PACU

Question 1

Three Phases of Recovery

Answer 1

1: Early recovery - pt awakens, recovers AW reflexes and motor fxn, may be fast tracked. 2: step down, pt becomes full ready for discharge. 3: After discharge, until resuming normal activities // Aldrete - thru phase 1 recovery, PADSS - thru phase 2 recovery

Question 2

Requirements prior to transport from OR

Answer 2

1: Stable Airway 2: Ventilation is adequate 3: HD stable

Question 3

PACU Report

Answer 3

Name/Sx/Anesthesia Type/Vitals/Med Hx/Last dosings/ALLERGIES/EBL/I&Os/complications/special treatments

Question 4

Monitoring Pearls

Answer 4

Pulse ox first on, last off / temp always for general with avoidance of hypothermia/shivering / freq n/v/pain assessment

Question 5

Goals of Post Op pain Mgmt

Answer 5

control acute pain / allow early activity / resume enteral nutrition / use “balanced analgesia”, helps to reduce side effects, local infiltration helps

Question 6

Spinal/Epidural Narcotics

Answer 6

Provide prolonged anesthesia. Fent: more immediate effect, resp effect quicker, less itching, less movement. Morphine: slower onset, delayed resp depression, more itching and more mvmt than fentanyl

Question 7

PONV risk factors

Answer 7

female, hx motion sickness, nonsmokers, adolescents, use of post op opioids / sx type: intra abdo, GYN, laparoscopic, breast, eye, ENT // GETA more emetogenic then spinal/regional

Question 8

Physio rationale for PONV tx

Answer 8

Multiple receptors in CTZ: dopaminergic, muscarinic/cholinergic, seratonin, histamine // ulse multimodal therapy, avoid emetogenic rx, use modest opioid amounts

Question 9

Effective Rx for PONV

Answer 9

5HT3 antagonist (ondansteron) anti-dopamine (droperidol, metocloperamide) glucocorticoid (dexamethasone, not a rescue tx), periop hydration @ 20ml/kg

Question 10

Rx plan for high risk PONV

Answer 10

propofol, no nitrous, decadron, 5HT3 antagonists

Question 11

Most Common PACU problems 1/3: Neuro/Shivering Causes/Tx

Answer 11

Due to redistribution of core –> peripheral blood resulting in hypothermia/heat redistribution. Increase o2 demand. Hypo effect: impaired healing, cardiac events, discomfort/pain exac, altered metabolism, coagulopathy // tx w/ demerol, clonidine, muscle relaxants and forced air warmers / ALOC - spectrum of lethargy to agitation (hypoxia, meds, pain, ETOH w/d)

Question 12

Most Common PACU problems 2/3: Pulmo

Answer 12

AW obstuction (by tongue, laryngospasm) / Hypoventilation must assist vent (d/t residual anesthesia most common, analgesia, muscle relaxant) / Hypoxia (shunting d/t decr FRC/atelectasis) give 100%, listen lungs, cxr, tx cause / OSA, use CPAP, HOB up, must return to baseline O2 sat, obstruct in PACU = 7 hour monitoring

Question 13

Most Common PACU problems 3/3: Cardiac

Answer 13

HTN (pain, full bladder) tx stimulus, then anti HTN / Hypotension (warms and redistributes, IVF tx 250-500, keep spinal pt supine) must R/O serious causes / Dysrhythmias - many causes, stable vitals, add o2, check lytes and 12lead, consult

Question 14

Most Common discharge issues

Answer 14

Tolerating PO fluids: not true, assoc with incr n/v & longer PACU stays // Voiding: not high risk ok for d/c prior to void (hx of post op retention, neuraxial anesthesia, pelvic/uro procedure, periop catheterization) // Regional - must be steady on feet, proprioception awareness intact

Question 15

Mod Alderete Score (PACU admission)

Answer 15

Activity: moves voluntarily or on command
Respiration: NL, hypovent, apneic
Circulation: BP w/i; 20, 20-50, 50 mmHg
Consciousness: Fully awake, arousable, no response
O2 Sat: 92+ on RA, req o2 for 90+, <90 with O2

Question 16

PADSS (PACU d/c criteria)

Answer 16

Vital sign stability / Activity level / N/V / Pain / Sx bleeding