Exam 2: PACU and other yikes things Flashcards
What is Standard 1 for postanesthesia care?
All patients who have received any type of anesthetic care should receive appropriate post-anesthetic care.
S4
What is standard 2 for postanesthesia care?
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.
S4
What is Standard 3 for postanesthesia care?
Upon arrival to PACU the patient should be re-evaluated and a verbal report to RN should be given by the anesthesia personnel.
S5
What is Standard 4 for postanesthesia care?
The patient shall be evaluated continually in the PACU.
S5
What is Standard 5 for postanesthesia care?
A physician is responsible for discharge of the patient from the PACU.
S5
What is the more intense phase of post-anesthetic recovery?
Phase 1
S16
In phase 1, what are monitored continuously?
- HR
- SAT
- RR
- ECG
- airway patency
S16
In phase 1, what are monitored frequently?
- Mental Status
- Blood pressure
- Temp
- pain
S16
What has to be assessed if a patient is still intubated in the PACU?
Neuromuscular function
S16
In phase 1, how often are vitals monitored and we want them within ____% of baseline
- vital signs:
- q5min for the first 15 min
- q15min for the duration of phase 1
we usually want the pts vitals within 20% of baseline
S17
What tools are used to determine patients criteria for discharge from PACU? (happens in stage 2)
- Standard Aldrete Score
- Modified Aldrete Score
- PACU Discharge Score
S18
Describe the Standard Aldrete Score, what are the 5 items it looks at?
- Activity
- Respiration
- Circulation
- Consciousness
- O2 sat
S19
Describe the Modified Aldrete Score, and what is it usually used for?
Usually used for sedation cases
1. Activity
2. Respiration
3. Circulation
4. Consciousness
5. O2 sat
S20
Describe the Postanesthesia Discharge Score.
- Vital signs (BP and pulse)
- Activity
- Nausea and vomiting
- Pain
- Surgical Bleeding
S21
A score of 10 is a perfect score
What is the standard for how often vital signs must be checked in Phase II of recovery?
30 - 60 min
S22
What 5 items should be monitored in Phase II of recovery? (other than vital signs)
- Airway and ventilation status
- Pain level
- PONV
- Fluid balance
- Wound integrity
S22
What are the most common complications that could be seen in the PACU?
Top 3:
1. Overall (~22%)
2. N/V (~10%)
3. Upper airway support needed (~8%)
S24
6 examples of Airway complications
- Airway obstruction
- Laryngospasm
- Airway Edema/hematoma
- Vocal Cord Palsy
- Residual Neuromuscular Block
- OSA
S26
3 risk factors for airway complications
- Pt related: examples include COPD, OSA, obesity, HF, tobacco, URI and a high ASA
- Prodecure related: examples include surgery near diaphragm, ENT procedures, severe incisional pain, long procedure
- Anesthesia related: examples include GETA, NMBD, and opioids
S27
Causes of upper airway obstruction
- Loss of pharyngeal muscle tone (biggest reason)
- Paradoxical breathing.
S28
What is the treatment of upper airway obstruction?
- Jaw thrust (must keep holding)
- CPAP
- Oral/Nasal airway
S28
What are laryngospasms?
Vocal cord closure leading to loss of air movement and hypoxemia and negative pressure pulmonary edema.
S29
What are the three most common causes of laryngospasms?
- Stimulation of pharynx and/or vocal cords
- Secretions, blood, foreign material
- Regular extubations
S29
What is negative pressure pulmonary edema?
Non-cardiogenic pulmonary edema that results from high negative intrathoracic pressures attempting to overcome upper airway obstruction.
S30
What is the most common etiology of negative pressure pulmonary edema?
Laryngospasm (or biting on the tube while trying to spont breathe)
Occurs in 12% of laryngospasm cases.
S30
What is the physiology behind laryngospasm?
Prolonged exacerbation of glottic closure reflex due to superior laryngeal nerve stimulation.
S31
What are the symptoms of a laryngospasm?
- Faint inspiratory stridor
- Increased respiratory effort
- Increased diaphragmatic excursion
- Flailing of lower ribs
FIRD
S31
At what pressure should the bag be squeezed when treating laryngospasm?
Do not squeeze bag during laryngospasm.
Lecture
How should a BVM be utilized in laryngospasm emergency?
Apply facemask with tight seal and 100% FiO₂ and closed APL valve to about 40cmH2O.
Do NOT squeeze the bag.
S32
What is the first step in treatment of laryngospasm?
Call for help
S32
What should be done after a BVM is utilized for laryngospasm?
- Suction airway
- Chin lift and/or jaw thrust
- Oral/nasal airways
- Laryngospasm notch pressure
S32
What is Larson’s point?
What is its significance?
Pressure point behind of the lobule of the pinna of each ear that can help relieve laryngospasm.
I.e. Laryngospasm notch
S33
Forcible jaw thrust with bilateral digital pressure resolves the spasm by clearing airway and stimulation.
Apply for 3-5 seconds, then release for 5-10 seconds, while maintaining tight seal with the facemask.
What will indicate a patient is crumping if you can’t break a laryngospasm?
- Tachycardia
- Fast desaturation
S35
What should be done for a laryngospasm thats failed to respond to conventional treatment?
Atropine, Propofol, Succinylcholine, reintubate.
S35
What initial dose of Succinylcholine is typically used for laryngospasm?
0.1mg/kg of normal dose
lecture
What neuromuscular blocking drug can cause bradycardia in pediatric patients.
Succinylcholine
lecture
Airway edema is associated with…
- prolonged intubation
- long surgeries in the prone or T-Burg position
- Cases with large blood loss = agressive fluid resussitation
S36
What would be noted on visual assessment that would indicate to the CRNA that a patient is developing airway edema?
Facial and scleral edema
S36
What should be done prior to extubation with expected pulmonary edema?
- Suction Oropharynx
- ETT cuff leak test
S37
How is an ETT cuff leak test done?
Remove small amount of air from cuff and assess for air movement around the cuff. If air cannot be heard then leave the tube in place.
S37
When are airway hematomas most often seen?
- Neck dissections
- Thyroid removal
- Carotid surgeries
S38
A rapidly expanding hematoma may precipitate ____ edema.
supraglottic
S38
In the instance of airway hematoma, deviated tracheal rings and compression of the trachea below the ____ are seen.
cricoid cartilage
S38
What is the treatment for airway hematoma post extubation?
- Decompress airway by releasing surgical clips or sutures.
- Remove SQ blood clot before reintubating
- Reintubate (have advanced airway equipment ready)
- Surgical backup (tracheostomy)
S39
Corn says an awake intubation would be a good idea - a paralytic will relax the airway and collapse it more yikes
What surgeries and procedures is vocal cord palsy associated with?
- ENT surgery (orolaryngologic surgery)
- Thyroidectomy & parathyroidectomy
- Rigid Bronchoscopy
- Hyperinflated ETT cuff
S40
If vocal cord palsy is unilateral, then the patient is often ___________.
asymptomatic
S40
How would damage to the external branch of the superior laryngeal nerve present?
- Vocal weakness and “huskiness” (cords cannot tense up)
- Paralyzed cricothyroid muscle
- Loss of tension → vocal cord looks “wavy”.
S41
What does bilateral Recurrent Laryngeal Nerve damage result in?
Aphonia & paralyzed vocal cords
S43
What position do the vocal cords assume with bilateral Recurrent Laryngeal Nerve damage?
Intermediate position (not adducted or abducted).
S43
What is the biggest risk associated with bilateral Recurrent Laryngeal Nerve damage?
Airway obstruction during inspiration because the cords can close during inspiration (extrememly rare)
S43
Corn says have a high index of suspition if the person can’t talk
How long does it typically take for the hypocalcemia associated with thyroid surgery to present?
24 - 48 hours postop
S46
What is Chvostek’s and Trouseau’s sign?
- Facial spasm
- Carpal spasm with BP cuff
S46
What are some ways to assess for residual neuromuscular blockade?
- Grip strength
- Tongue protrusion
- Ability to lift legs
- Able to hold head up for 5 seconds
just because you see these signs doesn’t mean your patient’s airway reflexes have returned
S47
meds can also contribute (lido drip or mag) can result in more weakness in PACU
What medication class are OSA patients sensitive to?
Opioids (try regional techniques for post-op pain)
S48
What is the STOP-BANG assessing?
Snore
Tired
Observed
Pressure
BMI > 35
Age > 50
Neck circumference > 16 in
Gender (male)
S49
What score on the STOP-BANG assessment is indicative of a low risk for OSA?
0 - 2
S49
What score on the STOP-BANG assessment is indicative of a intermediate risk for OSA?
3 - 4
S49
What score on the STOP-BANG assessment is indicative of a high risk for OSA?
5 - 8
S49
What is the full STOP-BANG questionnaire?
S49
What are common causes of arterial hypoxemia in a PACU patient?
- Room air
- Hypoventilation (too many pain meds, or benzos)
- OSA
S50
Corn added OSA to the slide
What are common treatments for arterial hypoxemia in the PACU patient?
- O₂ with NC or mask
- Opioid/Benzo reversal
- Stimulate patient
S50
What is Diffusion Hypoxia?
- Rapid diffusion of N₂O into alveoli at end of anesthetic. (second gas effect in reverse)
- Dilutes and decreases PaO₂ and PaCO₂ → hypoxemia w/ ↓ respiratory drive at room air.
*The decrease PaO2 produces arterial hypoximea while the PaCO2 depresses the resp. drive
S51
How long can diffusion hypoxia persist after discontinuation of N₂O anesthetic?
5-10 min
may contribute to arterial hypoxemia during phase 1 of PACU
S52
What are the standard treatment thresholds for hypertension in the PACU?
SBP > 180
DBP > 110
S54
Common causes of systemic hypertension in the PACU
- Emergence excitement
- shivering
- hypercapnia (Corn highlighted this)
- Pain
- Agitation
- Bowel/abd distension (including insuflation pain)
- urinary retention
S54
What medications (and doses) are typically used for treatment of systemic HTN in the PACU?
Labetalol (5 - 25mg)- HTN + Tachy
Hydralazine (5 - 10mg) - Okay with bradycardia
Metoprolol (1 - 5mg)- With HF patient, right?
Dont forget to treat the underlying cause tho
S55
Hypotension that is due to decreased preload is ____.
Hypovolemic shock
S56
Hypotension that is due to decreased afterload is ____
Distributive shock
S56
Hypotension that is due to intrinsic pump failure is ____
Cardiogenic shock
S56
What are four common causes of decreased preload?
- Third spacing
- Inadequate fluid replacement
- Neuraxial blockade → SNS tone loss (sympathetcomy)
- Bleeding
S57
What are four common causes of decreased afterload?
- Sepsis
- Anaphylaxis
- Critical illness
- Iatrogenic sympathectomy
S58
What are the two primary types of allergic reactions?
Anaphylactic & Anaphylactoid
From Dr. Google: Anaphylaxis is an allergic reaction caused by the release of mediators from mast cells and basophils in response to an allergen (IgE). Anaphylactoid reactions are caused by the release of mediators from mast cells and basophils by non-IgE-mediated triggering events.
S60
What is the drug of choice for hypotension in an allergic reaction?
Epinephrine
S60
What are the most common drug classes (and material) cause anaphylactic reactions?
Top 3:
1. Muscle relaxants! most common is Roc
2. Rubber/latex
3. Abx
S60-61
Why would NMBD cause anaphylaxis?
- Engineered with quaternary ammonium ions (causes IgE allergic reactions)
S62
Symptoms of allergeic reaction from NMBD
- vasodilation, erythema, edema, HoTN, GI constriction, tachycardia, pruritus etc
S62
We may not see the traditional allergic symptoms if our patient is asleep, what would we see and why?
- you will likely only see hemodynamic changes:
- Potent inflammatory leukotrienes (LTC) and prostaglandins (PGD) = bronchial constriction & increased vascular permeability
look for increased airway pressures and hypotension
S62
What patient populations are at high risk for latex allergy?
- Repeated exposures (HCW’s)
- Spina Bifida patients
- several surgical procedures
S63
What are the three latex-mediated reactions?
- Irritant contact dermatitis
- Type IV cell-mediated reactions
- Type I IgE-mediated hypersensitivity reactions
S63
What antibiotic causes a direct histamine release?
Vancomycin (but red man syndrome is not IgE mediated - histamine only)
S64
What is the most common ABX allergy?
Penicillin
S64
What two surgical procedures mentioned in lecture can lead to sudden sepsis?
Procedures involving urinary tract & biliary tract manipulation
S65
Immediate treatment of sudden sepsis
- fluid resuscitaiton
- pressure support
S65
What are the three most common causes of intrinsic pump failure?
- Myocardial ischemia/infarction
- Tamponade (pump fails because it can’t fill)
- Dysrhythmias
S66
What is the risk stratification guideline for non-cardiac surgery?
S67
I feel like this is the 3rd class we have had to memorize this risk stuff for
What are factors that decrease myocardial O₂ supply?
S69
What are factors that increase myocardial O₂ demand?
S69
Causes of cardiac dysrhythmias
- Hypoxemia.
- Hypoventilation.
- Endogeneous and exogenous Catecholamine.
- Electrolyte abnormalities.
- Anemia.(not adequate o2 carrying capacity)
- Fluid overload.
S70
What are the most common causes of sinus tachycardia?
- SNS stimulation
- ↓ volume
- Anemia
- Shivering
- Agitation
S71
Risk for atrial dysrhythmias is greatest after what types of surgeries?
Cardiac and Thoracic
S72
What are risk factors for atrial dysthrythmias?
- Pre-existing cardiac conditions
- Hypervolemia
- Electrolyte abnormalities
- O₂ desaturation
S72
Patients that are hemodynamically unstable due to atrial dysrhythmias require ____
cardioversion
most pts will respond to B-blocker or calcium channel blockers
S73
What medications tend to work well for atrial fibrillation?
- β blockers
- CCBs
S73
Greater than ____ ms QRS complex is considered wide.
120 ms
PVCs are common but true Ventrucular tachycardia is rare and indicative of underylying cardiac pathyology
S74
What should be investigated with true ventricular tachycardia?
H’s & T’s
S74
What procedures are associated with bradydysrhythmias?
- Bowel Distention from GI stuff
- ↑ ICP (Trendelenburg, etc.)
- ↑ Intraocular (eye sx’s)
- Spinal Anesthesia
S75
High spinals reaching the ____ level can block the cardioaccelerator fibers.
T1 - T4
The combination of the sympathectomy, bradycardia, and lack of intravascular volume can produce cardiac arrest…even in young healthy patients.
S76
What risk factors for Postoperative Cognitive Dysfunction (POCD) were discussed in lecture?
-greater than 70 years old
-Pre-operative cognitive impairment
-↓ Functional status
-EtOH abuse
S79
What intra-operative factors are associated with POCD?
- Surgical blood loss (HCT < 30%, PRBC infusions)
- hypotension
- N2O administration (volatiles too)
- GETA
S80
Differential for delayed awakening
- Eval vitals (hypercapnia)
- Neuro exam
- O2 stats
- BG eval
S82
What is the #1 cause of delayed awakening?
Residual sedation from anesthetic
S83
For delayed awakening secondary to opioids treat with ________ mcg of naloxone.
20 - 40 mcg
S83
For delayed awakening secondary to benzodiazepines treat with ________ mg of flumazenil.
0.2mg
S83
For delayed awakening secondary to scopolamine treat with ____ mg of ____
0.5 - 2mg IV Physostigmine.
S83
What (besides residual sedation) are some common reasons for delayed awakening from anesthesia?
- Hypothermia < 33°C
- ↓BG
- ↑ICP
- Residual NMBD’s
S84
What are some basic recommendations for discharge from PACU?
S85
What is/are the criteria for Determination of Discharge from PACU Score?
S86
