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Investigation into Significant Anesthesia Adverse Events during the Post-Op Period

Investigation into Significant Anesthesia Adverse Events during the Post-Op Period. Research by: Ryan Dietz RNAI Stephen Both RNAI Gonzaga University Providence Sacred Heart Medical Center March 20, 2014. Methodology. Retrospective Chart Review At PHSMC Populations

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Investigation into Significant Anesthesia Adverse Events during the Post-Op Period

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  1. Investigation into Significant Anesthesia Adverse Events during the Post-Op Period Research by: Ryan Dietz RNAI Stephen Both RNAI Gonzaga University Providence Sacred Heart Medical Center March 20, 2014

  2. Methodology • Retrospective Chart Review • At PHSMC • Populations • Strokes, cardiopulmonary arrests (CPAs), and deaths (within 30 days of an anesthetic) • PACU physiologic instability • Hemodynamic problems • Bleeding • Oxygenation issues

  3. Number of Patients Investigated Study numbers: Charts from 2013 PACU physiologic instability 29 Strokes 13 CPAs 16 Mortality 41 99 (1 mo.) (6mo.) (6mo.) (6mo.)

  4. ~Inpatient Research Study~

  5. Hypotension Dynamics

  6. 44% of this group received Spinal Anesthesia

  7. Determinants of Cerebral Blood Flow • Two Determinants of cerebral blood flow: • Cerebral Vascular Resistance • PaCO2 • PaO2 • Metabolism • Cerebral Perfusion Pressure (CPP) • Blood Pressure • ICP

  8. EMBOLIC STROKES

  9. PaCO2 39.4-42.6 44.2-49.6 28.8-33.2 J. of Cerebral Blood Flow, (2003) : 23 (6). 665-670 [15]

  10. Detrimental Effect of Hypocapnia Hypocapnia[1,2,3,8,9] • Directly neurotoxic • ↑ neuronal excitability while ↓ cerebral O2 supply • ↓ V/Q matching • Causes lung injury via inflammation activation • Increase risk of infection • Undermines respiratory drive postop • ↓myocardial O2 supply ST depression syndrome • ↓ SvO2 • Prolongs wakeups • ↑Pain in postop

  11. Summary of Findings • Hypertension was the #1 cause of physiologic instability in the PACU • 44% of ASA II patients that experienced hypotension also received spinals • 54% of patients that experienced strokes during the post op period had etCO2 levels maintained between 25-30 mmHg

  12. Hypertension Recommendations Continuing Education in Anaesthesia, Critical Care & Pain. (2004) 4 (5): 139-143[10] Miller’s Anesthesia (2010) p.1094-1095 [21]

  13. Hypotension Algorithm Journal of PeriAnesthesia Nursing. (2002). 17 (3) 159-163. [7]

  14. Spinal Hypotension Mechanism[5] A) Blockade of sympathetic efferents (arterial and venodilation) B) Potential for cardiac accelerator suppression (T1-T4) Treatment[5] • Crystalloid: (500-1500ml ) pretreatment better than co-treatment • Colloid: superior to crystalloid (↑SVR) (30 min half-life) Hespan= $12.04/500ml bag * • Ephedrine superior to Phenylephrine (caution tachyphylaxis) • Dopamine short term upon ephedrine tachyphylaxis onset • Cautious use of phenylephrine in the elderly: with reports of ↓ C.O. and LV dysfunction * Cost at PSHMC /Tony Hill (Materials Management Manager PSHMC)

  15. Hypercapnia • Benign (paCO2≤70) [1] • Enhances respiratory drive [9] • Protects lung tissues [14] • Advance warning of inadequate analgesia and relaxation [1] • ↑in PaCO2 by 10mmHG ↑the C.I. by about 10-15% [17] • ↓ SVR, ↑SvO2 [17] • 3-5% alteration in CBF for every 1 mmHg change in PaCO2 [2] • Decrease in infection postop [2,3,34] • Avoid hypercapnia and hypocapnia in known cerebral ischemic patients [21]

  16. Mild Respiratory Acidosis (A good Thing?) • Hypercapnia can, and many times will lead to mild respiratory acidosis [14,28] • Respiratory Acidosis is different than metabolic acidosis (slight sympathetic activation) [17] • ↑ Inotropy • ↓ SVR • ↑ Blood pressure • ↑ HR • PH of 7.15 is tolerated before buffering agents/ ↑RR are necessary [14,28] “I’m pretty comfortable with a low pH threshold of 7.17 in the healthy or appropriate respiratory acidosis patient” Dr. Chris Vernon DO (Intensivist PSHMC )

  17. Elevated ICP Recommendations Hypocapnia: Should only be utilized in two instances[13] • Impending brain herniation • To increase surgical field of view • Normal goal in head injury or elevated ICP is a PaCO2=35-40 [13] • Hypocapnia is only viable for 20 minutes due to cerebral ischemia [13] Treating impending herniation with hyperventilation [6,21,30] • Goal of PaCO2=30-32 • Strictly avoid PaCO2 levels below 25 mm HG • Not to be used for >20 minutes

  18. Recommendations: StrokeGroup • Delay elective surgery at least 6 weeks after stroke [21] • Continue anticoagulation for minor surgeries (esp. afib + prior stroke) [25] • Continue low dose aspirin in patients under procedures of high risk for bleeding and stroke (Bridge with heparin for pt with afib and Hx of Tia/Stroke) [25] • Continue beta blockers and statins preop and restart postop [25] • Metoprolol controversial during the case (3-4 fold ↑in strokes). Esmolol & Labetalol, Bisoprolol better choices [4,19,27]

  19. Recommendations: Stroke Group • Regional is only beneficial in orthopedic cases[20,25] • Avoid hyperventilation during surgery: theories such as “Inverse steal” and “Robin Hood” actually increase the region at risk for stroke [22,29,33] • Recommended goal of PCO2 should be normocapnia (35-45). Avoid hypo and hypercapnia in potential cerebral ischemia cases [24] • Hypo-albuminemia is a predictor of stroke risk [12] • Maintain glucose 60-150mg/dl [11,16]

  20. Conclusion • The purpose of this research project was to identify potential themes in patient comorbidities, surgery type, and anesthetic management that may potentially contribute to significant postop complications. Although we did not uncover any “smoking gun” anesthesia related issues, we highlighted and made recommendations regarding 3 interesting findings. Anesthesia is a journey and we will need to continually re-evaluate the method in which we deliver anesthesia.

  21. QUESTIONS?

  22. References • Akca, O. (2006). Optimizing the intraoperative management of carbon dioxide concentration. CurrOpinAnaesthesiol. 19 (1): 19-25 • Akca, O., Doufas, A., Morioka N. (2002). Hypercapnia improves tissue oxygenation. Anesthesiology. 97. 801-806 • Akca, O., Liem E., Suleman, M., Doufas, A., Galandiuk, S., Sessler, D. (2003) Effect of intra-operative end-tidal carbon dioxide partial pressure on tissue oxygenation. Anaesthesia. 58 (6): 536-42 • Ashes, C., Judelman, S., Wijeysundera, D, et al. (2013). Selective β1-antagonism with bisoprolol is associated with fewer postoperative strokes than atenolol or metoprolol: a single-center cohort study of 44, 092 consecutive patients. Anesthesiology. 119 (4): 777-787. • Barash, P., Cullen, B., Stoelting, R., Cahalan, M., Stock, C., Ortega. R (2013). Clinical Anesthesia. Lippincott Williams & Wilkins. Philidelphia. 923-925. • Brain Trauma Foundation (2007). American association of neurological surgeons: congress of neurological surgeons: joint section on neurotrauma and critical care, AANS/CNS, Bratton SL, Chestnut RM, Ghajar J, et al. Guidelines for the management of severe trauma brain injury. XIV. Hyperventilation. J neurotrauma 2007: 24 Suppl 1:S87-90

  23. References • Cowling, G., Hass, R. (2002). Hypotension in the pacu: an algorithmic approach. Journal of perianesthesia nursing. 17 (3) : 159-163. • Curley, G., Kavanagh, B., Laffey, J. (2010). Hypocapnia and the injured brain: more harm than benefit. Critical care medicine. 38 (5). 1348-1355. • Curley, G., Laffey, J., Kavanagh, B. (2010). Bench-to-bedside review: carbon dioxide. Critical Care. (14) 220-227. • Dphil, P., Sear, J. (2004). The surgical hypertensive patient. Continuing education in anaesthesia, critical care & pain. 4 (5). 139-143. • Engelhard, K. (2013). Anaesthetic techniques to prevent perioperative stroke. Curropinanaesthesiol. 26: 368-374. • Famakin, B., Weiss, P., Hertzberg, V., McClellan, W., et al. (2010). Hypoalbuminemia predicts acute stroke mortality: Paul coverdellgeorgia stroke registry. J. stroke cerebrovasc disease. 19 (1): 17-22.

  24. References • Gelb, A., Craen, R., Rao, G., Reddy, K., et al. (2008). Does hyperventilation improve operating condition during supratentorial craniotomy? AnesthAnalg. 106 (2). 585-594. • Hemmila, M., Napolitano, L. (2006). Severe respiratory failure: advanced treatment options. 34: S278-90. • Ito, H., Kanno, I., Ibaraski, M., Hatazawa, J., Miura, S. (2003). Changes in human cerebral blood flow and cerebral blood volume during hypercapnia and hypocapnia measured by positron emission tomography. Journal of cerebral blood flow & metabolism. 23. 665-670. • Jacobi, J., Birtcher, N., Krinsley, J, et al. (2012). Guidelines for the use of an insulin infusion for the management of hyperglycemia in critically ill patients. Crit care med. 40: 3251-3276. • Kiely, D., Cargill, R., Lipworth, B. (1996). Effects of hypercapnia on hemodynamic, inotropic, lucitropic, and electrophysiologic indices in humans. Chest. 109 (5): 1215-1221. • Laffey, J., Kavanagh, B. (2002). Hypocapnia. New england journal of medicine. 347 (1). 43-53.

  25. References • Mashour, G., Sharifpour, M., Freundlich, R, et al. (2013). Perioperative metoprolol and risk of stroke after noncardiac surgery. 119 (6). 1340-6. • Memtsoudis, S., Sun, S., Chiu, Y, et al. (2013). Perioperative comparative effectiveness of anesthetic technique in orthopedic patients. 118. (5). 1046-1058. • Miller, R, et al. (2010). Miller’s Anesthesia. Phillidelphia. Churchill Livingstone Elsevier. • Michenelder, J., Milde, J. (1977). Failure of prolonged hypocapnia, hypothermia, or hypertension to favorably alter acute stroke in primates. Stroke. 8: 87-91. • Miyamoto, E., Tomimoto, H., Nakao, S., Wakita, H., Akiguchi, I., Miyamoto, K., Shingu, K. (2001). Caudaputamen is damaged by hypocapnia during mechanical ventilation in a rat model of chronic cerebral hypoperfusion. Stroke. 32 (12). 2920-2925. • Mohr, L., Wolf., P., Grotta, J., et al. (2011). Stroke: Pathophysiology, Diagnosis, and Management. Philadelphia, Elsevier Saunders.

  26. References • Mortazavi, S., Kakli, H., Bican, O., Moussouttas, M., et al. (2010). Perioperative stroke after total joint arthroplasty: prevalence, predictors, and outcome. J Bone Joint Surg Am. 92 (11).: 2095-2101. • Pickkers, P., Garcha, R., Schachter, M., Smits, P., Hughes, A. (1999). Inhibition of carbonic anhydrase accounts for the direct vascular effects of hydrochlorothiazide. Hypertension. 33 (4). 1043-1048. • Poise: Devereaux P., Yang, H., Yusuf. S. et al (2008). POISE Study Group. effects of extended-release metoprolol succinate in patients undergoing non-cardiac surgery (POISE trail: a randomized controlled trial. Lancet 371 (9627): 1839-1847. • Rogovik, A., Goldman, R. (2008). Permissive hypercapnia. Emergency medical clinic of north america. 26. 941-952. • Ruta, T., Drummond, J., Cole, D. (1993). The effect of acute hypocapnia on local cerebral blood flow during middle cerebral artery occlusion in isoflurane anesthetized rats. Anesthesiology. 78 (1) : 134-140.

  27. References • Sharifpour, M., Mashour, G. (2013). Brain Attack. NeuroAnesthesia. 77 (12). 18,19,61. • Solano, M., Castillo, I., Nino de Mejia, M. (2012). Hypocapnia in Neuroanesthesia: current sitation. Rev. Colomb. Anestesiol. 40 (2). 137-144. • Stiver, S., Manley, G. (2008) Prehospital management of traumatic brain injury. Neurosurg Focus. 25 (4): Et. • Stringer, W., Hasso, A., Thompson, J. et al. (1993). Hyperventilation-induced cerebral ischemia in patients with acute brain lesions: demonstration by xenon-enhanced ct. AJNR AM J neuroradiol. 14 : 475-484. • Way, M., Hill, G. (2011). Intraoperative end-tidal carbon dioxide concentrations: What is the target? Anesthesiology research and practice. doi:10.1155/2011/271539 • Weksler, N., Klein, M. Szendro, G., et al. (2003). The dilemma of immediate preoperative hypertension: To treat and operate, or to postpone surgery? J Clin Anesthesia. 15: 179-183.

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