PACU Flashcards
All patients who have received general anesthesia, regional anesthesia, or monitored anesthesia care shall receive appropriate postanesthesia management
PACU standard 1
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.
PACU standard 2
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
Pacu standard 3
The patient’s condition shall be evaluated continually in the PACU. Max ratio is 2:1.
Pacu standard 4
A physician is responsible for the discharge of the patient from the postanesthesia care unit. DC from recovery -> hospital. Discharge from PACU is not the same ad DC from the hospital.
Pacu Standard 5
monitoring for travel to the ICU from OR
same level of monitoring that was in the or (transport monitor)
Arrival to PACU
Assess - airway patency (oral or nasal airway), RR, Sat %, HR, BP, mental status, pain, presence of PONV.
Assess for & treat hypoxemia: causes
Room air, Obesity, Sedation, Respiratory rate, advanced age (> 60).
Connect the patient to the PACU monitors.
Admission to the PACU
CRNA assesses the patient.
Patient connected to the PACU monitors.
Report given to the PACU RN.
PACU RN assesses the patient.
CRNA Report
The admissions report needs to be specific, organized, and completed only when you have the full attention of the receiving RN.
ID patient
Medical history
Anesthesia
Intraoperative course
Postoperative
Phase 1 of Recovery
This is the more intense phase.
HR, SAT, RR, ECG, & airway patency are monitored continuously.
Mental status, Blood Pressure, temperature, & pain are monitored frequently.
If the patient is intubated the neuromuscular function will also be monitored
First 15-30 min = 1:1.
stay in phase 1 for 30 min
Phase 1 recovery VS assessment
Vital Signs -
q 5 minutes for the 1st 15 minutes.
q 15 minutes for the duration of Phase I.
Typically want to keep the patient’s vitals within 20% of baseline
Phase II of Recovery
Patient criteria for discharge.
Standard Aldrete Score.
Modified Aldrete Score.
Postanthesia Discharge Score.
Standard Aldrete Score
activity;
O= unable to move extremities
1= move 2 extremities
2= move all extremities voluntarily on command
Respiration
0= apneic
1=dyspneic, shallow or limited breathing
2= breaths deeply and coughs freely
Circulation
0= BP + 50 mm of preaneesthetic level
1= Bp + 20-50 mm of preanesthetic level
2= BP + 20 mm of preanesthetic score
Consciousness
0= not responding
1= arrousable on calling
2= fully awake
Oxygen saturation
0= < 92% with o2
1= supplemental o2 required to maintain 90%
2= > 92% on RA
To move from pacu = need to have score of 9 or 10.
Postanesthesia Discharge Scoring System
VS;
0= > 40% of preanesthetic level
1= 20-40% of preoperative baseline
2= within 20% of preoperative baseline
Activity;
0= unable to ambulate
1= requires assistance
2= steady gain, no dizziness
N/V
0= Continues to require treatment
1= moderate treat with IM meds
2= Minimal; treat with PO meds
Pain
1= not acceptable to the patient, not controlled with PO meds
2= acceptalbe control per the patient, controlled with PO meds
Surgical bleeding
0= severe more than 3 dressing changes
1= moderate up to 2 dressing changes
2= minimal; no dressing changes required
Phase 2 recovery VS
Vitals taken every 30 - 60 minutes.
Monitor:
Airway and ventilation status.
Pain level & PONV.
Fluid balance.
Integrity of the wound.
PACU Airway Complications
Airway Obstruction.
Laryngospasm.
Airway edema/Hematoma.
Vocal Cord Palsy; are VC moving/ have them talk.
Residual Neuromuscular Block.
OSA.
Patient related Risk Factors for Airway Complications
Patient related = COPD, Asthma, OSA, obesity, heart failure, Pulmonary HTN, Upper respiratory tract infection, tobacco use, & higher ASA score.
Procedure related Risk factors for airway complications
Procedure related = Surgery near diaphragm, ENT procedures, severe incisional pain, IV fluids, long procedure (3 hours); w/ weird positions. And if they gets lots of fluid while in the weird positions.
Anesthesia related risk factors for airway complications
Anesthetic related = General, muscle relaxers, administration of opioids.
Spinal or epidural or even just a PNB; don’t well in advance. Don’t have someone with LAST 4 hrs later. General = will have complications
Over administration of opioids; still problematic. Respiraotry depressed to doing ketamine/ precedex. Pt w/ OSA = don’t want still sedated in recovery.
Upper Airway Obstruction causes
Loss of pharyngeal muscle tone.
Paradoxical breathing; belly and chest breathing.
Upper airway obstruction treatment
Jaw thrust.
Continuous positive airway pressure.
Oral/Nasal airway.
Vocal cords close and prevent any air movement resulting in hypoxemia and possible (-) pressure pulmonary edema.
Laryngospasms
Causes of laryngospasms
Stimulation of pharynx or vocal cords. (sections or blood)
Over aggressive Secretions, blood, foreign material.
Regular extubations;
Negative Pressure Pulmonary Edema
A form noncardiogenic pulmonary edema that results from a generation of high negative intrathoracic pressure needed to overcome upper airway obstruction.
Resolves in 12-48 hrs.
Pt breathing against closed upper airway. Ett kinked/ sections/ apl is closed and you didn’t open it. Vaccuming and closed airway = pull interstitial fluid out of the lungs.
Largynogspasm physiology
Physiology - is a prolonged exaggeration of the glottic closure reflex due to stimulation of the superior laryngeal nerve.
Laryngospasm symptoms
Symptoms - Faint inspiratory stridor due to increased respiratory effort, increased diaphragmatic excursion, and finally flailing of the lower ribs.
Laryngospasm Treatment
Get help in the OR,
Apply the facemask on the patient with a very tight seal. 100% FiO2, close your APL valve to about 40 cm H2O. Do NOT squeze the bag - wait for them to breath.
Suction airway.
Chin lift/jaw thrust, oral or nasal airways.
Pressure on the “laryngospasm notch”.
Laryngospasm Notch
Larson’s Point - Behind the lobule of the pinna of each ear.
Helps break laryngosmasm
Forcible jaw thrust with bilateral digital pressure on larsons point 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.
S/S of patient unable to break the laryngospasm
Fast desaturation.
Increased heart rate. Slows with extreme desaturation
Treatment if unable to break the laryngospasm
Atropine (treat bradycardia, but treat hypoxia more, can also help dry up secretions), Propofol, Succinylcholine. (deepen anesthesia) (remember pts can bradycardia from sux) (dose for SUCC; 1/10th dose))
Re-Intubate.
Airway edema associated with -
Prolonged intubation or long surgical procedures in the prone or Trendelenburg position.
Cases with large blood loss = aggressive fluid resuscitation.
Facial and scleral edema alert the CRNA that the patient most likely has airway edema.
Assessment for airway edema
Prior to extubation suction the oral pharynx and perform a ETT cuff leak test.
Cuff Leak test - remove a small amount of air and assess for air moving around the cuff.
If you cannot hear air leave the Tube in place.
don’t extubate = have sig airway edema
Airway Hematoma causes
Seen following neck dissections, Thyroid removal, & carotid surgeries.(smaller branch of artery)
A rapidly expanding hematoma may cause supraglottic edema.
Can see deviated trachea & compression of the trachea below the level of the cricoid cartilage.
Airway Hematoma Treatment
Decompress the airway by releasing the clips or sutures on surgical incision, subcutaneous clot removed before attempting reintubation.
Re-intubate - have advanced airway equipment ready.
Surgical backup - tracheostomy.
Vocal Cord Palsy Associated with
Otolaryngologic surgery, thyroidectomy, parathyroidectomy, rigid bronchoscopy, over inflated ETT cuff.
Can be unilateral or bilateral nerve injury.
If unilateral paralysis, patient is often asymptomatic.
Unilateral vs bilateral vocal cord nerve injury
Bilateral; is the result of airway stuff and is always symptomatic
Unilateral; is the result of surgical misadventures may be asymptomatic
Damage to the External Branch of the Superior Laryngeal Nerve
Section of the external laryngeal nerve produces weakness and huskiness of the voice, as the vocal cords cannot tense up.
The cricothyroid muscle is paralyzed.
Injury results in a loss of tension, with the vocal cord appearing wavy./ flopping around
Bilateral Recurrent laryngeal Nerve Damage
This injury results in aphonia and paralyzed cords.
Each paralyzed cord assumes an intermediate postion (midway between abduction & adduction.
The cords can close causing airway obstruction during inspiration.
This is extremely rare.
Cords stuck half way open, loss of tone can close and obstruct when they breathe in.
Thyroid Surgery complications
Hypocalcemia - Can see 24 to 48 hrs post-op.
Chvostek’s sign = facial spasm.
Trouseau’s sign = carpal spasm.
Hematoma formation can be immediate or within 24 hours.
Also, caused by recurrent laryngeal nerve damage.
Residual Neuromuscular Blockade
Complete reversal of muscle relaxants is necessary.
Clinical evaluation includes grip strength, tongue protrusion, the ability to lift the legs of the bed, & able to hold the head up for 5 seconds. Think of TOF; usually ppl have full train of 4 but will be weak, check grip strength, sustained muscular activity, (pick up arm for 5 seconds) stick out tongue.
Just because you see these signs doesn’t mean your patient’s airway reflexes have returned.
Obstructive Sleep Apnea
Considered a syndrome - in which patients have a partial or complete blockage of the upper airway.
Obviously prone to airway obstruction - make sure they are awake and following commands prior to extubation.
Sensitive to opioids - try regional techniques for post-operative pain.
CPAP - hopefully they bought it to surgery with them.
STOP BANG
Snore
Tired
Observed you stopping breathing
Pressure ( high bp)
BMI > 35
Age
Neck circ
Gender (male > women)
5-8 – high risk for OSA
3-4- intermediate
0-2 = low risk
Quantitative means to assess risk of OSA
Causes of Arterial Hypoxemia
Patient on room air. (lazy/ provider doesn’t forget to hook up oxygen)
Hypoventilation - too much pain meds or benzodiazepines
Arterial hypoxemia treatment
Apply oxygen via NC or Facemask.
Reverse the opioid or Benzodiazepines.
Continue to stimulate the patient.
Diffusion Hypoxia
Rapid diffusion of nitrous oxide into alveoli at the end of a nitrous oxide anesthetic.
Nitrous oxide dilutes the alveolar gas and decreases the PaO2 and PaCO2.
At room air, the resulting decrease in PAO2 can produce arterial hypoxemia while the drop in PaCO2 can depress the respiratory drive.
In the absence of oxygen, diffusion hypoxia can persist for 5 - 10 minutes after discontinuation of a nitrous oxide anesthetic.
May contribute to arterial hypoxemia during phase I of PACU
Systemic Hypertension
A significant number of patients will have hypertension following surgery.
Treatment threshold varies…treat if SBP > 180 mmHg or DBP > 110mmHg.
Common Causes: Emergence excitement, shivering, hypercapnia, pain, agitation, bowel distention, urinary retention.
Systemic Hypertension Treatment
Surgeon will usually give you a range to keep the patient’s blood pressure.
Treat underlying causes…
Use rapid acting meds - Labetalol 5 - 25mg. Hydralyzine 5 - 10mg, Metoprolol 1 - 5mg.
Systemic Hypotension characterized as…..
Hypovolemic - decreased preload.
Distributive - decreased after load. (post stone removal)
Cardiogenic - intrinsic pump failure.
Hypovolemic Decreased Preload - Causes:
Third spacing.
Inadequate intraoperative IV fluid replacement.
Loss of sympathetic nervous system tone due to neuraxial blockade.
Ongoing bleeding.
Distributive decreased afterload; cuases
Sepsis.
Allergic reactions.
Critical illness.
Iatrogenic sympathectomy.
Critically Ill Patients
Very fragile patients -
Small doses of anesthetics, pressors, downers, could have an exaggerated effect.
May rely on exaggerated sympathetic nervous system tone to maintain systemic blood pressure & HR.
Allergic Reactions and tx
Primary types - Anaphylactic & Anaphylactoid.
Epinephrine is the drug of choice to treat HoTN r/t an allergic reaction.
10-20 mcg IV and can give more
Most common drug class to cause anaphylactic reactions; muscle relaxants
Most common cause of allergic reactions
muscle relaxants
latex allergies
antibiotics
hypnotics
colloids
opioids
Symptoms of NMB allergic reaction
Histamine release = vasodilation, erythema, edema, HoTN, GI constriction, tachycardia, pruritus…
Potent inflammatory leukotrienes (LTC) and prostaglandins (PGD) = bronchial constriction & increased vascular permeability.
Latex Allergy seen in…
Seen in high-risk groups -
Repeated exposures(health care providers), several surgical procedures, Spina-bifida patients, and us.
Latex-mediated reactions -
Irritant contact dermatitis.
Type IV cell - mediated reactions.
Type I IgE - mediated hypersensitivity reactions.
Antibiotic Allergies most common
PCN is the most common.
Vanc causes direct histamine release through______
rapid admin
S/S of antibiotic allergies
Pruritus
Flushing
Urticaria
Angioedema
Bronchospasm
Hypotension
Death
Most common pts that have hypotension/ cv collapse
urinary tract procedures or biliary stones
Kidney stones; just an eswal or cysto; but don’t know whats behind the stone so be prepared
Treatment for sepsis
-Fluid resuscitation. And quickly move to ->
- Pressure support.
Common causes of intrinsic pump failure
Myocardial ischemia & infarctions.
Cardiac tamponade.
Cardiac dysrhythmias. Acute a fib – loss of preload.
Risk stratification for non-cardiac surgery
High risk; aortic and other major vascular surgery
peripheral artery surgery
intermediate; carotid endarterectomy
head and neck surgery
intraoperative and intrathoracic surgery
orthopedic surgery
prostate surgery
Low risk
ambulatory surgery
endoscopic procedures
superficial procedures
cataract surgery
breast surgery
MI in the OR/ PACU
Continuous ECG monitoring in the PACU.
Want leads II & V5.
Computerized ST - segment analysis.
12 lead ECG if you suspect anything.
Serum troponin levels.
Treat MI by avoiding this…..
factors that decrease o2 supply; nicreased hr decreased arterial o2 ocntent (hbg/ dec SAo3)
hypotension, increased cardiac resistance
Causes of Cardiac Dysrhythmias
Hypoxemia.
Hypoventilation.
Endogeneous and exogenous Catecholamine.
Eletrolyte abnormalities.
Anemia.
Fluid overload.
Sinus Tachycardia
A narrow complex regular tachycardia with HR > 100 bpm.
Caused by several factors: Bleeding, cardiogenic/septic shock, Thyroid storm, pulmonary embolism.
Most common: Sympathetic stimulation (pain), Hypovolemia, anemia, Shivering, & agitation.
Common causes of Atrial Dysrhythmias
Higher after cardiac & thoracic surgery.
Preexisting cardiac risk factors.
Positive fluid balance.
Electrolyte abnormalities.
Oxygen desaturation.
Atrial Fibrillation
Rate control versus rhythm control for new onset?
Hemodynamically unstable patients = cardioversion.
Most patients will respond to beta-blockers or calcium channel blockers.
Ventricular Dysrhythmias
Have a wide QRS complex ( > 120 ms).
Premature ventricular contractions are common.
True ventricular tachycardia is rare and indicative of underlying cardiac pathology.
Investigate the “Hs” & the “Ts”.
Bradydysrhythmias
Heart rate < 60 bpm.
Causes: late hypoxia
Procedures: Bowel distention, ICP & intra-ocular pressure, spinal anesthesia.
Bradydysrhythmias and spinal blocks
High spinals reaching T1-T4 level can block the cardioaccelerator fibers resulting in profound bradycardia.
The combination of the sympathectomy, bradycardia, and lack of intravascular volume can produce cardiac arrest…even in young healthy patients.
an acute change in cognition or disturbance of consciousness that cannot be attributed to a preexisting medical condition, substance intoxication, or medication.
Delirium
Postoperative Cognitive Dysfunction
Delirium
High incidence for the elderly and associated with specific surgical procedures.
Unable to tell who is suffering from it immediately in the PACU b/c of our anesthesia.
Risk factors for Postoperative Cognitive Dysfunction
Advanced age > 70 years old.
Preoperative cognitive impairment.
Decreased functional status.
Alcohol abuse.
Intra-operative Factors Associated with Delirium
Surgical blood loss (hematocrit < 30% & increased number of intra-operative blood transfusions).
Hypotension.
Administration of nitrous oxide.
Anesthetic technique (general vs regional).
Management of Delirium
Identify the high-risk patient prior to surgery.
Severly agitated patients may require additional PACU assistance.
Early identification can help guide choice of medications and anesthetic.
Elderly patients undergoing minor surgery should be treated at an outpatient center to minimize post-operative delirium.
Delayed Awakening
Evaluate the vital signs. Too high ETCO2 = sleepy patient.
Perform neurological exam.
Monitor patient’s oxygenation status.
Send lab for potential electrolyte abnormalities or high or low glucose concentrations.
Causes of Delayed Awakening and treatment
1 = residual sedation from the anesthetic.
Opioids - treat with Narcan 20 - 40 mcg increments in adults.
Benzodiazepines - treat with Flumazenil 0.2 mg.
Scopolamine - treat with Physostigmine 0.5 - 2mg IV may be effective in reversing the central nervous system sedative effects of anticholinergic drugs
Hypothermia - < 33℃.
Hypoglycemia.
Increased intracranial pressure.
Residual neuromuscular blockers.
