Post Anesthesia Care Flashcards
The PACU was first suggested by
Florence Nightingale in the 1860s
The first recovery rooms were established across the US in the
1960s & 1970s
The PACU operates under the
anesthesia department
Phase 1 of PACU is
immediate intensive care level recovery
cares for patients during emergence and awakening
continues until standard discharge criteria is met
Phase 2 of PACU is
less intense than phase 1
ensures patient is ready for discharge
“Fast-tracking” directly to phase 2 PACU care is appropriate for some patients (dependent on surgical procedure & patient comorbidities)
Prior to the patient leaving the OR:
patent, stable airway
adequate ventilation and oxygenation
hemodynamic stability
The appropriate position to transport patients to the PACU includes
adults- supine with HOB elevated
children- side lying position
transport with supplemental oxygen if needed
Essential steps to arrival and admission to the PACU include
assess attach to monitors provide oxygen measure/record vital signs Report to PACU nurse
The report given to the PACU nurse is this AANA standard of care.
Standard 11: transfer of care
Included in the handoff report is:
Patient’s name, age, comprehension limits
diagnosis, surgical procedure & surgeon
Review pre-anesthetic assessment, VS, allergies, medical/surgical history, daily medications
anesthetic technique, anesthetic course, complications, agents used, intraoperative fluids
preoperative laboratory data
timing/dosage of medications- antibiotics, antiemetics, narcotics
Post anesthesia orders
With the emergence from general anesthesia, we frequently see:
airway obstruction hypothermia/shivering agitation/delirium pain Nausea/vomiting autonomic lability
Recovery from inhalation anesthetics is based upon:
- speed of emergence directly proportional to alveolar ventilation but inversely proportional to agent’s blood solubility
- Speed of emergence is dependent on total tissue uptake: degree of metabolism, agent solubility, duration of exposure to the agent
The speed of emergence is dependent on total tissue uptake:
degree of metabolism, agent solubility, duration of exposure to the agent
Recovery from IV anesthetics is based upon
the function of the pharmacokinetic profile of the drug:
routes for metabolism and excretion, elimination half-life, redistribution profile, degree of lipid solubility, time and quantity of last dose
Delayed emergence is defined as
failure to regain consciousness 30-60 minutes after general anesthesia is discontinued
Delayed emergence is MOST commonly due to
residual drug effects
Consider treatment: Narcan, flumazenil, neuromuscular blocking agent reversal
Other less common causes of delayed emergence include:
hypothermia, hypoxia, hypercarbia, marked metabolic disturbances, perioperative stroke
Postoperative complications include:
Pain, PONV, agitation, emergence delirium, hemodynamic complications, respiratory complications, fluid & electrolyte imbalance, neurologic deficits, drug interactions
Postoperative hemodynamic complications include
hypotension, hypertension, & arrhythmias
Postoperative respiratory complications include:
airway obstruction, hypo/hyperventilation, hypoxemia, bronchospasm, pulmonary edema, & aspiration
The most common postoperative issue is
pain
Methods of pain management include
opioids, non-opioids, regional, and alternative methods
Alternative methods for pain relief include
distraction, ice/heat, massage, acupuncture, immobilize, TENS unit
Postoperative nausea and vomiting significantly contribute to:
delayed discharge
unanticipated postsurgical admissions
The etiology of PONV is
multifactorial and reasons include anesthetic agents, type of procedure, patient factors
Patient factors for PONV risk factors include:
female (3x > risk than males) young age large body habitus history of PONV or motion sickness non-smokers
Anesthetic technique risk factors for PONV include:
general anesthesia
medications: volatiles, N2O, opioids, anticholinesterase
Surgical procedures that increase the risk for PONV include
laryngoscopy, gyn, eye, ENT, breast, neurosurgery
Postoperative risk factors for PONV include
hypotension and postoperative pain
Receptor types that contribute to PONV include:
dopaminergic, histaminic, cholinergic muscarinic, 5-HT (serotonin)
The vomiting center in the brain
receives afferent inputs from many areas of the body
The vomiting center is also known as the
nucleus tractus solitarius
PONV management includes
adequate hydration, P6 acupuncture point on the wrist, antiemetics
Classes of antiemetics include
5 HT-3 receptor antagonists benzamides phenothiazines butyrophenones antihistamines anticholinergics others
The 5 HT-3 receptor antagonists include
ondansetron, dolasetron, and granisetron
The benzamides include
metoclopramide, cisapride
Phenothiazines include
chloropromazine, promethazine
Butyrophenones include
droperidol, haloperidol
Antihistamines include
diphenhydramine
anticholinergics include
scopolamine, atropine
Other drugs that help with PONV include
steroids, ginger root
Postoperative delirium and dysfunction is inclusive of
emergence delirium or agitation
postoperative delirium
postoperative cognitive dysfunction
Emergence delirium or agitation occurs in
10-20% of patients
more common among- younger populations, patients with preoperative anxiety, patients with psychological disturbances
Emergence delirium or agitation is often a manifestation of
pain
Other contributing factors to agitation that must be ruled out include
hypoxemia, acidosis, hypotension, bladder distension/ foley catheter, occult bleeding
Causes of postoperative delirium include
withdrawal psychosis, toxic psychosis, circulatory psychosis, & functional pscyhosis
Postoperative delirium is costly because
it increases ICU length of stay, hospital length of stay, functional decline, number of days mechanically ventilated
Predisposing factors for delirium include
reduced cognitive reserve: dementia, depression & advanced age
Reduced physical reserve
& sensory impairment
Reduced physical reserve as it relates to delirium includes
atherosclerotic disease, renal impairment, pulmonary disease, advanced age, and preoperative beta blockade
Sensory impairment as it relates to delirium includes
alcohol abuse, malnutrition, dehydration, and apolipoprotein E4 genotype
Precipitating medication risk factors for delirium include:
medications or medication withdrawal- anticholinergics, muscle relaxants, antihistamines, GI antispasmodics, opioid analgesics, antiarrhythmics, corticosteroids, >6 total medications, >3 new inpatient medications
Additional precipitating risk factors for delirium include:
pain, hypoxemia, electrolyte abnormalities, malnutrition, dehydration, environmental change (ICU admission)
Postoperative cognitive dysfunction is
a decline in memory and executive function after surgery and anesthesia
can last days to months after surgery
Risk factors for postoperative cognitive decline include
patients >65 years or have pre-existing cognitive impairment
type of surgery, re-operation, inflammation, depression, sleep deprivation, anesthetic technique
Postoperative cognitive dysfunction can be caused by
cerebral microemboli inflammatory mechanisms hypotension decreased cerebral blood flow hyperventilation resulting in significant hypercapnia/cerebral vasoconstriction & extreme hypocapnia
Deleterious effects of decreased temperature include:
impaired immune system, increased incidence of infection, increased blood loss and need for transfusion, increased myocardial risks, prolonged need for mechanical ventilation, decreased drug metabolism
Methods to warm patients include
increase room temperature, body warming blankets, fluid warmers, warm irrigation fluid, humidified gases
Hypothermia symptoms include:
shivering, clumsiness, slurred speech, & confusion
drowsiness, shallow breathing, and a weak pulse
Shivering in the absence of hypothermia may be related to
pain
it increases O2 consumption, increases CO2 production, increases cardiac output, & predisposes at risk patients to cardiac morbidity
Shivering is concerning because it increases
oxygen consumption
Shivering may be treated with
Demerol 25 mg IV in the PACU
Causes of airway obstruction include
tongue falling back against posterior pharynx, glottic edema, secretions vomitus or blood in the airway, laryngospasm, external pressure on trachea (hematoma)
A partial obstruction will result in
snoring
A complete obstruction will result in
cessation of airflow, absent breath sounds, & paradoxical chest movements
Hypoventilation is defined as
PaCO2 >45 mmHg
Signs and symptoms of hypoventilation include
excessive or prolonged somnolence, airway obstruction, slow RR or tachypnea with shallow breathing, labored breathing
Causes of respiratory complications can be due to
residual depressant effects of anesthetic agents, inadequate neuromuscular blockade reversal, hypothermia, splinting secondary to pain
Treat the underlying cause
Respiratory complications can lead to
hypoxemia- mild to moderate PaO2 50-60 mmHg
Hypoxemia is initially well-tolerated by the healthy but
acidosis and CV depression occurs as it worsens
Early indication of hypoxemia include
restlessness, tachycardia, and cardiac irritability
tachypnea, dyspnea, diaphoresis, retractions, altered LOC, HA
Late indications of hypoxemia include
obtundation, bradycardia, hypotension, and cardiac arrest
dyspnea, decreased respirations, & cyanosis
Hypoxemia symptoms in pediatrics are different and include
nasal flaring, stridor, grunting, and feeding problems
Causes of hypoxemia include
hypoventilation, increased intra-pulmonary shunting, decrease in cardiac output, increase in O2 consumption (shivering)
The treatment for hypoxemia is
O2 therapy with or without positive airway pressure
Respiratory complications can include
bronchospasm, pulmonary edema, pulmonary embolism, & aspiration
Hypotension is defined as
BP 25% below pre-op baseline
Causes of hypotension include
hypovolemia (most common cause), pain medications (cause venodilation), volatiles (decreased venous return), postoperative MI, hypoxia, cardiac tamponade, pneumothorax, LV dysfunction
Treatment for hypotension includes
fluid challenge, vasopressors, consider/treat underlying cause
Causes of hypertension include
pain (most common cause), hypoxemia/hypercarbia, bladder distension, fluid overload, hypervolemia, not taking routine antihypertensives
The treatment for hypertension includes
adequate pain relief, bladder catheterization, beta blockers, & vasodilators
Possible causes of cardiac dysrhythmias in the PACU include
bradycardia- opioids, beta blockers
tachycardia- anticholinergics, antisialogogues, albuterol, pain, hypovolemia
PACs or PVCs
Populations most commonly affected by fluid and electrolyte imbalance include
elderly, debilitated patients, hypertensive patients pretreated with diuretics, diabetic patients, neurosurgical patients
Fluid and electrolytes abnormalities include:
hyponatremia (water intoxication)
hypocalcemia
hypermagnesemia
Hypermagnesemia may result from patients treated with
magnesium sulfate for pre-eclampsia or ESRD
S/S of hypermagnesemia include
N/V, sedation, decreased reflexes, weakness, hypotension, bradycardia, respiratory paralysis, cardiac arrest
Hypocalcemia may be a result of
hepatic failure, massive volume replacement, acute pancreatitis, hypoparathyroidism, ESRD
S/S of hypocalcemia include
irritability & anxiety, paresthesia, seizures, laryngospasm, bronchospasm, HF, and muscle cramps
S/S of hyponatremia include
stupor/coma anorexia lethargy tendon reflexes decreased limp muscles orthostatic hypotension seizures/HA
Neurologic deficits include
peripheral nerve injuries
post-dural puncture HAs
transient focal deficits
postoperative vision loss
Drug interactions should be suspected when
unexpected changes in neurologic status or vital signs occur
Drug interactions are more common due to
increased use of non-FDA regulated herbal supplements
Minimal criteria for discharge from the PACU includes:
easily arousable, fully oriented (return to baseline), maintains and protects airway, VS stable for minimum of 15-30 minutes, able to call for help if necessary, no obvious surgical complications such as active bleeding
Patients must be observed for a minimum of
20-30 minutes after last dose of parenteral narcotic
Neuromuscular blocking affects of some
antibiotics are potentiated by calcium channel blockers
Hypokalemia from diuresis or rapid fluid replacement may precipiate
digitalis toxicity
dopamine effects are reduced by
phenothiazines and antipsychotic drugs
Ketamine enhances the
dysrythmogenicity of ephedrine
Clearance of steroids is reduced by
phenytoin
The _____ score is used to determine PACU discharge
Aldrete score based on respiration, O2 saturation, consciousness, circulation, and activity
The Aldrete score must be
> /= 9 prior to PACU discharge; 10 is recommended
