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Mar: Sem 4 - Principles II > Exam 2: PACU and other yikes things > Flashcards

Exam 2: PACU and other yikes things Flashcards

1
Q

What is Standard 1 for postanesthesia care?

A

All patients who have received any type of anesthetic care should receive appropriate post-anesthetic care.

S4

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2
Q

What is standard 2 for postanesthesia care?

A

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

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3
Q

What is Standard 3 for postanesthesia care?

A

Upon arrival to PACU the patient should be re-evaluated and a verbal report to RN should be given by the anesthesia personnel.

S5

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4
Q

What is Standard 4 for postanesthesia care?

A

The patient shall be evaluated continually in the PACU.

S5

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5
Q

What is Standard 5 for postanesthesia care?

A

A physician is responsible for discharge of the patient from the PACU.

S5

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6
Q

What is the more intense phase of post-anesthetic recovery?

A

Phase 1

S16

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7
Q

In phase 1, what are monitored continuously?

A
  • HR
  • SAT
  • RR
  • ECG
  • airway patency

S16

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8
Q

In phase 1, what are monitored frequently?

A
  • Mental Status
  • Blood pressure
  • Temp
  • pain

S16

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9
Q

What has to be assessed if a patient is still intubated in the PACU?

A

Neuromuscular function

S16

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10
Q

In phase 1, how often are vitals monitored and we want them within ____% of baseline

A
  • 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

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11
Q

What tools are used to determine patients criteria for discharge from PACU? (happens in stage 2)

A
  • Standard Aldrete Score
  • Modified Aldrete Score
  • PACU Discharge Score

S18

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12
Q

Describe the Standard Aldrete Score, what are the 5 items it looks at?

A
  1. Activity
  2. Respiration
  3. Circulation
  4. Consciousness
  5. O2 sat

S19

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13
Q

Describe the Modified Aldrete Score, and what is it usually used for?

A

Usually used for sedation cases
1. Activity
2. Respiration
3. Circulation
4. Consciousness
5. O2 sat

S20

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14
Q

Describe the Postanesthesia Discharge Score.

A
  1. Vital signs (BP and pulse)
  2. Activity
  3. Nausea and vomiting
  4. Pain
  5. Surgical Bleeding

S21

A score of 10 is a perfect score

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15
Q

What is the standard for how often vital signs must be checked in Phase II of recovery?

A

30 - 60 min

S22

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16
Q

What 5 items should be monitored in Phase II of recovery? (other than vital signs)

A
  • Airway and ventilation status
  • Pain level
  • PONV
  • Fluid balance
  • Wound integrity

S22

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17
Q

What are the most common complications that could be seen in the PACU?

A

Top 3:
1. Overall (~22%)
2. N/V (~10%)
3. Upper airway support needed (~8%)

S24

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18
Q

6 examples of Airway complications

A
  • Airway obstruction
  • Laryngospasm
  • Airway Edema/hematoma
  • Vocal Cord Palsy
  • Residual Neuromuscular Block
  • OSA

S26

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19
Q

3 risk factors for airway complications

A
  1. Pt related: examples include COPD, OSA, obesity, HF, tobacco, URI and a high ASA
  2. Prodecure related: examples include surgery near diaphragm, ENT procedures, severe incisional pain, long procedure
  3. Anesthesia related: examples include GETA, NMBD, and opioids

S27

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20
Q

Causes of upper airway obstruction

A
  • Loss of pharyngeal muscle tone (biggest reason)
  • Paradoxical breathing.

S28

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21
Q

What is the treatment of upper airway obstruction?

A
  • Jaw thrust (must keep holding)
  • CPAP
  • Oral/Nasal airway

S28

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22
Q

What are laryngospasms?

A

Vocal cord closure leading to loss of air movement and hypoxemia and negative pressure pulmonary edema.

S29

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23
Q

What are the three most common causes of laryngospasms?

A
  • Stimulation of pharynx and/or vocal cords
  • Secretions, blood, foreign material
  • Regular extubations

S29

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24
Q

What is negative pressure pulmonary edema?

A

Non-cardiogenic pulmonary edema that results from high negative intrathoracic pressures attempting to overcome upper airway obstruction.

S30

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25
Q

What is the most common etiology of negative pressure pulmonary edema?

A

Laryngospasm (or biting on the tube while trying to spont breathe)

Occurs in 12% of laryngospasm cases.

S30

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26
Q

What is the physiology behind laryngospasm?

A

Prolonged exacerbation of glottic closure reflex due to superior laryngeal nerve stimulation.

S31

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27
Q

What are the symptoms of a laryngospasm?

A
  • Faint inspiratory stridor
  • Increased respiratory effort
  • Increased diaphragmatic excursion
  • Flailing of lower ribs

FIRD

S31

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28
Q

At what pressure should the bag be squeezed when treating laryngospasm?

A

Do not squeeze bag during laryngospasm.

Lecture

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29
Q

How should a BVM be utilized in laryngospasm emergency?

A

Apply facemask with tight seal and 100% FiO₂ and closed APL valve to about 40cmH2O.

Do NOT squeeze the bag.

S32

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30
Q

What is the first step in treatment of laryngospasm?

A

Call for help

S32

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31
Q

What should be done after a BVM is utilized for laryngospasm?

A
  • Suction airway
  • Chin lift and/or jaw thrust
  • Oral/nasal airways
  • Laryngospasm notch pressure

S32

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32
Q

What is Larson’s point?
What is its significance?

A

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.

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33
Q

What will indicate a patient is crumping if you can’t break a laryngospasm?

A
  • Tachycardia
  • Fast desaturation

S35

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34
Q

What should be done for a laryngospasm thats failed to respond to conventional treatment?

A

Atropine, Propofol, Succinylcholine, reintubate.

S35

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35
Q

What initial dose of Succinylcholine is typically used for laryngospasm?

A

0.1mg/kg of normal dose

lecture

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36
Q

What neuromuscular blocking drug can cause bradycardia in pediatric patients.

A

Succinylcholine

lecture

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37
Q

Airway edema is associated with…

A
  • prolonged intubation
  • long surgeries in the prone or T-Burg position
  • Cases with large blood loss = agressive fluid resussitation

S36

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38
Q

What would be noted on visual assessment that would indicate to the CRNA that a patient is developing airway edema?

A

Facial and scleral edema

S36

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39
Q

What should be done prior to extubation with expected pulmonary edema?

A
  • Suction Oropharynx
  • ETT cuff leak test

S37

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40
Q

How is an ETT cuff leak test done?

A

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

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41
Q

When are airway hematomas most often seen?

A
  • Neck dissections
  • Thyroid removal
  • Carotid surgeries

S38

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42
Q

A rapidly expanding hematoma may precipitate ____ edema.

A

supraglottic

S38

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43
Q

In the instance of airway hematoma, deviated tracheal rings and compression of the trachea below the ____ are seen.

A

cricoid cartilage

S38

44
Q

What is the treatment for airway hematoma post extubation?

A
  • 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

45
Q

What surgeries and procedures is vocal cord palsy associated with?

A
  • ENT surgery (orolaryngologic surgery)
  • Thyroidectomy & parathyroidectomy
  • Rigid Bronchoscopy
  • Hyperinflated ETT cuff

S40

46
Q

If vocal cord palsy is unilateral, then the patient is often ___________.

A

asymptomatic

S40

47
Q

How would damage to the external branch of the superior laryngeal nerve present?

A
  • Vocal weakness and “huskiness” (cords cannot tense up)
  • Paralyzed cricothyroid muscle
  • Loss of tension → vocal cord looks “wavy”.

S41

48
Q

What does bilateral Recurrent Laryngeal Nerve damage result in?

A

Aphonia & paralyzed vocal cords

S43

49
Q

What position do the vocal cords assume with bilateral Recurrent Laryngeal Nerve damage?

A

Intermediate position (not adducted or abducted).

S43

50
Q

What is the biggest risk associated with bilateral Recurrent Laryngeal Nerve damage?

A

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

51
Q

How long does it typically take for the hypocalcemia associated with thyroid surgery to present?

A

24 - 48 hours postop

S46

52
Q

What is Chvostek’s and Trouseau’s sign?

A
  • Facial spasm
  • Carpal spasm with BP cuff

S46

53
Q

What are some ways to assess for residual neuromuscular blockade?

A
  • 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

54
Q

What medication class are OSA patients sensitive to?

A

Opioids (try regional techniques for post-op pain)

S48

55
Q

What is the STOP-BANG assessing?

A

Snore
Tired
Observed
Pressure
BMI > 35
Age > 50
Neck circumference > 16 in
Gender (male)

S49

56
Q

What score on the STOP-BANG assessment is indicative of a low risk for OSA?

A

0 - 2

S49

57
Q

What score on the STOP-BANG assessment is indicative of a intermediate risk for OSA?

A

3 - 4

S49

58
Q

What score on the STOP-BANG assessment is indicative of a high risk for OSA?

A

5 - 8

S49

59
Q

What is the full STOP-BANG questionnaire?

A

S49

60
Q

What are common causes of arterial hypoxemia in a PACU patient?

A
  • Room air
  • Hypoventilation (too many pain meds, or benzos)
  • OSA

S50

Corn added OSA to the slide

61
Q

What are common treatments for arterial hypoxemia in the PACU patient?

A
  • O₂ with NC or mask
  • Opioid/Benzo reversal
  • Stimulate patient

S50

62
Q

What is Diffusion Hypoxia?

A
  • 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

63
Q

How long can diffusion hypoxia persist after discontinuation of N₂O anesthetic?

A

5-10 min
may contribute to arterial hypoxemia during phase 1 of PACU

S52

64
Q

What are the standard treatment thresholds for hypertension in the PACU?

A

SBP > 180
DBP > 110

S54

65
Q

Common causes of systemic hypertension in the PACU

A
  • Emergence excitement
  • shivering
  • hypercapnia (Corn highlighted this)
  • Pain
  • Agitation
  • Bowel/abd distension (including insuflation pain)
  • urinary retention

S54

66
Q

What medications (and doses) are typically used for treatment of systemic HTN in the PACU?

A

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

67
Q

Hypotension that is due to decreased preload is ____.

A

Hypovolemic shock

S56

68
Q

Hypotension that is due to decreased afterload is ____

A

Distributive shock

S56

69
Q

Hypotension that is due to intrinsic pump failure is ____

A

Cardiogenic shock

S56

70
Q

What are four common causes of decreased preload?

A
  • Third spacing
  • Inadequate fluid replacement
  • Neuraxial blockade → SNS tone loss (sympathetcomy)
  • Bleeding

S57

71
Q

What are four common causes of decreased afterload?

A
  • Sepsis
  • Anaphylaxis
  • Critical illness
  • Iatrogenic sympathectomy

S58

72
Q

What are the two primary types of allergic reactions?

A

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

73
Q

What is the drug of choice for hypotension in an allergic reaction?

A

Epinephrine

S60

74
Q

What are the most common drug classes (and material) cause anaphylactic reactions?

A

Top 3:
1. Muscle relaxants! most common is Roc
2. Rubber/latex
3. Abx

S60-61

75
Q

Why would NMBD cause anaphylaxis?

A
  • Engineered with quaternary ammonium ions (causes IgE allergic reactions)

S62

76
Q

Symptoms of allergeic reaction from NMBD

A
  • vasodilation, erythema, edema, HoTN, GI constriction, tachycardia, pruritus etc

S62

77
Q

We may not see the traditional allergic symptoms if our patient is asleep, what would we see and why?

A
  • 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

78
Q

What patient populations are at high risk for latex allergy?

A
  • Repeated exposures (HCW’s)
  • Spina Bifida patients
  • several surgical procedures

S63

79
Q

What are the three latex-mediated reactions?

A
  • Irritant contact dermatitis
  • Type IV cell-mediated reactions
  • Type I IgE-mediated hypersensitivity reactions

S63

80
Q

What antibiotic causes a direct histamine release?

A

Vancomycin (but red man syndrome is not IgE mediated - histamine only)

S64

81
Q

What is the most common ABX allergy?

A

Penicillin

S64

82
Q

What two surgical procedures mentioned in lecture can lead to sudden sepsis?

A

Procedures involving urinary tract & biliary tract manipulation

S65

83
Q

Immediate treatment of sudden sepsis

A
  • fluid resuscitaiton
  • pressure support

S65

84
Q

What are the three most common causes of intrinsic pump failure?

A
  • Myocardial ischemia/infarction
  • Tamponade (pump fails because it can’t fill)
  • Dysrhythmias

S66

85
Q

What is the risk stratification guideline for non-cardiac surgery?

A

S67

I feel like this is the 3rd class we have had to memorize this risk stuff for

86
Q

What are factors that decrease myocardial O₂ supply?

A

S69

87
Q

What are factors that increase myocardial O₂ demand?

A

S69

88
Q

Causes of cardiac dysrhythmias

A
  • Hypoxemia.
  • Hypoventilation.
  • Endogeneous and exogenous Catecholamine.
  • Electrolyte abnormalities.
  • Anemia.(not adequate o2 carrying capacity)
  • Fluid overload.

S70

89
Q

What are the most common causes of sinus tachycardia?

A
  • SNS stimulation
  • ↓ volume
  • Anemia
  • Shivering
  • Agitation

S71

90
Q

Risk for atrial dysrhythmias is greatest after what types of surgeries?

A

Cardiac and Thoracic

S72

91
Q

What are risk factors for atrial dysthrythmias?

A
  • Pre-existing cardiac conditions
  • Hypervolemia
  • Electrolyte abnormalities
  • O₂ desaturation

S72

92
Q

Patients that are hemodynamically unstable due to atrial dysrhythmias require ____

A

cardioversion

most pts will respond to B-blocker or calcium channel blockers

S73

93
Q

What medications tend to work well for atrial fibrillation?

A
  • β blockers
  • CCBs

S73

94
Q

Greater than ____ ms QRS complex is considered wide.

A

120 ms

PVCs are common but true Ventrucular tachycardia is rare and indicative of underylying cardiac pathyology

S74

95
Q

What should be investigated with true ventricular tachycardia?

A

H’s & T’s

S74

96
Q

What procedures are associated with bradydysrhythmias?

A
  • Bowel Distention from GI stuff
  • ↑ ICP (Trendelenburg, etc.)
  • ↑ Intraocular (eye sx’s)
  • Spinal Anesthesia

S75

97
Q

High spinals reaching the ____ level can block the cardioaccelerator fibers.

A

T1 - T4

The combination of the sympathectomy, bradycardia, and lack of intravascular volume can produce cardiac arrest…even in young healthy patients.

S76

98
Q

What risk factors for Postoperative Cognitive Dysfunction (POCD) were discussed in lecture?

A

-greater than 70 years old
-Pre-operative cognitive impairment
-↓ Functional status
-EtOH abuse

S79

99
Q

What intra-operative factors are associated with POCD?

A
  • Surgical blood loss (HCT < 30%, PRBC infusions)
  • hypotension
  • N2O administration (volatiles too)
  • GETA

S80

100
Q

Differential for delayed awakening

A
  • Eval vitals (hypercapnia)
  • Neuro exam
  • O2 stats
  • BG eval

S82

101
Q

What is the #1 cause of delayed awakening?

A

Residual sedation from anesthetic

S83

102
Q

For delayed awakening secondary to opioids treat with ________ mcg of naloxone.

A

20 - 40 mcg

S83

103
Q

For delayed awakening secondary to benzodiazepines treat with ________ mg of flumazenil.

A

0.2mg

S83

104
Q

For delayed awakening secondary to scopolamine treat with ____ mg of ____

A

0.5 - 2mg IV Physostigmine.

S83

105
Q

What (besides residual sedation) are some common reasons for delayed awakening from anesthesia?

A
  • Hypothermia < 33°C
  • ↓BG
  • ↑ICP
  • Residual NMBD’s

S84

106
Q

What are some basic recommendations for discharge from PACU?

A

S85

107
Q

What is/are the criteria for Determination of Discharge from PACU Score?

A

S86

Mar: Sem 4 - Principles II (27 decks)

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