 10% calcium chloride IV
● Adult: 20 ml of 10% calcium gluconate IV
● Child: 0.2 ml/kg of 10% calcium chloride IV
● Child: 0.5 ml/kg of 10% calcium gluconate IV
TRANEXAMIC ACID:
● Child: 15 mg/kg IV bolus then 2 mg/kg/h until bleeding stops
● Adult: 1 g IV bolus, then:
a. Obstetric haemorrhage, repeat dose 30 mins later
b. Non-obstetric haemorrhage, 1 g IV infusion over next 8 h
THANK YOU FOR LISTENING
SOURCES
https://anaesthetists.org/Home/Resources-publications/Guidelines/Measurement-o
f-adult-blood-pressure-and-management-of-hypertension-before-elective-surgery