We’ve been learning a lot from Kimberly Zweygardt, CRNA. This is the fourth post in a five part series. You can find Part I, Part II, and Part III by following the links. Kim is filling us in on great ways to add conflict to your operating room scenes by covering some complications.
Welcome back, Kim.
Anesthesia is sometimes defined as a controlled emergency. Here are some complications that would create great tension for our characters.
The number one cause of death related to anesthesia is also the most preventable: aspiration pneumonia. When someone eats or drinks 8 hours before surgery then are anesthetized, the vomitting/gag reflex is lost and anything in the stomach flows into the trachea and lungs causing pneumonia. If the patient isn’t NPO 8 hours, surgery may be delayed or canceled. However, if they ate lunch then fell out of a tree, surgery can’t be delayed. Drugs are given while pressure is put on the esophogus and the breathing tube gotten in as quickly as possible to prevent aspiration(called RSI or Rapid Sequence Induction).
During the pre-op interview, we ask about family complications with anesthesia. Two major complications with anesthesia are genetic.
The first is a genetic defiency of an enzyme (psuedocholinesterase) that metabolizes the muscle relaxant, Anectine (also called Succinylcholine or nicknamed “Sux”). Instead of being metabolized in10 minutes, the drug effect lasts hours with the patient on a ventilator until it wears off(2 hours to 8 hours). It is not life threatening except for being unable to breathe! In other words, the deficiency is easily diagnosed and the patient (and family) is instructed to avoid the drug. There are other drugs that are longer acting and reversible with medications that can be substituted in the future.
The other complication is also genetic but is life threatening. Certain anesthetic agents trigger a hypermetabolic state called malignant hyperthermia (MH). Though called hyperthermia, the increased body temperature is a late symptom. If the patient’s temp is rising before you diagnose it, it is too late.
The first alert is when the muscle relaxant causes the jaw muscles to tighten instead of relax. At that point, I am on hyper alert, looking for other symptoms such as increased heart rate (also a sign of an anxious patient or a light anesthetic), arrhythmia’s (premature heart beats called PVC’s) and a rising CO2 (carbon dioxide) level despite adequate ventilation. The urine becomes dark brown as the body breaks down muscles and calcium and potassium are released into the blood stream. This is every anesthesia provider’s nightmare.
Every OR has a poster describing MH treatment and the phone number to MHAUS, an organization dedicated to education and treatment of MH. If MH is suspected, someone calls the hotline to get an expert on the phone. With proper treatment, mortality ranges from 5% in some literature to 20% in other. At one time, MH was 95% fatal. The key is early recognition and treatment. Delaying treatment while trying to figure out if it is MH or not accounts for higher mortality.
Treatment involves turning off all anesthetic agents and ventilating the patient with 100% O2. Surgery is stopped and the surgeon “closes” or sutures the incision shut. All new hoses and the CO2 absorber is changed on the anesthesia machine. Dantrolene, a powdered drug to reverse MH, is mixed with 60 cc of sterile water and given. Dantrolene is difficult to mix and a dose is up to 36 vials so one of the first things done after diagnosis is to get plenty of help to do nothing but mix drug.
All the treatment is too extensive to go into here, but if interested, check out www.MHAUS.org.
***Content originally posted February 4, 2011.***
Kimberly Zweygardt is a Christ follower, wife, mother, writer, blogger, dramatist, worship leader, Certified Registered Nurse Anesthetist, a fused glass artist and a taker of naps. Her writings have been featured in Rural Roads Magazine, The Rocking Chair Reader, and Chicken Soup for the Soul Healthy Living Series on Heart Disease. She is the author of Stories From the Well and Ashes to Beauty, The Real Cinderella Story and was featured in Stories of Remarkable Women of Faith. She lives in Northwest Kansas with her husband where their nest is empty but their lives are full. For more information: www.kimzweygardt.com