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Gangguan Akibat

Anestesia
Muhammad Gusno Rekozar, dr. SpAn
Fakultas Kedokteran Universitas
Batam
20015

Anaesthesia is from the Greek and


means 'loss of sensation'.
Anaesthesia allows invasive and
painful procedures to be performed
with little distress to the patient.

There are three main types of


anaesthesia

General anaesthesia: the patient is


sedated, using either intravenous
medications or gaseous substances,
and occasionally muscles paralysed,
requiring control of breathing by
mechanical ventilation
.

Regional anaesthesia: this can be described


as central where anaesthetic drugs are
administered directly in or around the spinal
cord, blocking the nerves of the spinal cord
(eg, epidural or spinal anaesthesia). The main
benefit of this method is that ventilation is not
needed (provided the block is not too high).
Regional anaesthesia can also be peripheral for example:

Plexus blocks - eg, brachial plexus.

Nerve blocks - eg, femoral.

Intravenous blocks whilst preventing


venous flow out of the region - eg, Bier's block.

Local anaesthesia: the anaesthetic is


applied to one site, usually topically
or subcutaneously

Important complications of general


anaesthesia
The practice of anaesthesia is
fundamental to the practice of medicine.
However, anaesthesia is not without its
problems. It is difficult to determine
exactly the incidence of deaths directly
attributable to general anaesthetics, as
the cause of death is often multifactorial
and study methodology varies making
comparisons difficult.

Estimates of the number of deaths where


general anaesthesia was the direct cause
have been quoted in the range from
1:10,000 operations to 1:1700 (study in
1982 by the Association of Anaesthetists
of Great Britain and Ireland). Nonetheless,
in 1987 a confidential enquiry into
perioperative deaths revealed that very
few deaths were actually as a direct result
of general anaesthesia - incidence of 1 in
185,086 (first Confidential Enquiry into
Perioperative Deaths (CEPOD)).[1]

Figures of anaesthetic-related morbidity are more


difficult to determine. Estimates suggest that up
to 2% of intensive care unit admissions at any one
time are related to anaesthetic problems.[1]
Although general anaesthesia is not without risk,
it should be remembered that it allows necessary
procedures to be performed in a humane way without which the patient might otherwise die.
Along these lines, if a patient is high-risk for a
general anaesthetic (eg, pre-existing
comorbidities) then they should still be referred
for surgery like any other patient. The decision to
operate and which form of anaesthesia to use
should then be decisions made by the surgeon
and anaesthetist.

Important complications of general anaesthesia

Pain.
Nausea and vomiting - up to 30% of patients.
Damage to teeth - 1 in 4,500 cases.
Sore throat and laryngeal damage.
Anaphylaxis to anaesthetic agents - figures
such as 0.2% have been quoted.

Cardiovascular collapse.

Respiratory depression.

Aspiration pneumonitis - up to 4.5% frequency


has been reported; higher in children.

Hypothermia.

Hypoxic brain damage.

Nerve injury - 0.4% in general anaesthesia and 0.1%


in regional anaesthesia.

Awareness during anaesthesia - up to 0.2% of


patients; higher in obstetrics and cardiac patients.

Embolism - air, thrombus, venous or arterial.

Backache.

Headache.

Idiosyncratic reactions related to specific agents - eg,


malignant hyperpyrexia with suxamethonium,
succinylcholine-related apnoea.

Iatrogenic - eg, pneumothorax related to central line


insertion.

Death.

Some specific complications of general


anaesthesia
Anaphylaxis

Anaphylaxis can occur to any anaesthetic


agent and in all types of anaesthesia.[1] The
severity of the reaction may vary but features
may include rash, urticaria, bronchospasm,
hypotension, angio-oedema, and vomiting. It
needs to be carefully looked for in the preoperative assessment and previous general
anaesthetic charts may help.
.

Patients who are suspected of an


allergic reaction should be referred for
further investigation to try to determine
the exact cause.[2] If necessary, this
may involve provocation testing or skin
prick testing and patients should be
referred to local immunologists.
Anaphylaxis needs to be promptly
recognised and managed and patients
should be advised to wear a medical
emergency identification bracelet or
similar once they recover

Aspiration pneumonitis

A reduced level of consciousness can lead to an


unprotected airway. If the patient vomits they can
aspirate the vomitus contents into their lungs. This
can set up lung inflammation with infection. The risk
of aspiration pneumonitis and aspiration pneumonia
is reduced by fasting for several hours prior to the
procedure and cricoid cartilage pressure during
induction of anaesthesia.[1] However, the evidence
for the use of cricoid pressure is not clearly
documented and further investigation is required.[3]

Other methods of reducing aspiration


pneumonitis associated with anaesthesia are
the use of metoclopramide to enhance gastric
emptying and ranitidine or proton pump
inhibitors to increase the pH of gastric
contents. The evidence for the benefit of these
methods appears promising.[4]

Aspiration pneumonitis may also occur in


spinal anaesthesia if the level of spinal block is
too high, leading to paralysis or impairment of
the vocal cords and respiratory impairment.

Peripheral nerve damage

This can occur with all the types of


anaesthesia and results from nerve compression.
The most common cause is exaggerated
positioning for prolonged periods of time. Both
the anaesthetist and the surgeons should be
aware of this potential complication and patients
should be moved on a regular basis if possible.
The severity varies and recovery may be
prolonged. The most common nerves affected
are the ulnar nerve and the common peroneal
nerve. More rarely, the brachial plexus may be
affected.[1]

Injury to nerves can be avoided by prevention of


extreme postures for lengthy periods during surgery. If
nerve damage occurs then patients should be followed
up and further investigations such as electromyography
may be required.[5]
Damage to teeth
It is now common practice to check the teeth in the
anaesthetist's pre-operative assessment. Damage to
teeth is actually the most common cause of claims made
against anaesthetists. The tooth most commonly affected
is the upper left incisor.[6]

Embolism
Embolism is rare during an anaesthetic but
is potentially fatal. Air embolism occurs
more commonly during neurosurgical
procedures or pelvic operations.
Prophylaxis of thromboembolism is
common and begins pre-operatively with
thromboembolic deterrents (TEDS) and low
molecular weight heparin (LMWH).[7]

Important complications of regional anaesthesia


Central regional anaesthesia was first used at the
end of the 18th century. It provided a method of
blocking afferent and efferent nerves by injecting
anaesthetic agents in either the epidural space
around the spinal cord (epidural anaesthesia) or
directly in the cerebrospinal fluid surrounding the
spinal cord (ie in the subarachnoid space called
spinal anaesthesia). All nerves are blocked including
motor nerves, sensory nerves and nerves of the
autonomic system.

Epidural anaesthesia takes slightly longer


than spinal anaesthesia to take effect and
provides predominantly analgesic properties.
With both, the need for muscle paralysis and
ventilation is not usually required but there is
a risk that a high block will impair respiration,
meaning that ventilation will be necessary.
Results from a review of 114 studies and a
Cochrane systematic review have shown that
regional anaesthesia is associated with
reduced mortality and reduction in serious
complications in comparison with general
anaesthesia.[8][9]

Pain - 25% of patients still experience pain despite


spinal anaesthesia.

Post-dural headache from cerebrospinal fluid


(CSF) leak.

Hypotension and bradycardia through blockade


of the sympathetic nervous system.

Limb damage from sensory and motor block.

Epidural or intrathecal bleed.

Respiratory failure if block is 'too high'.

Direct nerve damage.

Hypothermia.

Damage to the spinal cord - may be transient


or permanent.

Spinal infection.

Aseptic meningitis.

Haematoma of the spinal cord - enhanced


by use of LMWH pre-operatively.

Anaphylaxis.

Urinary retention.

Spinal cord infarction.

Anaesthetic intoxication.[10]

Some specific complications of regional


anaesthesia
Post-dural puncture headache

Post-dural puncture headache is very


common after spinal anaesthesia and
especially in young adults and obstetrics. The
headache results from CSF leak from the
puncture site. It is enhanced by use of largergauge needles and reduced by pencil-tipped
needles. Presenting symptoms may include
headache, photophobia, vomiting and
dizziness.[11]

Post-dural puncture headache is usually treated with


analgesia, bed rest and adequate hydration. The
evidence does not suggest that bed rest prevents or
changes the outcome.[12] [13] Occasionally epidural
blood patch is used where 15 ml of the patient's blood
are injected at the site of the meningeal tear.[11]
Caffeine is also used and acts as a stimulant of the
CNS and has shown benefit.[14] Other medications
with benefit include gabapentin, theophylline and
hydrocortisone.[14] Subcutaneous sumatriptan,
adrenocorticotrophic hormone (ACTH) and epidural
saline have not shown consistent benefits.[12][14]

Total spinal block


Total spinal block can occur with the
injection of large amounts of anaesthetic
agents into the spinal cord. It is detected by
a high sensory level and rapid muscle
paralysis. The block moves up the spinal
cord so that respiratory embarrassment may
occur, as can unconsciousness. In these
situations the patient needs prompt
assessment and may need to be intubated
and ventilated until the spinal block wears
off.

Hypotension
Up to half of patients receiving spinal
anaesthesia will develop transient
hypotension as sympathetic nerves are
blocked. This usually responds to
prompt fluid replacement, usually
starting with crystalloids followed by
colloids. Occasionally hypotension can
be severe and may require
vasopressors along with fluids.[10][15]

Care must be taken in patients with a cardiac


history, as they may develop myocardial
ischaemia with minor drops in blood pressure.
[16] It is suggested that heart rate variability
prior to spinal anaesthesia represents
autonomic dysfunction and may help
determine patients who are more likely to
develop hypotension.[17]

Cases of bradycardia with asystole leading


to cardiac arrest have also occurred and it
appears the underlying aetiology is
complicated and not just related to
autonomic dysfunction.

Neurological deficits

Cauda equina syndrome may occur and can be


transient or permanent. This is a common reason
for patients to refuse spinal anaesthesia. There
may also be traumatic injury to the spinal cord.
[10][18]

Adhesive arachnoiditis is a longer-term sequela


of spinal anaesthesia, occurring weeks and even
months later.[18] It is characterised by
proliferation of the meninges and vasoconstriction
of spinal cord blood vessels. This results in
gradual sensory and motor deficits from
ischaemia and infarction of the spinal cord.[19]

Important complications of local


anaesthesia

Pain.
Bleeding and haematoma
formation.

Nerve injury due to direct injury.

Infection.

Ischaemic necrosis.

All forms of anaesthetics are invasive to


a patient and therefore consent should
be obtained as for other procedures.
Ideally patients should be given a leaflet
regarding anaesthesia and then
counselled regarding the intended
benefits and the risks of anaesthesia. In
a general practice setting it will be the
responsibility of the clinician who
administers the local anaesthesia to
ensure good, non-coercive consent is
obtained.

Further reading & references

Aitkenhead AR; Injuries associated with anaesthesia. A


global perspective.; Br J Anaesth. 2005 Jul;95(1):95-109.
Epub 2005 May 20.
Kroigaard M, Garvey LH, Menne T, et al; Allergic reactions
in anaesthesia: are suspected causes confirmed on
subsequent testing?; Br J Anaesth. 2005 Oct;95(4):468-71.
Epub 2005 Aug 12.
Butler J, Sen A; Best evidence topic report. Cricoid
pressure in emergency rapid sequence induction. Emerg
Med J. 2005 Nov;22(11):815-6.
Hong JY; Effects of metoclopramide and ranitidine on
preoperative gastric contents in day-case surgery.; Yonsei
Med J. 2006 Jun 30;47(3):315-8.
Borgeat A; Neurologic deficit after peripheral nerve block:
what to do?; Minerva Anestesiol. 2005 Jun;71(6):353-5.

Hoffmann J, Westendorff C, Reinert S; Evaluation of dental injury


following endotracheal intubation using the Periotest technique.; Dent
Traumatol. 2005 Oct;21(5):263-8.

Bombeli T, Spahn DR; Updates in perioperative coagulation:


physiology and management of thromboembolism and haemorrhage.;
Br J Anaesth. 2004 Aug;93(2):275-87. Epub 2004 Jun 25.

Rodgers A, Walker N, Schug S, et al; Reduction of postoperative


mortality and morbidity with epidural or spinal anaesthesia: results from
overview of randomised trials.; BMJ. 2000 Dec 16;321(7275):1493.

Guay J, Choi P, Suresh S, et al; Neuraxial blockade for the prevention


of postoperative mortality and major morbidity: an overview of
Cochrane systematic reviews. Cochrane Database Syst Rev. 2014 Jan
25;1:CD010108. doi: 10.1002/14651858.CD010108.pub2.

Picard J, Meek T; Complications of regional anaesthesia. Anaesthesia.


2010 Apr;65 Suppl 1:105-15. doi: 10.1111/j.1365-2044.2009.06205.x.

Kuczkowski KM; Post-dural puncture headache in the


obstetric patient: an old problem. New solutions.; Minerva
Anestesiol. 2004 Dec;70(12):823-30.

Turnbull DK, Shepherd DB; Post-dural puncture headache:


pathogenesis, prevention and treatment.; Br J Anaesth. 2003
Nov;91(5):718-29.

Arevalo-Rodriguez I, Ciapponi A, Munoz L, et al; Posture


and fluids for preventing post-dural puncture headache.
Cochrane Database Syst Rev. 2013 Jul 12;7:CD009199. doi:
10.1002/14651858.CD009199.pub2.

Basurto Ona X, Martinez Garcia L, Sola I, et al; Drug


therapy for treating post-dural puncture headache. Cochrane
Database Syst Rev. 2011 Aug 10;(8):CD007887. doi:
10.1002/14651858.CD007887.pub2.

Complications of Regional Anaesthesia; Anaesthesia UK, 2005

Jin F, Chung F; Minimizing perioperative adverse events in


the elderly.; Br J Anaesth. 2001 Oct;87(4):608-24.

Hanss R, Bein B, Weseloh H, et al; Heart rate variability


predicts severe hypotension after spinal anesthesia.;
Anesthesiology. 2006 Mar;104(3):537-45.

Hyderally H; Complications of spinal anesthesia.; Mt Sinai J


Med. 2002 Jan-Mar;69(1-2):55-6.

Killeen T, Kamat A, Walsh D, et al; Severe adhesive


arachnoiditis resulting in progressive paraplegia following
obstetric spinal anaesthesia: a case report and review.
Anaesthesia. 2012 Dec;67(12):1386-94. doi:
10.1111/anae.12017. Epub 2012 Oct 12.

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