Emergence & PACU/ICU Transport Flashcards
complications associated with emergence
Airway obstruction Agitation Delirium Pain Nausea/vomiting Hypothermia Shivering Autonomic lability
when do you start planning emergence?
as soon as the patient is asleep
what are 5 main factors to consider when emerging a patient
reversed? breathing spontaneously? comfortable? are they gonna vomit? can they be safely extubated?
what are 3 factors that directly influence emergence time?
Agent Solubility (directly) Agent Concentration (directly) Duration of Anesthesia (directly)
Emergence of inhalational anesthesia depends chiefly on what?
pulmonary elimination
____________ blunt the ventilatory responses to both hypercarbia and hypoxemia.
IV or inhalational anesthetics
PaCO2 where spontaneous ventilation is initiated
Apneic threshold
Maintain FiO2 >_____ during hypoventilation
> 0.85
how long do most non-depolarizing blockers work?
15-45 mins
a condition where too much CO2 becomes an anesthetic
Hypercarbic narcosis
succinylcholine depolarizes the end-plate _______ receptor
nicotinic
why does succ have a short duration?
short duration due to pseudocholinesterase metabolism of Succs. It works to depolarize the motor end-plate and then diffuses away and is metabolized
which NMB can cause sinus bradycardia?
Succ
how to non-depolarizing NMB work?
Competitively inhibit end plate nicotinic cholinergic receptor
name 4 possible locations for the nerve stimulator
Ulnar nerve
Facial nerve
Posterior tibial nerve
External peroneal nerve
which twitch monitor location most closely reflects blockade at diaphragm?
facial nerve
TOF = 4 stimulations @ ___ Hz
2
Tetany = __-___ Hz for 5 sec
50-100
4/4 = \_\_% 3/4 = \_\_% 2/4 = \_\_% 1/4 = \_\_% 0/4 = \_\_%
4/4 = 75% 3/4 = 85% 2/4 = 90% 1/4 = 95% 0/4 = 99%
what class of drug do you reverse NMB with?
anticholinesterase
side effects of anticholinesterase
BLUDS
what class of drug is used to counter-act the BLUDS?
anti-muscarinic
max dose of neostigmine?
peak onset?
0.07mg/kg
5-10 mins
how do you assess the adequacy of ventilation during emergence?
- ETCO2
- SpO2 (>90%)
- Tidal Volume (>250ml)
3 major candidates for a NAW or OAW
Obesity
OSA
Hx snoring
what is the major factor in arousal of OSA patients?
hypoxia
Factors that increase incidence of PONV
Hx* including motion sickness Female gender Hypotension Non-smoker Postoperative pain/narcotic use Type of Surgery: (Eye, ENT, Abdominal, GI/GU) Anesthetic Rx Gastric distention Swallowed heme
Surgical sites that have increased risk of PONV.
Intra-abdominal Laparoscopic Orthopedic Gynecological ENT Breast Plastic Neurosurgical
what class of drug is Zofran?
Serotonin 5-HT3 receptor antagonist
30mg Toradol = ___mg Morphine
10
what class of drug is toradol?
NSAID
Dilaudid = ____ relative potency morphine
How long does it last?
8x
4-8 hrs
Fentanyl = \_\_\_\_\_ relative potency to morphine Duration \_\_\_\_\_hour(s)
100x
0.5-1 hrs
Titrate narcotics to RR _____ BPM
Titrate to RR 10-16 BPM
factors for extubation
Airway protective reflexes intact Clinical stability Intact neurological function Adequate pulmonary function Normal body temp (T 35-37 C) Normal neuromuscular function Normal coagulation
what is a major contraindication for droperidol?
parkinson’s
at what stage(s) is it safe to extubate?
- awake
- surgical
(NOT 2. excitatory or 4. depression)
what are some immediate hazards of extubation?
laryngospasm
vomiting
bronchospasm
purpose of deep extubation
Minimize tracheal stimulation
Minimize coughing/bucking
Contraindications of deep extubation
Difficult mask airway
Difficult intubation
Aspiration risk
Airway edema
criteria for deep extubation
MAC 1.3 NMB completely reversed Spont ventilation at regular rate/rhythm No airway reflexes 100% O2 Lidocaine (0.5 mg/kg)
NEVER extubate a patient deep without _______ in place
an oral airway
what do you do immediately following extubation?
Suction the pharynx one more time Place mask on the patient Keep your right hand on the bag Test for airway patency Help them breathe for a while if they are not doing an adequate job on their own.
ASA Standard 1 PACU
All patients who have received general, regional, or monitored anesthesia care shall receive appropriate post-anesthesia management
ASA Standard 2 PACU
A patient transported to the PACU shall be accompanied by a member of the anesthesia care team who is knowledgeable about the patient’s condition.
The patient shall be continually evaluated and treated during transport with monitoring and support appropriate to the patient’s condition
What must be continually evaluated during pt transport?
Ventilation
Oxygenation
Circulation
all pts must be transported with what?
O2
what equipment must you have when transporting an ICU patient?
Cardiac Monitor or defibrillator Airway management equipment Oxygen Source with 30 minute reserve Standard Resuscitation drugs Medication
what must be continuously monitored for ICU patients?
EKG
SpO2
what is included in the PACU report
Pt name, Allergies, preop vitals ASA class, Medical Hx Procedure, Surgeon, Anesthesia Type Anesthesia Pre-meds, narcotics, paralytics, Rx Fluids, lines Orders
