ANESTHESIOLOGY FAST REVIEW

ANESTHESIOLOGY_FAST_REVIEWKAPAK1-0-25

INTRAOPERATIVE PROBLEMS AND TREATMENT MODELS

Bilal Atilla Bezen

Afyonkarahisar Health Science University, Faculty of Medicine, Department of Anesthesiology, Afyonkarahisar, Türkiye

Bezen BA. Intraoperative Problems and Treatment Models. In: Kazancı D, editor. Anesthesiology Fast Review. 1st ed. Ankara: Türkiye Klinikleri; 2025. p.467-479.

ABSTRACT

  • The intraoperative period is the phase in which the patient is exposed to factors such as anesthesia and surgery, which affect many systems.
  • Common intraoperative complications include problems involving the respiratory system and cardiovascular system.
  • Problems originating from the respiratory system include hypoxemia, hypercarbia, and hypocarbia. Hypoxemia, defined as peripheral oxygen saturation below 90%, can be a serious clinical indicator requiring intervention. Hypercarbia occurs due to increased CO2 production or decreased CO2 excretion, while ventilatory inadequacies.
  • Hypotension, defined as mean arterial pressure below 65 mmHg or a decrease in systolic blood pressure exceeding 20% of baseline, can lead to end-organ damage and death.
  • Intraoperative hypertension may be due to the presence of essential hypertension, pain, hypercarbia, and hypoxia.
  • Arrhythmias influenced by patient and surgical factors are common during anesthesia. Bradycardic and tachycardic patients require close intraoperative monitoring. Intraoperative cardiac arrest is often associated with high-risk surgery or comorbidities. It should be recognized early in the intraoperative period and intervention should be initiated.
  • Transfusion-related complications are another cause of intraoperative problems that can lead to haemodynamic instability and require careful monitoring for timely intervention.
  • Perioperative anaphylactic reactions can result from exposure to blood transfusions, anesthetics, antibiotics or latex and may present with hypotension, bronchospasm or rash. Treatment includes adrenaline, intravenous fluids, vasopressors, steroids and antihistamines.
  • Malignant hyperthermia, a genetic disorder triggered by certain anesthetic agents, disrupts calcium homeostasis in skeletal muscles, causing hypermetabolism. Despite its rarity, prompt diagnosis and intervention are necessary to prevent fatal outcomes.
  • Anesthesiologists can improve survival in the perioperative period through early recognition and management of intraoperative problems.

Keywords: Intraoperative period; Hypoxia; Hypotension; Hypertension; Arrhythmias; Cardiac; Blood transfusion; Anaphylaxis; Malignant hyperthermia

Referanslar

  1. Berhanu M, Dadi N, Mengistu B, Muluken Z, Tolesa A, Tageza T, et al. Magnitude of early postoperative hypoxemia and its associated factors among adult patients who undergo emergency surgery under general anesthesia at Jimma Medical Center, Jimma, Southwest Ethiopia, 2021: a prospective observational study. Perioperative Medicine. 2023;12(1):1. [Crossref]  [PubMed]  [PMC]
  2. Ehrenfeld JM, Funk LM, Van Schalkwyk J, Merry AF, Sandberg WS, Gawande A. The incidence of hypoxemia during surgery: evidence from two institutions. Canadian Journal of Anesthesia/Journal canadien d'anesthésie. 2010;57(10):888-97. [Crossref]  [PubMed]  [PMC]
  3. de Graaff JC, Bijker JB, Kappen TH, van Wolfswinkel L, Zuithoff NPA, Kalkman CJ. Incidence of Intraoperative Hypoxemia in Children in Relation to Age. Anesth Analg. 2013;117(1):169-75. [Crossref]  [PubMed]
  4. Dillon FX. Common Intraoperative Problems. In: Anesthesia Student Survival Guide. Springer New York; 2010:243-262. [Crossref]
  5. Palermo J, Tingey S, Khanna AK, Segal S. Evaluation and Prevention of Perioperative Respiratory Failure. J Clin Med. 2024;13(17):5083. [Crossref]  [PubMed]  [PMC]
  6. Hans GA, Sottiaux TM, Lamy ML, Joris JL. Ventilatory management during routine general anaesthesia. Eur J Anaesthesiol. 2009;26(1):1-8. [Crossref]  [PubMed]
  7. Couture EJ, Provencher S, Somma J, Lellouche F, Marceau S, Bussières JS. Effect of position and positive pressure ventilation on functional residual capacity in morbidly obese patients: a randomized trial. Canadian Journal of Anesthesia/ Journal canadien d'anesthésie. 2018;65(5):522-8. [Crossref]  [PubMed]
  8. Katz S, Arish N, Rokach A, Zaltzman Y, Marcus EL. The effect of body position on pulmonary function: a systematic review. BMC Pulm Med. 2018;18(1):159. [Crossref]  [PubMed]  [PMC]
  9. Narani KK. Deep vein thrombosis and pulmonary embolism - Prevention, management, and anaesthetic considerations. Indian J Anaesth. 2010;54(1):8. [Crossref]  [PubMed]  [PMC]
  10. Nandhakumar A, Jayabalan S, Subramaniyan N. Reversible cause of intra operative hypoxia in an aspirated patient. Indian J Anaesth. 2015;59(6):382. [Crossref]  [PubMed]  [PMC]
  11. Dunn JO, Mythen M, Grocott M. Physiology of oxygen transport. BJA Educ. 2016;16(10):341-8. [Crossref]
  12. Cortazzo JA, Lichtman AD. Methemoglobinemia: A Review and Recommendations for Management. J Cardiothorac Vasc Anesth. 2014;28(4):1043-7. [Crossref]  [PubMed]
  13. Gutta R, Louis PJ. Methemoglobinemia-an unusual cause of intraoperative hypoxia. Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontology. 2007;103(2):197-202. [Crossref]  [PubMed]
  14. Ford GT, Whitelaw WA, Rosenal TW, Cruse PJ, Guenter CA. Diaphragm Function after Upper Abdominal Surgery in Humans. American Review of Respiratory Disease. 1983;127(4):431-6. [Crossref]  [PubMed]
  15. Campos JH, Feider A. Hypoxia During One-Lung Ventilation-A Review and Update. J Cardiothorac Vasc Anesth. 2018;32(5):2330-8. [Crossref]  [PubMed]
  16. Shum S, Huang A, Slinger P. Hypoxaemia during one lung ventilation. BJA Educ. 2023;23(9):328-36. [Crossref]  [PubMed]  [PMC]
  17. Lumb A, Biercamp C. Chronic obstructive pulmonary disease and anaesthesia. Continuing Education in Anaesthesia Critical Care & Pain. 2014;14(1):1-5. [Crossref]
  18. Nonaka DF, Grichnik KP, Whitener GB. Pulmonary Hypertension and Thoracic Surgery: Diagnostics and Advances in Therapy and Intraoperative Management. Curr Anesthesiol Rep. 2014;4(2):135-41. [Crossref]
  19. Nolan JP. Severe hypoxia in theatre. In: Freedman R, Herbert L, O'Donnell A, Ross N, Wilson IH, Allman KG, eds. Oxford Handbook of Anaesthesia. 5th Edition. Oxford University Press; 2022. P.1070-72. [Crossref]
  20. Lundberg SM, Nair B, Vavilala MS, Horibe M, Eisses MJ, Adams T, et al. Explainable machine-learning predictions for the prevention of hypoxaemia during surgery. Nat Biomed Eng. 2018;2(10):749-60. [Crossref]  [PubMed]  [PMC]
  21. Dony P, Dramaix M, Boogaerts JG. Hypocapnia measured by end-tidal carbon dioxide tension during anesthesia is associated with increased 30-day mortality rate. J Clin Anesth. 2017;36:123-6. [Crossref]  [PubMed]
  22. Atkinson TM, Giraud GD, Togioka BM, Jones DB, Cigarroa JE. Cardiovascular and Ventilatory Consequences of Laparoscopic Surgery. Circulation. 2017;135(7):700-10. [Crossref]  [PubMed]
  23. Saugel B, Fletcher N, Gan TJ, Grocott MPW, Myles PS, Sessler DI, et al. PeriOperative Quality Initiative (POQI) international consensus statement on perioperative arterial pressure management. Br J Anaesth. 2024;133(2):264-76. [Crossref]  [PubMed]  [PMC]
  24. Saasouh W, Manafi N, Manzoor A, McKelvey G. Mitigating Intraoperative Hypotension. Adv Anesth. 2024;42(1):67-84. [Crossref]  [PubMed]
  25. Robinson BJ, Ebert TJ, O'Brien TJ, Colinco MD, Muzi M. Mechanisms whereby Propofol Mediates Peripheral Vasolidation in Humans. Anesthesiology. 1997;86(1):64-72. [Crossref]  [PubMed]
  26. Lonjaret L, Lairez O, Geeraerts T, Minville V. Optimal perioperative management of arterial blood pressure. Integr Blood Press Control. Published online September 2014:49. [Crossref]  [PubMed]  [PMC]
  27. Navas-Blanco JR, Louro J, Reynolds J, Epstein RH, Dudaryk R. Intraoperative Focused Cardiac Ultrasound for Assessment of Hypotension: A Systematic Review. Anesth Analg. 2021;133(4):852-9. [Crossref]  [PubMed]
  28. Fasting S, Gisvold SE. Serious intraoperative problems - a five-year review of 83,844 anesthetics. Canadian Journal of Anesthesia/Journal canadien d'anesthésie. 2002;49(6):545-53. [Crossref]  [PubMed]
  29. Sessler DI, Bloomstone JA, Aronson S, Berry C, Gan TJ, Kellum JA, et al. Perioperative Quality Initiative consensus statement on intraoperative blood pressure, risk and outcomes for elective surgery. Br J Anaesth. 2019;122(5):563-74. [Crossref]  [PubMed]
  30. Paix AD, Runciman WB, Horan BF, Chapman MJ, Currie M. Crisis management during anaesthesia: hypertension. Qual Saf Health Care. 2005;14(3):e12-e12. [Crossref]  [PubMed]  [PMC]
  31. Ghoneim MM, Block RI, Haffarnan M, Mathews MJ. Awareness During Anesthesia: Risk Factors, Causes and Sequelae: A Review of Reported Cases in the Literature. Anesth Analg. 2009;108(2):527-35. [Crossref]  [PubMed]
  32. Aronow WS. Management of hypertension in patients undergoing surgery. Ann Transl Med. 2017;5(10):227. [Crossref]  [PubMed]  [PMC]
  33. Varon J, Marik PE. Perioperative hypertension management. Vasc Health Risk Manag. 2008;Volume 4:615-27. [Crossref]  [PubMed]  [PMC]
  34. Tobias J. Treatment of perioperative hypertension: Is clevidipine the answer? Saudi J Anaesth. 2009;3(2):45. [Crossref]  [PubMed]  [PMC]
  35. Tural E, Özsarı L. Perioperative blood pressure control in pheochromocytoma: The role of intravenous urapidil. Endocrinology Research and Practise. 2024;28(2):133-6. [Link]
  36. Sert B, Yargı M, Özdemir M, Erbatur M, Karaaslan T, Uzundere O. Acute and Resistant İntraoperative Hypertension during Mitral Valve Replacement: A Case Presentation. Med Res Arch. 2024;12(2). [Crossref]
  37. Hanada S, Kawakami H, Goto T, Morita S. Hypertension and anesthesia. Curr Opin Anaesthesiol. 2006;19(3):315-9. [Crossref]  [PubMed]
  38. Kwon CH, Kim SH. Intraoperative management of critical arrhythmia. Korean J Anesthesiol. 2017;70(2):120. [Crossref]  [PubMed]  [PMC]
  39. Feeley TW. Management of perioperative arrhythmias. J Cardiothorac Vasc Anesth. 1997;11(2):10-5. [Crossref]  [PubMed]
  40. Dua N, Kumra VP. Management of perioperative arrhythmias. Indian J Anaesth. 2007;51(4):310-23. [Link]
  41. Altınbaş A, Taş N, Bektaş O. Perioperative arrhythmias. Middle Black Sea Journal of Health Science. Published online December 28, 2017:41-8. [Crossref]
  42. Deshmukh S, Pahuja H, Palsodkar S, Jagtap R. Persistent intraoperative sinus tachycardia: threat of thyroid storm? A case report. Int J Res Med Sci. 2014;2(3):1168. [Crossref]
  43. Parida S, Thangaswamy C. Cardiac tachyarrhythmias and anaesthesia: General principles and focus on atrial fibrillation. Indian J Anaesth. 2017;61(9):712. [Crossref]  [PubMed]  [PMC]
  44. Stewart AM, Greaves K, Bromilow J. Supraventricular tachyarrhythmias and their management in the perioperative period. Continuing Education in Anaesthesia Critical Care & Pain. 2015;15(2):90-7. [Crossref]
  45. Gabrielli A, Gallagher TJ, Caruso LJ, Bennett NT, Layon AJ. Diltiazem to treat sinus tachycardia in critically ill patients: A four-year experience. Crit Care Med. 2001;29(10):1874-9. [Crossref]  [PubMed]
  46. Demiri M, Antunes T, Fletcher D, Martinez V. Perioperative adverse events attributed to α2-adrenoceptor agonists in patients not at risk of cardiovascular events: systematic review and meta-analysis. Br J Anaesth. 2019;123(6):795-807. [Crossref]  [PubMed]
  47. Ben-Jacob TK, Pasch S, Patel AD, Mueller D. Intraoperative cardiac arrest management. Int Anesthesiol Clin. Published online August 17, 2023. [Crossref]  [PubMed]
  48. Jian-xiong AN, Zhang LM, Sullivan EA, Qu-lian GUO, Williams JP. Intraoperative cardiac arrest during anesthesia: a retrospective study of 218 274 anesthetics undergoing non-cardiac surgery in a US teaching hospital. Chin Med J (Engl). 2011;124(2):227-32. [Crossref]
  49. Constant AL, Montlahuc C, Grimaldi D, Pichon N, Mongardon N, Bordenave L, et al. Predictors of Functional Outcome after Intraoperative Cardiac Arrest. Anesthesiology. 2014;121(3):482-491. [Crossref]  [PubMed]
  50. Hinkelbein J, Andres J, Böttiger BW, Brazzi L, De Robertis E, Einav S, et al. Cardiac arrest in the perioperative period: a consensus guideline for identification, treatment, and prevention from the European Society of Anaesthesiology and Intensive Care and the European Society for Trauma and Emergency Surgery. European Journal of Trauma and Emergency Surgery. 2023;49(5):2031-46. [Crossref]  [PubMed]  [PMC]
  51. Öztürk F, Parlak I, Yolcu S, Tomruk O, Erdur B, Kılıçaslan R, et al. Effect of End-Tidal Carbon Dioxide Measurement on Resuscitation Efficiency and Termination of Resuscitation. Turk J Emerg Med. 2014;14(1):25-31. [Crossref]  [PubMed]  [PMC]
  52. Lott C, Truhlář A, Alfonzo A, Barelli A, González-Salvado V, Hinkelbein J, et al. European Resuscitation CouncilGuidelines 2021: Cardiac arrest in special circumstances. Resuscitation. 2021;161:152-219. [Crossref]  [PubMed]
  53. Sahu S, Hemlata, Verma A. Adverse events related to blood transfusion. Indian J Anaesth. 2014;58(5):543. [Crossref]  [PubMed]  [PMC]
  54. Baker L, Park L, Gilbert R, Ahn H, Martel A, Lenet T, et al. Intraoperative Red Blood Cell Transfusion Decision-making. Ann Surg. 2021;274(1):86-96. [Crossref]  [PubMed]
  55. Koo BN, Kwon MA, Kim SH, Kim JY, Moon YJ, Park SY, et al. Korean clinical practice guideline for perioperative red blood cell transfusion from Korean Society of Anesthesiologists. Korean J Anesthesiol. 2019;72(2):91-118. [Crossref]  [PubMed]  [PMC]
  56. Tinegate H, Birchall J, Gray A, Haggas R, Massey E, Norfolk D, et al. Guideline on the investigation and management of acute transfusion reactions Prepared by the Prepared by the BCSH Blood Transfusion Task Force. Br J Haematol. 2012;159(2):143-53. [Crossref]  [PubMed]
  57. Strobel E. Hemolytic Transfusion Reactions. Transfusion Medicine and Hemotherapy. 2008;35(5):346-53. [Crossref]  [PubMed]  [PMC]
  58. Cohen R, Escorcia A, Tasmin F, Lima A, Lin Y, Lieberman L, et al. Feeling the burn: the significant burden of febrile nonhemolytic transfusion reactions. Transfusion (Paris). 2017;57(7):1674-83. [Crossref]  [PubMed]
  59. Clifford L, Jia Q, Subramanian A, Yadav H, Schroeder DR, Kor DJ. Risk Factors and Clinical Outcomes Associated with Perioperative Transfusion-associated Circulatory Overload. Anesthesiology. 2017;126(3):409-18. [Crossref]  [PubMed]  [PMC]
  60. Volcheck GW, Hepner DL. Identification and Management of Perioperative Anaphylaxis. J Allergy Clin Immunol Pract. 2019;7(7):2134-42. [Crossref]  [PubMed]
  61. Banerji A, Bhattacharya G, Huebner E, Fu X, Camargo CA, Guyer A, et al. Perioperative Allergic Reactions: Allergy Assessment and Subsequent Anesthesia. J Allergy Clin Immunol Pract. 2021;9(5):1980-91. [Crossref]  [PubMed]
  62. Takazawa T, Yamaura K, Hara T, Yorozu T, Mitsuhata H, Morimatsu H. Practical guidelines for the response to perioperative anaphylaxis. J Anesth. 2021;35(6):778-93. [Crossref]  [PubMed]
  63. Amano Y, Fujii T, Tamura T, Hirai T, Nishiwaki K. Timing of onset of intraoperative transfusion anaphylaxis: a literature review. Nagoya J Med Sci. 2024;86(3):351-60. [Crossref]
  64. Kroigaard M, Garvey LH, Gillberg L, Johansson SGO, Mosbech H, Florvaag E, et al. Scandinavian Clinical Practice Guidelines on the diagnosis, management and follow-up of anaphylaxis during anaesthesia. Acta Anaesthesiol Scand. 2007;51(6):655-70. [Crossref]  [PubMed]
  65. Gupta PK, Bilmen JG, Hopkins PM. Anaesthetic management of a known or suspected malignant hyperthermia susceptible patient. BJA Educ. 2021;21(6):218-24. [Crossref]  [PubMed]  [PMC]
  66. Schneiderbanger D, Johannsen S, Roewer N, Schuster, F. Management of malignant hyperthermia: diagnosis and treatment. Ther Clin Risk Manag. Published online May 2014:355. [Crossref]  [PubMed]  [PMC]
  67. Gong X. Malignant hyperthermia when dantrolene is not readily available. BMC Anesthesiol. 2021;21(1):119. [Crossref]  [PubMed]  [PMC]
  68. Hopkins PM, Girard T, Dalay S, Jenkins B, Thacker A, Patteril M, et al. Malignant hyperthermia 2020. Anaesthesia. 2021;76(5):655-64. [Crossref]  [PubMed]