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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
Q

vestibular system PONV areas

A
  • H1 receptor

- M1 receptor

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26
Q

CTZ or area postrema PONV areas

A
  • chemoreceptors
  • D2 receptor
  • NK1 receptor
  • 5-HT3 receptor
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27
Q

vomiting center PONV areas

A
  • located in NTS
  • H1 receptor
  • M1 receptor
  • NK1 receptor
  • 5-HT3 receptor
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28
Q

GI tract and heart PONV areas

A
  • mechanoreceptors
  • chemoreceptors
  • 5-HT3 receptors
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29
Q

PONV management

A
  • adequate hydration
  • P6 acupuncture/pressure point on wrist
  • antiemetics (multi modal)
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30
Q

7 antiemetic classes

A
  • 5-HT3 receptor antagonists
  • benzamides (dopamine receptor antagonist)
  • phenothiazines/antihistamines (H1 receptor antagonist)
  • butyrophenones (dopamine receptor antagonist)
  • anticholinergics
  • Neurokinin 1 receptor antagonist
  • steroids
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31
Q

5-HT 3 receptor antagonists

A

ondansetron (zofran), dolasetron, granisetron, palonsetron

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32
Q

benzamides/dopamine receptor antagonist

A

metoclopramide (Reglan), cisapride

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33
Q

phenothiazines/H1 receptor antagonist

A

promethazine (phenergan), chlorpromazine

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34
Q

butyrophenones/dopamine receptor antagonist

A

droperidol, haloperidol

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35
Q

antihistamine

A

diphenhydramine (benadryl), dimenhydrinate (dramamine)

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36
Q

anticholinergics

A

scopolamine, atropine

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37
Q

neurokinin 1 recpetor antagonist

A

aprepitant (emend)

38
Q

steroids

A

dexamethasone (decadron)

39
Q

post operative delirium risk factors

A
  • PTSD
  • fear
  • depression
  • anxiety
  • trauma
  • history of sexual trauma or abuse
40
Q

emergence delirium/agitation

A
  • 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
Q

post operative delirium

A

lasts for a more extended period of time after surgery

42
Q

post operative delirium causes

A
  • withdrawal psychosis
  • toxic psychosis
  • circulatory psychosis
  • functional psychosis
43
Q

why is post operative delirium costly?

A
  • increases ICU LOS
  • increases hospital LOS
  • increased number of days mechanically ventilated
  • increased functional decline
44
Q

what is the mortality % of post op delirium?

A

all cause mortality is 10-20% for every 2 days of post-op delirium

45
Q

risk factors for post op delirium

A
  • 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
Q

precipitating factors for post op delirium

A
  • meds or medication withdrawal
  • pain
  • hypoxemia
  • electrolyte abnormalities
  • malnutrition
  • dehydration
  • environmental change (ICU admission)
47
Q

meds that can precipitate post-op delirium or withdrawal

A
  • anticholinergics
  • muscle relaxants
  • antihistamines
  • GI antispasmodics
  • opioid analgesics
  • antiarrhythmics
  • cortciosteroids
  • > 6 total meds
  • > 3 new inpatient meds
48
Q

postop cognitive dysfunction (POCD)

A
  • 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
Q

POCD etiology/patho

A
  • pathophysiology not well understood
  • cerebral microemboli
  • hyperventilation, significant hypercapnia, cerebral vasoconstriction, extreme hypocapnia
  • inflammatory mechanisms
  • hypotension
  • decreased cerebral blood flow
50
Q

POCD risk factors

A
  • patients over the age of 65
  • preexisting cognitive impairment
  • type of surgery
  • re-operation
  • inflammation
  • depression
  • sleep deprivation
  • anesthetic technique
51
Q

hypothermia in the OR

A
  • common post operatively

- room is kept very cold, so puts patient at increased risk

52
Q

adverse effects of hypothermia

A
  • 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
Q

methods to warm

A
  • increase room temp
  • body warming blankets
  • fluid warmers
  • warm irrigation fluid
  • humidified gases
  • these should begin in the OR and not the PACU
54
Q

hypothermia symptoms

A
  • shivering
  • clumsiness
  • slurred speech
  • confusion
  • drowsiness
  • shallow breathing
  • weak pulse
55
Q

what can shivering in absence of hypothermia be caused by?

A

pain

56
Q

effects of shivering

A
  • increases O2 consumption (by 300% or more)
  • increases CO2 production
  • increases CO
  • predisposes at risk patients to cardiac morbidity
57
Q

treatment for shivering

A
  • Demerol 25 mg IV in PACU

- Zofran also potentially helps too, but Demerol is gold standard

58
Q

airway obstruction causes

A
  • 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
Q

partial obstruction

A

snoring

60
Q

complete obstruction

A
  • cessation of airflow
  • absent breath sounds
  • paradoxical chest movements
61
Q

hypoventilation

A

defined as PaCO2 > 45mmHg

62
Q

hypoventilation S/S

A
  • excessive or prolonged somnolence
  • airway obstruction
  • slow RR or tachypnea with shallow breathing
  • labored breathing
63
Q

hypoventilation causes

A
  • residual depressant effects of anesthetic agents
  • inadequate NMBD reversal
  • hypothermia
  • splinting secondary to pain
  • TREAT CAUSE
64
Q

hypoxemia

A
  • 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
Q

hypoxemia early signs

A
  • restlessness
  • tachycardia
  • tachypnea
  • dyspnea
  • increased agitation
  • anxiety
  • diaphoresis
  • retractions
  • altered LOC
  • HA
66
Q

hypoxemia late signs

A
  • increased restlessness
  • somnolence
  • stupor
  • dyspnea
  • decreased respirations
  • bradycardia
  • cyanosis
67
Q

hypoxemia signs in pediatrics

A
  • nasal flaring
  • stridor
  • grunting
  • feeding problems
68
Q

hypoxemia causes

A
  • hypoventilation
  • increased intra-pulmonary shunting
  • decreased CO
  • increase in O2 consumption (shivering)
69
Q

hypoxemia treatment

A

O2 therapy with or without positive airway pressure

70
Q

other respiratory complications

A
  • bronchospasm
  • pulmonary edema
  • PE
  • aspiration
71
Q

hypotension

A

defined as BP 25% below pre-op baseline

72
Q

hypotension causes

A
  • hypovolemia (most common cause)
  • pain meds (cause venodilation)
  • volatile anesthetics (decrease venous return)
  • post-op MI
  • hypoxia
  • cardiac tamponade
  • pneumothorax
  • LV dysfunction
73
Q

hypotension treatment

A
  • specific to cause, treat underlying cause
  • fluid challenge
  • vasopressors
74
Q

hypertension causes

A
  • pain (most common)
  • hypoxemia/hypercarbia
  • bladder distention (causes SNS activation)
  • fluid overload, hypervolemia
  • not taking routine anti-hypertensives
75
Q

hypertension treatment

A
  • treat the cause
  • adequate pain relief
  • bladder cath
  • beta blockers
  • vasodilators
76
Q

cardiac dysrhythmias causes

A
  • bradycardia - residual anticholinesterase, beta blockers, opioids, hypoxemia
  • tachycardia - anticholinergics, vagolytics, beta agonist (albuterol), pain, hypovolemia
  • PACs or PVCs - electrolyte imbalance, myocardial ischemia
77
Q

populations commonly affected by fluid and electrolyte imbalance

A
  • elderly
  • debilitated patients
  • hypertensive patients pretreated with diuretics
  • diabetic patients
  • neurosurgical patients
78
Q

hyponatremia

A
  • common cause = water intoxication
  • S/S = SALTLOS
  • stupor/coma
  • anorexia (N/V)
  • lethargy
  • tendon reflexes (decreased)
  • limp muscles (weakness)
  • orthostatic hypothension
  • seizures/HA
79
Q

hypocalcemia

A
  • common causes = hepatic failure, massive volume replacement, acute pancreatitis, hypoparathyroidism, ESRD
  • S/S:
  • irritability + anxiety
  • paresthesias
  • siezures
  • laryngospasms
  • bronchospasm
  • heart failure
  • muscle cramps
80
Q

hypermagnesemia

A
  • 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
Q

neurologic deficits

A
  • 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
Q

drug interactions

A
  • suspect when unexpected changes in neurologic status or VS

- increased use of non-FDA regulated herbal supplements –> increased risk of interactions

83
Q

common effects of drug interactions

A
  • 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
Q

discharge from PACU

A
  • STRICT

- must observe patients for a MINIMUM of 20-30 minutes after last dose of parenteral narcotic

85
Q

minimal discharge criteria from PACU

A
  • 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
Q

Modified Aldrete Score

A
  • 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
Q

Aldrete score components

A
  • respiration
  • O2 saturation
  • consciousness
  • circulation/color
  • activity
88
Q

Aldrete Respiration Scores

A
  • 2 = able to take deep breath and cough
  • 1 = dyspnea/shallow breathing
  • 0 = apnea
89
Q

Aldrete O2 Saturation Scores

A
  • 2 = maintains >92% on RA
  • 1 = needs O2 inhalation to maintain O2 saturation >90%
  • 0 = saturation <90% even with supplemental O2
90
Q

Aldrete Consciousness Scores

A
  • 2 = fully awake
  • 1 = arousable on calling
  • 0 = not responding
91
Q

Aldrete Circulation/Color Scores

A
  • 2 = BP +/- 20 mmHg pre op
  • 1 = BP +/- 20-50 mmHg pre op
  • 0 = BP +/- 50 mmHg pre op
92
Q

Aldrete Activity Scores

A
  • 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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