PACU & Complications pt2 (Ex2) Flashcards
What are some ways to assess for residual neuromuscular blockade? (4)
- Grip strength
- Tongue protrusion
- Ability to lift legs
- Able to hold head up for 5 seconds
What medication class are OSA patients sensitive to?
Opioids
What is the STOP-BANG assessment? What is it for?
Questionnaire for assessing Sleep Apnea
Snore
Tired
Observed apnea
Pressure (BP)
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 Yes
What score on the STOP-BANG assessment is indicative of a intermediate risk for OSA?
3 - 4 Yes
What score on the STOP-BANG assessment is indicative of a high risk for OSA?
5 - 8 Yes
Review the STOP BANG Sleep Apnea Questionnaire:
What are common causes of arterial hypoxemia in a PACU patient?
- Room air - Need O₂
- Hypoventilation
What are common treatments for arterial hypoxemia in the PACU patient? (3)
- Apply O₂
- Opioid/Benzo reversal
- Stimulate patient
What is Diffusion Hypoxia?
Rapid diffusion of N₂O into alveoli at end of anesthetic.
Dilutes alveolar gas and decreases 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
may depend on the surgery and surgeon preference
What medications (and doses) are typically used for treatment of systemic HTN in the PACU?
Labetalol (5 - 25mg)
Hydralazine (5 - 10mg)
Metoprolol (1 - 5mg)
need to treat underlying cause
Hypotension that is due to decreased preload is __________.
Hypovolemic shock (lost volume)
Hypotension that is due to decreased afterload is __________.
Distributive shock (large tank)
Hypotension that is due to intrinsic pump failure is __________.
Cardiogenic shock (lost pump)
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/allergic rx
- Critical illness
- Iatrogenic sympathectomy
.
What are the two primary types of severe allergic reactions?
Anaphylactic & Anaphylactoid (not previous exposed)
What is the drug of choice for hypotension in an allergic reaction?
Epinephrine
What are the most common drug classes to cause anaphylactic reactions?
NMBD (especially Roc)
What potent inflammatory mediators can cause bronchial constriction and increased vascular permeability?
Leukotrienes and Prostaglandins
__________ drugs are engineered 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 (red-mans)
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 demand?
What are the most common causes of sinus tachycardia? (5)
- 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? (4)
- Pre-existing cardiac conditions
- Hypervolemia
- Electrolyte abnormalities
- O₂ desaturation
Patients that are hemodynamically unstable due to atrial dysrhythmias require _________. What consideration should be made prior?
- Cardioversion
- Need to consider if new onset: may need TEE prior to conversion due to potential for clots if not new onset.
What medications tend to work well for atrial fibrillation?
- β blockers
- CCBs
most common cardizem
Greater than ____ ms QRS complex is considered wide complex.
120 ms (0.12s)
What should be investigated with true ventricular tachycardia?
H’s & T’s
What procedures are associated with bradydysrhythmias? (4)
- Bowel Distention from GI stuff
- ↑ ICP (Trendelenburg, etc.)
- ↑ Intraocular pressure (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? (4)
- > 70 years old
- Pre-operative cognitive impairment
- ↓ Functional status
- EtOH abuse
What intra-operative factors are associated with POCD? (4)
- Surgical blood loss (HCT < 30%, PRBC infusions)
- HoTN
- N₂O administration
- GETA
What is the #1 cause of delayed awakening?
Residual sedation from anesthetic
For delayed awakening secondary to opioids treat with ________ mcg of ______.
20 - 40 mcg of narcan
For delayed awakening secondary to benzodiazepines treat with ________ mg of ______.
0.2mg of flumazenil
For delayed awakening secondary to scopolamine (anticholinergics) treat with ________ mg of ___________.
0.5 - 2mg IV Physostigmine.
What (besides residual sedation) are some common reasons for delayed awakening from anesthesia? (5)
- Hypothermia < 33°C
- ↑ ETCO₂
- ↓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?
What are common causes of hypertension intra/postoperatively? (6)
- emergence excitement
- shivering
- hypercapnia
- pain/agitation
- bowel distention
- urinary retention
What are some symptoms of histamine release? (5)
- vasodilation/HoTN
- erythema/pruritus
- edema
- tachycardia
- GI constriction
