What should be done immediately if a patient crashes during anesthesia?

Management of Patient Crashing During Anesthesia

When a patient crashes during anesthesia, immediately follow the ABC approach (Airway, Breathing, Circulation) while simultaneously calling for help, administering 100% oxygen, and preparing to give intravenous epinephrine 50 mcg (0.5 mL of 1:10,000 solution) if anaphylaxis is suspected, as this represents the most common life-threatening cause of intraoperative cardiovascular collapse. 1, 2

Immediate Recognition and Initial Actions

First 30 Seconds: Simultaneous Assessment and Intervention

• Call for help immediately and note the time - team-working enables multiple tasks to be accomplished simultaneously 1, 2
• Assess and secure the airway - exclude mechanical causes such as misplaced tracheal tube, circuit disconnection, or equipment failure before attributing collapse to other causes 1, 2
• Administer 100% oxygen - intubate the trachea if necessary and ventilate the lungs with oxygen 1, 2
• Check circulation - assess for pulse, blood pressure, and signs of cardiovascular collapse 3

Critical Differential: Anaphylaxis vs. Other Causes

Anaphylaxis is the leading consideration when a patient crashes intraoperatively, as cardiovascular collapse occurs in 50.8% of anaphylaxis cases during anesthesia 2. Key recognition points:

• Hypotension may be the sole presenting feature in approximately 10% of patients - do not wait for cutaneous signs 2
• Cutaneous signs are absent in 28% of cases - flushing and urticaria occur in only 72% of anaphylaxis cases 2
• Bradycardia occurs in 10% of cases, not just tachycardia 2
• Bronchospasm is present in 39.8% of allergic anaphylaxis cases 2

Pharmacological Management for Suspected Anaphylaxis

First-Line: Intravenous Epinephrine

Administer IV epinephrine 50 mcg (0.5 mL of 1:10,000 solution) immediately for adults with suspected anaphylaxis 1, 2, 4. This is the definitive treatment with alpha-agonist (vasoconstriction), beta-agonist (inotropy, bronchodilation), and mediator release inhibition properties 2.

• Repeat doses every few minutes as needed for severe hypotension or bronchospasm 1, 2
• Start continuous IV infusion if multiple boluses required - prepare 1 mg (1 mL of 1:1000) in 250 mL D5W = 4 mcg/mL, infuse at 1-4 mcg/min initially, titrate up to 10 mcg/min 2
• Alternative infusion preparation: 1 mg in 100 mL saline (1:100,000), infuse at 30-100 mL/h (5-15 mcg/min) 2

Pediatric dosing: 1 mcg/kg IV (0.1 mL/kg of 1:10,000 solution), titrated to response - prepare 1 mL of 1:10,000 per 10 kg body weight and start with one-tenth of syringe contents 1, 2

Aggressive Fluid Resuscitation

Administer normal saline 0.9% or lactated Ringer's solution at high rate through large-bore IV cannula 1, 2, 4:

• Adults: 1-2 L at 5-10 mL/kg in first 5 minutes - up to 7 L may be required due to massive vasodilation 5, 2, 4
• Children: up to 30 mL/kg in first hour 2
• Rationale: Increased vascular permeability can transfer 50% of intravascular fluid to extravascular space within 10 minutes 2

Remove All Potential Causative Agents

Stop all IV colloids, antibiotics, and remove latex exposure - maintain anesthesia only with inhalational agent if necessary 1, 2

Positioning

Elevate the patient's legs if hypotension is present to improve venous return and prevent orthostatic hypotension 1, 2, 4

Cardiopulmonary Resuscitation if Indicated

Start CPR immediately if cardiac arrest occurs, following Advanced Life Support Guidelines 1. High-quality cardiopulmonary resuscitation is necessary to reduce the duration of cerebral anoxia, as cardiac arrest causes irreversible brain damage within 3-5 minutes 3.

Secondary Management (After Initial Stabilization)

Adjunctive Medications

These are administered after epinephrine and fluids, not as first-line therapy 4:

• Chlorphenamine 10 mg IV (adult dose) - reduces histamine-mediated symptoms 1, 5
• Hydrocortisone 200 mg IV (adult dose) - may prevent biphasic reactions 1, 5

Pediatric dosing for adjunctive medications 1:

• Chlorphenamine: 6-12 years: 5 mg; 6 months-6 years: 2.5 mg; <6 months: 250 mcg/kg
• Hydrocortisone: 6-12 years: 100 mg; 6 months-6 years: 50 mg; <6 months: 25 mg

Refractory Hypotension

If blood pressure does not recover despite epinephrine infusion, consider alternative IV vasopressor such as metaraminol 1, or dopamine 400 mg in 500 mL at 2-20 mcg/kg/min 5

Persistent Bronchospasm

Treat with IV salbutamol infusion - alternatively use metered-dose inhaler if appropriate breathing-system connector available 1. Consider IV aminophylline or magnesium sulphate 1.

Bradycardia Management

Administer atropine 600 mcg IV if bradycardia develops 5

Diagnostic Confirmation: Mast Cell Tryptase

Obtain serial mast cell tryptase levels (5-10 mL clotted blood) at specific time points 1, 2, 4:

1. First sample: As soon as feasible after resuscitation starts - do not delay resuscitation to take the sample 1, 2, 4
2. Second sample: 1-2 hours after symptom onset 1, 2, 4
3. Third sample: At 24 hours or in convalescence - establishes baseline, as some individuals have elevated baseline levels 1, 2

Label all samples with time and date 1

Post-Resuscitation Care and Monitoring

Immediate Transfer

Arrange transfer to Critical Care area for continued monitoring 1, 2. All patients with anaphylaxis or serious reactions should be transferred to a hospital with emergency department capabilities, even if symptoms improve 5.

Observation Requirements

• Monitor vital signs continuously until complete resolution of symptoms 5
• 24-hour observation is recommended after severe reactions, ideally in a hospital setting 5
• Monitor for biphasic anaphylaxis, which occurs in 1-7% of patients, with risk factors including severe initial presentation and requiring >1 dose of epinephrine 4

Documentation

Record the following 5, 2:

• Exact timing of reaction onset
• All anesthetic agents administered
• Vital signs throughout event
• All treatments given and patient response
• Details of any difficulties during intubation

Critical Pitfalls to Avoid

• Never delay epinephrine administration while giving antihistamines or corticosteroids - these are not first-line therapy and do not prevent biphasic reactions 4
• Do not exclude anaphylaxis based on absence of cutaneous signs - 28% of cases lack skin manifestations 2
• Do not assume tachycardia will be present - bradycardia occurs in 10% of cases 2
• Avoid multiple repeated intubation attempts if intubation is difficult - progressive laryngeal edema and hemorrhage will develop and the ability to ventilate via mask may be lost 6
• Exclude equipment failure (misplaced tracheal tube, circuit disconnection) before attributing symptoms solely to anaphylaxis 1, 2
• Use IV route when IV access is available in the anesthesia setting - IV allows for precise titration rather than IM administration 2

Special Considerations

• Neuraxial blockade exaggerates hypotension in anaphylaxis 2
• Tourniquet deflation may trigger anaphylaxis if allergen sequestered in limb 2
• Patients with pre-existing asthma may have more prominent bronchospasm 2
• Symptoms typically develop within minutes but may be delayed up to one hour with latex, antibiotics, IV colloids, or Cidex OPA 2

Post-Event Management

Permanently document the causative agent as a severe allergy in all medical records 5. Refer patient for allergy testing to identify specific causative agent for future avoidance 1.