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Clinical assessment > PACU > Flashcards

PACU Flashcards

1
Q

Immediate PACU priority

A

respiratory and circulator adequacy

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2
Q

Alderete score: Discharge from PACU protions

A
  1. Able to move extremities on command
  2. Breathing
  3. Circulation
  4. Consciousness
    5.O2 sats
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3
Q

Aldrete activity scoring

A

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

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4
Q

Aldrete respiration score

A

0: Apneic
1: dyspneic, shallow or inadequate
3: Normal, cough effective

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5
Q

Aldrete Circulation score

A

0: BP>50 mmHg of preanesthetic vaclue
1: BP within 50 mmHg of preanesthetic value
2: BP within 20 mmHg

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5
Q

Aldrete O2 sat scoring

A

0: SPO2 <90% on supplemental O2
1: SPO2 > 90% but needs supplemental O2
2: SPO2 > 92% RA

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6
Q

Aldrete consciousness scoring

A

0: Unresponsive to voice
1: arousable to voice
2: fully awake

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7
Q

Most common cause of airway obstruction in immediate postoperative phase

A

loss of pharyngeal muscle tone in sedated or obtunded patient

s/sx: snoring and use of accessory muscles

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8
Q

Laryngeal obstruction

A

Occludes the airway from partial or complete spasm of intrinsic or extrinsic muscles of the larynx

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9
Q

Laryngospasm can cause

A

negative pressure pulmonary edema

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10
Q

Laryngospasm pathway

A

see notability

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11
Q

Afferent laryngospasm

A

Internal branch SLN –> afferent limb–>brain

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12
Q

Efferent laryngospasm

A

brain–>efferent limb–> External branch of SLN AND recurrent laryngeal nerve

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13
Q

External branch of SLN innervates

A

Cricothyroid (elongates (tenses) vocal cords

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14
Q

Recurrent laryngeal nerve innervates

A

Lateral cricoid
Thyroarytendoid

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15
Q

Lateral cricoid does

A

ADDucts the vocal cords (closes glottis)

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16
Q

Thyroarytenoid does

A

ADDucts the vocal cords (closes glottis)

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17
Q

Muscular innervation of the vocal cords

A

SCAR
Superior laryngeal nerve = Cricothyroid muscles

All other muscles: Recurrent laryngeal nerve

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18
Q

Extrinsic muscles

A

end in ‘-hyoid’

and digastric

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19
Q

Treatment of laryngospasm

A
  1. 100% O2
  2. Deepen anesthesia (propofol, lidocaine)
  3. Larson manuever/vigorous jaw thrust/postive pressure ventilation
  4. 0.1 mg/kg succ
  5. reintubation
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20
Q

Larsons maneuver

A

bilateral digital pressure on styloid process behind posterior ramus of mandible

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21
Q

laryngospasm drug treatments

A
  1. propofol low dose 0.5 mg/kg
  2. IV lidocaine
  3. partial succs dose 0.1 mg/kg
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22
Q

Virchows triad

A

pulmonary embolis risk

  1. venous stasis
  2. hypercoagulabilty
  3. abnormalities of the blood vessel wall
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23
Q

Bronchospasm cause

A

smooth muscle in airway inflammation

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24
Q

bronchospasm treatment(5)

A

decrease airway irritability and promote bronchodilation

Beta-2 agonist (i.e. albuterol)

anticholinergics

IV/inhaled lidocaine

steroids

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25
Q

Causes of increased dead space postoperatively

A
  1. PE (block alveoli)
  2. deceased CO is most likely acute cause post op
  3. ARDS/TRALI (destruction of pulmonary microvasculature, irreversible)
26
Q

Causes of postoperative increased CO2

A
  1. MH
  2. Sepsis, fever
27
Q

Best indicator of pulmonary oxygen transfer from alveolar gas to pulmonary capillary

A

PaO2

why are they not getting better?

28
Q

PVO2 (mixed venous PO2) falls if

A
  1. PaO2 decreases
  2. Tissue extraction increases
29
Q

What increases oxygen extraction (context: decreased PVO2)

A

Shivering, infection, hypertetabolism

30
Q

What decreases tissue oxygen delivery (context: low PVO2)

A

Low CO and hypotension

31
Q

Critical DO2

A

actual level at which shock occurs (lack of tissue oxygen delivery)

32
Q

classic hypotension definition

A

<20% of baseline BP

33
Q

Leading cause of post-operative hypertension

A

Pain

somatic afferent nerve stim–>pressor response (somatosympathetic resonse)

34
Q

with delerium, first:

A

always assume hypoxemia until proven otherwise

35
Q

if delirium is not hypoxemia:

A

Treat with sedatives after hypoxemia has been eliminated as a cause

midaz, propofol, dex most common

36
Q

Main differentials for delayed emergence (3):

A
  1. Drug-induced (not dex)
  2. metabolic
  3. neurologic (stroke, seizure, increased ICP)
37
Q

Drug-induced delayed emergence(what drugs can be the cause)

A

Opioids
Sedatives
residual anesthetic
inadequate NMB reversal

38
Q

Metabolic delayed emergence

A

Hypoxia
Hypercapnia/carbia
hyponatremia
acidosis
hypo/er glycemia
hypo/er thermia

39
Q

Best measure of post op analgesia

A

patient perception

40
Q

Hypothermia temp

A

below 36 degrees

41
Q

What issues does hypothermia cause?

A
  1. prolongs recovery
  2. compromises physiologic stability
    3.contributes to postoperative morbidity
42
Q

Hypothermia: physiologic problems

A
  1. Reduces O2 availability (shifts oxyhemoglobin curve to left)
  2. shivering increase O2 demand by 400%
  3. Drug biotransformation is decreased as metabolic dependent processes slow
  4. Renal transport processes are slowed (decreased GFR)
  5. Cardiac rate/rhythm disturbances (bradydysrythimias, PVCs)
  6. CNS depressino
  7. discomfort
  8. increasing adrenergic stimulation
  9. coagulopathy
  10. Impaired wound healing, surgical site infection, increased hospital costs
43
Q

Hypothermia prevention

A

Heated blankets

Increase room temp

fluid warmers

warm irrigation

44
Q

Shivering treatment

A

Rewarm

small doses of:
1. meperidine
2. ketamine
3 dexmedetomidine
4. hydrocortison
5. granisetron
6. ondansatron

45
Q

Primary risk factors for N/V

A
  1. Female
  2. less than 50
  3. nonsmoker
  4. hx PONV
  5. hx motion sickness
46
Q

Anesthetic risk factors for N/V

A

1.Use of volatiles
2. use of nitrous
3. higher doses of opioids used

47
Q

Surgery related risk factors for N/V

A
  1. duration > 1 hr
  2. type of surgery (esp laparocscopy)
48
Q

Classes of drugs that help PONV

A
  1. 5-HT2 receptor antagonists
  2. D2 dopamine receptor antagonists
  3. Histamine receptro antagonists
  4. NK-1 receptor antagonist
  5. Dexametahsone
  6. Ephedrine (keep BP up)
  7. Antimuscarinic

combination therapy is most effective

49
Q

5-HT3 serotonin receptor antagonist drugs

A
  1. ondansetron
  2. dolasetron
  3. granisetron
  4. palonosetron
50
Q

D2 dopamine receptor antagonist drugs

A
  1. droperidol
  2. Procholrperazine
  3. metoclopramide
51
Q

Histamine receptor antagonist drugs

A
  1. diphenhydramine
  2. promethazin
  3. dimenhydrinate
52
Q

Antimuscarinic drugs

A
  1. glycopyrrolate
  2. scopolamine
53
Q

NK-1 receptor antagonist drugs

A
  1. aprepitant
54
Q

Non-pharmacologic PONV intervention

A
  1. accupuncture
  2. transcutaneous electrical nerve stim
  3. acupoint stim
  4. acupressure
  5. aromatherapy - peppermint, alcohol
  6. P6 stim (wrist)
55
Q

Ondansatron timing

A

30 min before end of surgery

56
Q

aprepitant timing

A

3 hrs before surgery

57
Q

scopolamine timing

A

in preoperative holding area

58
Q

Dexamethasone timing

A

shortly after anesthetic induction

59
Q

Pt is oliguric. What is the FIRST aspect of perioperative care that should be evaluated

A

calculate fluid and blood product input and EBL

60
Q

Urine output should be

A

0.5 mg/kg/hr

61
Q

output/voiding and epidural/sinal

A

autonomic effects and interferes with sphincter relaxation–>urinary retention

62
Q
A

Clinical assessment (10 decks)

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