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
