Perioperative and Intraoperative Emergencies

Patient Complications and Management

Understanding common surgical complications and their management is crucial for perioperative nurses.

Disseminated Intravascular Coagulation (DIC)

• What happens: An extreme inflammatory response leading to widespread clotting, followed by severe hemorrhage. The body consumes all available clotting factors, leading to uncontrolled bleeding.
• Causes:
  1. Systemic Response: Trauma (large or multiple injuries, leaving a wound open with a wound vac), sepsis, and obstetric complications (e.g., amniotic fluid embolism).
  2. Release of Procoagulants: Such as from bone tumors.
• Complications: Severe bleeding (from nose, old wounds, IV sites, surgical sites), stroke, kidney and liver damage/overload (potentially requiring dialysis), and insufficient blood flow to organs and the spinal cord (e.g., paraplegia).
• Correction/Treatment:
  • Address the underlying cause: Control bleeding, close wounds, and prevent further tissue factor release.
  • Administer FFP (Fresh Frozen Plasma) & Cryoprecipitate: To replenish clotting factors.
  • Volume/Blood Replacement: To manage hemorrhage.
  • Heparin: Can be given in early stages to prevent further clotting. Monitor serial PTTs every 1-2 hours for trends indicating shorter clot times (e.g., 37→35→32).

Air Embolism

Air embolisms are serious complications that can occur during surgery.

Common Procedures Resulting in Venous Air Embolism (VAE)

• Neurosurgery in sitting position: The pressure in the right atrium (RA) is lower than atmospheric pressure, and dural veins may not collapse, allowing air to enter the vascular system if not sealed by the surgeon.
• Hysteroscopy and TURP (Transurethral Resection of the Prostate): These procedures involve vascular, hollow organs with fluid pumped under pressure. If air is in the circuit, it can be pushed into the vascular system.
  • Hysteroscopy Risk: Also heightened by cervical tears from unsupported instruments.

Common Causes of Arterial Air Embolism (AAE)

• Cardiac bypass: (Pushing air in during the bypass process).
• Dialysis: (Similarly, pushing air in during the process).

Signs of an Air Embolism (Both Venous and Arterial)

• Rapid onset Pulmonary Edema (alveoli cannot exchange oxygen).
• Decreased CO2 (due to gas trapping/ineffective exchange).
• Decreased SpO2.
• Decreased Blood Pressure (BP).
• Potential for brain damage due to lack of oxygen.

Treatment Differences: Venous vs. Arterial Air Embolism

• Venous Air Embolism (VAE):
  • Durant’s Maneuver: Position the patient in left lateral Trendelenburg (head up slightly).
  • Aspirate air from the Right Atrium (RA) using a catheter, guided by echocardiography.
• Arterial Air Embolism (AAE):
  • Deep Trendelenburg (head DOWN) to keep air away from the cerebral circulation.
  • Aspirate air from the circuit (e.g., during cardiac bypass or dialysis).

Precautions to Prevent Venous Air Embolism

• Neurosurgery: Occlude entry points with “sloppy wet sponges” and have an irrigation syringe ready to “Irrigate → Detect → Occlude Vessel.”
• Bone Wax: Apply to open bone surfaces.
• Discontinue Nitrous Oxide: Nitrous oxide can cause small air bubbles to coalesce into larger, more dangerous bubbles.

What NOT to Use in a Venous Air Embolism

• Nitrous Oxide: Avoid, as it can enlarge small air bubbles.

Cardiac Emergencies in Surgery

Perioperative nurses must be prepared to respond to cardiac events.

Common Cause of Cardiac Arrest in Surgery

• Blood loss leading to hypovolemic shock.

RN Actions During Cardiac Arrest

1. Call for help immediately.
2. Retrieve the defibrillator.
3. Initiate documentation: Record medications (time and dose), rhythms, and CPR start/stop times.
4. Receive orders from a single designated doctor who is leading the code.

Mnemonic for Cardiac Emergencies

O.M.I.

• Oxygen
• Monitors
• IV fluids

Anticipated Steps for Inadequate HR or BP (Ventricular Rhythm Issue)

• CPR
• Defibrillator
• Epinephrine (to increase BP)
• Amiodarone (to improve myocardial contractility)

Anticipated Steps for Cardiac Emergency with Adequate HR

• Medications:
  • Epinephrine (for BP support).
  • Amiodarone (for ventricular contractility).
  • Dopamine (to support HR and BP).
• Transfer to an ICU monitored bed.
• Cardioversion: A controlled, scheduled, non-emergent procedure, usually attempted after medications.

Ventricular Fibrillation (V-Fib)

• Steps:
  1. ASSESS for a pulse.
  2. If no pulse, start CPR.
  3. Defibrillate early! (Defibrillation is for a pulseless patient).

Premature Ventricular Contractions (PVCs)

• What occurs: The ventricles initiate the heartbeat, not the SA node, leading to an ineffective beat due to lack of ventricular filling. May feel like “heart flip-flopping.” A few are usually benign, but many can lead to VTach.

Ventricular Tachycardia (V-Tac)

• What occurs: The ventricles rapidly initiate beats, often without adequate filling, resulting in no cardiac output or perfusion (may have no HR or BP).
• Monitor appearance: V-Tac appears as larger and more uniform waves than V-Fib.
• Treatment:
  1. Assess for a pulse.
  2. Start CPR.
  3. Defibrillate early.
  4. Epinephrine (for BP).
  5. Amiodarone (to help ventricular contractility).

Bigeminy

• What it is: A PVC occurring every other beat.
• Action:
  • Support BP.
  • Administer medications to break the rhythm (start a drip).
  • Consider cardioversion if medications are ineffective.

Couplet

• What it is: Two PVCs in a row. Patients can often self-correct this.

Run vs. Couplet

• A run consists of several PVCs in a row (more than two). It is considered unsustained VTach and can progress to sustained VTach, but patients may still self-correct.

Supraventricular Tachycardia (SVT)

• What occurs: Electrical impulses originate above the ventricles. The heart rate is typically >170 bpm, and the ventricles cannot fill fast enough.
• Medication to AVOID: Amiodarone, as it primarily targets ventricular arrhythmias.
• Treatment Steps:
  1. Vagal maneuvers/Valsalva: Bear down, cough, or apply ice to the carotid (in infants).
  2. Adenosine: Administer rapidly (slam and flush) and be prepared for a brief period of asystole afterward due to its very short half-life.
  3. Synchronized Cardioversion: If other measures fail.

Bradycardia (Slow Heart Rate)

• Medications:
  • Atropine: (Contraindicated in glaucoma; use Epinephrine instead).
  • Dopamine drip: To maintain pulse and BP.
• Treatment Steps:
  1. Atropine.
  2. Dopamine Drip.
  3. Pacing.

Pulseless Electrical Activity (PEA)

• What occurs: Electrical activity is present on the monitor, but the heart is not effectively pumping, resulting in no pulse.
• Treatment: Treated like asystole.
  • CPR!
  • Vasopressin.
  • Identify and address the 6 Hs and 6 Ts (common causes).

The 6 Hs and 6 Ts (Causes of PEA)

• Hs: Hypovolemia, Hypoxia, Hydrogen ions (acidosis), Hypo-/Hyperkalemia, Hypoglycemia, Hypothermia.
• Ts: Toxins (overdose), Tamponade, Tension Pneumothorax, Thrombosis (MI/PE), Tachycardia, Trauma.