Nagelhout Chapter 55 Flashcards
What are the postanesthesia recovery goals?
Stabilization of vitals (respiratory, cardiovascular, neurological), detection and prevention of complications, and facilitating patient transition from the OR to PACU, ICU, inpatient ward, or home.
What is Phase I PACU?
Intensive monitoring after general/regional anesthesia where patients requiring ventilator support or close monitoring remain longer.
What is Phase II PACU?
Focuses on recovery before discharge home for outpatient surgery. Patients must meet discharge criteria including stable vitals, minimal pain, controlled nausea, and mobility.
What is the importance of advance notification to PACU staff?
Allows staff to prepare necessary equipment and prevents delays in providing critical postanesthesia care.
What is the role of the anesthesia provider during patient transfer to PACU?
Ensures airway patency and hemodynamic stability during transport and provides a verbal handoff report to PACU staff.
What is the role of the PACU nurse during patient transfer?
Prepares necessary equipment and monitors the patient immediately upon arrival, assessing oxygenation, airway patency, and circulation.
What are the initial PACU priorities?
Respiratory system assessment, cardiovascular assessment, neurological and mental status, pain and comfort assessment, temperature regulation, and fluid and electrolyte balance.
What does respiratory system assessment in PACU involve?
Monitoring oxygenation and ventilation, identifying airway obstruction, and immediate intervention for hypoxia.
What does cardiovascular assessment in PACU involve?
ECG monitoring for arrhythmias, blood pressure monitoring, and perfusion assessment.
How is neurological and mental status assessed in PACU?
Using the Glasgow Coma Scale (GCS) to assess level of consciousness and orientation.
What is used for pain and comfort assessment in PACU?
Numeric pain scale (0-10) or visual analog scale (VAS) and administration of analgesics based on PACU pain protocols.
What is monitored for temperature regulation in PACU?
Monitoring for hypothermia (<36°C) and using forced-air warmers or heated IV fluids.
What is involved in fluid and electrolyte balance monitoring in PACU?
Urine output monitoring and electrolyte assessment to correct imbalances.
What is the purpose of the anesthesia handoff report?
To ensure patient safety and continuity of care by providing structured information.
What should the anesthesia handoff report include?
Patient identification, surgical procedure details, anesthetic technique, intraoperative course, postoperative considerations, and PACU treatment plan.
What are the initial PACU assessment and monitoring requirements?
Continuous monitoring for at least 30-60 minutes post-surgery or until discharge criteria are met.
What should be monitored for airway and breathing in PACU?
Hypoventilation, upper airway obstruction, and adequate reversal of neuromuscular blockade.
What cardiovascular stability checks are performed in PACU?
Monitoring heart rate, rhythm, and blood pressure for signs of hypotension.
What is assessed for neurologic function in PACU?
Level of consciousness and monitoring for emergence delirium or excessive sedation.
How is pain and discomfort managed in PACU?
Administering appropriate analgesics based on pain assessment scales and using multimodal pain management.
What measures are taken for temperature regulation in PACU?
Preventing hypothermia and implementing active warming measures when necessary.
What is involved in surgical site and drain management in PACU?
Assessing for excessive bleeding, hematoma formation, or infection, and monitoring dressings and drains.
What gastrointestinal function assessments are performed in PACU?
Evaluating for nausea and vomiting and monitoring bowel sounds.
What is monitored for urine output and renal function in PACU?
Ensuring adequate urine output and watching for signs of acute kidney injury or urinary retention.
What are Postanesthesia Recovery Scoring Systems used for?
They are used to determine when a patient is ready for discharge from PACU.
What is the Aldrete Score?
A scoring system on a 0-10 scale that assesses activity, respiration, circulation, consciousness, and oxygen saturation. A score of 9-10 is required for PACU discharge.
What does the Modified Postanesthesia Discharge Scoring System (PADS) include?
It includes assessments of pain control, nausea, and ambulation.
What are the criteria for PACU discharge?
Criteria include airway & breathing, hemodynamic stability, neurologic status, pain control, nausea/vomiting, and surgical site stability.
What should be assessed for respiratory function postoperatively?
Assess for airway obstruction, hypoxemia, and hypercarbia.
What should be monitored for cardiovascular function Preoperatively and postop?
Monitor for hypotension, hypertension, and dysrhythmias.
What are the clinical signs of airway obstruction?
Signs include snoring and noisy breathing, use of accessory muscles, hypoxia and cyanosis, and somnolence with difficulty arousing.
What is the most frequent cause of airway obstruction after surgery?
Loss of pharyngeal muscle tone due to residual effects of anesthesia, neuromuscular blocking agents, and opioids.
What is laryngospasm?
An involuntary closure of the vocal cords or laryngeal structures, leading to airflow restriction.
What are some triggers for laryngospasm?
Triggers include secretions, blood, or vomitus in the airway, intubation or extubation trauma, and bronchospasm.
What are the symptoms of laryngospasm?
Symptoms include a crowing sound (stridor), silent airway, and severe respiratory distress.
What is the immediate intervention for laryngospasm?
A jaw thrust with CPAP (up to 40 cm H₂O) often breaks the spasm.
What medications may be administered if laryngospasm persists?
IV succinylcholine (0.1–1 mg/kg) or IM succinylcholine (4 mg/kg) may be administered.
What are preventive measures for laryngospasm?
Preventive measures include suctioning to clear blood or secretions, timing of extubation, and pharmacologic prevention with IV or topical lidocaine and corticosteroids.
What are the respiratory signs and symptoms of hypoxia?
Shallow, rapid respirations or normal, infrequent respirations; Tachypnea; Dyspnea; Oxygen saturation <90%
What are the neurologic signs and symptoms of hypoxia?
Anxiety, restlessness, inattentiveness; Altered mental status, confusion; Dimmed peripheral vision; Seizures; Combativeness, late; Unresponsiveness, late
What are the skin signs and symptoms of hypoxia?
Diaphoresis; Cyanosis
What are the cardiac signs and symptoms of hypoxia?
Early: Tachycardia, Increased cardiac output, Increased stroke volume, Increased blood pressure; Late: Bradycardia, hypotension, Dysrhythmias
What is hypoventilation in relation to hypoxemia?
Alveolar ventilation is abnormally low in relation to oxygen uptake or carbon dioxide output; causes a raised arterial Pco2 and arterial hypoxemia
What is diffusion limitation in relation to hypoxemia?
Oxygen and carbon dioxide are affected as they cross the blood-gas barrier by simple passive diffusion
What is a shunt in relation to hypoxemia?
The entry of blood into the systemic arterial system without going through ventilated areas of the lung
What are ventilation-perfusion relationships in relation to hypoxemia?
A mismatch of ventilation and blood flow
What is Obstructive Sleep Apnea (OSA)?
A condition characterized by periodic airway collapse during sleep due to reduced muscle tone.
What are the higher risks of OSA in postoperative patients?
Difficult Intubation, Prolonged PACU Stay, Respiratory and Cardiovascular Complications, Unplanned ICU Admissions.
What tool is used for preoperative screening for OSA?
STOP-Bang Questionnaire is a validated tool used to assess OSA risk.
What is the preferred anesthesia for postoperative management of OSA patients?
Regional Anesthesia is preferable to general anesthesia to reduce airway complications.
What should be avoided to prevent airway collapse in OSA patients?
Minimized Sedation: Avoid opioids and excessive sedation.
What should OSA patients bring for postoperative use?
Patients should bring their CPAP machines for postoperative use.
What positioning is optimal for maintaining airway patency in OSA patients?
Elevate the head of the bed or use a lateral position.
What monitoring is recommended for OSA patients postoperatively?
Close Monitoring: Continuous pulse oximetry and capnography.
What is hypoxemia?
A state of low oxygen levels in arterial blood (PaO₂ < 60 mmHg), which can lead to tissue hypoxia, organ dysfunction, and irreversible organ failure.
What are early neurological signs of hypoxemia?
Agitation, restlessness, confusion.
What are late neurological signs of hypoxemia?
Somnolence, stupor, coma.
What are the compensatory cardiovascular signs of hypoxemia?
Hypertension, tachycardia.
What are the decompensatory cardiovascular signs of hypoxemia?
Hypotension, bradycardia, arrhythmias.
What are mild respiratory signs of hypoxemia?
Tachypnea (increased respiratory rate).
What are severe respiratory signs of hypoxemia?
Cyanosis (bluish lips, nails), use of accessory muscles.
What metabolic condition can occur due to hypoxemia?
Lactic acidosis (due to anaerobic metabolism in hypoxic tissues).
What is the role of Pulse Oximetry in diagnosing hypoxemia?
Non-invasive but may be inaccurate in anemic, hypothermic, or vasoconstricted patients.
What does Arterial Blood Gas (ABG) Analysis confirm?
Confirms hypoxemia (PaO₂ < 60 mmHg) and evaluates pH, CO₂ retention, and metabolic status.
What does a left shift in the Oxyhemoglobin Dissociation Curve indicate?
Hemoglobin holds oxygen tightly (caused by alkalosis, low CO₂, low temp).
What does a right shift in the Oxyhemoglobin Dissociation Curve indicate?
Oxygen release is enhanced (caused by acidosis, high CO₂, fever).
What are common causes of postoperative hypoxemia?
Atelectasis, Pulmonary Edema, Pulmonary Embolism, Aspiration Pneumonitis, Bronchospasm, Hypoventilation, Ventilation-Perfusion (V/Q) Mismatch, Intrapulmonary Shunting.
What is Atelectasis?
Atelectasis is the collapse of alveoli, leading to impaired gas exchange and hypoxemia due to decreased lung compliance and oxygenation.
What are the causes of Atelectasis?
- Bronchial Obstruction: Due to mucus plugs or retained secretions.
- Reduced Lung Expansion: Shallow breathing after surgery.
- Prolonged Immobility: Lack of deep breathing increases alveolar collapse.
- Low Cardiac Output & Hypotension: Decreases pulmonary blood flow.
What are the symptoms and signs of Atelectasis?
- Decreased breath sounds over affected lung fields.
- Dullness to percussion.
- Mild tachypnea and respiratory distress.
- Hypoxemia despite supplemental oxygen.
What are the prevention and treatment methods for Atelectasis?
- Incentive Spirometry: Encourages deep breathing.
- Early Ambulation: Reduces risk of alveolar collapse.
- Pain Control: Prevents shallow breathing due to discomfort.
- Humidified Oxygen Therapy: Keeps airways moist.
- Postural Drainage & Chest Physiotherapy: Clears mucus.
- Smoking Cessation (6-8 weeks pre-op): Improves lung function.
What is Pulmonary Edema?
Pulmonary Edema is fluid accumulation in the alveoli, leading to severe respiratory distress and hypoxemia.
What are the types and causes of Cardiogenic Pulmonary Edema?
- Fluid Overload: IV fluids, transfusions.
- Left Ventricular Failure: Caused by heart disease, hypertension.
- Mitral Valve Dysfunction: Impaired blood flow from left atrium.
What are the types and causes of Noncardiogenic Pulmonary Edema?
- Sepsis: Damages alveolar-capillary membranes.
- Aspiration Pneumonitis: Causes lung injury.
- Anaphylaxis, Trauma, Burns.
What is Negative Pressure Pulmonary Edema?
Occurs after prolonged airway obstruction (e.g., laryngospasm). Strong inspiratory efforts create extreme negative pressure, pulling fluid into alveoli. Most common in young, muscular patients who generate powerful inspiratory forces.
What are the symptoms and signs of Pulmonary Edema?
- Severe hypoxemia (PaO₂ < 60 mmHg).
- Dyspnea, tachypnea.
What is the prognosis for Noncardiogenic Pulmonary Edema?
Noncardiogenic Pulmonary Edema resolves within 12–48 hours with proper treatment.
What is Pulmonary Embolism (PE)?
PE occurs when a blood clot blocks pulmonary circulation, causing sudden cardiovascular collapse and respiratory failure.
What are the risk factors for Pulmonary Embolism (Virchow’s Triad)?
- Venous Stasis: Immobilization, prolonged surgery, obesity.
- Hypercoagulability: Cancer, pregnancy, clotting disorders.
- Vascular Damage: Surgery, fractures, trauma.
What are the symptoms and signs of Pulmonary Embolism?
- Acute dyspnea and tachypnea (even with oxygen therapy).
- Pleuritic chest pain (sharp pain with breathing).
- Tachycardia, hypotension, right heart strain.
- Cyanosis, hemoptysis (coughing blood).
What is the diagnosis for Pulmonary Embolism?
- CT Pulmonary Angiography (CTA): Gold standard for PE.
- D-dimer test: Elevated in clot formation.
- Echocardiography: Right ventricular dysfunction.
- Ventilation-Perfusion (V/Q) Scan: Alternative to CTA.
What are the treatments for Pulmonary Embolism?
- Oxygen Therapy: CPAP or mechanical ventilation for severe cases.
- Anticoagulation: IV Heparin, Low Molecular Weight Heparin (LMWH), Rivaroxaban, Unfractionated Heparin.
- Thrombolytics (tPA, Alteplase): For massive PE with hemodynamic instability.
- Surgical Thrombectomy: If anticoagulation is contraindicated.
- IVC Filter: Prevents embolization in high-risk patients.
What are the prevention methods for Pulmonary Edema?
- Frothy pink sputum.
- Crackles (rales) on auscultation.
- Chest X-ray: Bilateral infiltrates.
- Oxygen Therapy: CPAP, BiPAP, or mechanical ventilation with PEEP.
- Diuretics (Furosemide): Reduces fluid overload.
- Vasodilators (Nitroglycerin, Nitroprusside): Reduces cardiac workload.
- Fluid Restriction: Limits excess fluid retention.
What is Pulmonary Embolism (PE)?
Occurs when a blood clot blocks pulmonary circulation, causing sudden cardiovascular collapse and respiratory failure.
What are the components of Virchow’s Triad risk factors for PE?
- Venous Stasis: Immobilization, prolonged surgery, obesity. 2. Hypercoagulability: Cancer, pregnancy, clotting disorders. 3. Vascular Damage: Surgery, fractures, trauma.
What are the symptoms and signs of PE?
Acute dyspnea and tachypnea, pleuritic chest pain, tachycardia, hypotension, right heart strain, cyanosis, hemoptysis.
What is the gold standard for diagnosing PE?
CT Pulmonary Angiography (CTA).
What tests are used to diagnose PE?
- D-dimer test: Elevated in clot formation. 2. Echocardiography: Right ventricular dysfunction. 3. Ventilation-Perfusion (V/Q) Scan: Alternative to CTA.
What is the treatment for severe cases of PE?
Oxygen Therapy: CPAP or mechanical ventilation.
What anticoagulation treatments are used for PE?
- IV Heparin: Prevents clot expansion. 2. Low Molecular Weight Heparin (LMWH), Rivaroxaban: Preferred in low-risk cases. 3. Unfractionated Heparin: Preferred for renal failure patients.
What are thrombolytics used for in PE treatment?
Thrombolytics (tPA, Alteplase) are used for massive PE with hemodynamic instability.
What is a surgical option for PE treatment?
Surgical Thrombectomy: If anticoagulation is contraindicated.
What is an IVC Filter used for?
Prevents embolization in high-risk patients.
What are some prevention strategies for PE?
- Early Mobilization: Encourages venous return. 2. Compression Stockings, SCDs: Prevent blood pooling. 3. Prophylactic Anticoagulation: Low-dose Heparin or LMWH.
What is aspiration?
Occurs when foreign material enters the airway, potentially leading to airway obstruction, chemical pneumonitis, or infectious pneumonia.
What are common sources of foreign matter aspiration?
Teeth, food, surgical debris.
What are the effects of foreign matter aspiration?
Airway obstruction, bronchospasm, atelectasis, pneumonia.
What are the signs and symptoms of aspiration?
Coughing, reflex sympathetic nervous system activation leading to hypertension, tachycardia, dysrhythmias.
What is the treatment for foreign matter aspiration?
Encourage coughing or perform bronchoscopy for removal. Supportive care.
What causes blood aspiration?
Surgical trauma (e.g., oropharyngeal, pulmonary surgery).
What is the most severe type of aspiration?
Gastric Content Aspiration.
What are the consequences of gastric content aspiration?
Chemical pneumonitis, hypoxemia, atelectasis, pulmonary edema, and hemorrhage.
What are prevention strategies for gastric content aspiration?
- Preoperative prophylaxis: H2 blockers, gastrokinetics, nonparticulate antacids. 2. Rapid Sequence Induction (RSI) to secure airway. 3. Nasogastric tube (NGT) to decompress the stomach.
What are the effects of loss of airway protection from anesthesia?
Airway injuries, minor blood aspiration cleared by cough, large-volume aspiration leading to chronic fibrosis or pulmonary hemochromatosis.
What is the treatment for large-volume aspiration?
Clear obstruction (suctioning or bronchoscopy), oxygen therapy to correct hypoxemia, antibiotics if infection develops.
What is the recommended treatment for hypoxemia in aspiration cases?
Oxygen therapy: CPAP, PEEP, or mechanical ventilation.
What should be done if a bacterial infection occurs after aspiration?
Antibiotics ONLY if bacterial infection occurs.
What is the recommendation regarding steroids in aspiration cases?
Steroids are NOT recommended due to the risk of bacterial superinfection.
What is Wells’s Clinical Prediction Rule used for?
It is used to assess the likelihood of pulmonary embolism (PE).
What are the predisposing factors in Wells’s Clinical Prediction Rule?
- Previous VTE
- Recent surgery or immobilization
- Cancer
What symptoms are considered in the Wells’s Clinical Prediction Rule?
Hemoptysis
What signs are evaluated in the Wells’s Clinical Prediction Rule?
- Heart rate >100 beats/min
- Clinical signs of DVT
What does clinical judgment refer to in the Wells’s Clinical Prediction Rule?
It refers to the assessment that an alternative diagnosis is less likely than PE.
What are the categories of clinical probability in Wells’s Clinical Prediction Rule?
- Low
- Moderate
- High
What is bronchospasm?
Bronchospasm is the excessive contraction of bronchial smooth muscles, leading to airway narrowing and increased resistance.
What are the causes of bronchospasm?
Causes include aspiration, airway manipulation (intubation, extubation, suctioning), histamine release (e.g., from opioids, neuromuscular blockers), allergic reactions (e.g., latex allergy), and conditions like asthma or COPD.
What are the symptoms and signs of bronchospasm?
Symptoms include wheezing (diffuse), dyspnea, tachypnea, use of accessory muscles, and increased peak inspiratory pressures in ventilated patients.
What is the treatment for bronchospasm?
Treatment involves identifying and removing triggers, pharmacologic therapy (bronchodilators, anticholinergics), inhaled anesthetics for rescue therapy, intravenous steroids if asthma-related, and supportive measures like CPAP or high-flow oxygen.
What is hypoventilation?
Hypoventilation occurs when alveolar ventilation is inadequate, leading to CO₂ retention (hypercapnia) and respiratory acidosis.
What are the causes of hypoventilation?
Causes include decreased central respiratory drive (opioids, benzodiazepines, general anesthetics, neuromuscular blockers) and poor respiratory muscle function (inadequate reversal of neuromuscular blockade, upper abdominal/thoracic surgery, obesity, obstructive sleep apnea, neuromuscular diseases, severe scoliosis).
What are the symptoms and signs of hypoventilation?
Symptoms include shallow respirations, respiratory acidosis (high PaCO₂, low pH), drowsiness, confusion (CO₂ narcosis), bradypnea,
What is the treatment for hypoventilation?
Treatment includes opioid reversal (Naloxone), benzodiazepine reversal (Flumazenil), neuromuscular blockade reversal (Neostigmine + Glycopyrrolate), supportive respiratory therapy, oxygen therapy, CPAP/BiPAP for OSA, and mechanical ventilation if severe hypoventilation persists.
What is hypotension?
Hypotension is a fall in arterial blood pressure of more than 20% below baseline, with an absolute systolic blood pressure below 90 mmHg or a mean arterial pressure below 60 mmHg.
What are the causes of hypotension in the PACU?
Causes include hypovolemia (most common due to inadequate fluid/blood replacement), surgical blood loss, inadequate fluid administration, and cardiogenic hypotension (intrinsic pump failure).
What is the initial treatment for hypovolemia?
Initial treatment involves fluid resuscitation with a 300-500 mL bolus of normal saline or lactated Ringer’s solution.
**Footnote
If no response → Consider other causes like myocardial dysfunction.
What are some causes of cardiogenic hypotension?
Causes include myocardial infarction, cardiac tamponade, and pulmonary embolism.
How do you diagnose hypoventilation?
- Pulse Oximetry (monitors oxygenation but NOT ventilation).
- Capnography (monitors end-tidal CO₂ levels for early detection).
- ABG Analysis (identifies respiratory acidosis).
What are the signs of hypotension in PACU?
Severe hypotension unresponsive to fluids, chest pain, dyspnea, jugular venous distension (JVD).
What is the management for hypotension in PACU?
Treat underlying cause (e.g., thrombolysis for PE, pericardiocentesis for tamponade) and use inotropes (e.g., dobutamine, milrinone) for cardiac support.
In hypotension, what causes decreased afterload (low systemic vascular resistance - SVR)?
Vasodilatory anesthetics (e.g., morphine, atracurium, volatile anesthetics, spinal anesthesia), vasodilator drugs (e.g., hydralazine, sodium nitroprusside, nitroglycerin), and sepsis (septic shock).
What are the vasoconstrictive agents used in hypotension management?
Ephedrine (5-50 mg IV bolus), epinephrine (10-100 mcg IV bolus), phenylephrine (50-200 mcg IV bolus), vasopressin (1-4 units IV), and continuous infusion of dopamine or epinephrine for persistent cases.
In hypotension, what dysrhythmias affect cardiac output?
Tachydysrhythmias (e.g., atrial fibrillation, SVT) lead to inadequate ventricular filling, while bradyarrhythmias (e.g., heart blocks) result in poor cardiac output.
What is the management for dysrhythmias?
Correct electrolyte imbalances (K+, Mg2+) and treat arrhythmia based on type (e.g., amiodarone for AFib, atropine for bradycardia).
What is hypertension?
Hypertension is defined as SBP or DBP >20% above baseline or absolute blood pressure above age-corrected limits.
What are common causes of postoperative hypertension?
Common causes include sympathetic nervous system stimulation due to pain, respiratory compromise, visceral distention, and surgical stress response.
How does hypoxemia and hypercarbia affect blood pressure?
Direct stimulation of the vasomotor center in the medulla leads to increased vasomotor tone and arterial constriction, resulting in high blood pressure.
What effect does bladder, bowel, or stomach distention have on blood pressure?
Distention activates afferent fibers of the SNS, increasing catecholamines and raising blood pressure. Relieving the distention corrects hypertension.
What causes hypothermia-induced hypertension?
Cold exposure during surgery stimulates catecholamine release, leading to peripheral vasoconstriction and increased blood pressure.
What is the management for hypothermia-induced hypertension?
Management includes active rewarming and gradual warming to prevent sudden vasodilation and hypotension.
What percentage of PACU patients have a history of chronic hypertension?
30% of PACU patients have a history of chronic hypertension.
What are common antihypertensive medications?
Common medications include ACE inhibitors, angiotensin II receptor blockers, and beta-blockers.
What should be done for patients with preexisting hypertension?
Restart home antihypertensive medications as soon as possible and monitor BP closely.
What is the management for postoperative revascularization and baroreceptor stimulation?
Management includes using vasodilators for BP control and close BP monitoring.
What is the first-line treatment for hypertension if nonpharmacologic interventions fail?
IV antihypertensives are used for BP control.
What is sodium nitroprusside?
Sodium nitroprusside is a powerful arterial and venous vasodilator used for rapid BP control in severe hypertension.
What is nitroglycerin used for?
Nitroglycerin preferentially dilates veins and is used in patients with myocardial ischemia.
What are beta-blockers used for?
Beta-blockers are used for tachycardia and hypertension.
What is labetalol?
Labetalol is a beta-blocker that blocks both α- and β-receptors, reducing heart rate and blood pressure.
What is hydralazine?
Hydralazine is a direct arterial vasodilator that preferentially relaxes vascular smooth muscle, reducing afterload.
What do alpha-2 agonists do?
Alpha-2 agonists reduce SNS outflow, gradually lowering blood pressure and preventing rebound hypertension if beta-blockers were withheld preoperatively.
Factors Leading to Postoperative Hypertension
• Preoperative hypertension
• Arterial hypoxemia
• Hypervolemia
• Emergence excitement
• Shivering
• Drug rebound
• Increased intracranial pressure
• Increased sympathetic nervous
system activity
• Hypercapnia
• Pain
• Agitation
• Bowel distention
• Urinary retention
What are dysrhythmias?
Dysrhythmias are common in the PACU and may be benign, transient, or indicate serious cardiac compromise.
What are some causes of dysrhythmias?
Causes include hypokalemia, excess fluid administration, anemia, hypoventilation with hypercarbia, altered acid-base imbalances, substance withdrawal, and circulatory instability.
Why are dysrhythmias clinically important?
Persistent or severe dysrhythmias may indicate compromised cardiac output, myocardial ischemia, or hemodynamic instability.
Which dysrhythmias can be life-threatening?
Certain rhythms such as ventricular tachycardia, complete heart block, and torsades de pointes can be life-threatening.
What is a major cause of postoperative dysrhythmias?
Hypoxia and hypercarbia are major causes, with arterial desaturation being a common PACU complication.
What does hypoxia lead to?
Hypoxia reduces myocardial oxygen supply, leading to cardiac irritability, ST-segment depression, & Premature ventricular contractions (PVCs), atrial fibrillation (AF), or ventricular tachyarrhythmias.
What does hypercarbia cause?
Hypercarbia causes SNS activation, leading to tachycardia and hypertension, increased myocardial workload, and risk of ventricular dysrhythmias.
What are some ECG manifestations of dysrhythmias?
ECG manifestations include sinus tachycardia, atrial fibrillation or flutter, and ventricular ectopy.
What is the management for dysrhythmias?
Management includes supplemental oxygen, ventilation support, reversal of opioid-induced respiratory depression, and treating the underlying cause.
What is hypokalemia?
Hypokalemia is defined as serum potassium levels less than 3.5 mEq/L.
What are some causes of hypokalemia?
Causes include hyperventilation-induced respiratory alkalosis, diuretics, gastric suctioning, and insulin administration.
What are ECG manifestations of hypokalemia?
ECG manifestations include flattened T waves, prominent U waves, and prolonged QT interval.
What is the management for hypokalemia?
Management includes IV potassium chloride replacement and continuous ECG monitoring for arrhythmia progression.
What is hyperkalemia?
Serum K+ >5.5 mEq/L
What are the causes of hyperkalemia?
Renal failure, metabolic acidosis, massive blood transfusions.
What are the ECG changes in hyperkalemia?
Peaked T waves, widened QRS complex, bradycardia, heart block, or ventricular fibrillation.
What is the management for hyperkalemia?
Calcium gluconate, insulin and glucose, sodium bicarbonate, dialysis in severe cases.
What are the effects of acidosis on the heart?
Cardiac excitability and dysrhythmias.
What are the effects of alkalosis on the heart?
Prolonged QT and atrial dysrhythmias.
What is the management for acid-base disturbances?
Identify and treat the underlying cause, optimize ventilation, bicarbonate therapy in severe metabolic acidosis.
How does hypotension affect myocardial ischemia?
Reduces coronary perfusion, increasing ischemia risk.
What are the causes of hypotension?
Hypovolemia, cardiac dysfunction, vasodilatory effects of anesthetics.
What are the ECG manifestations of hypotension?
ST-segment depression, atrial fibrillation, sinus bradycardia, or heart blocks.
What is the management for hypotension?
Fluid resuscitation, serial troponins and ECGs if MI is suspected.
What causes hypothermia?
Prolonged surgery, neuraxial anesthesia, or environmental exposure.
What are the effects of hypothermia?
Bradycardia, atrial fibrillation, ventricular fibrillation if severe.
What is the management for hypothermia?
Active rewarming, atropine for symptomatic bradycardia.
What is the effect of vagal stimulation?
(eye surgery, carotid sinus pressure) ->
Causes bradycardia.
What is the effect of sympathetic overactivity?
(pain, surgical stress) → Causes tachycardia and atrial fibrillation.
What medications are used for autonomic dysregulation?
Atropine (0.5 mg IV) for symptomatic bradycardia, beta-blockers (labetalol, esmolol) for rate control.
What can contribute to dysrhythmias in the PACU?
General anesthetics and residual sedatives present in the bloodstream or tissues postoperatively.
How do anesthetic agents affect the heart?
They alter autonomic balance, myocardial excitability, and oxygenation, leading to potential tachyarrhythmias, bradyarrhythmias, or conduction abnormalities.
What effect does Ketamine have on the heart?
It causes sympathetic stimulation, increasing norepinephrine release, heart rate, and blood pressure, while inhibiting vagal tone, predisposing to tachyarrhythmias.
What are Vagal Blockers and their effect?
Vagal Blockers (Atropine, Glycopyrrolate) block parasympathetic (vagal) influence on the heart, leading to unopposed sympathetic stimulation and increased heart rate.
What is the effect of Opioids on respiration and heart rhythm?
Opioids (Morphine, Fentanyl, Sufentanil) cause respiratory depression, leading to hypoventilation and hypercarbia, which stimulates the SNS and increases arrhythmia risk.
What is the effect of Anticholinesterase Agents?
They activate the parasympathetic system, potentially causing severe bradycardia or heart block.
What triggers the sympathetic stress response during surgery?
Acute pain and surgical stress trigger a catecholamine surge, increasing norepinephrine and epinephrine levels.
What are the critical issues related to residual neuromuscular blockade in PACU?
It increases mortality and can lead to airway obstruction, hypoventilation, and inability to clear secretions.
What are key signs of residual paralysis?
Weak cough, ineffective airway clearance, shallow breathing, stridor, and delayed emergence with somnolence.
What does a Train-of-four (TOF) ratio <0.90 indicate?
It indicates incomplete neuromuscular recovery.
What are some bedside clinical tests for neuromuscular function?
Head lift for 5 seconds, handgrip strength, tongue protrusion and sustained bite.
What is a negative inspiratory pressure > -25 cm H20 indicative of?
It indicates adequate ventilatory muscles with a forced capacity of 10-12 mL/kg.
What are reversal agents for neuromuscular blockade?
Acetylcholinesterase inhibitors (Neostigmine, Edrophonium) used with atropine or glycopyrrolate to counteract bradycardia.
What is Sugammadex used for?
It is a selective reversal agent for rocuronium and vecuronium, more reliable and faster than traditional methods.
Who is at risk for prolonged paralysis?
Elderly patients, those with neuromuscular diseases, and hypothermic patients due to reduced metabolism and excretion of neuromuscular blockers.
What should be confirmed before extubation?
TOF ratio >0.9 should be confirmed.
What should be assessed in managing residual neuromuscular blockade?
Airway patency and spontaneous ventilation should be assessed.
What should be considered if incomplete reversal is suspected?
Consider sugammadex.
What ventilatory support options are available if needed?
CPAP, BiPAP, or reintubation can be provided.
What is Emergence Delirium?
Acute confusion, agitation, and altered perception occurring immediately after anesthesia emergence.
What are the risks associated with Emergence Delirium?
High risk of self-injury and to caregiver, increased resources used, extended stay.
What characterizes Delirium?
Extreme disturbances of arousal, attention, orientation, perception, intellectual function, and affect accompanied with fear and agitation.
What is agitation?
Mild restlessness and mental distress that can be due to pain, physiological compromise, or anxiety.
What is the incidence of Emergence Delirium in general surgery patients?
4% to 31%.
What is the incidence of Emergence Delirium in pediatric patients?
50% to 80%.
Who has higher rates of Emergence Delirium?
Combat veterans and psychiatric patients.
What are risk factors for pediatric patients regarding Emergence Delirium?
Separation anxiety and rapid emergence from sevoflurane.
What are risk factors for adults regarding Emergence Delirium?
Psychiatric history, PTSD, alcohol/substance use, benzodiazepines.
How can pain and anxiety affect Emergence Delirium?
They can worsen emergence agitation.
What environmental factors can alter brain function post-anesthesia?
Hyperthermia or hypothermia.
What is the first step in managing Emergence Delirium?
Rule out hypoxia first! Provide supplemental oxygen.
How should pain be managed in Emergence Delirium?
Assess and treat pain appropriately using multimodal analgesia.
What tools can be used to assess Emergence Delirium?
CAM-ICU, PAED, RASS.
What should be identified as contributing factors to Emergence Delirium?
Endotracheal tube, bladder distention, visceral pain, anxiety, hyperthermia, hypothermia.
What is an important aspect of the environment for managing Emergence Delirium?
Provide verbal reassurance and a calm environment.
What pharmacologic interventions can be considered for Emergence Delirium?
Dexmedetomidine, Propofol infusion, low-dose ketamine.
What is the role of Dexmedetomidine in Emergence Delirium?
Reduces emergence agitation, especially in children.
What are some prevention strategies for Emergence Delirium?
Preoperative education, balanced anesthetic approach, use of regional anesthesia, avoid rapid emergence from volatile anesthetics.
What is Postoperative Delirium (POD)?
Occurs later than emergence delirium, hours to days post-surgery.
Who is more commonly affected by Postoperative Delirium?
Elderly patients.
What are some causes of Postoperative Delirium?
Hypoxia, metabolic disorders, sepsis, electrolyte imbalances, withdrawal from alcohol or sedatives, polypharmacy.
What tools are used for diagnosing Postoperative Delirium?
Confusion Assessment Method (CAM-ICU) for adults, Pediatric Anesthesia Emergence Delirium (PAED) scale for children, Richmond Agitation-Sedation Scale (RASS) for severity classification.
What is the first step in managing postoperative delirium?
Eliminate reversible causes such as hypoxia, hypercapnia, electrolyte imbalances, infections, and sedative or opioid withdrawal.
How can pain control be optimized in postoperative delirium?
Use multimodal analgesia including NSAIDs and acetaminophen, while minimizing opioids where possible.
What strategies can help reorient a patient with postoperative delirium?
Reorient the patient frequently, provide familiar objects and family presence, and optimize sleep-wake cycles.
What pharmacologic treatments are considered for severe agitation in postoperative delirium?
Dexmedetomidine is preferred for sedation; haloperidol or atypical antipsychotics may be used if delirium is severe. Avoid benzodiazepines unless treating alcohol withdrawal.
What is delayed awakening?
Delayed awakening refers to a prolonged recovery of consciousness after anesthesia, where a patient does not regain wakefulness within the expected timeframe.
What are common causes of delayed awakening?
Common causes include prolonged effects of anesthetic drugs, metabolic abnormalities, and neurological injury.
What factors contribute to delayed awakening?
Factors include prolonged action of anesthetic drugs, age-related changes, drug interactions, hypothermia, neuromuscular blockade residual effects, pre-existing conditions, and herbal supplements.
What key drugs can cause delayed awakening?
Inhaled anesthetics, opioids, benzodiazepines, and neuromuscular blockers can all contribute to delayed awakening.
What are the symptoms and management of hypoglycemia?
Symptoms include confusion and coma if glucose <50 mg/dL. Management involves IV Dextrose 50% (D50W) bolus.
What is hyperglycemia and its management?
Hyperglycemia >600 can cause hyperosmolar hyperglycemic state (HHS) leading to altered mental status. Management includes insulin therapy and IV fluids.
What electrolyte disturbances can affect postoperative patients?
Hyponatremia can cause confusion and coma; hypocalcemia can lead to muscle weakness; hypermagnesemia can cause sedation and respiratory depression.
What are potential neurological injuries in postoperative patients?
Rare but must be ruled out; causes include postoperative stroke or intracranial hemorrhage from carotid artery disease, AFib, emboli, and increased ICP.
What is the management for delayed awakening?
Ensure airway, oxygenation, and ventilation; reverse residual sedation if appropriate; correct metabolic abnormalities; consider CT brain for suspected neurologic causes.
What is the dosage and purpose of Flumazenil?
Flumazenil (0.1-0.2 mg IV q1min, max 1 mg) → Reverses benzodiazepines.
What is the dosage and purpose of Naloxone?
Naloxone (40 mcg IV q2min, max 200 mcg) → Reverses opioids.
What is the dosage and purpose of Physostigmine?
Physostigmine (1-2 mg IV) → Reverses anticholinergic toxicity.
What is Serotonin Syndrome?
A life-threatening condition due to excess serotonin activity in the CNS.
What triggers Serotonin Syndrome?
Triggered by serotonergic drugs such as SSRIs, SNRIs, tramadol, fentanyl, meperidine, MAOIs, TCAs, and St. John’s Wort.
When can Serotonin Syndrome be triggered in the PACU?
When opioids interact with serotonergic antidepressants.
What are the symptoms of Serotonin Syndrome?
Triad of symptoms: autonomic hyperactivity, neuromuscular abnormalities, & mental status changes.
What are the mild symptoms of Serotonin Syndrome?
Dilated pupils, diaphoresis, myoclonus, tachycardia, anxiety, & restlessness.
What are the severe symptoms of Serotonin Syndrome?
Fever, mental status changes, muscle rigidity, & multiple organ failure.
How is Serotonin Syndrome managed?
Management depends on severity: cardiac monitoring, IVFs, O2, & discontinuation of serotonergic drugs.
What supportive care is provided for Serotonin Syndrome?
IV fluids, oxygen, cooling measures for hyperthermia, and benzodiazepines for agitation.
What assessment tools are used for postoperative pain management?
Verbal/Numeric Rating Scale, Visual Analog Scale, behavioral indicators, and physiologic signs.
What is a multimodal pain management approach?
Includes opioid analgesics, non-opioid analgesics, regional anesthesia, and adjuvant therapies.
What are examples of opioid analgesics for severe pain?
Morphine, hydromorphone, fentanyl via IV bolus or PCA.
What are examples of non-opioid analgesics?
NSAIDs like ketorolac and ibuprofen, acetaminophen, and gabapentinoids for neuropathic pain.
What is the purpose of regional anesthesia and nerve blocks?
Used for pain management in thoracic and abdominal surgeries.
What are adjuvant therapies for pain management?
Dexmedetomidine, ketamine infusion, and magnesium infusion.
What is opioid-induced bowel dysfunction?
Includes constipation and ileus, managed with opioid antagonists and encouraging ambulation, hydration, and fiber intake.
What are ERAS protocols?
Encourage multimodal opioid-sparing analgesia and strict PCA opioid monitoring.
What is hypothermia in a surgical context?
Core body temperature <36°C (96.8°F) due to systemic heat loss exceeding heat production.
Why is hypothermia common in surgical patients?
Due to anesthetic effects, cold surgical environments, and exposure to IV fluids.
What are the major consequences of hypothermia?
Prolonged PACU recovery, increased risk of surgical complications, delayed wound healing, and increased hospital costs.
What impairs normal thermoregulation in the perioperative period?
Anesthetic-induced vasodilation and loss of heat-preserving mechanisms.
What is the largest contributor to heat loss?
Radiation (40-50%)
Loss of heat from the patient’s body to a cooler environment.
What factors contribute to radiation heat loss?
Heat loss occurs to OR tables, drapes, air, IV fluids, and prep solutions.
Most significant in ORs with low ambient temperatures.
What percentage of heat loss is due to convection?
25-30%
Air movement removes body heat as warmer air is replaced with cooler air.
What are the causes of convection heat loss?
Cold OR ventilation systems, patient exposure during surgery, forced-air exchange systems.
These increase heat loss.
What percentage of heat loss is attributed to conduction?
5-10%
Direct heat transfer from the patient’s body to another cooler surface.
What are examples of conduction heat loss?
Cold surgical tables, prep solutions applied to the skin, unwarmed IV fluids and irrigants.
What percentage of heat loss is due to evaporation?
20-25%
Heat loss due to fluid evaporation from the body.
What are the causes of evaporation heat loss?
Occurs through respiration, sweating, open wounds, and exposed viscera.
Significant in open abdominal procedures.
What are risk factors for perioperative hypothermia in elderly patients?
Decreased subcutaneous fat, reduced metabolic rate, impaired hypothalamic function.
What are risk factors for perioperative hypothermia in neonates and infants?
High surface-area-to-volume ratio and immature thermoregulatory systems.
How do intoxicated or sedated patients contribute to heat loss?
Alcohol and sedatives cause vasodilation and suppress shivering and heat conservation.
What effect do vasodilators have on heat retention?
Impaired vasoconstriction and thermoregulation.
Why do burn patients experience severe heat loss?
Due to damaged skin barrier.
How does peripheral vascular disease affect heat retention?
Poor circulation results in inadequate heat retention.
What is a surgery-related risk factor for hypothermia under general anesthesia?
Depresses hypothalamic thermoregulation and promotes vasodilation.
What is the effect of regional anesthesia on heat loss?
Inhibits autonomic vasoconstriction and blocks shivering response.
How does prolonged surgery contribute to hypothermia?
Greater exposure to the cold OR environment increases heat loss.
What is the effect of cold IV fluids on core temperature?
Administering large volumes decreases core temperature.
What risk do cardiac surgery patients face regarding hypothermia?
High risk due to receiving cold cardioplegia.
What is a significant cause of heat loss in open abdominal or thoracic surgeries?
Significant evaporative heat loss from exposed organs.
What are the physiologic effects of hypothermia on oxygen delivery and metabolism?
Shifts oxyhemoglobin dissociation curve left → reduced oxygen release to tissues. Increased oxygen consumption due to shivering (up to 400-500%) → cardiac stress. Slows enzymatic reactions, leading to delayed drug metabolism.
What cardiovascular effects are associated with hypothermia?
Bradycardia and dysrhythmias (PVCs, atrial fibrillation) due to slowed conduction. Severe hypothermia (<33°C) can cause cardiac arrest. Vasoconstriction increases afterload, possibly causing hypertension.
What are the coagulation and hemodynamic effects of hypothermia?
Platelet dysfunction → increased risk of bleeding. Impaired clotting factor activation → higher risk of postoperative hemorrhage. Increased risk of surgical site infections (SSI) due to immune suppression.
What neurologic effects can hypothermia cause?
CNS depression → confusion, delayed emergence from anesthesia. Shivering causes significant discomfort and may increase pain perception.
What are the prevention strategies for hypothermia?
Prewarming for 30-60 minutes before surgery (forced-air warming). Maintaining OR temperature ≥21°C. Warming IV fluids & blood products.
What are the active warming methods for intraoperative temperature maintenance?
Forced-air warming (e.g., Bair Hugger) – Most effective. Heated IV & irrigation fluids – Prevents internal cooling. Radiant warmers, warming blankets – Increases body temperature.
What are the passive warming methods for intraoperative temperature maintenance?
Insulating blankets and drapes. Head covering to reduce heat loss from the scalp.
What should be done for postoperative temperature restoration?
All PACU patients should be assessed for hypothermia. Forced-air warming is the gold standard for treating hypothermia in PACU. Combination of warming strategies (prewarming, intraoperative warming, heated IV fluids) reduces PACU stay.
What is the primary treatment for postoperative shivering?
Rewarming. Pharmacologic options if needed: Meperidine (Demerol) 12.5–25 mg IV – Most effective opioid for shivering; small doses can be effective within 3 mins in the treatment of shivering.
What are the causes of postoperative shivering?
Heat loss-induced: Core temperature drop. Anesthetic-related: Volatile anesthetics & opioids alter thermoregulation. Pain-related: Stress-induced sympathetic activation.
What are the effects of postoperative shivering?
Increases metabolic demand & oxygen consumption. Causes significant discomfort and distress.
What are the patient-specific risk factors for postoperative nausea and vomiting (PONV)?
Female gender, age <50 years, nonsmoker, history of PONV, history of motion sickness.
What are the anesthetic-related risk factors for PONV?
Use of volatile anesthetics, duration of anesthesia, use of nitrous oxide, postoperative opioid use.
What are the surgery-related risk factors for PONV?
Type of surgery, especially laparoscopy, gynecologic, cholecystectomy.
What is the incidence of PONV based on the number of risk factors Apfel Scoring system??
1 risk factor: 10-20%, 2 risk factors: 40%, 3 risk factors: 60%, ≥4 risk factors: 80%.
**Footnote
Includes Female gender, age <50 years, nonsmoker, history of PONV, history of motion sickness.
What is the incidence of PDNV based on the number of risk factors for the Apfel Scoring system?
1 risk factor: 10%, 2 risk factors: 20%, 3 risk factors: 30%, 4 risk factors: 50%, 5 risk factors: 60%, ≥6 risk factors: 80%.
**Footnote
Includes Female gender, history of motion sickness and/or PONV, age <50 years, use of postoperative opioids, PONV in the PACU.
What is Postoperative Nausea and Vomiting (PONV)?
PONV is a significant and common post-surgical complication.
What percentage of surgical patients are affected by PONV?
PONV affects 20-30% of all surgical patients.
What is the incidence of PONV in high-risk individuals?
The incidence of PONV in high-risk individuals is 70-80%.
What are some consequences of PONV?
PONV can result in prolonged hospital stays, delayed patient discharge, electrolyte imbalances, wound dehiscence, increased patient discomfort and dissatisfaction, and aspiration risk.
What is Postdischarge Nausea and Vomiting (PDNV)?
PDNV is an issue that affects recovery at home, particularly in ambulatory surgery patients.
What is the Apfel Risk Score used for?
Used preoperatively to guide prophylactic antiemetic selection.
What is the risk percentage for 0 factors in the Apfel Risk Score?
10% risk
What is the risk percentage for 1 factor in the Apfel Risk Score?
20% risk
What is the risk percentage for 2 factors in the Apfel Risk Score?
40% risk
What is the risk percentage for 3 factors in the Apfel Risk Score?
60% risk
What is the risk percentage for 4 factors in the Apfel Risk Score?
80% risk
What is the Koivuranta Score?
Similar to Apfel but includes duration of surgery (>60 min) as an additional risk factor.
What does the Koivuranta Score help predict?
Helps predict both PONV and PDNV.
What factors increase PONV risk in children >3 years old?
History of motion sickness, History of PONV, Female gender (post-puberty)
What is the increased risk for children regarding surgeries?
Increased risk after surgeries >30 minutes with opioid use.
What is recommended for high-risk patients in PONV management?
Recommend multimodal prophylaxis.
How should antiemetic therapy be administered based on risk level?
1 risk factor → 1 antiemetic; ≥2 risk factors → ≥2 antiemetics from different classes.
What are 5-HT3 Antagonists used for in PONV prevention?
Ondansetron, Granisetron, Palonosetron → Block serotonin in the CTZ.
What is the role of Corticosteroids in PONV prevention?
Dexamethasone → Reduces inflammation and suppresses PONV.
What do Neurokinin-1 (NK-1) Antagonists do?
Aprepitant, Fosaprepitant → Long-acting prevention of nausea.
What is the function of Dopamine Antagonists in PONV?
Droperidol, Metoclopramide → Block dopamine pathways.
How are Anticholinergics used in PONV?
Scopolamine patch → Used for motion sickness.
What do Histamine H1 Blockers do?
Promethazine, Diphenhydramine → Reduces nausea, sedation effect.
What is the effect of Alpha-2 Agonists on PONV?
Clonidine, Dexmedetomidine → Provide mild antiemetic effects.
How does Regional Anesthesia help with PONV?
Eliminates volatile anesthetic exposure, lowering PONV incidence.
What is the importance of Adequate IV Fluids in PONV?
Prevents hypovolemia, which can contribute to nausea.
What is the approach for Opioid-Sparing Analgesia?
Use NSAIDs, acetaminophen, regional nerve blocks.
What should be done if PONV occurs despite prophylaxis?
Use a different drug class than previously given.
What are the first-line treatments for PONV?
Ondansetron (4 mg IV), Metoclopramide (10 mg IV).
What treatments are recommended for severe PONV cases?
Dexamethasone (4-8 mg IV), Aprepitant (NK-1 antagonist), Scopolamine patch.
What should be considered for refractory PONV?
Consider IV fluids, oxygen, and reassessment of opioid use.
What are 5-HT3 Antagonists used for in PONV prevention?
Ondansetron, Granisetron, Palonosetron → Block serotonin in the CTZ.
What is the role of Corticosteroids in PONV prevention?
Dexamethasone → Reduces inflammation and suppresses PONV.
What do Neurokinin-1 (NK-1) Antagonists do?
Aprepitant, Fosaprepitant → Long-acting prevention of nausea.
What is the function of Dopamine Antagonists in PONV?
Droperidol, Metoclopramide → Block dopamine pathways.
How are Anticholinergics used in PONV?
Scopolamine patch → Used for motion sickness.
What do Histamine H1 Blockers do?
Promethazine, Diphenhydramine → Reduces nausea, sedation effect.
What is the effect of Alpha-2 Agonists on PONV?
Clonidine, Dexmedetomidine → Provide mild antiemetic effects.
How does Regional Anesthesia help with PONV?
Eliminates volatile anesthetic exposure, lowering PONV incidence.
What is the importance of Adequate IV Fluids in PONV?
Prevents hypovolemia, which can contribute to nausea.
What is the approach for Opioid-Sparing Analgesia?
Use NSAIDs, acetaminophen, regional nerve blocks.
What should be done if PONV occurs despite prophylaxis?
Use a different drug class than previously given.
What are the first-line treatments for PONV?
Ondansetron (4 mg IV), Metoclopramide (10 mg IV).
What treatments are recommended for severe PONV cases?
Dexamethasone (4-8 mg IV), Aprepitant (NK-1 antagonist), Scopolamine patch.
What should be considered for refractory PONV?
Consider IV fluids, oxygen, and reassessment of opioid use.
What is Postdischarge Nausea and Vomiting (PDNV)?
Nausea & vomiting occurring after discharge from ambulatory surgery.
What are the risk factors for PDNV?
Young age, female gender, opioid use, history of PONV, high-risk surgery (laparoscopy, gynecologic).
What are the prevention strategies for PDNV?
Long-acting antiemetics (Palonosetron, Aprepitant), reducing opioid use, ensuring adequate hydration before discharge.
What is the goal of fluid management?
To maintain adequate intravascular volume, left ventricular filling pressure, cardiac output, systemic blood pressure, and optimal oxygen delivery to tissues.
What can excessive fluid administration lead to?
Pulmonary edema, delayed wound healing, and prolonged recovery.
What can inadequate fluid replacement cause?
Hypovolemia, hypotension, organ ischemia, and acute kidney injury (AKI).
What are the types of intravenous fluids?
Crystalloid Solutions: Normal Saline (0.9% NaCl), Lactated Ringer’s (LR), Dextrose 5% in Water (D5W).
What are the characteristics of Normal Saline (NS)?
Rapidly distributes out of the intravascular space, provides temporary hemodynamic support, can cause hyperchloremic metabolic acidosis if administered in large volumes.
What should be considered when using Lactated Ringer’s (LR)?
LR contains potassium, which should be avoided in renal failure patients.
Why is Dextrose 5% in Water (D5W) not suitable for resuscitation?
It is rapidly metabolized to free water.
What are colloid solutions?
Colloid solutions include Albumin (5% or 25%), Hydroxyethyl starch (HES), and Dextran. They remain in the intravascular space longer than crystalloids and provide better plasma volume expansion with smaller volumes.
What is Albumin used for?
Albumin is commonly used in sepsis and hypoalbuminemia.
What are the clinical considerations for HES?
HES is associated with renal dysfunction and should be used cautiously.
When are Packed Red Blood Cells (PRBCs) used?
PRBCs are used for significant blood loss (>30% blood volume loss).
What is Fresh Frozen Plasma (FFP) indicated for?
FFP is indicated in coagulopathy and massive transfusion protocols.
When are platelets required?
Platelets are required in thrombocytopenia or active bleeding.
What is Goal-Directed Fluid Therapy (GDFT)?
GDFT is a personalized fluid management strategy based on dynamic hemodynamic parameters rather than fixed-volume administration.
What are the benefits of GDFT?
GDFT prevents fluid overload and tissue edema, reduces postoperative cardiopulmonary complications, and decreases length of hospital stay.
What monitoring parameters are used in GDFT?
Monitoring parameters include Stroke Volume Variation (SWV), Cardiac Output (CO), Central Venous Pressure (CVP), Lactate levels, and hypotension.
What fluid boluses should be given to high-risk surgical patients?
In high-risk surgical patients, small fluid boluses (250-500 mL) should be given based on real-time assessments.
What do Enhanced Recovery After Surgery (ERAS) protocols favor?
ERAS protocols favor euvolemia over liberal fluid administration to minimize complications.
What is encouraged in the PACU to promote gut motility?
Early oral hydration in the PACU is encouraged to promote gut motility and prevent ileus.
What factors are important in postoperative fluid management in the PACU?
Important factors include preoperative hydration status, duration and type of surgery, estimated intraoperative blood loss, total intraoperative fluid administration, and postoperative hemostasis.
What are physical signs of hypovolemia?
Physical signs include cold, clammy, and pale skin, oliguria (<0.5 mL/kg/hour), hypotension, tachycardia and tachypnea, and delayed capillary refill (>2 seconds).
What are the causes of postoperative hypovolemia?
Causes include inadequate intraoperative fluid replacement, ongoing hemorrhage, increased fluid loss into tissues (third-spacing), prolonged fasting preoperatively, and sepsis or anaphylaxis-induced vasodilation.
What are the treatment strategies for fluid deficits?
Crystalloid boluses (3× estimated blood loss). Colloids for prolonged deficits. Severe Deficit (>1500 mL loss or Shock): Blood transfusion (PRBCs) if hemoglobin <7 g/dL. Vasopressors if fluid resuscitation fails. Monitoring of CVP, lactate, and SvO2.
What is the purpose of monitoring urinary output?
Prevention of renal dysfunction in high-risk patients. Early detection of postoperative urinary retention (POUR). Avoidance of catheter-associated complications.
What are the causes of postoperative urinary retention (POUR)?
Regional Anesthesia (Spinal/Epidural), Medications (Opioids, Ketamine, NSAIDs), Diabetes Mellitus, Surgical Factors (high incidence in urologic, inguinal, and genital surgeries).
How is postoperative urinary retention managed?
Bladder Scanning: If bladder volume >400-500 mL, catheterization is recommended. In-and-Out Catheterization: Used for temporary relief of retention. Indwelling Catheters: Reserved for prolonged retention or high-risk patients.
What are the criteria for discharge regarding urinary retention?
Patients can be discharged before voiding if they are low risk for retention, have no history of urinary retention, and a bladder scan shows <400 mL residual urine.
What should patients do if they do not void within 6–8 hours after discharge?
They must seek medical attention.
What is oliguria and its causes?
Oliguria is urine output <0.5 mL/kg/hour. Causes include hypovolemia, renal hypoperfusion from anesthesia or hemorrhage, and obstruction.
What defines polyuria?
Polyuria is defined as excessive urine output exceeding 4–5 mL/kg/hour, indicating abnormal regulation of water clearance.
What are the causes of polyuria?
Too much IVF administration during intraoperative, osmotic diuresis from hyperglycemia and glycosuria, and diuretics given during surgery.
What is diabetes insipidus (DI) and its causes?
DI occurs due to damage to the hypothalamus or pituitary gland, leading to vasopressin deficiency. Causes include intracranial surgery, head trauma, increased ICP, and omission of preoperative vasopressin.
What is the diagnostic approach to polyuria?
Urine Analysis: Urine osmolality, glucose, and sodium. Serum Tests: Serum osmolality and electrolytes.
What are the criteria for discharge from the Postanesthesia Care Unit (PACU)?
Patient’s physical status, need for additional monitoring, and availability of medical resources.
What neurological status is required for discharge?
The patient should be oriented and alert, able to assess their condition, have adequate motor function, and show no severe confusion.
What airway and respiratory function criteria must be met for discharge?
Airway reflexes intact, adequate ventilation and oxygenation, monitored oxygen saturation, and ability to maintain oxygenation without support.
What hemodynamic stability criteria are needed for discharge?
Vital signs within preoperative ranges, consistent peripheral perfusion, and no signs of ongoing bleeding or hemodynamic instability.
What thermoregulation criteria must be met for discharge?
Core body temperature at least 96.8°F (36°C), correction of hypothermia, and resolution of shivering.
What pain and nausea control criteria are required for discharge?
Pain managed with appropriate analgesia, control of nausea and vomiting, and no excessive discomfort interfering with mobility.
What surgical and medical considerations should be ruled out before discharge?
Postoperative complications, review of diagnostic test results, and examination of wound sites and drains.
What are the discharge requirements for urination?
Urination is not mandatory for all patients, but ambulatory patients should void within 6-8 hours after discharge.
What are discharge scoring systems?
Scoring systems standardize discharge criteria. Aldrete Modified Postanesthesia Recovery (PAR) Score requires a score of 9 or higher for safe discharge.
What are the advantages and risks of fast-tracking outpatients?
Advantages: Reduces costs, decreases PACU congestion, speeds up recovery. Risks: Unrecognized complications and need for reliable assessment tools.
What are the discharge instructions for outpatients?
Patients must be discharged to a responsible adult. Written instructions should cover dietary guidelines, medication schedules, activity restrictions, signs of complications, and emergency contact numbers.
Postanesthesia Care Unit Discharge Criteria
• Regular respiratory pattern
• Respiratory rate appropriate for age
• Absence of restlessness and confusion
• Vital signs within preoperative range
• Pulse oximetry indicates 95% saturation* or value equal to preoperative saturation
• Arterial blood gas values within normal limits”
• Ability to maintain patent airway
• Surgical stability of operative site or system
• Pain status controlled
• Postoperative nausea and vomiting addressed
• Temperature within normal limits
What is the Aldrete Modified Postanesthesia Recovery (PAR) Score?
A system to assess a patient’s readiness for discharge from Phase I Post-Anesthesia Care Unit (PACU).
What is the maximum total score in the Aldrete PAR Score?
10 points.
What is the scoring for Activity (Mobility) in the Aldrete PAR Score?
2 – Able to move all extremities voluntarily or on command.
1 – Able to move two extremities voluntarily or on command.
0 – Unable to move any extremity voluntarily or on command.
What is the scoring for Respiration in the Aldrete PAR Score?
2 – Able to breathe deeply and cough freely.
1 – Dyspnea or limited breathing.
0 – Apneic or requiring ventilation support.
What is the scoring for Circulation (Blood Pressure) in the Aldrete PAR Score?
2 – Blood pressure within 20% of pre-anesthesia level.
1 – Blood pressure within 20-50% of pre-anesthesia level.
0 – Blood pressure deviates more than 50% from pre-anesthesia level.
What is the scoring for Consciousness in the Aldrete PAR Score?
2 – Fully awake.
1 – Arousable on calling.
0 – Not responding.
What is the scoring for Oxygen Saturation (O₂ Saturation) in the Aldrete PAR Score?
2 – SpO₂ ≥ 92% on room air.
1 – Needs oxygen to maintain SpO₂ ≥ 90%.
0 – SpO₂ < 90% even with supplemental oxygen.
What does a score of 9-10 indicate in the Aldrete PAR Score?
Patient is generally ready for discharge from Phase I PACU to Phase II or a hospital room.
What does a score of less than 9 indicate in the Aldrete PAR Score?
Requires further monitoring and recovery in PACU.
What is the STOP-BANG Score?
The STOP-BANG Score is a widely used screening tool for Obstructive Sleep Apnea (OSA) that assesses the risk of OSA based on eight yes/no questions. STOP stands for Symptoms and Risk Factors. BANG stands for Physical Characteristics.
What does a higher STOP-BANG Score indicate?
A higher score indicates a greater likelihood of moderate-to-severe OSA.
What are the four questions in the STOP category?
- Snoring
- Tired
- Observed Apnea
- Pressure (Blood Pressure)
**Footnote
Yes (1 point) / No (0 points)
What are the four questions in the BANG category?
- Body Mass Index (BMI)
- Age
- Neck Circumference
- Gender
**Footnote
Yes (1 point) / No (0 points)
What does a score of 0-2 points indicate?
Low Risk – Low likelihood of moderate-to-severe OSA.
What does a score of 3-4 points indicate?
Intermediate Risk – Moderate likelihood of OSA.
What does a score of 5-8 points indicate?
High Risk – High likelihood of moderate-to-severe OSA.
What does a score of ≥3 suggest?
It suggests an increased risk for OSA and may warrant further evaluation with a sleep study.
