Exam 2 - PACU & Complications (Grayson's) Flashcards by Jennifer Valenciano

What is Standard 1 for PACU?

A. All patients who have received general, regional, or monitored anesthesia care shall receive appropriate postanesthesia management.

B. Upon arrival to the PACU, the patient shall be re-evaluated and a verbal report provided to the responsible PACU RN by the member of the anesthesia care team who accompanies the patient.

C. The patient’s condition shall be evaluated continually in the PACU.

D. 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.

A. All patients who have received general, regional, or monitored anesthesia care shall receive appropriate postanesthesia management.

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“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” is what standard?

A. standard 1
B. standard 2
C. standard 4
D. standard 5

B. standard 2

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PACU Standard 3 is:
A. The patient’s condition shall be evaluated continually in the PACU.
B. Physician is responsible for the discharge of the patient from the PACU.
C. Upon arrival to PACU the pt should be re-evaluated and a verbal report to RN should be given by the anesthesia personnel.
D. A pt transported to the PACU shall be accompanied by a member of the anesthesia care team who is knowledgeable about the patient’s condition.

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

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PACU Standard 4 states that:
A. pt should be evaluated q30 mins
B. pt should be evaluated continually in the PACU
C. RN can discharge patient from PACU once vitals stabilize
D. CRNA can leave patient intubated if respiratory therapist is covering PACU

B. The patient shall be evaluated continually in the PACU.

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PACU Standard 5 states that a ____ is responsible for discharge of the patient from the PACU.
A. CRNA
B. physician
C. PACU RN
D. OR manager

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

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What must be assessed if a patient remains intubated in PACU?
A. I & Os
B. neuromuscular function
C. pupils reactivitity
D. ETCO2

B. Neuromuscular function

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How often must vital signs be assessed and recorded during the phase I of recovery?

q5 min for 1st 15 minutes
q15 min for duration of phase 1.

Target vitals within 20% of baseline.

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How often must vital signs be assessed and recorded during the phase II of recovery?

q 30 - 60 mins

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The Modified Aldrete Score is a patient criteria tool for discharge from PACU. What are the 5 components of this tool? select all that apply.
A. O2 saturation
B. respiration and circulation
C. LOC
D. HR
E. presence of PONV
F. activity level
G. pain score

A. O2 saturation
B. respiration and circulation (BP)
C. Level of consciousness
F. activity level

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The Postanesthesia Discharge Score is another tool for determining if pt meets criteria for discharge. What are the 5 aspects of this scoring system? select all that apply
A. surgical bleeding
B. vitals (BP and HR)
C. consciousness
E. presence of PONV
F. activity (ambulation) level
G. pain score

A. surgical bleeding
B. vitals (BP and HR)
E. presence of PONV
F. activity (ambulation) level
G. pain score

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What are the top 2 most common complications that could be seen in the PACU? select 2.
A. hypotension
B. PONV
C. upper airway support required
D. dysrhythmias
E. hypertension

B. PONV = #1
C. upper airway support (OPA or NPA) required = #2

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A post-anesthesia upper airway obstruction is caused by either loss of pharyngeal muscle tone or paradoxical breathing. What are treatment options for this? select 3.
A. jaw thrust
B. apply facemask with tight seal
C. pressure on Larson’s point
D. place an oral/nasal airway
E. CPAP
F. suction airway

A. jaw thrust
D. place an oral/nasal airway
E. CPAP

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Describe a laryngospasm. select 2.

A. occurs from loss of pharyngeal tone
B. vocal cords closing and preventing any air movement
C. can lead to negative pressure pulm edema
D. occurs from paradoxical breathing pattern leading to hypoxemia

B. vocal cords closing and preventing any air movement
C. can lead to negative pressure pulm edema

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A cause of laryngospasms is:

A. stimulation of pharynx or vocal cords
B. usually after deep extubations
C. carotid surgeries
D. thyroidectomy

A. Stimulation of pharynx and/or vocal cords - like from secretions, blood, foreign material (ETT)

Can occur with Regular extubations too so don’t remove monitors right away after extubating a patient

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Negative pressure pulmonary edema results from:
A. high positive intrathoracic pressures attempting to cough
B. high negative intrathoracic pressures attempting to overcome upper airway obstruction
D. high negative intrathoracic pressures attempting to cough
E. high positive intrathoracic pressures attempting to overcome upper airway obstruction

B. high negative intrathoracic pressures attempting to overcome upper airway obstruction

(most common cause is a laryngospasm that is untreated!!)

non-cardiogenic

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A laryngospasm is a prolonged exaggeration of the glottic closure reflex due to stimulation of what nerve?
A. recurrent laryngeal nerve
B. inferior laryngeal nerve
C. superior laryngeal nerve
D. glossopharyngeal nerve

C. superior laryngeal nerve

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Signs/symptoms suggestive of a laryngospasm includes: select 3.
A. extreme deep coughing
B. flailing of upper ribs
C. faint inspiratory stridor
D. tracheal deviation
E. increased resp effort and diaphragmatic excursion
F. flailing of lower ribs

C. faint inspiratory stridor
E. increased resp effort and diaphragmatic excursion
F. flailing of lower ribs

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

Do not squeeze bag during laryngospasm. - WAIT for them to breathe.

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After asking for help, what should the CRNA do as part of the initial intervention to break a laryngospasm? select 2.

A. apply facemask w/ tight seal and 100% FiO2
B. pressure on larson’s point
C. close APL valve to about 40 cmH2O
D. OPA/NPA
E. open APL valve
F. squeeze reservoir bag for more positive pressure

A. apply facemask w/ tight seal and 100% FiO2
C. close APL valve to about 40 cmH2O

Do NOT squeeze the bag.

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

Suction airway
Chin lift and/or jaw thrust
Oral/nasal airways
Laryngospasm notch “Larson’s point” pressure

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Pressure on Larson’s point can help resolve the spasm by clearing airway and stimulation. Where is Larson’s point?
A. at the inion of the skull
B. above each ear lobe near tragus
C. at the conch of each ear
D. behind the lobule of the pinna of each ear

D. behind the lobule of the pinna of each ear

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If unable to break the laryngospasm, an adult patient will have:
A. fast desaturation and tachycardia
B. bradycardia first then desaturation
C. fast desaturation and bradycardia first then an increased hr
D. tachycardia first then desaturation

A. fast desaturation and tachycardia - then bradycardia if becomes hypoxic enough

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If unable to break the laryngospasm, pediatrics will usually have:
A. desaturation first then bradycardia
B. bradycardia first then desaturation
C. fast desaturation then an increased hr
D. tachycardia first then desaturation

B. bradycardia first then desaturation

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

Atropine, Propofol, Deepen Anesthetic, Succinylcholine, reintubate.

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What initial dose of Succinylcholine is typically used for laryngospasm?

0.1 mg/kg (*1/10 of the normal dose*)

# *left from last year's class..* What neuromuscular blocking drug can cause bradycardia in pediatric patients.

Succinylcholine

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

Facial and scleral edema

What factors can precipitate airway edema? select 2. A. long procedures in reverse trendelerburg position B. laryngospasms C. aggressive fluid resuscitation D. long procedures in prone or trendelerburg position

C. aggressive fluid resuscitation - *like in cases with large blood loss* D. long procedures in prone or trendelerburg position and/or *Prolonged intubation*

If the CRNA suspects airway edema, what should be done prior to extubation? select 3. A. suction nasopharynx B. place patient in reverse Tberg to allow airway swelling to decrease C. suction oropharynx D. remove small amount of air from cuff and assess for air moving around cuff E. administer lasix 20 mg IV F. ensure NMB reversal

C. suction oropharynx D. remove small amount of air in cuff and assess if air is moving around cuff = ETT cuff leak test! F. ensure NMB reversal ## Footnote *if you can't hear air around cuff, LEAVE TUBE IN PLACE.*

Airway hematomas are most often seen following: A. neck dissections B. thyroid removal C. carotid surgeries D. all of the above

D. all of the above - Neck dissections - Thyroid removal - Carotid surgeries

Airway hematomas can present as: select 2. A. facial and scleral edema B. tracheal deviation C. huskiness of the voice D. compression of trachea above level of cricoid cartilage E. compression of trachea below level of cricoid cartilage

B. tracheal deviation E. compression of trachea below level of cricoid cartilage

What are treatment options for an airway hematoma?

- Decompress airway be releasing surgical clips or sutures. - Remove SQ blood clot before reintubating - Reintubate - Surgical backup (tracheostomy)

What surgeries/procedures is vocal cord palsy associated with?

- otolaryngologic surgery - Thyroidectomy & parathyroidectomy - Rigid Bronchoscopy - Hyperinflated ETT cuff

If vocal cord palsy is unilateral, then the patient often presents ____. A. asymptomatic B. aphonic C. with voice huskiness D. weakness when speaking

A. asymptomatic

Damage to the external branch of the superior laryngeal nerve presents as: select 2. A. vocal weakness and huskiness B. dysphagia C. aphonia D. wavy-looking vocal cord

A. Vocal weakness and "huskiness" D. wavy-looking vocal cord - *Loss of tension on cord (b/c cricothyroid muscle is paralyzed)*

What does bilateral Recurrent Laryngeal Nerve damage result in?

Aphonia (no voice) & paralyzed vocal cords ## Footnote *extremely rare kind of injury*

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

Intermediate position (not adducted or abducted).

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

cords close causing an airway obstruction during inspiration

Hypocalcemia associated with thyroid surgery can be seen how many hours post-op? A. 6-12 hrs B. 12-24 hrs C. 24-48 hrs D. 48-72 hrs

C. 24 - 48 hours postop

What is Chvostek's sign vs Trousseau's sign? A. Trousseau's is a carpal spasm B. Chvostek's is a carcal spasm C. Trousseau's is a facial spasm D. Chvostek's is a facial spasm

A. Trousseau's = carpal spasm (when u inflate BP cuff) D. Chvostek's = facial spasm

Ways to assess for residual neuromuscular blockade include: select 2. A. patient nodding B. ask patient for their name and DOB C. ability lift arms up over head D. hold head up for 5 seconds E. tongue protrusion

D. hold head up for 5 seconds E. tongue protrusion also: - Grip strength - Ability to lift legs off the bed ## Footnote *just bc u see these signs tho doesn't confirm airway reflexes have returned, check TOF also.*

For patients with OSA, what post-operative pain mgmt is ideal? A. PCA pump with morphine B. regional techniques C. epidural catheter with fentanyl D. PO norco tablets q4-6h

B. regional techniques - *OSA pts are very sensitive to opioids*

What is the STOP-BANG assessment?

**S**nore **T**ired **O**bserved **P**ressure (have or being treated for high BP?) **B**MI > 35 **A**ge > 50 **N**eck circumference > 16in (or 40cm) **G**ender (male)

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

low: 0 - 2 mid: 3 - 4 **high risk of OSA: 5-8**

Flip card for entire STOP-BANG sleep apnea questionnaire

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

- pt is only on room air - Hypoventilation - too much pain meds or benzos

What are treatments for arterial hypoxemia in the PACU patient? select 3. A. apply o2 via NC or facemask B. CPAP or BiPAP C. narcan 20-40 mcg increments D. flumazenil 0.2 mg E. reintubate the patient

A. O₂ via NC or facemask C. narcan 20-40 mcg increments D. flumazenil 0.2 mg (*reverse the opioid or benzo*) and obviously continue to stimulate patient

Diffusion Hypoxia occurs from rapid diffusion of ____ into alveoli at end of its anesthetic. A. N2O B. sevoflurane C. air D. any volatile

A. Diffusion Hypoxia occurs from rapid diffusion of N2O into alveoli at end of nitrous oxide anesthetic. *Dilutes PaO₂ and PaCO₂! → hypoxemia w/ ↓ respiratory drive.*

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

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

What are the standard treatment thresholds for systemic HTN in the PACU?

SBP > 180 DBP > 110

Based on the ppt/lecture, what 3 medications are typically used for treatment of systemic HTN in the PACU? A. labetolol B. hydralazine C. cleviprex D. esmolol E. nicardipine F. lopressor

A. Labetalol (Trandate) : 5-25mg B. Hydralazine (Apresoline) : 5-10mg F. Metoprolol (Lopressor) : 1-5mg

Hypotension from hypovolemic shock that is due to: A. increased afterload B. decreased preload C. decreased afterload D. intrinsic pump failure

B. decreased preload - *from third spacing, ongoing bleeding, inadequate IV fluid replacement, loss of sympathetic tone d/t neuraxial block*

Hypotension from distributive shock is due to: A. increased afterload B. decreased preload C. decreased afterload D. intrinsic pump failure

C. decreased afterload - *from sepsis, allergic rxn, iatrogenic sympathectomy, critical illness*

Hypotension that is due to intrinsic pump failure is considered ____. A. distributive shock B. hypovolemic shock C. cardiogenic shock

C. Cardiogenic shock - from myocardial ischemia/infarctions, cardiac tamponade, cardiac dysrhythmias

What are the two primary types of allergic reactions?

Anaphylactic & Anaphylactoid

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

Epinephrine

What is the most common drug class to cause anaphylactic reactions? A. colloids B. antibiotics C. muscle relaxants D. opioids

C. muscle relaxants - *with Rocuronium being #1 per Dr Cornelius*

What potent inflammatory mediators can cause **bronchial constriction** and **increased vascular permeability**? select 2. A. nitric oxide B. cytokines C. leukotrienes D. histamine E. prostaglandins

C. Leukotrienes E. Prostaglandins

What patient populations are at high risk for latex allergy?

- Repeated exposures (HCW's) - Spina Bifida patients

What are the 3 latex-mediated reactions?

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

What antibiotic causes a direct histamine release? A. PCN B. gentamycin C. vancomycin D. flagyl

C. Vancomycin

What is the most common ABX allergy?

Penicillin

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

Urinary tract manipulation & biliary tract procedures ## Footnote *tx: fluid resuscitation and pressure support*

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

What are factors that decrease myocardial O₂ supply?

What are factors that increase myocardial O₂ demand?

What leads do we want to continuously monitor for myocardial ischemia? A. leads II and III B. leads I and II C. leads II and V5 D. leads V5 and V6

C. leads II and V5 ## Footnote *also want computerized ST segment analysis and get 12 lead EKG if suspicious*

What are the most common causes of sinus tachycardia?

- SNS stimulation - hypovolemia - Anemia - Shivering - Agitation

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

Cardiac and Thoracic sx

What are risk factors for atrial dysthrythmias?

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

Patients that are hemodynamically unstable due to atrial fibrillation require ____. A. amiodarone gtt B. cardioversion C. metoprolol 5 mg D. pacemaker

B. cardioversion - *usually TEE cardioversion*

What medications tend to work well for rate/rhythm control for afib? select 2. A. dobutamine B. adenosine C. CCBs D. beta blockers

C. CCB D. β blockers

Greater than ____ ms is considered a wide QRS complex.

120 ms

What should be investigated with true ventricular tachycardia?

H's & T's

What procedures are associated with bradydysrhythmias?

- Bowel Distention (insufflation?) - ↑ ICP (Trendelenburg, etc.) - ↑ Intraocular pressure (eye sx's) - high spinals (T1-T4)

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

* > 70 years old - Pre-operative cognitive impairment - ↓ Functional status - EtOH abuse

What intra-operative factors are associated with POCD?

- Surgical blood loss (HCT < 30%, PRBC infusions) - hypotension - N2O administration - GETA

What is the #1 cause of delayed awakening? A. hypothermia B. hypoglycemia C. residual sedation from anesthetic D. increased ICP

C. Residual sedation from anesthetic

For delayed awakening secondary to **opioids**, treat with: A. flumazenil 0.2 mg B. narcan 20-40 mcg increments C. physostigmine 0.5-2mg IV D. sugammadex 2 mg/kg

B. narcan 20 - 40 mcg increments

For delayed awakening secondary to **benzodiazepines**, treat with: A. flumazenil 0.2 mg B. narcan 20-40 mcg increments C. physostigmine 0.5-2mg IV D. sugammadex 2 mg/kg

A. flumazenil 0.2mg

For delayed awakening secondary to **scopolamine**, treat with: A. flumazenil 0.2 mg B. narcan 20-40 mcg increments C. physostigmine 0.5-2mg IV D. sugammadex 2 mg/kg

C. physostigmine 0.5-2mg IV

What (besides residual sedation) are common reasons for delayed awakening from anesthesia? (4)

- Hypothermia < 33°C - hypoglycemia - ↑ICP - Residual NMBD's

What are some basic recommendations for discharge from PACU?

What's the criteria for Determination of Discharge from PACU Score?