9) Understand the definition, causes

and management of hypoxia during

anaesthesia

Hypoxaemia
Definition- Hypoxaemia refers to arterial haemaglobin desaturation
or reduced arterial oxygen tension, hypoxia is oxygen deficiency at
the tissue level.
Hypoxic
Oxygen supply, flowmeters, breathing
inspired gas
oxygen
mixture
equipment
Hypoventilation Ventilator failure, inadequate minute volume
equipment
Breathing system (obstruction, leak,
disconnection)
Tracheal tube (obstruction, oesophageal
intubation)
Patient

Respiratory depression in spontaneously

breathing patients
Obstruction in oropharynx, larynx, trachea,
bronchi.

V/Q mismatch
patient

Inadequate ventilation like endobronchial

intubation, secretions, atelectasis,

Others

Methhaemoglobinemia, malignant hyperthermia

Management:
Routine use of pulse oximetry allow early detection and
treatment of hypoxaemia. If hypoxaemia is detected,
the following plan should be determined.
1. Palpate carotid pulse, simultaneously assess the ECG
and cardiac rhythm. Treat cardiac arrest if got
inadequate cardiac output or ventricular
tachycardia/fibrillation.
2. Exclude delivery of a hypoxic gas mixture using an
oxygen analyser. Increase inspired oxygen
concentration to 100%.
3. Test the integrity of breathing system by manual
ventilation of the lungs and confirm bilateral chest
movement and breath sound. Blow down the tracheal
tube if neccesary.

4. Search clinical evidence of the

cause of V/Q mismatch with early
exclusion of pneumothorax. If
atelectasis or reduced FRC is
contributory, gentle hyperinflation
of the lungs should improve
oxygenation. Lung volume can be
maintained by applying CPAP.
5.If the diagnosis is difficult,
measure core temprature and

10) Recognize
management of
bronchospasm
occurring during
anaesthesia

Bronchospasm (Management)
On suspecting bronchospasm

Switch to 100% oxygen

Ventilate by hand

Stop stimulation / surgery

Consider allergy / anaphylaxis; stop administration of suspected

drugs / colloid / blood products
Difficulty with
ventilation/falling
SpO2
Immediate management;
prevent hypoxia & reverse bronchoconstriction
FiO2(Fraction of Inspired Oxygen)-1.0
Switch to manuel bag ventilation
Increase concentration of volatile anesthesia (except dysflurane)
Deepening anesthesia with an intravenous anaesthetic (If
bronchospasm is related to inadequate depth)
Consider transfer to
HDU
/ ICU
Secondary
management,
provide ongoing therapy and address underlying cause

Optimise mechanical ventilation

Reconsider allergy/anaphylaxis - expose and examine the patient, review

medications

If no improvement consider pulmonary oedema/pneumothorax/pulmonary

embolus/foreign body

Consider abandoning / aborting surgery

Request & review chest X-ray

Consider transfer to a critical care area for ongoing investigations and therapy

Bronchospasm
1st line drug therapy

2nd line drug

Salbutamol
i) Metered Dose Inhaler: 68 puffs repeated as
necessary (using in-line
adaptor/barrel of 60ml
syringe with tubing or
down ETT directly)
ii) Nebulised: 5mg (1ml
0.5%) repeated as
necessary
iii) Intravenous: 250mcg
slow IV then 5mcg.min-1

therapy
Ipratropium bromide: 0.5mg
nebulised 6 hourly
Magnesium sulphate: 50mg.kg-1
IV over 20min
(max 2g)
Hydrocortisone: 200mg IV 6 hourly
Ketamine: Bolus 10-20mg. Infusion
1-3mg.kg-1.h-1
IN EXTREME: Epinephrine
(Adrenaline)
i)Nebulised: 5mls 1:1000
ii)Intravenous: 10mcg (0.1ml
1:10,000) to 100mcg
(1ml 1:10,000) titrated to