MODULE 4: INTRAOPERATIVE AND POSTOPERATIVE COMPLICATIONS

Q61: Write any two complications of spinal anesthesia

Answer:Complications of Spinal Anesthesia:

1. Hypotension:

• Incidence: 10-40% of patients
• Causes: Sympathetic blockade → vasodilation
• Management:
  • IV fluid bolus (500-1000 ml crystalloid)
  • Vasopressors (ephedrine 5-10 mg IV, phenylephrine 50-100 mcg IV)
  • Trendelenburg position

2. Post-Dural Puncture Headache (PDPH):

• Incidence: 1-2% (young adults higher risk)

• Characteristics:

  • Frontal/occipital headache
  • Worsens with upright position
  • Improves with lying down
  • May have neck stiffness, tinnitus

• Management:

  • Conservative: hydration, caffeine
  • Epidural blood patch (definitive treatment)
  • Analgesics

Other Complications:

• Neurological: Nerve injury, meningitis
• Cardiac: Bradycardia, cardiac arrest
• Respiratory: Respiratory depression (high spinal)

Q62: What is IBP and Advantages of it

Answer:IBP = Intra-arterial Blood Pressure Monitoring

Definition: Continuous monitoring of arterial blood pressure through an indwelling arterial catheter.

Advantages:

1. Continuous Monitoring:

• Real-time BP measurement
• Beat-to-beat pressure changes
• Immediate detection of hemodynamic instability

2. Accurate Measurements:

• More accurate than non-invasive methods
• No cuff-related artifacts
• Precise for hypotension/hypertension

3. Frequent Blood Sampling:

• ABG analysis
• Blood glucose monitoring
• Electrolyte measurements
• Lactate levels

4. Advanced Hemodynamic Data:

• Pulse pressure variation
• Mean arterial pressure tracking
• Cardiac output calculation (with special monitors)

5. Critical Care Applications:

• Major cardiovascular surgery
• Intensive care monitoring
• Hemodynamically unstable patients

Q63: Write any 2 induction drugs and their dosage

Answer:Common Induction Drugs:

1. Propofol:

• Dose: 2-2.5 mg/kg IV
• Onset: 30-60 seconds
• Duration: 5-10 minutes
• Characteristics:
  • Rapid emergence
  • Antiemetic properties
  • Cardiovascular depression
  • Respiratory depression

2. Thiopentone:

• Dose: 3-5 mg/kg IV
• Onset: 30-60 seconds
• Duration: 5-15 minutes
• Characteristics:
  • Barbiturate
  • Cerebral protection
  • Cardiovascular depression
  • Contraindicated in porphyria

Alternative Options:

• Etomidate: 0.3 mg/kg IV (hemodynamic stability)
• Ketamine: 1-2 mg/kg IV (bronchodilation)

Q64: What is complication of bed ridden patient

Answer:Complications of Bedridden Patients:

1. Pressure Ulcers (Bedsores):

• Risk Factors: Immobility, poor nutrition, incontinence
• Prevention: Regular position changes, pressure-relieving mattresses
• Management: Wound care, pressure redistribution

2. Deep Vein Thrombosis (DVT):

• Risk: Immobility → venous stasis
• Prevention: Anticoagulation, compression devices
• Complications: Pulmonary embolism

3. Respiratory Complications:

• Atelectasis: Poor lung expansion
• Pneumonia: Reduced clearance of secretions
• Prevention: Incentive spirometry, chest physiotherapy

4. Muscle Weakness:

• Disuse atrophy: Rapid muscle loss
• Contractures: Joint stiffness
• Prevention: Passive/active range of motion exercises

5. Other Complications:

• Constipation, urinary retention
• Osteoporosis, bone demineralization
• Depression, cognitive decline

Q65: Name cardiac stable inhalational agents and their colour coding

Answer:Cardiac Stable Inhalational Agents:

1. Sevoflurane:

• Colour Coding: Yellow
• Advantages:
  • Hemodynamic stability
  • Sweet odor, non-pungent
  • Rapid induction and emergence
  • Less arrhythmogenic

2. Isoflurane:

• Colour Coding: Purple
• Advantages:
  • Cardiovascular stability
  • Bronchodilation
  • Cerebral protection
  • Lower cost

3. Desflurane:

• Colour Coding: Blue
• Advantages:
  • Very rapid emergence
  • Low solubility
  • Hemodynamic stability
  • Quick offset

Agent Properties:

• Low Arrhythmogenic Potential: All three agents
• Minimal Myocardial Depression
• Maintained Baroreceptor Reflex
• Safe in Cardiac Patients

Q66: Explain Hypertonic, Isotonic, Hypotonic

Answer:Types of IV Fluids by Osmolarity:

1. Hypertonic Solutions:

• Definition: Osmolarity > 300 mOsm/L
• Examples: 3% Saline (513 mOsm/L), 5% Saline (855 mOsm/L)
• Effect: Draws water out of cells
• Uses: Cerebral edema, severe hyponatremia
• Risks: Fluid overload, cellular dehydration

2. Isotonic Solutions:

• Definition: Osmolarity ~ 280-300 mOsm/L
• Examples:
  • Normal Saline (0.9% NaCl) - 308 mOsm/L
  • Ringer's Lactate - 276 mOsm/L
• Effect: Fluid remains in extracellular space
• Uses: Volume resuscitation, maintenance
• Advantages: Safe, well-tolerated

3. Hypotonic Solutions:

• Definition: Osmolarity < 280 mOsm/L
• Examples: 0.45% Saline (154 mOsm/L), 5% Dextrose
• Effect: Water moves into cells
• Uses: Hypernatremia, diabetic ketoacidosis
• Risks: Cellular edema, cerebral swelling

Q67: What are the complications of ETT intubation?

Answer:Complications of Endotracheal Tube (ETT) Intubation:

Immediate Complications:

1. Intubation Trauma:

   • Dental damage, lip/tongue injury
   • Laryngeal trauma, vocal cord damage
   • Esophageal intubation

2. Cardiovascular Response:

   • Hypertension, tachycardia
   • Arrhythmias
   • Increased intracranial pressure

3. Respiratory Complications:

   • Bronchospasm
   • Aspiration
   • Pneumothorax (rare)

Early Complications (0-24 hours): 4. Airway Issues:

• Tube displacement
• Obstruction (kinking, secretions)
• Cuff-related problems

5. Post-intubation Croup:
   • Especially in children
   • Stridor, respiratory distress

Late Complications (>24 hours): 6. Laryngeal Complications:

• Vocal cord paralysis
• Laryngeal stenosis
• Granuloma formation

7. Other:
   • Aspiration pneumonia
   • Sinusitis
   • Tracheal stenosis (long-term)

Q68: How to maintain the Depth of Anesthesia during surgery & What is the combination of reversal and mixture per ml?

Answer:Maintaining Depth of Anesthesia:

Monitoring Depth:

1. Clinical Signs:

   • Eye signs, pupil size
   • Reflexes, movement
   • Vital signs stability

2. Technical Monitoring:

   • BIS monitor (target 40-60)
   • Entropy monitoring
   • EEG analysis

Adjustments:

1. Inhalational Agents:

   • Adjust MAC concentration
   • Sevoflurane: 1-2 MAC for maintenance
   • Avoid deep anesthesia

2. IV Agents:

   • Propofol infusion
   • Opioid supplementation
   • Muscle relaxant adjustment

Reversal Combination:Standard Mixture for Neuromuscular Reversal:

• Neostigmine: 0.05 mg/kg
• Glycopyrrolate: 0.01 mg/kg
• Total Volume: 2-3 ml total

Per ml Calculation:

• Neostigmine: ~0.02 mg/ml (for 70 kg adult)
• Glycopyrrolate: ~0.003 mg/ml (for 70 kg adult)
• Ratio: 5:1 (Neostigmine:Glycopyrrolate)

Q69: Explain hyperbaric, hypobaric

Answer:Baricity in Spinal Anesthesia:

Hyperbaric Solutions:

• Definition: Heavier than cerebrospinal fluid (CSF)
• Density: > CSF density
• Examples:
  • 0.5% Bupivacaine with 8% glucose
  • Lidocaine 5% with dextrose

Characteristics:

• Distribution: Depends on patient positioning
• Supine position: Spreads according to gravity
• Trendelenburg: Causes higher spread
• Head-up position: Limits spread

Hypobaric Solutions:

• Definition: Lighter than CSF
• Density: < CSF density
• Examples:
  • Bupivacaine with sterile water
  • Plain local anesthetic solutions

Characteristics:

• Distribution: Rises against gravity
• Positioning: Critical for distribution
• Used for: Hip surgery, unilateral blocks

Isobaric Solutions:

• Density: Equal to CSF
• Distribution: Based on injection volume and site
• Examples: Plain bupivacaine, plain lidocaine

Q70: What are the terms for low and high potassium levels in our body?

Answer:Potassium Level Abnormalities:

Hypokalemia:

• Definition: Serum K+ < 3.5 mEq/L
• Mild: 3.0-3.5 mEq/L
• Moderate: 2.5-3.0 mEq/L
• Severe: < 2.5 mEq/L

Causes:

• Diuretic use, vomiting, diarrhea
• Cushing's syndrome, hyperaldosteronism
• Insulin therapy, alkalosis

Clinical Effects:

• Muscle weakness, fatigue
• Cardiac arrhythmias
• ECG changes (U waves, ST depression)

Hyperkalemia:

• Definition: Serum K+ > 5.0 mEq/L
• Mild: 5.1-5.9 mEq/L
• Moderate: 6.0-6.9 mEq/L
• Severe: > 7.0 mEq/L

Causes:

• Renal failure, ACE inhibitors
• Tissue breakdown, acidosis
• Potassium supplements

Clinical Effects:

• Muscle weakness, paralysis
• Cardiac arrest (severe cases)
• ECG changes (tall T waves, widened QRS)

Q71: Define anemia and its causes, management

Answer:Anemia:

Definition: Hemoglobin < 13 g/dL (men), < 12 g/dL (women)

Classification by Severity:

• Mild: Hb 10-12 g/dL (men), 10-11 g/dL (women)
• Moderate: Hb 8-10 g/dL
• Severe: Hb < 8 g/dL

Causes:

1. Decreased Production:

• Iron deficiency
• Vitamin B12/folate deficiency
• Chronic disease
• Bone marrow failure

2. Increased Loss:

• Bleeding (GI, menstrual, surgical)
• Hemolysis
• Trauma

3. Increased Destruction:

• Autoimmune hemolysis
• Sickle cell disease
• G6PD deficiency

Management:

1. Preoperative Optimization:

• Identify and treat underlying cause
• Iron supplementation (if iron deficiency)
• Vitamin B12/folate replacement
• Consider erythropoietin in chronic disease

2. Intraoperative Management:

• Minimize blood loss
• Cell salvage when appropriate
• Hemostatic agents

3. Postoperative:

• Monitor hemoglobin levels
• Iron supplementation
• Blood transfusion if indicated

Q72: Enlist the drugs used for premedication, induction, muscle relaxation

Answer:Drugs for Anesthetic Phases:

Premedication:

1. Anxiolytics:

   • Midazolam: 0.05-0.1 mg/kg IV
   • Diazepam: 0.1-0.2 mg/kg PO

2. Opioids:

   • Morphine: 0.1 mg/kg IM
   • Fentanyl: 1-2 mcg/kg IV

3. Anti-emetics:

   • Ondansetron: 0.1 mg/kg IV
   • Metoclopramide: 0.1-0.2 mg/kg IV

4. Anticholinergics:

   • Atropine: 0.01 mg/kg IV
   • Glycopyrrolate: 0.005 mg/kg IV

Induction:

1. IV Agents:

   • Propofol: 2-2.5 mg/kg IV
   • Thiopentone: 3-5 mg/kg IV
   • Etomidate: 0.3 mg/kg IV

2. Adjuncts:

   • Fentanyl: 2-5 mcg/kg IV
   • Lidocaine: 1 mg/kg IV

Muscle Relaxation:

1. Depolarizing:

   • Succinylcholine: 1-2 mg/kg IV

2. Non-depolarizing:

   • Vecuronium: 0.08-0.1 mg/kg IV
   • Atracurium: 0.5 mg/kg IV
   • Rocuronium: 0.6-1.2 mg/kg IV

Reversal:

• Neostigmine: 0.05 mg/kg IV
• Sugammadex: 2-4 mg/kg IV

Q73: Write short note on Spinal anesthesia

Answer:Spinal Anesthesia:

Definition: Injection of local anesthetic into the subarachnoid space (cerebrospinal fluid).

Mechanism: Blocks nerve conduction by acting on sodium channels in nerve roots.

Technique:

1. Position: Lateral decubitus or sitting
2. Site: L3-L4 or L4-L5 interspace
3. Needle: 25-27 gauge spinal needle
4. Local anesthetic: 1-3 ml depending on drug

Local Anesthetics:

• Bupivacaine 0.5%: Most common
• Lidocaine 5%: Short duration
• Levobupivacaine: Fewer cardiovascular effects

Advantages:

• Excellent surgical anesthesia
• Reduced blood loss
• Postoperative analgesia
• Awake patient possible
• Lower risk of aspiration

Disadvantages:

• Limited duration
• Sympathetic blockade → hypotension
• Risk of PDPH
• Cannot use for all surgeries

Contraindications:

• Patient refusal
• Coagulopathy
• Infection at injection site
• Increased intracranial pressure

Q74: What are the post op complications of GA and their management?

Answer:Postoperative Complications of General Anesthesia:

1. Nausea and Vomiting (PONV):

• Incidence: 20-30%
• Risk Factors: Female, non-smoker, opioids
• Management:
  • Prevention: Ondansetron, dexamethasone
  • Treatment: IV fluids, antiemetics

2. Airway Complications:

• Sore throat: 20-40% patients
• Hoarseness: Temporary vocal cord irritation
• Management: Rest, throat lozenges, humidified oxygen

3. Cardiovascular:

• Hypotension: Due to residual anesthetic effects
• Management: IV fluids, vasopressors if needed

4. Respiratory:

• Atelectasis: Due to anesthetic effects
• Hypoxemia: Reduced functional residual capacity
• Management: Incentive spirometry, early mobilization

5. Delayed Emergence:

• Causes: Drug effects, hypothermia, electrolyte imbalance
• Management: Supportive care, reverse if indicated

6. Cognitive Dysfunction:

• Postoperative delirium: Elderly patients
• Management: Orientation, minimize medications

Q75: Explain all the monitoring parameters used in post-op

Answer:Postoperative Monitoring Parameters:

Vital Signs:

1. Blood Pressure:

   • Monitor every 15-30 minutes initially
   • Watch for hypotension/hypertension
   • Consider continuous monitoring if unstable

2. Heart Rate and Rhythm:

   • Continuous ECG monitoring
   • Watch for arrhythmias
   • Monitor response to pain/anxiety

3. Respiratory:

   • Respiratory rate and pattern
   • SpO2 monitoring (continuous initially)
   • Capnography if intubated

4. Temperature:

   • Monitor for hypothermia
   • Risk of malignant hyperthermia
   • Active warming if needed

Neurological: 5. Level of Consciousness:

• Glasgow Coma Scale
• Response to commands
• Pupil reactions

6. Pain Assessment:
   • Numeric rating scale (0-10)
   • Visual analog scale
   • Behavioral pain scale (if intubated)

Other Parameters: 7. Urine Output:

• Foley catheter monitoring
• Target: >0.5 ml/kg/hr

8. Drain Output:

   • Chest tubes, surgical drains
   • Monitor for bleeding

9. Laboratory:

   • CBC, electrolytes
   • ABG if indicated
   • Coagulation studies

Q76: Write a note of General anesthesia Procedure and its management, complications, indications, contraindications

Answer:General Anesthesia:

Procedure:

1. Preoperative: Assessment, consent, preoxygenation
2. Induction: IV/IV agents, muscle relaxants
3. Airway Management: Intubation, ventilation
4. Maintenance: Inhalational/IV agents, muscle relaxants
5. Emergence: Reversal agents, extubation
6. Recovery: Post-anesthesia care unit

Management:

• Preoperative: Complete history, physical exam, investigations
• Intraoperative: Standard monitoring, hemodynamic stability
• Postoperative: Pain management, complication monitoring

Indications:

• Patient preference
• Surgical requirements (position, duration)
• Patient cooperation issues
• Certain surgical procedures

Contraindications:

• Relative: Severe cardiac/pulmonary disease
• Absolute: Patient refusal, inability to secure airway

Complications:

• Cardiovascular: Hypotension, arrhythmias
• Respiratory: Hypoxemia, aspiration
• Neurological: Awareness, stroke
• Other: Malignant hyperthermia, allergy

Advantages:

• Complete unconsciousness
• Muscle relaxation
• Controlled ventilation
• Hemodynamic control

Q77: How to Monitor patient and management of complications in Intraoperatively & Postoperatively

Answer:Patient Monitoring and Complication Management:

Intraoperative Monitoring:

Standard Monitoring (ASA Standards):

1. Oxygenation: Pulse oximetry, oxygen analyzer
2. Ventilation: Capnography, respiratory rate, airway pressure
3. Circulation: ECG, blood pressure (NIBP/IBP)
4. Temperature: Core temperature monitoring

Advanced Monitoring (as indicated): 5. Neuromuscular: TOF monitoring 6. Depth of Anesthesia: BIS monitor 7. Neurological: EEG, evoked potentials 8. Cardiac: TEE, PAC monitoring

Intraoperative Complication Management:

Hypotension:

• Causes: Hypovolemia, anesthesia effects, cardiac dysfunction
• Management: IV fluids, vasopressors, adjust anesthesia depth

Hypoxemia:

• Causes: Airway problems, ventilation issues, oxygen supply
• Management: Airway repositioning, increase FiO2, check equipment

Arrhythmias:

• Causes: Electrolyte imbalance, hypoxia, drug effects
• Management: Correct underlying cause, specific antiarrhythmics

Hypertension:

• Causes: Pain, light anesthesia, medications
• Management: Analgesia, deepen anesthesia, antihypertensives

Postoperative Monitoring:

Recovery Phase:

1. Airway: Monitor patency, protective reflexes
2. Breathing: Respiratory rate, SpO2, chest expansion
3. Circulation: BP, HR, ECG
4. Neurological: Consciousness, movement, pain

Complication Management:

Respiratory Depression:

• Causes: Opioids, residual muscle relaxants
• Management: Naloxone, neostigmine, supportive ventilation

Nausea and Vomiting:

• Causes: Opioids, anesthetic agents
• Management: Antiemetics, IV fluids, positioning

Pain:

• Causes: Surgical trauma, positioning
• Management: Analgesics, regional techniques

Hemodynamic Instability:

• Causes: Fluid loss, cardiac dysfunction
• Management: Fluid resuscitation, inotropes

Delayed Emergence:

• Causes: Drug effects, hypothermia, metabolic
• Management: Time, warming, reverse if indicated

Monitoring Frequency:

• Immediate post-op: Every 15 minutes
• Stable patient: Every 30 minutes
• High-risk: Continuous monitoring

Discharge Criteria (PACU):

• Stable vital signs
• Alert and oriented
• Adequate pain control
• Minimal nausea/vomiting
• Stable surgical site