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DH: Principles II > PACU & Complications (Exam II) > Flashcards

PACU & Complications (Exam II) Flashcards

1
Q

What is Standard 1 for postanesthesia care?

A

All patients who have received any type of anesthetic care should receive appropriate post-anesthetic care.

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2
Q

What is Standard 3 for postanesthesia care?

A

Upon arrival to PACU the patient should be re-evaluated and a verbal report to RN should be given by the anesthesia personnel.

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3
Q

What is Standard 4 for postanesthesia care?

A

The patient shall be evaluated continually in the PACU.

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4
Q

What is Standard 5 for postanesthesia care?

A

A physician is responsible for discharge of the patient from the PACU.

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5
Q

What is the more intense phase of post-anesthetic recovery?

A

Phase 1

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6
Q

In what phase are HR, O₂sat, RR, ECG, and airway patency monitored continuously?

A

Phase 1

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7
Q

What has to be assessed if a patient is still intubated in the PACU?

A

Neuromuscular function

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8
Q

What is Standard 2 for postanesthesia care?

A

A patient being transported to PACU has to be monitored and taken by qualified anesthesia personnel.

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9
Q

How often must vital signs be assessed and recorded during the 1st phase of recovery?

A
  • q5 min for 1st 15 minutes
  • q15 min for duration of phase 1.

Target vitals to 20% of baseline.

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10
Q

What tools are used to determine patients criteria for discharge from PACU?

A
  • Standard Aldrete Score
  • Modified Aldrete Score
  • PACU Discharge Score

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11
Q

Describe the Standard Aldrete Score.

A
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12
Q

Describe the Modified Aldrete Score.

A

Modified Aldrete Score

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13
Q

Describe the Postanesthesia Discharge Score.

A
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14
Q

What is the standard for how often vital signs must be checked in Phase II of recovery?

A

30 - 60 min

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15
Q

What should be monitored in Phase II of recovery? (other than vital signs)

A
  • Airway and ventilation status
  • Pain level
  • PONV
  • Fluid balance
  • Wound integrity
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16
Q

What are the most common complications that could be seen in the PACU?

A
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17
Q

What are the causes (anatomically) of upper airway obstruction?

A
  • Loss of pharyngeal muscle tone
  • Paradoxical breathing
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18
Q

What is the treatment of upper airway obstruction?

A
  • Jaw thrust
  • CPAP
  • Oral/Nasal airway
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19
Q

What are laryngospasms?

A

Vocal cord closure leading to loss of air movement and hypoxemia and negative pressure pulmonary edema.

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20
Q

What are the three most common causes of laryngospasms?

A
  • Stimulation of pharynx and/or vocal cords
  • Secretions, blood, foreign material
  • Regular extubations
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21
Q

What is negative pressure pulmonary edema?

A

Non-cardiogenic pulmonary edema that results from high negative intrathoracic pressures attempting to overcome upper airway obstruction.

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22
Q

What is the most common etiology of negative pressure pulmonary edema?

A

Laryngospasm

Occurs in 12% of laryngospasm cases.

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23
Q

What is the physiology behind laryngospasm?

A

Prolonged exacerbation of glottic closure reflex due to superior laryngeal nerve stimulation.

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24
Q

What would laryngospasms present like upon inspection? 4

A

Faint inspiratory stridor
Increased respiratory effort
Increased diaphragmatic excursion
Flailing of lower ribs

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25
Q

At what pressure should the bag be squeezed when treating laryngospasm?

A

Do not squeeze bag during laryngospasm.

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26
Q

How should a BVM be utilized in laryngospasm emergency?

A

Apply facemask with tight seal and 100% FiO₂ and closed APL valve.

Do NOT squeeze the bag.

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27
Q

What is the first step in treatment of laryngospasm?

A

Call for help

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28
Q

What should be done after a BVM is utilized for laryngospasm?

A
  • Suction airway
  • Chin lift and/or jaw thrust
  • Oral/nasal airways
  • Laryngospasm notch pressure
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29
Q

What is Larson’s point?
What is its significance?

A

Pressure point behind of the lobule of the pinna of each ear that can help relieve laryngospasm.

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30
Q

What will indicate a patient who is crumping out from your inability to break a laryngospasm?

A
  • Tachycardia
  • Fast desaturation
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31
Q

What should be done for a laryngospasm thats failed to respond to conventional treatment?

A

Atropine, Propofol, Succinylcholine, reintubate.

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32
Q

What initial dose of Succinylcholine is typically used for laryngospasm?

A

1/10 of normal dose

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33
Q

What neuromuscular blocking drug can cause bradycardia in pediatric patients.

A

Succinylcholine

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34
Q

What would be noted on visual assessment that would indicate to the CRNA that a patient is developing airway edema?

A

Facial and scleral edema

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35
Q

What factors can precipitate airway edema?

A
  • Prolonged intubation (especially in prone or trendelenburg cases).
  • Cases with ↑EBL (aggressive fluid resuscitation).
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36
Q

What should be done prior to extubation with expected pulmonary edema?

A
  • Suction Oropharynx
  • ETT cuff leak test
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37
Q

How is an ETT cuff leak test done?

A

Remove small amount of air from cuff and assess for air movement around the cuff. If air cannot be heard then leave the tube in place.

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38
Q

When are airway hematomas most often seen?

A
  • Neck dissections
  • Thyroid removal
  • Carotid surgeries
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39
Q

A rapidly expanding hematoma may precipitate ____________ edema.

A

supraglottic

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40
Q

In the instance of airway hematoma, deviated tracheal rings and compression of the tracheal below the ________ ________ are seen.

A

cricoid cartilage

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41
Q

What is the treatment for airway hematoma post extubation?

A
  • Decompress airway be releasing surgical clips or sutures.
  • Remove SQ blood clot before reintubating
  • Reintubate
  • Surgical backup (tracheostomy)
42
Q

What surgeries and procedures is vocal cord palsy associated with?

A
  • ENT surgery
  • Thyroidectomy & parathyroidectomy
  • Rigid Bronchoscopy
  • Hyperinflated ETT cuff
43
Q

If vocal cord palsy is unilateral, then the patient is often ___________.

A

asymptomatic

44
Q

How would damage to the external branch of the superior laryngeal nerve present?

A
  • Vocal weakness and “huskiness”
  • Paralyzed cricothyroid muscle
  • Loss of tension → vocal cord looks “wavy”.
45
Q

What does bilateral Recurrent Laryngeal Nerve damage result in?

A

Aphonia & paralyzed vocal cords

46
Q

What position do the vocal cords assume with bilateral Recurrent Laryngeal Nerve damage?

A

Intermediate position (not adducted or abducted).

47
Q

What is the biggest risk associated with bilateral Recurrent Laryngeal Nerve damage?

A

Airway obstruction during inspiration

48
Q

How long does it typically take for the hypocalcemia associated with thyroid surgery to present?

A

24 - 48 hours postop

49
Q

What is Chvostek’s sign?

A

Facial spasm

50
Q

What is Trousseau’s sign?

A

Carpal spasm w/ BP cuff

51
Q

What are some ways to assess for residual neuromuscular blockade?

A
  • Grip strength
  • Tongue protrusion
  • Ability to lift legs
  • Able to hold head up for 5 seconds
52
Q

What medication class are OSA patients sensitive to?

A

Opioids

53
Q

What is the STOP-BANG assessment?

A

Snore
Tired
Observed
Pressure
BMI > 35
Age > 50
Neck circumference > 16 in
Gender (male)

54
Q

What score on the STOP-BANG assessment is indicative of a low risk for OSA?

A

0 - 2

55
Q

What score on the STOP-BANG assessment is indicative of a intermediate risk for OSA?

A

3 - 4

56
Q

What score on the STOP-BANG assessment is indicative of a high risk for OSA?

A

5 - 8

57
Q

What is the full STOP-BANG questionnaire?

A
58
Q

What are common causes of arterial hypoxemia in a PACU patient?

A
  • Room air
  • Hypoventilation
59
Q

What are common treatments for arterial hypoxemia in the PACU patient?

A
  • O₂
  • Opioid/Benzo reversal
  • Stimulate patient
60
Q

What is Diffusion Hypoxia?

A

Rapid diffusion of N₂O into alveoli at end of anesthetic.

Dilutes PaO₂ and PaCO₂ → hypoxemia w/ ↓ respiratory drive.

61
Q

How long can diffusion hypoxia persist after discontinuation of N₂O anesthetic?

A

5-10 min

62
Q

What are the standard treatment thresholds for hypertension in the PACU?

A

SBP > 180
DBP > 110

63
Q

What medications (and doses) are typically used for treatment of systemic HTN in the PACU?

A

Labetalol (5 - 25mg)
Hydralazine (5 - 10mg)
Metoprolol (1 - 5mg)

64
Q

Hypotension that is due to decreased preload is __________.

A

Hypovolemic shock

65
Q

Hypotension that is due to decreased afterload is __________.

A

Distributive shock

66
Q

Hypotension that is due to intrinsic pump failure is __________.

A

Cardiogenic shock

67
Q

What are four common causes of decreased preload?

A
  • Third spacing
  • Inadequate fluid replacement
  • Neuraxial blockade → SNS tone loss
  • Bleeding
68
Q

What are four common causes of decreased afterload?

A
  • Sepsis
  • Anaphylaxis
  • Critical illness
  • Iatrogenic sympathectomy
69
Q

What are the two primary types of allergic reactions?

A

Anaphylactic & Anaphylactoid

70
Q

What is the drug of choice for hypotension in an allergic reaction?

A

Epinephrine

71
Q

What are the most common drug classes to cause anaphylactic reactions?

A
72
Q

What inflammatory mediators can cause bronchial constriction and increased vascular permeability?

A

Leukotrienes and Prostaglandins

73
Q

__________ drugs are associated with quaternary ammonium ions.

A

Neuromuscular blocking

74
Q

What patient populations are at high risk for latex allergy?

A
  • Repeated exposures (HCW’s)
  • Spina Bifida patients
75
Q

What are the three latex-mediated reactions?

A
  • Irritant contact dermatitis
  • Type IV cell-mediated reactions
  • Type I IgE-mediated hypersensitivity reactions
76
Q

What antibiotic causes a direct histamine release?

A

Vancomycin

77
Q

What is the most common ABX allergy?

A

Penicillin

78
Q

What two surgical procedures mentioned in lecture can lead to sudden sepsis?

A

Procedures involving urinary tract & biliary tract manipulation

79
Q

What are the three most common causes of intrinsic pump failure?

A
  • Myocardial ischemia/infarction
  • Tamponade
  • Dysrhythmias
80
Q

What is the risk stratification guideline for non-cardiac surgery?

A
81
Q

What are factors that decrease myocardial O₂ supply?

A
82
Q

What are factors that increase myocardial O₂ supply?

A
83
Q

What are the most common causes of sinus tachycardia? 5

A
  • SNS stimulation
  • ↓ volume
  • Anemia
  • Shivering
  • Agitation
84
Q

Risk for atrial dysrhythmias is greatest after what types of surgeries?

A

Cardiac and Thoracic

85
Q

What are risk factors for atrial dysthrythmias?

A
  • Pre-existing cardiac conditions
  • Hypervolemia
  • Electrolyte abnormalities
  • O₂ desaturation
86
Q

Patients that are hemodynamically unstable due to atrial dysrhythmias require _________.

A

cardioversion

87
Q

What medications tend to work well for atrial fibrillation?

A
  • β blockers
  • CCBs
88
Q

Greater than ____ ms QRS complex is considered wide.

A

120 ms

89
Q

What should be investigated with true ventricular tachycardia?

A

H’s & T’s

90
Q

What procedures are associated with bradydysrhythmias?

A
  • Bowel Distention from GI stuff
  • ↑ ICP (Trendelenburg, etc.)
  • ↑ Intraocular (eye sx’s)
  • Spinal Anesthesia
91
Q

High spinals reaching the _______ level can block the cardioaccelerator fibers.

A

T1 - T4

92
Q

What risk factors for Postoperative Cognitive Dysfunction (POCD) were discussed in lecture?

A
  • > 70 years old
  • Pre-operative cognitive impairment
  • ↓ Functional status
  • EtOH abuse
93
Q

What intra-operative factors are associated with POCD? 4

A
  • Surgical blood loss (HCT < 30%, PRBC infusions)
  • ↓ BP
  • NO administration
  • GETA
94
Q

What is the #1 cause of delayed awakening?

A

Residual sedation from anesthetic

95
Q

For delayed awakening secondary to opioids treat with ________ mcg of naloxone.

A

20 - 40 mcg

96
Q

For delayed awakening secondary to benzodiazepines treat with ________ mg of flumazenil.

A

0.2mg

97
Q

For delayed awakening secondary to scopolamine treat with ________ mg of ___________.

A

0.5 - 2mg IV Physostigmine.

98
Q

What (besides residual sedation) are some common reasons for delayed awakening from anesthesia? 4

A
  • Hypothermia < 33°C
  • ↓BG
  • ↑ICP
  • Residual NMBD’s
99
Q

What are some basic recommendations for discharge from PACU?

A
100
Q

What is/are the criteria for Determination of Discharge from PACU Score?

A

DH: Principles II (36 decks)

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