Complete COVER ABCD - A SWIFT CHECK
(1)
Confirm the blood pressure change is real (2)
Don't hesitate to treat as cardiac arrest
Inform and discuss with surgeon
Recheck vaporisers are off (3)
Improve posture: lie flat, elevate legs if possible
IV fluids: crystalloid bolus - 10 ml/kg, and repeat as necessary
Give vasopressor: metaraminol bolus 0.005-0.01 mg/kg IV (4)
If severe give adrenaline: For an
adult, 0.1 mg IV bolus
very slowly.
For a child 0.001 mg/kg IV very slowly;
titrate to clinical response,
followed if necessary by an infusion of adrenaline
For adults, 1 mg in 100 ml burette starting at
60ml/hr.
For children, 1 mg in 1000 ml (1 mcg/ml),
starting at 0.1 mcg/kg/minute
If erythema, rash or wheeze is evident go to
anaphylaxis
If bradycardic go to bradycardia
If desaturated or cyanosed go to desaturation
If pulseless go to cardiac arrest
Increase monitoring - ECG, arterial line, CVP, filling pressures.
FURTHER CARE
Review and treat probable cause(s)
See precipitating factors (3) to (9) below
Consider further fluid/drug therapy
Consider invasive haemodynamic monitoring
Arterial pressures
Filling pressures
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NOTES:
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It was judged that correct use of the algorithm would have led to earlier
recognition of the problem and/or better management in 6% of 438 relevant
incidents reported to AIMS.
(1) COVER ABCD accounted fully for 12% of hypotension incidents.
(2) Use a sphygmomanometer and auscultate the blood pressure. When using an
arterial line, check the zero and calibration.
(3) Drugs were a factor in 26% of cases (inhalational and anaesthetic agents
7% each, opioids 5%, suxamethonium 2%). Other drugs implicated
included vasodilators, inotropes (pump malfunction), IV local anaesthetics,
vancomycin, protamine and phenytoin. Vaporiser problems made up 32% of
inhalational agent induced hypotension. 2% of all drug related hypotension was
related to syringe or ampoule errors.
(4) Options include IV boluses of ephedrine 0.05mg/kg (especially with
pregnancy).
(5) Based on reported incidents timely and effective management was best
achieved by using specific algorithms in 85% of cases (cardiac arrest 25%,
desaturation 21%, bradycardia 31%, anaphylaxis 5%, non sinus tachycardia 3%).
The remaining 15% required review of further possible specific causes. Multiple
causes were involved in 23% of cases.
(6) Hypovolaemia was a factor in 2% of cases, but is often unreported. It is
such a common cause of hypotension that it is not usually reported as an
incident.
(7) Regional anaesthesia was a factor in 14% of cases
(8) Surgical events were a factor in at least 5% of cases. Reflex stimulation was
induced by anaesthetic procedures (laryngoscopy, CVC placement) as well as
surgical manipulations (mesenteric traction, eye surgery).
(9) Cardiopulmonary problems were a factor in 6% of cases.
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