pacu study guide Flashcards
what is the primary purpose the PACU?
The critical assessment and stabilization of patients after procedures with an emphasis on prevention and detection of complications.
what happens during phase 1?
Providing immediate post anesthesia nursing care and transitioning the patient to the intensive care, inpatient, or phase II outpatient care
what must be captured and ensured during phase 1?
ensuring the patient’s full recovery from anesthesia and return of vital signs to near baseline
what has been described as the most important room in the hospital, because it poses the greatest potential dangers to the patient?
Phase I Level of Care - pacu
what levels should the anesthesia provider accompany to pacu?
level one
name the critical elements of phase 1 PACU
Report has been received from the anesthesia care provider, questions answered, and the transfer of care has occurred
Patient has a stable/secure airway on Initial assessment is complete
Patient is hemodynamically stable
Patient is free from agitation, restlessness, combative behaviors
what is the focus of phase 2? give examples
Focuses on preparing the patient/family/significant other for care in the home or extended level of care
Example: discharge teaching, medication instructions, post op appointments removing IV, calling PT for ambulation instruction
prior to transfer of the patient, the anesthesia provider should communicate with the pacu nurses what?
ETA and special equipment needed
name the first two things that should be obtained on arrival to the pacu?
heart rhythm (ECG)
pulse ox
this two are the priorities not the temperature
name the respiratory signs and symptoms of inadequate oxygenation
shallow, rapid respirations or normal infreqent respirations
tachypnea
dyspnea
oxyhemoglobin saturation less than 90%
name the neurologic signs and symptoms of inadequate oxygenation
anxiety restlessness inattentiveness ALOC confusion dimmed peripheral vision seizures unresponsiveness
name the skin signs and symptoms of inadequate oxygenation
diaphoresis
cyanosis
name the cardiac signs and symptoms of inadequate oxygenation
early: tachycardia increased cardiac output increased stroke volume increased blood pressure late: bradycardia, hypotension dysrhythmia
what is the general information that should be communicated during the anesthesia handoff?
Patient Name Patient age Surgical Procedure Name of surgeon and anesthesia providers (if MD involved) Type of procedure
what information should be provided about the patient history to the PACU nurse by the anesthesia provider?
Acute (indications for this surgery)
Chronic (medical history, medication use, Allergies, OSA)
what information should be provided about the intraoperative period to the PACU nurse by the anesthesia provider?
Anesthetic agents, including dose and technique
Time of last opioid (if applicable)
Administration of reversal agents
Intraoperative medications (antibiotics, antiemetics, vasopressors)
Estimated blood loss
Fluid and blood administration
Urine Output
Unexpected response to anesthesia
Unexpected surgical course
Laboratory results (ABG, glucose, hemoglobin)
what information should be provided about the Post anesthesia care unit plan to the PACU nurse by the anesthesia provider?
Potential and expected problems
Pain and comfort management interventions
Other suggested interventions
Limits of acceptability of laboratory tests
Discharge criteria
Responsible contact person
name the components of the aldrete scoring system?
remember acorn airway circulation oxygenation respiration neurological
what is the purpose of the aldrete scoring system?
Provides a set of objective criteria the patient must meet before discharge from the PACU
if a facility used the aldrete scoring system, what must happen>
they pay a fee
what is the maximum score you can get with an aldrete scoring system?
10
what are acceptable aldrete discharge scores?
8 and above
what should be assessed for the respiratory system in the PACU?
respiratory rate
depth of ventilation
auscultation of breath sounds
oxygen saturation level
end-tidal carbon dioxide, if appropriate.
Type of oxygen delivery system and presence of any artificial airway should be noted
what should be assessed for the cardiac system in the PACU?
auscultation of heart sounds & quality of heart sounds
presence of any adventitious sounds
Note any irregularities in rate or rhythm
Arterial pulses are evaluated for strength and equality.
An ECG strip is obtained on admission to the PACU and compared with the preoperative ECG
unexpected finding on assessment in pacu are ?
compared with preoperative data
what should be assessed for the neurological system in the PACU?
level of consciousness
orientation
sensory function
motor function
pupil size, equality, and reactivity (PERRLA)
ability to follow commands
move extremities purposefully and equally
what should be assessed for the renal system in the PACU?
fluid intake and output (e.g., blood, crystalloids, and colloids), as well as volume and electrolyte status.
describe the information that should be communicated about intraoperative fluid totals
irrigation solutions, and infusions that enter the patient along with any output and surgical loss
the anesthesia provider communicates all lines and drains to the PACU nurse, which will include what further information?
All output devices, including drains, catheters, and tubes, are inspected, and the color and consistency of any drainage are noted.
The surgical site is examined.
The amount and color of any drainage on the bandage are noted.
what is the most common cause of airway obstruction in the immediate post-operative phase? Which is due to what?
loss of pharyngeal muscle tone in a sedated or obtunded patient
mainly due to the lasting effects of the anesthetic agents, neuromuscular blocking drugs, and opioids
what anatomical part causes most airway obstructions in pacu?
the tongue
the tongue falls back into a position that occludes the pharynx and blocks the flow of air into and out of the lungs)
what are s/s of airway obstruction?
snoring, activation of accessory muscles (Intercostal and suprasternal retractions may be noted)
what are the risk factors for airway obstruction ?
obesity
large neck
short neck
poor muscle tone: secondary to opioids, sedation, residual nmb, or neuromuscular disease;
swelling: secondary to surgical manipulation, edema, or anaphylaxis
what is the treatment for airway obstruction?
Stimulating patient to take deep breaths
repositioning of the airway (chin lift, jaw thrust) insertion of a nasal or oral airway
if all else fails, reintubation
what is tolerated more nasal airway or oral airway?
The nasal airway is tolerated much better by patients emerging from general anesthesia, and, unlike the oral airway, it is unlikely to cause gagging or vomiting.
what causes a laryngospasm?
Airway irritation that predisposes a patient to laryngospasm may be the result of laryngoscopy, secretions, vomitus, blood, artificial airway placement, coughing, bronchospasm, or frequent suctioning.
what type of laryngospasm results in a Manifests as intermittent obstruction?
Intrinsic
what type of laryngospasm results in a Manifests as complete obstruction?
extrinsic
signs and symptoms of laryngospasms?
agitation decreased oxygen saturation absent breath sounds acute respiratory distress Incomplete obstruction manifests as crowing or stridor.
what is the treatment for laryngospasm
Jaw thrust with continuous airway pressure-if ineffective then, sub-paralytic dose of IV Succinylcholine (this requires 5-10 minutes of ventilatory support.
Reintubation is not recommended and should be done only if there is significant airway edema or with persistent obstruction.
what is the preventative treatment for postoperative laryngospasms?
- Treatment with lidocaine and steroids
- obtaining meticulous hemostasis during surgery
- suctioning the oropharynx before extubation to clear any retained blood or secretions
- extubating the patient when they are either in a very deep plane of anesthesia or the awake state.
obstructive sleep apnea is associated with what during sleep?
diminished muscle tone in the airway which leads to airway obstruction during sleep
OSA is associated with an increased incidence of complications including ?
difficult intubation
length of stay in the PACU
unplanned admission
other respiratory and cardiovascular complications
how can an anesthesia provider prevent complications for a patient with OSA?
Regional anesthesia when possible
Minimal use of sedation
Known OSA w/CPAP patients should be asked to bring their CPAP to the hospital for use in the PACU
what is hypoxemia?
PaO2 less than 60
name the most common causes of hypoxemia in PACU??
Atelectasis Pulmonary edema Pulmonary embolism Aspiration Bronchospasm Hypoventilation Increased right-to-left intrapulmonary shunting
atelectasis results from?
bronchial obstruction caused by secretions or decreased lung volumes, hypotension and low cardiac output
what is the treatment of atelectasis?
humidified oxygen, coughing, deep breathing, postural drainage, increased mobility
what causes pulmonary edema?
fluid accumulation within the alveoli
Fluid accumulation caused by increase in hydrostatic pressure, a decrease in interstitial
pressure, or an increase in capillary permeability
Non-cardiogenic pulmonary edema is what?
Decreased interstitial pressure is seen after prolonged airway obstruction (laryngospasm) causing an
extreme negative intrapleural pressure that increases the pulmonary transvascular hydrostatic pressure gradient.
what are additional causes of non-cardiogenic pulmonary edema?
Can also be seen with bolus dosing of naloxone, incomplete reversal of nmb, significant period of hypoxia
signs and symptoms of pulmonary edema are? (6)
hypoxemia, cough, frothy sputum, rales, decreased lung compliance, pulmonary infiltrates on x-ray.
treatment for pulmonary edema is geared toward?
identification of the cause and reduction of hydrostatic
pressure within the lungs
list all treatment for pulmonary edema?
Oxygen administration,
diuretics,
dialysis,
preload/afterload reduction.
describe non-cardiogenic pulmonary edema recovery prognosis?
NPPE patients recover quickly with no permanent sequalae
what is the leading cause of morbidity and mortality in the postoperative patients?
pulmonary embolism
90% of pulmonary emboli arise from where?
deep veins in the legs
what are the signs and symptoms of pulmonary emboli?
acute-onset tachypnea, dyspnea, tachycardia (particularly when already on oxygen) chest pain, hypotension, hemoptysis, dysrhythmias, and congestive heart failure
Diagnosis for a pulmonary embolism can be made with
V/Q perfusion scan, CT pulmonary angiography
treatment for pulmonary embolism?
correction of hypoxemia and hemodynamic support,
IV heparin
prevent for pulmonary embolism?
antiembolic stockings,
sequential compression devices,
subcutaneous heparin
Aspiration may occur where during the postoperative period?
in OR, PACU, or any time during transfer
bronchospasm results from ? (pathophysiology)
Results from increased bronchial smooth muscle tone, with resultant closure of small airways d/t aspiration, suctioning, intubation, histamine release secondary to medications (allergic response)
bronchospasm is seen more in patients with?
Seen more in patients with history of asthma or COPD
signs and symptoms of bronchospasm?
wheezing,
dyspnea,
use of accessory muscles,
tachypnea
why does patient with bronchospasm result in airway edema or NPPE?
Patients usually will try to breath against a closed airway
treatment of bronchospasm is?
Confirmation and removal of cause then, beta-2-agonists, IV epinephrine, atropine, glycopyrrolate, ipratropium, lidocaine, steroids if underlying cause is asthma, some studies show sevoflurane as a rescue
hypoventilation ____ occurs in PACU
commonly
signs and symptoms of hypoventilation?
decreased respiratory rate resulting in an increase in PaCO2
causes of hypoventilation?
decreased central respiratory drive, poor respiratory muscle function, or both
- Depression of central respiratory drive: IV and IH anesthetics
- Poor respiratory muscle function: inadequate NMB reversal, surgery of upper
abdomen, obesity, OSA, neuromuscular diseases
▪ Eaton-Lambert syndrome
▪ Guillain-Barré syndrome
• In PACU , hypotension is the most commonly caused by?
hypovolemia
what classifies as hypotension in the PACU?
Fall of ABP greater than 20% from baseline, or an absolute value of SPB <90 torr or MAP <60 torr.
hypotension S/S which would be reflective of the failure of physiologic compensation may indicate
__________ to vital organs
hypoperfusion
hypotension may result in increase in lactic acid from hypo perfusion leading to ?
cerebral ischemia, cerebrovascular accident, myocardial infarction or ischemia, renal ischemia, bowel infarction, and spinal cord damage
treatment of hypotension is aimed at?
Treatment aimed at restoring circulating volume
If fluid bolus does not help with hypotension, what should be considered as the cause?
, myocardial dysfunction should be considered as the cause
interventions for hypotension should include what additional things beside fluid rescusitation?
Interventions should always include oxygen, elevation of the legs while determining the
cause of the hypotension.
what classifies as hypertension in the post anesthesia period?
An increase in ABP greater than 20% from baseline, or an absolute value above age corrected limits (aged <65 140/90 and >65 150-80)
hypertension can be cause by?
Can be caused by SNS stimulation, pain, respiratory compromise, visceral distention,
increases (significant) in plasma catecholamine levels.
treatment for hypertension is aimed at?
Treatment is aimed at the root cause
describe the duration of dysrhythmias in the postoperative period?
• Often transient
most common causes of dysrhythmias in the postoperative period?
hypokalemia, excess fluid administration, anemia, hypoventilation with subsequent hypercarbia, altered acid-base status, substance withdrawal, circulatory instability Residual anesthetics in blood and tissue: ketamine, atropine or glycopyrrolate, opioids, anticholinesterase agents
incomplete reversal of NMB causes what respiratory system concerns?
Compromises cough, airway patency
how can an anesthesia provider assess for adequate reversal of NMB?
Assess by Sustained head elevation in supine position, hand grip, ability to bite down,
swallow, stick out tongue in addition to train-of-four assessment
what remains the leading cause of hypertension and tachycardia in the PACU? How can you treat this?
Pain remains the leading cause of hypertension and tachycardia in the PACU and results in stimulation of the somatic afferent nerves, producing a pressor response known as the somatic sympathetic reflex.
The use of analgesics attenuates the sympathetic response, thereby normalizing blood pressure.
Vagotonic medications such as neostigmine also can produce these dysrhythmias, like what? how could you try to prevent this?
bradycardia
Mix neostigmine with robinul to prevent the bradycardia
Postoperative mental status changes are associated with ______outcomes
poor
emergence delerium is characterize by?
Characterized by
extreme disturbances of arousal, attention, orientation,
perception, intellectual function, and affect. Usually accompanied by fear and agitation
what surgery has a majority of the patient experience emergence delirium (62%)?
hip surgery
combat vets experience emergence delirium with a ______ incidence than non combat vets
greater
name the four general causes of postoperative delirium?
withdrawal psychosis
toxic psychosis
circulatory and respiratory origin
functional psychosis
what is withdrawal psychosis?
withdrawal from alcohol or drugs)
signs and symptoms of withdrawal psychosis?
remember they are a HEC of a psycho
hallucinations,
extreme combativeness, and
confusion
toxic psychosis is caused by a
toxin
Circulatory and respiratory origin psychosis is caused by?
hypercarbia or hypoxemia
what is functional psychosis?
Brief reaction of paranoia and other changes not caused by an organic abnormality.
functional psychosis is a diagnosis by?
exclusion
what is a major cause of functional psychosis in children?
sevoflurane
causes of functional psychosis?
Temperature (high or low) Anxiety Pain Irritation - ETT or visceral distenstion Drugs - Ketamine, local anesthetics, nitrous oxide, droperidol, naloxone, sevoflurane, muscle relaxants
name the most common causes of delayed awakening? (3 general categories)
Prolonged action of anesthetic drugs
Metabolic causes
Neurologic Injury
what is the Most common cause of delayed awakening
prolonged action of anesthetic drugs
what are the causes of prolonged action of anesthetic drugs causing delayed awakening?
alterations in pharmacokinetics - Distribution - Redistribution - Metabolism - Excretion Pharmacodynamics - Sensitivity d/t age, hypothermia, concomitant alcohol, drug use Inhalation agents d/t hypoventilation
what are the metabolic causes of delayed awakening?
hypoglycemia
hyperglycemia
electrolyte disturbances
hypothyroidism
what are the neurological causes of delayed awakening?
CVA, intracranial hemorrhage, increased intracranial pressure, uncontrolled extreme hypertension, air or fat emboli, uncontrolled hypotension
once delayed awakening has been identified, further evaluation begins with?
Evaluation begins with an assessment of preoperative status and intraoperative events
what intraoperative events should be evaluated for delayed awakening?
Verification of oxygenation and ventilation
R/O residual drug effects, reversal if necessary
when is a CT scan & neurology consult warranted for delayed awakening patients?
CT-scan and neurology consult is warranted if all causes are ruled out and delayed awakening d/t neurologic injury is suspected.
what is serotonin syndrome related to?
medication treatment-related serotonin level elevation
serotonin syndrome is precipitated by?
May be precipitated by administration of 2 or more serotonergic meds such as MAOI,
TCA, SSRIs, and serotonin and norepinephrine reuptake inhibitors
what are the signs and symptoms of serotonin syndrome?
(appear quickly and severe) dilated pupils, diaphoresis, myoclonus, tachycardia, anxiety, restlessness, possibly fever, mental status changes, muscle rigidity, multiple organ failure
what determines the treatment plan of serotonin syndrome?
Treatment based on severity of symptoms with early intervention desirable
what are the treatment for serotonin syndrome?
ECG, IVF resuscitation, oxygen, discontinuation of serotonergic medications, hemodynamic stabilization
what is the primary goal of PACU?
Primary goal of PACU is relief of surgical pain with minimal side effects
what are the most common causes of delayed discharge from an ambulatory surgical facility?
Excessive postoperative pain and PONV are the most common causes of delayed
discharge from ambulatory surgical facilities
what is the black box warning for doses over 25 mg of Droperidol?
sudden cardiac death
what temperature classifies as hypothermia?
Temperature less than 36 degrees C
what is the most common anesthetic complication requiring hospital admission after
out-patient surgery
PONV
PONV affects 20-30% of all surgical patients, and _____ % of high risk patients?
70-80%
what are the Risk factors for PONV?
Remember Female 40 and Fluffy. Female o Age less than 50 years o Nonsmoker o History of PONV History of motion sickness o Use of volatile anesthetics o Duration of anesthesia o Use of nitrous oxide o Postoperative opioid use o Type of surgery: specifically gynecological, laparoscopic
prophylaxis for PONV is administered to who?
Prophylaxis is administered to those “at-risk”
what medication can be used for prophylaxis of PONV
Serotonin receptor antagonists (5-HT3) Dopaminergic blockers (D2) Histamine blockers Muscarinic receptor blockers Steroids-decadron
what are the prophylaxis non-pharmacological treatments for PONV?
Acupuncture
Transcutaneous electrical nerve stimulation
Acupressure
Aromatherapy (isopropyl alcohol, peppermint oil)
The Goal in the intraoperative period is to maintain adequate ?
intravascular fluid volume left ventricular filling pressure cardiac output systemic blood pressure oxygen delivery to the tissues
the ability to do what should be assess after epidural and spinal anesthesia?
The ability to void after spinal or epidural anesthesia should be assessed
Neuraxial and opioids may interfere with ?
sphincter relaxation
Post operative urine retention can also be caused by?
Opioids, ketamine, general anesthetics, and NSAIDS
urinary retention is common after which surgeries? and often delay what?
Common after urologic, inguinal, genital surgery and will often delay discharge
prior to discharge from PACU, patients should be sufficiently _______ to participate in
the assessment
oriented
what is the PACU discharge critieria?
o Regular respiratory pattern and rate appropriate to age
o Absence of restlessness or confusion
o Vital signs within 20% of baseline
o Achievement of normal body temperature (>96.8 F)
o Pulse oximeter ≥95% or equal to baseline
o ABG (if indicated) within normal limits
o Ability to maintain patent airway
o Stability of surgical site (swelling and bleeding)
what is the PACU discharge criteria to home?
Stability of surgical site (swelling and bleeding)
o Ability to take in PO fluids without nausea or vomiting
o Vital signs within 20% of baseline
o Patient should be able to ambulate (if he could prior to surgery)
o Analgesia controlled with oral medications
o Must be able to void after urologic procedures or neuraxial blockade
anesthesia related deaths are _____.
rare, 3.4 deaths/million deaths
when does anesthesia related deaths occur?
24 hours to 1 month
the chance of anesthesia related death increases with the?
ASA score ▪ ASA 1 0.04 per 10,000 ▪ ASA 2 0.5 per 10,000 ▪ ASA 3 2.7 per 10,000 ▪ ASA 4 5.5 per 10,000
Anesthesia complications in the obstetrics is the ____ leading cause of pregnancy related mortality in the US
7th
what are major risk factors for anesthesia-related maternal mortality?
african american and obesity
Perioperative mortality and morbidity R/T age, especially what age?
Higher risk to those age >70 years
Postoperative cognitive issues
POCD* ▪ Delirium* ▪ Dementia ▪ Confusion ▪ Learning problems ▪ Memory problems
what is POCD stand for?describe it?
Postoperative Cognitive Dysfunction s subtle deterioration of memory, concentration, and
information processing
when is POCD incidence the highest?
within 1 week following surgery
what are potential causes of POCD?
- Brain hypoxia caused by arterial hypoxemia or low flow
- Residual concentration of general anesthetics (BZD)
- Long lasting effects of GA on cholinergic or glutaminergic neurotransmission
delirium is associated with what in the elderly?
increased LOS and mortality
what is the incidence of delirum in the hospitalized elederly? and the elderly in ICU?
hospitalized 20%
ICU 80%
describe the incidence of morbidity and mortality of the elderly and cardiac surgerys?
3% and continuing to decline
describe the risk of POCD and delirium elderly with cardiac surgery? attributed to what?
30-80%
Increased amount of atheromatous plaques and vascular disease
what are the Anesthetic complications related to pediatrics
Anesthetic drugs could adversely affect neurologic, cognitive, and social development of neonates and young children
Neuronal apoptosis when exposed to periods of brain development
Neuronal apoptosis represents an intrinsic suicide program by which a neuron orchestrates its own destruction.
