PACU & Complications (Exam II) COPY 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. Surgeon
C. Anesthesia technician
D. Physician
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)
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?
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 all 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
ECG 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
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
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
C) 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 Aldrete Score?
A) Activity
B) Respiration
C) Circulation
D) Pain
E) Consciousness
F) Oxygen Saturation
D) Pain
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
True or False
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?
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. Respiratoin
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) (Correct)
B. Moderate, up to 2 dressing changes required (1 point) (Correct)
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 or 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
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
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
Inadequate reversal
C - 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
What is the treatment of upper airway obstruction?
- Jaw thrust
- CPAP
- Oral/Nasal airway
What are laryngospasms?
Vocal cord closure leading to loss of air movement and hypoxemia and negative pressure pulmonary edema.
What are the three most common causes of laryngospasms?
- Stimulation of pharynx and/or vocal cords
- Secretions, blood, foreign material
- Regular extubations
What is negative pressure pulmonary edema?
Non-cardiogenic pulmonary edema that results from high negative intrathoracic pressures attempting to overcome upper airway obstruction.
What is the most common etiology of negative pressure pulmonary edema?
Laryngospasm
Occurs in 12% of laryngospasm cases.
What is the physiology behind laryngospasm?
Prolonged exacerbation of glottic closure reflex due to superior laryngeal nerve stimulation.
What would laryngospasms present like upon inspection?
Faint inspiratory stridor
Increased respiratory effort
Increased diaphragmatic excursion
Flailing of lower ribs
At what pressure should the bag be squeezed when treating laryngospasm?
Do not squeeze bag during laryngospasm.
How should a BVM be utilized in laryngospasm emergency?
Apply facemask with tight seal and 100% FiO₂ and closed APL valve.
Do NOT squeeze the bag.
What is the first step in treatment of laryngospasm?
Call for help
What should be done after a BVM is utilized for laryngospasm?
- Suction airway
- Chin lift and/or jaw thrust
- Oral/nasal airways
- Laryngospasm notch pressure
What is Larson’s point?
What is its significance?
Pressure point behind of the lobule of the pinna of each ear that can help relieve laryngospasm.
What will indicate a patient who is crumping out from your inability to break a laryngospasm?
- Tachycardia
- Fast desaturation
What should be done for a laryngospasm thats failed to respond to conventional treatment?
Atropine, Propofol, Succinylcholine, reintubate.
What initial dose of Succinylcholine is typically used for laryngospasm?
1/10 of normal dose
What neuromuscular blocking drug can cause bradycardia in pediatric patients.
Succinylcholine
What would be noted on visual assessment that would indicate to the CRNA that a patient is developing airway edema?
Facial and scleral edema
What factors can precipitate airway edema?
- Prolonged intubation (especially in prone or trendelenburg cases).
- Cases with ↑EBL (aggressive fluid resuscitation).
What should be done prior to extubation with expected pulmonary edema?
- Suction Oropharynx
- ETT cuff leak test
How is an ETT cuff leak test done?
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.
When are airway hematomas most often seen?
- Neck dissections
- Thyroid removal
- Carotid surgeries
A rapidly expanding hematoma may precipitate ____________ edema.
supraglottic
In the instance of airway hematoma, deviated tracheal rings and compression of the tracheal below the ________ ________ are seen.
cricoid cartilage
What is the treatment for airway hematoma post extubation?
- Decompress airway be releasing surgical clips or sutures.
- Remove SQ blood clot before reintubating
- Reintubate
- Surgical backup (tracheostomy)
What surgeries and procedures is vocal cord palsy associated with?
- ENT surgery
- Thyroidectomy & parathyroidectomy
- Rigid Bronchoscopy
- Hyperinflated ETT cuff
If vocal cord palsy is unilateral, then the patient is often ___________.
asymptomatic
How would damage to the external branch of the superior laryngeal nerve present?
- Vocal weakness and “huskiness”
- Paralyzed cricothyroid muscle
- Loss of tension → vocal cord looks “wavy”.
What does bilateral Recurrent Laryngeal Nerve damage result in?
Aphonia & paralyzed vocal cords
What position do the vocal cords assume with bilateral Recurrent Laryngeal Nerve damage?
Intermediate position (not adducted or abducted).
What is the biggest risk associated with bilateral Recurrent Laryngeal Nerve damage?
Airway obstruction during inspiration
How long does it typically take for the hypocalcemia associated with thyroid surgery to present?
24 - 48 hours postop
Slide 46
Kaitlyn STOP
What is Chvostek’s sign?
Facial spasm
Slide 46
KRISTA’s START
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 inflationCarpal spasm w/ BP cuff
Slide 46
Which of the following complications may develop after thyroid surgery? (Select all that appl)
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 all 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
**
What medication class are OSA patients sensitive to?
Opioids
Which of the following statements are true about Obstructive Sleep Apnea (OSA)? (Select 4.)
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.
Slide 48
What is the STOP-BANG assessment?
Snore
Tired
Observed
Pressure
BMI > 35
Age > 50
Neck circumference > 16 in
Gender (male)
What score on the STOP-BANG assessment is indicative of a low risk for OSA?
0 - 2
What score on the STOP-BANG assessment is indicative of a intermediate risk for OSA?
3 - 4
What score on the STOP-BANG assessment is indicative of a high risk for OSA?
5 - 8
What is the full STOP-BANG questionnaire?
What are common causes of arterial hypoxemia in a PACU patient?
- Room air
- Hypoventilation
What are common treatments for arterial hypoxemia in the PACU patient?
- O₂
- Opioid/Benzo reversal
- Stimulate patient
What is Diffusion Hypoxia?
Rapid diffusion of N₂O into alveoli at end of anesthetic.
Dilutes PaO₂ and PaCO₂ → hypoxemia w/ ↓ respiratory drive.
How long can diffusion hypoxia persist after discontinuation of N₂O anesthetic?
5-10 min
What are the standard treatment thresholds for hypertension in the PACU?
SBP > 180
DBP > 110
What medications (and doses) are typically used for treatment of systemic HTN in the PACU?
Labetalol (5 - 25mg)
Hydralazine (5 - 10mg)
Metoprolol (1 - 5mg)
Hypotension that is due to decreased preload is __________.
Hypovolemic shock
Hypotension that is due to decreased afterload is __________.
Distributive shock
Hypotension that is due to intrinsic pump failure is __________.
Cardiogenic shock
What are four common causes of decreased preload?
- Third spacing
- Inadequate fluid replacement
- Neuraxial blockade → SNS tone loss
- Bleeding
What are four common causes of decreased afterload?
- Sepsis
- Anaphylaxis
- Critical illness
- Iatrogenic sympathectomy
What are the two primary types of allergic reactions?
Anaphylactic & Anaphylactoid
What is the drug of choice for hypotension in an allergic reaction?
Epinephrine
What are the most common drug classes to cause anaphylactic reactions?
What inflammatory mediators can cause bronchial constriction and increased vascular permeability?
Leukotrienes and Prostaglandins
__________ drugs are associated with quaternary ammonium ions.
Neuromuscular blocking
What patient populations are at high risk for latex allergy?
- Repeated exposures (HCW’s)
- Spina Bifida patients
What are the three latex-mediated reactions?
- Irritant contact dermatitis
- Type IV cell-mediated reactions
- Type I IgE-mediated hypersensitivity reactions
What antibiotic causes a direct histamine release?
Vancomycin
What is the most common ABX allergy?
Penicillin
What two surgical procedures mentioned in lecture can lead to sudden sepsis?
Procedures involving urinary tract & biliary tract manipulation
What are the three most common causes of intrinsic pump failure?
- Myocardial ischemia/infarction
- Tamponade
- Dysrhythmias
What is the risk stratification guideline for non-cardiac surgery?
What are factors that decrease myocardial O₂ supply?
What are factors that increase myocardial O₂ supply?
What are the most common causes of sinus tachycardia?
- SNS stimulation
- ↓ volume
- Anemia
- Shivering
- Agitation
Risk for atrial dysrhythmias is greatest after what types of surgeries?
Cardiac and Thoracic
What are risk factors for atrial dysthrythmias?
- Pre-existing cardiac conditions
- Hypervolemia
- Electrolyte abnormalities
- O₂ desaturation
Patients that are hemodynamically unstable due to atrial dysrhythmias require _________.
cardioversion
What medications tend to work well for atrial fibrillation?
- β blockers
- CCBs
Greater than ____ ms QRS complex is considered wide.
120 ms
What should be investigated with true ventricular tachycardia?
H’s & T’s
What procedures are associated with bradydysrhythmias?
- Bowel Distention from GI stuff
- ↑ ICP (Trendelenburg, etc.)
- ↑ Intraocular (eye sx’s)
- Spinal Anesthesia
High spinals reaching the _______ level can block the cardioaccelerator fibers.
T1 - T4
What risk factors for Postoperative Cognitive Dysfunction (POCD) were discussed in lecture?
- > 70 years old
- Pre-operative cognitive impairment
- ↓ Functional status
- EtOH abuse
What intra-operative factors are associated with POCD?
- Surgical blood loss (HCT < 30%, PRBC infusions)
- ↓ BP
- NO administration
- GETA
What is the #1 cause of delayed awakening?
Residual sedation from anesthetic
For delayed awakening secondary to opioids treat with ________ mcg of naloxone.
20 - 40 mcg
For delayed awakening secondary to benzodiazepines treat with ________ mg of flumazenil.
0.2mg
For delayed awakening secondary to scopolamine treat with ________ mg of ___________.
0.5 - 2mg IV Physostigmine.
What (besides residual sedation) are some common reasons for delayed awakening from anesthesia?
- Hypothermia < 33°C
- ↓BG
- ↑ICP
- Residual NMBD’s
What are some basic recommendations for discharge from PACU?
What is/are the criteria for Determination of Discharge from PACU Score?
