Qual Saf Health Care
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Qual Saf Health Care · Jun 2005
Crisis management during anaesthesia: myocardial ischaemia and infarction.
Myocardial ischaemia and infarction are significant perioperative complications which are associated with poor patient outcome. Anaesthetic practice should therefore focus, particularly in the at risk patient, on their prevention, their accurate detection, on the identification of precipitating factors, and on rapid effective management. ⋯ Close and continuous monitoring of patients at risk of myocardial ischaemia during anaesthesia is necessary, using optimal ECG lead configurations, but sensitivity of this monitoring is not 100%. Coronary vasodilatation with glyceryl trinitrate (GTN) should not be withheld when indicated and the early use of beta blocking drugs should be considered even with normal blood pressures and heart rates.
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Irrigation of closed body spaces may lead to substantial perioperative fluid and electrolyte shifts. A syndrome occurring during transurethral resection of prostate (TURP), and a similar syndrome described in women undergoing transcervical endometrial ablation (TCEA) are both characterised by a spectrum of symptoms which may range from asymptomatic hyponatraemia to convulsions, coma, and death. Such potentially serious consequences require prompt recognition and appropriate management of this "water intoxication" syndrome. ⋯ This relatively uncommon problem is managed poorly using the "core" crisis management sub-algorithm and requires a simple specific sub-algorithm for water intoxication.
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Pneumothorax is a potentially dangerous condition which may arise unexpectedly during anaesthesia. The diagnosis is one of exclusion, as initial changes in vital signs (cardiorespiratory decompensation and difficulty with ventilation) are non-specific, and other causes of such changes are more common, whereas local signs may be difficult to elicit, especially without full access to the chest. ⋯ Any pneumothorax may become a dangerous tension pneumothorax with the application of positive pressure ventilation. Limited access to the chest during anaesthesia may compromise the diagnosis. Recognition of any preoperative predisposition to a pneumothorax (for example, iatrogenic or traumatic penetrating procedures around the base of the neck) and close communication with the surgeon are important. Aspiration diagnosis in suspected cases and correct insertion of a chest drain are essential for the safe conduct of anaesthesia and surgery.
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Qual Saf Health Care · Jun 2005
Crisis management during anaesthesia: obstruction of the natural airway.
Obstruction of the natural airway, while usually easily recognised and managed, may present simply as desaturation, have an unexpected cause, be very difficult to manage, and have serious consequences for the patient. ⋯ Airway management is a fundamental anaesthetic responsibility and skill. Airway obstruction demands a rapid and organised approach to its diagnosis and management and undue delay usually results in desaturation and a potential threat to life. An uncomplicated pre-learned sequence of airway rescue instructions is an essential part of every anaesthetist's clinical practice requirements.
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In confronting an evolving crisis, the anaesthetist should consider the vascular catheter as a potential cause, abandoning assumptions that the device has been satisfactorily placed and is functioning correctly. ⋯ The approach has potential as an easily remembered and applied clinical tool to lead to early resolution of vascular access problems occurring during anaesthesia.