Emergence & PACU/ICU Transport

Question 1

complications associated with emergence

Answer 1

Airway obstruction
Agitation
Delirium
Pain
Nausea/vomiting
Hypothermia
Shivering
Autonomic lability

Question 2

when do you start planning emergence?

Answer 2

as soon as the patient is asleep

Question 3

what are 5 main factors to consider when emerging a patient

Answer 3

reversed?
breathing spontaneously?
comfortable?
are they gonna vomit?
can they be safely extubated?

Question 4

what are 3 factors that directly influence emergence time?

Answer 4

Agent Solubility (directly)
Agent Concentration (directly)
Duration of Anesthesia (directly)

Question 5

Emergence of inhalational anesthesia depends chiefly on what?

Answer 5

pulmonary elimination

Question 6

____________ blunt the ventilatory responses to both hypercarbia and hypoxemia.

Answer 6

IV or inhalational anesthetics

Question 7

PaCO2 where spontaneous ventilation is initiated

Answer 7

Apneic threshold

Question 8

Maintain FiO2 >_____ during hypoventilation

Answer 8

> 0.85

Question 9

how long do most non-depolarizing blockers work?

Answer 9

15-45 mins

Question 10

a condition where too much CO2 becomes an anesthetic

Answer 10

Hypercarbic narcosis

Question 11

succinylcholine depolarizes the end-plate _______ receptor

Answer 11

nicotinic

Question 12

why does succ have a short duration?

Answer 12

short duration due to pseudocholinesterase metabolism of Succs. It works to depolarize the motor end-plate and then diffuses away and is metabolized

Question 13

which NMB can cause sinus bradycardia?

Answer 13

Succ

Question 14

how to non-depolarizing NMB work?

Answer 14

Competitively inhibit end plate nicotinic cholinergic receptor

Question 15

name 4 possible locations for the nerve stimulator

Answer 15

Ulnar nerve
Facial nerve
Posterior tibial nerve
External peroneal nerve

Question 16

which twitch monitor location most closely reflects blockade at diaphragm?

Answer 16

facial nerve

Question 17

TOF = 4 stimulations @ ___ Hz

Answer 17

2

Question 18

Tetany = __-___ Hz for 5 sec

Answer 18

50-100

Question 19

4/4 = \_\_%
3/4 = \_\_%
2/4 = \_\_%
1/4 = \_\_%
0/4 = \_\_%

Answer 19

4/4 = 75%
3/4 = 85%
2/4 = 90%
1/4 = 95%
0/4 = 99%

Question 20

what class of drug do you reverse NMB with?

Answer 20

anticholinesterase

Question 21

side effects of anticholinesterase

Answer 21

BLUDS

Question 22

what class of drug is used to counter-act the BLUDS?

Answer 22

anti-muscarinic

Question 23

max dose of neostigmine?

peak onset?

Answer 23

0.07mg/kg

5-10 mins

Question 24

how do you assess the adequacy of ventilation during emergence?

Answer 24

• ETCO2
• SpO2 (>90%)
• Tidal Volume (>250ml)

Question 25

3 major candidates for a NAW or OAW

Answer 25

Obesity OSA Hx snoring

Question 26

what is the major factor in arousal of OSA patients?

Answer 26

hypoxia

Question 27

Factors that increase incidence of PONV

Answer 27

``` 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 ```

Question 28

Surgical sites that have increased risk of PONV.

Answer 28

``` Intra-abdominal Laparoscopic Orthopedic Gynecological ENT Breast Plastic Neurosurgical ```

Question 29

what class of drug is Zofran?

Answer 29

Serotonin 5-HT3 receptor antagonist

Question 30

30mg Toradol = ___mg Morphine

Answer 30

10

Question 31

what class of drug is toradol?

Answer 31

NSAID

Question 32

Dilaudid = ____ relative potency morphine | How long does it last?

Answer 32

8x | 4-8 hrs

Question 33

``` Fentanyl = _____ relative potency to morphine Duration _____hour(s) ```

Answer 33

100x | 0.5-1 hrs

Question 34

Titrate narcotics to RR _____ BPM

Answer 34

Titrate to RR 10-16 BPM

Question 35

factors for extubation

Answer 35

``` Airway protective reflexes intact Clinical stability Intact neurological function Adequate pulmonary function Normal body temp (T 35-37 C) Normal neuromuscular function Normal coagulation ```

Question 36

what is a major contraindication for droperidol?

Answer 36

parkinson's

Question 37

at what stage(s) is it safe to extubate?

Answer 37

1. awake 3. surgical (NOT 2. excitatory or 4. depression)

Question 38

what are some immediate hazards of extubation?

Answer 38

laryngospasm vomiting bronchospasm

Question 39

purpose of deep extubation

Answer 39

Minimize tracheal stimulation | Minimize coughing/bucking

Question 40

Contraindications of deep extubation

Answer 40

Difficult mask airway Difficult intubation Aspiration risk Airway edema

Question 41

criteria for deep extubation

Answer 41

``` MAC 1.3 NMB completely reversed Spont ventilation at regular rate/rhythm No airway reflexes 100% O2 Lidocaine (0.5 mg/kg) ```

Question 42

NEVER extubate a patient deep without _______ in place

Answer 42

an oral airway

Question 43

what do you do immediately following extubation?

Answer 43

``` 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. ```

Question 44

ASA Standard 1 PACU

Answer 44

All patients who have received general, regional, or monitored anesthesia care shall receive appropriate post-anesthesia management

Question 45

ASA Standard 2 PACU

Answer 45

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

Question 46

What must be continually evaluated during pt transport?

Answer 46

Ventilation Oxygenation Circulation

Question 47

all pts must be transported with what?

Answer 47

O2

Question 48

what equipment must you have when transporting an ICU patient?

Answer 48

``` Cardiac Monitor or defibrillator Airway management equipment Oxygen Source with 30 minute reserve Standard Resuscitation drugs Medication ```

Question 49

what must be continuously monitored for ICU patients?

Answer 49

EKG | SpO2

Question 50

what is included in the PACU report

Answer 50

``` Pt name, Allergies, preop vitals ASA class, Medical Hx Procedure, Surgeon, Anesthesia Type Anesthesia Pre-meds, narcotics, paralytics, Rx Fluids, lines Orders ```