Intraoperative bronchospasm
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Transcript of Intraoperative bronchospasm
BRONCHOSPASM DURING INDUCTION
WHAT SHALL I DO..?
PRAY GOD THAT THIS SITUATION DOESN’T ARISE….
IN WHICH PATIENTS IT CAN OCCUR..?
BRONCHIAL ASTHMA
COPD
URI – esp IN CHILDREN
SMOKERS
Non allergic etiology – 79%Allergic cause - 21%
IN WHICH SITUATIONS IT CAN OCCUR…?
UNDER PREPARED PATIENTS WITH WHEEZING
GASTRIC ASPIRATION
LIGHTER PLANE – PREMATURE ATTEMPT
ANAPHYLAXIS
HOW TO DIAGNOSE….?
TIGHT BAG
FALLING OXYGEN SATURATION
FALLING EtCO2 LEVEL
NORMAL/REDUCED/NO CHEST MOVEMENT
WHEEZE / NO BREATH SOUNDS
HOW TO DIAGNOSE..?
COVER - WESTHORPE
C1 – COLOUR, CUTANEOUS MANIFESTATION FOR ALLERGYC2 – CAPNOGRAPHYO1 – LOW SpO2, CHECK ROTA METER,O2 SOURCEV1 - VENTILATION BY HAND, OBSERVE COMPLIANCE AND AUSCULTATEV2- CHECK VAPORISER FOR FLUID LEVEL, GAS LEAKSE1 – CHECK E.T.TE2 – EQUIPMENT RELATED CAUSESR1 – REVIEW ALL MONITORS
WHY BRONCHOSPASM IS FEARED..?
The narrowing of airway is so much that air entry sometimes become impossible….
1.Rapid de-saturation2.Increasing airway resistance3.Worsening lung compliance4.Decreased venous return5.Falling cardiac output6.Severe hypotension and collapse
WHAT SHOULD BE DONE..?
ASSESS THE SITUATION
ASSESSING THE SITUATION:ELECTIVE SURGERY:
MILD SPASM SEVERE SPASM
TREAT & PROCEEDTREAT AND POSTPONE THE SURGERY
CONSIDER EXTUBATION
EMERGENCY SURGERY
MILD SPASM SEVERE SPASM
TREAT AND PROCEEDWITH THE SURGERY
ASSESSING THE SITUATION:
HOW TO TREAT…?100% OXYGEN – Switch to Bain circuit
INHALED β2 AGONIST –Salbutamol Nebulizer, metered dose inhaler5 mg ( 5ml of 0.5%) or 8 to 10 puffs
INTRAVENOUS DRUGS – ETOPHYLLINE?AMINOPHYLLINE
STEROIDSMethyl prednisolone ( 1 mg / kg)
NEBULISED IPRATROPIUM 0.5 mg in 5 ml
How to attach the nebuliser to the Breathing circuit….?
A simple way of attaching the nebulizer circuit if T adaptor is not available….
TREATMENT – contd….
Whether to deepen the anaesthesia withinhalational agent or lighten the patient..?
STABLE HAEMODYNAMICS:
Give Halothane/isoflurane/sevoflurane
If spasm is severe- go for intravenous anaestheticsketamine/propofol
TREATMENT – contd…
TREATMENT – contd….
ROLE OF ADJUVANTS:
oKETAMINE – 10 -20 mg bolus , 1to 3mg/kg/hour
oMAGNESIUM – 50 mg/kg to a maximum of 2G
oXYLOCARD – 100mg bolus
o? ADRENALINE – useful in anaphylaxis
Consider extubation in resistant cases as a treatment modality….
HOW TO PREVENT SPASM DURING INDUCTION..?
NO ELECTIVE SURGERY IN A PATIENT WITH WHEEZE
ADEQUATE PREPARATION
STOP SMOKING
IF POSSIBLE – SELECT REGIONAL ANAESTHESIA
ROLE OF STEROIDS
44% of bronchospasm incidence occur during intubation – Westhorpe et al
HOW TO PREVENT SPASM DURING INDUCTION..?GIVE A GOOD PRE-MEDICATIONALWAYS USE ATROPINE/GLYCOPYROLATEANXIOLYTICS IN THE WARD OXYGEN SUPPLEMENTATIONINDUCTION- SMOOTH BY USING LIBERAL DOSESWITCH ON INHALATIONAL AGENT FROM THE BEGINNINGUSE XYLOCARD?XYLOCAINE SPRAYPROPOFOL or KETAMINE INDUCTION
HOW TO PREVENT SPASM DURING MAINTENANCE…?
REGIONAL ANAESTHESIA WITH G.A
CONSIDER SIMPLE NERVE BLOCKS
WOUND INFILTRATION
ADEQUATE ANALGESIA
36% bronchospasm incidence occur during maintenance phase - Westhorpe
HOW TO PREVENT SPASM DURING EXTUBATION..?
Tricky situationIf the type of surgery permits,
deeper plane of extubationXylocard, low dose ketamineGood post-operative analgesia and
oxygenation
The rest of 20% of cases occur during this phase of anaesthesia
Summary:Bronchospasm during induction can occur because of 2 reasons
1.Non-allergic airway hyperreactivity 2.As a part of anaphylactic syndrome
Needs urgent intervention as the vitals will deteriorate rapidly
A systematic approach helps in the early diagnosis
Inhalational β2 agonists is the mainstay of treatment
Summary..:
In resistant cases, adjuvants like ipratropium, magnesium have a role to play
As lighter plane of anaesthesia triggers spasm, patient has to be in deeper plane
Inhalational agents like halothane,sevoflurane possess broncho-dilating property
Adequate preparation, good analgesia and depth of anaesthesia help in avoiding this situation
Concluding…..
Prevention is better than cure
Thank you
dr.r.selvakumarprofessor of anaesthesiologyk.a.p.viswanatham govt medical collegetrichy