General anaesthesia is a reversible state of controlled unconsciousness, produced by combination of

different medicine. With general anaesthesia, surgical procedures can be done to the patient, which
would otherwise inflict unbearable pain. Essential to successful general anaesthesia, is balanced
hypnosis, analgesia and optimal muscular relaxation. It is desirable that sufficient amnesia through
hypnosis is achieved.

The use of general anaesthesia is increasingly safe, but it may come with certain risks and
complications. These complications range from an instant perioperative issues such as an aesthetic
anaphylaxis to minor and major post-operative complications. The minor post-operative
complications are common and include Throat soreness, post-operative nausea and vomiting and
dental damage. The major complications consist of pulmonary, circulatory and neurologic
complications. The range of different medication and techniques used during General anaesthesia
and the patient’s own general condition can induce an array of these issues. It is important for
nurses to know how to react and observe changes In order to prevent such complications from
causing major damage, further Complications and hospital care, or even possible death.

Observing and monitoring during general anaesthesia.

Surgery and anaesthesia cause the patients vital signs to change. The effect of the change depends
on the patient’s health and how complex the surgery and Anaesthesia is. In cases of large operations
or non-healthy patients, even the anaesthesia itself presents a risk for unstable vitals. Observation is
done by seeing, hearing, perceiving, asking, feeling and by recording and analysing information. All
of these make up one big picture, where the nurse anaesthetist is using his or her senses and critical
thinking, to analyse the information subjectively. To ensure patient safety, different forms of
monitoring are used in general anaesthesia. Monitoring leads to prevention, early recognition and
treatment of possible complications. Different equipment is used in monitoring of the patient.

Cardiac monitor

Breathing is closely monitored and observed, because in every general anaesthesia the risk of
respiratory depression is always present. The goal of monitoring breathing is to identify sudden or
developing berthing deficiency. During the operation, breathing is monitored with the pulse
oximeter and by observing the breathing frequency, pressure, breathing movements and sounds,
oxygenation and gas exchange. The monitor provides a capnogram, which is a graphical
representation of the amount of carbon dioxide entering and leaving the lungs. The measurement
provides information whether the ventilation is sufficient enough or not. During combination and
inhalation anaesthesia, various settings of the ventilator are also observed, such as minute volume,
single volume, airway pressure and oxygen flow.
Circulation is monitored to ensure sufficient oxygenation for tissues and to prevent hypoxia. During
general anaesthesia patient’s circulation is monitored by measuring blood pressure, pulse,
temperature, blood volume and diuresis. Blood pressure can be monitored either by non-invasive or
invasive method, where the invasive method requires an arterial cannula. The invasive blood
pressure monitoring provides a continuous stream of data, whereas the non-invasive method
measures the blood pressure usually once every five minutes. Patient is also connected to the
electrocardiogram (EKG or ECG) to provide data on the electrical activity of the heart. By observing
the ECG, information is gained about the changes in the pulse, myocardial ischemia, arrhythmias,
electrolyte imbalances and various myocardial diseases. In more complex operations, central venous
pressure (CVP) might also be needed to monitor the blood volume and pressure.

Temperature should be actively monitored and losses of temperature treated accordingly. Surgery
typically exposes the patient for loss of temperature, such as; cool environment of the operating
room, administration of unwarmed intravenous fluids, evaporation from within surgical incisions,
vasodilation caused by anaesthesia and exposure of skin to make needed preparations. Temperature
can be monitored by measuring the peripheral temperature, or by measuring core temperature of
the body. When measuring core temperature only, one must keep in mind that body reacts to the
loss of temperature first by trying to preserve the core temperature around vital organs, on the
expense of peripheral temperature. For that reason, core temperature might be inaccurate to show
the real loss of temperature in acute situations. Most accurate and ideal locations for monitoring
core temperature are the pulmonary artery, nasopharynx and distal oesophagus. These locations
might not always be available, or require invasive monitoring, like in the case measuring
temperature from the pulmonary artery. Locations like bladder, mouth and rectum are slow in terms
of monitoring, but usually more easily available. These have some limitations, but can be used
clinically in appropriate circumstances. Observing the colour, moisture and temperature of skin
should not be forgotten even with other monitoring attached to the patient.

Fluid balance and blood volume are observed throughout the operation. General fluid therapy
principles are followed; basic need for fluids is taken care of and additional fluid losses, such as
blood loss or evaporation are also treated accordingly. The goal for intra-operative fluid therapy is to
maintain the body’s own fluid and electrolyte balance, so that the metabolism would function as
normal as possible through the whole operation and during recovery. With fluid therapy, normal
function of kidneys and natural blood flow are ensured. Fluid balance is monitored during general
anaesthesia by observing the relation of ingoing and outgoing fluid amount. Functioning of cannulas
and tools used with fluid infusions, such as perfusors, is also essential to provide the patient with
good quality fluid therapy. Blood volume is monitored by observing skin colour, temperature, pulse,
blood pressure, blood loss, breathing frequency and diuresis. When measuring the amount of blood
loss, different factors should be added up together. These factors are; assessing the amount of blood
suctioned, by weighing surgical swabs to estimate the amount of blood absorbed in them and all else
that can be seen with bare eyes (e.g. blood on the floor and blood absorbed into surgical dressings)

Diuresis is observed to assess the functioning of kidneys, to note sufficient diuresis of about
1ml/kg/hour and to assess the fluid balance and circulation of the patient. To monitor the amount of
diuresis, a urine catheter is used. Although not all patients who go under general anesthesia, are
catheterized. Some motives for catheterization are; heart failure, acute kidney failure, prolonged
hypotension, hypovolemia or in case an operation is suspected to last more than five hours. Certain
types of operations also require it, such as; urological, neurosurgical or cardiac operations, along
with any other major ones. In the end, it comes down to the operating surgeon or the
anaesthesiologist to decide if catheterization is needed or not. Urine output is monitored
cumulatively, which means that hourly diuresis and total diuresis are monitored separately.

Muscle relaxation observation is needed during the induction, reversing and in the upkeep of
hypnosis. Before intubation or extubation is done, proper relaxation is essential to ensure safety of
the procedure. During the upkeep phase of hypnosis, the need of muscle relaxant is based on the
need of surgical procedure being done. Relaxation is monitored by peripheral nerve stimulation.
Most often two electrodes are attached on top of the ulnar nerve on the volar side of wrist. The
stimulator is placed on the thumb of the patient, from where it sends the electrical stimulation
towards the electrodes. Most commonly used measurement is called TOF (train-of-four), where the
stimulator sends four of those electrical stimulation signals and then the amount and strength of
signals reaching the electrodes is measured. TOF measurement should only be started after the
patient is already sleeping.

Pain and sleep are observed to ensure optimal hypnosis and analgesia, so the operation can be done
without unpleasant experiences for the patient. Observing pain and hypnosis is also important, so
that right balance of medicine can be given. Too much of hypnotics or analgesics, could have
malevolent side-effects and a prolonged recovery phase. In observing pain and sleep, you have to
pay attention to many different details. It is important to know, how the patient’s vitals are and how
the patient looks and feels, when everything is just right. Only then you can make the comparison, if
the patient is feeling pain or lingering in too shallow hypnosis. When measuring the depth of the
hypnosis multiple parameters should always be followed . Some common signs in vitals for the
feeling of pain, are elevated heartrate and blood pressure. For hypnosis in inhalation or combined
anaesthesia, the amount of anaesthetics going in and out, must be monitored closely. BIS (bi-
spectral index scale) monitoring can be used in measuring hypnosis. BIS is based on
electroencephalography monitoring, which records the electrical activity of the brain.

Complications of Anaesthesia

Complications may be divided into minor (non life threatening) and major (life threatening).

Minor complications

Although minor complications are not life threatening, they may be very important to the patient
and some may have the potential for litigation.

1) Airway injuries

Injuries to the mouth, throat and teeth can be caused by placement of a laryngoscope blade,
oropharyngeal airway, laryngeal mask airway (LMA) or endotracheal tube (ETT). A patient’s dentition
must always be examined pre-operatively and precautions taken if risks are high, e.g. expensive
bridge work or loose teeth. A gum guard may be used and laryngoscopy should be performed with
extra care. The correct size ETT and careful placement will prevent damage to vocal cords. Avoid
over-inflating the cuff as this may cause oedema and postoperative intubation stridor; and in the
long term, tracheal stenosis. The use of cuffed ETTs is controversial in children under the age of 8
years. Select the correct size of oropharyngeal airway and LMA to avoid trauma to the pharynx.
2) Eye injuries

Facemasks should fit properly and avoid pressure on the eyes. Anaesthesia obtunds the corneal
reflex and paralysed patients are unable to blink. Corneal ulceration will occur if eyes are not taped
closed during anaesthesia. In the prone position, eyes should be checked regularly to ensure that
they are free from pressure. Eyes should be padded before taped shut for head and neck surgery.

3) Positional injuries

Improper positioning of patients allowing pressure on peripheral nerves can lead to nerve damage;
particularly those nerves passing over bony prominences. Nerves at risk include the radial nerve
(Saturday night palsy); ulnar nerve; brachial plexus from hyper-extending the arm beyond 90
degrees; the lateral popliteal nerve in the lithotomy position (foot drop), and the femoral nerve
during surgery in the Lloyd-Davis (extended lithotomy) position. During long procedures, pressure
points should be padded to avoid the development of pressure sores and the limbs moved from
time to time by the anaesthetist, if possible.

4) Complications of regional anaesthesia

Spinal and epidural anaesthesia are not without risk. Without meticulous attention to asepsis and
proper technique, several complications can occur – Epidural abscess, meningitis, epidural
haematoma, and nerve injuries may follow. These are fortunately very rare, but catastrophic if they
do occur. Postspinal headache is a common complication and can be reduced by using a “pencil
point” needle, e.g. Whitacre or Sprotte, and a smaller gauge (25 G versus 22 G). Neuraxial
anaesthesia often causes hypotension that is easily managed. However it may also lead to profound
hypotension if the volume of local anaesthetic was too high or the patient volume depleted. A high
spinal is a risk for respiratory depression and cardiovascular collapse, and possibly an anaesthesia-
related death!

5) Complications of central venous cannulation

Early complications Late complications

Technical Infection
 Pneumothorax  Sepsis
 Haemothorax  Endocarditis
 Nerve damage  Thrombosis
 Dysrhythmias  Tamponade
 Air embolism

6) Postoperative nausea and vomiting (PONV)

PONV is common, second only to pain. Some patients with a history of severe PONV fear this
complication more than the postoperative pain. Do not confuse the risks for and treatment of PONV
with the risks of a full stomach and resultant aspiration. These are two very different complications.
There are patient, surgical and anaesthetic factors that increase the likelihood of PONV.

Risk factors for PONV

Patient factors:-Children, females, history of motion sickness, previous PONV, obesity.

Anaesthetic factors:- Prolonged pre-operative starvation. Hypotension with spinals or epidurals.

Emetic drugs, Opiates, etomidate, ketamine, N2O and all volatile anaesthetic agents.
Surgical factors:- Ear and eye surgery, especially strabismus (squint) surgery; intra-abdominal
surgery, particularly laparoscopy & gynaecological, and orchidopexy.

Post op factors:- Pain, opiates, hypotension and forcing oral fluids too soon postoperatively.

Management

Administration of commonly used anti-emetic drugs in theatre: e.g. Droperidol (Inapsin),a

butyrophenone; prochlorperazine (Stemetil), a phenothiazine; Ondansetron (Zofran), a serotonin-3
antagonist, and dexamethasone or betamethasone, steroids.Metoclopramide (Maxolon), a
dopamine agonist, is also commonly used postoperatively; however, it only has a moderate anti-
emetic effect and is really a prokinetic agent, better used to promote gastric emptying in patients
with a full stomach. Routine pharmacological prophylaxis is not indicated and should be reserved for
high-risk patients. In high-risk patients, prophylaxis with dexa- / beta- methasone and droperidol is a
good combination. Dexa- / beta- methasone is a prophylactic measure and will not be effective if
given postoperatively for the treatment of vomiting. Ondansetron and the other serotonin-3
antagonists, or prochlorperazine are used postoperatively.

Non-pharmacological management includes keeping the patient well hydrated with intravenous
fluids.

7)Hypothermia

Hypothermia is a core temperature below 35° C. It is quite common under both general and regional
anaesthesia. The temperature should be monitored for any case longer than 15 minutes. Heat loss
occurs due to the cool ambient theatre temperature (18 - 22° C) and exposure during the surgery.
Cold irrigation fluids and IV fluids can contribute to cooling. The anaesthetic agents interfere with
normal homeostatic thermal control. Most anaesthetic agents also result in vasodilatation and
increase the heat loss from the core. Compounding this is that while under anaesthesia, patient is
unable to move and ‘get warmer’ as he would usually do when awake.

There are many pathophysiological effects of hypothermia that are deleterious during the
perioperative period. It may lead to increased bleeding with platelet dysfunction and inactivate
clotting factors at < 35° C; delayed emergence from general anaesthesia; poor ventilatory efforts;
dysrhythmias (ventricular fibrillation at < 32° C); slowed drug metabolism due to inactive phase I and
phase II enzymes at lower temperatures; and shivering postoperatively causing pain and more
importantly increased O2 consumption by 200 %.

Prevent heat loss by covering exposed areas with a forced-air warming blanket or warming under-
blankets. Space blankets (metallic foil) have no role in warming the patient in theatre. Warm all IV
and irrigating fluids. Warm the gases the patient is inhaling. A heat moisture exchange filter (HMEF)
will help humidify, warm and filter gases. Warm the theatre temperature if necessary. If these non-
invasive methods are ineffective, you may require more aggressive and invasive methods of warming
such as intra-thoracic and / or peritoneal lavage, or even cardiopulmonary bypass (extracorporeal
circulation) to warm the patient.

Hypothermia, if severe, can be a cause of major and life threatening complications.

Major (life threatening) complications

The most feared complications of anaesthesia are brain damage and death. The incidence of death
attributable to anaesthesia in first world hospitals is approximately 1 : 40 000 anaesthetics. e. Most
major complications can be prevented through early recognition and correct management.

1. Pulmonary aspiration
Pulmonary aspiration of gastric contents is a serious complication. The contents of the patient’s
stomach rise up from the esophagus and end up in the trachea as the patient is under heavy
sedation and cannot control swallowing and couching him or herself. The consequences can be
acute lung damage or pneumonia or ARDS and can ultimately lead to death of the patient. It can
happen post-operatively due to several factors. These risk factors include emergency surgery, Full
stomach, Pregnancy, Gastric outlet obstruction (very high risk!) Obesity ,Hiatus hernia, acute
abdomen, general anesthesia, an inexperienced anesthetist and patient dependent reasons such as
lack of fasting, delayed gastric emptying or gastric hyper secretion.

Strategies to reduce the risk of aspiration include:

– Raising gastric pH with:

 A non-particulate antacid, e.g. sodium citrate 30 ml

 An H2-receptor antagonists, e.g. ranitidine 300 mg
 A proton-pump inhibitor (PPI), e.g. omeprazole 40 mg

– Increase gastric emptying and increase lower oesophageal sphincter tone with metoclopramide,

– Reduce gastric volume via suction with a nasogastric tube.

After surgery, the high risk patients should remain intubated until consciousness has been regained
and airway reflexes returned.

2. Respiratory complications

a) Laryngospasm

Causes

O Insertion of an ETT, LMA or oral airway while still in a light plane of anaesthesia

O Inhalation of irritating anaesthetic volatile agents (desflurane, isoflurane and enflurane)

O Secretions on the vocal cords

O Surgical stimulus, e.g. dilatation of the cervix or anal sphincter

O Surgical stimulus during light level of anaesthesia

Management

O Avoid manipulation of the airway whilst in a light plane of anaesthesia

O Stop the causative stimulus

O 80 – 100 % O2 with facemask and positive pressure ventilation is often all that is needed

O A small bolus of propofol (10 – 50 mg) is very helpful

O Consider spraying cords with 2 % lignocaine using the MacIntosh sprayer

O If fast control is needed, give suxamethonium 1 mg kg-1 and intubate.

If the laryngospasm occurs during emergence, then give only one quarter of the usual

Dose of suxamethonium and support the airway or intubate if not able to