PACU & Complications pt1 (Exam II) Flashcards
What is Standard 1 for postanesthesia care?
All patients who have received any type of anesthetic care should receive appropriate post-anesthetic care.
What is Standard 2 for postanesthesia care?
Patient transported to PACU shall be accompanied by member of anesthesia team. Continually evaluated/treated/monitored throughout transport.
What is Standard 3 for postanesthesia care?
Upon arrival to PACU the patient should be re-evaluated and a verbal report to PACU RN should be given by the anesthesia personnel.
What is Standard 4 for postanesthesia care?
The patient shall be evaluated continually in the PACU.
What is Standard 5 for postanesthesia care?
A physician is responsible for discharge of the patient from the PACU.
What is the more intense phase of post-anesthetic recovery?
Phase 1
In what phase are HR, O₂sat, RR, ECG, and airway patency monitored continuously?
Phase 1
What has to be assessed if a patient is still intubated in the PACU?
Neuromuscular function
How often must vital signs be assessed and recorded during the 1st phase of recovery? What is the target for vital management?
- q5 min for 1st 15 minutes
- q15 min for duration of phase 1.
Target vitals to 20% of baseline.
What tools are used to determine patients criteria for discharge from PACU? (3)
- Standard Aldrete Score
- Modified Aldrete Score
- PACU Discharge Score
Describe the Standard Aldrete Score.
A-R-C-C-S
0-2 score
0 = bad
2 = good
Describe the Modified Aldrete Score.
Modified Aldrete Score
only difference is the saturation?
Describe the Postanesthesia Discharge Score.
V-A-N/V-P-B
0-2 score
What is the standard for how often vital signs must be checked in Phase II of recovery?
30 - 60 min
What should be monitored in Phase II of recovery? (other than vital signs) (5)
- Airway and ventilation status
- Pain level
- PONV
- Fluid balance
- Wound integrity
What are the most common complications that could be seen in the PACU?
What are the causes (anatomically) of upper airway obstruction?
- Loss of pharyngeal muscle tone
- Paradoxical breathing
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, 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.
How would laryngospasms present upon inspection? (4)
- 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. Wait for pt to breath
How should a BVM be utilized in laryngospasm emergency?
Apply facemask with tight seal and 100% FiO₂ and closed APL valve (~40 cmH₂O).
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? (4)
- Suction airway
- Chin lift and/or jaw thrust
- Oral/nasal airways
- Laryngospasm notch pressure (larsons point)
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. Apply 3-5 seconds, release 5-10 seconds, maintain tight facemask seal.
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
(~0.1mg/kg)
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 two factors can precipitate airway edema?
- Prolonged intubation (especially in prone or trendelenburg cases).
- Cases with ↑EBL (aggressive fluid resuscitation).
What two things should be done prior to extubation with expected airway 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? (3)
- 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 trachea below the ________ ________ are seen.
cricoid cartilage
What is the treatment for airway hematoma post extubation? (4)
- 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? (4)
- ENT surgery
- Thyroidectomy & parathyroidectomy
- Rigid Bronchoscopy
- Hyperinflated ETT cuff
If vocal cord palsy is unilateral, then the patient is often ___________.
asymptomatic
pt may just sound hoarse, cough
How would damage to the external branch of the superior laryngeal nerve present? (3)
- 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 - midway).
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
What is Chvostek’s sign?
Facial spasm
What is Trousseau’s sign?
Carpal spasm w/ BP cuff
