Surgery and Healing in the Developing World - Dartmouth-Hitchcock

Anesthesia in the Third World
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Treatment Consists of the Following Steps
1. Call for help! Two anesthesia providers must attend all inductions.
2. Turn off the halothane vaporizer and flush with 100% oxygen.
3. Hyperventilate the patient with 100% oxygen.
4. If heart tones are absent over the precordium by stethoscope, immediately
initiate chest compressions.
5. Administer epinephrine 10 mg/kg by intravenous or intra-tracheal route.
6. If the patient does not recover rapidly, continue Pediatric Advanced Life
Support procedures.
Malignant Hyperthermia (MH)
Nonspecific early signs
• Elevation of the end-tidal CO2, unexplained tachycardia, tachypnea,
sweating, cyanosis, and overheating of the soda lime.
• Hypertonus of the skeletal muscle. After succinylcholine, either failure
of skeletal muscle to relax or intense masseter spasm should arouse
suspicion and be considered an indication to postpone surgery.
• MH may occur later during anesthesia, after the use of potent agents,
commonly halothane.
• A rapid rise in body temperature.
Biochemical changes include a severe metabolic acidosis, severe respiratory acidosis,
and possible elevated serum potassium. Generalized muscle rigidity, ventricular
arrhythmia, cyanosis, and increasing body temperature are highly predictive of
an impending MH crisis.
Therapeutic regimen:
1. Call for help!
2. Discontinue all inhalation anesthetics.
3. Discontinue surgery.
4. Hyperventilate the lungs with 100% oxygen.
5. Administer bicarbonate 1-2 mEq/kg.
6. Administer dantrolene 2.5 mg/kg IV (must be mixed with sterile water).
7. Start cooling techniques; i.e., ice to surface, nasogastric, intravenous, wound, 13
rectal.
8. Change the anesthetic circuit and soda lime if possible.
9. Ventricular dysrhythmias usually respond to treatment of acidosis and hyperkalemia.
If not, administer procainamide 20 to 30 mg/min IV until the
arrhythmia is suppressed or hypotension ensures, or the QRS complex is
widened by 50% of its original width or a total of 17 mg/kg has been given.
10. Titrate further doses of dantrolene as required (maximum dose 10 mg/kg)
11. Maintain urinary output. Monitor urine output, serum potassium, calcium,
arterial blood gases, and clotting studies.
12. Follow creatine phosphokinase, calcium, and potassium until they return
to normal.
13. Observe patients for disseminated intravascular coagulation (DIC). Monitor
patients in the ICU for at least 24 hours.