PACU & Complications (Cornelius) Exam II Flashcards
According to Standard 1, all patients who have received general anesthesia, regional anesthesia, or __________ shall receive appropriate postanesthesia management.
A. Epidural anesthesia
B. Spinal anesthesia
C. Monitored anesthesia care
D. Sedation only
C. Monitored anesthesia care
Slide 4
Which of the following are requirements according to Standard 2? (Select 3)
A. The patient must be accompanied by a knowledgeable anesthesia care team member.
B. The patient’s condition must be continually evaluated during transport to the PACU.
C. The patient can be transported without evaluating if stable.
D. The patient should receive support appropriate to their condition during transport.
E. A physician is responsible for the discharge of the patient from the postanesthesia care unit
A. The patient must be accompanied by a knowledgeable anesthesia care team member.
B. The patient’s condition must be continually evaluated during transport to the PACU.
D. The patient should receive support appropriate to their condition during transport.
C- For instance, if you have somebody who’s going back to the ICU, you probably are going to keep them on the cardiac monitor and check their blood pressure, pulse, oxygen sort of thing
On the other hand, most of our PACU patients will be be off all mechanical monitors and be more dependent on our observation skills.
Slide 4
According to Standard 3, upon arrival to the PACU, the patient shall be re-evaluated and a __________ provided to the responsible PACU RN by the member of the anesthesia care team.
A. Written report
B. Verbal report
C. Email report
D. Brief report
B. Verbal report
Slide 5
Standard 4 states that the patient’s condition shall be evaluated __________ in the PACU.
A. Occasionally
B. Once
C. Continually
D. Sporadically
C. Continually
Slide 5
Standard 5 specifies that a __________ is responsible for the discharge of the patient from the postanesthesia care unit.
A. Nurse
B. Hospitalist
C. CRNA
D. Physician
E. Charge RN
F. Respiratory Therapist
G. PACU Secretary
H. Patient’s family member
D. Physician
This can be a anesthesiologist or surgeon
Slide 5
In 1920, several __________ were opened in the United States as a response to recognizing the need for closer monitoring of post-surgical patients.
A. Intensive Care Units
B. Operating Rooms
C. Postanesthesia Care Units
D. Outpatient Surgery Centers
C. Postanesthesia Care Units (PACUs)
Slide 6
After __________, the number of PACUs increased as the military recognized the critical time period for patients following surgery.
A. The Great Depression
B. World War I
C. The Vietnam War
D. World War II
D. World War II
Slide 6
A study in 1947 showed that over an 11-year period, approximately __________ of deaths in the first 24 hours following surgery were preventable.
A. 30%
B. 50%
C. 70%
D. 90%
B. 50%
Slide 6
In 1949, PACU care became a __________ of care for postoperative patients.
A. New recommendation
B. Standard
C. Suggestion
D. Temporary solution
B. Standard
Slide 6
Which of the following staff members are NOT commonly found in a PACU?
A. Interventional radiologist
B. Respiratory therapists
C. Anesthesia personnel
D. Intensivists or hospitalists
E. Specially trained nurses
A. Interventional radiologist
Slide 7
In some PACUs, __________ or __________ are responsible for overseeing the care of patients if they are admitted to the hospital after surgery.
A. Nurses, nurse practitioners
B. Respiratory therapists, anesthesiologists
C. Intensivists, hospitalists
D. Surgeons, anesthesiologists
C. Intensivists, hospitalists
Slide 7
A __________ therapist may be assigned to float through the PACU to assist with specific needs such as ventilators or airway management.
A. Physical
B. Occupational
C. Respiratory
D. Speech
C. Respiratory
Slide 7
Postoperative care of patients in PACU includes:
A) Monitoring of oxygenation, ventilation, and circulation
B) Only monitoring oxygen levels
C) Monitoring ventilation and oxygenation
D) Monitoring of oxygen and ventilation
A) Monitoring of oxygenation, ventilation, and circulation (HR and BP)
Cornholio - Maybe it’s not common practice to transport patients on oxygen, but you’ve got to take them half mile.
Probably want to make sure you have oxygen. Do I need to take an Ambu bag with every patient? Probably not if I’m going across the hallway, but if I’m going a long way, it’s another story. Think about emergency medications and complications you can kind of encounter in between.
Slide 8
Which of the following actions should be taken upon a patient’s arrival in the PACU? Select 3
A) Assess airway patency
B) Assess respiratory rate
C) Connect the patient to monitors
D) Administer a diuretic
E) Taking the patient’s weight
A) Assess airway patency
B) Assess respiratory rate & Saturation %
C) Connect the patient to monitors
Slide 9
When assessing a patient on arrival to the PACU, which of the following is NOT required to be evaluated?
A) Mental status
B) Pain level
C) Oxygen saturation
D) PERRLA
D) Heart rate
E) Presence of PONV
D) PERRLA
Slide 9
The following factors should be considered in the treatment of hypoxemia in the PACU:
Select 3
A) Sedation
B) Patient’s mental status
C) Advanced age
D) Room air
E) Endentulous
A) Sedation
C) Advanced age (>60)
D) Room air
Also assess for respiratory rate and obesity
Slide 9
True or False
One of the biggest things we really worry about after anesthesia is hypovolemia.
FALSE
Corndog - *One of the biggest things we really worry about after anesthesia is hypoxemia. Are they older patients, people that are sedated that still have it in circulation. Do we have them on oxygen? Do they need oxygen? Is the oxygen adequate?
You will see that it’s part of your best efforts to monitor the patient and care for him that things will change between point A and point B. A patient that was 100% in the room may now suddenly be 50-60%, even though they’re still breathing…Having those monitors on quickly is pretty valuable.
Slide 9
What actions should the CRNA take upon the patient’s arrival to the PACU? Select 3
A) Reassess the patient
B) Connect the patient to monitors
C) Administer postoperative antibiotics
D) Provide a report to the PACU RN
A) Reassess the patient
B) Connect the patient to monitors
D) Provide a report to the PACU RN
Slide 10
What factors should you consider when giving a report to the PACU RN?
Select 2
A) Type of anesthetic used
B) Every medication and dose administered during surgery
C) Diabetes or hypertension
D) The exact time each medication was administered
A) Type of anesthetic used
C) Diabetes or hypertension
Slide 10
After monitors are placed on the patient in the PACU, the PACU RN assesses the patient and there are ________ separate phases of recovery.
A) 1
B) 2
C) 3
D) 4
B) 2
Slide 10
True or False
The admissions report needs to be specific, organized, and completed only when you have the full attention of the receiving RN.
TRUE
C - So no matter what you do, as far as report, try and make it organized, if you just hop around, it’s very hard for people to kind of follow your train of thoughts.
We all run into people with ADD that only listen for about 5 or 10 seconds.
So if they stop paying attention, start doing something else, sometimes I’ll just stop talking and wait. Sometimes I stare at them.
Sometimes I’ll ask are they listening?
Especially if I’m going to give something kind of important.
Slide 11
What does the acronym SBAR stand for in the context of patient handoff?
A) Situation, Background, Assessment, Recommendation
B) Summary, Background, Assessment, Report
C) Situation, Brief, Assessment, Response
D) Summary, Brief, Analysis, Recommendation
A) Situation, Background, Assessment, Recommendation
Slide 12
Which of the following is most important to communicate during a PACU handoff?
A) Every medication administered during surgery
B) Surgical duration and complications
C) Anesthetic events and complications
D) The name of the anesthesiologist and medications
C) Anesthetic events and complications
Slide 12
When should the CRNA ask if the PACU nurse has any questions about the handoff?
A) At the beginning of the report
B) After confirming patient allergies
C) At the end of the report
D) Before discussing the patient’s anesthesia history
C) At the end of the report
C - …and then at the end make sure that they don’t have any questions.
Slide 12
Which of the following are key features of the SBAR handoff process? Select 3 that apply.
A) Standardized
B) Covers non-essential patient information
C) Covers pertinent surgical and patient factors
D) Easy to remember
E) Only used for anesthesia providers
A) Standardized
C) Covers pertinent surgical and patient factors
D) Easy to remember
Slide 12
During the ICU handoff, which of the following should be emphasized?
A) Patient’s insurance details
B) The reason for postoperative complications
C) Patient’s family members present
D) Previous surgical procedures
B) The reason for postoperative complications
C - The one thing you’ll see that’s a little bit different here is usually you have the surgeon involved in this as well. So whether it’s the surgical resident, PA, NP or the staff surgeon themselves, somebody goes up there so they can answer a lot of those questions.
Slide 15
Which of the following is true about Phase 1 of recovery in the PACU?
A) It is the less intense phase.
B) HR, SAT, RR, and ECG are continuously monitored.
C) Patients are typically discharged during this phase.
D) Only the patient’s mental status is monitored continuously.
B) HR, SAT, RR, and ECG are continuously monitored.
And airway patency
Slide 16
Which of the following parameters is monitored frequently in Phase 1 of recovery?
A) Blood Pressure, temperature, and pain
B) Only ECG and SAT
C) Mental status and RR
D) Airway patency and HR
A) Blood Pressure, temperature, and pain
And Mental Status
Slide 16
If a patient is intubated in Phase 1 of recovery, what additional function is monitored?
A) Cardiac output
B) Neuromuscular function
C) Renal function
D) Pain score
B) Neuromuscular function
Slide 16
In Phase 1 of PACU care, how long does the PACU nurse typically remain at the patient’s bedside?
A) 45 to 60 minutes
B) 5 to 10 minutes
C) 15 to 30 minutes
D) 1 to 5 minutes
C) 15 to 30 minutes
Cornelius - the PACU nurse is going to stay at the patient’s bedside for at least the 1st 15 to 30 minutes before they wander off.
If they do, they’re not going to go very far.
Most places they will not care for another patient during this time period and be 1:1 care
Slide 16
Which patients are likely to bypass Phase 1 recovery and go directly to Phase 2?
A) Patients who received general anesthesia
B) Patients who required ICU care postoperatively
C) Patients who received minimal sedation
D) Patients recovering from major trauma surgery
C) Patients who received minimal sedation, such as those in cataract surgery
Slide 16
True or False
Anybody that’s been under general anesthesia has to go to phase one.
True
Slide 16
During the first 15 minutes of Phase 1 recovery, how often are vital signs checked?
A) Every 30 minutes
B) Every 10 minutes
C) Every 5 minutes
D) Every 15 minutes
C) Every 5 minutes
-* q5 min for 1st 15 minutes*
Slide 17
What is the goal for the patient’s vital signs during Phase 1 recovery?
A) Keep them within 10% of baseline
B) Keep them within 20% of baseline
C) Maintain a steady decrease from baseline
D) Only monitor for large fluctuations
B) Keep them within 20% of baseline
Slide 17
For the remainder of Phase 1 recovery, how often are vital signs checked?
A) Every 5 minutes
B) Every 10 minutes
C) Every 30 minutes
D) Every 15 minutes
D) Every 15 minutes
Slide 17
Which of the following are criteria used to assess a patient’s readiness for discharge in Phase II of recovery? Select 3
A) Standard Aldrete Score
B) Modified Aldrete Score
C) Postaldrete Discharge Score
D) Postanesthesia Discharge Score
E) Variable Aldrete Discharge Score
A) Standard Aldrete Score
B) Modified Aldrete Score
D) Postanesthesia Discharge Score
Slide 18
True or False
Phase I of Recovery is considered the more intense phase
True
Slide 16
Which of the following criteria is NOT included in the Standard Aldrete Score?
A) Activity
B) Respiration
C) Circulation
D) Pain
E) Consciousness
F) Oxygen Saturation
D) Pain
Slide 19
Select all that apply for Activity under the Standard Aldrete Score chart:
Select 3
A. Score 2: The patient moves all extremities voluntarily/on command.
B. Score 1: The patient moves two extremities.
C. Score 1: The patient moves only one extremity.
D. Score 0: The patient is unable to move extremities.
A. Score 2: The patient moves all extremities voluntarily/on command.
B. Score 1: The patient moves two extremities.
D. Score 0: The patient is unable to move extremities.
Slide 19
Select all that apply for Respiration under the Standard Aldrete Score:
Select 3
A. Score 2: The patient breathes deeply and coughs freely.
B. Score 1: The patient is dyspneic with shallow or limited breathing.
C. Score 0: The patient is apneic.
D. Score 0: The patient requires oxygen supplementation.
A. Score 2: The patient breathes deeply and coughs freely.
B. Score 1: The patient is dyspneic with shallow or limited breathing.
C. Score 0: The patient is apneic.
Slide 19
Select all that apply for Circulation under the Standard Aldrete Score:
select 3
A. Score 2: Blood pressure is within 25mm of the preanestheitc level
B. Score 2: Blood pressure is within 20 mm of the preanesthetic level.
C. Score 1: Blood pressure is 20-50 mm of the preanesthetic level.
D. Score 0: Blood pressure is more than 50mm different from the preanesthetic level.
B. Score 2: Blood pressure is within 20 mm of the preanesthetic level.
C. Score 1: Blood pressure is 20-50 mm of the preanesthetic level.
D. Score 0: Blood pressure is more than 50 mm different from the preanesthetic level.
slide 19
Select all that apply for Oxygen Saturation under the Standard Aldrete Score:
Select 3
A. Score 2: Spo2 > 92% on room air.
B. Score 1: Spo2 > 90% on supplemental oxygen.
C. Score 0: Spo2 > 92% even with supplemental oxygen.
D. Score 0: Spo2 < 92% even with supplemental oxygen.
A. Score 2: Spo2 > 92% on room air.
B. Score 1: Spo2 > 90% on supplemental oxygen.
D. Score 0: Spo2 < 92% even with supplemental oxygen.
Slide 19
What is the primary difference in the Modified Aldrete Scoring System compared to the original version?
A. It has a higher oxygen saturation threshold
B. It focuses on the heart rate rather than circulation.
C. It provides more detailed criteria for assessing patients.
D. It removes the oxygen saturation score entirely.
C. It provides more detailed criteria for assessing patients.
The O2 Saturation’s a little bit lower
Slide 20
The Modified Aldrete Scoring System is often used for:
A. Sedation monitoring during patient recovery
B. General anesthesia recovery only.
C. ICU discharge criteria.
D. Monitoring heart rate and rhythm only.
A. Sedation monitoring during patient recovery
C - This is really used more for like sedation monitoring, sometimes not necessarily for discharge criteria…what I mean by sedation monitoring is not something like a RASS score, but as far as like sedation while there there.
Slide 20
Which of the following are correct for the O2 Saturation scoring in the Modified Aldrete Score? Select 3.
A. The patient is able to maintain O2 saturation >90% on room air. (Score: 2)
B. The patient is able to maintain O2 saturation >92 on room air. (Score: 2)
C. The patient needs O2 inhalation to maintain O2 saturation >90%. (Score: 1)
D. The patient’s O2 saturation is <90%, even with O2 supplementation. (Score: 0)
A. The patient is able to maintain O2 saturation >90% on room air. (Score: 2)
C. The patient needs O2 inhalation to maintain O2 saturation >90%. (Score: 1)
D. The patient’s O2 saturation is <90%, even with O2 supplementation. (Score: 0)
Slide 20
Which of the following factors is included in the Post Anesthesia Discharge Scoring System?
A. Body temperature regulation
B. Nausea and vomiting control
C. Intraoperative medication administration
D. Level of consciousness during surgery
E. Respiration
B. Nausea and vomiting control
Slide 21
Select all that apply regarding Vital Signs (BP and Pulse) for Post-anesthesia discharge scoring system:
Select 3
A. Vital signs within 20% of preoperative baseline (2 points)
B. Vital signs 20-40% of preoperative baseline (1 point)
C. Vital signs 20-50% of preoperative baseline (1 point)
D. Vital signs >50% of preoperative baseline (0 points)
E. Vital signs >40% of preoperative baseline (0 points)
A. Vital signs within 20% of preoperative baseline (2 points)
B. Vital signs 20-40% of preoperative baseline (1 point)
E. Vital signs >40% of preoperative baseline (0 points)
Slide 21
Select all that apply regarding Activity for Post-anesthesia discharge scoring system:
Select 3
A. Steady gait, no dizziness (2 points)
B. Patient must walk 100 feet unassisted, no dizziness (2 points)
C. Requires assistance (1 point)
D. Able to walk with support for short distance (1 point)
E. Unable to ambulate (0 points)
A. Steady gait, no dizziness (2 points)
C. Requires assistance (1 point)
E. Unable to ambulate (0 points)
Slide 21
Select all that apply regarding Nausea and Vomiting for Post-anesthesia discharge scoring system:
Select 3
A. Minimal, treat with PO meds (2 points)
B. Nausea absent for discharge (2 points)
C. Moderate, treat with IM meds (1 point)
D. Continues, repeated treatment required (0 points)
E. Vomiting requires continuous IV treatment required (0 points)
A. Minimal, treat with PO meds (2 points)
C. Moderate, treat with IM meds (1 point)
D. Continues, repeated treatment required (0 points)
Slide 21
Select all that apply regarding Pain for Post-anesthesia discharge scoring system:
Select 2
A. Acceptable control per the patient, controlled with PO meds (2 points)
B. Not acceptable to the patient, not controlled with PO meds (1 point)
C. Pain must be rated 0/10 (0 points)
D. Pain control can be achieved with non-pharmacologic methods only
A. Acceptable control per the patient, controlled with PO meds (2 points)
B. Not acceptable to the patient, not controlled with PO meds (1 point)
Slide 21
Select all that apply regarding Surgical Bleeding for Post-anesthesia discharge scoring system:
A. Minimal, no dressing changes required (2 points)
B. Moderate, up to 2 dressing changes required (1 point)
C. Severe, more than 3 dressing changes required (0 points)
D. Minimal, up to 1 dressing change, small amount of bleeding from the surgical site is acceptable (2 points)
E. Bleeding must be fully stopped (0 points)
A. Minimal, no dressing changes required (2 points)
B. Moderate, up to 2 dressing changes required (1 point)
C. Severe, more than 3 dressing changes required (0 points)
Slide 21
Which of the following would most likely prevent a patient from being discharged and admitted under the Post-anesthesia discharge scoring system?
Select 3
A. Nausea and Vomiting Score of 1
B. More than 3 dressing changes
C. Nausea and Vomiting Score of 0
D. Activity score of 1
E. Pain score of 1
B. More than 3 dressing changes (Surgical Bleeding Score of 0)
C. Nausea and Vomiting Score of 0 Continues: Repeated treatment
E. Pain score of 1: Not acceptable or controlled by PO meds
Cornelius - …somebody that continues to have nausea and vomiting…We will admit patients to the hospital because they have continual nausea and vomiting. We don’t send people home with continual pain. From a procedural standpoint, look at their wounds. If you’ve got somebody that’s oozie or continuing to bleed, they’re soaking dressings. They don’t need to go home like that.
Slide 21
During Phase II of recovery, how often are vital signs taken?
A. Every 15-30 minutes
B. Every 30-60 minutes
C. Every 1-2 hours
D. Every 5 minutes
B. Every 30-60 minutes
Slide 22
What determines if a patient can move directly to Phase II without staying in Phase I?
A. The type of surgery
B. The patient’s vital signs
C. The patient’s sedation level
D. The patient’s age
C. The patient’s sedation level and airway status
slide 22
In addition to airway and ventilation, what else is monitored during Phase II of recovery?
A. Vital signs every 15 minutes
B. Blood glucose levels
C. Fluid balance
D. Blood pressure only
C. Fluid balance
Slide 22
Which of the following is not included in the standard monitoring during Phase II of recovery?
A. Pain level
B. PONV
C. Wound integrity
D. Temperature regulation
D. Temperature regulation
Slide 22
What complication is often responsible for cardiac arrest in the PACU?
Select 2
A. Intraoperative MI
B. Hypertension
C. Aortic dissection
D. Septic shock
E. Occluded airway
A. Intraoperative MI
E. Respiratory arrest due to an occluded airway
Slide 24
In Dr. C’s story, what rhythm abnormality did the patient display that raised concerns for Wolff-Parkinson-White syndrome (WPW)?
A. Delta wave on EKG
B. ST elevation
C. PR interval elongation
D. T-wave inversion
A. Delta wave on EKG
slide 24
What is a common complication cause of hypertension in post-anesthesia care besides pain?
A. Tachycardia
B. Dysrhythmia
C. Urinary retention
D. Prolonged sedation
C. Urinary retention
Slide 24
What are potential causes of altered mental status in the PACU setting?
A. Pain and hypertension
B. Dysrhythmias and MI
C. Urinary retention and sedation
D. Prolonged sedation and confusion
D. Prolonged sedation and confusion
C - it’s just prolonged sedation, so be mindful of the medications you’re giving them. Some things like gabapentin and dexmedatomadine have been implicated in prolonged sedation.
Slide24
According to the graph, which of the following complications occurred the least in the PACU?
A. Dysrhythmia
B. Major cardiac arrest
C. Altered mental status
D. Upper airway support
B. Major cardiac arrest
Slide 24
Which of the following symptoms would NOT typically be associated with Local Anesthetic Systemic Toxicity (LAST)?
A. Tachycardia
B. Tingling and numbness
C. Ringing in the ears
D. Hyperthermia
D. Hyperthermia
Slide 24
What is the primary airway complication to be concerned with postoperatively?
A. Laryngospasm
B. Airway Obstruction
C. Vocal Cord Palsy
D. Hypoxemia
B. Airway Obstruction
C - So the big thing we have to worry about here is generally airway obstruction. A lot of times we cause this problem for ourselves because the patient’s either too sedated, has tissue edema.
Slide 26
Which of the following can cause airway obstruction after surgery?
A. Sedation and tissue edema
B. Traumatic intubation
C. Expanding hematoma
D. All of the above
D. All of the above
Slide 26
Vocal cord palsy can cause airway obstruction as a result from damage to which nerve during neck surgeries?
A. Phrenic nerve
B. Vagus nerve
C. Recurrent laryngeal nerve
D. Hypoglossal nerve
C. Recurrent laryngeal nerve (this was said in lecture 29 minutes 32 seconds)
Slide 26
What is one of the most common causes of residual neuromuscular block in PACU?
A. Inadequate reversal
B. Failure to provide oxygen
C. Undiagnosed sleep apnea
D. Administration of opioids
A. Inadequate reversal
Corn - Just make sure your patients are fully reversed… we may not necessarily give the most appropriate doses. So calculate the patient’s actual dose based off their train of four and make sure that they’re getting an appropriate dose
slide 26
Which condition can be managed with CPAP or BiPAP in the PACU to prevent airway obstruction?
A. Laryngospasm
B. Obstructive Sleep Apnea
C. Vocal Cord Palsy
D. Airway Edema
B. Obstructive Sleep Apnea (OSA)
Slide 26
Which of the following is a patient-related risk factor for airway complications in the PACU?
A. Surgery near the diaphragm
B. COPD
C. Use of general anesthesia
D. Severe incisional pain
B. COPD
Corn - if they have breathing problems before anesthesia, it’s not magically gonna get better
COPD, Asthma, OSA, obesity, heart failure, Pulmonary HTN, Upper respiratory tract infection, tobacco use, & higher ASA score.
Slide 27
A common anesthetic-related risk factor for airway complications is:
A. ENT procedures
B. Muscle relaxers
C. Upper respiratory tract infection
D. Tobacco use
B. Muscle relaxers
also includes administration of opioids, and general
Slide 27
Surgery near the diaphragm is a ______-related risk factor for airway complications.
A. Anesthetic
B. Patient
C. Procedure
D. Postoperative
C. Procedure
ENT procedures, severe incisional pain, long procedure (3 hours).
Slide 27
True or False
Giving IV fluids is considered an Anesthetic related risk factor for airway complications
FALSE
It is a Procedure related risk factor
Slide 27
The use of opioids during anesthesia is considered a(n) ___-related risk factor for airway complications.
A. Procedure
B. Patient
C. Anesthetic
D. Surgical
C. Anesthetic
Slide 27
Which of the following are patient-related risk factors for airway complications? Select 3
A. Pulmonary hypertension
B. Obesity
C. IV fluid administration
D. Asthma
E. ENT procedures
A. Pulmonary hypertension
B. Obesity
D. Asthma
OSA, heart failure, Pulmonary HTN, Upper respiratory tract infection, tobacco use
Slide 27
A higher ASA score is classified as which type of risk factor for airway complications?
A. Procedure-related
B. Anesthetic-related
C. Patient-related
D. Postoperative
C. Patient-related
Slide 27
Maintaining a patient’s ______ throughout a case is preferable if you’re concerned about airway complications.
A. Pain control
B. Spontaneous breathing
C. General anesthesia
D. Mechanical breathing
B. Spontaneous breathing
Corn - I would much rather have someone awake in pain and breathing, then sedated and having to go to the ICU, intubated, because I gave them too many opioids.
Slide 27
What is a common cause of upper airway obstruction after anesthesia?
A. Bronchospasm
B. Loss of pharyngeal muscle tone
C. Large uvula
D. Upper airway tumor
B. Loss of pharyngeal muscle tone
Corn - generally we tend to cause this problem. It’s usually because the patient is over sedated. Maybe they were on a volatile anesthetic and it’s not out of their system yet. Maybe they were getting like ativan or propofol infusion, and it hasn’t redistributed, but this is usually on us.
Slide 28
One of the simplest ways to manage upper airway obstruction caused by the tongue falling back is by using ______.
A. Positive pressure ventilation
B. Chin lift
C. Reintubation
D. Tracheostomy
B. Chin lift aka Jaw thrust
Corn - if you take somebody’s head and turn it to the side, instead of that tongue falling straight back into the airway a lot of times, it’ll fall off to one side or the other.
So you may not have to hold that airway open anymore. You can just turn their head.
Slide 28
Which of the following are treatment options for upper airway obstruction? Select 2
A. BURP
B. Continuous positive airway pressure
C. Tracheostomy
D. Oral/nasal airway
B. Continuous positive airway pressure (CPAP)
D. Oral/nasal airway
Corn - I’ll go ahead and put those nasal airways in before waking up the patient
The nasal airways tend to be tolerated a little bit better and I’ll go ahead and put lidocaine on there.
Oral Airways work a little bit better, but they’re far more stimulating…as soon as they start waking up, they’re going to want to pull that out.
Slide 28
Paradoxical breathing during upper airway obstruction refers to:
A. Abdomen moving sporadically in and out
B. Chest and abdomen moving in opposite directions during breathing
C. Rapid shallow breathing in the nose and out the mouth
D. No movement of the diaphragm
B. Chest and abdomen moving in opposite directions during breathing
Slide 28
Laryngospasms occur when the vocal cords close and prevent any air movement, potentially leading to ______.
A. Hypotension
B. Hypocapnia
C. Hypoxemia
D. Tachycardia
C. Hypoxemia
and possible (-) pressure pulmonary edema
Slide 29
What are the most common causes of laryngospasms?
Select 4
A. Stimulation of the pharynx
B. Dehydration of mucosal airways
C. Secretions or foreign material
D. Regular extubations
E. Pulmonary Hypertension
F. Stimulation of the vocal cords
G. NG Tubes
A. Stimulation of the pharynx
C. Secretions, blood, or foreign material
D. Regular extubations
F. Stimulation of the vocal cords
Slide 29
What is a potential complication of laryngospasm?
A. Bronchospasm
B. Negative pressure pulmonary edema
C. Aspiration
D. Pneumothorax
B. Negative pressure pulmonary edema
Slide 29
What is the most common etiology of Negative Pressure Pulmonary Edema?
A. Aspiration
B. Bronchospasm
C. Laryngospasm
D. Hypoventilation
C. Laryngospasm
Slide 30
Negative Pressure Pulmonary Edema typically resolves in ____.
A. 1-2 hours
B. 12-48 hours
C. 48-72 hours
D. 72-96 hours
B. 12-48 hours
Slide 30
Negative pressure pulmonary edema is estimated to occur in about _______ of the cases, with the most common etiology being ________.
A) 12%, laryngospasm
B) 8%, bronchospasm
C) 5%, airway obstruction
D) 15%, laryngospasm
A) 12%, laryngospasm
Slide 30
Negative pressure pulmonary edema is a form of _______ pulmonary edema that results from a generation of high negative intrathoracic pressure needed to overcome _______.
A. cardiogenic, airway obstruction
B. noncardiogenic, pulmonary edema
C. cardiogenic, laryngospasm
D. noncardiogenic, airway obstruction
D. noncardiogenic, airway obstruction
Cornelius - It’s going to pull that interstitial fluid out of the tissue into the lung.
Slide 30
Which of the following scenarios can lead to negative pressure pulmonary edema in patients?
Select 2
A. Biting down on an endotracheal tube
B. Occlusion of a tube during spontaneous breathing
C. Bronchospasm untreated for several minutes
D. Excessive positive pressure ventilation
A. Biting down on an endotracheal tube
B. Occlusion of a tube during spontaneous breathing
Corn - easiest treatment for us at that point is to deflate the cuff.
Slide 30
Which of the following symptoms is associated with laryngospasm?
A) Bronchoconstriction
B) Faint inspiratory stridor
C) Hypotension
D) Increased heart rate
B) Faint inspiratory stridor
Slide 31
Laryngospasm is a prolonged exaggeration of the glottic closure reflex due to stimulation of the ___________ nerve.
A) Vagus
B) Recurrent laryngeal
C) Superior laryngeal
D) Phrenic
C) Superior laryngeal
Slide 31
Symptoms of laryngospasm include faint inspiratory stridor due to increased respiratory effort, increased diaphragmatic excursion, and flailing of the ___________.
A) Upper arms
B) Lower ribs
C) Chest wall
D) Neck muscles
B) Lower ribs
Slide 31
When assessing for laryngospasm, what is an unreliable sign of effective breathing?
A) Inspiratory stridor
B) Movement of the chest or abdomen
C) Fogging in the face mask
D) Feeling air movement over the mouth
B) Movement of the chest or abdomen
Corn - we have this bad habit of looking at their belly or looking at their chest and see that it’s moving and assume they’re breathing. They may not actually be breathing. They’re obviously trying to breathe, but there may not be any actual air movement, so don’t rely on the patient’s chest or abdomen.
Slide 31
What is the first step you should take when managing a patient experiencing a laryngospasm?
A) Apply positive pressure ventilation
B) Administer a muscle relaxant
C) Perform a jaw thrust and open the airway
D) Call for additional help
D) Call for additional help
Slide 32
Which of the following is not a recommended treatment for laryngospasm?
A) Apply a facemask with 100% FiO₂ and a tight seal
B) Squeeze the bag to force air into the patient’s lungs
C) Perform chin lift or jaw thrust
D) Apply pressure to the “laryngospasm notch”
B) Squeeze the bag to force air into the patient’s lungs
Slide 32
If you are unable to break a laryngospasm with manual airway maneuvers, the next step is to apply _________ by closing the APL valve to _________ cm H2O.
A) negative pressure, 20-30
B) suctioning, 40-50
C) positive pressure, 40-70
D) oxygen, 10-20
E) positive pressure, 40-50
C) positive pressure, 40-70
Slide 32
A reassuring sign that the glottic aperture is open during a laryngospasm treatment is when the patient begins to ________, which indicates the glottis is _______.
A) cry, obstructed
B) cough, open
C) snore, obstructed
D) breathe deeply, open
B) cough, open
Slide 32
After applying positive pressure during a laryngospasm, the next step is to _________ to remove any secretions that may be obstructing the airway.
A) use a bronchoscope
B) suction the airway
C) increase FiO₂
D) use a laryngoscope
B) suction the airway
Slide 32
What is the correct anatomical location for applying pressure to relieve a laryngospasm, also known as Larson’s Point?
A) In front of the earlobe behind the pinna of each ear
B) Behind the lobule of the pinna of each ear
C) On the mastoid process
D) At the base of the skull
B) Behind the lobule of the pinna of each ear
Corn - Between the mastoid process and the base of the skull. If you press too hard you can dislocate the jaw
Slide 33
To resolve a laryngospasm, pressure should be applied to Larsons point for ___________, then released for _____________, while maintaining tight seal with the facemask.
A) 1-2 seconds, 3-4 seconds
B) 3-5 seconds, 5-10 seconds
C) 6-8 seconds, 10-15 seconds
D) 3-5 seconds, 4-6 seconds
B) 3-5 seconds, 5-10 seconds
This forcible jaw thrust with bilateral digital pressure resolves the spasm by clearing airway and stimulation.
Slide 34
When unable to break a laryngospasm, the patient will demonstrate rapid ___ and an increased ___.
A) Oxygen saturation; blood pressure
B) Oxygen saturation; heart rate
C) Desaturation; heart rate
D) Desaturation; blood pressure
C) Desaturation; heart rate
Slide 35
In the event of a persistent laryngospasm, the appropriate actions include administering ___ or ___, and considering re-intubation.
A) Propofol; Succinylcholine
B) Epinephrine; Lidocaine
C) Atropine; Epinephrine
D) Ketamine; Succinylcholine
A) Propofol; Succinylcholine
And Atropine
Corn - Other things you can do is deepen your anesthetic. So while I’m holding that Larson’s maneuver and holding pressure with my face mask, I may just turn my SEVO or ISO up as far as it’ll go and see if deepening them is enough to make them relax
Slide 35
In pediatric patients experiencing laryngospasm, you may not see desaturation until their heart rate drops to ___.
A) 50-60s
B) 40-50s
C) 20-30s
D) 10-20s
C) 20-30s
Slide 36
What is the typical dose range of Succinylcholine used to break a laryngospasm?
A) 0.1 mg/kg
B) 1.0 mg/kg
C) 0.01 mg/kg
D) 0.5 mg/kg
A) 0.1 mg/kg
1/10 of normal dose
Corn - usually what we found is that a dose as small as like 0.1mg/kg is enough to ‘cause that spasm to break.
Slide 35
Airway edema is commonly associated with prolonged intubation or long surgical procedures in the _______ and ______position.
Select 2
A) Trendelenburg
B) Supine
C) Prone
D) Lateral
A) Trendelenburg
C) Prone
Slide 36
Which of the following are signs that a patient most likely has airway edema? (Select 2)
A) Facial edema
B) Scleral edema
C) Nasal edema
D) Bilateral leg edema
A) Facial edema
B) Scleral edema
Slide 36
A significant risk factor for developing airway edema is ___ and ______
Select 2
A) Minimal fluid shifts during surgery
B) Short surgical procedures
C) Large fluid shifts
D) Early extubation
E) Aggressive resuscitation
C) Large fluid shifts
E) Aggressive resuscitation d/t large amounts of blood loss
Slide 36
What is the purpose of performing an endotracheal tube (ETT) cuff leak test before extubation?
A) To check for secretions in the oral pharynx
B) To assess if there is air moving around the cuff
C) To check if the cuff is fully inflated
D) To confirm tube placement
B) To assess if there is air moving around the cuff indicating no airway edema
Cornelius - we wanna make sure that we’re able to hear air moving around the cuff.
Sometimes you can just hear that with your ear. Sometimes you have to put your stethoscope around their mouth to be able to see or hear it.
The other thing you can do is look at your ventilator and when you see the your exhaled tidal volume, it’s gonna pretty big disparity from your delivered tidal volume.
Slide 37
Before extubation, suction the _______ to prevent airway obstruction.
A. Trachea
B. Oral pharynx
C. Nasal cavity
D. Esophagus
B. Oral pharynx
Slide 37
What should be your action if you do not hear air moving around the ETT during the cuff leak test?
A) Extubate immediately
B) Apply positive pressure ventilation
C) Leave the tube in place
D) Deflate the cuff further
C) Leave the tube in place
slide 27
Airway hematomas are commonly seen following which types of surgeries?
Select 3
A. Spinal surgeries
B. Neck dissections
C. Thyroid removal
D. Orthopedic surgeries
E. Carotid surgeries
B. Neck dissections
C. Thyroid removal
E. Carotid surgeries
slide 38
A rapidly expanding airway hematoma can lead to which of the following complications?
A. Bronchospasm
B. Supraglottic edema
C. Pulmonary embolism
D. Pleural effusion
B. Supraglottic edema
Slide 38
Compression or deviation of the trachea below the level of the _______ can occur with a large hematoma.
A. Hyoid bone
B. Cricoid cartilage
C. Tracheal bifurcation
D. Sternum
B. Cricoid cartilage
Slide 38
Which of the following symptoms might indicate an airway hematoma in a post-operative patient?
Select 2
A. Pain in the lower back
B. Hoarseness
C. Excessive bleeding from the surgical site
D. Visible neck swelling
E. Bilateral arm weakness
B. Hoarseness
D. Visible neck swelling
Slide 38
If a patient develops an expanding airway hematoma after thyroid surgery, what might also be a concern?
A. Pneumothorax
B. Bronchospasm
C. Sinusitis
D. Nerve dissection
A. Pneumothorax
Corn - if you have somebody with a pneumothorax, you may notice they have subcutaneous emphysema in there as well. So that may cause swelling in the neck.
slide 38
What is the initial step in treating an airway hematoma?
A. Apply cold compress to the neck
B. Decompress the airway by releasing clips or sutures
C. Administer diuretics to reduce swelling
D. Perform a bronchoscopy
B. Decompress the airway by releasing clips or sutures
subcutaneous clot removed before attempting reintubation.
Slide 39
What advanced airway intervention might be necessary if reintubation fails due to an airway hematoma?
A. Nasal intubation
B. Cricothyrotomy
C. Tracheostomy
D. Bronchial stent placement
C. Tracheostomy
Slide 39
In the treatment of airway hematomas, if reintubation is necessary, you should ensure _______ is readily available.
A. Advanced airway equipment
B. IV fluids
C. Cardiac monitoring
D. Portable suction
A. Advanced airway equipment
slide 39
Why might muscle relaxants make intubation more difficult during an airway hematoma?
A. They increase airway secretions
B. They remove muscle tone
C. They cause excessive bleeding
D. They increase heart rate, making the patient unstable
B. They remove muscle tone, worsening airway compression
Corn - a lot of times what we do is consider intubating the patient while we’re waiting on the surgeon. But if you have an airway that’s already being compressed by hematoma, and you take away muscle tone with a muscle relaxant, it’s going to be even harder to get them intubated.
Slide 39
In cases of airway hematoma, if you are uncomfortable decompressing the airway, consider performing _______.
A. A tracheostomy
B. An awake intubation
C. A cricothyrotomy
D. Bag-valve-mask ventilation
B. An awake intubation
Brian G. Cornelius - if it were me and I didn’t feel comfortable, I would probably consider an awaken intubation.
slide 39
Which of the following surgeries is associated with the risk of vocal cord palsy?
A. Otolaryngologic surgery
B. Appendectomy
C. Hip replacement surgery
D. Cataract surgery
A. Otolaryngologic surgery
thyroidectomy, parathyroidectomy, rigid bronchoscopy, over inflated ETT
Slide 40
If vocal cord palsy is unilateral, the patient is most likely:
A. Experiencing severe dyspnea
B. Unable to speak
C. Asymptomatic
D. Experiencing dysphonia
C. Asymptomatic
Corn - they may be talking funny
Slide 40
Which of the following are NOT possible causes of vocal cord palsy?
A. Thyroidectomy
B. Parathyroidectomy
C. Overinflated endotracheal tube cuff
D. Dental surgery
E. Rigid bronchoscopy
D. Dental surgery
Slide 40
What is a common vocal change you may notice in a patient with damage to the External Branch of the Superior Laryngeal Nerve postoperatively?
A. Complete loss of voice
B. Hoarseness or husky voice
C. High-pitched voice
D. Whistling sound when breathing
B. Hoarseness or husky voice
Slide 41
Which muscle is paralyzed due to injury of the external branch of the superior laryngeal nerve?
A. Thyroarytenoid muscle
B. Cricothyroid muscle
C. Posterior cricoarytenoid muscle
D. Lateral cricoarytenoid muscle
B. Cricothyroid muscle
Slide 41
Why might a surgeon want to evaluate a patient’s vocal cords immediately after surgery?
A. To ensure the cords are tense
B. To perform a biopsy
C. To check for airway patency
D. To perform a vocal cord transplant
A. To ensure the cords are tense and functioning
The vocal cords look wavy ~ when they have lost tension
Damage to the External Branch of the Superior Laryngeal Nerve
Slide 41
What is the result of bilateral recurrent laryngeal nerve damage?
A. Aphonia and airway patency
B. Aphonia and paralyzed cords
C. Dysphonia and hyperactive cords
D. Whispering and partially functional cords
B. Aphonia and paralyzed cords
Slide 43
What position do the paralyzed vocal cords assume in bilateral recurrent laryngeal nerve damage?
A. Full abduction
B. Full adduction
C. Intermediate
D. Inverted adduction
C. Intermediate (midway between abduction and adduction)
Corn - both cords are paralyzed, and it’s kind of stuck halfway open and halfway closed because there’s no muscle tone. You may see that those cords will actually close and you’re going to wind up with airway obstruction. So now they can’t breathe.
Slide 43
Bilateral recurrent laryngeal nerve damage is rare and can cause the vocal cords to close, leading to airway obstruction during _________.
A. Inspiration
B. Expiration
A. Inspiration
Slide 43
Which type of tube is commonly used during thyroid surgeries to monitor the laryngeal nerves?
A. Nasal airway tube
B. NIM tube
C. LMA tube
D. Reinforced ETT
B. NIM tube
neural integrity monitor
Slide 45
Postoperative hypocalcemia can be observed ______ after thyroid surgery.
A. 1-2 hours
B. 12-24 hours
C. 24-48 hours
D. 72-96 hours
C. 24-48 hours
Slide 46
Which sign is associated with facial spasms in hypocalcemia after thyroid surgery?
A. Trousseau’s sign
B. Babinski’s sign
C. Chvostek’s sign
D. Brudzinski’s sign
C. Chvostek’s sign
Facial spasms when cheek is tapped
Slide 46
What is Trousseau’s sign?
A. Facial twitching when the cheek is tapped
B. Carpal spasm with blood pressure cuff inflation
C. Spasm of the lower limbs when standing
D. Muscle weakness during deep breathing
B. Carpal spasm with blood pressure cuff inflation
hypocalcemia post thyroid surgery
Slide 46
Which of the following complications may develop after thyroid surgery? (Select 3 that apply)
A. Hypocalcemia
B. Hematoma formation
C. Recurrent laryngeal nerve damage
D. Tracheal injury
A. Hypocalcemia - Can see 24 to 48 hrs post-op
B. Hematoma formation - can be immediate or within 24 hours
C. Recurrent laryngeal nerve damage
Slide 46
True or False
Incomplete reversal of muscle relaxants is necessary after surgery
FALSE
Complete reversal of muscle relaxants is necessary after surgery
Slide 47
Which of the following are included in the clinical evaluation for residual neuromuscular blockade? (Select 4 that apply)
A. Deep breathing
B. Ability to hold the head up for 5 seconds
C. Grip strength
D. Ability to maintain eye contact
E. Ability to lift legs off the bed
F. Tongue protrusion
B. Ability to hold the head up for 5 seconds
C. Grip strength
E. Ability to lift legs off the bed
F. Tongue protrusion
Slide 47
True or False
If a patient shows clinical signs, it means their airway reflexes have fully returned.
False
Just because you see these signs doesn’t mean your patient’s airway reflexes have returned.
Slide 47
Which of the following statements are true about Obstructive Sleep Apnea (OSA)? (Select 4 that apply.)
A. It is considered a syndrome where patients have a partial or complete blockage of the upper airway.
B. It is a condition where patients have no airway obstruction during sleep.
C. Patients with OSA are obviously prone to airway obstruction.
D. Patients with OSA should be extubated while still sedated.
E. Before extubation, patients with OSA should be fully awake and following commands.
F. Patients with OSA should ideally bring their CPAP machine to surgery.
A. It is considered a syndrome where patients have a partial or complete blockage of the upper airway.
C. Patients with OSA are obviously prone to airway obstruction.
E. Before extubation, patients with OSA should be fully awake and following commands.
F. Patients with OSA should ideally bring their CPAP machine to surgery.
Corn: you may wanna call respiratory before you even wake the patient up and have them bring CPAP to recovery.
Slide 48
Patients with Obstructive Sleep Apnea are sensitive to which of the following medications?
A. Acetaminophen
B. NSAIDs
C. Opioids
D. Steroids
C. Opioids
try regional techniques for post-operative pain
Corn: don’t wanna give them a long lasting agent. I may do something like Remifentanil…use something like ketamine to control their pain.
Slide 48
What is the STOP-BANG assessment for Sleep Apnea?
Snore (loudly)
Tired (during daytime)
Observed (apnea while sleeping)
Pressure (Hypertension)
BMI > 35
Age > 50
Neck circumference > 16 in
Gender (Male)
Slide 49
What score on the STOP-BANG assessment indicates a low risk for Obstructive Sleep Apnea (OSA)?
A. 0 - 2
B. 3 - 4
C. 5 - 6
D. 7 - 8
A. 0 - 2
Slide 49
What score on the STOP-BANG assessment indicates an intermediate risk for Obstructive Sleep Apnea (OSA)?
A. 0 - 2
B. 3 - 4
C. 5 - 6
D. 7 - 8
B. 3 - 4
Slide 49
What score on the STOP-BANG assessment indicates a high risk for Obstructive Sleep Apnea (OSA)?
A. 0 - 2
B. 3 - 4
C. 5 - 8
D. 1 - 5
C. 5 - 8
Slid 49
What are the 2 common causes of arterial hypoxemia in a PACU patient?
A. Hyperventilation and supplemental oxygen
B. Patient on room air
C. Hypoventilation due to excessive pain medications or benzodiazepines
D. Hyperventilation due to anxiety
E. Hypoventilation due to inadequate pain control
B. Patient on room air
Corn: Sometimes patients need a little bit of extra oxygen as they wake up from general anesthesia.
C. Hypoventilation due to excessive pain medications or benzodiazepines
Corn: Unfortunately, a lot of times we’re to blame for this. Maybe we gave them too many opioids.
Slide 50
What are the appropriate treatments for arterial hypoxemia in a PACU patient? (Select 3 that apply)
A. Apply oxygen via nasal cannula or facemask
B. Reverse opioid or benzodiazepine medications
C. Administer supplemental oxygen and sedatives
D. Continue to stimulate the patient
E. Increase fluid administration
F. Place the patient in Trendelenburg position
G. Perform deep suctioning
A. Apply oxygen via nasal cannula or facemask
B. Reverse opioid or benzodiazepine medications
D. Continue to stimulate the patient
Slide 50
Which of the following are true about diffusion hypoxia? (Select 3 that apply)
A. Rapid diffusion of nitrous oxide into alveoli at the end of of a nitrous oxide anesthetic..
B. Nitrous oxide dilutes the alveolar gas, increasing PaO2 and PaCO2 levels.
C. Diffusion hypoxia occurs only when patients are breathing supplemental oxygen post-anesthesia.
D. Decrease in PaO2, if the patient is breathing room air post-anesthesia
E. Supplemental oxygen should not be provided post-anesthesia to prevent diffusion hypoxia.
F. A drop in PaCO2 can depress the respiratory drive
A. Rapid diffusion of nitrous oxide into alveoli at the end of of a nitrous oxide anesthetic.
Nitrous oxide dilutes the alveolar gas and decreases the PaO2 and PaCO2.
D. Decrease in PaO2, if the patient is breathing room air post-anesthesia
F. A drop in PaCO2 can depress the respiratory drive
Corn: we’ll use nitrous oxide during our case and at the back end of the case, as we start to wake people up, that nitrous oxide is going to rapidly diffuse out of the blood into the lungs.
So we almost cause a hypoxia because that nitrous oxide is going to displace the true oxygen. The good news is it’s very quick….it also does something we want because when it comes out of the blood, it’s going to cause all those volatile anesthetics to come out with it he downside is when it’s doing that, it may cause hypoxia. Good news, easy to treat. We just have to make sure we’re oxygenating the patient.
Slide 51
How long can diffusion hypoxia persist after the discontinuation of nitrous oxide (N₂O) anesthesia?
A. 1-2 minutes
B. 3-5 minutes
C. 5-10 minutes
D. 10-15 minutes
C. 5-10 minutes
Corn: if it’s somebody that doesn’t use nitrous oxide very often will do what we call a nitrous wake up… if this case is dragging on and on and on or maybe you had this person on a large amount of volatile anesthetics and you know that’s going to take a while to come out of their tissue. So to kind of bridge that gap, we’ll turn our turn our volatile gas down, but we’ll turn some nitrous on. Just be mindful as you do that that it’s gonna take a little bit for the nitrous to come out…make sure your patient doesn’t wind up hypoxic on the back end.
Slide 52
At what systolic and diastolic blood pressure should treatment for systemic hypertension be initiated following surgery?
A. SBP > 160 mmHg or DBP > 90 mmHg
B. SBP > 180 mmHg or DBP > 110 mmHg
C. SBP > 150 mmHg or DBP > 100 mmHg
D. SBP > 190 mmHg or DBP > 120 mmHg
B. SBP > 180 mmHg or DBP > 110 mmHg
A significant number of patients will have hypertension following surgery.
Slide 54
Which of the following are common causes of systemic hypertension following surgery? Select 6 that apply.
A. Hypocapnia
B. Emergence excitement
C. Hypercapnia
D. Shivering
E. Pain
F. Urinary retention
G. Agitation
H. Hypoventilation
B. Emergence excitement
C. Hypercapnia
D. Shivering
E. Pain
F. Urinary retention
G. Agitation
and Bowel Distention
Slide 54
True or False
The surgeon will typically provide a target range for blood pressure management in postoperative hypertension
TRUE
Corn: So where do we worry about the blood pressure? Part of it depends on the patient. Part of it depends on the surgical procedure. So lots of times if we have something where the surgeons concerned about their blood pressure or their vascular status, they’re going to lay out parameters for you
Slide 55
What is the appropriate management approach for postoperative systemic hypertension? Select 2 that apply.
A. Treat underlying causes
B. Administer rapid-acting medications like labetalol, hydralazine, or metoprolol.
C. Wait and observe unless blood pressure exceeds 200/120 mmHg.
D. Increase the dose of sedatives.
A. Treat underlying causes
Corn: so take care of their pain, get them calmed down, get them to stop shivering,
B. Administer rapid-acting medications like labetalol, hydralazine (5 to 10 mgs), or metoprolol. (1-5 mgs)
Slide 55
At what dosage range should Labetalol be administered to treat systemic hypertension postoperatively?
A. 5 - 15 mg
B. 10 - 25 mg
C. 5 - 25 mg
D. 10 - 50 mg
C. 5 - 25 mg
Corn: usually we’ll dose it in 5 mg. My doses and repeated like every five or 10 minutes up to like 20 or 40 mg. So if I have somebody that’s hypertensive and tachycardic, Labetalol’s kind of my go to drug for that.
Memory Trick : “5 to 10 Minute Break of Labetalol”
Think of Labetalol as giving your blood pressure a break, and the break time is anywhere from 5 to 25 minutes.
before giving another dose, make sure 1st dose had enough time to work.
Slide 55
What is the appropriate dosage range for Hydralazine when treating postoperative systemic hypertension?
A. 1 - 5 mg
B. 5 - 10 mg
C. 10 - 15 mg
D. 15 - 20 mg
B. 5 - 10 mg
Corn: somebody that’s not necessarily bradycardic but heart rates like 60s kind of on the lower end, but they’re also hypertensive…dosing is five to 10 mg repeat every 20 to 30 minutes. Be very cautious when you’re using hydralazine versus labetalol because the onset’s a lot longer.
Memory Trick: “Hydra Has 5 to 10 Heads”
Imagine a Hydra, the mythical creature with multiple heads
before giving another dose, make sure 1st dose had enough time to work.
Slide 55
What is the recommended dosage range for Metoprolol in the treatment of postoperative hypertension?
A. 1 - 2 mg
B. 1 - 5 mg
C. 5 - 10 mg
D. 5 - 20 mg
B. 1 - 5 mg
Corn: usually if we’re using metoprolol, it’s patients that are already on a beta blocker preoperatively…I may just give them a milligram or two and then repeat it as opposed to giving 5 mg which is kind of our common experience with other things.
Memory Trick: “Metoprolol’s 5-Star Rating”
Think of a rating system where Metoprolol’s performance is ranked between 1 and 5 stars
you can always give more, but you can’t take it away
Slide 55
Match the type of systemic hypotension with its characteristic:
1. Hypovolemic
2. Distributive
3. Cardiogenic
A. Decreased afterload
B. Intrinsic pump failure
C. Decreased preload
1. Hypovolemic - C. Decreased preload
behind on fluid or we didn’t realize that they’d had as much blood loss as they had, or bad NPO deficit
2. Distributive - A. Decreased afterload
somebody’s having an anaphylactic event. Maybe this is a patient with a spinal cord issue, so they’ve got decreased afterload
3. Cardiogenic - B. Intrinsic pump failure
had the intraoperative MI, but they didn’t have any EKG changes.
Slide 56
Hypovolemic
Which of the following are common causes of decreased preload? (Select 4 that apply)
A. Third spacing
B. Inadequate fluid replacement
C. SNS tone loss
D. Bleeding
E. Increased afterload
F. Hypervolemia
A. Third spacing
B. Inadequate fluid replacement
C. SNS tone loss (d/t neuraxial blockade)
D. Bleeding (ongoing)
Slide 57
Distributive
Which of the following are common causes of decreased afterload? (Select 4 that apply)
A. Sepsis
B. Hypervolemia
C. Anaphylaxis
D. Critical illness
E. Iatrogenic sympathectomy
F. Hypertension
A. Sepsis
C. Anaphylaxis
D. Critical illness
E. Iatrogenic sympathectomy
Slide 58
Accordibg to lecture
Which of the following conditions are providers most concerned about due to a pronounced sepsis response? (Select 2 that apply)
A. Neurosepsis
B. Urosepsis
C. Sepsis in cystoscopy cases
D. Cardiogenic sepsis
B. Urosepsis
C. Sepsis in cystoscopy cases
Corn: you will see that they quickly become hypotensive, tachycardic because of that huge viral load or that huge bacterial load that just experienced. Sometimes these patients will wind up having to go to the ICU…make sure you’ve got some pretty heavy duty vasopressors available because of that.
Slide 58
Which of the following statements about critically ill patients are true? (Select 2 that apply)
A. Small doses of anesthetics, pressors, or downers could have an exaggerated effect.
B. Critically ill patients are typically very stable and tolerate medication changes well.
C. Critically ill patients may rely on exaggerated sympathetic nervous system tone to maintain systemic blood pressure and heart rate.
D. Critically ill patients have diminished sensitivity to anesthetic agents and require higher doses for effectiveness.
Very fragile patients
A. Small doses of anesthetics, pressors, or downers could have an exaggerated effect.
C. Critically ill patients may rely on exaggerated sympathetic nervous system tone to maintain systemic blood pressure and heart rate.
Silide 59
Which of the following are primary types of allergic reactions? (Select 2 that apply)
A. Anaphylactic
B. Anaphylactoid
C. Cytotoxic
D. Delayed-type hypersensitivity
A. Anaphylactic
immediate systemic reaction caused by rapid, IgE-mediated immune release of potent mediators from tissue mast cells and peripheral blood basophils; occur after exposure to an allergen
B. Anaphylactoid
immediate systemic reactions that mimic anaphylaxis but are not caused by IgE-mediated immune responses; occur after the first exposure to a substance
Slide 60
The drug of choice for treating hypotension in an allergic reaction is:
A. Dopamine
B. Epinephrine
C. Norepinephrine
D. Vasopressin
B. Epinephrine
Corn: If you’ve got an allergic reaction, so we’ll use other medications to treat it but Epinephrine is really the go to then Benadryl, then steroid
Slide 60
Using the table provided, arrange the following substances in order of incidence of perioperative anaphylaxis from highest to lowest:
- Natural rubber latex
- Hypnotics
- Colloids
- Muscle relaxants
- Antibiotics
- Opioids
- Other substances
Answer Options:
A. Muscle relaxants > Natural rubber latex > Antibiotics > Hypnotics > Colloids > Other substances > Opioids
B. Muscle relaxants > Hypnotics > Natural rubber latex > Colloids > Antibiotics > Other substances > Opioids
C. Other substances > Muscle relaxants > Colloids > Natural rubber latex > Hypnotics > Opioids > Antibiotics
D. Muscle relaxants > Natural rubber latex > Antibiotics > Hypnotics > Colloids > Opioids > Other substances
A. Muscle relaxants > Natural rubber latex > Antibiotics > Hypnotics > Colloids > Other substances > Opioids
Most Nurses Administer Helpful Care Over Opioids:
Corn: those are really the big three. You see your muscle relaxants, latex and antibiotics
Slide 61
Neuromuscular blockers are engineered with ___ ions.
A) Quaternary ammonium
B) Tertiary amine
C) Divalent calcium
D) Monovalent sodium
A) Quaternary ammonium
Slide 62
Match the symptom with the correct cause:
Symptoms:
- Vasodilation
- Bronchial constriction
- Erythema
- Increased vascular permeability
- Hypotension (HoTN)
- Gastrointestinal constriction
- Pruritus
- Tachycardia
- Edema
Causes:
A. Histamine release
B. Leukotrienes (LTC) and prostaglandins (PGD)
- Vasodilation → A (Histamine release)
- Bronchial constriction → B (LTC and PGD)
- Erythema → A (Histamine release)
- Increased vascular permeability → B (LTC and PGD)
- Hypotension (HoTN) → A (Histamine release)
- Gastrointestinal constriction → A (Histamine release)
- Pruritus → A (Histamine release)
- Tachycardia → A (Histamine release)
- Edema → A (Histamine release)
Slide 62
Which of the following groups is considered high-risk for latex allergies?
A) Patients with a history of multiple surgical procedures
B) Spina bifida patients
C) Healthcare workers
D) All of the above
D) All of the above
Slide 63
Which of the following is a type of latex-mediated reaction? (select 3 that apply)
A) Irritant contact dermatitis
B) Type IV cell-mediated reactions
C) Type I IgE-mediated hypersensitivity reactions
D) Delayed-type hypersensitivity
E) Anaphylactic shock
F) All of the above
G) None of the above
A) Irritant contact dermatitis
B) Type IV cell-mediated reactions
C) Type I IgE-mediated hypersensitivity reactions
Slide 63
What antibiotic causes a direct histamine release?
A) Penicillin
B) Vancomycin
C) Ciprofloxacin
D) Azithromycin
B) Vancomycin
Slide 64
What is the most common antibiotic allergy?
A) Sulfa
B) Cephalosporins
C) Penicillin
D) Macrolides
C) Penicillin
Slide 64
Which of the following are 7 clinical manifestations of an antibiotic allergies?
A) Pruritus
B) Urticaria
C) Bronchospasm
D) Hypertension
E) Flushing
F) Angioedema
G) Death
H) Vomiting
I) Hypotension
J) Seizures
A) Pruritus
B) Urticaria
C) Bronchospasm
E) Flushing
F) Angioedema
G) Death
I) Hypotension
Slide 64
Two surgical procedures that can lead to sudden sepsis are procedures involving the ____ and ____ tracts.
A) Gastrointestinal & Respiratory
B) Urinary & Biliary
C) Cardiac & Musculoskeletal
D) Neurological & Endocrine
B) Urinary & Biliary
Slide 65
Treatment for sepsis includes ____ and ____.
A) Blood transfusions & antibiotics
B) Rest & oxygen therapy
C) Fluid resuscitation & pressure support
D) Surgery & physical therapy
C) Fluid resuscitation & pressure support
Slide 65
Which of the following are 3 common causes of intrinsic pump failure?
A) Myocardial ischemia/infarction
B) Pulmonary embolism
C) Tamponade
D) Dysrhythmias
E) Aortic aneurysm
A) Myocardial ischemia/infarction
C) Tamponade
D) Dysrhythmias
Slide 66
Which of the following procedures are categorized as high risk for cardiac death or nonfatal MI? (select 2 that apply)
A) Aortic and major vascular surgery
B) Peripheral artery surgery
C) Breast surgery
D) Endoscopic procedures
A) Aortic and major vascular surgery
B) Peripheral artery surgery
Slide 67
Which of the following procedures are considered intermediate risk for cardiac death or nonfatal MI? (Select 5 that apply)
A) Carotid endarterectomy
B) Prostate surgery
C) Orthopedic surgery
D) Head and neck surgery
E) Intraperitoneal and intrathoracic surgery
F) Breast surgery
A) Carotid endarterectomy
B) Prostate surgery
C) Orthopedic surgery
D) Head and neck surgery
E) Intraperitoneal and intrathoracic surgery
Slide 67
Which of the following procedures are considered low risk for cardiac death or nonfatal MI (less than 1%)? (Select 5 that apply)
A) Ambulatory surgery
B) Endoscopic procedures
C) Superficial procedures
D) Cataract surgery
E) Aortic surgery
F) Breast surgery
A) Ambulatory surgery
B) Endoscopic procedures
C) Superficial procedures
D) Cataract surgery
F) Breast surgery
Slide 67
Select the 3 factors that can decrease oxygen supply to the myocardium:
A. Increased heart rate
B. Decreased coronary blood flow
C. Increased systolic blood pressure
D. Decreased arterial oxygen content
A. Increased heart rate
B. Decreased coronary blood flow
D. Decreased arterial oxygen content
Slide 69
Select the 3 factors that can increase myocardial oxygen demand:
A. Increased heart rate
B. Increased contractility
C. Decreased LV systolic wall stress
D. Increased LV systolic wall stress
A. Increased heart rate
B. Increased contractility
D. Increased LV systolic wall stress
Slide 69
Which of the following are potential causes of sinus tachycardia? (Select 5 that apply)
A. SNS stimulation
B. Agitation
C. Hypovolemia
D. Anemia
E. Bradycardia
F. Shivering
A. SNS stimulation
B. Agitation
C. Hypovolemia
D. Anemia
F. Shivering
Slide 71
Risk for atrial dysrhythmias is greatest after which 2 types of surgeries?
A. Cardiac surgery
B. Thoracic surgery
C. Neurosurgery
D. Orthopedic surgery
E. Abdominal surgery
A. Cardiac surgery
B. Thoracic surgery
Slide 72
What are the risk factors for atrial dysrhythmias? (Select 4 that apply)
A. Pre-existing cardiac conditions
B. Hypervolemia
C. Electrolyte abnormalities
D. O₂ desaturation
E. Hypovolemia
A. Pre-existing cardiac conditions
B. Hypervolemia/positive fluid balance
C. Electrolyte abnormalities
D. O₂ desaturation
Slide 72
Which of the following is NOT a factor that causes sinus tachycardia?
A. Bleeding
B. Pulmonary embolism
C. Hypothermia
D. Thyroid storm
E. Cardiogenic/Septic shock
C. Hypothermia
Slide 71
Which of the following is NOT part of myocardial ischemia monitoring in the PACU?
A. Continuous ECG monitoring
B. ST-segment analysis
C. Serum troponin levels
D. Measuring respiratory rate
E. Monitoring leads II & V5
F. 12 lead ECG if suspected
D. Measuring respiratory rate
Slide 68
Which of the following is NOT a common cause of cardiac dysrhythmias?
A. Hypoxemia
B. Hypoventilation
C. Hypotension
D. Electrolyte abnormalities
E. Catecholamine excess
F. Anemia
G. Fluid overload
C. Hypotension
Slide 70
Patients that are hemodynamically unstable due to atrial dysrhythmias such as a-fib require ___.
A. Defibrillation
B. Cardioversion
C. Pacemaker implantation
D. Antiarrhythmic medication
B. Cardioversion
Slide 73
Which of the following medications tend to work well for atrial fibrillation? (Select 2 that apply)
A. β blockers
B. Calcium Channel Blockers
C. Diuretics
D. Anticholinergics
E. ACE Inhibitors
A. β blockers
B. Calcium Channel Blockers
Slide 73
When assessing a patient in atrial fibrillation, what is one of the key initial questions to ask?
A. Is the patient anticoagulated?
B. Is this an existing arrhythmia or a new onset?
C. Has the patient been cardioverted previously?
D. Has the patient had a thyroid function test?
B. Is this an existing arrhythmia or a new onset?
Corn:If this is something new, then we probably want to go ahead and try and get them out of it as quickly as possible. If it’s not new or we’re not sure really the duration of it, you have to be cautious
Slide 73
Which of the following is a characteristic of ventricular dysrhythmias?
A. Narrow QRS complex
B. Wide QRS complex (> 120 ms)
C. Regular P-wave rhythm
D. Sinus rhythm with T-wave inversion
B. Wide QRS complex (> 120 ms)
Premature ventricular contractions are common.
Slide 74
True ventricular tachycardia is:
A. Always benign and self-resolving
B. Rare and indicative of underlying cardiac pathology
C. Common and treated with beta-blockers
D. Caused by hypovolemia and dehydration
B. Rare and indicative of underlying cardiac pathology
Investigate the “Hs” & the “Ts”.
Slide 74
Which of the following procedures or conditions are associated with bradydysrhythmias? (Select 4 that apply)
A. Bowel distention from GI procedures
B. Increased intracranial pressure (ICP)
C. Increased intraocular pressure
D. Spinal anesthesia
E. Hypothermia
A. Bowel distention from GI procedures
B. Increased intracranial pressure (Trendelenburg, etc.)
C. Increased intraocular pressure (eye sx’s)
D. Spinal anesthesia
Bradydysrhytmias:
Heart rate < 60 bpm.
Causes: too many to list.
Slide 75
High spinals reaching the ___ level can block the cardioaccelerator fibers resulting in profound bradycardia.
A. C1 - C4
B. T1 - T4
C. L1 - L4
D. S1 - S4
B. T1 - T4
The combination of the sympathectomy, bradycardia, and lack of intravascular volume can produce cardiac arrest…even in young healthy patients.
Slide 76
Which of the following best defines delirium in a postoperative setting?
A. A chronic change in cognition related to pre-existing medical conditions
B. An acute change in cognition or disturbance of consciousness not attributed to a pre-existing condition, substance intoxication, or medication
C. A common long-term complication in all surgical patients
D. A disturbance primarily related to substance intoxication or medication overdose
B. An acute change in cognition or disturbance of consciousness not attributed to a pre-existing condition, substance intoxication, or medication
Slide 78
Which of the following statements about postoperative cognitive dysfunction and delirium are true? (Select 3 that apply)
A. High incidence of postoperative cognitive dysfunction is seen in the elderly.
B. It is associated with specific surgical procedures.
C. It can be immediately identified in the PACU regardless of anesthesia.
D. Anesthesia makes it difficult to identify who is suffering from delirium immediately in the PACU.
E. Delirium is a chronic condition that develops gradually over time.
A. High incidence of postoperative cognitive dysfunction is seen in the elderly.
B. It is associated with specific surgical procedures.
D. Anesthesia makes it difficult to identify who is suffering from delirium immediately in the PACU.
Slide 78
Which of the following are risk factors for postoperative cognitive dysfunction? (Select 4 that apply)
A. Advanced age > 70 years old
B. Preoperative cognitive impairment
C. Increased functional status
D. Alcohol abuse
E. Decreased functional status
F. Advance age > 50 years old
G. Smoking
A. Advanced age > 70 years old
B. Preoperative cognitive impairment
D. Alcohol abuse
E. Decreased functional status
Slide 79
Which of the following intra-operative factors are associated with postoperative cognitive dysfunction (POCD)? (Select 4 that apply)
A. Surgical blood loss
B. Hypotension
C. Nitrous Oxide administration
D. Anesthetic technique - General
E. Hyperoxia
F. Local anesthesia
A. Surgical blood loss
(hematocrit < 30% & increased number of intra-operative blood transfusions)
B. Hypotension
C. Nitrous Oxide administration
D. Anesthetic technique - General
Corn: So a lot of times what we’ll try and do for these patients is a regional or neuraxial blockade. And then if we’re not able to do that, we may consider doing something like a Propofol based TIVA
Slide 80
Which of the following are management strategies for delirium? (Select 4 that apply)
A. Identify the high-risk patient prior to surgery
B. Severely agitated patients may require additional PACU assistance
C. Early identification can help guide the choice of medications and anesthetics
D. Delay treatment in elderly patients to observe symptoms first
E. Elderly patients undergoing minor surgery should be treated at an outpatient center to minimize postoperative delirium
A. Identify the high-risk patient prior to surgery
B. Severely agitated patients may require additional PACU assistance
C. Early identification can help guide the choice of medications and anesthetics
E. Elderly patients undergoing minor surgery should be treated at an outpatient center to minimize postoperative delirium
Slide 81
Which of the following are appropriate steps in managing delayed awakening? (Select 4 that apply)
A. Evaluate vital signs
B. Perform neurological exam
C. Administer sedatives
D. Monitor oxygenation status
E. Send labs
A. Evaluate vital signs
Too high ETCO2 = sleepy patient
B. Perform neurological exam
D. Monitor oxygenation status
E. Send labs
for potential electrolyte abnormalities or high/low glucose concentrations
Slide 82
What is the #1 cause of delayed awakening?
A. Hypoxia
B. Electrolyte abnormalities
C. Hypoglycemia
D. Residual sedation from anesthetic
E. Hypercapnia
F. Stroke
D. Residual sedation from anesthetic
Slide 83
For delayed awakening secondary to opioids, treat with __ mcg of naloxone
A. 5-10 mcg
B. 10-20 mcg
C. 20-40 mcg
D. 40-60 mcg
C. 20-40 mcg
Memory Trick:
“20 to 40, Naloxone gets you sporty.”
Slide 83
For delayed awakening secondary to benzodiazepines, treat with __ mg of flumazenil.
A) 0.1 mg
B) 0.2 mg
C) 0.5 mg
D) 1.0 mg
B) 0.2mg
Memory Trick:
“Flu-ma-zero-two”
Slide 83
For delayed awakening secondary to scopolamine, treat with ___.
A) 0.5 - 2 mg IV Atropine
B) 0.2 - 1 mg IV Physostigmine
C) 0.5 - 2 mg IV Physostigmine
D) 1 - 3 mg IV Naloxone
C) 0.5 - 2mg IV Physostigmine.
Memory trick:
“Half to two, Physostigmine will do!”
Slide 83
What (besides residual sedation) are some common reasons for delayed awakening from anesthesia? (Select 4 that apply)
A) Hypothermia (< 33°C)
B) Hyperglycemia
C) Decreased blood glucose (↓BG)
D) Increased intracranial pressure (↑ICP)
E) Residual neuromuscular blocking drugs (NMBDs)
F) Hypertension
A) Hypothermia (< 33°C)
C) Decreased blood glucose (↓BG)
D) Increased intracranial pressure (↑ICP)
E) Residual neuromuscular blocking drugs (NMBDs)
Slide 84
Recommendations for PACU Discharge
What is required for discharge according to the patient’s mental status?
A. Patient should be sedated
B. Patient should be alert and oriented
C. Patient must be unconscious
D. Patient can be discharged regardless of mental status
B. Patient should be alert and oriented
Slide 85
Recommendations for PACU Discharge
Which of the following is true about the minimum mandatory stay?
A. It is required for all patients
B. It depends on the patient’s condition
C. A minimum mandatory stay is not required
D. It is required only for elderly patients
C. A minimum mandatory stay is not required
Slide 85
Recommendations for PACU Discharge
What is required for the patient’s vital signs before discharge?
A. Vital signs should be documented every 30 minutes
B. Vital signs should be stable and within acceptable limits
C. Vital signs do not need to be checked before discharge
D. Only heart rate should be monitored
B. Vital signs should be stable and within acceptable limits
Slide 85
Recommendations for PACU Discharge
When should discharge occur?
A. After patients have met specified criteria
B. After patients have been awake for 2 hours
C. After patients have had a meal
D. After patients have received medications
A. After patients have met specified criteria
Slide 85
Recommendations for PACU Discharge
What may assist in documenting fitness for discharge?
A. Scoring systems
B. Vital sign charts
C. Anesthesia report
D. Length of stay
A. Scoring systems
Slide 85
Recommendations for PACU Discharge
Which statement about urination prior to discharge is correct?
A. Urination is always required
B. It should not be part of a routine discharge protocol
C. Patients must urinate and drink fluids
D. Urination is only required for selected patients
B. It should not be part of a routine discharge protocol
although they may be appropriate for selected patients
Slide 85
Recommendations for PACU Discharge
Outpatients should be discharged to:
A. A hospital
B. A care facility
C. A responsible adult
D. Home, alone
C. A responsible adult
who will accompany them home
Slide 85
Match the level of activity with the correct score:
- Able to move four extremities on command
- Able to move two extremities on command
- Able to move no extremities on command
Score:
2
1
0
- Able to move four extremities on command - 2
- Able to move two extremities on command - 1
- Able to move no extremities on command - 0
Slide 86
Match the breathing condition with the correct score:
- Able to breathe deeply and cough freely
- Dyspnea
- Apnea
Score:
2
1
0
- Able to breathe deeply and cough freely - 2
- Dyspnea - 1
- Apnea - 0
Slide 86
Match the circulation condition with the correct score:
- Systemic blood pressure ≠ 20% of the preanesthetic level
- Systemic blood pressure is 20% to 49% of the preanesthetic level
- Systemic blood pressure ≠ 50% of the preanesthetic level
Score:
2
1
0
- Systemic blood pressure ≠ 20% of the preanesthetic level - 2
- Systemic blood pressure is 20% to 49% of the preanesthetic level - 1
- Systemic blood pressure ≠ 50% of the preanesthetic level - 0
Slide 86
Match the consciousness condition with the correct score:
- Fully awake
- Arousable on calling
- Not responding
Score:
2
1
0
- Fully awake - 2
- Arousable on calling - 1
- Not responding - 0
Slide 86
Match the oxygen saturation level with the correct score:
- Saturation > 92% on room air
- Needs oxygen to maintain saturation > 90%
- Saturation < 90% even with oxygen
Score:
2
1
0
- Saturation > 92% on room air - 2
- Needs oxygen to maintain saturation > 90% - 1
- Saturation < 90% even with oxygen - 0
Slide 86
