anaesthetics post-op

Question 1

how do you wake a patient up

Answer 1

change inspired gases to 100% oxygen then stop anaesthetic drug infusions

when some spontaneous reversal of muscle block has returned (check with peripheral nerve stimulator) reverse any muscle paralysis with neostigmine (approx 2.5mg in adults) and an anticholinergic to prevent muscarinic SE eg atropine (1.2mg)/glucopyrronium (0.5mg)

when spontaneously breathing inspect mouth and oropharynx under direct vision

• remove ET tube
• administer oxygen by facemask - as long as necessary to counteract hypoxia due to diffusion hypoxia, resp depression or ventilation/perfusion mismatch

if no problems transfer to recovery

Question 2

indications to keep a patient sedated

Answer 2

• Really ill when came in – septic
• Needed for recovery
• Came from ITU
• Something went wrong
• Really long surgery – if upside down then face all swollen – keep them sedated for a while

Question 3

what is sedation

Answer 3

sedation is a depression of awareness - pt response to external stimuli is limited. May be minimal, moderate or deep. Pt wont feel pain but is aware of what is going on around them

Minimal - only to relieve anxiety, little effect on patient awareness,

moderate - depresses consciousness, leaves the patient capable of responding to external stimuli (tactile or verbal).

deep - only responds to painful or repeated stimuli.

Question 4

effect of GA

Answer 4

complete loss of consciousness

Question 5

comparison between GA and sedation

Answer 5

the adverse effects that may be associated with general anesthesia are avoided with sedation.

patients maintain natural physiological reflexes; capable of breathing on their own. Some resp support might still be needed

recovery period quicker from sedation

GA allows anaesthetist to have complete control of the airway

Question 6

observations made in recovery

Answer 6

look for hypoventilation - is there inadequate reversal, check with nerve stimulator

narcosis - reverse opiates with naloxone cautiously to minimise pain

check for airway obstruction

ensure adequate analgesia

monitor temp, HR, BP

Question 7

recall criteria for discharge from recovery

Answer 7

when happy with CVS, resp status and pain relief

give clear instructions on postop fluid regimens, blood transfusions, oxygen therapy, pain relief and physiotherapy

Question 8

anaesthetics handover

Answer 8

• What happened
• What you’ve given the pt
• Any concerns
• PMH

Question 9

what if hypotensive post-op

Answer 9

• If hypotensive – check they have enough fluids, if not might need vasopressor drug on an infusion – cant have that on a ward so have to go somewhere else

Question 10

what if massive haemorrhage in recovery

Answer 10

surgeons

Question 11

clinical response to NEWS scores

Answer 11

Question 12

interpretation of NEWS score

Answer 12

Question 13

Answer 13

Hudson face mask

Question 14

Answer 14

venturi

Question 15

Answer 15

non-rebreather mask

Question 16

confusion post-op

Answer 16

sx - agitation, disorientation, attempts to leave the hospital - esp at night

gently reassure pt in well lit surroundings

causes:

• hypoxia - pneumonia, atelectasis, LVF, PE
• drugs - opiates, sedatives
• urinary retention
• MI or stroke
• infection
• alcohol withdrawal
• liver/renal failure

Question 17

Mx of confusion post-op

Answer 17

occaisionally sedation is necessary

lorazepam 1mg PO//IM

haloperiodol 0.5-2mg IM

reassure relatives that it is common and reversible

Question 18

dyspnoea/hypoxia post op

Answer 18

any prev lung disease

sit pt up and give ox

monitor sats

look for evidence of:

• pneumonia, pulmonary collapse or aspiration
• LVF - MI, fluid overload
• PE
• pneumothorax due to CVP line, intercostal block, or mechanical ventilation

tests - FBC, ABG, CXR, ECG

Question 19

hypotension post-op

Answer 19

if severe - tilt bed head-down and give ox

check BP and pulse, compare to pre-op

caused by hypovolaemia because of inadquate fluid input - replace

• monitior UO
• CVP line can monitor fluid resus

hypovolaemia also caused by haemorrhage - review wounds, drains and abdomen

return to theatre for haemostasis if unstable

beware cardiogenic and neurogenic causes - look for MI/PE

consider sepsis and anaphylaxis

Question 20

hypertension post-op

Answer 20

from pain, urinary retention, idiopathic, inotropic drugs

oral cardiac medication inc antihypertensives should be continued through op

treat cause

if not absorping orally - 50mg labetalol IV over 1min

Question 21

low UO post-op

Answer 21

aim for UO of >30ml/h or >0.5ml/kg/h

anuria from - blocked/malsited catheter, AKI

flush or replace the catheter

oliguria - little replacement of lost fluid - increase fluid input

review fluids

examine for signs of vol depletion

urinary retention common - palpable bladder

establish normovolaemia - CVP line, fluid challenge may help

catheterise bladder for accurate monitoring, check UE

if intrisic renal failure is suspected, stop nephrotoxic drugs and refer

Question 22

post op N and V

Answer 22

any mechanical obstruction, ileus, emetic drugs (opiates, diogoxin, anaesthetics)

AXR, NGT and anti-emetic