PACU, Pain Management, MH

Question 1

How much does minute ventilation increase for every 1 mmHg increase in PC02?

Answer 1

Normally, minute ventilation increases by approximately 2 L/min for every 1–mm Hg increase in arterial PCO2.

Question 2

Train of four percentage of block

Answer 2

Question 3

Most appropriate/available monitors for transport

Answer 3

Pulse oximeter

• Hypoventilation may not be reliably detected by monitoring with pulse oximetry
• Time to desaturation may be longer than time to PACU
• Adequate ventilation must be confirmed by watching for the appropriate rise and fall of the chest wall with inspiration

◦Listening for breath sounds (precordial stethoscope)

◦Feeling for exhaled breath with the palm of one’s hand over the patient’s nose and mouth (roll glove down)

Question 4

What is the alveolar oxygen pressure of a normocapnic patient breathing room air?

A rise in PaCO2 from 40-80mmHg results in what PaO2?

Answer 4

100mmHg is normal

PaO2 = 50mmHg when patient goes from PaCO2 of 40-80mmHg

“This demonstrates that even a patient with normal lungs will become hypoxic if allowed to significantly hypoventilate while breathing room air.”

Question 5

Name at least three treatments for alveolar hypoventillation

Answer 5

Supplemental oxygen

Raise the head of the bed 30 degrees

Normalizing the PaCO2

External stimulation of the patient to wakefulness

Reversal of opioid or benzodiazepine

Mechanical ventilation

Question 6

What is diffusion hypoxia and effects of it?

Answer 6

When using nitrous oxide, the gas diffuses into the alveoli towards the end of the case and dilutes alveolar gas thus decreasing PAO2and PACO2 producing arterial hypoxia and can persist for 5-10 minutes after the case on the way to the PACU.

Using supplemental oxygen on the way to PACU should erradicate the effects and decrease chances of PONV

Question 7

Why is there a need for upper airway support in the postoperative period?

Answer 7

Loss of pharyngeal muscle tone in a sedated or obtunded patient

Residual depressant effects of inhaled and injected anesthetics

Common symptoms/observations:
Reflex compensatory increase in respiratory effort
Negative inspiratory pressure
Retraction of the sternal notch
Exaggerated abdominal muscle activity
Collapse of the chest wall
Protrusion of the abdomen with inspiratory effort (rocking horse motion)

Question 8

Common treatment for airway support in PACU?

Answer 8

Jaw thrust
CPAP
LMA/Oral or nasal airway
ETT tube

Question 9

If your patient is having an upper airway obstruction, what are the steps to take?

Answer 9

1. Jaw thrust with CPAP (5 to 15 cm H2O)
2. If ineffective, insert oral, nasal or LMA
3. Can reverse opioids or benzos (naloxone (0.3 to 0.5 μg/kg IV) or flumazenil)
4. NMB agents can also be reversed, although they already should be. Might have residual paralysis

_Main goa_l: Determine what is causing the obstruction quickly and effectively and treat it

Question 10

Considerations for a patient with sleep apnea?

Answer 10

Redundant pharyngeal tissue
Prone to airway obstruction
Should not be extubated until they are fully awake and following commands
Subsequent intubation may be difficult or impossible!
Very sensitive to narcotics

Treatment:
CPAP immediately in PACU, have patient bring thiers or get respiratory therapy to bring one down

Question 11

What has more of an effect on decreased pharyngeal muscle tone, benzos or narcotics?

Answer 11

Benzos

Question 12

What is a TOF ratio?

Answer 12

TOF = T4/T1
3 twitches = TOF is zero

-Succinylcholine (Phase I) does not exhibit any fade
Phase II block you could exhibit fade

-Nondepolarizing MR do exhibit fade

Subjectively, a sustained head lift for 5 seconds is considered the GOLD STANDARD

Question 13

Treatment for laryngospasm?

Answer 13

Jaw thrust with CPAP (up to 40 cm H2O)

If fails, succinylcholine (0.1 to 1.0 mg/kg IV or 4 mg/kg IM)

Don’t attempt to forcibly pass a tracheal tube through a glottis that is closed because of laryngospasm

Question 14

Common causes of pulmonary edema, treatment options?

Answer 14

Causes:
Intravascular fluid volume overload
Congestive heart failure
Sepsis
Transfusion-related pulmonary edema
Post-obstructive pulmonary edema

Treatment:
Oxygen
Diuresis
Positive-pressure ventilation of the patient’s lungs

Question 15

As a result of edema or hematoma after a thyroid or carotid surgery, your patient has an airway obstruction. What is the best course of action?

Answer 15

1. Call surgeon
2. May need to release the clips or sutures on the wound and evacuating the hematoma
3. Get difficult airway equipment
4. Surgical backup for performance of an emergency tracheostomy
5. If spontaneous ventilation, an awake technique is preferred
6. Visualization of the cords by direct laryngoscopy may not be possible

Question 16

Name five causes of PACU hypertension

Answer 16

Postoperative pain
Hypoventilation and associated hypercapnia
Emergence excitement (sedation usually takes care of this)
Advanced age
Cigarette smoking
Preexisting renal disease
History of essential hypertension (greatest risk)
Intracranial operations seem to be at increased risk for postoperative hypertension
Postoperative nausea and vomiting (PONV) increases risk

Question 17

Causes of hypotension in the PACU

Answer 17

Hypovolemia (decreased preload)

Cardiogenic (intrinsic pump failure)

Distributive (decreased afterload)

Question 18

In as high as 65% (range, 5% to 65%) after general, and 33% after epidural and spinal anesthesia patients exhibit hypothermia and an increase of O2 consumption up to 400%, what class of patients are more at risk?

Answer 18

Greatest risk: male gender and propofol for induction of anesthesia

Treatment: warming patient and meperidine (12.5 to 25 mg IV)

Question 19

Name five risk factors of PONV

Answer 19

Female gender
History of motion sickness
Previous PONV
Nonsmoking
Postoperative opioids

Treatment:
Decadron (up front) and Zofran (just before emergence) - Decreases risk by 26%
Propofol decreases by 19%
Suction gastric contents whenever you can, “Dan’s informal study 1976”

Question 20

SBAR

Answer 20

SBAR (situation, background, assessment, recommendation)

Used for “hand-off” criteria in some hospitals

Question 21

What items are most commonly missed in a handoff?

Answer 21

Preoperative Cognitive Function

Lines/catheters

Antiemetic’s

Question 22

What are the 6 key elements on a handoff checklist?

Answer 22

Patient identification using the patient’s name band

Patient allergy information

Antibiotic information

Intake and output

Estimated blood loss

Pain management

Question 23

What is “closed loop” communication?

Answer 23

ASA and the Joint Commission describe two-way communication as an integral part of any transition of care

The receiver repeats the message the sender states, thus closing the loop

Question 24

Malignant Hyperthermia (MH)

Answer 24

Volatile agents and succinylcholine can induce a drastic and uncontrolled increase in oxidative metabolism in skeletal muscle

Autosomal dominant disorder
At least 6 genetic loci of interest
The ryanodine receptor gene (RYR1)
Susceptibility is phenotypically and genetically related to central core disease (CCD)
Usually revealed upon or shortly after exposure to certain general anesthetic agents

Question 25

Typical signs of MH

Answer 25

Hyper catabolic state
Very high temperature
Tachycardia
Tachypnea
Hypercarbia
Hypoxia
Muscle rigidity
Mixed acidosis
Rhabdomyolysis

Question 26

First signs of MH

Answer 26

Hypoxia
Hypercarbia
Sinus tachycardia
Masseter spasm

Question 27

Treatment for MH

Answer 27

Declare MH Emergency

Discontinue Triggering Agents

Abandon machine (Ambu)

100% Oxygen at High Flow

Give Dantrolene

36 vials of dantrolene sodium for injection must be available wherever MH trigger agents are used

2.5 mg/kg IV push (Titrate to effect)

Question 28

Relapse rate in MH victims

Answer 28

19% relapse rate

New clinical sign of MH>120 minutes after initial presentation
Including cardiac arrests and death

Question 29

What is DIC?

Answer 29

Disseminated Intravascular Coagulopathy

(DIC) is characterized by systemic activation of blood coagulation, which results in generation and deposition of fibrin, leading to microvascular thrombi in various organs and contributing to multiple organ dysfunction syndrome (MODS).

Hence, a patient with DIC can present with a simultaneously occurring thrombotic and bleeding problem

Question 30

For every 30 minute increase in the interval between 1st MH sign and 1st Dantrolene dose, the complication likelihood increased ___ times

Answer 30

1.6

Question 31

For every 2°C increase in maximal temperature, the complication likelihood increased ___ times

Answer 31

2.9

To avoid MH complications, you need to give Dantrolene early andyou need to control temperature