Post Anesthesia Care Flashcards
PACU
- post anesthesia care unit
- under auspices of anesthesia department
- transition from intraoperative to post anesthesia
phase 1 of anesthesia recovery
- immediate intensive care level recovery
- cares for patients during emergency and awakening
- continues until standard discharge criteria met
phase 2 of anesthesia recovery
- less intense care than phase 1
- ensures patient is ready for discharge
- “fast tracking” directly to phase 2 appropriate for some outpatients
patient requirements before leaving OR
- patent, stable airway
- adequate ventilation and oxygenation
- hemodynamic stability
admission to PACU essential steps
- assess
- attach to monitors
- provide oxygen
- measure/record VS
- report to PACU nurse (standard 11)
PACU Handoff components
- 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
frequent problems on emergence from anesthesia
- airway obstruction
- hypothermia/shivering
- agitation/delirium
- pain
- N/V
- autonomic lability
recovery from inhalation anesthetics
- 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
recovery from IV anesthetics
- function of pharmacologic profile of drug
- route for metabolism/excretion
- e 1/2
- redistribution profile
- degree of lipid solubility
- time/quantity of last dose
delayed emergence
failure to regain consciousness 30-60 min after GA is discontinued
common causes of delayed emergence
- residual drug effects
- consider treatment with narcan, flumazenil, or NMBD reversal
less common causes of delayed emergence
- hypothermia
- hypoxia
- hypercarbia
- marked metabolic disturbances
- perioperative stroke
postoperative complications
- pain
- PONV
- agitation
- emergence delirium
- hemodynamic complications
- respiratory complications
- fluid/electrolyte imbalance
- neurologic deficit
- drug interactions
what is the most common post op issue in PACU?
pain
methods of pain management
- opioids
- non-opioids
- regional
- atlernative - distraction, ice/heat, massage, acupuncture, immobilize, TENS
PONV contributes to
- delayed discharge
- unanticipated postsurgical admission
etiology of PONV
- anesthetic agents
- type of procedure
- patient factors
PONV patient factors
- female (3x higher risk than males)
- young age
- large body habitus
- history of PONV or motion sickness
- non-smoker
PONV anesthetic techniques
- GA
- meds - volatiles, nitrous oxide, opioids, anticholinesterase
PONV surgical procedures
- laparoscopic
- GYN
- eye
- ENT (esp middle ear)
- breast
- neurosurgery
PONV post-op factors
- hypotension
- hypovolemia
- postoperative pain
- CTZ stimulated by toxic endogenous substances
CTZ
- area postrema in dorsomedial medulla oblongata
- receives afferent input from many areas of the body
receptors that contribute to PONV
- dopaminergic
- histamine
- cholinergic muscarinic
- 5-HT (serotonin)
CNS PONV areas
- cortex
- thalamus
- hypothalamus
- meninges
vestibular system PONV areas
- H1 receptor
- M1 receptor
CTZ or area postrema PONV areas
- chemoreceptors
- D2 receptor
- NK1 receptor
- 5-HT3 receptor
vomiting center PONV areas
- located in NTS
- H1 receptor
- M1 receptor
- NK1 receptor
- 5-HT3 receptor
GI tract and heart PONV areas
- mechanoreceptors
- chemoreceptors
- 5-HT3 receptors
PONV management
- adequate hydration
- P6 acupuncture/pressure point on wrist
- antiemetics (multi modal)
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
5-HT 3 receptor antagonists
ondansetron (zofran), dolasetron, granisetron, palonsetron
benzamides/dopamine receptor antagonist
metoclopramide (Reglan), cisapride
phenothiazines/H1 receptor antagonist
promethazine (phenergan), chlorpromazine
butyrophenones/dopamine receptor antagonist
droperidol, haloperidol
antihistamine
diphenhydramine (benadryl), dimenhydrinate (dramamine)
anticholinergics
scopolamine, atropine
neurokinin 1 recpetor antagonist
aprepitant (emend)
steroids
dexamethasone (decadron)
post operative delirium risk factors
- PTSD
- fear
- depression
- anxiety
- trauma
- history of sexual trauma or abuse
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
post operative delirium
lasts for a more extended period of time after surgery
post operative delirium causes
- withdrawal psychosis
- toxic psychosis
- circulatory psychosis
- functional psychosis
why is post operative delirium costly?
- increases ICU LOS
- increases hospital LOS
- increased number of days mechanically ventilated
- increased functional decline
what is the mortality % of post op delirium?
all cause mortality is 10-20% for every 2 days of post-op delirium
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
precipitating factors for post op delirium
- meds or medication withdrawal
- pain
- hypoxemia
- electrolyte abnormalities
- malnutrition
- dehydration
- environmental change (ICU admission)
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
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
POCD etiology/patho
- pathophysiology not well understood
- cerebral microemboli
- hyperventilation, significant hypercapnia, cerebral vasoconstriction, extreme hypocapnia
- inflammatory mechanisms
- hypotension
- decreased cerebral blood flow
POCD risk factors
- patients over the age of 65
- preexisting cognitive impairment
- type of surgery
- re-operation
- inflammation
- depression
- sleep deprivation
- anesthetic technique
hypothermia in the OR
- common post operatively
- room is kept very cold, so puts patient at increased risk
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
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
hypothermia symptoms
- shivering
- clumsiness
- slurred speech
- confusion
- drowsiness
- shallow breathing
- weak pulse
what can shivering in absence of hypothermia be caused by?
pain
effects of shivering
- increases O2 consumption (by 300% or more)
- increases CO2 production
- increases CO
- predisposes at risk patients to cardiac morbidity
treatment for shivering
- Demerol 25 mg IV in PACU
- Zofran also potentially helps too, but Demerol is gold standard
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
partial obstruction
snoring
complete obstruction
- cessation of airflow
- absent breath sounds
- paradoxical chest movements
hypoventilation
defined as PaCO2 > 45mmHg
hypoventilation S/S
- excessive or prolonged somnolence
- airway obstruction
- slow RR or tachypnea with shallow breathing
- labored breathing
hypoventilation causes
- residual depressant effects of anesthetic agents
- inadequate NMBD reversal
- hypothermia
- splinting secondary to pain
- TREAT CAUSE
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
hypoxemia early signs
- restlessness
- tachycardia
- tachypnea
- dyspnea
- increased agitation
- anxiety
- diaphoresis
- retractions
- altered LOC
- HA
hypoxemia late signs
- increased restlessness
- somnolence
- stupor
- dyspnea
- decreased respirations
- bradycardia
- cyanosis
hypoxemia signs in pediatrics
- nasal flaring
- stridor
- grunting
- feeding problems
hypoxemia causes
- hypoventilation
- increased intra-pulmonary shunting
- decreased CO
- increase in O2 consumption (shivering)
hypoxemia treatment
O2 therapy with or without positive airway pressure
other respiratory complications
- bronchospasm
- pulmonary edema
- PE
- aspiration
hypotension
defined as BP 25% below pre-op baseline
hypotension causes
- hypovolemia (most common cause)
- pain meds (cause venodilation)
- volatile anesthetics (decrease venous return)
- post-op MI
- hypoxia
- cardiac tamponade
- pneumothorax
- LV dysfunction
hypotension treatment
- specific to cause, treat underlying cause
- fluid challenge
- vasopressors
hypertension causes
- pain (most common)
- hypoxemia/hypercarbia
- bladder distention (causes SNS activation)
- fluid overload, hypervolemia
- not taking routine anti-hypertensives
hypertension treatment
- treat the cause
- adequate pain relief
- bladder cath
- beta blockers
- vasodilators
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
populations commonly affected by fluid and electrolyte imbalance
- elderly
- debilitated patients
- hypertensive patients pretreated with diuretics
- diabetic patients
- neurosurgical patients
hyponatremia
- common cause = water intoxication
- S/S = SALTLOS
- stupor/coma
- anorexia (N/V)
- lethargy
- tendon reflexes (decreased)
- limp muscles (weakness)
- orthostatic hypothension
- seizures/HA
hypocalcemia
- common causes = hepatic failure, massive volume replacement, acute pancreatitis, hypoparathyroidism, ESRD
- S/S:
- irritability + anxiety
- paresthesias
- siezures
- laryngospasms
- bronchospasm
- heart failure
- muscle cramps
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
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
drug interactions
- suspect when unexpected changes in neurologic status or VS
- increased use of non-FDA regulated herbal supplements –> increased risk of interactions
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
discharge from PACU
- STRICT
- must observe patients for a MINIMUM of 20-30 minutes after last dose of parenteral narcotic
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)
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
Aldrete score components
- respiration
- O2 saturation
- consciousness
- circulation/color
- activity
Aldrete Respiration Scores
- 2 = able to take deep breath and cough
- 1 = dyspnea/shallow breathing
- 0 = apnea
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
Aldrete Consciousness Scores
- 2 = fully awake
- 1 = arousable on calling
- 0 = not responding
Aldrete Circulation/Color Scores
- 2 = BP +/- 20 mmHg pre op
- 1 = BP +/- 20-50 mmHg pre op
- 0 = BP +/- 50 mmHg pre op
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
