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N928 - Basics of Anesthesia > Post Anesthesia Care > Flashcards

Post Anesthesia Care Flashcards

1
Q

PACU

A
  • post anesthesia care unit
  • under auspices of anesthesia department
  • transition from intraoperative to post anesthesia
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2
Q

phase 1 of anesthesia recovery

A
  • immediate intensive care level recovery
  • cares for patients during emergency and awakening
  • continues until standard discharge criteria met
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3
Q

phase 2 of anesthesia recovery

A
  • less intense care than phase 1
  • ensures patient is ready for discharge
  • “fast tracking” directly to phase 2 appropriate for some outpatients
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4
Q

patient requirements before leaving OR

A
  • patent, stable airway
  • adequate ventilation and oxygenation
  • hemodynamic stability
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5
Q

admission to PACU essential steps

A
  • assess
  • attach to monitors
  • provide oxygen
  • measure/record VS
  • report to PACU nurse (standard 11)
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6
Q

PACU Handoff components

A
  • patient’s name, age, baseline mental status
  • diagnosis, surgery, surgeon
  • review pre-anesthetic assessment, VS, allergies, medical/surgical history, daily meds
  • anesthetic technique, anesthetic course, complications, agents used, intraoperative fluids (I & Os)
  • preoperative labs
  • timing/dose of meds (antibiotics, antiemetics, narcotics)
  • post anesthesia orders
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7
Q

frequent problems on emergence from anesthesia

A
  • airway obstruction
  • hypothermia/shivering
  • agitation/delirium
  • pain
  • N/V
  • autonomic lability
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8
Q

recovery from inhalation anesthetics

A
  • speed of emergence directly proportional to alveolar ventilation
  • speed of emergency inversely proportional to agent’s blood solubility
  • speed of emergence dependent on total tissue uptake - degree of metabolism, agent solubility, duration of exposure to agent
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9
Q

recovery from IV anesthetics

A
  • function of pharmacologic profile of drug
  • route for metabolism/excretion
  • e 1/2
  • redistribution profile
  • degree of lipid solubility
  • time/quantity of last dose
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10
Q

delayed emergence

A

failure to regain consciousness 30-60 min after GA is discontinued

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11
Q

common causes of delayed emergence

A
  • residual drug effects

- consider treatment with narcan, flumazenil, or NMBD reversal

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12
Q

less common causes of delayed emergence

A
  • hypothermia
  • hypoxia
  • hypercarbia
  • marked metabolic disturbances
  • perioperative stroke
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13
Q

postoperative complications

A
  • pain
  • PONV
  • agitation
  • emergence delirium
  • hemodynamic complications
  • respiratory complications
  • fluid/electrolyte imbalance
  • neurologic deficit
  • drug interactions
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14
Q

what is the most common post op issue in PACU?

A

pain

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15
Q

methods of pain management

A
  • opioids
  • non-opioids
  • regional
  • atlernative - distraction, ice/heat, massage, acupuncture, immobilize, TENS
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16
Q

PONV contributes to

A
  • delayed discharge

- unanticipated postsurgical admission

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17
Q

etiology of PONV

A
  • anesthetic agents
  • type of procedure
  • patient factors
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18
Q

PONV patient factors

A
  • female (3x higher risk than males)
  • young age
  • large body habitus
  • history of PONV or motion sickness
  • non-smoker
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19
Q

PONV anesthetic techniques

A
  • GA

- meds - volatiles, nitrous oxide, opioids, anticholinesterase

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20
Q

PONV surgical procedures

A
  • laparoscopic
  • GYN
  • eye
  • ENT (esp middle ear)
  • breast
  • neurosurgery
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21
Q

PONV post-op factors

A
  • hypotension
  • hypovolemia
  • postoperative pain
  • CTZ stimulated by toxic endogenous substances
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22
Q

CTZ

A
  • area postrema in dorsomedial medulla oblongata

- receives afferent input from many areas of the body

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23
Q

receptors that contribute to PONV

A
  • dopaminergic
  • histamine
  • cholinergic muscarinic
  • 5-HT (serotonin)
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24
Q

CNS PONV areas

A
  • cortex
  • thalamus
  • hypothalamus
  • meninges
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25
vestibular system PONV areas
- H1 receptor | - M1 receptor
26
CTZ or area postrema PONV areas
- chemoreceptors - D2 receptor - NK1 receptor - 5-HT3 receptor
27
vomiting center PONV areas
- located in NTS - H1 receptor - M1 receptor - NK1 receptor - 5-HT3 receptor
28
GI tract and heart PONV areas
- mechanoreceptors - chemoreceptors - 5-HT3 receptors
29
PONV management
- adequate hydration - P6 acupuncture/pressure point on wrist - antiemetics (multi modal)
30
7 antiemetic classes
- 5-HT3 receptor antagonists - benzamides (dopamine receptor antagonist) - phenothiazines/antihistamines (H1 receptor antagonist) - butyrophenones (dopamine receptor antagonist) - anticholinergics - Neurokinin 1 receptor antagonist - steroids
31
5-HT 3 receptor antagonists
ondansetron (zofran), dolasetron, granisetron, palonsetron
32
benzamides/dopamine receptor antagonist
metoclopramide (Reglan), cisapride
33
phenothiazines/H1 receptor antagonist
promethazine (phenergan), chlorpromazine
34
butyrophenones/dopamine receptor antagonist
droperidol, haloperidol
35
antihistamine
diphenhydramine (benadryl), dimenhydrinate (dramamine)
36
anticholinergics
scopolamine, atropine
37
neurokinin 1 recpetor antagonist
aprepitant (emend)
38
steroids
dexamethasone (decadron)
39
post operative delirium risk factors
- PTSD - fear - depression - anxiety - trauma - history of sexual trauma or abuse
40
emergence delirium/agitation
- incidence - 10-20% of patients after GA - often manifestation of pain - other factors to r/o - hypoxemia, acidosis, hypotension, bladder distention/foley, occult bleeding - more common among - younger populations, patients with preop anxiety, patients with other psychological disturbances - manifests as - restlessness, agitation, delirium, irritability
41
post operative delirium
lasts for a more extended period of time after surgery
42
post operative delirium causes
- withdrawal psychosis - toxic psychosis - circulatory psychosis - functional psychosis
43
why is post operative delirium costly?
- increases ICU LOS - increases hospital LOS - increased number of days mechanically ventilated - increased functional decline
44
what is the mortality % of post op delirium?
all cause mortality is 10-20% for every 2 days of post-op delirium
45
risk factors for post op delirium
- reduced cognitive reserve (dementia, depression, advanced age) - reduced physical reserve (atherosclerosis, renal impairment, pulmonary disease, advanced age, preop beta blockade) - sensory impairment (vision/hearing) - alcohol abuse - malnutrition - dehydration - apolipoprotein E4 genotype
46
precipitating factors for post op delirium
- meds or medication withdrawal - pain - hypoxemia - electrolyte abnormalities - malnutrition - dehydration - environmental change (ICU admission)
47
meds that can precipitate post-op delirium or withdrawal
- anticholinergics - muscle relaxants - antihistamines - GI antispasmodics - opioid analgesics - antiarrhythmics - cortciosteroids - >6 total meds - >3 new inpatient meds
48
postop cognitive dysfunction (POCD)
- decline in memory and executive function after surgery and anesthesia - may last for days, weeks, or in some cases even months after a major surgery
49
POCD etiology/patho
- pathophysiology not well understood - cerebral microemboli - hyperventilation, significant hypercapnia, cerebral vasoconstriction, extreme hypocapnia - inflammatory mechanisms - hypotension - decreased cerebral blood flow
50
POCD risk factors
- patients over the age of 65 - preexisting cognitive impairment - type of surgery - re-operation - inflammation - depression - sleep deprivation - anesthetic technique
51
hypothermia in the OR
- common post operatively | - room is kept very cold, so puts patient at increased risk
52
adverse effects of hypothermia
- decreased drug metabolism - impaired immune system - increased incidence of infection - increase blood loss and need for transfusion - increased myocardial risks - prolonged need for mechanical ventilation
53
methods to warm
- increase room temp - body warming blankets - fluid warmers - warm irrigation fluid - humidified gases - these should begin in the OR and not the PACU
54
hypothermia symptoms
- shivering - clumsiness - slurred speech - confusion - drowsiness - shallow breathing - weak pulse
55
what can shivering in absence of hypothermia be caused by?
pain
56
effects of shivering
- increases O2 consumption (by 300% or more) - increases CO2 production - increases CO - predisposes at risk patients to cardiac morbidity
57
treatment for shivering
- Demerol 25 mg IV in PACU | - Zofran also potentially helps too, but Demerol is gold standard
58
airway obstruction causes
- tongue falling back against posterior pharynx - glottic edema - secretions, vomit, or blood in airway - laryngospasm - external pressure on trachea (like from hematoma) - treat underlying cause
59
partial obstruction
snoring
60
complete obstruction
- cessation of airflow - absent breath sounds - paradoxical chest movements
61
hypoventilation
defined as PaCO2 > 45mmHg
62
hypoventilation S/S
- excessive or prolonged somnolence - airway obstruction - slow RR or tachypnea with shallow breathing - labored breathing
63
hypoventilation causes
- residual depressant effects of anesthetic agents - inadequate NMBD reversal - hypothermia - splinting secondary to pain - TREAT CAUSE
64
hypoxemia
- mild to moderate is PaO2 50-60 mmHg - initially well tolerated by healthy, but acidosis and CV depression as it worsens - early signs - restlessness, tachycardia, cardiac irritability - late signs - obtundation, bradycardia, hypotension, cardiac arrest
65
hypoxemia early signs
- restlessness - tachycardia - tachypnea - dyspnea - increased agitation - anxiety - diaphoresis - retractions - altered LOC - HA
66
hypoxemia late signs
- increased restlessness - somnolence - stupor - dyspnea - decreased respirations - bradycardia - cyanosis
67
hypoxemia signs in pediatrics
- nasal flaring - stridor - grunting - feeding problems
68
hypoxemia causes
- hypoventilation - increased intra-pulmonary shunting - decreased CO - increase in O2 consumption (shivering)
69
hypoxemia treatment
O2 therapy with or without positive airway pressure
70
other respiratory complications
- bronchospasm - pulmonary edema - PE - aspiration
71
hypotension
defined as BP 25% below pre-op baseline
72
hypotension causes
- hypovolemia (most common cause) - pain meds (cause venodilation) - volatile anesthetics (decrease venous return) - post-op MI - hypoxia - cardiac tamponade - pneumothorax - LV dysfunction
73
hypotension treatment
- specific to cause, treat underlying cause - fluid challenge - vasopressors
74
hypertension causes
- pain (most common) - hypoxemia/hypercarbia - bladder distention (causes SNS activation) - fluid overload, hypervolemia - not taking routine anti-hypertensives
75
hypertension treatment
- treat the cause - adequate pain relief - bladder cath - beta blockers - vasodilators
76
cardiac dysrhythmias causes
- bradycardia - residual anticholinesterase, beta blockers, opioids, hypoxemia - tachycardia - anticholinergics, vagolytics, beta agonist (albuterol), pain, hypovolemia - PACs or PVCs - electrolyte imbalance, myocardial ischemia
77
populations commonly affected by fluid and electrolyte imbalance
- elderly - debilitated patients - hypertensive patients pretreated with diuretics - diabetic patients - neurosurgical patients
78
hyponatremia
- common cause = water intoxication - S/S = SALTLOS - stupor/coma - anorexia (N/V) - lethargy - tendon reflexes (decreased) - limp muscles (weakness) - orthostatic hypothension - seizures/HA
79
hypocalcemia
- common causes = hepatic failure, massive volume replacement, acute pancreatitis, hypoparathyroidism, ESRD - S/S: - irritability + anxiety - paresthesias - siezures - laryngospasms - bronchospasm - heart failure - muscle cramps
80
hypermagnesemia
- common causes = eclamptic patients treated with magnesium sulfate, ESRD - Mg 3-5 = nausea, vomiting - Mg 4-7 = sedation, decreased reflexes, weakness - Mg 5-10 = hypotension, bradycardia, quadriplegia - Mg 10-15 = no reflexes, respiratory paralysis, cardiac arrest
81
neurologic deficits
- peripheral nerve injuries - postdural puncture headahces (PDPH) - place a spinal, and excessive amount of CSF leaks out of needle prior to injection of LA - transient focal deficits - postoperative vision loss
82
drug interactions
- suspect when unexpected changes in neurologic status or VS | - increased use of non-FDA regulated herbal supplements --> increased risk of interactions
83
common effects of drug interactions
- NMB effects of some antibiotics potentiated by some CCBs - hypokalemia from diuresis or rapid fluid replacement may precipitate digitalis toxicity - dopamine effects reduced by phenothiazines and antipsychotic drugs - ketamine enhances dysrhythmogenicity of ephedrine - clearance of steroids reduced by phenytoin
84
discharge from PACU
- STRICT | - must observe patients for a MINIMUM of 20-30 minutes after last dose of parenteral narcotic
85
minimal discharge criteria from PACU
- easily arousable - fully oriented (return to baseline) - maintains and protects airway - stable VS for min of 15-30 min - able to call for help (if necessary) - no obvious surgical complications (i.e., active bleeding)
86
Modified Aldrete Score
- commonly used scale for determining when people can be safely discharged from the post-anesthesia care unit (PACU) to either the postsurgical ward or to the second stage (Phase II) recovery area - 5 categories, each of which is scored 0-2 based on patient assessment - score must be >/= to 9 prior to PACU discharge; 10 is recommended
87
Aldrete score components
- respiration - O2 saturation - consciousness - circulation/color - activity
88
Aldrete Respiration Scores
- 2 = able to take deep breath and cough - 1 = dyspnea/shallow breathing - 0 = apnea
89
Aldrete O2 Saturation Scores
- 2 = maintains >92% on RA - 1 = needs O2 inhalation to maintain O2 saturation >90% - 0 = saturation <90% even with supplemental O2
90
Aldrete Consciousness Scores
- 2 = fully awake - 1 = arousable on calling - 0 = not responding
91
Aldrete Circulation/Color Scores
- 2 = BP +/- 20 mmHg pre op - 1 = BP +/- 20-50 mmHg pre op - 0 = BP +/- 50 mmHg pre op
92
Aldrete Activity Scores
- 2 = able to move 4 extremities voluntarily or on command - 1 = able to move 2 extremities voluntarily or on command - 0 = able to move 0 extremities voluntarily or on command

N928 - Basics of Anesthesia (17 decks)

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