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N928 Basic Principles of Anesthesia > Post Anesthesia Care > Flashcards

Post Anesthesia Care Flashcards

1
Q

The PACU was first suggested by

A

Florence Nightingale in the 1860s

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2
Q

The first recovery rooms were established across the US in the

A

1960s & 1970s

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3
Q

The PACU operates under the

A

anesthesia department

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4
Q

Phase 1 of PACU is

A

immediate intensive care level recovery
cares for patients during emergence and awakening
continues until standard discharge criteria is met

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5
Q

Phase 2 of PACU is

A

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)

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6
Q

Prior to the patient leaving the OR:

A

patent, stable airway
adequate ventilation and oxygenation
hemodynamic stability

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7
Q

The appropriate position to transport patients to the PACU includes

A

adults- supine with HOB elevated
children- side lying position
transport with supplemental oxygen if needed

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8
Q

Essential steps to arrival and admission to the PACU include

A 
assess
attach to monitors
provide oxygen 
measure/record vital signs
Report to PACU nurse
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9
Q

The report given to the PACU nurse is this AANA standard of care.

A

Standard 11: transfer of care

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10
Q

Included in the handoff report is:

A

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

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11
Q

With the emergence from general anesthesia, we frequently see:

A 
airway obstruction
hypothermia/shivering
agitation/delirium
pain
Nausea/vomiting
autonomic lability
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12
Q

Recovery from inhalation anesthetics is based upon:

A
  • 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
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13
Q

The speed of emergence is dependent on total tissue uptake:

A

degree of metabolism, agent solubility, duration of exposure to the agent

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14
Q

Recovery from IV anesthetics is based upon

A

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

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15
Q

Delayed emergence is defined as

A

failure to regain consciousness 30-60 minutes after general anesthesia is discontinued

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16
Q

Delayed emergence is MOST commonly due to

A

residual drug effects

Consider treatment: Narcan, flumazenil, neuromuscular blocking agent reversal

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17
Q

Other less common causes of delayed emergence include:

A

hypothermia, hypoxia, hypercarbia, marked metabolic disturbances, perioperative stroke

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18
Q

Postoperative complications include:

A

Pain, PONV, agitation, emergence delirium, hemodynamic complications, respiratory complications, fluid & electrolyte imbalance, neurologic deficits, drug interactions

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19
Q

Postoperative hemodynamic complications include

A

hypotension, hypertension, & arrhythmias

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20
Q

Postoperative respiratory complications include:

A

airway obstruction, hypo/hyperventilation, hypoxemia, bronchospasm, pulmonary edema, & aspiration

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21
Q

The most common postoperative issue is

A

pain

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22
Q

Methods of pain management include

A

opioids, non-opioids, regional, and alternative methods

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23
Q

Alternative methods for pain relief include

A

distraction, ice/heat, massage, acupuncture, immobilize, TENS unit

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24
Q

Postoperative nausea and vomiting significantly contribute to:

A

delayed discharge

unanticipated postsurgical admissions

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25
Q

The etiology of PONV is

A

multifactorial and reasons include anesthetic agents, type of procedure, patient factors

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26
Q

Patient factors for PONV risk factors include:

A 
female (3x > risk than males)
young age
large body habitus
history of PONV or motion sickness
non-smokers
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27
Q

Anesthetic technique risk factors for PONV include:

A

general anesthesia

medications: volatiles, N2O, opioids, anticholinesterase

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28
Q

Surgical procedures that increase the risk for PONV include

A

laryngoscopy, gyn, eye, ENT, breast, neurosurgery

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29
Q

Postoperative risk factors for PONV include

A

hypotension and postoperative pain

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30
Q

Receptor types that contribute to PONV include:

A

dopaminergic, histaminic, cholinergic muscarinic, 5-HT (serotonin)

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31
Q

The vomiting center in the brain

A

receives afferent inputs from many areas of the body

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32
Q

The vomiting center is also known as the

A

nucleus tractus solitarius

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33
Q

PONV management includes

A

adequate hydration, P6 acupuncture point on the wrist, antiemetics

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34
Q

Classes of antiemetics include

A 
5 HT-3 receptor antagonists
benzamides
phenothiazines
butyrophenones
antihistamines
anticholinergics
others
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35
Q

The 5 HT-3 receptor antagonists include

A

ondansetron, dolasetron, and granisetron

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36
Q

The benzamides include

A

metoclopramide, cisapride

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37
Q

Phenothiazines include

A

chloropromazine, promethazine

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38
Q

Butyrophenones include

A

droperidol, haloperidol

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39
Q

Antihistamines include

A

diphenhydramine

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40
Q

anticholinergics include

A

scopolamine, atropine

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41
Q

Other drugs that help with PONV include

A

steroids, ginger root

42
Q

Postoperative delirium and dysfunction is inclusive of

A

emergence delirium or agitation
postoperative delirium
postoperative cognitive dysfunction

43
Q

Emergence delirium or agitation occurs in

A

10-20% of patients

more common among- younger populations, patients with preoperative anxiety, patients with psychological disturbances

44
Q

Emergence delirium or agitation is often a manifestation of

A

pain

45
Q

Other contributing factors to agitation that must be ruled out include

A

hypoxemia, acidosis, hypotension, bladder distension/ foley catheter, occult bleeding

46
Q

Causes of postoperative delirium include

A

withdrawal psychosis, toxic psychosis, circulatory psychosis, & functional pscyhosis

47
Q

Postoperative delirium is costly because

A

it increases ICU length of stay, hospital length of stay, functional decline, number of days mechanically ventilated

48
Q

Predisposing factors for delirium include

A

reduced cognitive reserve: dementia, depression & advanced age
Reduced physical reserve
& sensory impairment

49
Q

Reduced physical reserve as it relates to delirium includes

A

atherosclerotic disease, renal impairment, pulmonary disease, advanced age, and preoperative beta blockade

50
Q

Sensory impairment as it relates to delirium includes

A

alcohol abuse, malnutrition, dehydration, and apolipoprotein E4 genotype

51
Q

Precipitating medication risk factors for delirium include:

A

medications or medication withdrawal- anticholinergics, muscle relaxants, antihistamines, GI antispasmodics, opioid analgesics, antiarrhythmics, corticosteroids, >6 total medications, >3 new inpatient medications

52
Q

Additional precipitating risk factors for delirium include:

A

pain, hypoxemia, electrolyte abnormalities, malnutrition, dehydration, environmental change (ICU admission)

53
Q

Postoperative cognitive dysfunction is

A

a decline in memory and executive function after surgery and anesthesia
can last days to months after surgery

54
Q

Risk factors for postoperative cognitive decline include

A

patients >65 years or have pre-existing cognitive impairment
type of surgery, re-operation, inflammation, depression, sleep deprivation, anesthetic technique

55
Q

Postoperative cognitive dysfunction can be caused by

A 
cerebral microemboli
inflammatory mechanisms
hypotension
decreased cerebral blood flow
hyperventilation resulting in significant hypercapnia/cerebral vasoconstriction & extreme hypocapnia
56
Q

Deleterious effects of decreased temperature include:

A

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

57
Q

Methods to warm patients include

A

increase room temperature, body warming blankets, fluid warmers, warm irrigation fluid, humidified gases

58
Q

Hypothermia symptoms include:

A

shivering, clumsiness, slurred speech, & confusion

drowsiness, shallow breathing, and a weak pulse

59
Q

Shivering in the absence of hypothermia may be related to

A

pain
it increases O2 consumption, increases CO2 production, increases cardiac output, & predisposes at risk patients to cardiac morbidity

60
Q

Shivering is concerning because it increases

A

oxygen consumption

61
Q

Shivering may be treated with

A

Demerol 25 mg IV in the PACU

62
Q

Causes of airway obstruction include

A

tongue falling back against posterior pharynx, glottic edema, secretions vomitus or blood in the airway, laryngospasm, external pressure on trachea (hematoma)

63
Q

A partial obstruction will result in

A

snoring

64
Q

A complete obstruction will result in

A

cessation of airflow, absent breath sounds, & paradoxical chest movements

65
Q

Hypoventilation is defined as

A

PaCO2 >45 mmHg

66
Q

Signs and symptoms of hypoventilation include

A

excessive or prolonged somnolence, airway obstruction, slow RR or tachypnea with shallow breathing, labored breathing

67
Q

Causes of respiratory complications can be due to

A

residual depressant effects of anesthetic agents, inadequate neuromuscular blockade reversal, hypothermia, splinting secondary to pain
Treat the underlying cause

68
Q

Respiratory complications can lead to

A

hypoxemia- mild to moderate PaO2 50-60 mmHg

69
Q

Hypoxemia is initially well-tolerated by the healthy but

A

acidosis and CV depression occurs as it worsens

70
Q

Early indication of hypoxemia include

A

restlessness, tachycardia, and cardiac irritability

tachypnea, dyspnea, diaphoresis, retractions, altered LOC, HA

71
Q

Late indications of hypoxemia include

A

obtundation, bradycardia, hypotension, and cardiac arrest

dyspnea, decreased respirations, & cyanosis

72
Q

Hypoxemia symptoms in pediatrics are different and include

A

nasal flaring, stridor, grunting, and feeding problems

73
Q

Causes of hypoxemia include

A

hypoventilation, increased intra-pulmonary shunting, decrease in cardiac output, increase in O2 consumption (shivering)

74
Q

The treatment for hypoxemia is

A

O2 therapy with or without positive airway pressure

75
Q

Respiratory complications can include

A

bronchospasm, pulmonary edema, pulmonary embolism, & aspiration

76
Q

Hypotension is defined as

A

BP 25% below pre-op baseline

77
Q

Causes of hypotension include

A

hypovolemia (most common cause), pain medications (cause venodilation), volatiles (decreased venous return), postoperative MI, hypoxia, cardiac tamponade, pneumothorax, LV dysfunction

78
Q

Treatment for hypotension includes

A

fluid challenge, vasopressors, consider/treat underlying cause

79
Q

Causes of hypertension include

A

pain (most common cause), hypoxemia/hypercarbia, bladder distension, fluid overload, hypervolemia, not taking routine antihypertensives

80
Q

The treatment for hypertension includes

A

adequate pain relief, bladder catheterization, beta blockers, & vasodilators

81
Q

Possible causes of cardiac dysrhythmias in the PACU include

A

bradycardia- opioids, beta blockers
tachycardia- anticholinergics, antisialogogues, albuterol, pain, hypovolemia
PACs or PVCs

82
Q

Populations most commonly affected by fluid and electrolyte imbalance include

A

elderly, debilitated patients, hypertensive patients pretreated with diuretics, diabetic patients, neurosurgical patients

83
Q

Fluid and electrolytes abnormalities include:

A

hyponatremia (water intoxication)
hypocalcemia
hypermagnesemia

84
Q

Hypermagnesemia may result from patients treated with

A

magnesium sulfate for pre-eclampsia or ESRD

85
Q

S/S of hypermagnesemia include

A

N/V, sedation, decreased reflexes, weakness, hypotension, bradycardia, respiratory paralysis, cardiac arrest

86
Q

Hypocalcemia may be a result of

A

hepatic failure, massive volume replacement, acute pancreatitis, hypoparathyroidism, ESRD

87
Q

S/S of hypocalcemia include

A

irritability & anxiety, paresthesia, seizures, laryngospasm, bronchospasm, HF, and muscle cramps

88
Q

S/S of hyponatremia include

A 
stupor/coma
anorexia
lethargy 
tendon reflexes decreased
limp muscles 
orthostatic hypotension
seizures/HA
89
Q

Neurologic deficits include

A

peripheral nerve injuries
post-dural puncture HAs
transient focal deficits
postoperative vision loss

90
Q

Drug interactions should be suspected when

A

unexpected changes in neurologic status or vital signs occur

91
Q

Drug interactions are more common due to

A

increased use of non-FDA regulated herbal supplements

92
Q

Minimal criteria for discharge from the PACU includes:

A

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

93
Q

Patients must be observed for a minimum of

A

20-30 minutes after last dose of parenteral narcotic

94
Q

Neuromuscular blocking affects of some

A

antibiotics are potentiated by calcium channel blockers

95
Q

Hypokalemia from diuresis or rapid fluid replacement may precipiate

A

digitalis toxicity

96
Q

dopamine effects are reduced by

A

phenothiazines and antipsychotic drugs

97
Q

Ketamine enhances the

A

dysrythmogenicity of ephedrine

98
Q

Clearance of steroids is reduced by

A

phenytoin

99
Q

The _____ score is used to determine PACU discharge

A

Aldrete score based on respiration, O2 saturation, consciousness, circulation, and activity

100
Q

The Aldrete score must be

A

> /= 9 prior to PACU discharge; 10 is recommended

N928 Basic Principles of Anesthesia (16 decks)

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