PACU Flashcards
Immediate PACU priority
respiratory and circulator adequacy
Alderete score: Discharge from PACU protions
- Able to move extremities on command
- Breathing
- Circulation
- Consciousness
5.O2 sats
Aldrete activity scoring
0: cannot move extremities or lift head
1: Moves 2 extremities voluntarily or on command and can lift head
2: Moves all extremities voluntarily or on command
Aldrete respiration score
0: Apneic
1: dyspneic, shallow or inadequate
3: Normal, cough effective
Aldrete Circulation score
0: BP>50 mmHg of preanesthetic vaclue
1: BP within 50 mmHg of preanesthetic value
2: BP within 20 mmHg
Aldrete O2 sat scoring
0: SPO2 <90% on supplemental O2
1: SPO2 > 90% but needs supplemental O2
2: SPO2 > 92% RA
Aldrete consciousness scoring
0: Unresponsive to voice
1: arousable to voice
2: fully awake
Most common cause of airway obstruction in immediate postoperative phase
loss of pharyngeal muscle tone in sedated or obtunded patient
s/sx: snoring and use of accessory muscles
Laryngeal obstruction
Occludes the airway from partial or complete spasm of intrinsic or extrinsic muscles of the larynx
Laryngospasm can cause
negative pressure pulmonary edema
Laryngospasm pathway
see notability
Afferent laryngospasm
Internal branch SLN –> afferent limb–>brain
Efferent laryngospasm
brain–>efferent limb–> External branch of SLN AND recurrent laryngeal nerve
External branch of SLN innervates
Cricothyroid (elongates (tenses) vocal cords
Recurrent laryngeal nerve innervates
Lateral cricoid
Thyroarytendoid
Lateral cricoid does
ADDucts the vocal cords (closes glottis)
Thyroarytenoid does
ADDucts the vocal cords (closes glottis)
Muscular innervation of the vocal cords
SCAR
Superior laryngeal nerve = Cricothyroid muscles
All other muscles: Recurrent laryngeal nerve
Extrinsic muscles
end in ‘-hyoid’
and digastric
Treatment of laryngospasm
- 100% O2
- Deepen anesthesia (propofol, lidocaine)
- Larson manuever/vigorous jaw thrust/postive pressure ventilation
- 0.1 mg/kg succ
- reintubation
Larsons maneuver
bilateral digital pressure on styloid process behind posterior ramus of mandible
laryngospasm drug treatments
- propofol low dose 0.5 mg/kg
- IV lidocaine
- partial succs dose 0.1 mg/kg
Virchows triad
pulmonary embolis risk
- venous stasis
- hypercoagulabilty
- abnormalities of the blood vessel wall
Bronchospasm cause
smooth muscle in airway inflammation
bronchospasm treatment(5)
decrease airway irritability and promote bronchodilation
Beta-2 agonist (i.e. albuterol)
anticholinergics
IV/inhaled lidocaine
steroids
Causes of increased dead space postoperatively
- PE (block alveoli)
- deceased CO is most likely acute cause post op
- ARDS/TRALI (destruction of pulmonary microvasculature, irreversible)
Causes of postoperative increased CO2
- MH
- Sepsis, fever
Best indicator of pulmonary oxygen transfer from alveolar gas to pulmonary capillary
PaO2
why are they not getting better?
PVO2 (mixed venous PO2) falls if
- PaO2 decreases
- Tissue extraction increases
What increases oxygen extraction (context: decreased PVO2)
Shivering, infection, hypertetabolism
What decreases tissue oxygen delivery (context: low PVO2)
Low CO and hypotension
Critical DO2
actual level at which shock occurs (lack of tissue oxygen delivery)
classic hypotension definition
<20% of baseline BP
Leading cause of post-operative hypertension
Pain
somatic afferent nerve stim–>pressor response (somatosympathetic resonse)
with delerium, first:
always assume hypoxemia until proven otherwise
if delirium is not hypoxemia:
Treat with sedatives after hypoxemia has been eliminated as a cause
midaz, propofol, dex most common
Main differentials for delayed emergence (3):
- Drug-induced (not dex)
- metabolic
- neurologic (stroke, seizure, increased ICP)
Drug-induced delayed emergence(what drugs can be the cause)
Opioids
Sedatives
residual anesthetic
inadequate NMB reversal
Metabolic delayed emergence
Hypoxia
Hypercapnia/carbia
hyponatremia
acidosis
hypo/er glycemia
hypo/er thermia
Best measure of post op analgesia
patient perception
Hypothermia temp
below 36 degrees
What issues does hypothermia cause?
- prolongs recovery
- compromises physiologic stability
3.contributes to postoperative morbidity
Hypothermia: physiologic problems
- Reduces O2 availability (shifts oxyhemoglobin curve to left)
- shivering increase O2 demand by 400%
- Drug biotransformation is decreased as metabolic dependent processes slow
- Renal transport processes are slowed (decreased GFR)
- Cardiac rate/rhythm disturbances (bradydysrythimias, PVCs)
- CNS depressino
- discomfort
- increasing adrenergic stimulation
- coagulopathy
- Impaired wound healing, surgical site infection, increased hospital costs
Hypothermia prevention
Heated blankets
Increase room temp
fluid warmers
warm irrigation
Shivering treatment
Rewarm
small doses of:
1. meperidine
2. ketamine
3 dexmedetomidine
4. hydrocortison
5. granisetron
6. ondansatron
Primary risk factors for N/V
- Female
- less than 50
- nonsmoker
- hx PONV
- hx motion sickness
Anesthetic risk factors for N/V
1.Use of volatiles
2. use of nitrous
3. higher doses of opioids used
Surgery related risk factors for N/V
- duration > 1 hr
- type of surgery (esp laparocscopy)
Classes of drugs that help PONV
- 5-HT2 receptor antagonists
- D2 dopamine receptor antagonists
- Histamine receptro antagonists
- NK-1 receptor antagonist
- Dexametahsone
- Ephedrine (keep BP up)
- Antimuscarinic
combination therapy is most effective
5-HT3 serotonin receptor antagonist drugs
- ondansetron
- dolasetron
- granisetron
- palonosetron
D2 dopamine receptor antagonist drugs
- droperidol
- Procholrperazine
- metoclopramide
Histamine receptor antagonist drugs
- diphenhydramine
- promethazin
- dimenhydrinate
Antimuscarinic drugs
- glycopyrrolate
- scopolamine
NK-1 receptor antagonist drugs
- aprepitant
Non-pharmacologic PONV intervention
- accupuncture
- transcutaneous electrical nerve stim
- acupoint stim
- acupressure
- aromatherapy - peppermint, alcohol
- P6 stim (wrist)
Ondansatron timing
30 min before end of surgery
aprepitant timing
3 hrs before surgery
scopolamine timing
in preoperative holding area
Dexamethasone timing
shortly after anesthetic induction
Pt is oliguric. What is the FIRST aspect of perioperative care that should be evaluated
calculate fluid and blood product input and EBL
Urine output should be
0.5 mg/kg/hr
output/voiding and epidural/sinal
autonomic effects and interferes with sphincter relaxation–>urinary retention
