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Anesthesiology:
doi: 10.1097/ALN.0b013e318280a62d
Reviews of Educational Material

Anaesthetic and Perioperative Complications

Glassenberg, Raymond M.D.

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Anesthesia, like most fields of medicine, has now become evidence based. Protocols are established for management of scenarios ranging from conscious sedation to cardiac arrest. The chapters of the Clinical Aspects of Complications section of Anaesthetic and Perioperative Complications begin with the ABCs of anesthesia: airway, breathing (respiration), and circulation. They are organized in the format of prevention, recognition, and management of anesthetic-related complications. Checklists are included in several chapters, but are sorely missed in others.
The chapter devoted to airway complications lists the Difficult Airway Society algorithm for managing unanticipated difficult intubation. It wisely includes the point of not making more than three attempts at rigid laryngoscopy and the need to use an alternative laryngoscope (either video or fiberoptic through a laryngeal mask airway). The chapter includes the caveat from the American Society of Anesthesiologists closed claims studies showing that fatal complications can occur after oversedation during attempts at awake intubation. In the presence of a compromised airway, less sedation and more cooperation are better than obtundation and airway obstruction.
The sections on cardiovascular complications include a table on the differential diagnosis of intraoperative hypotension and an excellent table covering perioperative pharmacological cardiac protection. It would have been useful to have included a forest plot of the efficacy of the various therapies of antiplatelet, antithrombin, β blockers, and statins in preventing perioperative myocardial ischemia.
The obstetric anesthetic chapter makes the recommendation that the conversion rate of regional to general anesthesia should be less than 3%. This is a laudable goal, considering that the National Audit Project (NAP4) found that two out of four failed intubations for cesarean section occurred in association with failed regional anesthesia. The paragraph on providing adequate doses of local anesthetic states that fentanyl 10 mg given intrathecally needs to be corrected to 10 mcg. This chapter lacks a section on the prevention and management of postpartum hemorrhage, now a major cause of maternal mortality.
The chapter devoted to perioperative neurological complications presents several current controversies in the realm of whether more monitoring can prevent complications. Logically, one would suspect that operative spinal cord injury should be reduced by monitoring somatosensory evoked potentials, motor-evoked potentials, and electromyography, but this information is not referenced.
The B-Aware and B-Unaware trials failed to show that awareness occurs more often with solely monitoring end-tidal concentrations of volatile anesthetics compared with the bispectral index monitor. However, many anesthetics are delivered as total intravenous agents, with propofol providing amnesia and remifentanil supplying the analgesia, so there is no vapor level to measure, thus making the bispectral index an essential monitor of anesthetic depth.
A good part of the regional anesthesia complications chapter is devoted to vertebral canal hematomas after epidural placement. A table listing drugs acting on the coagulation cascade and their half-lives should have been provided. Instead, a figure, labeled management of leg weakness following epidural anesthesia, lists pager numbers of the acute pain team at Derriford Hospital, Plymouth, England. However, the table devoted to management of local anesthetic toxicity is well annotated.
The drug reaction chapter clearly states that two thirds of allergic anaphylactic reactions in anesthesia are due to succinylcholine and rocuronium. Serum tryptase levels should be measured to confirm an immunoglobulin E–mediated reaction.
The last portion of the book discusses the legal ramifications of anesthetic mishaps. The case of Mrs. Elaine Bromiley, the 37-yr-old wife of an airline pilot, is presented. As the result of a “can’t intubate, can’t ventilate” situation, multiple attempts at intubation were made, rather than an emergency cricothyroidotomy. Despite all the algorithms and training, perhaps our basic equipment needs updating to the 21st century. Would this complication have been avoided if the initial attempt at intubation was with a video laryngoscope or an inexpensive disposable video bronchoscope?
With the advent of electronic medical records, it will be possible to monitor performance of individual anesthesiologists, especially when complications occur. This book outlines potential pitfalls. We would be wise to read it carefully and incorporate its lessons into our daily practice.

© 2013 American Society of Anesthesiologists, Inc.

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